Fredrik R. Johansson

Descriptive profile of scapulothoracic position, strength and flexibility variables in adolescent elite tennis players

Study design Descriptive study, cross-sectional design. Background Tennis requires repetitive overhead movement patterns that can lead to upper extremity injury. The scapula plays a vital role in injury-free playing. Scapular dysfunction has been associated with shoulder injury in the overhead athlete. Objectives The purpose of this study was to describe variables regarding scapular position, muscle strength and flexibility in young elite tennis players. Methods Thirty-five adolescent Swedish elite tennis players (19 boys, aged 13.6 (±1.4) years, 16 girls, aged 12.6 (±1.3) years), selected on the basis of their national ranking, underwent a clinical screening protocol consisting of: scapular upward rotation at several angles of arm elevation; isometric scapular muscle strength; and anthropometric measurement of pectoralis minor (PM) length. Results The players showed significantly more scapular upward rotation on their dominant side (p<0.001). For both genders, upper trapezius (p=0.003) and serratus anterior (p=0.01) strength was significantly greater on the dominant side, whereas middle and lower trapezius strength showed no side differences. PM was shorter on the dominant side (p<0.001), and in the female players (p=0.006) compared with the boys. Conclusion These results indicate some sports-related adaptations of young tennis players on their dominant side at the scapulothoracic level to exposure to their sport. These data may assist the clinician in the prevention and rehabilitation of sport-specific injuries in adolescent tennis players.

Age-Related, Sport-Specific Adaptions of the Shoulder Girdle in Elite Adolescent Tennis Players

CONTEXT Tennis requires repetitive overhead movements that can lead to upper extremity injury. The scapula and the shoulder play a vital role in injury-free playing. Scapular dysfunction and glenohumeral changes in strength and range of motion (ROM) have been associated with shoulder injury in the overhead athlete. OBJECTIVE To compare scapular position and strength and shoulder ROM and strength between Swedish elite tennis players of 3 age categories (<14, 14-16, and >16 years). DESIGN Cross-sectional study. SETTING Tennis training sports facilities. PATIENTS OR OTHER PARTICIPANTS Fifty-nine adolescent Swedish elite tennis players (ages 10-20 years) selected based on their national ranking. MAIN OUTCOME MEASURE(S) We used a clinical screening protocol with a digital inclinometer and a handheld dynamometer to measure scapular upward rotation at several angles of arm elevation, isometric scapular muscle strength, glenohumeral ROM, and isometric rotator cuff strength. RESULTS Players older than 16 years showed less scapular upward rotation on the dominant side at 90° and 180° (P < .05). Although all absolute scapular muscle strength values increased with age, there was no change in the body-weight-normalized strength of the middle (P = .9) and lower (P = .81) trapezius or serratus anterior (P = .17). Glenohumeral internal-rotation ROM and total ROM tended to decrease, but this finding was not statistically significant (P = .052 and P = .06, respectively). Whereas normalized internal-rotator strength increased from 14 to 16 years to older than 16 years (P = .009), normalized external-rotator and supraspinatus strength remained unchanged. CONCLUSIONS Age-related changes in shoulder and scapular strength and ROM were apparent in elite adolescent tennis players. Future authors should examine the association of these adaptations with performance data and injury incidence.

Prevention of shoulder injuries in overhead athletes: a science-based approach.

The shoulder is at high risk for injury during overhead sports, in particular in throwing or hitting activities, such as baseball, tennis, handball, and volleyball. In order to create a scientific basis for the prevention of recurrent injuries in overhead athletes, four steps need to be undertaken: (1) risk factors for injury and re-injury need to be defined; (2) established risk factors may be used as return-to-play criteria, with cut-off values based on normative databases; (3) these variables need to be measured using reliable, valid assessment tools and procedures; and (4) preventative training programs need to be designed and implemented into the training program of the athlete in order to prevent re-injury. In general, three risk factors have been defined that may form the basis for recommendations for the prevention of recurrent injury and return to play after injury: glenohumeral internal-rotation deficit (GIRD); rotator cuff strength, in particular the strength of the external rotators; and scapular dyskinesis, in particular scapular position and strength.

