Richard Partner

Background: Shoulder injuries and ongoing shoulder complaints pose a substantial burden for rugby players of all playing levels from both codes and sexes of participation. Current rugby shoulder injury epidemiology data primarily covers time loss episodes underestimating the true cost of continued participation with dysfunction. Existing player/patient reported outcome measures (PROMs) for the shoulder are not rugby specific, bar the single construct Rugby Shoulder Score (RSS), or were development for non-athletic populations. There is, therefore, limited clinical utility for existing shoulder PROMS for rugby players. The use of a reliable and validated PROM is recommended by the world health organisation (WHO). Aims: To develop, validate and apply a rugby specific multi construct PROM, the Rugby Shoulder Function (RSF) questionnaire, to an objective measure of shoulder force characteristics, Athletic Shoulder (ASH) Test, in cohorts of fit to play rugby players. Methods: The programme of research comprised of three main studies: 1. Rugby Shoulder Function questionnaire development: A multi-disciplinary three stage online Delphi study with two groups of participants (expert n=12, experienced n=25) and a steering group (n=3) established content and face validity of the 22-tiem 4 construct (activities of daily living, range of motion, strength and conditioning, sport specific training and competition) RSF questionnaire. 2. Validation study of the RSF: Construct and criterion validity was established with university level rugby players who completed RSF, RSS and the ASH Test using portable force plates for each shoulder with the additional 48-72hour test-retest of the RSF. Agreement, correlations and reliability were examined with Bland-Altman plots, Spearman’s rank, intraclass coefficients (ICC) creating thresholds for minimal detectable change (MDC). 3. Cross sectional RSF study: Normative RSF scores (AU) across different codes and sexes with analysis by position and prior history of a career loss injury (TLI) were generated and discussed in relation to playing characteristics. Results: The Delphi study produced a 22-item, four construct questionnaire developed with multi-disciplinary team of experts and players. The RSF contains new rugby shoulder specific items not seen in other PROMs. The RSF showed significant positive Spearman’s rank correlation (rho 0.76) and high levels of agreement (Cronbach’s  0.90) to the RSS. In a short wash out period the level of agreement (Cronbach’s  0.98, ICC 0.98) was rated as nearly perfect showing a strong correlation between repeat measures (rho 0.89). The RSF score significantly correlated to the ASH test with higher perceived dysfunction negatively associated with lower rate of force development (RFD) in the I, Y and T positions and with lower peak force (PF) in the T position (p<0.05). Players reporting known perceived shoulder dysfunction had significantly lower I position PF and RFD and T position PF compared to players without prior knowledge of a dysfunction (p<0.05). Expressions of force with the ASH test was not correlated with previous TLI whereas in the cross-section study perceived shoulder dysfunction was significantly higher in those with a history of TLI (p<0.05). Only one quarter of players with a previous shoulder TLI reported full resolution of perceived dysfunction and 59% of the entire cohort of the cross-section study reported perceive shoulder dysfunction despite being fit to play aligning to previous work. Conclusions: The new RSF questionnaire is a multi-construct PROM with demonstrated content and face validity through design, construct validity against another PROM (RSS) and criterion validity through association with isometric shoulder force (ASH test). Its short-term reliability and minimal detectable change (MDC) allow valid surveillance of shoulder health in players who continue to participate allowing practitioners to identify deterioration, adjust load/exposure and evaluate interventions beyond the binary prevention of time loss injuries. Future work should look to expand the normative data to those at the elite level and those with minimal level of medical support in the amateur games. The RSF may be integrated alongside serial measures of kinetic and kinematic shoulder function to further understand the objective and subjective dysfunction relationship, including minimal important change (MIC), in response to injury risk reduction (IRR) programmes. Keywords: Rugby, Shoulder, Delphi, Athletic Shoulder Test, Reliability, Validity, Patient/Player Reported Outcome Measures

The shoulder has been reported as the most commonly injured joint in rugby league (McDonough & Funk 2014, Physical Therapy in Sport, 15, 91-96). Whilst contact injuries make up the majority of shoulder injuries in rugby league, many shoulder pathologies are of insidious onset or linked to training loads (King et al., 2014, International Journal of Sports Science and Coaching, 9, 417 – 431). Given that previous injury is the greatest risk factor for future injury in many sports (Benita 2016, Sports Medicine, 46, 79), it is pertinent to develop methods which detect early stage pathology. At present, it is not yet known what the incidence of players playing with an existing sub-clinical shoulder dysfunction are. The Rugby Shoulder Score (Roberts and Funk, 2013, British Journal of Sports Medicine, 47, 920 – 926), a uni-dimensional 120 point (20 – 140), scale was developed to monitor shoulder function in players undergoing rehabilitation from shoulder injury. The aim of this study was to determine whether the Rugby Shoulder Score (RSS) was capable of detecting sub clinical shoulder dysfunction in players actively engaged in training and match play. Following University ethics approval, 18 professional super league rugby players were invited to provide written informed consent. A total of 12 players completed the RSS at the midway point of the season. One player reported a perfect score (20) and the remaining 11 indicated varying levels of shoulder dysfunction (23-69) as measured by the RSS. On average players reported a score of 45 indicating that players were training and playing ~21% below maximum function. This study reported that 91% of this small sample (n=12) of professional rugby players were training and playing with some level of shoulder dysfunction at the midway point in the super league season. This pilot study warrants further investigation in a representative sample.

