Sports Biomechanics

ISSN: 1476-3141 (Print) 1752-6116 (Online) Journal homepage: http://www.tandfonline.com/loi/rspb20

The volleyball athlete’s shoulder: biomechanical

adaptations and injury associations

Dimitrios Challoumas, Antonio Stavrou & Georgios Dimitrakakis

To cite this article: Dimitrios Challoumas, Antonio Stavrou & Georgios Dimitrakakis (2016):
The volleyball athlete’s shoulder: biomechanical adaptations and injury associations, Sports
Biomechanics, DOI: 10.1080/14763141.2016.1222629

To link to this article: http://dx.doi.org/10.1080/14763141.2016.1222629

Published online: 23 Sep 2016.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=rspb20

Download by: [University of California, San Diego] Date: 24 September 2016, At: 06:39
Sports Biomechanics, 2016
http://dx.doi.org/10.1080/14763141.2016.1222629

The volleyball athlete’s shoulder: biomechanical adaptations

and injury associations
Dimitrios Challoumasa , Antonio Stavroub and Georgios Dimitrakakisc
a
Department of Trauma & Orthopaedic Surgery, Royal United Hospital, Bath, UK; bSchool of Medicine, Cardiff
University, Cardiff, UK; cDepartment of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK

ABSTRACT ARTICLE HISTORY

In volleyball, the dominant shoulder of the athlete undergoes Received 17 March 2016
biomechanical and morphological adaptations; however, definitive Accepted 7 August 2016
conclusions about their exact nature, aetiology, purpose and KEYWORDS
associations with shoulder injury have not been reached. We present a Muscular imbalance;
systematic review of the existing literature describing biomechanical rotation; dominant;
adaptations in the dominant shoulders of volleyball players and strengthening; pain
factors that may predispose to shoulder pain/injury. A thorough
literature search via Medline, EMBASE and SCOPUS was conducted
for original studies of volleyball players and 15 eligible articles were
identified. Assessment of study quality was performed using the
STROBE statement. The reviewed literature supports the existence of
a glenohumeral internal rotation deficit (GIRD) and a possible (and
less pronounced) external rotation gain in the dominant vs. the non-
dominant shoulder of volleyball athletes. Unlike other overhead sports,
the GIRD in volleyball athletes appears to be anatomical as a response
to the repetitive overhead movements and not to be associated with
shoulder pain/injury. Additionally, the dominant shoulder exhibits
muscular imbalance, which appears to be a significant risk factor
for shoulder pain. Strengthening of the external rotators should be
used alongside shoulder stretching and joint mobilisations, core
strengthening and optimisation of spike technique as part of injury
management and prevention programmes.

1. Introduction
The volleyball attack (‘spike’) is a highly technical, unique overhead movement that is
repetitively performed at high frequencies, which may reach up to 40,000 times a year in
professional players (Kugler, Kruger-Franke, Reininger, Trouillier, & Rosemeyer, 1996).
The spike movement belongs to the wider category of the overhead/throwing motion
and consists of the following phases: the windup (Figure 1; positions 1–2), where the arm
is elevated to a position of more than 90° from the anatomical position and the shoul-
der is slightly horizontally abducted; the cocking (Figure 1; positions 2–4), during which
abduction and external rotation (ER) reach their maximal levels; the acceleration (Figure
1; positions 4–8), which rapidly internally rotates and adducts the shoulder up to the point

CONTACT Dimitrios Challoumas dchalloumas@nhs.net

© 2016 Informa UK Limited, trading as Taylor & Francis Group
2 D. Challoumas et al.

Figure 1. The phases of the volleyball spike. 1–2: windup phase; 2–4: cocking phase; 4–8: acceleration
phase; 8–9: deceleration and follow-through phases. Taken with permission from Seminati et al. (2015).
Shoulder 3D ROM and humerus rotation in two volleyball spike techniques: injury prevention and
performance. Sports Biomechanics, 14(2), 216–231. Permission also granted from Taylor & Francis Ltd,
www.tandfonline.com.

where the hand strikes the ball (shoulder abducted at 140°–170° in neutral rotation); the
deceleration and follow-through (Figure 1; positions 8–9), which extend from ball impact
until the arm finally stops on the side of the trunk. During deceleration, the hitting shoul-
der continues to adduct and internally rotate, and its purpose is to reduce the momentum
of the arm and dissipate its remaining kinetic energy that was not transferred to the ball
(Escamilla & Andrews, 2009; Rokito, Jobe, Pink, Perry, & Brault, 1998).
During the volleyball spike, elite players abduct and extend the humerus of their hit-
ting arm in a circular motion at angular velocities of 920 ± 130 °/s during flexion and
4,520 ± 1,020 during internal rotation (IR), resulting in hand speeds of approximately 20
m/s and ball velocities as high as 33.3 m/s (Chung, Choi, & Shin, 1990; Coleman, Benham,
& Northcott, 1993; Seminati & Minetti, 2013; Wagner et al., 2012). With regard to forces,
an approximate value of 50 Nm has been estimated to be produced in the shoulder for the
maximum IR torque at the end of the acceleration phase (Reeser, Fleisig, Bolt, & Ruan,
2010a). Just after ball impact, the shoulder experiences an adduction torque of about 115
Nm and a glenohumeral compressive force of 800–1,500 Nm (Reeser et al., 2010a). Finally,
with respect to the temporal characteristics of the spike motion, the total pre-impact motion
(from start of windup to end of acceleration) was found to be as rapid as 0.378 ± 0.051 s and
deceleration and follow-through phases were found to last approximately 0.10 and 0.30 s,
respectively (Chung et al., 1990; Rokito et al., 1998).
The ‘serve’ is another repetitive overhead motion in volleyball and it also places signif-
icant loads on the player’s hitting shoulder. It is usually performed in two styles: the ‘float’
serve where the player is on the ground and strikes the ball giving it a floating trajectory,
and the ‘jump’ serve during which, as its name suggests, the player throws the ball in the
air, jumps and strikes it with a motion similar to the spike. Even though the volleyball serve
has not received as much attention in the literature as the volleyball spike, the general con-
sensus among authors is that the ‘float’ serve is associated with a significantly smaller risk
for shoulder pathology compared with the ‘jump’ serve, presumably due to less extreme
shoulder positions reached, smaller angular velocities and hence forces exerted on the
hitting shoulder (Reeser et al., 2010a, 2010b; Seminati & Minetti, 2013).
The constant repetition of these technical movements may result in functional, morpho-
logical and biomechanical alterations of the dominant shoulder, such as changes in the range
of motion (ROM), muscle strength, the shoulder capsule and the scapula (Borsa, Laudner,
 Sports Biomechanics  3

