PERSISTENT OVERUSE INJURIES IN THE OVERHEAD ATHLETE

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Kellie A. Sullivan

Research Advisor, Dr. Thomas F. West
California, Pennsylvania
2012

ii

iii

ACKNOWLEDGEMENTS
I would like to take this time to thank all of the
individuals that helped make this year possible. First and
foremost, I would like to thank my parents for supporting
me and guiding me throughout all my decisions. Cait and
Coll, thank you for always pushing me to be the best that I
can be.
I would like to thank my committee chair, Dr. Tom
West, and my committee members Mr. Adam Annaccone and Mr.
Marc Federico for all your time and effort you put in
throughout this process. I value the knowledge they shared
with me and I am grateful to have been afforded such great
mentors.
Thank you to all the members of the athletic
department at Washington and Jefferson College for a great
experience this past year. I would particularly like to
thank Mike and Mark Lesako for their guidance and learning
experiences that I will continue to utilize in my future.
Your help has greatly been appreciated.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES
INTRODUCTION
METHODS

. . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . 7

Research Design
Subjects

. . . . . . . . . . . . . . 7

. . . . . . . . . . . . . . . . . 8

Preliminary Research. . . . . . . . . . . . . 9
Instruments . . . . . . . . . . . . . . . . 9
Procedures

. . . . . . . . . . . . . . . . 10

Hypotheses

. . . . . . . . . . . . . . . . 11

Data Analysis
RESULTS

. . . . . . . . . . . . . . . 12

. . . . . . . . . . . . . . . . . . 13

Demographic Information
Hypothesis Testing

. . . . . . . . . . . 13

. . . . . . . . . . . . . 14

Additional Findings . . . . . . . . . . . . . 16
DISCUSSION . . . . . . . . . . . . . . . . . 21
Discussion of Results . . . . . . . . . . . . 21
Conclusion

. . . . . . . . . . . . . . . . 27

Recommendations

. . . . . . . . . . . . . . 28

REFERENCES . . . . . . . . . . . . . . . . . 30

v
APPENDICES . . . . . . . . . . . . . . . . . 31
APPENDIX A: Review of Literature

. . . . . . . . 32

Introduction . . . . . . . . . . . . . . . . 33
Anatomy of the Shoulder

. . . . . . . . . . . 34

Risk Factors . . . . . . . . . . . . . . . . 37
Mechanical Errors . . . . . . . . . . . . 38
Muscular Weakness and Imbalances . . . . . 43
Flexibility . . . . . . . . . . . . . . . 45
Prevention of Overhead Overuse Injuries
Preseason Programs .

. . . . . 48

. . . . . . . . . . 49

Improving Imbalances and Flexibility .

. . 54

Treatment of Overhead Overuse Injuries . . . . 59
Summary . . . . . . . . . . . . . . . . . . 64
APPENDIX B: The Problem . . . . . . . . . . . . 67
Statement of the Problem . . . . . . . . . . . 68
Definition of Terms . . . . . . . . . . . . . 68
Basic Assumptions . . . . . . . . . . . . . . 70
Limitations of the Study . . . . . . . . . . . 70
Significance of the Study

. . . . . . . . . . 70

APPENDIX C: Additional Methods .

. . . . . . . . 72

Overhead Overuse Injury Survey (C1)

. . . . . . 73

IRB: California University of Pennsylvania (C2) . . 135
Cover Letter (C3) . . . . . . . . . . . . . . 150

vi
REFFERENCES . . . . . . . . . . . . . . . . . 152
ABSTRACT . . . . . . . . . . . . . . . . . . 156

vii

LIST OF TABLES
Table

Title

Page

1

Sports Participation

2

Injury Groups Mean Number of Training
Exercises . . . . . . . . . . . . . . 15

3

Injury Groups Mean Number of Rehabilitation
Exercises . . . . . . . . . . . . . . 16

4

Injury Status

5

Type of Injury . . . . . . . . . . . . 17

6

Length of Injury . . . . . . . . . . . 18

7

Medical Professionals Providing Treatment . 18

8

Athlete’s Participation in Training
by Type . . . . . . . . . . . . . . . 19

9

Injury Groups Mean Number of Preseason Exercises
Performed In Each Training Category
. . . 20

10

Injury Groups Mean Number of
Rehabilitation Exercises Performed In Each
Training Category . . . . . . . . . . . 20

. . . . . . . . . 14

. . . . . . . . . . . . 17

1

INTRODUCTION

Constant overhead motion in an athlete can lead to
many biomechanical errors, range of motion deficits and
muscular imbalances; further predisposing an athlete to
injury. Many overhead athletes injure their shoulder season
after season, creating an unstable shoulder for the rest of
their careers. It is possible that improper management of
these injuries in their initial stages could have
contributed to the long-term nature of conditions, such as
rotator cuff tendonitis, bicipital tendonitis, shoulder
instability and impingement syndrome.
The purpose of this study is to recognize the
persistent overuse injuries occurring in the overhead
athlete and examine the effective ways to treat and prevent
these injuries. Specifically this study will examine the
time of the initial onset of these overuse injuries and the
initial treatment rendered.
In a study examining the incidence of shoulder
injuries among collegiate overhead athletes, thirty-percent
of intercollegiate overhead athletes experienced a shoulder
injury at some point in their career.1 Volleyball players

2
experienced the highest incidence of injury, having a 43%
incidence rate of shoulder injuries. When looking at
specific injuries, subacromial impingement syndrome and
rotator cuff tendonitis account for 27% and 24% of the
total shoulder injuries. Significantly higher incidence
rates were found for baseball players diagnosed with
subacromial impingement, softball players diagnosed with
subacromial impingement and rotator cuff tendonitis and
swimmers diagnosed with subacromial impingement, rotator
cuff tendonitis, and bicipital tendonitis. No significant
differences were reported for the incidence rates of
shoulder disorders among volleyball players. These results
show that overhead athletes are suffering from a variety of
overuse injuries based on the demands of the sport. Due to
the high incidence of overuse shoulder injuries in the
overhead athlete, it is important to understand the
effective ways to prevent and treat these injuries.
For many years, several different stretching
techniques have been used for preventative treatment before
and after performing overhead motions in an attempt to
lengthen the soft tissue,2 allowing the shoulder complex to
move through a full range of motion. Laudner et al2 and
Oyama et al3 examined the effects of the sleeper stretch on
shoulder range of motion. Laudner et al2 found that the

3
side-lying sleeper stretch produced a 2.3° increase in
posterior shoulder motion and a 3.1° increase in internal
rotation for the group containing baseball players. Oyama
et al3 found that the sleeper stretch at 45°, sleeper
stretch at 90° and the horizontal cross-arm stretch
produced a 4.3° increase in internal rotation and a 3.4° in
horizontal adduction. The increase in range of motion
produced through stretching will allow the athlete to
participate in the sports specific movements required in
their sport. If the athlete is not able to move freely
throughout the full range of motion, it can lead to more
force being placed on the shoulder throughout overhead
movements.2,3 Decreasing the amount of force being placed on
the dynamic stabilizers of the shoulder can ultimately
decrease the athletes risk of injury.
Van de Velde et al4 examined the effects of a sports
specific, twelve week training program on muscular
strength, muscular endurance, side-to-side differences in
strength and protractor/retractor ratio. The 18 swimmers
were split into 2 groups based on which program they would
complete; a muscular endurance or muscular strength
training program. These programs consisted of exercises
consisting of: scapular dynamic hug, scapular protraction,
elbow push-ups and prone bilateral glenohumeral horizontal

4
abduction with scapular retraction. The results showed that
a 12-week swimming training program produced an increase in
muscular strength, improved protractor/retractor ratio and
improved side-to-side muscular strength. However, the
program did not produce a change in muscular endurance.
Myers et al5 also examined the effects of sports
specific baseball program by studying the effects of 12
commonly used resistance tubing exercises on activating the
shoulder muscles vital to throwing. The 15 participants
randomly performed the 12 resisting tubing exercises while
the muscle activation of the subscapularis, supraspinatus,
teres minor, rhomboid major pectoralis major, anterior
deltoid, middle deltoid, latissimus dorsi, serratus
anterior, biceps brachii, triceps brachii, lower trapezius,
and infraspinatus muscles were tested. The results showed
that seven exercises; external rotation at 90°of abduction,
throwing deceleration, humeral flexion, humeral extension,
low scapular rows, throwing acceleration, and scapular
punches, resulted in the highest level of muscle
activation. Each of these seven exercises exhibited
moderate activation in the rotator cuff, primary humeral
movers and scapular stabilizers. The movements during
overhead throwing requires the coordination of the rotator
cuff, scapular stabilizers and humeral movers; making it

5
important to perform exercises with high activity in these
muscles.
It is also important to perform exercises with high
activity of the rotator cuff, scapular muscles and deltoid
throughout the rehabilitation process in order for the
muscles to return to their original state before
competition. Reinold et al6 examined the electromyographic
activity of the supraspinatus, middle deltoid and posterior
deltoid during the “empty-can”, “full-can” and “prone full
can” exercises in 22 asymptomatic subjects. The results
showed no statistical differences between the exercises for
the supraspinatus. However, the middle deltoid showed
significantly greater activity during the “empty-can” and
“prone full-can” exercises. The “prone full-can” exercise
produced the greatest amount of activity in the posterior
deltoid. Even though each of these exercises were able to
produce activity in the posterior deltoid, middle deltoid
and supraspinatus, in certain injuries some of these
exercises should not be used. In patients with impingement
syndrome, the “empty-can” exercise decreases the
subacromial space, predisposing the tendons underneath the
coracoacromial ligament to impingement.7,8 In the patient
population with impingement syndrome, it would be more
appropriate to use the “full-can” exercise.8

6
The purpose of this study is to examine and
understand the persistent overuse injuries occurring in the
overhead athlete. Many athletes participating in overhead
sports throughout their childhood and into collegiate
athletics are faced with numerous overhead injuries.
Many of the athletes are entering college already
having shoulder instabilities and chronic injuries,
ultimately persisting throughout their collegiate careers.
Since these athletes have been playing with an injury
season after season, it is difficult to correct the
anatomical and functional adaptations. Instead, the athlete
is often managed for pain, but is still playing with a
shoulder that is not performing at the best of their
ability. It is important as health care providers to
understand the risk factors and preventative measures
associated with common overuse injuries in order to
understand ways to treat and prevent these injuries at a
young age. It will also be useful to determine when the
initial onset of these conditions occur as that may be the
best time for intervention to prevent long term, chronic
dysfunction.

7

METHODS

The primary purpose of this study was to examine the
ways in which persistent overuse injuries in the overhead
athlete are prevented and treated. This research sought to
understand the risk factors, treatment protocols and
preventative measures associated with these overuse
injuries in hopes of reducing the number of injuries
occurring throughout their careers. This section will
include the following subsections:

research design,

participants, instruments, procedures, hypotheses, and data
analysis.