Netball is ranked second behind football for female sports participation in the United Kingdom. The epidemiology of netball injuries has been reported at elite level but not amateur (Best and Gledhill 2017, IOC Conference on the Prevention of Injury and Illness in Sport, 16 March 2017 - 18 March 2017, Monaco). The aim of this study was to report the prevalence and incidence of injury in amateur female netball players during the 2016/2017 UK season. Following ethical approval from the Leeds Beckett University research ethics committee, 134 Female netball players (mean (range): age 23y (16-54), height 170cm (140-190cm), weight 66kg (50 – 100kg) provided electronic informed consent. Players completed a retrospective injury history questionnaire adapted from a football consensus statement on injury reporting (Fuller et al., 2006, Scandinavian journal of medicine & science in sports, 16(2), 83-92). Severity of injury was categorised using a time loss definition: slight (1-3 days), minor (4-7 days), moderate (1-4 weeks) and major (4 weeks plus). The one season prevalence of injury in this sample was 54%. The overall (match and training) incidence of injury was 5.72/1000h. More injuries occurred during match play (9.14/1000h) than in training (3.00/1000h). Injuries to the ankle (36%), knee (22%) and the wrist/hand/fingers (24%) were the most common. Ligaments were the most commonly injured tissues (53% of all injuries). The most commonly reported mechanism was landing from a jump (33% of all injuries). The majority of injuries were first-time injuries (81%). Moderate injuries were most common (47%), followed by major (35%) and minor injuries (18%). This is the first data set to retrospectively analyse netball injures at amateur level. We report a lower injury incidence than that found at the elite level (5.72 vs. 9.08/1000h). At elite and amateur level, a similar relative percentage of injuries occur during match and training. The nature and mechanism of injury also remain common to both playing standards. Insufficient neuromuscular control when landing from a jump appears to stress ligaments beyond their physiological load tolerance in female netball players. Prospective studies are required to confirm these findings.

Introduction: The shoulder is the most commonly injured joint in rugby league and among the top 3 in rugby union. Contact injuries make up the majority of shoulder injuries in rugby, but many shoulder pathologies are of insidious onset or linked to training loads. Given that previous injury is the greatest risk factor for future injury in many sports, it is pertinent to develop methods which detect early stage pathology. At present, it is not yet known what the prevalence of players playing with an existing sub-clinical shoulder dysfunction are. The Rugby Shoulder Score (RSS), a uni-dimensional 120-point scale (20 – 140), was developed to monitor shoulder function in players undergoing rehabilitation from shoulder injury. The aim of this study was to use the RSS to estimate the prevalence of sub-clinical shoulder dysfunction in a sample of professional and amateur rugby players. Methods: Following ethical approval from the Leeds Beckett University research ethics committee, 86 uninjured players provided written informed consent. RSS assessments were administered, via paper questionnaire, at the mid-point of the season. All players were participating in training and match play at the time of assessment. The sample consisted of 34 professional and 52 amateur players respectively. A RSS of 20 represents a perfect score. An increasing RSS indicates increasing shoulder dysfunction. Results: The mean RSS score for the entire sample was 35. Professional players demonstrated greater shoulder dysfunction than amateur players (RSS 42 vs. 30; P<0.05). Fifty five percent of all players indicated varying levels of shoulder dysfunction (mean 47, range 22-105). Of players with a recorded shoulder dysfunction, 17 reported it affecting their match play or training despite being classified as uninjured. The mean RSS of this sub group (n=17) was 62 (CI 50-75). Players who did not have a perfect RSS but did not report it affecting their match play or training had a RSS of 41 (CI 36-45). Conclusions: The results of this study indicate that the RSS can detect sub-clinical shoulder dysfunction in a sample of rugby players classified as uninjured. The prevalence of shoulder dysfunction (RSS >20) was more than half of the sample. Professionals tended to have greater shoulder dysfunction than amateurs. A threshold for minimal clinical importance of the RSS does not exist. However, for a sub group of players (n=17) an RSS range has been identified which appears to indicate a level of dysfunction which may affect match play and training.