Stretching the posterior shoulder structures in subjects with internal rotation deficit: comparison of two stretching techniques

Background Glenohumeral internal rotation deficit (GIRD) and posterior shoulder stiffness have been associated with impingement symptoms in the overhead athlete. Stretching of the posterior shoulder is advised in injury prevention as well as rehabilitation programs. The purpose of the present study was to determine if stretching of the posterior shoulder improves ROM and reduces symptoms, and to compare angular with non-angular stretching techniques. Methods 60 overhead athletes with GIRD (age 25 ± 7.2 years, height 176 ± 8 cm, weight 69.8 ± 10.2 kg) participated to the study. Thirty athletes had no shoulder pain, 30 had impingement symptoms on the dominant shoulder. The subjects were randomly assigned into an “angular” or a “non-angular” treatment group. They were treated for 3 weeks (9 sessions) and followed for another period of 3 weeks after completion of the treatment. Treatment outcome variables were glenohumeral internal rotation range of motion, and, in the patient group, pain (VAS) scores and functional performance (ROWE-score). Results Statistical analysis showed a significant increase in ROM (p < .05) in both treatment groups, in the patient as well as in the healthy control group. In addition, patients showed a significant improvement in pain assessment scores, and a significant increase in the Modified Rowe Score. There were no significant differences between both treatment techniques. Discussion Stretching, angular as well as non-angular techniques, increases internal rotation ROM in overhead athletes, and may decrease sport specific shoulder pain in overhead athletes with impingement symptoms.

Evidence-based rehabilitation of athletes with glenohumeral instability.

AbstractPurposeTo give an overview of current knowledge and guidelines with respect to evidence-based rehabilitation of athletes with glenohumeral instability.MethodsThis narrative review combines scientific evidence with clinical guidelines based on the current literature to highlight the different components of the rehabilitation of glenohumeral instability.Results Depending on the specific characteristics of the instability pattern, the severity, recurrence, and direction, the therapeutic approach may be adapted to the needs and demands of the athlete. In general, attention should go to (1) restoration of rotator cuff strength and inter-muscular balance, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with special attention to the internal rotation ROM, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) gradually increasing the functional sport-specific load on the shoulder girdle. The functional kinetic chain should be implemented throughout all stages of the rehabilitation program. Return to play should be based on subjective assessment as well as objective measurements of ROM, strength, and function.ConclusionsThis paper summarizes evidence-based guidelines for treatment of glenohumeral instability. These guidelines may assist the clinician in the prevention and rehabilitation of the overhead athlete.Level of evidenceExpert opinion, Level V.

Measuring Eccentric Strength of the Shoulder External Rotators Using a Handheld Dynamometer: Reliability and Validity

CONTEXT Shoulder strength assessment plays an important role in the clinical examination of the shoulder region. Eccentric strength measurements are of special importance in guiding the clinician in injury prevention or return-to-play decisions after injury. OBJECTIVE To examine the absolute and relative reliability and validity of a standardized eccentric strength-measurement protocol for the glenohumeral external rotators. DESIGN Descriptive laboratory study. SETTING Testing environment at the Department of Rehabilitation Sciences and Physiotherapy of Ghent University, Belgium. PATIENTS OR OTHER PARTICIPANTS Twenty-five healthy participants (9 men and 16 women) without any history of shoulder pain were tested by 2 independent assessors using a handheld dynamometer (HHD) and underwent an isokinetic testing procedure. INTERVENTION(S) The clinical protocol used an HHD, a DynaPort accelerometer to measure acceleration and angular velocity of testing 30°/s over 90° of range of motion, and a Biodex dynamometer to measure isokinetic activity. MAIN OUTCOME MEASURE(S) Three eccentric strength measurements: (1) tester 1 with the HHD, (2) tester 2 with the HHD, and (3) Biodex isokinetic strength measurement. RESULTS The intratester reliability was excellent (0.879 and 0.858), whereas the intertester reliability was good, with an intraclass correlation coefficient between testers of 0.714. Pearson product moment correlation coefficients of 0.78 and 0.70 were noted between the HHD and the isokinetic data, showing good validity of this new procedure. CONCLUSIONS Standardized eccentric rotator cuff strength can be tested and measured in the clinical setting with good-to-excellent reliability and validity using an HHD.

