Physical Therapy in Sport 27 (2017) 65e75

Contents lists available at ScienceDirect

Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Literature Review

The isokinetic rotator cuff strength ratios in overhead athletes:

Assessment and exercise effect
Kelly Berckmans, PT a, *, Annelies G. Maenhout, PhD, PT b, Lien Matthijs, PT b,
Louise Pieters, PT b, Birgit Castelein, PhD, PT b, Ann M. Cools, PhD, PT b
a
Ghent University, Department of Rehabilitation Sciences and Physiotherapy, Campus Heymans 3B3, De Pintelaan 185, 9000 Ghent, Belgium
b
Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University Hospital, Ghent, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Muscle strength imbalance in the shoulder region can be considered as a predisposing factor
Received 15 September 2016 in the development of movement dysfunctions, possibly leading to overuse injuries. Repetitive overhead
Received in revised form throwing, performed in sports, may result in muscle imbalance between the external (ER) and internal
19 January 2017
(IR) rotators. Muscle strength measured with an isokinetic device, is reported as a concentric (CON) or
Accepted 6 March 2017
eccentric (ECC) force. The balance between an agonist and an antagonist is mentioned as a ratio (CON/
CON or ECC/CON). The aim of this systematic literature review is to provide an overview of the existing
Keywords:
evidence considering the isokinetic muscle strength ratios of ER and IR of the shoulder in healthy
Shoulder
Isokinetic strength
overhead athletes. In addition, the effect of exercise programs on these ratios was investigated.
Functional deceleration ratio Methods: Two online databases (Web of Science and PubMed) were consulted using different search
Overhead sports strategies. Articles were selected based on inclusion and exclusion criteria. All included articles were
assessed on their methodological quality.
Results and conclusions: There is moderate evidence for a lower functional deceleration ratio (ECC ER/
CON IR) at the dominant side. This lower ratio is due to a large overweight of CON IR strength on that
side. There is no consensus about which exercise program is the most effective in altering the shoulder
isokinetic strength ratios.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction rotator cuff (RC) muscles are seen as the most important dynamic
stabilizers of the glenohumeral joint (van der Helm, 1994). A
The prevalence of shoulder problems in upper extremity sports balanced force couple ratio between the external and internal
amount to 44% with throwing related pain as the main complaint rotators is considered to be essential to ensure permanent
(Lo, Hsu, & Chan, 1990). The shoulder pain are largely attributed to centering of the humeral head (Codine, Bernard, Pocholle,
repetitive and excessive stress on the shoulder during overhead Benaim, & Brun, 1997). With respect to cut-off values dis-
sports. Such repeated motion is thought to create muscle fatigue, tinguishing a healthy shoulder from a shoulder at risk, an iso-
thereby increasing the risk of shoulder injury by altering muscle kinetic external rotation (ER)/internal rotation (IR) ratio of 66% or
activation patterns, force couples and kinematics in the shoulder an isometric ER/IR ratio of 75e100% (depending on the testing
girdle (Joshi, Thigpen, Bunn, Karas, & Padua, 2011). position) is advised, with a general RC strength increase of 10% of
The glenohumeral joint is the joint with the highest range of the dominant (D) throwing side compared to the non-dominant
motion in the human body. To generate strength and power in this (ND) side (Cools et al., 2016). The presence of significantly
joint, an efficient stabilization mechanism is needed. This stabi- greater IR fatigue resistance without a concomitant increase in ER
lization can be generated by negative pressure and both passive fatigue resistance is thought to predispose athletes for injury
(labrum, ligaments and joint capsule) and active mechanisms (Ellenbecker & Roetert, 1999). In overhead athletes an imbalance
(shoulder musculature) (Wilk, Arrigo, & Andrews, 1997). The in the functional deceleration ratio (FDR) of ECC ER strength over
CON IR strength increases stress on the passive stabilizers, leading
to detrimental translation of the humeral head (David et al., 2000;
* Corresponding author. Hess, 2000; Rizio & Uribe, 2001; Rokito, Jobe, Pink, Perry, & Brault,
E-mail address: [email protected] (K. Berckmans).

http://dx.doi.org/10.1016/j.ptsp.2017.03.001
1466-853X/© 2017 Elsevier Ltd. All rights reserved.
66 K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75