& Sauers, 2008; Myers, Laudner, Pasquale, Bradley, & Lephart, 2005). Despite the growing
body of evidence on shoulder adaptations in overhead/throwing athletes, definitive asso-
ciations are yet to be made mostly due to the difficult, multifaceted nature of the question
and the limited number of well-designed studies (Dwelly, Tripp, Tripp, Eberman, & Gorin,
2009; Manske, Wilk, Davies, Ellenbecker, & Reinold, 2013; Meister et al., 2005). Although
the majority of the relevant research on overhead sports is in baseball athletes, studies are
increasingly being conducted in volleyball players as questions specific to volleyball still
remain unanswered.
Overhead sport athletes who perform a throwing motion similar to the volleyball spike
have been shown to demonstrate increases in the ROM of ER (external rotation gain; ERG)
and reductions in the ROM of IR (glenohumeral internal rotation deficit; GIRD) in their
dominant shoulders compared with the opposite side. Additionally, overhead athletes appear
to display muscular imbalance in their dominant shoulder with lower ER strength than
IR strength and this has been linked with shoulder pathology (Noffal, 2003; Yildiz et al.,
2006). Definitive conclusions about these patterns and their associations with injury have
not been reached in volleyball.
The primary aim of this systematic review was to test the two following hypotheses: (a) the
dominant shoulder of volleyball players is biomechanically and morphologically different
to their non-dominant shoulders; and (b) these possible dominant shoulder adaptations are
associated with shoulder injury and/or pain. Our secondary aim was to suggest strategies
based on the existing literature that could be used both by athletes individually for preven-
tion and quicker recovery of chronic shoulder pathology and by coaches for the improve-
ment of training sessions with respect to injury prevention and performance optimisation.
To the best of our knowledge, this is the first article reviewing the literature on shoulder
adaptations in volleyball players specifically. We believe that, although overhead sports may
share similar patterns and features, each one should be studied separately for more reliable
and specific associations to be made.

2. Methods
2.1. Search strategy
A thorough literature search via Medline, EMBASE and SCOPUS was conducted in June 2015
with the following keywords, their combinations and associated terms: ‘volleyball’, ‘shoulder’,
‘adaptations’, ‘strength’ and ‘injury’. More specifically, the following Boolean operators were
used: ‘((volleyball) AND shoulder) AND (injury OR pain OR biomechanics OR electromy-
ography OR isokinetic OR isometric OR glenohumeral OR rangeofmotion OR adaptations)’.
MeSH terms were not used to minimise the risk of missing relevant articles. Review arti-
cles were used to identify relevant articles that were missed at the initial search. Additionally,
reference list screening and citation tracking in Google Scholar was performed for each
relevant article.

2.2. Inclusion and exclusion criteria

Original studies of volleyball or beach volleyball players that described biomechanical
shoulder adaptations and possible associations with shoulder adaptations and shoulder
pain or injury were included. Specifically, included studies measured shoulder ROM,
4 D. Challoumas et al.

performed isokinetic or isometric testing of shoulder internal and external rotators or

reported on associations of biomechanical shoulder adaptations with shoulder injury.
Studies with mixed populations consisting of volleyball athletes and other overhead ath-
letes were excluded. Non-peer-reviewed articles were excluded for a higher strength of
evidence to be maintained and so were articles written in languages other than English.
No time criteria were applied.

2.3. Screening
From an initial total of 117 articles that were identified by two independent reviewers, after
exclusion of duplicate and non-eligible articles, title and abstract screening and addition of
missed studies identified by review articles, reference list screening and citation tracking,
15 studies were found to fulfil the inclusion and exclusion criteria. Thirteen of these were
cross-sectional studies, one prospective and retrospective cohort and one both prospective
cohort and cross sectional. No articles of other types of original research (including ran-
domised trials, case-control studies and case series) were found that fulfilled the inclusion
criteria. Figure 2 illustrates the steps taken in article selection from the initial electronic
search to the final identification of the 15 eligible studies.

2.4. Quality assessment

Study quality was assessed by the first author and was confirmed by both co-authors using
the ‘Strengthening The Reporting of Observational studies in Epidemiology (STROBE)’
statement and in particular, the 22-item ‘STROBE Statetement—Checklist of items that
should be addressed in reports of observational studies’ (von Elm et al., 2007). A three-
category grading system was used as follows: (a) ‘Good’ quality articles scored >14 items
on the checklist (little risk of minor or major bias), ‘fair’ quality articles scored 7–14 (little
risk of major bias) and ‘poor’ quality articles <7 (high-risk of major bias).
Additionally, we added an extra criterion which is absent from the aforementioned state-
ment as it is important for reducing the risk of bias by increasing the power of the study:
population size. Articles were only classified as ‘good’ quality if their population consisted
of at least 50 athletes and ‘fair’ quality if they included more than 15 athletes.
We also classified studies by their ‘level of evidence’, which refers to a grading system
based on the study methodology that is used in evidence-based practice to describe the
strength of the results reported. The ‘Oxford Centre for Evidence-Based Medicine—Levels of
Evidence’ report was used which ranks studies from 1 to 5, with 1 representing the strongest
evidence and 5 the weakest (Centre for Evidence-Based Medicine, 2009).

2.5. Data analysis

Each of the 15 articles was initially read by the first author to gain familiarity and subse-
quently each article was re-read and placed into one or more of the following three categories
based on their content/aims: (a) adaptations in shoulder ROM, (b) adaptations in shoulder
strength and (c) associations of shoulder adaptations with shoulder pain/pathology. Both
qualitative and quantitative data were inserted into three tables (one for each category) to
facilitate analysis and presentation.
 Sports Biomechanics  5

Figure 2. Flow chart of articles selection.

6 D. Challoumas et al.

3. Results
Table 1 summarises the characteristics and quality assessment of the 15 studies identified.

3.1. Biomechanical adaptations

3.1.1. Range of motion
A total of nine studies assessing the ROM of ER and IR were identified (Table 2). Three stud-
ies reported a combined ERG and GIRD of the dominant vs. the non-dominant shoulder,
while four found an isolated GIRD (Forthomme, Wieczorek, Frisch, Crielaard, & Croisier,
2013; Lajtai et al., 2009; Martelli, Ciccarone, Grazzini, Signorini, & Urgelli, 2013; Reeser
et al., 2010b; Saccol, Almeida, & de Souza, 2015; Wang, Macfarlane, & Cochrane, 2000;
Witvrouw et al., 2000). Two studies reported similar ROM in dominant and non-dominant
shoulders (Kugler et al., 1996; Schwab & Blanch, 2009). ERG of the dominant compared
with the non-dominant shoulder ranged between −2.3° and 13° and GIRD between −2.2°
and −20°.

3.1.1.1. Combined ERG and GIRD. In a study of high-level Belgian volleyball players
by Forthomme et al. (2013), the population demonstrated significant GIRDs and ERGs in
the dominant shoulders with no differences in the total arc of motion (TROM), supporting
the suggested theory of the preserved TROM described by Seroyer et al. (2009). In a group
of semi-professional volleyball players, Martelli et al. (2013) found a GIRD and an ERG of
their dominant vs. the non-dominant shoulders reinforcing the majority of the literature
and suggesting an antero-inferior laxity of the glenohumeral joint and a possible posterior
capsule tightness that has the potential to cause postero-superior impingement, as well as
increased anterior translation of the humerus. Lajtai et al. (2009) was in agreement with
the aforementioned findings having also described a combined ERG and GIRD of the
dominant shoulder both at 0° adduction and 90° abduction of the shoulder in a population
of professional beach volleyball players.

