ReviewShoulder injury in water polo: A systematic review of incidence and intrinsic risk factors
Introduction
Water polo originated in the mid-19th century in England and Scotland as an aquatic form of rugby.1 Men’s water polo was introduced at the modern Olympics in 1900 making the sport of water polo the first Olympic team competition.2 Presently, the International Swimming Federation (FINA) is the international governing body for the sport.3
Water polo is a physically demanding sport, particularly on athletes’ upper limbs, with intense bursts of sprint swimming, changing direction every 6.2 s,4 and passing and shooting the ball repetitively from end-of-range shoulder abduction (Abd) and external rotation (ER) at arm speeds of up to 24.1 ± 1.58 ms−1.5
Risk factors identified for shoulder pain in swimmers are often extrapolated to water polo, despite the unique demands. Unlike competitive swimmers, water polo players use an adapted upright swimming posture to allow transport of the ball and a clear view of the opposition. The elevated posture eliminates the body roll observed in traditional freestyle swimming, increasing the required shoulder Abd and internal rotation (IR) and placing stress on the rotator cuff.6 Also in contrast to swimming, water polo is a contact sport. In defensive play, athletes keep their arms above their head to physically obstruct the opposition and block opposing players’ throws, placing external force on the shoulder joint.7, 8
The aquatic environment means that water polo players generate throwing force without the contribution of a solid base of support, making it difficult to produce the conventional throwing proximal-distal kinematic chain sequence.6, 9 When throwing in water polo, power is produced by the trunk rotating forward from hyperextension to 20° flexion to maximise shoulder ER by leaving the arm and ball behind the body (Fig. 1).9 The arm then moves in an arc, shifting the body towards the horizontal plane as the trunk simultaneously laterally flexes away from the throwing arm, increasing the height and velocity for ball release.9, 10
Despite the lower average ball velocity observed in water polo (16.5 ms−1) compared to baseball (33 ms−1) and American football (23 ms−1), resultant joint torques is similar.11 Horizontal adduction and IR torque in the penalty shot is 64/59 Nm compared to 100/67 Nm and 78/66 Nm for baseball and American football respectively.10, 12, 13 The observed force can be explained by the larger size and weight of the water polo ball (400–450 g) compared to baseball, and the reduced contribution of the lower extremity to the kinetic chain.10, 14, 15
The aim of this paper was to review the available literature regarding shoulder injury rates and risk factors for shoulder injury in water polo. It has been previously suggested that shoulder injury rates are as high as 80% in elite water polo,1, 6, 16 however due to limited research results are often extrapolated from other overhead sports. Evaluation of the incidence of shoulder injury and the relationship between intrinsic risk factors and shoulder injury may help identify “at risk” athletes and enable targeted injury prevention strategies. Further, this review serves to identify current gaps in water polo research regarding shoulder injury rates, normative data and risk factors associated with shoulder injury.
Section snippets
Methods
CINAHL, AUSPORT, Pubmed, Pedro and SPORTDiscus databases were searched using the key terms (“water polo”) AND (shoulder OR glenohumeral* OR arm OR “upper limb”). No date limits were applied and the search was completed in August 2016. Two reviewers conducted the selection process and independently evaluated the characteristics and key outcomes of the study. Studies were included if they were in English and original research, and could be anthropometrical, descriptive, epidemiological or
Results
The review process returned 20 papers. Six papers considered epidemiology of shoulder pain and injury and the remaining 14 investigated intrinsic risk factors of shoulder injury in water polo players. Injury incidence was defined as the number of new injuries in a specified time period,18 and injury rate as the number of injuries divided by athlete-time-exposure.19
Shoulder injury incidence at major championships. Three studies evaluated shoulder injury incidence at major international
Discussion
Previous descriptive reports have suggested shoulder injury rates in elite water polo are as high as 80%.1, 6, 16 In contrast, the present review found injury rates for elite male water polo players was 24% and up to 51% for college level males.22, 24 Due to methodological limitations of retrospective studies, such as incomplete medical records and failure to report injury re-occurance, future prospective studies with a clear definition of ‘injury’ as well as capturing time-loss to sport
Conclusion
Review of the current literature indicates that shoulder pain and injury are common in water polo with reported rates for male players ranging from 24% to 51%. Risk for shoulder injury is multifactorial, however the relative contribution of intrinsic factors remains unclear.
Future implications for research include development of normative data sets in water polo regarding shoulder ROM, strength ratio and proprioception. Simultaneously, further prospective analysis with a clear definition of
Practical implications
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For injury prevention, monitoring individual athlete loading and daily reported shoulder pain is encouraged.
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Visual assessment for scapular dyskinesis pre and post training can enable targeted shoulder stretching prescription.
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Measurement and preservation of dominant/throwing arm IR ROM is recommended.
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A shoulder strength ratio for IR:ER > 1.0:0.67 is desirable.
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For performance outcome, increased overall athlete fitness may improve athlete’s goal shooting accuracy.
Acknowledgments
Andrea Miller is currently supported by a joint QAS-University of Canberra PhD scholarship for the duration of her PhD candidature.
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2019, Physical Therapy in SportCitation Excerpt :Regardless of these similarities, this approach fails to recognise the unique physical requirement of throwing in water. The aquatic playing environment requires the water polo athlete to generate throwing force without a firm base of support, the athlete therefore is unable to transfer ground reaction forces through the body (Garrett & Kirkendall, 2000), reducing the contribution of the lower extremity to the kinetic chain (Miller et al., 2017). Although the baseball literature provides an evidence-informed foundation for clinical decision-making when working with athletes that play water polo, to enable targeted injury prevention programs and prevent recurrent shoulder injury, risk factors for injury specifically for water polo athletes need to be explored through prospective injury studies.
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