1998). and abstract. For all possible, eligible studies, full texts were
Isokinetic testing is used as an objective technique to evaluate retrieved. In the second phase, selection was based on the full text
CON and ECC strength of the ER and IR. Outcome of this testing articles.
allows comparison of ECC and CON ER and IR strength between the Three assessors searched potential literature for this topic in-
D and ND side. The evaluation of muscle balance is also possible. dependent and blinded from each other. The screening for inclusion
The ratio CON ER strength/CON IR strength is reported as the bal- in both phases were also performed by the 3 assessors independent
ance ratio (BR). The functional deceleration ratio (FDR) is defined as and blinded from each other. If there was any discussion about
the mixed ratio of ECC ER strength/CON IR strength. Especially the inclusion in the first phase, the article was anyway included to
FDR is thought to be of importance for injury prevention (Wang & screen on full text. In the second phase, a consensus meeting was
Cochrane, 2001). Up to now there is no consensus on “the optimal reached in case of discussion.
shoulder ratio” in overhead sports, which causes difficulties in
interpreting isokinetic RC strength evaluation. Also, there is no 2.3. Quality assessment
consensus about the effect of an exercise program on these iso-
kinetic strength ratios. Therefore, this review aims to provide an Methodological quality of the studies was scored by two in-
overview of literature on isokinetic RC strength assessment in an dependent blinded assessors and revised by another indepen-
overhead athlete population, particularly focusing on the RC ratios. dent author. The checklist of the Dutch Institute for Healthcare
The second purpose of this review implies to summarize the Improvement CBO (www.cbo.nl/en) was used for Randomized
available evidence on the potential effect of exercises on these Controlled Trials (RCT), prospective cohort study and cross-
isokinetic strength ratios. sectional studies. A score was attributed to each article based
on nine criteria for a RCT, eight criteria for prospective cohort
2. Methods study or six criteria for a cross-sectional study (Table 1). RCT's
were scored on randomization, blinding of randomization,
This systematic review has been compiled according to the blinding of participants, blinding of therapists, blinding of as-
PRISMA (Preferred Reporting Items for Systematic reviews and sessors, equal exposure of both groups, loss-to-follow-up,
Meta-Analyses) guidelines (Liberati et al., 2009; Moher, Liberati, intention-to-treat analysis and comparability of treatment.
Tetzlaff, & Altman, 2009). No systematic literature reviews on the Cross-sectional studies were scored on reference test, blinded
same to this topic were found. assessment, independent evaluation index test, work-up of
verification bias, paradox of treatment and selection bias for
2.1. Identification and selection of the literature study inclusion. Furthermore, prospective cohort studies were
scored on description of patients, selection bias, exposure
The search strategy was based on a combination of key words comparable, outcome, blind evaluation, follow-up, loss-to-
derived from the PICOS (Population e Intervention e Compari- follow up and accounting for confounders. For each of the
son e Outcome e Study design) question. Selected articles had to criteria fulfilled, the study received one point (þ). A negative
report the results of clinical trials (S) evaluating isokinetic ECC score () was attributed when criteria were not attained or
and CON RC strength (O) in healthy overhead athletes (P) when there was a lack of information. After rating the selected
comparing the D and ND shoulder within this group or compared articles, results of both reviewers were compared and the points
to a non-athletic population (C). In addition, studies including of difference were discussed after a second screening of the
evaluation of the effect of an exercise program (I) on isokinetic manuscript.
RC strength (O) in a population of overhead athletes (P) were also Based on the study design and the methodological quality, a
searched. level of evidence was attributed to the studies. Afterwards a
Articles were searched in PubMed (http://www.ncbi.nlm.nih. strength of conclusion was determined based on the level of evi-
gov/entrez) and Web of Science (http://isiwebofknowledge.com). dence.1 A strength of conclusion of level 2 means that 2 studies
Search strategies were last executed on 31st August 2015. In addi- were independently executed from each other.
tion, hand searching using reference lists of relevant published
articles was performed to make the search as complete as possible. 2.4. Data extraction
Several search strategies were used before finding the final search
strategy who reported the most relevant studies. From each study, information was extracted and presented in an
The final search strategy was based on a combination of the evidence table (Appendix 1) regarding: (1) sports discipline and
following Mesh-terms or free-text words: (“Athletes” (MESH) OR characteristics of study group (and controls), (2) inclusion criteria
“Tennis”) AND “Rotator cuff” (MESH) AND (“Strength” (MESH) OR and exclusion criteria, (3) comparators, (4) outcome measures, (5)
“Eccentric”). intervention (if study with an intervention), (6) follow up, (7) main
results of strength and (8) main results of ratios. Three assessors
2.2. Study selection extracted the information independently. After comparison, the
final table of evidence was composed.
To be included in this systematic literature review, articles had
to fulfill the following inclusion criteria (1) subjects were healthy
3. Results
overhead athletes performing one of the following overhead sports
disciplines: baseball, volleyball, tennis, badminton or handball (2)
3.1. Study selection
subjects were without history of shoulder injuries (3) the article
reported isokinetic testing and (4) was written in English (5) a full
As shown in the flowchart (Fig. 1), 158 potentially relevant
text report of the original research was available without need to
purchase the article. Studies were excluded based on the following
criteria: population (1) underwent a surgical shoulder intervention 1
Evidence-based Richtlijnontwikkeling. Handleiding voor werkgroepleden.
(2) suffered from shoulder pain, or (3) were wheelchair athletes. (2007). Consulted on Oktober 2015 at http://www.ha-ring.nl/download/literatuur/
In the first phase, the selection criteria were only applied to title EBRO_handl_totaal.pdf.
K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75 67

Table 1
Methodological quality.

Article Study type 1 2 3 4 5 6 7 8 9 Score Score (%) Level of evidence

Andrade Mdos et al. (2010) CS þ ? þ þ þ þ 5/6 83.3% B

Carter et al. (2007) RCT ? ? e e e þ þ þ þ 4/9 44.4% B
Ellenbecker et al. (1988) RCT þ þ e e e ? ? þ þ 4/9 44.4% B
Forthomme et al. (2013) Prospective þ e þ þ ? þ þ þ 6/8 75% B
cohort
Mont et al. (1994) RCT þ þ e e e þ e þ þ 5/9 55.6% B
Ng and Lam (2002) CS þ ? þ þ þ þ 5/6 83.3% B
Niederbracht et al. (2008) RCT e e e e e þ ? þ þ 3/9 33.3% B
Noffal (2003) CS þ þ þ þ þ þ 6/6 100% B
Saccol et al. (2010) CS þ ? þ þ þ þ 5/6 83.3% B
Scoville et al. (1997) CS þ ? þ þ þ þ 5/6 83.3% B
Stickley et al. (2008) CS þ ? þ þ þ ? 4/6 66.7% B
Wang et al. (2000) CS þ ? þ þ þ þ 5/6 83.3% B
Yildiz et al. (2006) CS þ ? þ þ þ þ 5/6 83.3% B
Zanca et al. (2011) CS þ þ þ þ þ þ 6/6 100% B

þ ¼ yes, - ¼ no, ? ¼ lack of information.