3.1.1.2. Isolated GIRD. A study that investigated the shoulder biomechanics of the
English men’s volleyball squad is partly in agreement with the proposed mechanisms, as
GIRD (both in active and passive IR) but not an ERG was demonstrated in the dominant vs.
the non-dominant arms of the athletes (Wang et al., 2000). Similarly, Reeser et al. (2010b)
described a significant GIRD and a non-significant ERG in the dominant vs. the non-
dominant shoulders of collegiate volleyball players. In accordance with the existence of a
significant GIRD but not an ERG were also Saccol et al. (2015) and Witvrouw et al. (2000)
in Brazilian female beach volleyball players and Belgian male volleyball players, respectively.

3.1.1.3. No significant differences in ROM. Schwab and Blanch (2009) reported non-
statistically significant differences in ROM between the two shoulders despite humeral
retroversion (backward bend) in the dominant arm, which should normally result in increased
ER and reduced IR according to the proposed theories. Finally, in the study by Kugler et al.
(1996), ER and IR ROM were similar both between the two shoulders in all participants and
between the three groups (volleyball players with shoulder pain, asymptomatic volleyball
Table 1. Characteristics and quality assessment of included studies.
Study Type (level of Study
First author, Year evidence) Aims Population quality
Kugler et al. (1996) Cross-Sectional (3) Identify features which may correlate with shoulder problems in volleyball 30 competitive semi-professional volleyball Fair
attackers. players (15 with shoulder pain; 8 females)
and 15 recreational athletes (control; 3
females)
Alfredson et al. (1998) Cross-Sectional (3) Measure and compare maximal isokinetic concentric and eccentric muscle 11 elite adult female volleyball players Fair
strength of IR and ER. 11 non-active females (control)
Wang et al. (2000) Cross-Sectional (3) Evaluate the difference in strength and mobility of rotator cuff muscles in DOM 10 elite adult male volleyball players Poor
and NDOM of 10 elite volleyball players.
Wang and Cochrane (2001) Cross-sectional and Evaluate the relationship between shoulder mobility, rotator muscles’ strength 16 elite adult male volleyball players Fair
Prospective Cohort and scapular symmetry, and shoulder injuries and/or pain in elite volleyball
(3) players.
Witvrouw et al. (2000) Cross-Sectional (3) Study the possible association between the ROM of the shoulder joint and the 16 professional adult male volleyball players Fair
presence of suprascapular neuropathy.
van Cingel et al. (2006) Cross-Sectional (3) Determine concentric shoulder ER/IR strength, DOM and NDOM shoulder differ- 35 elite adult male volleyball players Fair
ences and agonist/antagonist ratios.
Stickley et al. (2008) Cross-Sectional (3) Compare medial and lateral isokinetic peak torques of the rotator cuff among skill 38 female adolescent volleyball players Fair
levels and between athletes with and without a history of shoulder injury. aged 10–15 years
Lajtai et al. (2009) Cross-Sectional (3) Recognise the clinical and imaging findings in the hitting shoulders of fully 84 professional adult beach volleyball Fair
competitive professional beach volleyball players, as compared with their players (30 females)
non-hitting shoulders.
Schwab and Blanch (2009) Cross-Sectional (3) Evaluate variations in humeral torsion in elite male volleyball players and deter- 24 elite adult male volleyball players Fair
mine whether these changes are related to training history, retrospective injury
history and volleyball performance.
Reeser et al. (2010b) Cross-Sectional (3) Identify risk factors for volleyball-related shoulder pain and dysfunction. 276 collegiate volleyball players (90 females) Good
Lajtai et al. (2012) Cross-Sectional (3) Assess possible early pathological findings of infraspinatus atrophy with surface 35 professional adult male beach volleyball Fair
electromyography and nerve conduction velocity measurements. players
Forthomme et al. (2013) Cross-Sectional (3) Identify the most significant intrinsic risk factors for shoulder pain by measuring 66 professional adult volleyball players (32 Good
strength developed by shoulder rotators and by carrying out various morphos- females)
tatic assessments.
Martelli et al. (2013) Cross-Sectional (3) Evaluate the function of the rotator cuff muscles with the use of a specific device. 30 semi-professional volleyball players (15 Fair
females)
Hadzic et al. (2014) Cross-Sectional (3) Evaluate shoulder strength asymmetry and a history of shoulder injury in a large 183 high-level volleyball players (84 Good
sample of professional volleyball players of both sexes across different playing females)
positions and skill levels.
Sports Biomechanics 

Saccol et al. (2015 Cross-Sectional (3) Compare the bilateral ROM and rotation strength in the shoulders of young 33 elite beach volleyball players (14 females) Fair
beach volleyball players.
7

Notes: ER: external rotation; IR: internal rotation; DOM: dominant arm; NDOM: non-dominant arm; ROM: range of motion.
8 D. Challoumas et al.

Table 2. Findings of studies assessing ROM differences of passive internal and ER at 90° abduction be-
tween the dominant and non-dominant shoulders of volleyball players.
Passive ROM (DOM - NDOM)/deg
First author, Year Population size ER IR
Kugler et al. (1996) 30 ↕ NA ↕ NA
Wang et al. (2000) 10 ↕ +5 ↓ −20
Witvrouw et al. (2000) 16 ↕ −1.5 ↓ −7.3
Lajtai et al. (2009) 84 ↑ +4 ↓ −5
Schwab and Blanch (2009) 24 ↕ −2.3 ↕ −2.2
Reeser et al. (2010b) 276 ↕ +2 ↓ −8.9
Forthomme et al. (2013) 66 ↑ +3.5 ↓ −4.4
Martelli et al. (2013) 30 ↑ +13 ↓ −10
Saccol et al. (2015) 33 ↕ +5.1 ↓ −9.6
Notes: ER: external rotation; IR: internal rotation; ROM: range of motion; DOM: dominant arm; NDOM: non-dominant arm; ↑:
higher (p < 0.05); ↓: lower (p < 0.05); ↕similar (p > 0.05); NA: not available.

players, asymptomatic recreational athletes); however, measurements or other details are

not presented.

3.1.2. Strength
Eleven studies compared the strength of the dominant and non-dominant shoulder internal
rotators (mainly subscapularis and teres major) and external rotators (mainly infraspinatus
and teres minor) through either isometric (n = 5) or isokinetic (n = 6) tests (Table 3).

