The game of rugby union has evolved over the years into a professional sport in which an increased incidence of injury is evident. This also applies to the shoulder joint. It appears that certain risk factors are associated with shoulder pathology among rugby players as well as among the general population. In a competitive sporting environment where high stress loads are placed upon the body and joints, this association may be even more pronounced. Despite the fact that numerous studies have investigated the various factors that potentially play a role in the occurrence of shoulder injuries among sports participants generally, similar studies involving rugby union players in particular are limited. Previous studies have investigated and profiled rugby players with regards to posture, shoulder isokinetic muscle strength and electromyographic patterns, but no study has yet investigated the relationship between these factors and the role they may play in the risk of being injured. It would be beneficial to have a better understanding of the interplay between these factors and to identify the most likely factors to predict and/or prevent shoulder injuries in rugby players. With this information at hand, it might be possible to identify players who are at risk of shoulder injuries in order that they may potentially benefit from effective “pre-habilitation” protocols. The aim of this study was to determine what the relationship between thoracic posture, isokinetic shoulder strength and scapulae muscle activation patterns in injured and uninjured rugby players was, and to determine which of these variables might predict shoulder injuries. Methods Ninety-one (91) uninjured semi-professional rugby union players’ shoulder joint range of motion differences (ROM) were manually tested with the hand-behind-the-neck and hand- behind-the-back method. The profiling and classification of the thoracic posture was performed using the New York Posture Test. Scapular muscle activation patterns were determined by means of electromyography (EMG) measuring the activation of the upper and lower trapezius, serratus anterior and infrapinatus muscles. The isokinetic muscle strength of the rotator cuff muscles was determined at 60°/sec (Kin-Com 500H) measuring concentric and eccentric forces during internal and external rotation. Results Some participants presented with non-ideal or unsatisfactory shoulder internal rotators (59%) and external rotators (85%) bilateral ROM differences. Of all the participants, 68% presented with an abnormal shoulder position in the lateral view, and the sequence of muscle activation of the scapula stabiliser muscles was found to be: serratus anterior; lower trapezius; infraspinatus and then upper trapezius. The isokinetic antagonist/agonist strength ratio for shoulder rotation during concentric muscle contraction was 64% for the non-dominant and 54% for the dominant shoulder. The corresponding ratios for the eccentric muscle contraction of the non-dominant and dominant shoulders were 67% and 61% respectively. The median muscle onset times of the backline players’ non-dominant infraspinatus muscles were 35.90 ms for ideal, 95.20 ms for non-ideal, and 93.90 ms for the unsatisfactory external rotators’ range of motion (ROM) differences. The median firing orders of the forwards’ dominant lower trapezius muscle was 3 for ideal, 1 for non-ideal, and 2 for unsatisfactory external rotators’ ROM differences. Among the forward shoulder group and the normal shoulder position group of the forwards respectively, the median muscle onset time of their non-dominant infraspinatus muscle was 113 milliseconds (ms) and 42 ms. Their non- dominant serratus anterior muscles’ median onset time was 78.85 ms among the players with a rounded back, and 31.90 ms among the players with a normal thoracic curvature. The backline players displayed a median non-dominant serratus anterior onset time of 47.45 ms (in the uneven shoulder group) versus 32.75 ms (in the even shoulder group). The median firing order of the backline players’ non-dominant infraspinatus muscle was third in the normally curved back group. Among the players with an abnormally rounded back, however, the median firing order changed to second. The median external rotation/internal rotation isokinetic strength ratio of the forward players was 63% (forward shoulders), versus 56.50% (normal shoulder position). This was for their non-dominant shoulders. Certain isokinetic shoulder strength ratios displayed statistically significant correlations with scapular muscle activation patterns but they were not clinically significant. Players who had sustained shoulder injuries during the season differed significantly from those who had not sustained injuries with regards to the following baseline measurements: age (the injured were older), height (the injured were taller) and non-dominant/dominant concentric external rotation ratio (the injured had a higher ratio). Among the backline players baseline differences occurred within age (the injured were older), weight (the injured were heavier), height (the injured were taller) and the body mass index (BMI) (the injured had a higher BMI). The variables that displayed statistically significant predictive values towards future injury were age (1.34 times increase for each year older), insufficient shoulder external rotator ROM differences (16.15 times increase if an unsatisfactory ROM difference occurs), uneven shoulders (4.43 times increase if shoulders were abnormally uneven) and the non- dominant/dominant concentric external rotation strength ratio (a 1.42 times increase for every 10% that the ratio increases). Conclusion Profiling of the group of players revealed that their non-ideal or unsatisfactory flexibility of shoulder external rotators, their forward shoulders in the lateral view, and their weakness of the shoulder external rotators did not result in abnormal scapular muscle activation patterns. Positive relationships were found between certain postural abnormalities (forward shoulders, a rounded back and uneven shoulders) and the delay of muscle onset times of infraspinatus and serratus anterior, as well as the firing order of infraspinatus. Forward shoulders increased antagonist/agonist isokinetic shoulder rotation strength ratios. Non-ideal or unsatisfactory flexibility of shoulder external rotators displayed positive relationships with altered infraspinatus muscle onset times and an altered lower trapezius muscle firing order. No clinically significant correlations were found between isokinetic shoulder strength ratios and scapulae muscle activation patterns. It appears that posture (uneven shoulders), has a higher predictive ability than shoulder strength imbalance (non-dominant/dominant concentric external rotation ratio) regarding future shoulder injury. However, age and especially external rotator ROM deficiency proved to be strong predictors of future shoulder injury in semi-professional rugby players. / Thesis (PhD (Human Movement Science))--North-West University, Potchefstroom Campus, 2013.