Preoperative hypofibrinogenemia is associated with increased intraoperative bleeding in ruptured abdominal aortic aneurysms

INTRODUCTION Ruptured abdominal aortic aneurysm (rAAA) is associated with coagulopathy and intraabdominal hemorrhage. Fibrinogen acts as a key coagulation factor and has previously been suggested as a biomarker for increased perioperative bleeding in other surgical areas. The aim of the present study was to investigate fibrinogen and standard laboratory parameters and their association to preoperative hemodynamic status, intraoperative bleeding (IOB), and outcome in treatment of rAAA. METHODS This is a single university center retrospective cohort study of 91 consecutive patients with rAAA undergoing open surgery or endovascular aneurysm repair (EVAR) between 2008 and 2013. Patients were analyzed using the Swedish Vascular Registry (Swedvasc), and local hospital medical and laboratory records. Laboratory data analyzed included fibrinogen, hemoglobin, platelet count, prothrombin time ratio, activated partial thrombin time, and creatinine. Odds ratios (OR) with 95% confidence intervals (CI) were calculated in a logistical regression model. RESULTS In the study cohort (n = 91), median age was 74 (57-91) years; 80 % men; open surgical repair (n = 72; 77%); EVAR (n = 19; 23%). Median preoperative fibrinogen concentration was 1.8 g/L (IQR = 1.4) and varied significantly across bleeding groups: ≤1999 ml 2.3g/L, IQR = 1.4 (n = 35); 2000-4999 ml 1.6 g/L, IQR = 1.5 (n = 33); ≥5000 ml 1.4 g/L, IQR = 1.0 (n = 23) (P < 0.001). Preoperative fibrinogen concentration showed a linear relationship with preoperative blood pressure (r = .447, P = 0.01). When analyzing other preoperative laboratory values, only platelets showed a similar linear relationship with preoperative blood pressure (r = .247, P = 0.05). Patients with blood pressure <70 mmHg had an associated median fibrinogen concentration of less than 1.5 g/L (P = 0.001). In the multivariable logistic regression analysis, preoperative fibrinogen < 1.5 g/L [OR 10.0, CI (1.8-57.1), P = 0.009] was associated with IOB >2000 ml and preoperative blood pressure < 70 mmHg was associated with IOB >2 000 ml [OR 3.7, CI (1.1-12.6), P = 0.03] and >5000 ml [OR 5.2, CI (1.3-21.1), P = 0.02]. Low fibrinogen concentration (< 1.5 g/L) was associated with 30-day mortality in the univariate analysis but not in the multivariable logistic regression analysis. CONCLUSION Low preoperative fibrinogen concentration was significantly associated with preoperative hypotension and increased intraoperative bleeding in patients with rAAA. Patients in hemodynamic shock with blood pressure <70 mmHg had an associated fibrinogen concentration of less than 1.5 g/L. A fibrinogen concentration less than 1.5 g/L was associated with a ten-fold increased risk of intraoperative hemorrhage of more than 2000 ml.

Elevated Troponin Levels in Acute Stroke Patients Predict Long-term Mortality

BACKGROUND Elevated plasma levels of troponin in acute stroke patients are common and have in several studies been shown to predict in-hospital and short-term mortality. Little is, however, known about the long-term prognosis of these patients. The aim of this study was to determine patient characteristics and 5-year mortality in patients with acute stroke and troponin elevation on admission. METHODS A retrospective cohort study of all consecutive patients with acute stroke and a plasma troponin I (TnI) analyzed on admission to Danderyd Hospital between January 1, 2005, and January 1, 2006 (n = 247). Patient characteristics were obtained from the Swedish National Stroke Register, Riksstroke, as well as hospital records. Mortality data were obtained from the Swedish Cause of Death Register. RESULTS There were 133 patients (54%) with TnI less than .03 μg/L (normal), 74 patients (30%) with TnI .03-.11 μg/L (low elevation), and 40 patients (16%) with TnI greater than .11 μg/L (high elevation). TnI elevations were associated with a higher age, prior ischemic stroke, chronic heart failure, renal insufficiency, stroke severity, and ST segment elevation or depression on admission. The rate of hyperlipidemia decreased with increasing TnI. Adjusted for age and comorbidity, elevated TnI values on admission had a significantly and sustained increased mortality over the 5-year follow-up, with a hazard ratio of 1.90 (95% confidence interval, 1.33-2.70). CONCLUSIONS Troponin elevation in patients with acute stroke, even when adjusted for several possible confounders, is associated with an almost 2-fold increased risk of 5-year mortality.

