Preseason shoulder range of motion screening and in-season risk of shoulder and elbow injuries in overhead athletes: systematic review and meta-analysis

Abstract

Objective: To characterise whether preseason screening of shoulder range of motion (ROM) is associated with the risk of shoulder and elbow injuries in overhead athletes.

Design: Systematic review and meta-analysis.

Data sources: Six electronic databases up to 22 September 2018.

Eligibility criteria: Inclusion criteria were (1) overhead athletes from Olympic or college sports, (2) preseason measures of shoulder ROM, (3) tracked in-season injuries at the shoulder and elbow, and (4) prospective cohort design. Exclusion criteria were (1) included contact injuries, (2) lower extremity, spine and hand injuries, and (3) full report not published in English.

Results: Fifteen studies were identified, and they included 3314 overhead athletes (baseball (74.6%), softball (3.1%), handball (16.1%), tennis (2.0%), volleyball (2.0%) and swimming (2.2%)). Female athletes are unrepresented (12% of the overall sample). Study quality ranged from 11 to 18 points on a modified Downs and Black checklist (maximum score 21, better quality). In one study, swimmers with low (<93°) or high (>100°) shoulder external rotation were at higher risk of injuries. Using data pooled from three studies of professional baseball pitchers, we showed in the meta-analysis that shoulder external rotation insufficiency (throwing arm <5° greater than the non-throwing arm) was associated with injury (odds ratio=1.90, 95% confidence interval 1.24 to 2.92, p<0.01).

Conclusion: Preseason screening of shoulder external rotation ROM may identify professional baseball pitchers and swimmers at risk of injury. Shoulder ROM screening may not be effective to identify handball, softball, volleyball and tennis players at risk of injuries. The results of this systematic review and meta-analysis should be interpreted with caution due to the limited number of studies and their high degree of heterogeneity.

Prospero registration number: CRD42017072895.

Keywords: baseball; handball; swimming.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. Superscript numbers indicate the corresponding reference. ROM, range of motion.

Figure 2

Forest plot indicating the meta-analysis results for all preseason ROM screening and subsequent risk of shoulder and elbow injuries. The summarised effect estimate was the odds ratios for absolute external, internal and total rotation and external and flexion deficit. The summarised effect estimate for internal rotation deficit was the risk ratio. a, adjusted for history of shoulder surgery. b, adjusted for sex and history of shoulder pain during the last season. c, adjusted for sex and shoulder pain at baseline. d, adjusted for player position (back player) and history of shoulder surgery. e, authors reported poor inter-rater and intrarater reliabilities of ROM measurements. CI, confidence interval; OR, odds ratio; ROM, range of motion; RR, risk ratio.

Figure 3

Overall, the plot indicates that all reported studies lie within the 95% confidence limits, suggesting limited reporting bias. The proximity of most studies to the solid black line indicates the null results observed in the bulk of included studies. Some asymmetry is noted, especially for external rotation deficit, indicating likely reporting bias for this exposure.