CS (cross-sectional study): 1 ¼ reference test, 2 ¼ blind evaluation, 3 ¼ independent evaluation index test, 4 ¼ work-up of verification bias, 5 ¼ paradox of treatment,
6 ¼ selection bias for study inclusion.
RCT (randomized clinical trial): 1 ¼ randomization, 2 ¼ blindness of randomization, 3 ¼ blindness of patients, 4 ¼ blindness of therapists, 5 ¼ blindness of research team,
6 ¼ equality of groups, 7 ¼ loss-to-follow up, 8 ¼ intention-to-treat analysis, 9 ¼ comparability of treatment.
PROSPECTIVE COHORT STUDY: 1 ¼ description patients, 2 ¼ selection bias, 3 ¼ exposure comparable, 4 ¼ outcome, 5 ¼ blind evaluation, 6 ¼ follow-up, 7 ¼ loss to follow up,
8 ¼ accounted for confounders.

publications were identified of which 14 remained after the two players, 1 on handball players, 1 on badminton players and 3 on
screening phases and removing duplicates. Of the 14 studies mixed sports disciplines).
included in this review, nine were cross-sectional studies, four Isokinetic strength of the shoulder rotators was assessed in all
randomized controlled trials and one prospective cohort study 14 studies, with 12 studies measuring both CON and ECC for ER and
(Andrade Mdos et al., 2010; Carter et al., 2007; Ellenbecker, IR (Andrade Mdos et al., 2010; Ellenbecker et al., 1988; Forthomme
Davies, & Rowinski, 1988; Forthomme, Wieczorek, Frisch, et al., 2013; Mont et al., 1994; Ng & Lam, 2002; Noffal, 2003; Saccol
Crielaard, & Croisier, 2013; Mont, Cohen, Campbell, Gravare, & et al., 2010; Scoville et al., 1997; Stickley et al., 2008; Wang et al.,
Mathur, 1994; Ng & Lam, 2002; Niederbracht, Shim, Sloniger, 2000; Yildiz et al., 2006; Zanca et al., 2011). The other 2 studies
Paternostro-Bayles, & Short, 2008; Noffal, 2003; Saccol et al., measured IR only CON and ER only ECC (Carter et al., 2007;
2010; Scoville, Arciero, Taylor, & Stoneman, 1997; Stickley, Hetzler, Niederbracht et al., 2008).
Freemyer, & Kimura, 2008; Wang, Macfarlane, & Cochrane, 2000; Eight studies compared isokinetic strength between the D and
Yildiz et al., 2006; Zanca, Oliveira, Saccol, Ejnisman, & Mattiello- ND shoulder in overhead athletes (Andrade Mdos et al., 2010;
Rosa, 2011). Forthomme et al., 2013; Ng & Lam, 2002; Noffal, 2003; Saccol
et al., 2010; Scoville et al., 1997; Wang et al., 2000; Yildiz et al.,
2006). One study compared the D side of healthy athletes with
3.2. Risk of bias and level of evidence
athletes who had an injury in the past (Stickley et al., 2008).
Another study compared the D side of healthy athletes with a
The risk of bias and level of evidence of the different studies
control group or with athletes with shoulder impingement syn-
are reported in Table 1. In 93% (91/98) of cases, authors agreed for
drome (Zanca et al., 2011). Four studies investigated the effect of
the scoring of different items of methodological quality. All
an exercise program on isokinetic ECC ER strength (Carter et al.,
studies achieved a level B on the assessment of level of evidence.
2007; Ellenbecker et al., 1988; Mont et al., 1994; Niederbracht
A level B considered randomized clinical trials (non-double
et al., 2008). Only Carter et al. reported the effect on the FDR
blinded) of moderate quality or insufficient size or other
and the results of statistical analysis on the FDR (Carter et al.,
comparative studies (non-randomized cohort studies, case
2007).
control).
Results (PT/BW ¼ peak torque-to-body weight) of isokinetic
None of the RCT's blinded their participants, therapists or
testing of the shoulder rotators of the D and ND side in healthy
research team for group allocation. Three RCT's did not report loss-
overhead athletes were extracted from all studies, included in this
to-follow up (Ellenbecker et al., 1988; Mont et al., 1994;
review and brought together in Tables 2e4 to give an overview.
Niederbracht et al., 2008). Only two of the nine cross-sectional
When original results were expressed as peak torques (N m),
studies reported that outcome evaluation was performed blinded
normalization to mean body weight of the group was performed
(Noffal, 2003; Zanca et al., 2011). Besides the prospective cohort
by the authors of this review. The authors computed the
study did not mention if the evaluation of the outcome variables
normalization for 8 article, one article reported PT/BW (Andrade
was blinded (Forthomme et al., 2013).
Mdos et al., 2010; Forthomme et al., 2013; Mont et al., 1994;
Niederbracht et al., 2008; Noffal, 2003; Saccol et al., 2010;
3.3. Study characteristics Scoville et al., 1997; Stickley et al., 2008; Zanca et al., 2011). Five
studies did not include numerical data tables of the mean PT (¼
All studies included participants involved in overhead sports (4 peak torque) or enough information in their manuscript and could
studies on tennis players, 3 on volleyball players, 2 on baseball
68 K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75

PotenƟally relevant citaƟons

idenƟfied: 211

AddiƟonal potenƟally relevant

citaƟons (hand searching): 1
Duplicates: 54

PotenƟally relevant citaƟons aŌer

removing duplicates: 158

Based on Ɵtle and abstract

evaluaƟon, citaƟons excluded: 126
Reasons:
PopulaƟon: 57
IntervenƟon: 32
Outcome: 37

Studies retrieved for

more detailed evaluaƟon: 32

Based on full text evaluaƟon,

studies excluded: 18
Reasons:
PopulaƟon: 3
IntervenƟon: 0
Outcome: 13
Design: 0
Language: 1
Other: 1

Relevant studies: 14

Fig. 1. Flowchart.