Research Design

This research is a retrospective, descriptive study
with the data collected using a survey. The independent
variable was the athletes’ injury group. This condition had
three levels consisting of current history, previous
history and no history. The current history group consisted
of athletes currently suffering from impingement syndrome,
bicipital tendonitis, rotator cuff tendonitis or shoulder

8
instability and had the injury for more than two years. The
previous history group was made up of athletes not
currently suffering from an overuse shoulder injury but had
previously suffered from impingement syndrome, bicipital
tendonitis, rotator cuff tendonitis or shoulder instability
for more than two years. The no history group consisted of
athletes that are not currently injured and had no history
of an overhead overuse injury. The dependent variables are
the number of rehabilitation exercises performed and the
number of training exercises performed.

Participants

The survey was mailed out electronically to 4
colleges, composed of approximately 250 Division II and
Division III collegiate overhead athletes.

The

participants consisted of collegiate athletes that are
members of the baseball, softball, volleyball or swim team.
Informed consent was implied by completing and returning of
the survey.

9

Preliminary Research

A review of the survey was be completed by a panel of
experts consisting of three Certified Athletic Trainers.
The panel made suggestions and improvements on the question
clarity, grammar and validity of the survey.
Following Institutional Review Board (IRB) approval, a
pilot study was conducted to confirm the reliability of the
survey. The survey was administered to 15 members of the
women’s volleyball team at Washington and Jefferson
College. After one week, these athletes were surveyed a
second time and reliability coefficients were calculated
for each question. Of the 15 athletes, 9 completed the
survey both times and their data was used in the
reliability analysis. The questions and overall survey
displayed a relativity score of .30 or higher, indicating a
moderate to strong correlation.

Instruments

The Overhead Overuse Injury Survey (Appendix C1) was
used in this study and was distributed to the athletes
using www.surveymonkey.com. This survey was developed to

10
determine the current injury status of these athletes and
how the treatment of previous injuries and preventative
measures has affected their current injury status. The
survey contained 129 questions regarding the type of
overuse injuries encountered, sport in which the injury
occurred, preseason-training programs, current injury
status and treatment protocol associated with that injury.

Procedure

The researcher received approval by the California
University of Pennsylvania’s Institutional Review Board for
Protection of Human Subjects (Appendix C2) before
conducting research. Upon approval from the IRB, a direct
link to the survey was created using www.surveymonkey.com.
A cover letter (Appendix C3) was sent to the overhead
athletes explaining the purpose of the study. The email
containing the cover letter also contained a link giving
the athlete direct access to the survey.
Before distributing the survey, the researcher
contacted the Athletic Directors at the chosen Division II
and Division III institutions, requesting that the survey
be sent to the baseball, softball, volleyball and swimming
teams at their institution. The researcher allowed ample

11
time to complete the survey. The athletes received a second
email 7-10 days after the initial email as a reminder to
complete the survey.
Surveys were completed via the internet and upon
closing of the survey, the researcher downloaded the data
as a password protected spreadsheet file for manipulation
and analysis.

Hypotheses

The following hypotheses were developed based previous
research and the researcher’s intuition after a review of
the literature.
1.

There will be a difference in the number of
training exercises regularly performed between
the current history, previous history and no
history groups.

2.

The previous history group will have performed
more rehabilitation exercises when compared to
the current history group.

12
Data Analysis

1. A one-way ANOVA test was used to test the difference
in the number of training exercises performed in all
three injury groups.

2. An independent T-test was used to compare the number
of rehabilitation exercises performed in the current
history and previous history groups.

13

RESULTS

Demographic Information

Subjects that voluntarily participated in this survey
consisted of collegiate athletes on the baseball, softball,
volleyball and swim team from Division II (n=3)and Division
III (n=1)schools in Pennsylvania and Massachusetts. The
survey was electronically sent out to 250 collegiate
athletes. A total of 59 student athletes completed the
survey, resulting in a return rate of 23%. Forty-eight
participants were female (81.4%) and eleven were male
(18.6%).
The largest percent of athletes (96.6%) reported to be
within the 18-25 age group and the lowest percent of
athletes (3.4%) reported to be 25 and older. Table 1
represents the athletes’ sports participation previous to
high school, throughout high school and their current
participation in college. The majority of the participants
in this survey are currently participating in softball
(n=23) and swimming (n=21).

14

Table 1. Sports Participation
Sport
Baseball
Softball
Volleyball
Swimming
Football
Basketball
Soccer
Lacrosse
Field Hockey
Ice Hockey
Cross Country
Track
Tennis
Golf
Gymnastics
Water Polo

Previous to
High School
8
25
22
28
5
29
37
5
5
0
3
11
3
3
3
2

High School
5
24
20
22
1
15
8
3
2
2
1
9
0
2
0
3

College
4
23
9
21
0
0
0
0
1
0
0
0
0
0
0
0

Hypothesis Testing

All hypotheses were tested at an alpha level of .05.
Hypothesis 1: There will be a difference in the number
of training exercises regularly performed between the
current history, previous history or no history injury
groups.
The mean number of training exercises performed by the
current history, previous history and no history group were
compared using a one-way ANOVA. No significant difference

15
was found (F(2,39) = .259, p> .05). The athletes from the
three different injury groups did not differ significantly
in the number of training exercises performed. Athletes in
the current history group performed a mean of 23.1
(sd=7.99) exercises. Athletes in the previous history group
performed a mean of 26.4 (sd=7.50) exercises. Athletes in
the no history group performed a mean of 20.3 (sd=9.90)
exercises.

Table 2. Injury Groups Mean Number of Training Exercises
Injury Status
Current History
Previous History
No History

N
12
8
33

Mean
23.1
26.4
20.3

SD
7.99
7.50
9.90

Hypothesis 2: The previous history group will have
performed a higher number of rehabilitation exercises when
compared to the current history group.
An independent-samples t test was calculated comparing
the mean rehabilitation exercises performed by participants
who currently have an injury to the mean exercises
performed by participants who had a previous injury. No
significant difference was found (t(13) = .942, p> .05).
The mean number of exercises performed by the currently
injured group (m=22.3, sd = 12.07) was not significantly

16
different from the mean of the previously injured group (m=
16.8, sd= 6.46).

Table 3. Injury Groups Mean Number of Rehabilitation
Exercises
Injury Status
Current History
Previous History

N
10
5

Mean (SD)
22.3 (12.1)
16.8 (6.5)

t
.942

p
.363

Additional Findings

Due to the descriptive nature of this study,
additional tests were performed using the data found in the
preseason training, rehabilitation and injury status
portion of the survey.
Since one of the major purposes of this study was to
examine the major overhead overuse injuries and the initial
onset of these injuries, further tests were conducted to
examine these factors. The athletes were asked several
questions regarding injury status, type of injury and
length of injury. The number of athletes with a current
injury, previous injury and those with no history of injury
can be found in Table 4.

17
Table 4. Injury Status
Injury Status
Current History
Previous History
No History

Frequency
12
8
33

Percent
22.6
15.1
62.3

From these injury groups we were able to analyze the
number of athletes who have previously or are currently
suffering from bicipital tendonitis, rotator cuff
tendonitis, impingement syndrome and shoulder instability.
Table 5 represents the frequencies of these injuries. Of
the 20 athletes that had reported having an injury at some
point during their career, 60% suffered from rotator cuff
tendonitis, 35% bicipital tendonitis, 35% shoulder
instability and 25% impingement syndrome. Table 6 includes
the initial onset of these injuries by looking at the
length of injury. Totals equal over 100% as subjects were
allowed to choose multiple injuries.
Table 5. Type of Injury
Injury
Bicipital Tendonitis
Rotator Cuff Tendonitis
Impingement Syndrome
Shoulder Instability

Frequency
7
12
5
7

Percent
35
60
25
35

18
Table 6. Length of Injury
Years
1-2
3-5
5-7
7-10
10 or more

Frequency
5
5
3
1
1

Percent
40
35
15
5
5

Table 7 represents the medical professionals that
provided treatment to these athletes following their
injuries.

Totals equal over 100% as subjects were allowed

to choose multiple providers.
Table 7. Medical Professionals Providing Treatment
Medical
Professional
Medical Doctor
Nurse Practitioner
Chiropractor
Athletic Trainer
Physical Therapist

Frequency

Percent

10
0
1
8
13

71.4
0
7.1
57.1
92.9

Even though the hypothesis testing examined the mean
number of training exercises performed between the current
history, previous history and no history injury groups;
further tests were performed examining at mean number of
exercises performed for each individual training type. The
specific type of training exercises performed as a part of
preseason training, as well as the athletes’ rehabilitation
program are summarized in Table 8. Totals equal over 100%
as subjects were allowed to choose multiple training types.

19

Table 8. Athlete’s Participation in Training by Type
Training
Program

N

Weight
Training

Plyo.

Endur.

Speed

Agility

Core

Stretch

Preseason

47

45
(95.7%)

25
29
(53.2%) (61.7%)

Rehab

17

12
(70.6%)

4
4
3
4
3
17
(23.5%) (23.5%) (17.6%) (23.5%) (17.6%)(100%)

29
28
36
44
(61.7%) (59.6%) (76.6%)(93.6%)

The specific type of exercises were reviewed further
by analyzing the mean number of exercises performed in each
category of training for the current history, previous
history and no history group. Table 9 represents the mean
number of preseason training exercises performed in each
training category for the current history, previous history
and no history groups. The mean number of rehabilitation
exercises performed in each training category for the
current history and previous history is presented in Table
10.

20
Table 9. Injury Groups Mean Number of Preseason Exercises
Performed In Each Training Category
Injury
Status
Current
History
Previous
History
No History

Theraband
5.7

Weight
Training
5.1

Medicine
Ball
2.8

Core

Stretching

6.9

2.7

5.6

5.6

4.3

7.6

3.3

4.9

4.1

2.9

6.0

1.9

Table 10. Injury Groups Mean Number of Rehabilitation
Exercises Performed In Each Training Category
Injury
Status
Current
History
Previous
History

Theraband
8.6
6.0

Weight
Training
4.4
4.4

Medicine
Ball
1.5
1.2

Core

Stretching

3.4

3.4

1.8

3.0

21
DISCUSSION

The discussion of findings will be broken up into the
following three subsections: 1) Discussion of Results, 2)
Conclusions and 3) Recommendations.