3.1.2.1. Isometric testing. A large Slovenian study with a population of 183 volleyball
players participating in the first and second division of the Slovenian championship reported
interesting findings (Hadzic, Sattler, Veselko, Markovic, & Dervisevic, 2014). Both male and
female players had increased IR strength in the dominant vs. the non-dominant shoulder,
regardless of shoulder injury history, while a decreased ER strength of the dominant vs. the
non-dominant shoulder was only observed in females without previous shoulder injury.
The strength ratio of ER/IR was only lower on the dominant vs. the non-dominant shoulder
of male players, but not female players, and was not associated with previous shoulder
injury. Therefore, the authors speculate that females may be less likely to develop dominant
shoulder injury, as this has been shown to be linked with an abnormal strength ratio. This
assumption, however, has not been reported elsewhere. Interestingly, playing positions did
not influence strength ratios and strength asymmetry (Hadzic et al., 2014).
Isometric testing in the study by Martelli et al. (2013) showed similar strengths of the rota-
tor cuff between the two arms at 0° adduction and stronger internal rotators (in men only)
and external rotators in the dominant arms at 90° abduction that is most likely secondary
to the repetitive spike and serving movements according to the authors. Additionally, lower
strength values of the subscapularis were reported in the dominant vs. the non-dominant
shoulder.
Isometric tests of Lajtai et al. (2009) found decreased average strength of the external
rotators and stronger abduction of the hitting shoulder vs. the non-dominant shoulder,
and those of Lajtai et al. (2012) revealed weaker elevation and ER of the dominant vs. the
non-dominant shoulder. Reeser et al. (2010b) found a 17% and 6% prevalence of IR and
ER strength imbalance, respectively, between the two arms, however, further details or
numerical measurements are not available. Finally, Saccol et al. (2015) described similar
Table 3. Findings of studies assessing shoulder strength in volleyball players.
Isokinetic testing (DOM vs. NDOM)
ER/IR strength at 60 deg/s
Population test speed
First author, Year size (deg/s) IR ER DOM NDOM Isometric Testing
Alfredson et al., 22 60 ↑ c-IR ↕ e-IR ↕ c-ER ↕ e-ER 0.72 0.79 –
(1998) 180
Wang et al., (2000) 10 60 ↑ c-IR ↑ e-IR ↓ c-ER ↕ e-ER 0.67 0.98 –
120
Wang & Cochrane, 16 60 ↑ c-IR ↑ e-IR ↓ c-ER ↕ e-ER 0.73 1.06
(2001) 120
van Cingel et al., 35 60 ↑ c-IR ↑ e-IR ↕ c-ER ↕ e-ER NA NA –
(2006) 180
300
Lajtai et al., (2009) 84 – – – – Weaker ER and stronger abduction in
DOM vs. NDOM
Reeser et al., 276 – – – – Imbalanced DOM vs. NDOM ER strength
(2010b) in 17% and IR strength in 6%
Lajtai et al., (2012) 35 – – – – (a)Weaker elevation and ER of DOM vs.
NDOM
(b) More pronounced loss in strength
in ER in DOM in those with severe vs.
those with mild infraspinatus atrophy
Forthomme et al., 66 60 ↑ c-IR ↑ e-IR ↕ c-ER ↕ e-ER 0.71 0.80 –
(2013) 240
Martelli et al., 30 – – – – – – (a) Similar strengths in ER and IR in DOM
(2013) vs. NDOM at 0° adduction
(b) At 90° abduction, stronger IR and ER
in males and stronger ER in females in
DOM vs. NDOM
(c) Higher values of lift-off test in NDOM
vs. DOM
Hadzic et al., (2014) 183 60 ↑ c-IR - ↕ c-ER - 0.65 0.65 –
Saccol et al., 33 – – – 0.66 0.72 (a) Similar strengths in ER and IR bilater-
(2015) ally in both men and women
(b) Shoulder ratio imbalance in majority
of athletes
Sports Biomechanics 

Notes: ER: external rotation; IR: internal rotation; DOM: dominant arm; NDOM: non-dominant arm; c-: concentric; e-: eccentric; ↑: higher (p < 0.05); ↓: lower (p < 0.05); ↕similar (p > 0.05); NA: not
available.
9
10 D. Challoumas et al.

strengths in dominant vs. non-dominant shoulders in both ER and IR, however, the majority
of athletes displayed strength ratio imbalance in their shoulders.

3.1.2.2. Isokinetic testing. Forthomme et al. (2013) performed shoulder isokinetic

assessment which revealed stronger internal rotators in both the concentric and eccentric
modes and similar external rotators strength in the dominant vs. the non-dominant side. The
values of all agonist/antagonist ratios were lower in the dominant shoulder. In the study by
Wang et al. (2000), isokinetic testing at 60°/s and 120°/s showed stronger concentric IR and
eccentric IR at the lower speed, weaker concentric-ER and similar eccentric-ER at the two
speeds on the dominant compared with the non-dominant side. Strength ratios (ER/IR) were
lower in the dominant arm at both speeds for both types of contraction, and this difference
was significantly more pronounced in concentric compared with eccentric contractions.
These strength patterns were reproduced when the authors repeated isokinetic testing in
the same population with six additional athletes a year later (Wang & Cochrane, 2001).
van Cingel, Kleinrensink, Stoeckart, Aufdemkampe, and Kuipers (2006) isokinetically
assessed the strength of shoulder internal rotators and external rotators at various test speeds
in elite volleyball players and found that internal rotators were significantly stronger than
external rotators of the same shoulder on both sides and internal rotators of the dominant
arm were stronger than internal rotators of the non-dominant arm. ER strength was found
to be similar between the two arms, while the strength ratio of ER/IR was lower on the
dominant side.
Similarly, Alfredson, Pietilä, and Lorentzon (1998) performed isokinetic testing in profes-
sional volleyball players and non-active females, all asymptomatic, and found higher values
of eccentric and concentric peak torques of internal rotators and external rotators at both
testing velocities (60°/s and 180°/s) in the dominant shoulder in the former group. At the
low test speed, signs of rotator cuff imbalance were noted in the dominant arm, as the ER/
IR strength ratio was lower than the opposite arm, with the IR strength at this speed being
significantly greater in the dominant arm and the ER strength being similar in the two arms.
Finally, Stickley, Hetzler, Freemyer, and Kimura (2008) assessed the isokinetic peak
torque ratios in female players between 10 and 15 years of age; their tests revealed
stronger concentric-IR, concentric-ER, eccentric-IR and eccentric-ER in higher (under-
15 & under-14) compared with lower (under-12) skill levels. However, all ratios measured
(concentric-ER/concentric-IR, eccentric-ER/eccentric-IR, eccentric-ER/concentric-IR,
eccentric-IR/concentric-ER) were similar in different skill levels, suggesting increases in
internal rotators and external rotators strength at similar rates with increasing skill.

3.2. Associations with shoulder pain/pathology

A total of nine articles attempted to correlate present/past shoulder injury or pain with
biomechanical and morphological adaptations (Table 4).