not be normalized (Carter et al., 2007; Ellenbecker et al., 1988; Ng 3.4. Dominant shoulder compared to non-dominant shoulder in
& Lam, 2002; Wang et al., 2000; Yildiz et al., 2006). A few authors overhead athletes
wrote the BR in their manuscript (Andrade Mdos et al., 2010;
Noffal, 2003; Saccol et al., 2010). Concerning the FDR, 7 articles Six out of eight articles found moderate evidence for a higher
mentioned the ratio whereas the authors computed the FDR for 4 CON and ECC IR PT/BW at the D compared to the ND side of over-
of the included studies (Andrade Mdos et al., 2010; Carter et al., head athletes (strength of conclusion 2) (Andrade Mdos et al., 2010;
2007; Forthomme et al., 2013; Mont et al., 1994; Niederbracht Forthomme et al., 2013; Noffal, 2003; Saccol et al., 2010; Wang
et al., 2008; Noffal, 2003; Saccol et al., 2010; Scoville et al., 1997; et al., 2000; Yildiz et al., 2006). Scoville et al. showed only a dif-
Stickley et al., 2008; Yildiz et al., 2006; Zanca et al., 2011). For 3 ference between sides (D > ND) for ECC IR PT/BW (Scoville et al.,
of them, the FDR was not mentioned in the manuscript and 1997). All studies except three showed a moderate evidence for a
couldn't be computed by the authors (Ellenbecker et al., 1988; Ng higher CON ER PT/BW at the D side and all but four studies showed
& Lam, 2002; Wang et al., 2000). higher ECC ER PT/BW at the D side (strength of conclusion 2)
(Andrade Mdos et al., 2010; Forthomme et al., 2013; Ng & Lam,
K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75 69

Table 2
Overview results PT/BW e concentric ER and IR.

Test Speed Study Sports Gender Da NDb D D-ND ((D-ND/D))

CON ER 60 /s Andrade Mdos et al., (2010) handball female 0.35 0.34 2.86%
Forthomme et al., (2013) volleyball mixed 0.40 0.41 0.03%
Mont et al., (1994) tennis male 0.87
Saccol et al., (2010) tennis male 0.38 0.35 7.89%
Saccol et al., (2010) tennis female 0.30 0.27 10.00%
Stickley et al., (2008) volleyball female 0.27
90 /s Scoville et al., (1997) mixed male 0.19 0.18 5.26%
Zanca et al., (2011) mixed male 0.48
180 /s Andrade Mdos et al., (2010) handball female 0.32 0.30 6.25%
Mont et al., (1994) tennis male 0.65
Saccol et al., (2010) tennis male 0.33 0.30 9.09%
Saccol et al., (2010) tennis female 0.24 0.23 4.17%
Zanca et al., (2011) mixed male 0.46
240 /s Forthomme et al., (2013) volleyball mixed 0.33 0.33 0.00%
300 /s Andrade Mdos et al., (2010) handball female 0.29 0.25 13.79%
Noffal (2003) baseball male 0.37 0.36 2.70%

Mean difference D e ND 5.63%

CON IR 60 /s Andrade Mdos et al., (2010) handball female 0.45 0.40 11.11%
Forthomme et al., (2013) volleyball mixed 0.56 0.50 12.00%
Mont et al., (1994) tennis male 0.85
Saccol et al., (2010) tennis male 0.48 0.41 14.58%
Saccol et al., (2010) tennis female 0.40 0.28 30.00%
Stickley et al., (2008) volleyball female 0.37
90 /s Scoville et al., (1997) mixed male 0.26 0.26 0.00%
Zanca et al., (2011) mixed male 0.53
120 /s Niederbracht et al., (2008) tennis female 0.67
180 /s Andrade Mdos et al., (2010) handball female 0.40 0.35 12.50%
Mont et al., (1994) tennis male 0.62
Saccol et al., (2010) tennis male 0.43 0.36 16.28%
Saccol et al., (2010) tennis female 0.35 0.24 31.43%
Zanca et al., (2011) mixed male 0.51
240 /s Forthomme et al., (2013) volleyball mixed 0.46 0.41 10.87%
300 /s Andrade Mdos et al., (2010) handball female 0.36 0.30 16.67%
Noffal (2003) baseball male 0.57 0.50 12.28%

Mean difference D e ND 15.25%

a
Reporting PT/BW for dominant side. Author calculated PT/BW when it was not clearly reported in the articles.
b
Reporting PT/BW for non-dominant side. Author calculated PT/BW when it was not clearly reported in the articles.

2002; Noffal, 2003; Saccol et al., 2010; Scoville et al., 1997; Wang 2008).
et al., 2000; Yildiz et al., 2006). All studies except one, showed a moderate evidence for an in-
When taking into account all the results of the studies crease of CON IR strength after exercising in experimental groups
comparing D side with ND side, there is moderate evidence for a (strength of conclusion 2) (Carter et al., 2007; Ellenbecker et al.,
larger overweight for IR force at de D side compared to ER force for 1988; Mont et al., 1994; Niederbracht et al., 2008). Niederbacht
CON and ECC (strength of conclusion 2) (Andrade Mdos et al., 2010; et al. reported no difference for CON IR after strength training of the
Forthomme et al., 2013; Noffal, 2003; Saccol et al., 2010; Scoville shoulder (Niederbracht et al., 2008). Regarding to ECC ER strength,
et al., 1997). The CON IR force showed a mean difference of moderate evidence for an increase was reported after exercises in
15.25% and ECC IR a mean difference of 14.77%. The CON ER, who all studies (Carter et al., 2007; Ellenbecker et al., 1988; Mont et al.,
presented lower PT/BW, has a mean difference of 5.63% and 2.89% 1994; Niederbracht et al., 2008). Both, CON ER and ECC IR strength
for the ECC ER. This is also expressed in the lower FDR at the D increased after exercises in experimental group (strength of
shoulder. The mean difference between the FDR of the D and ND conclusion 2) (Ellenbecker et al., 1988; Mont et al., 1994).
side amounts 17.39%. Only one study found a slightly higher mean As mentioned above, only the study of Carter et al. investigated
difference (6.52%) for FDR at the D shoulder of overhead athletes the FDR where no significant differences between training-groups
involved in mixed sports disciplines (Scoville et al., 1997). were found (Carter et al., 2007). However, when the authors of
this review computed the data of pre- and post-test themselves,
two studies report an increase of the FDR after training (Mont et al.,
3.5. The effect of exercises on isokinetic strength and strength ratio 1994; Niederbracht et al., 2008).

Four out of the 14 included articles investigated the effect of an

exercise program (plyometric training, general shoulder strength 4. Discussion
training and isokinetic training) on the isokinetic strength of in-
ternal and external shoulder rotators (Carter et al., 2007; The aim of the present systematic literature review was to give
Ellenbecker et al., 1988; Mont et al., 1994; Niederbracht et al., an overview of the evidence of isokinetic strength and strength
70 K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75

Table 3
Overview results PT/BW e eccentric ER and IR.