Discussion of Results

This study focused on the persistent overuse injuries
occurring in the overhead athlete and the effective ways to
prevent and treat these injuries. Specifically, the
researcher examined the initial onset of these injuries and
how they were initially managed. The researcher examined
the athletes’ preseason and rehabilitation training
programs to see if their training regimen potentially
affected their injury status.
The first hypothesis stated that there will be a
difference in the number of training exercises performed
between the current history, previous history and no
history injury groups. As shown in Table 2, the previous
history group performed the greatest number of exercises
(26.4), followed by the current history group (23.1) and
lastly the no history group (20.3). However, the
statistical analysis for this study did not find a

22
significant difference between the number of exercises
performed between the current history, previous history and
no history injury groups. This is due to the large
variability of exercises.
The assumption that there will be a difference in the
number of training exercises performed between each injury
group was based on previous research supporting preseason
training programs for athletes participating in baseball,
softball, volleyball and swimming. Van de Velde et al4 and
Myers et al5 found that the participation in a sports
specific training program produced an increase in overall
muscular strength4, while resulting in moderate activation
of the rotator cuff, humeral movers and scapular
stabalizers5. Even though these studies were able to show an
improvement in the muscular strength and activation in the
muscles associated with overhead motion, research lacks on
the effects of these exercises on an athlete’s injury
status.
The second hypothesis examined the difference in the
number of rehabilitation exercises performed between the
current and previous history groups. Even though there was
a difference in the mean number of rehabilitation exercises
performed between the current history (22.3) and previous

23
history (16.8) groups, the difference was not statistically
significant.
Reinold et al6 found that common rehabilitation
exercises such as the “empty-can”, “full-can” and “prone
full-can” were able to produce activation in the posterior
deltoid, middle deltoid and supraspinatus. However, certain
injuries are negatively affected by the use of these
exercises due to the stresses placed upon the shoulder. For
this reason, future research should examine the effective
exercises for specific shoulder injuries.
In addition to the hypotheses, the researcher
discovered additional findings by using supplementary
training and injury status questions. An important
component to this study was to examine the overuse injuries
occurring in these athletes, along with the length of
injury.
This study found that 38% of intercollegiate athletes
participating in softball, baseball, volleyball and
swimming have had an injury at some point during their
career. Of the 20 athletes who had reported an injury at
some point in their career, 60% had suffered from rotator
cuff tendonitis, 35% from shoulder instability, 35% from
bicipital tendonitis and 25% with shoulder impingement.
These results were surprising in that over half of the

24
injured athletes have experienced rotator cuff tendonitis
and also that many of these athletes have suffered from
multiple overuse shoulder injuries. The athlete’s length of
injury ranged from 1-2 years to 10 or more years, with a
majority of them suffering from injury for 1-2 years (40%)
and 3-5 years (35%). It was also important to note that 25%
of these athletes suffered from their injury for 5 or more
years. Since the majority of athletes fell within the 18-25
age group, these athletes that experienced their injury for
3-5 years had injured their shoulder during their high
school careers. Those experiencing their injury for 5 or
more years were likely to become injured early in their
high school careers, some even middle school. Even though
these athletes are performing in shoulder exercises both in
the preseason and throughout their rehabilitation, the long
term nature of these conditions can lead to anatomical and
functional adaptations that are often difficult to treat.
Many of these athletes are managed for pain, while still
playing on a shoulder that is not performing at the best of
its ability. Not correcting these injuries in their early
stages can lead to further biomechanical alterations,
further leading to injury.
The additional tests examining the injury status,
injury type and injury length supported the findings of

25
Sipes et al1 These researchers found that 30% of
intercollegiate athletes had an injury at some point in
their career, with shoulder impingement and rotator cuff
tendonitis accounting for the largest number of injuries.
Even though the hypotheses examined the mean number of
training exercises performed between the injury groups,
further testing analyzed the mean number of exercises
performed in each category of training. When comparing the
categories of training performed in the athlete’s preseason
and rehabilitation programs, overall athletes performed in
a greater variety of training during preseason when
compared to their rehabilitation program. The majority of
the athlete’s rehabilitation program consisted of
stretching and weight training. Only 17.6% of athletes
participated in core exercises during their rehabilitation
program while 76.6% participated in core exercises in their
preseason training programs. These results were reproduced
in Table 10, looking at the injury groups mean number of
rehabilitation exercises performed in each training
category. Out of 12 core exercises, the current history
group performed a mean of 3.4 core exercises, while the
previous history group performed a mean of 1.8 core
exercises. Lust et al9 found that a 6-week core training

26
program resulted in significant gains in core stability,
proprioception and throwing accuracy.
Another additional finding discovered that majority of
the athletes received treatment from a physical therapist
(92.9%), medical doctor (71.4%) and an athletic trainer
(57.1%). This finding was surprising in that even though a
majority of these athletes had received treatment from a
health care professional, 12 out of the 20 athletes who had
reported an injury are still currently injured.
Another interesting finding was the use of postural
assessments. Before receiving treatment from these medical
professionals, 79% of the athletes had stated that they had
not received a postural assessment. Without a proper
postural evaluation examining the postural concerns,
muscular imbalances, overactive and underactive muscles,
and biomechanical deficiencies; it is difficult to know if
each athlete had performed the correct exercises.
The results of this study demonstrated that the
athletes’ injury status is not directly related to the
number of rehabilitation and preseason training exercises
performed. The findings differed from the expected results,
in part due to the fact that the athletes were required to
recall exercises and injuries dating back to their
childhood. The athletes’ number of preseason training

27
exercises may not have differed between currently injured,
previously injured and those with no history of injury due
to more athletes participating in similar sports specific
training programs rather than individualized training
regimens. Similarly, rather than individualized
rehabilitation programs, many rehabilitation programs are
based on the injury rather than the client. For this
reason, athletes with similar injuries would be
participating in similar rehabilitation programs.

Conclusion

There were no significant differences found between
the number of preseason exercises performed between the
current history, previous history and no history groups or
the number of rehabilitation exercises performed between
the previous history and current history groups. Based on
the results, we can conclude that the number of exercises
performed does not have an effect on the injury status of
the athlete. However, it can be concluded that overhead
overuse injuries are still a problem that affect many
baseball, softball, volleyball and swimming athletes, with
a majority of them being affected by rotator cuff
tendonitis.

28
While the results of this study were not as expected,
it raises awareness on the incidence of overuse shoulder
injuries. The results produced in this study open many
doors for future research examining overuse overhead
injuries in baseball, softball, volleyball and swimming
athletes.

Recommendations

The results of this study demonstrate that, in
general, overhead athletes are suffering from overuse
injuries in which they are being treated for. In order to
determine the overall effects of training exercises on
shoulder injuries, future research should focus on the
effects of specific training exercises on specific overuse
shoulder injuries. Looking deeper into the effectiveness of
individual exercises will raise awareness on specific ways
to treat and prevent each injury.
Future research should also examine the effect of a
postural assessment before preseason and rehabilitation
training programs. This would give the medical professional
a better outlook on the athletes individualized needs to
effectively correct their postural concerns. In addition, a

29
study containing a larger, more diverse population could
produce different results.
Further research into this topic can facilitate the
reduction of overuse injuries occurring in the overhead
athlete.

30

REFERENCES
1.

Sipes R. The incidence of shoulder injury among
collegiate overhead athletes. J Intercollegiate Sport.
2009; 2: 260-268.

2.

Laudner K, Sipes R, Wilson J. The acute effects of
sleeper stretches on shoulder range of motion. J Athl
Training. 2008; 43(4): 359-363.

3.

Oyama S, Goerger C, Goerger B, Lephart S, Myers J.
Effects of non-assisted posterior shoulder stretches
on shoulder range of motion among collegiate baseball
players. Athl Training & Sports Health Care. 2010;
2(4): 163-169.

4.

Van de Velde A, Mey K, Maenhout A, Calders, Cools A.
Scapular-muscle performance : two training programs
in adolescent swimmers. J Athl Training. 2011; 46(2):
160-167.

5.

Myers J, Pasquale M, Laudner K, Sell T, Bradley J,
Lephart S. On-the-field resistance-tubing exercises
for throwers: a electromyographic analysis. J Athl
Training. 2005; 40(1): 15-22.

6.

Reinold M, Macrina L, Wilk K, et al. Electromyographic
analysis of the supraspinatus and deltoid muscles
during 3 common rehabilitation exercises.J Athl
Training. 2007; 42(4): 464-469.

7.

Escamilla R, Yamashiro K, Paulos L, Andrews J.
Shoulder muscle activity and function in common
shoulder rehabilitation exercises. Sports Med. 2009;
39(8): 663-685.

8.

Yanai T, Fuss FK, Fukunaga T. In vivo measurements of
subacromial impingement: substantial compression
develops in abduction with large internal rotation.
Clin Biomech. 2006;21(7):692–700.

9.

Lust K, Sandrey M, Bulger S, Wilder N. The effects of
6- week training programs on throwing accuracy,
proprioception and core endurance in baseball. J Sport
Rehabil. 2009; 18(3): 407-427.

31

APPENDICES

32

APPENDIX A
Review of Literature

33

REVIEW OF LITERATURE

The prevalence of persistent overuse shoulder injuries
in overhead athletes has become a major issue to the
profession of athletic training. Repetitive overhead
movements can lead to mechanical deficiencies, muscular
imbalances, muscular weakness and changes in shoulder
flexibility, ultimately leading to injury. Often these
injuries have persisted in these athletes for years. It is
possible that improper management of these injuries in
their initial stages could have contributed to the longterm nature of these conditions.
The purpose of this literature review is to present
information on the important risk factors, preventative
measures and treatments that are associated with overhead
overuse shoulder injuries in sports such as volleyball,
baseball, softball and swimming.
This literature review will discuss: 1) Shoulder
Anatomy 2) Risk Factors Associated with Overuse Injuries in
the Overhead Athlete, 3) Prevention of Overuse Injuries and
Management of Overhead Overuse Injuries.

34

Anatomy of the Shoulder

The shoulder girdle produces fluid shoulder movement
through the interconnection of its parts including, bony
anatomy, bony articulations and the static and dynamic
stabilizers.1 Each of the components working together as a
unit allows the shoulder to move through three degrees of
motion. The bony anatomy of the shoulder consists of the
humerus, which is the longest and largest bone in the upper
extremity, the triangular shaped scapula and the clavicle.1
The shoulder complex consists of four different
articulations including: the glenohumeral joint,
sternoclavicular joint, acromioclavicular joint and the
scapulothoracic articulation.2
The glenohumeral joint (GH joint) is the articulation
between the large humeral head and comparatively small
glenoid surface.1 At any given time, only 25% to 30% of the
humeral head is in contact with the glenoid surface, making
it the most mobile joint in the body, allowing for 180°of
total rotation.1-3 The sternoclavicular joint (SC joint)
consists of the articulation between the medial end of the
clavicle and the upper portion of the sternum, denoting the
only true articulation between the trunk and upper

35
extremity.1-2 This joint allows 30° to 35° of upward
rotation, 35° of combined anterior and posterior movement,
and 45° to 50° of rotation around its long axis.1 The
acromioclavicular joint (AC joint) is the connection
between the acromion process of the scapula and the lateral
border of the clavicle. The AC joint allows for 20° to 30°
of motion in three planes of motion. Even though it is not
considered a true joint, the scapulothoracic articulation
is a space between the convex surface of the posterior
thoracic cage and concave surface of the anterior scapula.
The seventeen muscles that attach to the scapula help
stabilize and produce motion at the scapula. The increased
shoulder motion that is available at the scapulothoracic
articulation allows for movement beyond the 120° offered
solely by the glenohumeral joint.1 Due to the large amounts
of mobility present in the shoulder, the dynamic
stabilizers play a crucial role in providing stability to
the joint.2
The rotator cuff provides dynamic stability by
compressing the humeral head within the glenoid fossa
during overhead movements.3 The rotator cuff muscles are
include the supraspinatus, infraspinatus, teres minor and
subscapularis. The supraspinatus, the most commonly
affected rotator cuff muscle3, originates from the

36
supraspinous fossa of the scapula and inserts into the
greater tuberosity of the humerus. The supraspinatus is
responsible for the first 30° of shoulder abduction and
provides stability to the humeral head between 60° to 90°
of shoulder abduction.1 After the first 30° of shoulder
abduction, the middle deltoid becomes the primary shoulder
abductor. The infraspinatus originates from the
infraspinous fossa and goes to insert on the greater
tuberosity of the humerus. The last of the posterior
rotator cuff muscles, the teres minor originates from the
mid to upper regions of the axillary portion of the scapula
and also inserts on the greater tuberosity of the humerus.
Along with the infraspinatus, the teres minor acts as an
external rotator and also stabilizes the glenohumeral
joint.1 The anterior portion of the rotator cuff, the
subscapularis, originates from the subscapular fossa and
inserts on the lesser tuberosity of the humerus. The
subscapularis functions as an internal rotator, especially
during maximal internal rotation.1 The movements produced by
the rotator cuff muscles closely mimic the overhead
movements seen in sports such as baseball, softball,
volleyball and swimming; making them a crucial muscle group
in overhead activities.