In 2016, competitive cheerleading was granted provisional recognition as an Olympic sport thus allowing it to be considered for future games inclusion. Team England including the ‘all girl elite’ and ‘co-ed elite’ won gold and silver respectively at the ICU World Cheerleading Championships. The aim of this study was to report the prevalence and incidence of injury in cheerleaders during the 2016/2017 UK season. Following ethical approval from the Leeds Beckett University research ethics committee, 182 competitive (3.7 ± 1.8 years’ experience) cheerleaders (173 female, mean (±SD): age 21 ± 4 y, height 165 ± 7 cm, weight 64.7 ± 13.9 kg) provided electronic informed consent. Players completed a retrospective injury history questionnaire adapted from a football consensus statement on injury reporting (Fuller et al., 2006, Scandinavian journal of medicine & science in sports, 16(2), 83-92). Severity of injury was categorised using a time loss definition: slight (1-3 days), minor (4-7 days), moderate (1-4 weeks) and major (4 weeks plus). On average, cheerleaders engaged in ~5 hours training per week and ~3.4 competitions during the season. The one season prevalence of injury in this sample was 73%. A total of 226 injuries were reported. First time injuries (69%) were more common than recurrent injuries (31%). The maximum number of injuries reported by a single cheerleader was 5. The overall (competition and training) incidence of injury was 4.9/1000h. The majority (86%) of injuries occurred during training (4.76/1000h). Injuries to the ankle (11.9%), face (11.5%) and low back (10.2%) were the most common. Ligaments were the most commonly injured tissues (22.9% of all injuries). The most commonly reported mechanism of injury was during a stunting manoeuvre (54.9% of all injuries). Minor injuries were most common (61%), followed by moderate (21%) and major injuries (18%). This is the first study to report the prevalence and incidence of injury in cheerleading. Unlike many sports, the majority of injuries occur during training rather than competition. We suggest that this is mainly down to differences in exposure. On average, competitions last for 2.5 minutes. It may also be that cheerleaders are more aggressive in their training practices in order to perfect routines for competition, which may indicate fewer mistakes leading to injury occur on the day of competition. Prospective studies are required to develop this area of research.

Background Fixed-frame dynamometry systems are used worldwide to assess isometric strength in both general and athletic populations. There is currently a paucity of published work where reliability estimates for fixed-frame dynamometry systems have been estimated. The aim of this study was to determine the inter-and intra-rater reliability of the KangaTech (KT360) fixed frame dynamometry system when measuring maximal isometric strength of the knee flexor muscles. Study Design Inter and intra-rater reliability single cohort study. Methods Twenty healthy university-level athletes (age= 21.65 ± 3 years, weight= 74.465 ± 30kg, height= 170.1 ± 7.0cm) took part in two testing sessions where two raters collected data during a 90° hip and knee flexion protocol. Participants performed each test twice, building to a maximal isometric contraction holding over a 5 second period with 30 second rest between sets. Data were checked for normality using a Shapiro-Wilk test. Intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated. Finally, a Bland-Altman analysis was used to determine the levels of agreement for intra-and inter-rater measurements. Results High levels of agreement were demonstrated between left and right knee flexion as 95% of the differences were less than two standard deviations away from the mean. ‘Almost perfect’ intraclass correlation coefficient (ICC) values were demonstrated (Knee flexion: Inter-rater: Left, 0.99; Right, 0.99; Intra-rater: Left, 0.99; Right:0.99). Standard error of measurement (SEM) for inter-and intra-rater strength ranged from 0.26-0.69 kg, SEM% ranged from 1.34-2.71% and minimal detectable change (MDC) ranged from 1.14-2.31kg. Conclusion Overall, high level of inter-and intra-rater reliability were demonstrated when testing maximal isometric knee flexion. Therefore, the KT360 fixed frame dynamometry system may be considered a viable tool for measuring maximal isometric contraction of the knee flexors when repeat measures are required in clinical settings. Level of Evidence 3b