Test Speed Study Sports Gender Da NDb D D-ND ((D-ND/D))

ECC ER 60 /s Forthomme et al., (2013) volleyball mixed 0.53 0.54 1.89%
Mont et al., (1994) tennis male 0.57
Saccol et al., (2010) tennis male 0.43 0.39 9.30%
Saccol et al., (2010) tennis female 0.36 0.31 13.89%
Stickley et al., (2008) volleyball female 0.39
90 /s Scoville et al., (1997) mixed male 0.24 0.23 4.17%
Zanca et al., (2011) mixed male 0.52
120 /s Niederbracht et al., (2008) tennis female 0.84
180 /s Andrade Mdos et al., (2010) handball female 0.47 0.45 4.26%
Mont et al., (1994) tennis male 0.41
Saccol et al., (2010) tennis male 0.45 0.42 6.67%
Saccol et al., (2010) tennis female 0.36 0.36 0.00%
Zanca et al., (2011) mixed male 0.56
300 /s Andrade Mdos et al., (2010) handball female 0.52 0.51 1.92%
Noffal (2003) baseball male 0.65 0.73 12.31%

Mean difference D e ND 2.89%

ECC IR 60 /s Forthomme et al., (2013) volleyball mixed 0.63 0.58 7.94%
Mont et al., (1994) tennis male 0.65
Saccol et al., (2010) tennis male 0.54 0.43 20.37%
Saccol et al., (2010) tennis female 0.42 0.31 26.19%
Stickley et al., (2008) volleyball female 0.54
90 /s Scoville et al., (1997) mixed male 0.32 0.31 3.13%
Zanca et al., (2011) mixed male 0.72

180 /s Andrade Mdos et al., (2010) handball female 0.51 0.45 11.76%
Mont et al., (1994) tennis male 0.46
Saccol et al., (2010) tennis male 0.50 0.43 14.00%
Saccol et al., (2010) tennis female 0.42 0.32 23.81%
Zanca et al., (2011) mixed male 0.70
300 /s Andrade Mdos et al., (2010) handball female 0.54 0.49 9.26%
Noffal (2003) baseball male 0.85 0.71 16.47%

Mean difference D e ND 14.77%

a
Reporting PT/BW for dominant side. Author calculated PT/BW when it was not clearly reported in the articles.
b
Reporting PT/BW for non-dominant side. Author calculated PT/BW when it was not clearly reported in the articles.

Table 4
Overview results PT/BW e functional deceleration ratio ECC ER/CON IR.

Test Speed Study Sports Gender Da NDb D D-ND ((D-ND/D))

Ratio ECC ER/CON IR 60 /s Forthomme et al., (2013) volleyball mixed 0.94 1.08 14.89%
Mont et al., (1994) tennis male 0.67
Saccol et al., (2010) tennis male 0.84 1.11 32.14%
Saccol et al., (2010) tennis female 0.91 1.03 13.19%
Stickley et al., (2008) volleyball female 1.05
90 /s Scoville et al., (1997) mixed male 0.92 0.86 6.52%
Yildiz et al., (2006) mixed male 1.03 1.19 15.53%
Zanca et al., (2011) mixed male 0.92
120 /s Niederbracht et al., (2008) tennis female 1.26
180 /s Andrade Mdos et al., (2010) handball female 1.21 1.32 9.09%
Carter et al., (2007) baseball 1.14
Mont et al., (1994) tennis male 0.66
Saccol et al., (2010) tennis male 0.97 1.20 23.71%
Saccol et al., (2010) tennis female 1.12 1.45 29.46%
Zanca et al., (2011) mixed male 1.10
(60 /s)/(240 /s) Forthomme et al., (2013) volleyball mixed 1.27 1.47 15.75%
300 /s Andrade Mdos et al., (2010) handball female 1.54 1.81 17.53%
Carter et al., (2007) baseball 1.30
Noffal (2003) baseball male 1.17 1.48 26.50%

Mean difference D e ND ¡17.39%

a
Reporting PT/BW for dominant side. Author calculated PT/BW when it was not clearly reported in the articles.
b
Reporting PT/BW for non-dominant side. Author calculated PT/BW when it was not clearly reported in the articles.

ratios measurements of both IR and ER of the shoulder in healthy This systematic review is the first to describe the current evi-
overhead athletes. Also, the effect of an exercise program on iso- dence of isokinetic strength measurements in the shoulder IR and
kinetic strength and strength ratio was summarized. ER in overhead athletes and the first to describe the effect of
K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75 71