Antibiotic prescriptions for inpatients having non-bacterial diagnosis at medicine departments of two private sector hospitals in Madhya Pradesh, India: a cross-sectional study

Objectives To present and compare antibiotic prescribing for inpatients among the most common non-bacterial diagnoses groups at medicine departments of a teaching (TH) and a non-teaching hospital (NTH) in central India. Setting An observational cross-sectional study was conducted at two tertiary care settings in Ujjain district, Madhya Pradesh, India. Data and participants The data were collected manually, using a customised form. Complete records of all inpatients, who were >15 years of age and had stayed for at least one night in either of the hospitals during 2008–2011, were analysed. Outcome measures Inpatients were grouped according to the presence or absence of a bacterial infectious diagnosis, viral/malaria fever or cardiovascular disease. Classes of antibiotics prescribed to these groups and adherence to the available prescribing guidelines were compared between the hospitals using the notes from the patient files and the diagnoses. Results Of 20 303 inpatients included in the study, 66% were prescribed antibiotics. Trade name prescribing and use of broad-spectrum antibiotics were more frequent at the NTH than at the TH (p<0.001). At the TH a significantly higher proportion of patients having fever without registered bacterial infection were prescribed antibiotics (82%) compared with the NTH (71%, p<0.001). Patients admitted for cardiovascular diagnosis without registered bacterial infections received antibiotic prescriptions at both hospitals (NTH 47% and TH 37%) but this was significantly higher at the NTH (p<0.001). None of the diagnoses were confirmed by microbiology reports. Conclusions Prescribing antibiotics, including broad-spectrum antibiotics, to inpatients without bacterial infections—that is, viral fever, malaria and cardiovascular disease, was common at both hospitals, which increases the risk for development of bacterial resistance, a global public health threat. In view of the overprescribing of antibiotics, the main recommendations are development and implementation of local prescription guidelines, encouragement to use laboratory facilities and prescription analysis, with antibiotic stewardship programmes.

Asymptomatic Elite Adolescent Tennis Players' Signs of Tendinosis in Their Dominant Shoulder Compared With Their Nondominant Shoulder

CONTEXT Tennis is an asymmetric overhead sport with specific muscle-activation patterns, especially eccentrically in the rotator cuff. Magnetic resonance imaging (MRI) findings in asymptomatic adolescent elite tennis players have not previously been reported. OBJECTIVE The first aim of the study was to describe MRI findings regarding adaptations or abnormalities, as well as muscle cross-sectional area (CSA), of the rotator cuff. The second aim of the study was to investigate the rotator cuff based on the interpretation of the MRI scans as normal versus abnormal, with the subdivision based on the grade of tendinosis, and its association with eccentric rotator cuff strength in the dominant arm (DA) of the asymptomatic elite adolescent tennis player. SETTING Testing environment at the radiology department of Medicinsk Röntgen AB. PATIENTS OR OTHER PARTICIPANTS Thirty-five asymptomatic elite tennis players (age = 17.4 ± 2.7 years) were selected based on ranking and exposure time. INTERVENTION(S) We assessed MRI scans and measured the CSA of the rotator cuff muscle. The non-DA (NDA) was used as a control. In addition, eccentric testing of the external rotators of the DA was performed with a handheld dynamometer. RESULTS The DA and NDA displayed different frequencies of infraspinatus tendinosis (grade 1 changes) (P < .05). Rotator cuff measurements revealed larger infraspinatus and teres minor CSA (P < .05) in the DA than in the NDA. Mean eccentric external-rotation strength in the DA stratified by normal tendon and tendinosis was not different between groups (P = .723). CONCLUSIONS Asymptomatic adolescent elite tennis players demonstrated infraspinatus tendinosis more frequently in the DA than in the NDA. Clinicians must recognize these tendon changes in order to modify conditioning and performance programs appropriately.