37
The increase in shoulder motion provided from the
scapulothoracic articulation can be largely attributed to
the scapulothoracic muscles. The scapulothoracic muscles
consist of scapular retractors (trapezius, rhomboid major
and rhomboid minor), scapular protractors (serratus
anterior and pectoralis minor), scapular elevators (levator
scapulae, trapezius, rhomboid major, rhomboid minor and
deltoid) and scapular rotators (levator scapulae, serratus
anterior, pectoralis minor and deltoid). The combination of
bony articulations, ligaments and muscular forces allows
for the shoulder to engage in many sports specific overhead
activities.1

Risk Factors Associated with Overuse Injuries in Overhead
Athlete

The constant “wear and tear” that occurs in the
shoulder over time in sports such as baseball, softball,
volleyball and swimming can lead to compensatory
alterations in the shoulder, affecting overall performance.
Much of the current research focuses on changes that occur
in the shoulders of baseball players and how they affect
overall performance. The movement that occurs in baseball
players during throwing closely resembles that of the

38
movements occurring in swimming, volleyball and softball,
resulting in similar changes in shoulder positioning,
flexibility and ability to perform.2
The alterations that occur in the shoulder are
considered to be the major risk factors for overuse
injuries in the shoulder. The constant overhead motion can
lead to decreased glenohumeral internal rotation, increased
glenohumeral external rotation, change in scapular
positioning, muscle fatigue and muscular imbalances. These
risk factors have been shown to lead to injuries such as
rotator cuff pathology, SLAP lesion, impingement syndrome
and bicipital tendonitis2. Many athletes have difficulty
recognizing the adaptations until an injury has occurred.
For this reason, many of these injuries are persisting into
chronic conditions, making it difficult for athletic
trainers to treat. Understanding and recognizing the risk
factors and the specific overuse shoulder injuries that
they occur can allow athletic trainers to create training
protocols to hinder the alterations that occur in the
shoulder.

Mechanical Errors
Sports that require the coordination of the kinetic
chain throughout full shoulder range of motion can often

39
lead to biomechanical issues. Biomechanics plays a huge
role in throwing a baseball, spiking a volleyball or
completing the butterfly stroke. If an overhead athlete
continues to use improper mechanics, the shoulder is placed
under stresses that can result in faulty adaptations, as
well as injuries. The changes in motion that often result
from improper biomechanics can affect normal function of
the shoulder and often place tension on both the dynamic
(muscular support) and static (glenoid labrum, capsule and
ligaments) stabilizers of the shoulder.4
The tension being placed on the dynamic and static
stabilizers of the shoulder can lead to a decrease in
scapular movement, decrease in internal rotation and
increase in external rotation.4-7 Mechanical adaptations such
as these can lead to a change in the way the shoulder
complex is able to perform during the movements required in
baseball, softball, volleyball and swimming. Much of the
literature focuses on the adaptations that occur over the
course of a season, as well as how these mechanical factors
play a role on athletes of many different performance
levels.
Swanik et al4 looked to examine the changes in
glenohumeral rotation and scapular position of 19 baseball
players after the completion of a scholastic season. The

40
changes were observed by measuring dominant and nondominant glenohumeral internal and external rotation, as
well as scapular positioning before and after the 12-week
baseball season. The results showed that the baseball
players’ dominant arm had significantly less internal
rotation and total motion when compared to their nondominant arm. The results also showed that the dominant arm
had significantly more external rotation.
In these athletes, scapular upward rotation at 0°
abduction significantly increased over the course of the
season and scapular upward rotation at 90° and 120°
significantly decreased. Scapular protraction at 45° and
90° significantly decreased from preseason to postseason.
In another study, Swanik et al5 compared the glenohumeral
internal-rotation deficits (GIRD), glenohumeral external
rotation gain (ERG) and scapular positioning between
collegiate and high school baseball players.
The participants in this study5 included 31 collegiate
Division I baseball players and 21 male high school
baseball players. The non-dominant and dominant arm were
measured for glenohumeral internal and external rotation,
scapular upward rotation at 0°, 60°, 90° and 120° of
abduction and scapular protraction. The results showed that
high school baseball players had less GIRD, greater ERG and

41
less total motion deficit. It was also found that
collegiate baseball players had a greater scapular upward
rotation at rest when compared to high school baseball
players. Many of these biomechanical adaptations that are
occurring throughout years of throwing can help explain the
widely seen shoulder injuries in collegiate baseball
players.
Aguinaldo et al6 also looked to determine the
biomechanical differences that existed between different
levels of competition to examine the effects throwing over
many years has on the shoulder. The study that they
conducted compared the biomechanical patterns of upper
trunk rotation and shoulder joint torque during baseball
pitching between professional, collegiate, high school and
youth. The participants included 38 baseball pitchers; 6
professional, 11 collegiate, 12 high school and 9 youth
pitchers. Each pitcher threw up to 15 fastballs, choosing
their best one to be analyzed using Real-Time motion
analysis, assessing trunk rotation, pelvic kinematics and
shoulder torque. The only kinematic difference to appear
between the groups was that professional pitchers started
to rotate their hips much later in the pitching motion than
the younger levels. Youth pitchers also exhibited the least

42
amount of internal rotation torque compared to the higher
levels of competition.
Gray et al7 looked to understand the shoulder
kinematics by comparing the mechanisms of coordination
between skilled and unskilled arms of eight recreational
baseball players. The researchers used a search-coil
technique to look at the angular positions of five arm
segments and their relationship to mean time of ball
release and ball speed. Each of the participants were
instructed to throw 30 balls at a slow speed, 30 at a
medium speed and 30 fast pitches to understand how throwing
kinematics adapt with speed. The results showed that the
skilled arm had a larger angular deceleration of the upper
arm in the forward horizontal direction, larger shoulder
internal rotation velocity at ball release and an increase
of wrist velocity with an increase of ball speed.
The research shows that biomechanical adaptations can
occur to athletes at many different competition levels,
transpiring over the course of many seasons or even a
single season. Fatigue, muscular weakness and a decrease in
flexibility can lead to a decrease in shoulder efficiency.
The shoulder alters itself to try to perform at its maximum
during these conditions, which can lead to biomechanical
adaptations. In order to ensure that these biomechanical

43
changes do not become permanent and lead to injury, it is
important to understand the most effective treatment and
prevention for overuse injuries in the overhead athlete.

Muscular Weakness and Imbalance
The instability of the glenohumeral joint places large
emphasis on the dynamic stabilizers of the shoulder;
including the rotator cuff, trapezius and scapulothoracic
muscles.8-9 It is essential for the muscles stabilizing the
shoulder to have a balanced force production and balanced
timing of muscle recruitment.8 The accelerators and
decelerators, as well as protractors and retractors7 of the
shoulder muscle maintain balance in order to produce
coordinated shoulder movements.

Muscular weakness or an

imbalance of the muscles stabilizing the shoulder has been
shown to increase the risk of overuse shoulder injuries.
Cools et al8 sought to understand how muscular
imbalances and weakness in the scapulothoracic8 and
trapezius9 muscles played a role on shoulder injuries in the
overhead athlete. In the first study, they compared the
force output and muscle balance of the scapulothoracic
muscles in thirty overhead athletes with impingement
syndrome to a control group of thirty healthy overhead
athletes. The experimental group had their uninjured side

44
tested following their injured side, while the control
group tested their non-dominant side followed by their
dominant. The maximal protraction and retraction isokinetic
tests were performed using a Biodex System at a linear
speed of 12.2 cm/s and 36.6cm/s.

The results showed that

overhead athletes with impingement syndrome showed a
decreased force output/body weight at both velocities for
the protractor muscles compared to their uninjured side and
the control group.
In another study, Cools et al9 compared the
intramuscular balance and trapezius activity between
thirty-nine overhead athletes with chronic impingement
syndrome and thirty non-injured overhead athletes. The
intramuscular balance and trapezius activity was measured
by examining the electromyographic activity of the upper,
middle and lower trapezius during isokinetic abduction and
external rotation. The EMG analysis provided data that
showed a significant increase in upper trapezius activity
on the injured side, as well as a significant decrease in
lower trapezius on the injured side.
Both of these studies demonstrated the importance of
maintaining the muscular strength and balance of the
dynamic shoulder stabilizers. The group of participants
diagnosed with impingement syndrome were able to produce

45
findings that indicated a decrease in intramuscular
balance, coordination and force output. Due to the crucial
role that the trapezius and scapulothoracic muscles play in
overhead athletics, the restoration of muscular strength
and intramuscular balance is an important component of the
rehabilitation and prevention of overhead injuries.

Flexibility
Overhead sports such as baseball, softball, volleyball
and swimming not only involve the coordination of upper
body movements, they all require coordination of full body
movements. In order for the body to move freely through the
full body movements required in these sports, it is
important to maintain full range of motion. A decrease in
range of motion can lead to a more force being placed on
the shoulder in overhead activities.10
Over time many overhead athletes begin to develop an
increase in glenohumeral external rotation and decrease in
glenohumeral internal rotation. These changes have been
shown to cause joint laxity11 and posterior joint
stiffness.12 The motions that are produced due to changes in
range of motion and increase in joint stiffness are
believed to be major risk factors to the overuse shoulder
injuries faced by many of these athletes.

46
Scher et al10 studied the differences in hip and
shoulder range of motion between professional baseball
players with a history of shoulder injury and those with no
history of injury, as well as assessing the relationship
between hip and shoulder ROM in professional baseball
players. A total of 57 baseball players participated in the
study, 11 pitchers and 12 non-pitchers with a history of
injury, as well as 18 pitchers and 16 non-pitchers with no
history of injury. Each participant had hip internal
rotation, external rotation and extension, as well as
shoulder internal and external rotation measured on their
dominant and non-dominant sides. The results showed no
difference in shoulder external and internal rotation
between pitchers with a history of shoulder injury and
pitchers with no history of injury. Non-pitchers with a
history of shoulder injuries had more shoulder external
rotation and less shoulder internal rotation than pitchers
without a history or injury. The non-pitchers with and
without an injury produced a significant difference in nondominant internal rotation. The differences that were
produced in internal and external rotation could be
attributed to the amount of joint stiffness and laxity
present in the shoulder.