exercises on these measurements. All 14 included articles had a & Lam, 2002; Niederbracht et al., 2008; Scoville et al., 1997; Stickley
level B of evidence and measured the ECC ER and the CON IR et al., 2008; Zanca et al., 2011). In addition, the abduction of the arm
strength in different sports disciplines (e.g. volleyball, baseball, (range from 30 to 90 ) and the position of the wrist differed
handball, tennis, badminton and mixed sports). The strength values (pronated or neutral wrist position) between studies. No studies
were expressed as peak force, except one (Ng & Lam, 2002). Ng used the position that represents the sporting posture.
et al. reported all results in total work normalized to body weight (J/ Also, the isokinetic speeds varied between 30 and 300 /s
kg) (Ng & Lam, 2002). In order to compare between subjects, values concentrically and between 30 and 300 /s eccentrically. The
were normalized to BW. amount of repetitions of different velocities also varied between
The results of this systematic review reveal moderate evidence studies.
that in overhead athletes the D shoulder shows higher CON and ECC In order to decrease the risk of injury and improve the FDR in
IR strength compared to the ND side. For ER strength, conflicting overhead athletes, an ECC exercise program is often recom-
results are reported. Most studies reported higher values for (both mended for the RC muscles. However, this advice is not supported
ECC and CON) strength of ER at the D side (Andrade Mdos et al., by evidence. The exercise programs that were used in the included
2010; Noffal, 2003; Saccol et al., 2010; Scoville et al., 1997; Yildiz articles show substantial differences. Carter et al. used a ballistic
et al., 2006). However, a few studies mentioned a lower CON ER six plyometric training which consisted of 6 upper extremity
and ECC ER strength at the D side (Forthomme et al., 2013; Noffal, plyometric exercises commonly used in the advanced stages of
2003; Wang et al., 2000; Yildiz et al., 2006). Only Wang et al. re- rehabilitation (Carter et al., 2007). On the other hand Niederbacht
ported no difference between the D side and ND side regarding the et al. used a shoulder strength exercise program (Niederbracht
ECC ER strength (Wang et al., 2000). et al., 2008). Both studies differ in imposed modalities to the
The results from this systematic review with respect of the subjects. Athletes performed the exercises twice a week for 8
CON ER/CON IR ratio or BR show a range between 0.46 and 1.05 weeks or 4 times a week during 5 weeks (Carter et al., 2007;
(depending on the testing protocol). Most of the studies reported Niederbracht et al., 2008). Two other studies used an isokinetic
a lower BR at the D side compare to the ND side (Andrade Mdos exercise program, where also the modalities of the used velocity
et al., 2010; Forthomme et al., 2013; Noffal, 2003; Saccol et al., and amount of repetitions differ (Ellenbecker et al., 1988; Mont
2010; Wang et al., 2000; Yildiz et al., 2006). In contrast, Scoville et al., 1994). The comparison of the 4 studies was difficult
et al. mentioned a higher BR at the D side (Scoville et al., 1997). As through the difference of used training program. Nevertheless, all
well as the BR, the FDR, which is the ECC ER/CON IR ratio, seem to reported a gain in ECC ER strength after performing an exercise
be lower at the dominant side (Andrade Mdos et al., 2010; program (Carter et al., 2007; Ellenbecker et al., 1988; Mont et al.,
Forthomme et al., 2013; Noffal, 2003; Saccol et al., 2010; Yildiz 1994; Niederbracht et al., 2008). However, Ellenbecker et al. re-
et al., 2006). Scoville et al. reported the same result as BR ported no significant increase of ECC ER strength in the ECC
regarding to FDR, namely a higher ratio at D side (Scoville et al., training group at both 60 /s and 180 /s (Ellenbecker et al., 1988).
1997). The FDR range between 0.66 and 1.54 (depending on the In contrast, Mont et al., observed an increase of ECC ER strength in
testing protocol). the ECC training group at both 60 /s and 180 /s (Mont et al., 1994).
Regarding the effect of exercises on RC strength and strength Both studies reported an increase of ECC ER strength from groups
ratios, in general an increase of both concentric and eccentric who practiced a CON isokinetic training program. To date, there is
strength of internal and external rotators is shown after an exercise no consensus regarding the most appropriate exercise program to
protocol. However, conflicting results on the effect of an exercises improve eccentric ER strength and therefore influence the FDR in
program on the FDR are reported. a positive way.
Comparison between the different studies was difficult due to
several factors. Not all 14 articles reported information regarding
body weight, which made comparison between studies rather 5. Conclusion
difficult. The authors calculated the PT/BW to normalize the data
and to simplify the comparison, however no statistical analyses In healthy overhead athletes, it was shown that the D side had
could be made with those results. The interpretation of the results a higher CON and ECC IR strength compared with the ND side.
might be comprised because of this reason. There is less consensus about the CON and ECC ER force. The BR
The large variety in testing protocols also restrained the com- and FDR seem to be lower at the D side. The BR ranges between
parison between studies. Different devices were used: a Cybex 0.46 and 1.05, relative to a range between 0.66 and 1.54 for the
isokinetic system was used in 5 studies (Andrade Mdos et al., 2010; FDR.
Forthomme et al., 2013; Ng & Lam, 2002; Saccol et al., 2010; Yildiz Several studies utilizing shoulder strength exercises has resul-
et al., 2006). Four other studies used a KinCom dynamometer and ted in an increase of both ECC and CON IR and ER strength. However
also the Biodex isokinetic dynamometer was used (Carter et al., there is no consensus about which combination of exercises is the
2007; Mont et al., 1994; Niederbracht et al., 2008; Noffal, 2003; most appropriate to improve the FDR.
Scoville et al., 1997; Stickley et al., 2008; Wang et al., 2000; Zanca
et al., 2011). Ellenbecker et al. tested with two devices: a KinCom
dynamometer for ECC strength and a Cybex isokinetic system for Funding
CON testing (Ellenbecker et al., 1988).
Besides the device, the test position also varied. Most studies The authors declare that no funding was received for this work.
used the supine position (Andrade Mdos et al., 2010; Carter et al.,
2007; Ellenbecker et al., 1988; Forthomme et al., 2013; Noffal,
2003; Saccol et al., 2010; Wang et al., 2000; Yildiz et al., 2006). Acknowledgments
Others used the seated or half-seated position (Mont et al., 1994; Ng
None.
72
Appendix 1. Evidence table of included studies

Author, year of Characteristics of study group Inclusion and/or exclusion Comparators Outcome measures Intervention Follow up Main results: strength Main results: ratio's
publication criteria

Andrade Mdos 27 athletes Inclusion: No pain in upper ND side D and ND side con IR- 1) Con IR and ER: D BR
et al. (2010) Handball limb last 12 months ER at 60 /s, 180 /s side > ND side for all testing(con ER/con IR)
National team Exclusion: Fracture or and 300 /s speeds (significantly) 1) At 60 /s ¼ 0.79
(23.0 ± 3.4 years, M/F: 0/27) surgery upper limb last 12 D and ND side ecc IR- 2) Ecc IR: D side > ND side 2) At 180 /s ¼ 0.82
months ER at 180 /s and for both testing speeds 3) At 300 /s ¼ 0.81 D side < ND side
300 /s (significantly) FDR
(ecc ER/con IR)
1) At 180 /s ¼ 1.21 ± 0.28 D
side < ND side (not significant)
2) At 300 /s ¼ 1.54 ± 0.41 D
side < ND side (significant)
Carter et al. 24 athletes Exclusion: Shoulder/elbow No plyometric D side con IR 180 /s Ballistic six 8 weeks, AFTER TRAINING: BR
(2007) Baseball surgery; shoulder/elbow exercises (only off- and 300 /s plyometric training (6 2x a week 1) At 180 /s: (con ER/con IR) No report of data