3.2.1. Shoulder external rotators and internal rotators imbalance

Wang and Cochrane (2001), in their prospective study, assessed muscle strength and bal-
ance, scapular symmetry and shoulder mobility of the national English men’s volleyball
squad and found that the only factor significantly associated with shoulder injury was
imbalance of the internal and external rotators of the dominant shoulder. Similarly, Reeser
 Sports Biomechanics  11

Table 4. Key findings of the studies assessing associations of shoulder adaptations with shoulder pain
or injury in volleyball players.
First author, Year Population size Associations of shoulder adaptations with injury/pain
Kugler et al., (1996) 30 Morphological differences (DOM depressed, scapula lateralised and
dorsal muscles and posterior and inferior part of shoulder capsule
shortened vs. NDOM) more pronounced in those suffering from
shoulder pain.
Witvrouw et al., (2000) 16 None of the athletes with infraspinatus atrophy experienced shoulder
injuries, pain or loss of function.
Wang & Cochrane, (2001) 16 Significant association between muscle strength imbalance and shoul-
der injury.
Stickley et al., (2008) 38 a) Higher strength measures in DOM of those with vs. those without
past shoulder injury.
b)Lower cocking ratio (e-IR/c-ER) and spiking ratio (e-ER/c-IR) in DOM of
those with vs. those without past shoulder injury.
Reeser, (2010) 276 Shoulder pain/injury associated with (a) coracoid tightness/pectoral
shortening; (b) SICK scapula score; (c) age; (d) team role; (e) strength
imbalance of external rotators or internal rotators in DOM vs. NDOM;
(f) degree of scapular lateralisation at shoulder abduction 90° and
maximal IR.
Forthomme et al., (2013) 66 More marked forward-presenting shoulder bilaterally in affected vs.
unaffected.
Hadzic et al., (2014) 183 Past shoulder injury not associated with abnormal strength ratio of
dominant shoulder.
Notes: ER: external rotation; IR: internal rotation; DOM: dominant arm; NDOM: non-dominant arm; c-: concentric; e-: eccen-
tric; SICK: Scapula malposition, Inferior medial border prominence, Coracoid pain and malposition, Scapular dyskinesis.

et al. (2010b) identified a significant relationship between shoulder pain/problems and

shoulder strength imbalance of ER and/or IR between the two sides in 276 collegiate vol-
leyball athletes. Conversely, however, the large study by Hadzic et al. (2014) found no links
between muscular imbalance of the dominant shoulder and history of shoulder injury.
Stickley et al. (2008) compared adolescent female volleyball athletes with and without
past shoulder injury and no significant differences in any of the strength measurements
were identified. Those with previous injuries, however, appeared to have significantly
lower cocking ratios (eccentric-IR/concentric-ER) and lower spiking (deceleration) ratios
(eccentric-ER/concentric-IR) that approached statistical significance; these findings suggest
reduced eccentric strength in this group of athletes.

3.2.2. Infraspinatus atrophy

The prevalence of isolated infraspinatus atrophy in volleyball has been reported to be 12.5–
33% in the literature and, even though questions about its exact aetiology and relatively
high prevalence compared with other overhead sports remain unanswered, authors are in
agreement about the absence of effects on shoulder pathology (Ferretti, Cerullo, & Russo,
1987; Holzgraefe, Kukowski, & Eggert, 1994). Ferretti et al. (1987), Lajtai et al. (2009) and
Witvrouw et al. (2000) described an asymptomatic reduction in ER strength of the affected
shoulder in volleyball players with infraspinatus atrophy with no associations with shoulder
pain or injury.

3.2.3. Other morphological adaptations

In the study by Forthomme et al. (2013), the difference in forward presentation of the
dominant shoulder observed compared with the non-dominant side was more marked
in athletes with dominant shoulder pain. Martelli et al. (2013) observed a weakness of the
12 D. Challoumas et al.

subscapularis in the dominant arm (lift-off test), which, according to the authors, may be
the result of progressive lack of resistance of the anterior shoulder capsule and the forward
sliding of the humeral head; they propose that this impairment could represent early signs
of posterior capsule tightness and recommend a complete evaluation protocol both to
prevent injuries and to optimise performance.
In an early study, Kugler et al. (1996) found significant differences in the morphology of
the dominant vs. the non-dominant shoulders of volleyball players, which were revealed by
simple measurements in different shoulder positions. The dominant shoulder was found
to be depressed, the scapula lateralised and the dorsal muscles and posterior and inferior
part of the shoulder capsule shortened. These differences were more pronounced in those
with shoulder pain, while a control group of recreational athletes who did not perform any
overhead activity did not have any differences between the dominant and non-dominant
shoulder.
A similar study by Reeser et al. (2010b) revealed a 60% prevalence of abnormal scapular
mechanics, a 57% prevalence of SICK scapula (Scapula malposition, Inferior medial border
prominence, Coracoid pain and malposition, Scapular dyskinesis) and coracoid tightness/
pectoral shortening in 63% of the population. In their large study, the authors identified
significant associations of the prevalence of shoulder pain/problems with SICK scapula
score (higher with increasing score) and scapular lateralisation (higher with increasing
lateralisation) at a particular position (shoulder abduction 90° and maximal IR), addi-
tionally to muscle imbalance described above. GIRD did not appear to have any links with
shoulder injuries. Finally, the same study linked the following demographic factors to risk
for shoulder pain: (a) team role (higher in those with attacking roles); (b) serve type (higher
in those performing ‘jump’ compared with ‘float’ serve); and (c) age (higher with increasing
age) but not years of experience.

4. Discussion and implications

4.1. Summary of findings
The results of our systematic review strongly reinforced the validity of our two hypotheses
regarding the presence of differences in the dominant vs. the non-dominant shoulder of
volleyball players and their associations with shoulder pain and/or injury.
The findings of the identified and presented studies suggest the existence of a GIRD
and a possible, but less marked, ERG in the dominant shoulders of volleyball players. With
regard to isokinetic and isometric testing, the internal rotators of the dominant vs. the
non-dominant shoulder appear to be stronger and the evidence on ER strength is con-
troversial; studies have described higher, lower or similar strength in ER of dominant vs.
non-dominant shoulders. The existence of muscle imbalance in the dominant shoulder of
volleyball players, however, finds the literature in agreement as the vast majority of studies
reported lower strength (external rotators/internal rotators) ratio in the dominant vs. the
non-dominant shoulder. Shoulder abduction and elevation have been found to be stronger
and weaker respectively in dominant vs. non-dominant shoulders, however, these move-
ments have not been adequately assessed in the literature.
With regard to the associations of shoulder adaptations with shoulder injury, muscular
imbalance appears to be a significant risk factor for the development of dominant shoulder
 Sports Biomechanics  13

pain. Additionally, scapular and capsular alterations are also likely to be associated with
shoulder pathology, especially SICK scapula and coracoid tightness/pectoral shortening.

4.2. Biomechanical shoulder adaptations in overhead athletes

Biomechanically, the dominant shoulder of overhead athletes seems to demonstrate a
humeral ERG and a GIRD compared with the non-dominant side and with other pop-
ulations, as well as muscular imbalance mainly due to the increased strength of IR with
unchanged or lower ER strength (Baltaci & Tunay, 2004; Ellenbecker et al., 2002; Tonin,
Stražar, Burger, & Vidmar, 2013; Yildiz et al., 2006). Morphological shoulder adaptations
specific to overhead athletes (including volleyball players) include anterior hyperlaxity,
posterior shoulder immobility, humeral retroversion and scapular dyskinesis (Borsa et al.,
2008; Tonin et al., 2013).
Associations between morphological and biomechanical shoulder alterations have still
not been clearly identified. ERG may be the result of either anterior hyperlaxity, humeral
retroversion or a combination of the two. Similarly, GIRD may either be a consequence of
posterior shoulder immobility or it may simply be an adaptation to ERG, as some authors
propose that the TROM remains unchanged in healthy shoulders, therefore, an increase in
ER leads to a corresponding decrease in IR, something known as posterior shift (Seroyer
et al., 2009). Conversely, the ERG may be the consequence of the GIRD that is secondary
to posterior shoulder immobility, following the principle of the unchanged TROM (Seroyer
et al., 2009).