The game of rugby union has evolved over the years into a professional sport in which an increased incidence of injury is evident. This also applies to the shoulder joint. It appears that certain risk factors are associated with shoulder pathology among rugby players as well as among the general population. In a competitive sporting environment where high stress loads are placed upon the body and joints, this association may be even more pronounced. Despite the fact that numerous studies have investigated the various factors that potentially play a role in the occurrence of shoulder injuries among sports participants generally, similar studies involving rugby union players in particular are limited. Previous studies have investigated and profiled rugby players with regards to posture, shoulder isokinetic muscle strength and electromyographic patterns, but no study has yet investigated the relationship between these factors and the role they may play in the risk of being injured. It would be beneficial to have a better understanding of the interplay between these factors and to identify the most likely factors to predict and/or prevent shoulder injuries in rugby players. With this information at hand, it might be possible to identify players who are at risk of shoulder injuries in order that they may potentially benefit from effective “pre-habilitation” protocols. The aim of this study was to determine what the relationship between thoracic posture, isokinetic shoulder strength and scapulae muscle activation patterns in injured and uninjured rugby players was, and to determine which of these variables might predict shoulder injuries. Methods Ninety-one (91) uninjured semi-professional rugby union players’ shoulder joint range of motion differences (ROM) were manually tested with the hand-behind-the-neck and hand- behind-the-back method. The profiling and classification of the thoracic posture was performed using the New York Posture Test. Scapular muscle activation patterns were determined by means of electromyography (EMG) measuring the activation of the upper and lower trapezius, serratus anterior and infrapinatus muscles. The isokinetic muscle strength of the rotator cuff muscles was determined at 60°/sec (Kin-Com 500H) measuring concentric and eccentric forces during internal and external rotation. Results Some participants presented with non-ideal or unsatisfactory shoulder internal rotators (59%) and external rotators (85%) bilateral ROM differences. Of all the participants, 68% presented with an abnormal shoulder position in the lateral view, and the sequence of muscle activation of the scapula stabiliser muscles was found to be: serratus anterior; lower trapezius; infraspinatus and then upper trapezius. The isokinetic antagonist/agonist strength ratio for shoulder rotation during concentric muscle contraction was 64% for the non-dominant and 54% for the dominant shoulder. The corresponding ratios for the eccentric muscle contraction of the non-dominant and dominant shoulders were 67% and 61% respectively. The median muscle onset times of the backline players’ non-dominant infraspinatus muscles were 35.90 ms for ideal, 95.20 ms for non-ideal, and 93.90 ms for the unsatisfactory external rotators’ range of motion (ROM) differences. The median firing orders of the forwards’ dominant lower trapezius muscle was 3 for ideal, 1 for non-ideal, and 2 for unsatisfactory external rotators’ ROM differences. Among the forward shoulder group and the normal shoulder position group of the forwards respectively, the median muscle onset time of their non-dominant infraspinatus muscle was 113 milliseconds (ms) and 42 ms. Their non- dominant serratus anterior muscles’ median onset time was 78.85 ms among the players with a rounded back, and 31.90 ms among the players with a normal thoracic curvature. The backline players displayed a median non-dominant serratus anterior onset time of 47.45 ms (in the uneven shoulder group) versus 32.75 ms (in the even shoulder group). The median firing order of the backline players’ non-dominant infraspinatus muscle was third in the normally curved back group. Among the players with an abnormally rounded back, however, the median firing order changed to second. The median external rotation/internal rotation isokinetic strength ratio of the forward players was 63% (forward shoulders), versus 56.50% (normal shoulder position). This was for their non-dominant shoulders. Certain isokinetic shoulder strength ratios displayed statistically significant correlations with scapular muscle activation patterns but they were not clinically significant. Players who had sustained shoulder injuries during the season differed significantly from those who had not sustained injuries with regards to the following baseline measurements: age (the injured were older), height (the injured were taller) and non-dominant/dominant concentric external rotation ratio (the injured had a higher ratio). Among the backline players baseline differences occurred within age (the injured were older), weight (the injured were heavier), height (the injured were taller) and the body mass index (BMI) (the injured had a higher BMI). The variables that displayed statistically significant predictive values towards future injury were age (1.34 times increase for each year older), insufficient shoulder external rotator ROM differences (16.15 times increase if an unsatisfactory ROM difference occurs), uneven shoulders (4.43 times increase if shoulders were abnormally uneven) and the non- dominant/dominant concentric external rotation strength ratio (a 1.42 times increase for every 10% that the ratio increases). Conclusion Profiling of the group of players revealed that their non-ideal or unsatisfactory flexibility of shoulder external rotators, their forward shoulders in the lateral view, and their weakness of the shoulder external rotators did not result in abnormal scapular muscle activation patterns. Positive relationships were found between certain postural abnormalities (forward shoulders, a rounded back and uneven shoulders) and the delay of muscle onset times of infraspinatus and serratus anterior, as well as the firing order of infraspinatus. Forward shoulders increased antagonist/agonist isokinetic shoulder rotation strength ratios. Non-ideal or unsatisfactory flexibility of shoulder external rotators displayed positive relationships with altered infraspinatus muscle onset times and an altered lower trapezius muscle firing order. No clinically significant correlations were found between isokinetic shoulder strength ratios and scapulae muscle activation patterns. It appears that posture (uneven shoulders), has a higher predictive ability than shoulder strength imbalance (non-dominant/dominant concentric external rotation ratio) regarding future shoulder injury. However, age and especially external rotator ROM deficiency proved to be strong predictors of future shoulder injury in semi-professional rugby players. / Thesis (PhD (Human Movement Science))--North-West University, Potchefstroom Campus, 2013.