47
A study conducted by Crawford et al11 examined the
posterior glenohumeral joint laxity and stiffness in the
throwing and non-throwing shoulders of 22 asymptomatic high
school baseball pitchers. This study used the LigMaster to
measure the joint laxity and stiffness of both the throwing
and non-throwing shoulders of each participant. Anterior
joint laxity and stiffness were measured with the shoulder
in a neutral position and at 90° of external rotation.
Posterior joint laxity was measured with the shoulder in
90° of abduction and neutral position. The findings in both
shoulders was that glenohumeral joint laxity was less and
glenohumeral joint stiffness was greater when tested in the
functional throwing position, 90° of external rotation and
90° of abduction, when compared to neutral position.
In a similar study, Clambers et al12 examined the
effects of posterior capsule tightness on humeral head
position of eight frozen shoulders in late cocking
simulation. Each shoulder was placed into the late cocking
phase of 90° abduction, 10° adduction and maximum external
rotation. 3D measurements were taken of humeral head
relationship in relation to the glenoid throughout the late
cocking phase. The results showed that in a normal
shoulder, there was a relative positive and inferior
translation of the glenohumeral joint when the shoulder was

48
in the late-cocking phase of throwing. The posterior and
inferior translation of the humeral head can help to
justify the large number of glenoid pathologies faced by
baseball players of all ages.
Shoulder adaptations, such as an increase in
glenohumeral internal rotation and increase in posterior
tightness, have been shown to be major risk factors for
overuse shoulder injuries such as rotator cuff pathologies
and labral tears.11-12 For this reason, it is important to
address these changes at a young age, in hopes of
decreasing the injuries faced by these athletes throughout
their careers.

Prevention of Overuse Injuries

Repetitive overhead movements in baseball, softball,
volleyball and swimming require coordinated overhead motion
that results in high forces experienced at the upper
extremity joints. The shoulder must maintain a combination
of flexibility and stability in order to successfully move
through the full range of motion (ROM) in both the
acceleration and deceleration phase of the throwing motion.
The coordination of the kinetic chain allows the athlete to
move smoothly throughout the full range of overhead motion.

49
Fatigue to a component of the kinetic chain can lead
compensation by the other components, resulting in an
overload being placed on the shoulder and elbow.13 The
constant overload being placed on the shoulder results in
an increased demand on the kinetic chain, ultimately
leading to injury. Understanding the throwing mechanics,
swimming strokes and volleyball motions along with the
musculature associated with the kinetic chain will allow an
individual to develop training programs to aid in
strengthening and stretching the muscles related the
functional movements related to each sport.

Preseason Programs
Baseball, softball, volleyball and swimming are sports
that require multi-joint and multi-dimensional movements.
In order to move fully through the full overhead motion,
the body utilizes every component of the kinetic chain to
produce maximum performance while decreasing the risk of
injury. The kinetic chain is composed of the glenohumeral
joint, upper arm, forearm, hand, hip, leg and trunk.

13-14

Training programs that are able to train each component of
the kinetic chain separately, as well as a whole kinetic
link14 should be utilized before, during and after the
athletic season.

50
Sports specific training is a crucial part of any
training regimen. Understanding and incorporating specific
movements related to a sport will allow the athlete to be
more functional, while simultaneously preventing injuries.
Training for overhead athletes should incorporate both open
and closed kinetic chain exercises involving lower and
upper body strength/power, torso rotational strength/power,
endurance, agility training, resistance tubing training
core stability and plyometrics.13-14
Since each of these sports requires numerous multidimensional and multi-joint movements, preseason programs
should incorporate sport specific strength, power and
endurance training. Szymanski et al14 looked to determine if
additional torso rotational strength through medicine ball
training would provide additional improvements in torso
rotational strength and power of fifty-five high school
baseball players. Each player participated in a 12 week
off-season training program in which they trained 3 days a
week using medicine ball exercises such as; the standing
side throw, the speed rotation, the hitter’s throw and the
standing figure 8. Each athlete took measurements of
height, body mass, body composition, 3RM dominant and nondominant torso rotational strength, sequential hip-torsoarm rotational strength and 3RM parallel squat and bench

51
press pre and post training. The group that took part in
the medicine ball program made significantly greater
increases in 3RM dominant and non-dominant torso rotational
strength.
Lust et al13 also looked to determine the effects of a
preseason program on baseball players. The program
consisted of 6-week training with open kinetic chain,
closed kinetic chain and core-stability exercises and their
effect on throwing accuracy, core stability and
proprioception of 25 collegiate baseball players. The
players were split up into 3 groups consisting of 12
players in the open kinetic/closed kinetic and 13 players
in the open kinetic/closed kinetic/core stability group.
The control group consisted of 15 college aged males that
had some baseball experience. The pre and posttest
measurements showed that the OKC/CKC group and the
OKC/CKC/CS group produced significantly greater posttest
scores than the control group. There was no significant
difference between the two experimental groups throughout
the pre and posttest.
Myers et al15 also examined the effects of baseball
specific exercises. The researchers studied the effects of
12 commonly used resistance tubing exercises by baseball
players on activating the shoulder muscles vital to

52
throwing. The 15 participants randomly performed the 12
resisting tubing exercises while the muscle activation of
the of the subscapularis, supraspinatus, teres minor,
rhomboid major pectoralis major, anterior deltoid, middle
deltoid, latissimus dorsi, serratus anterior, biceps
brachii, triceps brachii, lower trapezius, and
infraspinatus muscles was tested. The results showed that
seven exercises; external rotation at 90°of abduction,
throwing deceleration, humeral flexion, humeral extension,
low scapular rows, throwing acceleration, and scapular
punches, resulted in the highest level of muscle
activation. Each of these seven exercises exhibited
moderate activation in the rotator cuff, primary humeral
movers and scapular stabilizers. The movements during
overhead throwing requires the coordination of the rotator
cuff, scapular stabilizers and humeral movers; making it
important to perform exercises with high activity in these
muscles.
Swimming is also a sport that requires the
coordination of the scapular muscles in order to reduce the
athletes’ risk of injury.16 Van de Velde et al16 examined the
effects of a 12-week training program on muscular strength,
muscular endurance, side-to-side differences in strength
and protractor/retractor ratio. The 18 swimmers were split

53
up into a muscular endurance or muscular strength training
program that consisted of exercises such as; scapular
dynamic hug, scapular protraction, elbow push-ups and prone
bilateral glenohumeral horizontal abduction with scapular
retraction. The results showed that a 12-week swimming
training program produced an increase in muscular strength,
improved protractor/retractor ratio and improved side-toside muscular strength. However, the program did not
produce a change in muscular endurance.
Preseason training programs that incorporate sports
specific exercises including strength training, power,
plyometrics, core stability and endurance can lead to
improvements throughout the season.

13-14

These training

programs can vary in length but even a short program,
lasting six weeks, was able to produce pre and post test
improvements. Understanding the specific movements and
functional needs in each sport will allow an athlete to
participate in specific exercises to increase torso
strength, core stability and the accuracy and strength of
overhead motions, while reducing the athletes risk for
injury.

54
Improving Muscular Imbalances and Flexibility
Constant overhead motion can lead to many shoulder
adaptations that can predispose an individual to injury and
chronic shoulder pain.17-19 It has been researched that many
range of motion deficits can result from the soft tissue
adaptations including; increased shoulder external
rotation, decreased shoulder internal rotation and
horizontal adduction and increased posterior shoulder
tightness.17-

18

Alterations in range of motion and posterior

tightness resulting from the deceleration phase17 can lead
to impingement syndrome, rotator cuff pathologies, muscular
strains, SLAP lesions, bicipital tendonitis and ulnar
collateral ligament insufficiency.18 Miyashita et al.20
examined the correlation of maximum external rotation/
external rotation measurements to elbow injuries in forty
high school baseball players with and without a history of
medial elbow pain. The results showed that the non-throwing
shoulders of the injured group produced significantly
smaller external rotation measurements than the control
group. Since there is a correlation between the mechanics
in baseball and maximum external rotation and external
rotation, it is important to understand the preventative
measures in order to improve overall mechanics, in hopes of
decreasing the athlete’s risk of injury.

55
Many different stretching techniques have been used
for preventative treatment before and after performing
overhead motions in an attempt to lengthen the soft
tissue,17 allowing the shoulder complex to move through a
full range of motion. Many individuals that participate in
overhead activities use stretching techniques such as the
sleeper stretch,17-18 PNF techniques,21 Fauls stretching19 and
horizontal cross-arm stretching. There have been many
studies that looked at the evidence associated with
posterior shoulder stretching and its effect on the overall
ROM in external rotation, internal rotation and horizontal
adduction.
The constant overhead motion produced by overhead
athletes that often leads to an increase in external
rotation and decrease in internal rotation can also lead to
posterior shoulder tightness. Many athletes decrease
posterior shoulder tightness by using a technique known as
the sleeper stretch. The sleeper stretch looks to stabilize
the scapula to restrict movement while moving the shoulder
into internal rotation.17-18 Laudner et al17 examined the
effects of a side-lying sleeper stretch on the shoulder
range of motion of 33 Division I pitchers and 18 position
players. The control group consisted of 33 physically
active male college students who did not participate in any

56
stretching routine throughout the study. The measurements
completed before and after completing the 3 sets of 30second passive sleeper stretches produced a 2.3° increase
in posterior shoulder motion and a 3.1° increase in
internal rotation for the baseball group. Oyama et al18 also
found that the sleeper stretch at 45°, sleeper stretch at
90° and the horizontal cross-arm stretch produced a 4.3°
increase in internal rotation and 3.4° in horizontal
adduction. Even though the sleeper stretch showed a small
increase in internal rotation, athletes that maintain
stretching protocols throughout the season can maintain
flexibility and decrease the risk of injury.
Another stretching technique that has been used since
the 1980’s to decrease posterior shoulder tightness and
increase shoulder ROM in baseball players is known as Fauls
stretching routine. This routine consists of twelve passive
stretches that combine stretches and circular motions. Each
of the stretches is maintained for seven seconds and the
circular motions consists of ten repetitions.19 Sauers et
al19 examined the effects of the Fauls stretching routine on
shoulder ROM in 30 collegiate baseball players. The pre and
post-stretch measurements consisted of shoulder complex
external rotation, glenohumeral external rotation, shoulder
complex internal rotation, glenohumeral internal rotation

57
and posterior shoulder tightness (using Tyler’s test). The
results showed a decrease in posterior shoulder tightness,
9.2° increase in shoulder complex internal rotation and
6.4° increase in glenohumeral internal rotation. There was
no significant difference in external rotation. Overall,
the Fauls stretching routine played a major role in
increasing shoulder complex internal rotation as well as
decreasing posterior shoulder tightness.
Proprioceptive neuromuscular facilitation (PNF) is a
stretching routine that combines stretching and contraction
of a particular muscle group in order to improve
flexibility.21 The PNF patterns consist of hold-relax,
contract-relax and slow-reversal-hold-relax. The contractrelax pattern is performed by an isotonic contraction of
the antagonist muscle followed by passive stretch. The
hold-relax pattern is performed is an isometric contraction
of the agonist followed by a passive stretch. Decicco et
al21 looked at the effects of contract-relax and hold-relax
proprioceptive neuromuscular facilitation patterns on the
effects of increasing external rotation of the shoulder.
The 30 participants consisted of male and female overhead
athletes that were randomly assigned to 1 of 3 groups;
contract-relax, hold-relax and control group. The subjects
performed PNF stretches two times a week for 6 weeks to