4.2.1. Adaptations in range of motion—aetiology and effects

Hypotheses aiming to explain the posterior shoulder immobility of the dominant shoulder
in overhead athletes that could potentially lead to GIRD include fibrous tissue formation
in the posterior capsule, musculotendinous tightness in the posterior rotator cuff and bony
changes due to the repetitive overhead activity. The findings of a recent study in baseball
pitchers suggest that GIRD could be primarily attributed to retroversion rather than soft
tissue tightness (Hibberd, Oyama, & Myers, 2014).
Anterior capsule stretching (hyperlaxity), that is thought to contribute to the ERG, is
also thought to be a physiologic adaptation to the throwing/overhead motion. However, the
ERG of the dominant shoulder in this group of athletes seems to be predominantly owing
to increased humeral retroversion secondary to osseous changes, which has been hypoth-
esised to be an essential adaptive response to the ER demands exerted on the arm during
the throwing action (Baltaci & Tunay, 2004; Borsa et al., 2008). More specifically, increased
humeral retroversion is thought to assist the shoulder in achieving greater angles of ER in
the cocking phase, therefore resulting in higher accelerations of the arm and hence greater
speed of the ball during the throwing motion. Additionally, it has also been proposed to
have protective effects, minimising anterior shoulder laxity, capsular tension and the risk of
internal impingement (Borsa et al., 2008; Crockett, Gross, & Wilk, 2002; Osbahr, Cannon,
& Speer, 2002; Pieper, 1998). In fact, a recent prospective study in baseball reported an
increased risk of shoulder pain in pitchers with a dominant ERG of less than 5° compared
with the opposite side (Wilk et al., 2015).
The purposes and/or consequences of these alterations in ROM are controversial. Even
though some believe that the ERG is an adaptation to enhance performance, humeral
14 D. Challoumas et al.

retroversion reduces the ability of the rotator cuff to control high forces through the extremes
of shoulder ROM and this could result in excessive humeral head translation (movement
with respect to the glenoid) and shoulder pain (Crockett et al., 2002; Ellenbecker et al.,
2002). Anterior hyperlaxity is also thought to lead to impingement in the subacromial area.
With regard to scapular dyskinesis, authors seem to be in agreement, supporting unwanted
outcomes; although scapular alterations may be an adaptation to allow for the completion of
the follow-through phase of the throwing motion, scapular dyskinesis can decrease maximal
cocking and hence final ball speed and is either the cause or the result of overuse injuries,
such as subacromial impingement (Borsa et al., 2008).

4.2.2. The concept of TROM

TROM is defined as the sum of the IR ROM and ER ROM.
A healthy shoulder should remain relatively symmetrical with respect to the opposite
shoulder (side-to-side TROM symmetry) regardless of age or level (Cieminski et al., 2015;
Shanley et al., 2011). In the context of GIRD in overhead sports, when there is an IR deficit
with a concurrent ERG of similar magnitude, the side-to-side TROM remains symmetri-
cal and it does not appear to result in shoulder pathology, therefore this GIRD is termed
‘anatomical’. Conversely, ‘pathological’ GIRD is suggested to be present when shoulder IR
loss is significantly greater than ERG, resulting in a loss of TROM symmetricity between
the two shoulders. This important correlation has been demonstrated in a study of baseball
athletes where a change in side-to-side TROM of more than 5° was associated with a 2.5
times higher risk of sustaining shoulder injuries; additionally, it has been suggested that a
side-to-side TROM of more than 5° is linked with posterior shoulder soft tissue restrictions,
posterior shoulder capsule thickening and posterior rotator cuff muscle stiffness (Cieminski
et al., 2015; Harryman et al., 1990; Thomas et al., 2011; Wang et al., 2000).
When the decreased IR ROM is considered on its own without simultaneous ERG,
pathological GIRDs have been suggested to be a difference of more than 18°–20° compared
with the opposite side, while a GIRD of less than 18°–20° (which is usually associated with
a side-to-side TROM of less than 5°) is considered anatomical. Burkhart, Morgan, and
Kibler (2003) suggested a slightly higher threshold of 20°–25° above which GIRD may be
pathological. Interestingly, GIRDs greater than 20° were recently shown to be associated with
reduced isokinetic shoulder strength in a population of baseball players (Lee, Kim, Song,
Kim, & Woo, 2015). From the reviewed literature, it appears that GIRD of the dominant
shoulder in volleyball players may not be sufficiently marked to cause shoulder pain/injury.

4.2.3. Adaptations in shoulder musculature

Shoulder rotator muscle imbalance has been used to describe an unbalanced force couple
that occurs between agonist and antagonist muscles (internal and external rotators) in the
dominant shoulder or to describe the relative weakness of a specific muscle group between
the dominant and non-dominant sides. It is quantified by the strength ratio of ER/IR. ER
is important for acceleration in the cocking phase and for effective deceleration and con-
trol following the acceleration phase. Additionally, normal shoulder function is thought
to require equal strength of ER and IR and a ratio of <1 is thought to be associated with
shoulder injury, however, some authors proposed that ER strength of at least two thirds of
IR strength is sufficient to provide muscular balance (Ellenbecker & Davies, 2000; Wang &
Cochrane, 2001). In volleyball, the imbalance is thought to be predominantly secondary
 Sports Biomechanics  15

to increased strength of IR due to regular training, with unchanged ER strength (Baltaci

& Tunay, 2004).
An asymptomatic overhead athlete should have stronger internal rotators on the dom-
inant vs. the non-dominant side by 3–9%, while external rotators may be weaker in the
dominant shoulder by 0–14%; asymmetry beyond these thresholds is thought to be asso-
ciated with shoulder pathology (Reinold & Gill, 2010).

4.3. Recommendations
Based on the evidence, we recommend strengthening of the shoulder external rotators
(especially eccentric) in volleyball players with and without shoulder pain; this may be
used both as a prevention strategy and as part of the management plan for shoulder pain
and established shoulder overuse injuries in volleyball. Simultaneously, core strengthening
has also been suggested to be essential as the player may be overloading his/her shoulder
through altered biomechanics trying to compensate for inadequate power deriving from
the core muscles in the early phases of the throwing motion (Reeser, Verhagen, Briner,
Askeland, & Bahr, 2006). This speculation primarily derives from a study of overhead ath-
letes other than volleyball players, where athletes with shoulder pain appeared to have
weak core musculature; similar studies in volleyball, however, have not been performed
(Burkhart et al., 2003).
Equally, correct spiking and serving techniques should be taught and adopted for all
the participating shoulder anatomical structures to be used as safely and efficiently as pos-
sible and training sessions should be optimised to minimise unnecessary loads on the
players’ shoulders while maintaining performance. In this regard, a recent biomechanical
study found that the ‘backswing’ style spike technique might be both more effective (5%
greater spike speed) and safer for the shoulder as it reduces maximal shoulder flexion by
10° compared with the traditional ‘elevation’ style technique (Seminati, Marzari, Vacondio,
& Minetti, 2015).
Finally, shoulder stretching and joint mobilisations should be encouraged in all volleyball
athletes to improve and prevent capsular tightness which may also predispose to shoulder
injury. Although this has not been thoroughly investigated in volleyball, Burkhart et al.
(2003) showed a dramatic reduction in shoulder complaints in tennis and baseball players
through a consistent season-long stretching programme that aimed to minimise posterior
capsule tightness and hence GIRD.

