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Article

The Functional Assessment of the Shoulder in Water Polo Players with Surface Electromyography and Kinematic Analysis: A Pilot Study

by
Francesco Sgrò
1,
Andrea Demeco
2,*,
Nicola Marotta
3,4,
Giampiero Merati
5,
Mario Lipoma
1,
Antonio Ammendolia
4,6,
Cosimo Costantino
2 and
Teresa Iona
6
1
Department of Human and Society Sciences, University of Enna “Kore”, 94100 Enna, Italy
2
Department of Medicine and Surgery, University of Parma, 43125 Parma, Italy
3
Physical and Rehabilitative Medicine, Department of Experimental and Clinical Medicine, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
4
Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
5
Department of Biotechnology and Life Sciences, University of Insubria, 21100 Varese, Italy
6
Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(16), 7077; https://doi.org/10.3390/app14167077
Submission received: 12 June 2024 / Revised: 1 August 2024 / Accepted: 8 August 2024 / Published: 12 August 2024
(This article belongs to the Special Issue Sports Medicine: Latest Advances and Prospects)
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Abstract

:

Featured Application

The proposed kinematic analysis protocol can play a role in detecting electromyographic and kinematic alterations of the shoulder for the pre-clinical detection of the risk factors for overuse pathologies. Moreover, the proposed exercise prevention protocol has shown valuable results in optimizing shoulder movement and can be proposed to overhead athletes as a part of their athletic preparation.

Abstract

Scapular dyskinesia, glenohumeral internal rotation deficit, upper posterior labral anterior tears, and rotator cuff injuries are common in athletes who play “overhead” sports due to their repetitive excessive movements. The aims of this study are to propose a new protocol with kinematic analysis coupled with sEMG and to objectively analyze the effect of a specific prevention exercise protocol. Thirty-two subjects (age: 22 ± 4 years, height: 183 ± 3.2 cm, BMI: 23 ± 0.96 kg/m2), including sixteen healthy subjects (Group A) and sixteen male water polo athletes (Group B), underwent a three-dimensional motion analysis based on optoelectronic and sEMG systems. A functional evaluation was performed on Group A and Group B to assess the reliability of the operator-dependent tasks and collect a series of normative data, before starting the prevention protocol (T0) and after 8 weeks (T1). The athletes performed a specific exercise protocol to prevent shoulder injuries. In Group B, the movements of abduction (T0: 111° ± 24°; T1: 140° ± 13°) and extension (T0: 72°± 10°; T1: 84° ± 2.8°) of the glenohumeral joint and the scapulothoracic joint (T0: 33° ± 8.36°; T1: 40.5° ± 10.6°) significantly improved. A significant reduction (in %) in the maximum voluntary contraction (MCV) at T1 of the upper trapezius, teres minor, and pectoralis major was observed. This protocol provides objective data in a simple and reliable way for the functional assessment of the shoulder in water polo players during the sport season.