58
test the pre and post ROM differences. The contract-relax
produced a 14.6° increase in external rotation, compared to
a 13.5° increase produced by the hold-relax group. The
control group was not able to produce any difference in
measurements. Overall, proprioceptive neuromuscular
facilitation has been proven to be an effective form of
stretching by combining stretching and muscular
contractions, hoping to further increase overall range of
motion.
This section examined the effects of different
stretching techniques on ROM in overhead athletes
demonstrates evidence towards the use of stretching
programs to increase the overall motion produced at the
shoulder joint. All of the studies were able to show an
increase in total internal rotation, even though some did
not produce statistically significant data.17 Only one of
the studies was able to show an increase in the total
external rotation.21 The studies were not able to show any
significant differences between the measurements of the
different stretches. However, a combination of stretching
and circular motions was able to produce the greatest
change in ROM measurements.19 Based on the results produced
in the studies, overhead athletes can benefit from

59
participating in stretching programs before and after
practice sessions.
Stretching before and after overhead activities result
in improvements in flexibility, allowing an athlete to move
through a full range of motion. A decrease in ROM has led
to many biomechanical issues, soft-tissue adaptations and
overuse injuries. The published research has been able to
show an increase in shoulder ROM after a stretching
regimen.

Treatment of Overuse Shoulder Injuries

Approximately thirty-percent of intercollegiate
overhead athletes have experienced a shoulder injury at
some point during their career.22 Many of these injuries
have persisted from the time they were playing youth sports
up until their intercollegiate careers. It is possible that
the chronic effects of these injuries could be a result of
the improper management of these injuries in their initial
stages.
Shoulder pain is the third most common musculoskeletal
complaint, affecting 7%-34% of the general population.

23-25

Due to the fact that the glenohumeral joint exhibits the
greatest amount of motion of any joint in the body3, the

60
shoulder is placed under large amounts of stress during
overhead movements. The shoulder joint relies heavily on
the dynamic stabilizers to provide stability, allowing for
fluid overhead motion. However, athletes often overstress
the dynamic stabilizers during sports specific overhead
movements, ultimately leading overuse shoulder injuries.
Due to the large importance of the dynamic stabilizers
during overhead movements, rehabilitation of shoulder
should focus on exercises that stress the rotator cuff,
scapular muscles and deltoid. When performing
rehabilitation exercises it is important to perform those
exercises that exhibit the highest amount of activity from
these muscle groups.3,26 Those exercises that have shown the
greatest amount of activity from the rotator cuff, deltoid
and scapular muscles consist of prone horizontal abduction
at 100° abduction with external rotation, flexion and
abduction with external rotation, “full can”, “empty can”,
D1 and D2 flexion and extension diagonal patterns, external
rotation at 0° and 90° abduction, internal rotation at 0°
and 90° abduction, push-ups, dynamic scapular hug, scapular
punches and row-type exercises.26
Impingement syndrome and rotator cuff tendinopathy are
among the most common overuse shoulder conditions seen
throughout athletics and general medical practice.3,27 For

61
this reason, it is important to understand the key
exercises used to manage these conditions. Reinold et al3
examined the electromyographic activity of the
supraspinatus, middle deltoid and posterior deltoid during
the “empty-can”, “full-can” and “prone full can” exercises
in 22 asymptomatic subjects. The results showed no
statistical differences between the exercises for the
supraspinatus. However, the middle deltoid showed
significantly greater activity during the “empty-can” and
“prone full-can” exercises. The “prone full-can” exercise
produced the greatest amount of activity in the posterior
deltoid. Even though each of these exercises were able to
produce activity in the posterior deltoid, middle deltoid
and supraspinatus, in certain injuries some of these
exercises should not be used. In patients with impingement
syndrome, the “empty-can” exercise decreases the
subacromial space, predisposing the tendons underneath the
coracoacromial ligament to impingement.26,28 In the patient
population with impingement syndrome, it would be more
appropriate to use the “full-can” exercise.28
Bernhardsson et al24 also looked at the effects of an
exercise protocol on subacromial impingement syndrome.
These researchers evaluated the effect on pain intensity
and function of an exercise program including specific

62
eccentric strength training with progressive loading of the
supraspinatus and infraspinatus tendons in ten patients
with subacromial impingement syndrome. Each of the subjects
completed baseline testing of pain intensity using a visual
analogue scale, function using the Patient-Specific
Functional Scale, shoulder function evaluated with the
Constant score, and shoulder-related quality of life
evaluated with the Western Ontario Rotator Cuff Index. The
12-week exercise program consisted of eccentric
strengthening exercises for the supraspinatus and
infraspinatus muscles, shoulder shrugs, scapular retraction
and stretching of the lower trapezius. The before and after
measurements showed a pain intensity in eight of the ten
patients, increase in function in all ten subjects, the
Constant score increased in nine subjects and the Western
Ontario Rotator Cuff Index increased in seven subjects. Due
to the significant changes in baseline and treatment
scores, eccentric strengthening should be an important part
of rehabilitation protocols.
Araújo et al23 also wanted to look at the effects of
common rehabilitation exercises on shoulder function. The
researchers examined the effects of performing isometric 3point kneeling exercises on a Swiss ball on the EMG
activity of the posterior deltoid, pectoralis major, biceps

63
brachii, triceps brachii, upper trapezius and serratus
anterior when compared to performing the same exercise on a
stable surface. Each of the 12 volunteers randomly
performed 3 six-second contractions in different isometric
3-point kneeling exercises with the dominant limb placed
either on a stable surface or on a Swiss ball. The results
showed that isometric 3-point kneeling exercises on an
unstable base influenced the load values produced and the
muscle activation levels when compared with performing the
same exercise on a stable surface. A significant increase
was seen in the activation of the glenohumeral muscles, but
no difference was observed for the scapulothoracic muscles.
Improper management of shoulder injuries in their
initial stages can contribute to the long-term effects
faced by many overhead athletes. For this reason, it is
important to incorporate rehabilitation exercises that
stress the dynamic stabilizers of the shoulder. Exercises
such as the “full-can”, prone “full-can”, “empty-can”,
dynamic scapular hug, scapular punches, eccentricstrengthening of the infraspinatus and supraspinatus and
push-ups. Completing a variety shoulder exercises
throughout rehabilitation can ensure the activation of the
rotator cuff, scapular muscles and deltoid; providing
dynamic stability to the shoulder.

64

Summary

Shoulder pain is the third most common musculoskeletal
complaint, affecting 7%-34% of the general population.

23-25

The shoulder is constantly placed underneath stress because
the glenohumeral joint is the most mobile joint in the
body.3 The excessive mobility of the shoulder relies on the
dynamic and static stabilizers to provide stability to the
joint.2 If the dynamic stabilizers are put under too much
stress and not able to provide stability to the joint, many
biomechanical adaptations can occur.
The constant “wear and tear” that occurs in the
shoulder over time in sports such as baseball, softball,
swimming and volleyball can lead to decreased glenohumeral
internal rotation, increased glenohumeral external
rotation, muscular imbalances, muscle fatigue and change in
scapular positioning.4-7 These adaptations that can occur
due to the constant overhead motion can lead to injuries
such as; rotator cuff tendinopathy, impingement syndrome,
SLAP lesion, bicipital tendonitis and shoulder instability.
The adaptations that occur in the shoulder overtime can be
prevented by taking part in preseason programs that stress

65
the dynamic and static stabilizers of the shoulder joint,
as well as torso rotational strength14 to decrease the load
placed on the shoulder.
An athlete that performs in a sports specific training
program, such as resistance tubing for baseball players15
and or a scapular strengthening program for swimmers16, can
help to activate the dynamic stabilizers needed to produce
coordinated overhead motion. When creating a preseason
program, it is important to understand the specific motions
required throughout each sport. A crucial component to
every preseason program is the addition of a stretching
protocol to increase flexibility in the dynamic
stabilizers, ultimately reducing the risk of injury.
Stretching has been shown to increase the range of motion
in the shoulder, allowing for more fluid motion throughout
overhead movements. If the athlete does not properly manage
these adaptations by performing in proper exercises and
stretching protocols, the stresses placed on the shoulder
can predispose an athlete to an overhead overuse injury.
It is possible that many of the chronic effects of
overhead overuse injuries can be due to the improper
management of these injuries in their acute phase.
Exercises should focus on stressing the rotator cuff,
scapular muscles and deltoid in order to activate the

66
dynamic stabilizers. Those exercises that have shown the
greatest amount of activity from the rotator cuff, deltoid
and scapular muscles consist of prone horizontal abduction
at 100° abduction with external rotation, flexion and
abduction with external rotation, “full can”, “empty can”,
D1 and D2 flexion and extension diagonal patterns, external
rotation at 0° and 90° abduction, internal rotation at 0°
and 90° abduction, push-ups, dynamic scapular hug, scapular
punches and row-type exercises.26 Properly managing injuries
with the use of effective rehabilitation exercises can help
stop these injuries in their acute stages, decreasing the
amount of athletes with persisting overhead overuse
injuries.

67

APPENDIX B
The Problem

68
STATEMENT OF THE PROBLEM

Constant overhead motion in the overhead athlete can
lead to many biomechanical errors, range of motion deficits
and muscular imbalances; further predisposing an athlete to
injury. Many throwing athletes injure their shoulder season
after season, creating an unstable shoulder for the rest of
their careers. In a study looking at the incidence of
shoulder injuries among collegiate overhead athletes,
thirty-percent of intercollegiate overhead athletes had a
shoulder injury at some point in their career.22 The purpose
of this study is to recognize the persistent overuse
injuries occurring in the overhead athlete and examine the
effective ways to treat and prevent these injuries.

Definition of Terms
The following definitions of terms will be defined for
this study:
1)

Kinematics: Branch of mechanics studying the motion of
the body.

2)

4,6-7

Flexibility: The normal extensibility of all soft
tissues that allows full range of motion of a join and
optimal neuromuscular efficiency throughout all
functional movements.29

69
3)

Concentric Contraction: Developing tension while a
muscle is shortening; when developed tension overcomes
resistive force.29

4)

Eccentric Contraction: Developing tension while a
muscle is lengthening; when resistive force overcomes
developed tension.29

5)

Isometric Contraction: Generating force in the muscle
without changing length.29

6)

Current History Group: An athlete currently suffering
from impingement syndrome, bicipital tendonitis,
rotator cuff tendonitis or shoulder instability and
has had the injury for more than two years.

7)

Previous History Group: An athlete not currently
suffering from an overuse shoulder injury but has
previously suffered from impingement syndrome,
bicipital tendonitis, rotator cuff tendonitis or
shoulder instability for more than two years.