5. Conclusion
Based on the reviewed literature, the dominant shoulder of volleyball players appears to
display a GIRD and a possible ERG compared with the non-dominant side, as well as mus-
cular imbalance, which is likely to predispose to shoulder overuse injuries. Strengthening
of the shoulder external rotators may be used in combination with core strengthening,
shoulder stretching, joint mobilisations and technique optimisation as part of both injury
prevention and management plans.
For clearer associations to be made on the exact nature, aetiology and purpose of dom-
inant shoulder adaptations in volleyball players, well-designed biomechanical studies with
comparative designs (painful vs. asymptomatic shoulders) that will focus on both the
16 D. Challoumas et al.

kinematics and kinetics of the shoulder are warranted that will provide further insights
into the unanswered questions. For more definitive conclusions with regard to shoulder
pathology, prospective studies with large populations should be conducted in the future
that will follow-up initially asymptomatic athletes that later develop shoulder pain/inju-
ries, aiming to identify risk factors for shoulder pathology; this will greatly facilitate the
development of strategies for performance optimisation and injury prevention in volleyball.

ORCiD
Dimitrios Challoumas http://orcid.org/0000-0003-4640-6439

References
Alfredson, H., Pietilä, T., & Lorentzon, R. (1998). Concentric and eccentric shoulder and elbow muscle
strength in female volleyball players and non-active females. Scandinavian Journal of Medicine &
Science in Sports, 8, 265–270.
Baltaci, G., & Tunay, V. B. (2004). Isokinetic performance at diagonal pattern and shoulder mobility
in elite overhead athletes. Scandinavian Journal of Medicine & Science in Sports, 14, 231–238.
Borsa, P. A., Laudner, K. G., & Sauers, E. L. (2008). Mobility and stability adaptations in the shoulder
of the overhead athlete: A theoretical and evidence-based perspective. Sports Medicine, 38, 17–36.
Burkhart, S. S., Morgan, C. D., & Kibler, W. B. (2003). The disabled throwing shoulder: Spectrum of
pathology part I: Pathoanatomy and biomechanics. Arthroscopy, 19, 404–420.
Centre for Evidence-Based Medicine. (2009, March). Oxford centre for evidence-based medicine –
Levels of evidence. Retrieved October 10, 2015, from http://www.cebm.net/oxford-centre-evidence-
based-medicine-levels-evidence-march-2009/
Chung, C. K., Choi, K. J., & Shin, I. (1990). Three-dimensional kinematics of the striking arm during
the volleyball spike. Korean Journal of Sports Science, 2, 124–151.
Cieminski, C. J., Klaers, H., Kelly, S. M., Stelzmiller, M. R., Nawrocki, T. J., & Indrelie, A. J. (2015). Total
arc of motion in the sidelying position: Evidence for a new method to assess glenohumeral internal
rotation deficit in overhead athletes. International Journal of Sports Physical Therapy, 10, 319–331.
Coleman, S. G., Benham, A. S., & Northcott, S. R. (1993). A three-dimensional cinematographical
analysis of the volleyball spike. Journal of Sports Sciences, 11, 295–302.
Crockett, H. C., Gross, L. B., & Wilk, K. (2002). Osseous adaptation and range of motion at the
glenohumeral joint in professional baseball players. American Journal of Sports Medicine, 30, 20–26.
Dwelly, P. M., Tripp, B. L., Tripp, P. A., Eberman, L. E., & Gorin, S. (2009). Glenohumeral rotational
range of motion in collegiate overhead-throwing athletes during an athletic season. Journal of
Athletic Training, 44, 611–616.
Ellenbecker, T. S., Bailie, D. S., Mattalino, A. J., Carfagno, D. G., Wolff, M. W., Brown, S. W., &
Kulikowich, J. M. (2002). Intrarater and interrater reliability of a manual technique to assess
anterior humeral head translation of the glenohumeral joint. Journal of Shoulder & Elbow Surgery,
11, 470–475.
Ellenbecker, T. S., & Davies, G. J. (2000). The application of isokinetics in testing and rehabilitation
of the shoulder complex. Journal of Athletic Training, 35, 338–350.
Escamilla, R. F., & Andrews, J. R. (2009). Shoulder muscle recruitment patterns and related
biomechanics during upper extremity sports. Sports Medicine, 39, 569–590.
Ferretti, A., Cerullo, G., & Russo, G. (1987). Suprascapular neuropathy in volleyball players. Journal
of Bone and Joint Surgery (American Volume), 69, 260–263.
Forthomme, B., Wieczorek, V., Frisch, A., Crielaard, J. M., & Croisier, J. L. (2013). Shoulder pain
among high-level volleyball players and preseason features. Medicine & Science in Sports & Exercise,
45, 1852–1860.
Hadzic, C., Sattler, T., Veselko, M., Markovic, G., & Dervisevic, E. (2014). Strength asymmetry of the
shoulders in elite volleyball players. Journal of Athletic Training, 49, 338–344.
 Sports Biomechanics  17