1. Introduction

Water polo is a physically demanding sport, in particular for the upper limbs, with an intense snap in swimming, change in direction, passing, and repetitive shooting of the ball [1]. It is a contact sport with the highest incidence of injuries, in particular shoulder injuries, among the other aquatic sports [2,3]. In competitive situations, shoulder injury is reported to have an estimated incidence of 56.2 per 1000 h of play [4]. In particular, shoulder pain has a prevalence of 24 to 80% and represents the most common water polo injury [4].
The throwing pattern is similar to that of other overhead sports, requiring repetitive upper limb movement involving high-grade elevation and external rotation. In particular, the throwing activity can be divided into a first acceleration phase, in which the scapula rotates upward externally and tilts posteriorly; afterwards, the deceleration phase occurs, in which the scapula performs a movement of downward and internal rotation and tilts anteriorly [5].
Moreover, the aquatic environment makes it difficult to generate a high throwing force without the contribution of a solid base of support and the conventional throwing proximal–distal kinematic chain sequence [2]. In particular, the scapula represents an internal link between the body and the kinetic chain of the upper limb, and any type of difference in the scapular alignment represents a risk factor for shoulder injuries. Correct scapular control and symmetry are essential for efficient shoulder biomechanics, providing a stable base for rotator cuff muscle activation, which is considered to be an important link in the kinetic chain of the shoulder [6]. The overhead nature of this sport causes functional alterations that could precede pathological changes and represent a risk factor for soft tissue injury and glenohumeral joint instability [7]. However, it is necessary to specify that a certain grade of asymmetry between the dominant and non-dominant is physiological in healthy athletes in unilateral sports, e.g., tennis, and the physician should be aware of the pathologic threshold for scapular posture asymmetry at which the asymmetry becomes problematic [8,9].
The throwing motion forces the shoulder into its maximum flexion, abduction, and extra-rotation and may lead to shoulder pathologies, such as scapular dyskinesia, glenohumeral internal rotation deficit (GIRD), superior labral anterior–posterior (SLAP) tears, and rotator cuff tears [10,11,12].
This represents a serious concern for athletes considering the days spent out of competition, the risk of chronicity, and the detraining effect on their overall performance [2]. The therapeutic options for the treatment of shoulder injuries include, but are not limited to, intra-articular injections (e.g., hyaluronic acid, corticosteroids, and prp), physical therapy (e.g., laser and shockwave), and exercise therapy (e.g., strength training and visual feedback training) [13,14,15,16,17,18].
In this context, prevention plays a key role in the management of injuries, with an increasing need for prevention strategies, daily athlete functional monitoring, and tailored exercise programs targeting the athlete’s needs [2,5].
Several approaches could be utilized for the functional analysis of the shoulder. The first and most important step is the physical examination of the patients, starting from the anamnesis, the revision of the medical records, and the examination of the shoulder’s range of motion and muscle strength [19]. Moreover, it is common to make use of clinical scores, which are useful in clinical practice. However, technological advancements have provided the physician with new tools for a detailed and objective movement analysis [20]. There are different possibilities to choose from according to the ratio between the accuracy of the examination and the costs in terms of time and expensive equipment. However, 3D motion capture with optoelectronic systems represents the gold standard for the analysis of athletic gestures [21]. In particular, 3D motion cameras can be utilized to analyze a joint’s range of movement thanks to the detection of markers positioned on reference landmarks on the skin of the patient; meanwhile, surface electromyography (sEMG) can be utilized to assess muscle excitation, during the movement performed, for an in-depth analysis of the neuromuscular control [21,22].
However, the use of these technologies is often limited in a sport context because it requires specialized personnel to perform the kinematic analysis and the interpretation of the results [20]. Thanks to the integration of kinematic analysis and sEMG, it is possible to collect both movement and electromyographic data, providing new insight into muscle activation in relation to shoulder movement, thereby reducing the quantity of markers, cameras, and sEMG probes [11,20].
Thus, the aims of this study were double: (1) to verify the reliability of an easy-to-use protocol for the quantitative assessment of shoulder biomechanics in water polo players using kinematic analysis coupled with sEMG, identifying predictive factors for injuries and providing technical staff with information on the condition of the shoulder of the athlete; (2) to design and assess a structured prevention program of exercises to improve the scapular girdle biomechanics.