Indoor sport climbing will debut as a new Olympic discipline at the 2020 summer games in Tokyo. The annular pulleys of the fingers are the most commonly reported injured structure in climbing. There are five annular pulleys within each finger and referred to as the A1, A2, A3, A4 and A5. The A2 and A4 structurally maintain the integrity of the flexor tendon system due to their direct attachment to the underlying bone. The A2 is the largest pulley and capable of withstanding up to 400 newton of force. Anecdotal evidence suggests some climbers apply athletic tape to the fingers both as a prophylactic measure to prevent annular pulley injury and to increase their grip strength capability. Grip refers to the method by which the climber holds the climbing surface to facilitate movement. The type of grip the climber uses largely depends on the size and shape of the available hand-holds, the climber’s body orientation in relation to the climbing surface and the strength of the climber. A common type of grip used in climbing is the closed crimp position. In this position the proximal interphalangeal joint is flexed at approximately 100° and the distal interphalangeal joint is hyperextended at approximately 210°. The distal palmer surface of the index, middle and ring fingers are normally in contact with the surface and the thumb often placed over the dorsal surface of the index finger to generate more force. The aim of the study was to investigate if taping the fingers increased crimp grip strength in uninjured climbers. Following ethical approval by the Leeds Beckett University research ethics committee, 50 active climbers (25 male, 25 female) were recruited. Using a within subject repeated measures design, a Jamar plus digital dynamometer was used to measure crimp grip strength (3 trial mean, dominant and non-dominant hand, tape and no-tape). The order of conditions was randomised and each participant performed each grip. The tape condition involved applying a 10cm piece of 1” Lewis-Plast zinc oxide tape to the proximal interphalangeal joint of the index, middle and ring fingers using the H-tape method. There was no statistically significant difference (p = 0.922, paired t-test) in crimp grip strength between tape (24.03 ± 6.9kg) and no tape (23.99 ± 7.2kg) conditions. Taping the annular pulleys did not increase crimp grip strength as measured using hand held dynamometry in uninjured climbers.

OBJECTIVE: Develop a questionnaire to monitor symptoms of player perceived shoulder function/dysfunction. DESIGN: 3-Stage Online Delphi Study. METHODS: Participants: surgeons, sports and exercise medics, academic researchers, strength and conditioning coaches, therapists and athletes split by level of expertise/experience. Stage-1: experts (n = 12) rated constructs/items from the steering group and made changes/proposed additional constructs/items. Stage-2: experts rated/amended new constructs/items from stage-1. Stage-3: experienced professionals (n = 25) rated/ranked constructs/items from stage 2. Consensus thresholds were defined per stage (≥50% agreement/4-5 rating on 1-5 Likert scale (stages 1-2), ≥68% agreement, and items ranked for perceived importance (stage-3)). RESULTS: Stage-1, all four constructs (a. Activities of daily living, b. Range of motion, c. Strength and conditioning, d. Sports specific training and competition) and 26/42 original items achieved consensus. Twelve items were combined into five items. Four new items were also proposed. Stage-2, the combined items and three of the four new items achieved consensus. Stage-3 the four constructs and 22 items all achieved consensus. CONCLUSIONS: Following a 3-stage online Delphi process, involving expert and experienced clinicians, practitioners and athletes, a new four construct, 22 item RSF questionnaire has been developed which can be used with rugby players, to monitor perceived shoulder performance and symptoms.

Purpose Underwater Hockey (UWH) is an upcoming sport involving limited contact between players. To date there are no published estimates of injuries in UWH. The aim of this study was to provide estimate on overall injury incidence and injury period prevalence in a sample of UWH players. Methods A cross-sectional study design with a convenience sample of UWH players recorded injuries sustained over the previous 12-month period. A total of 441 UWH players completed the study online questionnaire. Descriptive statistics with confidence intervals, alongside a one variable Chi squared test (χ2) or independent sample t-test. Results The overall injury incidence was 2.33/1000 h. Wrist, hand, and finger injuries combined (31.8%) were the most frequently injured regions followed by isolated shoulder injuries (16.8%). Contact with another player was the most frequent injury mechanism (43.5%) attributed, whilst the most common injury duration was between 8 and 28 days (35.9%). Conclusion This is the first study to report injury data in a sample of UWH players. Incidence rates were similar to other water-based sports such as endurance swimming. The high prevalence of wrist, hand and finger and shoulder injuries suggest that future injury prevention programmes should look to include upper limb-focussed risk reduction strategies.

Objective: This study aimed to investigate the prevalence of self-reported shoulder dysfunction using the Rugby Shoulder Score (RSS) reported in arbitrary units (AU) of rugby players available for match selection (uninjured). Design: Cross-sectional survey. Methods: Paper survey at the mid-point of the season of uninjured players (n = 86 males (mean age (±SD): 26 ± 6.9y) from 8 squads (professional n = 34; amateur; n = 52)), using the RSS, subjective impact on rugby performance and previous shoulder injury, analysed using a Mann-Whitney U test. Results: 55% of players reported a level of RSS dysfunction despite being uninjured. Players who also reported their shoulder was impacting on performance had significantly higher median RSS (61, IQR 28AU, p = 0.02) than those who reported no impact on performance (40, IQR 22AU). Conclusions: Findings from this study show that over half of players were playing with a level of self-reported shoulder dysfunction. This figure is higher in the professional game, for those with a history of previous injury and for forwards.