Harryman, D. T., 2nd, Sidles, J. A., Clarkes, J. M., McQuade, K. J., Gibb, T. D., & Matsen, F. A., 3rd
(1990). Translation of the humeral head on the glenoid with passive glenohumeral motion. Journal
of Bone and Joint Surgery (American Volume), 72, 1334–1343.
Hibberd, E. E., Oyama, S., & Myers, J. B. (2014). Increase in humeral retrotorsion accounts for age-
related increase in glenohumeral internal rotation deficit in youth and adolescent baseball players.
American Journal of Sports Medicine, 42, 851–858.
Holzgraefe, M., Kukowski, B., & Eggert, S. (1994). Prevalence of latent and manifest suprascapular
neuropathy in high-performance volleyball players. British Journal of Sports Medicine, 28, 177–179.
Kugler, A., Kruger-Franke, M., Reininger, S., Trouillier, H. H., & Rosemeyer, B. (1996). Muscular
imbalance and shoulder pain in volleyball attackers. British Journal of Sports Medicine, 30, 256–259.
Lajtai, G., Pfirrmann, C. W., Aitzetmuller, T., Pirkl, C., Gerber, C., & Jost, B. (2009). The shoulders of
professional beach volleyball players: High prevalence of infraspinatus muscle atrophy. American
Journal of Sports Medicine, 37, 1375–1383.
Lajtai, G., Wieser, K., Ofner, M., Raimann, G., Aitzetmuller, G., & Jost, B. (2012). Electromyography
and nerve conduction velocity for the evaluation of the infraspinatus muscle and the suprascapular
nerve in professional beach volleyball players. American Journal of Sports Medicine, 40, 2303–2308.
Lee, J., Kim, L. N., Song, H., Kim, S., & Woo, S. (2015). The effect of glenohumeral internal rotation
deficit on the isokinetic strength, pain and quality of life in male high school volleyball players.
Annals of Rehabilitation Medicine, 39, 183–190.
Manske, R., Wilk, K. E., Davies, G., Ellenbecker, T., & Reinold, M. (2013). Glenohumeral motion
deficits: Friend or foe? International Journal of Sports Physical Therapy, 8, 537–553.
Martelli, G., Ciccarone, G., Grazzini, G., Signorini, M., & Urgelli, S. (2013). Isometric evaluation of
rotator cuff muscles in volleyball athletes. Journal of Sports Medicine & Physical Fitness, 53, 283–288.
Meister, K., Day, T., Horodyski, M., Kaminski, T. W., Wasik, M. P., & Tillman, S. (2005). Rotational
motion changes in the glenohumeral joint of the adolescent/little league baseball player. American
Journal of Sports Medicine, 33, 693–698.
Myers, J. B., Laudner, K. G., Pasquale, M. R., Bradley, J. P., & Lephart, S. M. (2005). Scapular position
and orientation in throwing athletes. American Journal of Sports Medicine, 33, 263–271.
Noffal, G. J. (2003). Isokinetic eccentric-to-concentric strength ratios of the shoulder rotator muscles
in throwers and nonthrowers. American Journal of Sports Medicine, 31, 537–541.
Osbahr, D. C., Cannon, D. L., & Speer, K. P. (2002). Retroversion of the humerus in the throwing
shoulder of college baseball pitchers. American Journal of Sports Medicine, 20, 347–353.
Pieper, H. G. (1998). Humeral torsion in the throwing arm of handball players. American Journal of
Sports Medicine, 26, 247–253.
Reeser, J. C., Fleisig, G. S., Bolt, B., & Ruan, M. (2010a). Upper limb biomechanics during the volleyball
serve and spike. Sports Health, 2, 368–374.
Reeser, J. C., Joy, E. A., Porucznik, C. A., Berg, R. L., Colliver, E. B., & Willick, S. E. (2010b). Risk factors
for volleyball-related shoulder pain and dysfunction. Physical Medicine & Rehabilitation, 2, 27–36.
Reeser, J. C., Verhagen, E., Briner, W. W., Askeland, T. I., & Bahr, R. (2006). Strategies for the prevention
of volleyball related injuries. British Journal of Sports Medicine, 40, 594–600.
Reinold, M. M., & Gill, T. J. (2010). Current concepts in the evaluation and treatment of the shoulder
in overhead-throwing athletes, part 1: Physical characteristics and clinical examination. Sports
Health, 2, 39–50.
Rokito, A. S., Jobe, F. W., Pink, M. M., Perry, J., & Brault, J. (1998). Electromyographic analysis of
shoulder function during the volleyball serve and spike. Journal of Shoulder & Elbow Surgery, 7,
256–263.
Saccol, M. F., Almeida, G. P. L., & de Souza, V. L. (2015). Anatomical glenohumeral internal rotation
deficit and symmetric rotational strength in male and female young beach volleyball players.
Journal of Electromyography & Kinesiology, 29, 121–125.
Schwab, L. M., & Blanch, P. (2009). Humeral torsion and passive shoulder range in elite volleyball
players. Physical Therapy in Sport, 10, 51–56.
Seminati, E., Marzari, A., Vacondio, O., & Minetti, A. E. (2015). Shoulder 3D range of motion and
humerus rotation in two volleyball spike techniques: Injury prevention and performance. Sports
Biomechanics, 14, 216–231.
18 D. Challoumas et al.

Seminati, E., & Minetti, A. E. (2013). Overuse in volleyball training/practice: A review on shoulder
and spine-related injuries. European Journal of Sport Science, 13, 732–743.
Seroyer, S. T., Nho, S. J., Bach, B. R., Bush-Joseph, C. A., Nicholson, G. P., & Romeo, A. A. (2009).
Shoulder pain in the overhead throwing athlete. Sports Health, 1, 108–120.
Shanley, E., Rauh, M. J., Michener, L. A., Ellenbecker, T. S., Garrison, J. C., & Thigpen, C. A. (2011).
Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school
softball and baseball players. American Journal of Sports Medicine, 39, 1997–2006.
Stickley, C. D., Hetzler, R. K., Freemyer, B. G., & Kimura, I. F. (2008). Isokinetic peak torque ratios
and shoulder injury history in adolescent female volleyball athletes. Journal of Athletic Training,
43, 571–577.
Thomas, S. J., Swanik, C. B., Higginson, J. S., Kaminski, T. W., Swanik, K. A., Bartolozzi, A. R., …
Nazarian, L. N. (2011). A bilateral comparison of posterior capsule thickness and its correlation
with glenohumeral range of motion and scapular upward rotation in collegiate baseball players.
Journal of Shoulder & Elbow Surgery, 20, 708–716.
Tonin, K., Stražar, K., Burger, H., & Vidmar, G. (2013). Adaptive changes in the dominant shoulders
of female professional overhead athletes: mutual association and relation to shoulder injury.
International Journal of Rehabilitation Research, 36, 228–235.
van Cingel, R., Kleinrensink, G., Stoeckart, R., Aufdemkampe, G., & Kuipers, H. (2006). Strength
values of shoulder internal and external rotators in elite volleyball players. Journal of Sport
Rehabilitation, 15, 236–244.
von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., & Vandenbroucke, J. C. (2007).
Strengthening the reporting of observational studies in epidemiology (STROBE) statement:
Guidelines for reporting observational studies. The Lancet, 370, 1453–1457.
Wagner, H., Pfusterschmied, J., Tilp, M., Landlinger, J., von Duvillard, S. P., & Muller, E. (2012).
Upper-body kinematics in team-handball throw, tennis serve, and volleyball spike. Scandinavian
Journal of Medicine & Science in Sports, 24, 345–354.
Wang, H. K., & Cochrane, T. (2001). Mobility impairment, muscle imbalance, muscle weakness,
scapular asymmetry and shoulder injury in elite volleyball athletes. Journal of Sports Medicine &
Physical Fitness, 41, 403–410.
Wang, H. K., Macfarlane, A., & Cochrane, T. (2000). Isokinetic performance and shoulder mobility
in elite volleyball athletes from the United Kingdom. British Journal of Sports Medicine, 34, 39–43.
Wilk, K. E., Macrina, L. C., Fleisig, G. S., Aune, K. T., Porterfield, R. A., Harker, P., … Andrews,
J. R. (2015). Deficits in glenohumeral passive range of motion increase risk of shoulder injury
in professional baseball pitchers: A prospective study. American Journal of Sports Medicine, 43,
2379–2385.
Witvrouw, E., Cools, A., Lysens, R., Cambier, D., Vanderstraeten, G., Victor, J., … Walravens, M.
(2000). Suprascapular neuropathy in volleyball players. British Journal of Sports Medicine, 34,
174–180.
Yildiz, Y., Aydin, T., Sekir, U., Kiralp, M. Z., Hazneci, B., & Kalyon, T. A. (2006). Shoulder terminal
range eccentric antagonist/concentric agonist strength ratios in overhead athletes. Scandinavian
Journal of Medicine & Science in Sports, 16, 174–180.