From research to clinic: how do injury prevention programs work to decrease shoulder injuries in sports?

Ann Cools, Clinical Pearls / Monday, May 10th, 2021

Although we don’t know their real interaction, common risk factors for sportsrelated shoulder pain have been described, such as range of motion deficits, mainly into internal rotation (IR), external rotator ER) strength deficits, scapular dysfunction, but also a lack of core stability, hip stability and mobility.  (Clarsen et al. BJSM 2014, Chalmers et al. Sports Health 2017). Additionally, prevention programs, focusing on these risk factors,  have been proven to be effective in reducing the prevalence of shoulder pain in handball players (Andersson et al. BJSM 2017). However, the researchers found a low adherence to the program from the players (Andersen et al. SJMSS2019). When asking the athletes why they did not do the program they said: “it takes too much time and it is boring”. So the message was: “Make it short and fun”.

Hilde Fredriksen from the OSTRC in Norway got the message and performed a Delphi study (Fredriksen et al. PTS 2020) (study to find consensus among experts on a specific topic) trying to find the optimal shoulder external rotation exercise with 2 questions:

a) Which shoulder external rotation exercise is the most effective?

And b) Which exercises will lead to the highest adherence?

Based on combined efficacy/adherence, two exercises won the price!

1/ shoulder external rotation in a bent-over position

2/ Shoulder external rotation in 90° of abduction combined with horizontal abduction and trunk rotation in a push-up position.

Next questions in view of efficient injury prevention strategies are:

a) if we would add a short external rotation strength program to the existing training, will these athletes become stronger?

And b) Do prevention programs, proven to be effective to reduce injury risk, change the risk factors themselves?

Once again Hilde looked at both research questions, and the answer is …no!…In a randomized controlled trial design, the group who did extra ER exercises was not stronger after 8 weeks (Fredriksen et al. JOSPT 2021), and the group who performed the preventive program did not change their risk factors in terms of ER strength and IR ROM after 18 weeks (Fredriksen et al. SJMSS 2020).

Is this a negative result? Not at all, it still means that the injury prevention programs work, but we don’t know why and how…


Clarsen B, Bahr R, Andersson SH, Munk R, Myklebust G. Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study. Br J Sports Med. 2014 Sep;48(17):1327-33

Chalmers PN, Wimmer MA, Verma NN, Cole BJ, Romeo AA, Cvetanovich GL, Pearl ML. The Relationship Between Pitching Mechanics and Injury: A Review of Current Concepts. Sports Health. 2017 May/Jun;9(3):216-221.

Andersson SH, Bahr R, Clarsen B, Myklebust G. Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. Br J Sports Med. 2017 Jul;51(14):1073-1080.

Andersson SH, Bahr R, Olsen MJ, Myklebust G. Attitudes, beliefs, and behavior toward shoulder injury prevention in elite handball: Fertile ground for implementation. Scand J Med Sci Sports. 2019 Dec;29(12):1996-2009.

Fredriksen H, Cools A, Myklebust G. Development of a short and effective shoulder external rotation strength program in handball: A delphi study. Phys Ther Sport. 2020 Jul;44:92-98.

Fredriksen H, Cools A, Myklebust G. No Added Benefit of 8 Weeks of Shoulder External Rotation Strength Training for Youth Handball Players Over Usual Handball Training Alone: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2021 Apr;51(4):174-187

Fredriksen H, Cools A, Bahr R, Myklebust G. Does an effective shoulder injury prevention program affect risk factors in handball? A randomized controlled study. Scand J Med Sci Sports. 2020 Aug;30(8):1423-1433.

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