Article Text

Preseason shoulder range of motion screening and in-season risk of shoulder and elbow injuries in overhead athletes: systematic review and meta-analysis
  1. Federico Pozzi1,2,
  2. Hillary A Plummer3,
  3. Ellen Shanley4,
  4. Charles A Thigpen4,
  5. Chase Bauer5,
  6. Melissa L Wilson6,
  7. Lori A Michener2
  1. 1 Department of Physical Therapy, University of Florida, Gainesville, Florida, USA
  2. 2 Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA
  3. 3 Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
  4. 4 ATI Physical Therapy, Greenville, South Carolina, USA
  5. 5 Western University of Health Sciences, Pomona, California, USA
  6. 6 Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA
  1. Correspondence to Dr Federico Pozzi, Department of Physical Therapy, University of Florida, Gainesville, FL 32611, USA; fpozzi{at}


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.

  • baseball
  • handball
  • swimming

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Twitter @FedPT1, @chuck-thigpen, @LoriM_PT

  • Collaborators Robert Edward Johnson.

  • Contributors FP, HAP and LAM: conception and design of the work, acquisition, analysis and interpretation of data; drafting of the manuscript and revision; and final approval. ES and CAT: design of the work and interpretation of data, manuscript revision and final approval. CB: acquisition and interpretation of data, manuscript revision and final approval. MLW: analysis and interpretation of data, manuscript revision and final approval.

  • Funding FP received salary to complete this work from the Career Development Award sponsored by tge Academy of Orthopaedic Physical Therapy; and the Rehabilitation Research Career Development Program sponsored by the National Institute of Health (K12 HD055929). This publication was supported by grants UL1TR001855 and UL1TR000130 from the National Center for Advancing Translational Science of the U.S. National Institutes of Health. The content is solely the responsibility of the authors anddoes not necessarily represent the official views of the National Institutes of Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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