Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis

ObjectiveTo produce a best evidence synthesis of exercise prescription used when treating shoulder pathology in the overhead athlete.DesignA systematic review of exercises used in overhead athletes including case studies and clinical commentaries.Data sourcesMEDLINE, PubMed, SPORTDiscus and CINAHL from database inception through July 8, 2016.MethodsWe examined data from randomised controlled trials and prospective cohort (level I–IV evidence) studies that addressed exercise intervention in the rehabilitation of the overhead athlete with shoulder pathology. Case studies and clinical commentaries (level V evidence) were examined to account for expert opinion-based research. Data were combined using best evidence synthesis and graded (A–F) recommendations (Centre for Evidence-Based Medicine).ResultsThere were 33 unique exercises in six level I–IV studies that met our inclusion criteria. Most exercises were single-plane, upper extremity exercises performed below 90oof elevation. There were 102 unique exercises in 33 level V studies that met our inclusion criteria. These exercises emphasised plyometrics, kinetic chain and sport-specific training.Conclusions and relevanceOverall, evidence for exercise interventions in overhead athletes with shoulder pathology is dominated by expert opinion (grade D). There is great variability between exercise approaches suggested by experts and those investigated in research studies and the overall level of evidence is low. The strongest available evidence (level B) supports the use of single-plane, open chain upper extremity exercises performed below 90° of elevation and closed chain upper extremity exercises. Clinical expert pieces support a more advanced, global treatment approach consistent with the complex, multidimensional nature of sport.