8)

No History Group: An athlete not currently suffering
and no previous history of impingement syndrome,
bicipital tendonitis, rotator cuff tendonitis or
shoulder instability.

70
Basic Assumptions
The following are basic assumptions of this study:
1)

The participants are representative of baseball,
softball, volleyball and swimming athletes at the
collegiate level.

2)

The participants will give their best effort when
participating in the survey.

3)

The participants will put time into completing the
survey.

Limitations of the Study
The following are possible limitations of the study:
1)

Only surveying select Division II and Division III
colleges

Significance of the Study
The purpose of this study is to examine and understand
the persistent overuse injuries in the throwing athlete.
Many athletes that participate in overhead sports
throughout their childhood and into collegiate athletics
are faced with numerous overhead injuries.
Many of these athletes are entering their collegiate
careers already having shoulder instabilities, ultimately
leading to injuries throughout the season. Since these

71
athletes have been playing with biomechanically unsound
shoulders season after season, it is difficult to correct
the adaptations. Instead, the athlete is often managed for
pain, but is still playing with shoulders that are not
performing at the best of their ability. It is important as
health care providers to understand the risk factors and
preventative measures associated with common overuse
injuries in order to understand ways to treat and prevent
these injuries at a young age.

72

APPENDIX C
Additional Methods

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APPENDIX C1
Overhead Overuse Injury Survey

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APPENDIX C2
Institutional Review Board –
California University of Pennsylvania

136
Proposal Number
Date Received

PROTOCOL for Research
Involving Human Subjects

Institutional Review Board (IRB) approval is required before
beginning any research and/or data collection involving human subjects

(Reference IRB Policies and Procedures for clarification)

Project Title Persistent Overuse Injuries in the Overhead Athlete
Researcher/Project Director

Kellie Sullivan

Phone # 774-249-4856

E-mail Address sul8358@calu.edu

Faculty Sponsor (if required) Tom West
Department Health Science
Project Dates January 1, 2012 to December 31, 2012
Sponsoring Agent (if applicable) NA
Project to be Conducted at California University of Athletic Training "via online survey"
Project Purpose:

Thesis

Research

Class Project

Keep a copy of this form for your records.

Other

137
Please attach a typed, detailed summary of your project AND complete items 2
through 6.
1. Provide an overview of your project-proposal describing what you plan to do and how you
will go about doing it. Include any hypothesis(ses)or research questions that might be
involved and explain how the information you gather will be analyzed. For a complete list of
what should be included in your summary, please refer to Appendix B of the IRB Policies and
Procedures Manual.
This proposal is a retrospective, descriptive study that will examine the effective preventative
and rehabilitation exercises of overhead overuse injuries in Division II and Division III
baseball, softball, volleyball and swimming athletes through the use of a survey. The survey
will be finalized after review from a panel of experts. Upon approval from the California
University of Pennysylvania's Institutional Review Board, the researcher will create a direct
link to the survey using www.surveymonkey.com. A cover letter (Appendix C3) will be sent
to the overhead athletes explaining the purpose of the study. The email containing the cover
letter will also contain a link that will give the athlete direct access to the survey. The
researcher will contact the Athletic Directors at the chosen Division II and Division III
institutions, requesting that the survey be sent to the baseball, softball, volleyball and
swimming teams at their institition.
Hypotheses:
1:There will be a difference in the number of training exercises regularly performed between
the current history, previous history or no history injury groups.
2.The previous history group will have performed a higher number of rehabilitation exercises
when compared to the current history group
2. Section 46.11 of the Federal Regulations state that research proposals involving human
subjects must satisfy certain requirements before the IRB can grant approval. You should
describe in detail how the following requirements will be satisfied. Be sure to address each
area separately.
a. How will you insure that any risks to subjects are minimized? If there are potential
risks, describe what will be done to minimize these risks. If there are risks, describe
why the risks to participants are reasonable in relation to the anticipated benefits.
There is a risk that the participants personal information and/or answers to the survey
could become public. In order to minimize these risks, the participants name will not
be asked in the survey. The surveys will be completed online and without a name.
Once the surveys are returned, they will be downloaded and password protected.
The participants are at minimal risk while completing the survey, considering the
rewards gained upon completion of the survey. Determining the effective
preventative and rehabilitation exercises for overhead overuse injuries can help
decrease the chronic effects associated with these injuries by treating these athletes at
a young age.
b. How will you insure that the selection of subjects is equitable? Take into account
your purpose(s). Be sure you address research problems involving vulnerable

138
populations such as children, prisoners, pregnant women, mentally disabled persons,
and economically or educationally disadvantaged persons. If this is an in-class
project describe how you will minimize the possibility that students will feel coerced.
The survey will be sent to the members of the baseball, softball, volleyball and
swimming teams of the chosen Division II and Division III institutions. The
demogrpahic section at the beginning of the survey will require the participant to
provide their age. If the athlete is not 18 or older, they will not have access to the
survey and will be sent to a page thanking them for their participation. The
participation of the survey may also be discontinued at any time without penalty and
all data disregarded.
c. How will you obtain informed consent from each participant or the subject’s legally
authorized representative and ensure that all consent forms are appropriately
documented? Be sure to attach a copy of your consent form to the project summary.
Informed consent will be implied upon completing and returning the survey. As
stated in the cover letter provided to the participants, the participants have the right to
not participate in the survey.
d. Show that the research plan makes provisions to monitor the data collected to insure
the safety of all subjects. This includes the privacy of subjects’ responses and
provisions for maintaining the security and confidentiality of the data.
This is an anonymous survey that does not contain the participants name or email
upon completion. Once the surveys are returned, they will be downloaded and
password protected. The electronic surveys will be stored on university servers,
where only the researcher and thesis chair have access.
3. Check the appropriate box(es) that describe the subjects you plan to use.

Adult volunteers

Mentally Disabled People

CAL University Students

Economically Disadvantaged People

Other Students

Educationally Disadvantaged People

Prisoners

Fetuses or fetal material

Pregnant Women

Children Under 18

Physically Handicapped People

Neonates

4. Is remuneration involved in your project?
5. Is this project part of a grant?
Title of the Grant Proposal
Name of the Funding Agency

Yes or

Yes or
No

No. If yes, Explain here.

If yes, provide the following information:

139
Dates of the Project Period
6.

Does your project involve the debriefing of those who participated?

Yes or

No

If Yes, explain the debriefing process here.
7. If your project involves a questionnaire interview, ensure that it meets the requirements of
Appendix
in the Policies and Procedures Manual.

140
California University of Pennsylvania Institutional Review Board
Survey/Interview/Questionnaire Consent Checklist (v021209)
This form MUST accompany all IRB review requests
Does your research involve ONLY a survey, interview or questionnaire?
YES—Complete this form
NO—You MUST complete the “Informed Consent Checklist”—skip the remainder
of this form
Does your survey/interview/questionnaire cover letter or explanatory statement include:
(1) Statement about the general nature of the survey and how the data will be
used?
(2) Statement as to who the primary researcher is, including name, phone, and
email address?
(3) FOR ALL STUDENTS: Is the faculty advisor’s name and contact information
provided?
(4) Statement that participation is voluntary?
(5) Statement that participation may be discontinued at any time without penalty
and all data discarded?
(6) Statement that the results are confidential?
(7) Statement that results are anonymous?
(8) Statement as to level of risk anticipated or that minimal risk is anticipated?
(NOTE: If more than minimal risk is anticipated, a full consent form is required—and
the Informed Consent Checklist must be completed)
(9) Statement that returning the survey is an indication of consent to use the data?
(10) Who to contact regarding the project and how to contact this person?
(11) Statement as to where the results will be housed and how maintained? (unless
otherwise approved by the IRB, must be a secure location on University premises)
(12) Is there text equivalent to: “Approved by the California University of
Pennsylvania Institutional Review Board. This approval is effective nn/nn/nn and
expires mm/mm/mm”? (the actual dates will be specified in the approval notice from
the IRB)?

141
(13) FOR ELECTRONIC/WEBSITE SURVEYS: Does the text of the cover letter
or
explanatory statement appear before any data is requested from the participant?
(14) FOR ELECTONIC/WEBSITE SURVEYS: Can the participant discontinue
participation at any point in the process and all data is immediately discarded?

142
California University of Pennsylvania Institutional Review Board
Informed Consent Checklist (v021209)
This form MUST accompany all IRB review requests
Does your research involve ONLY a survey, interview, or questionnaire?
YES—DO NOT complete this form. You MUST complete the
“Survey/Interview/Questionnaire Consent Checklist” instead.
NO—Complete the remainder of this form.
1. Introduction (check each)
(1.1) Is there a statement that the study involves research?
(1.2) Is there an explanation of the purpose of the research?
2. Is the participant. (check each)
(2.1) Given an invitation to participate?
(2.2) Told why he/she was selected.
(2.3) Told the expected duration of the participation.
(2.4) Informed that participation is voluntary?
(2.5) Informed that all records are confidential?
(2.6) Told that he/she may withdraw from the research at any time without
penalty or loss of benefits?
(2.7) 18 years of age or older? (if not, see Section #9, Special Considerations
below)
3. Procedures (check each).
(3.1) Are the procedures identified and explained?
(3.2) Are the procedures that are being investigated clearly identified?
(3.3) Are treatment conditions identified?
4. Risks and discomforts. (check each)
(4.1) Are foreseeable risks or discomforts identified?
(4.2) Is the likelihood of any risks or discomforts identified?
(4.3) Is there a description of the steps that will be taken to minimize any risks or
discomforts?
(4.4) Is there an acknowledgement of potentially unforeseeable risks?
(4.5) Is the participant informed about what treatment or follow up courses of
action are available should there be some physical, emotional, or psychological harm?
(4.6) Is there a description of the benefits, if any, to the participant or to others
that may be reasonably expected from the research and an estimate of the likelihood
of these benefits?
(4.7) Is there a disclosure of any appropriate alternative procedures or courses of
treatment that might be advantageous to the participant?

143
5. Records and documentation. (check each)
(5.1) Is there a statement describing how records will be kept confidential?
(5.2) Is there a statement as to where the records will be kept and that this is a
secure location?
(5.3) Is there a statement as to who will have access to the records?
6. For research involving more than minimal risk (check each),
(6.1) Is there an explanation and description of any compensation and other
medical or counseling treatments that are available if the participants are injured
through participation?
(6.2) Is there a statement where further information can be obtained regarding the
treatments?
(6.3) Is there information regarding who to contact in the event of researchrelated injury?
7. Contacts.(check each)
(7.1) Is the participant given a list of contacts for answers to questions about the
research and the participant’s rights?
(7.2) Is the principal researcher identified with name and phone number and
email address?
(7.3) FOR ALL STUDENTS: Is the faculty advisor’s name and contact
information provided?
8. General Considerations (check each)
(8.1) Is there a statement indicating that the participant is making a decision
whether or not to participate, and that his/her signature indicates that he/she has
decided to participate having read and discussed the information in the informed
consent?
(8.2) Are all technical terms fully explained to the participant?
(8.3) Is the informed consent written at a level that the participant can understand?
(8.4) Is there text equivalent to: “Approved by the California University of
Pennsylvania Institutional Review Board. This approval is effective nn/nn/nn and
expires mm/mm/mm”? (the actual dates will be specified in the approval notice from
the IRB)
9. Specific Considerations (check as appropriate)
(9.1) If the participant is or may become pregnant is there a statement that the
particular treatment or procedure may involve risks, foreseeable or currently
unforeseeable, to the participant or to the embryo or fetus?
(9.2) Is there a statement specifying the circumstances in which the participation
may be terminated by the investigator without the participant’s consent?
(9.3) Are any costs to the participant clearly spelled out?
(9.4) If the participant desires to withdraw from the research, are procedures for
orderly termination spelled out?