K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75

Division I (19.7 ± 1.3 years, M/ injury past year season strength D side ecc ER at 180 / exercises) [ pre-post for ecc ER in FDR
F:24/0) and conditioning s and 300 /s training group (significant) (ecc ER/con IR)
Training group (n ¼ 13) activities) [ pre-post training for con 1) At 180 /s ¼ 1.14 (pre mean both
Control group (n ¼ 11) IR in both groups groups)
(significant) No significant s pre-post for both
2) At 300 /s: groups
[ pre-post for ecc ER in 2) At 300 /s: 1.30 (pre mean both
both groups (significant) groups) No significant s pre-post
[ pre-post for con IR in for both groups
training group (significant)
Ellenbecker 22 athletes Injury UL or back Con training >< ecc D side con IR-ER at Isokinetic exercises 6 weeks, AFTER TRAINING: BR
et al. (1988) College varsity tennis players training 60 /s, 180 /s and (or concentric, or 2x a week 1) [ pre-post con strength (con ER/con IR) No report of data
Group 1: ecc training 210 /s eccentric): 6 x 10 IR & ER in con training FDR
Group 2: con training D side ecc IR-ER at repetitions at 60 , group and ecc training (ecc ER/con IR)
60 /s, 180 /s and 180 , 210 , 210 , group (significant) No report of data
210 /s 180 , 60 (100 ice 2) [ pre-post ecc strength
application) in con training group
(significant)
3) [ pre-post ecc strength
in ecc training group (not
significant)
Forthomme 66 athletes Inclusion: ND side D side and ND side 1) Con IR: D side > ND side BR
et al. (2013) Volleyball First and second division No injury compared con IR-ER at 60 /s and (highly significant) (con ER/con IR)

(24 ± 5 years, M/F: 34/32) (Be, Fr, Lux, Nl); to shoulder pain 240 /s 2) Con ER: D side s ND side 1) At 60 /s ¼ 0.71
Being considered fit for history D side and ND side (not significant) 2) At 240 /s ¼ 0.72 D side < ND side
competitive volleyball Risk factors for ecc IR-ER at 60 /s (highly significant)
activity by the team's injury in season FDR
medical staff; (ecc ER/con IR) ¼ 1.27 ± 0.32
Being normally involved in D side < ND side (highly significant)
training sessions through
the start of the new season
Mont et al. 30 athletes Inclusion: No specific D side con IR-ER at 60 Isokinetic training 6 weeks, AFTER TRAINING: BR
(1994) Tennis Minimum National Tennis shoulder training and 180 /s (concentric or 3x a week 1) [ pre-post for all types of (con ER/con IR)
(33 years, M/F: 30/0) Rating of 5 (control group) D side ecc IR-ER at 60 eccentric): 8x 10 strength training 1) At 60 /s ¼ 1.02 (pre mean all
Group 1: n ¼ 8 Exclusion: and 180 /s submaximal 2) Training group s control groups)
eccentric training Poor serve technique, repetitions at 90 , (significant) 2) At 180 /s ¼ 1.05 (pre mean all
Group 2: n ¼ 9 concentric shoulder injury or surgery 120 , 150 , 180 , groups)
training last 6 months 180 , 180 , 120 , 90 FDR
Group 3: n ¼ 13 (ecc ER/con IR)
control 1) At 60 /s ¼ 0.67 (pre mean all
groups)
2) At 180 /s ¼ 0.66 (pre mean all
groups)
Ng and Lam 25 athletes Inclusion: ND side D side and ND side All results reported in total All results reported in total work
(2002) Badminton At least 5 years of con IR-ER at 120 /s work normalized to body normalized to body weight (J/kg)
(29.4 ± 6.1 years, M/F: 25/0) badminton training (club D side and ND side weight (J/kg) Ratio ecc ER/con IR D side < ND side

level or above, more than ecc IR-ER at 120 /s 1) Ecc IR D side > ND side (significant)
4.5h training a week) (significant)
Exclusion: 2) Ecc ER no s between
Shoulder pain, laxity, sides
surgery or shoulder injury 3) Con IR: D side > ND side
last 12 months (significantly)
4) Con ER: D side s ND side
(not significant)
Niederbracht 12 athletes Tennis Exclusion: No specific D side con IR at 120 /s Strength training 5 weeks, AFTER TRAINING: BR
et al. (2008) Experimental group: n ¼ 6 Specific shoulder strength shoulder strength D side ecc ER at 120 / shoulder (External 4x a week 1) Con IR: pre-post no (con ER/con IR) No report of data
(20.0 ± 1.8 years, M/F: 0/6) training last 6 months, training (control s Rotation 90 , Seated difference FDR
Control group: n ¼ 6 (18.8 ± 0.8 shoulder pain or surgery group) Row, Scaption, Chest 2) Ecc ER: [pre-post in (ecc ER/con IR)
years, M/F: 0/6) last 12 months Press, and External experimental group 1) At 120 /s ¼ 1.33 (control group)
Shoulder Rotation) 3 (significant) 2) At 120 /s ¼ 1.19 (experimental
x 15 each exercise group)

