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Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best-evidence synthesis
  1. Martin Asker1,2,
  2. Hannah L Brooke3,
  3. Markus Waldén4,5,6,
  4. Ulrika Tranaeus1,7,
  5. Fredrik Johansson1,2,
  6. Eva Skillgate1,2,
  7. Lena W Holm1,3
  1. 1 Musculoskeletal and Sports Injury Epidemiology Center, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  2. 2 Naprapathögskolan—Scandinavian College of Naprapathic Manual Medicine, Stockholm, Sweden
  3. 3 Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  4. 4 Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  5. 5 Department of Orthopaedics, Hässleholm-Kristianstad-Ystad Hospitals, Hässleholm, Sweden
  6. 6 Football Research Group, Linköping, Sweden
  7. 7 Performance and Training Unit, The Swedish School of Sport and Health Sciences, GIH, Stockholm, Sweden
  1. Correspondence to Martin Asker, Musculoskeletal and Sports Injury Epidemiology Center, Institute of Environmental Medicine, Karolinska Institutet, Stockholm 171 77, Sweden; martin.asker{at}


Objective To assess the evidence for risk factors and prevention measures for shoulder injuries in overhead sports.

Design Systematic review with best-evidence synthesis.

Data sources Medline (Ovid), PubMed (complementary search), Embase (Elsevier), Cochrane (Wiley), SPORTDiscus (Ebsco) and Web of Science Core Collection (Thomson Reuters), from 1 January 1990 to 15 May 2017.

Eligibility criteria for selecting studies Randomised controlled trials, cohort studies and case-control studies on risk factors or prevention measures for shoulder injuries in overhead sports. The eligible studies were quality assessed using the Scottish Intercollegiate Guidelines Network criteria.

Results Of 4778 studies identified, 38 were eligible for quality review and 17 met the quality criteria to be included in the evidence synthesis. One additional quality study presented a shoulder injury prevention programme. Most studies focused on baseball, lacrosse or volleyball (n=13). The risk factors examined included participation level (competition vs training) (n=10), sex (n=4), biomechanics (n=2) and external workload (n=2). The evidence for all risk factors was limited or conflicting. The effect of the prevention programme within the subgroup of uninjured players at baseline was modest and possibly lacked statistical power.

Conclusions All investigated potential risk factors for shoulder injury in overhead sports had limited evidence, and most were non-modifiable (eg, sex). There is also limited evidence for the effect of shoulder injury prevention measures in overhead sports.

PROSPERO trial registration number CRD42015026850.

  • baseball
  • handball
  • tennis
  • injury prevention
  • cohort study

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  • MA and HLB contributed equally.

  • Twitter Follow Martin Asker @martinasker, Hannah Brooke @H_L_Brooke, Markus Waldén @MarkusWalden, Ulrika Tranaeus @UlrikaTranaeus, Fredrik Johansson @frjohansson, Eva Skillgate @skillgate_eva, Lena Holm @lw_holm.

  • Contributors MA, ES and LWH participated in the conception and design of the study. All authors were active in the screening procedure of studies retrieved in the literature search and in the procedure of assessing the quality of the relevant studies. MA, HLB and LWH extracted and analysed the data. MA and HLB drafted the manuscript and contributed equally (joint first authorship). All authors critically revised the manuscript for important intellectual content and approved the final version. LWH is the study guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.