144
(9.5) Is there a statement that the Principal Investigator will inform the participant
or any significant new findings developed during the research that may affect them
and influence their willingness to continue participation?
(9.6) Is the participant is less than 18 years of age? If so, a parent or guardian must
sign the consent form and assent must be obtained from the child
Is the consent form written in such a manner that it is clear that the
parent/guardian is giving permission for their child to participate?
Is a child assent form being used?
Does the assent form (if used) clearly indicate that the child can freely refuse
to participate or discontinue participation at any time without penalty or coercion?
(9.7) Are all consent and assent forms written at a level that the intended
participant can understand? (generally, 8th grade level for adults, age-appropriate for
children)

145
California University of Pennsylvania Institutional Review Board
Review Request Checklist (v021209)
This form MUST accompany all IRB review requests.
Unless otherwise specified, ALL items must be present in your review request.
Have you:
(1.0) FOR ALL STUDIES: Completed ALL items on the Review Request Form?
Pay particular attention to:
(1.1) Names and email addresses of all investigators
(1.1.1) FOR ALL STUDENTS: use only your CalU email
address)
(1.1.2) FOR ALL STUDENTS: Name and email address of your
faculty research advisor
(1.2) Project dates (must be in the future—no studies will be approved
which have already begun or scheduled to begin before final IRB approval—
NO EXCEPTIONS)
(1.3) Answered completely and in detail, the questions in items 2a through
2d?
2a: NOTE: No studies can have zero risk, the lowest risk is
“minimal risk”. If more than minimal risk is involved you MUST:
i. Delineate all anticipated risks in detail;
ii. Explain in detail how these risks will be minimized;
iii. Detail the procedures for dealing with adverse outcomes
due to these risks.
iv. Cite peer reviewed references in support of your
explanation.
2b. Complete all items.
2c. Describe informed consent procedures in detail.
2d. NOTE: to maintain security and confidentiality of data, all
study records must be housed in a secure (locked) location ON
UNIVERSITY PREMISES. The actual location (department, office,
etc.) must be specified in your explanation and be listed on any
consent forms or cover letters.
(1.4) Checked all appropriate boxes in Section 3? If participants under the
age of 18 years are to be included (regardless of what the study involves) you
MUST:
(1.4.1) Obtain informed consent from the parent or guardian—
consent forms must be written so that it is clear that the
parent/guardian is giving permission for their child to participate.
(1.4.2) Document how you will obtain assent from the child—
This must be done in an age-appropriate manner. Regardless of
whether the parent/guardian has given permission, a child is
completely free to refuse to participate, so the investigator must
document how the child indicated agreement to participate
(“assent”).

146
(1.5) Included all grant information in section 5?
(1.6) Included ALL signatures?
(2.0) FOR STUDIES INVOLVING MORE THAN JUST SURVEYS,
INTERVIEWS, OR QUESTIONNAIRES:
(2.1) Attached a copy of all consent form(s)?
(2.2) FOR STUDIES INVOLVING INDIVIDUALS LESS THAN 18
YEARS OF AGE: attached a copy of all assent forms (if such a form is used)?
(2.3) Completed and attached a copy of the Consent Form Checklist? (as
appropriate—see that checklist for instructions)
(3.0) FOR STUDIES INVOLVING ONLY SURVEYS, INTERVIEWS, OR
QUESTIONNAIRES:
(3.1) Attached a copy of the cover letter/information sheet?
(3.2) Completed and attached a copy of the
Survey/Interview/Questionnaire Consent Checklist? (see that checklist for
instructions)
(3.3) Attached a copy of the actual survey, interview, or questionnaire
questions in their final form?
(4.0) FOR ALL STUDENTS: Has your faculty research advisor:
(4.1) Thoroughly reviewed and approved your study?
(4.2) Thoroughly reviewed and approved your IRB paperwork? including:
(4.2.1) Review request form,
(4.2.2) All consent forms, (if used)
(4.2.3) All assent forms (if used)
(4.2.4) All Survey/Interview/Questionnaire cover letters (if used)
(4.2.5) All checklists
(4.3) IMPORTANT NOTE: Your advisor’s signature on the review request
form indicates that they have thoroughly reviewed your proposal and verified
that it meets all IRB and University requirements.
(5.0) Have you retained a copy of all submitted documentation for your records?

147

148
ACTION OF REVIEW BOARD (IRB use only)
The Institutional Review Board for Research Involving Human Subjects has reviewed this application to
ascertain whether or not the proposed project:
1.
2.
3.
4.
5.

provides adequate safeguards of the rights and welfare of human subjects involved in the
investigations;
uses appropriate methods to obtain informed, written consent;
indicates that the potential benefits of the investigation substantially outweigh the risk involved.
provides adequate debriefing of human participants.
provides adequate follow-up services to participants who may have incurred physical, mental, or
emotional harm.

Approved[_________________________________]
___________________________________________
_________________________
Chairperson, Institutional Review Board

Disapproved

Date

149

Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair
Dear Kellie Sullivan:
Please consider this email as official notification that your proposal titled
"Persistent overuse injuries in the overhead athlete” (Proposal #11-047)
has been approved by the California University of Pennsylvania
Institutional Review Board as submitted, with the following stipulation:
--:The consent/cover information must specify that only individuals 18
years of age or older may participate in the study.
Once you have updated the consent form, you may immediately begin data
collection. You do not need to wait for further IRB approval. At your earliest
convenience, you must forward a copy of the updated consent form for the
Board’s records.
The effective date of the approval is 1-31-2012 and the expiration date is 130-2013. These dates must appear on the consent form .
Please note that Federal Policy requires that you notify the IRB promptly
regarding any of the following:
(1) Any additions or changes in procedures you might wish for your
study (additions or changes must be approved by the IRB before
they are implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are
necessitated by any events reported in (2).
(4) To continue your research beyond the approval expiration date of
1-30-2013 you must file additional information to be considered for
continuing review. Please contact instreviewboard@cup.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

150

Appendix C3
Cover Letter

151

Date
Dear Participants:
My name is Kellie Sullivan and I am currently a graduate student at California University of
Pennsylvania pursing a Master of Science in Athletic Training. Part of the graduate study
curriculum is to complete a research thesis through conducting research. I am conducting survey
research to recognize the persistent overuse injuries occurring in the overhead athlete and
examine the effective ways to treat and prevent these injuries. Specifically this study will
examine the time of the initial onset of these overuse injuries and the initial treatment rendered.
Understanding the effective ways to prevent and treat these injuries at a young age can prevent
the chronic effects associated with overhead overuse injuries.
Overhead athletes participating in baseball, softball, volleyball and swimming at the chosen
Division II and Division III institutions are being asked to participate in this survey; however,
your participation is voluntary and you do have the right to choose not to participate. You also
have the right to discontinue participation at any time during the survey completion process at
which time your data will be discarded. The California University of Pennsylvania Institutional
Review Board has reviewed and approved this project. The approval is effective 01/31/12 and
expires 01/30/13 .
All survey responses are anonymous and will be kept confidential, and informed consent to use
the data collected will be assumed upon return of the survey. Aggregate survey responses will be
housed in a password protected file on the CalU campus. Participants must be 18 years or older in
order to participate in this study. Minimal risk is posed by participating as a subject in this study.
I ask that you please take this survey at your earliest convenience as it will take approximately 20
minutes to complete. If you have any questions regarding this project, please feel free to contact
the primary researcher, Kellie Sullivan at SUL8358@calu.edu. You can also contact the faculty
advisor for this research Thomas F. West, PhD, ATC by email west_t@calu.edu or phone 724938-5933. Thanks in advance for your participation. Please click the following link to access the
survey (INSERT LINK HERE).
Thank you for taking the time to take part in my thesis research. I greatly appreciate your time
and effort put into this task.
Sincerely,
Kellie Sullivan, ATC
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
774-249-4856
SUL8358@calu.edu

152
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156
ABSTRACT
Title:

PERSITENT OVERUSE INJURIES IN THE
OVERHEAD ATHLETE

Researcher:

Kellie A. Sullivan, ATC

Advisor:

Dr. Thomas F. West

Context:

Many overhead athletes are faced with
numerous overhead injuries throughout their
entire career. Many of the athletes are
entering college already having shoulder
instabilities and chronic injuries,
ultimately persisting throughout their
collegiate careers

Objective:

The purpose of this study was to recognize
the persistent overuse injuries occurring in
the overhead athlete and examine the ways
these athletes have attempted to treat and
prevent these injuries. Specifically this
study examined the initial onset of these
overuse injuries and exercises performed.

Design:

Descriptive Study

Setting:

Population-Based Online Survey

Participants:

A total of 59 collegiate athletes on the
baseball, softball, volleyball and swim team
from Division II (n=3)and Division III
(n=1)schools in Pennsylvania and
Massachusetts completed the survey. Fortyeight participants were female (81.4%) and
eleven were male (18.6%).

Interventions: A pilot study was conducted to determine the
reliability of the Overhead Overuse Injury
Survey. The questions and overall survey
displayed a reliability score of .30 or
higher, indicating a moderate to strong
correlation.
Main Outcome Measures:
The independent variable was the athletes’
injury group. This condition had three

157
levels consisting of current history,
previous history and no history. The
dependent variables included the number of
rehabilitation exercises performed and the
number of training exercises performed. The
first hypothesis stated that there will be a
difference in the number of training
exercises regularly performed between the
current history, previous history or no
history injury groups. The second hypothesis
stated that the previous history group will
have performed a higher number of
rehabilitation exercises when compared to
the current history group.
Results:

The mean number of training exercises
performed by the current history, previous
history and no history group were compared
using a one-way ANOVA. No significant
difference was found (F(2,39) = .259, p>
.05). The current history group performed a
mean of 23.1 exercises, compared to the
previous history group who performed a mean
of 26.4 exercises and the no history group
who performed a mean of 20.3 exercises. An
independent t-test was calculated comparing
the mean rehabilitation exercises performed
by participants who currently have an injury
to the mean exercises performed by
participants who had a previous injury. No
significant difference was found (t(13) =
.942, p> .05). The mean number of exercises
performed by the currently injured group
(m=22.3) was not significantly different
from the mean of the previously injured
group (m= 16.8).

Conclusion:

There were no significant differences found
between the number of exercises performed
and the athletes’ injury status. Based on
the results, we can conclude that the number
of exercises performed does not have an
effect on the injury status of the athlete.

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