K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75

Noffal (2003) 59 participants Inclusion: ND side D side and ND side 1) Con IR: D side > ND side BR
Baseball Non-thrower group: not Throwers con IR-ER at 300 /s 2) Con ER: D side > ND side (con ER/con IR) ¼ 0.65 ± 0.08 D
Thrower group: participating in overhead compared to non- D side and ND side 3) Ecc IR: D side > ND side side < ND side
16 athletes sports activities throwers ecc IR-ER at 300 /s 4) Ecc ER: D side < ND side FDR
Division I (20.1 ± 1.3 years, M/ Exclusion: (ecc ER/con IR) ¼ 1.17 ± 0.20
F:16/0) History of shoulder pain, D side < ND side
Non-thrower group: 43 students discomfort or weakness
(23.2 ± 3.7 years, M/F: 43/0) during activity
Saccol et al. 40 junior athletes Inclusion: ND side D side and ND side 1) Performance BR
(2010) Tennis (14 years, M/F: 26/14) Be part of the Brazilian con IR-ER at 60 /s and men > women (con ER/con IR) ¼ 0.78 at 60 /
tennis confederation, top 180 /s (significantly) s ¼ 0.74 at 180 /s D side < ND side
50 in their category, no D side and ND side 2) Con IR: D side > ND side FDR
shoulder injury ecc IR-ER at 60 /s and (significantly) (ecc ER/con IR) ¼ 0.88 at 60 /
180 /s 3) Ecc IR: D side > ND side s ¼ 1.05 at 180 /s D side < ND side
(significantly) (significant)
4) Con ER: D side > ND side
only in male (significantly)
5) Ecc ER: D side > ND side
only in male (significantly)
Scoville et al. 75 athletes Exclusion: ND side D side and ND side No results BR
(1997) Boxing þ baseball, volleyball, Shoulder instability, con IR-ER at 90 /s (con ER/con IR) ¼ 0.73 D side > ND
handball or a racket sport (19,7 impingement, shoulder D side and ND side side
years, M/F: 75/0) injury ecc IR-ER at 90 /s FDR (ecc ER/con IR) ¼ 0.92 D
side > ND side
Stickley et al. 38 athletes Exclusion: Different skill levels D side con IR-ER at COMPARISON BETWEEN SKILL LEVELS BR
(2008) Volleyball Shoulder pain, shoulder NI compared to PI 60 /s 1) U15 and U14 > U12 in all (con ER/con IR) ¼ 0.73
(13.0 ± 1.6 years, M/F: 0/38) injury D side ecc IR-ER at strength measures no s between PI and NI
Skill level: 60 /s (significant) FDR
U12 (n ¼ 11), U13 (n ¼ 7), U14 2) Con ER: U15 > U13 (ecc ER/con IR) ¼ 1.05
(n ¼ 8), U15 (n ¼ 12) (significant) PI < NI
No Injury (NI): DIFFERENCE BETWEEN INJURY
n ¼ 29 HISTORY GROUPS
Previous Injury (PI): 1) 4 strength measures no
n¼9 s between NI and PI
groups
(continued on next page)

73
(continued )

74
Author, year of Characteristics of study group Inclusion and/or exclusion Comparators Outcome measures Intervention Follow up Main results: strength Main results: ratio's
publication criteria

Wang et al. 10 athletes Inclusion: ND side D side and ND side 1) Con IR: D side > ND side BR
(2000) Volleyball Taking part in training and con IR-ER at 60 /s and (significant) (con ER/con IR) ¼ 0.67 ± 0.16 at 60 /
National team (20.4 ± 1.2 years, competition þ being able to 120 /s 2) Ecc IR: D side > ND side s ¼ 0.69 ± 0.17 at 120 /s D
M/F: 10/0) perform all testing D side and ND side 2) Con ER: D side < ND side side < ND side (significant)
procedures ecc IR-ER at 60 /s and (significant) FDR
Exclusion: 120 /s 2) Ecc ER: D side ¼ ND side (ecc ER/con IR) ¼ no report
Shoulder pain (significant)
Yildiz et al. 40 participantsVolleyball, Inclusion: ND side D side and ND side 1) Ecc IR: D side > ND side BR (end range)
(2006) handball and tennis Be part of “The army con IR-ER at 90 /s (significantly) (con ER/con IR) ¼ 0.46 D side < ND
Cadets Turkish army (17.2 ± 0.7 academy/land forces/ D side and ND side 2) Con IR: D side > ND side side
years, M/F:40/0) national teams” ecc IR-ER at 90 /s (significantly) FDR (end range)
Exclusion: (ecc ER/con IR) ¼ 1.03 D side < ND
Shoulder pain, instability, side (significantly)
shoulder surgery
Zanca et al. 67 participants Inclusion: Athletes with D side con IR-ER at 1) Con IR (at 180 /s): BR
(2011) Baseball (n ¼ 21) Group 1: posterosuperior impingement 4 90 /s and 180 /s healthy athletes > control (con ER/con IR) ¼ 0.91 at 90 /

K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75

Handball (n ¼ 17) shoulder pain, þ healthy athletes D side ecc IR-ER at (significant) s ¼ 0.90 at 180 /s
Volleyball (n ¼ 8) apprehesion/relocation test Athletes 4 control 90 /s and 180 /s FDR
Group 1: or þ Neer/Hawkins/Jobe group non- (ecc ER/con IR) ¼ 0.92 ± 0.17 at 90 /
Athletes with impingement Group 1 and 2: regular overhead athletes s ¼ 0.97 ± 0.16 at 180 /s
(n ¼ 21) (22.1 ± 2.3 years, M/F: involvement in overhead healthy athletes < control
21/0) sports (3x/week) (significantly)
Group 2: Group 3: no involvement in
Healthy athletes (n ¼ 25) overhead sports/upper limb
(21 ± 2.1 years, M/F: 25/0) work, no previous history
Group 3: shoulder/neck injury
Control (n ¼ 21) Exclusion:
(22.2 ± 2.4years, M/F: 21/0) Group 1-2-3: generalized
laxity, systemic/
neurological disease,
shoulder dislocation, head/
neck surgery,
physiotherapy last 12
months

Be: Belgium; con: concentric; D: dominant; ecc: eccentric; ER: external rotators; Fr: France; h: hours; IR: internal rotators; Lux: Luxemburg; M/F: man/female; n: number of participants; ND: non-dominant; NI: no injury; Nl: the
Netherlands; PI: previous injury; UL: upper limb; x: time.
K. Berckmans et al. / Physical Therapy in Sport 27 (2017) 65e75 75

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