2. Materials and Methods

2.1. Participants and Procedure

We conducted a longitudinal observational study to analyze the role of a structured prevention program of exercises in improving the scapular girdle biomechanics.
We enrolled 2 groups of subjects: healthy students of “Magna Graecia University” with an active lifestyle (Group A) and male athletes of a water polo team of the Italian Major League (Group B). The inclusion criteria were as follows: no previous history of shoulder or elbow injury or disease in the last year; a Neer and Hawkins test to exclude the clinical diagnosis of subacromial impingement syndrome; and no cervical pain or limitations. Informed consent was acquired from each of the participants and the Regional Ethics Committee approved the methodological approach proposed (Prot. N. 115/2022 Calabria Centrale).
All participants underwent a kinematic analysis of both shoulders consecutively using a stereophotogrammetry system and an sEMG wireless system. Data collected on Group A were utilized to test the intrasubject, inter-rater, and intra-rater reliability of the kinematic analysis protocol and to collect a series of normative data. Conversely, Group B underwent a kinematic analysis before (T0) and after (T1) the exercise protocol.
At the start and at the end of this study, each athlete completed a Kerlan–Jobe Orthopaedic Clinic Shoulder & Elbow (KJOCSE) questionnaire to assess the performance and function of the upper limb [23,24]. KJOCSE is intended for use with overhead athletes and aims to determine if there is pain during throwing, with a good–excellent reliability and a minimal detectable change of 6.7.
The stereophotogrammetry system was composed of two infrared cameras (Smart-DX (Smart-DX, BTS bioengineering–Garbagnate Milanese, Italy), BTS–Emilia-Romagna, Italy), with its sampling frequency set to 200 Hz. The optoelectronic system represents the gold standard for kinematic analysis, with reported errors of < 4.0° for movement in the sagittal plane and < 2.0° in the coronal plane [25]. The system was calibrated according to the instructions of the manufacturer. As shown in Figure 1, 17 reflective markers (9.5 mm diameter) were positioned at reference points on each participant’s body, detailed as follows: the processus spinosus of the seventh cervical (C7) and eighth thoracic vertebra (T8), the acromion process (AC), the center of the humerus diaphysis (Hm), the lateral epicondyle (EL), the ulnar styloid (US), the trigonum scapulae (TS), the inferior angle of the scapula (AI), and the anterior superior iliac spine (Clsup) [21].
Each participant also wore five sEMG wireless electrodes (freeemg 1000, BTS bioengineering–Garbagnate Milanese, Italy) on the following muscles: the pectoralis major, the deltoid, the trapezius, the latissimus dorsi, and the teres minor. The kinematic protocol was adapted from previous studies [11,21,26].
Before performing the analysis, the electrode sites on the skin surface were shaved and abraded, and alcohol was used to reduce the skin’s impedance. Surface electrodes were placed according to the recommendations of sEMG for Not-Invasive Assessment of Muscles (SENIAM) [27]. We compared the abduction, flexion, extension, and internal and external rotation ROM of both shoulders to calculate any difference between the scapular movement and the electromyographic data for the main muscles involved in the shoulder movement during throwing, as shown in Figure 2 [10,28,29].
All participants performed the maximum movement of flexion, extension, abduction, and internal and external rotations three times, firstly with the dominant limb and then with the non-dominant limb.
Three trials from each participant were analyzed in one session to assess the intra-subject reliability with 4 min of rest between tests. Each participant was rated by the same examiner over two days of testing with an average test-to-test interval of 10 days (±0.5 days) [30]. Additionally, the participants were evaluated by a second examiner on the second day of testing to assess the inter-rater reliability. Both examiners were experts in defining anatomical points. The participants performed the kinematic evaluation in a bathing suit and barefoot after a brief warm-up.
The raw sEMG data were recorded with a sampling frequency of 1000 Hz. All recorded signals were band-pass filtered with a high- and low-pass Hamming filter with cutoff frequencies of 5 and 500 Hz, respectively, and an additional 50 Hz 80 dB/decade notch filter. We rectified the sEMG signals, and we used a low-pass Hamming filter at 5 Hz to calculate the linear envelope for the representation of the sEMG wave.
We normalized the data considering the maximum voluntary isometric contractions (MVICs). The MVC was measured for each muscle. The participants were asked to initiate muscle contraction and slowly and gradually increase it until the maximum effort was reached. Each was asked to repeat this contraction 3 times and the maximum voluntary contraction (MVC) was defined as the average of these 3 peak loads. The sEMG signals were cut and resampled to 200 Hz, which was equivalent to the frame rate of the camera. The 3D coordinates of the markers were calculated with the software supplied with the Smart DX system, named Smart Analyzer 1.10.470.0 (BTS Bioengineering-Garbagnate Milanese, Italy).

2.2. Exercise Protocol

Under the guidance of an experienced coaching staff, all athletes performed a specific protocol of exercises to strengthen the shoulder muscles during the competitive season 4 times a week during the warm-up, before training or the match, for 2 sets of 10 repetitions (2 × 10) for each exercise, as shown in Figure 3. The normal warm-up includes breathing exercises; skips and jump ropes to increase the body temperature; active exercises at the full ROM of the shoulder and rotation of the upper limb, stretching the scapular muscle girdle and glenohumeral capsule; and finally, an activation phase with a squat hold, plank, and 15 min of easy-pace swimming.
Previous studies have highlighted the use of elastic resistance during shoulder exercises and shoulder rehabilitation programs [31,32].
The shoulder stabilization exercises were chosen to enhance muscle strength in the coronal, sagittal, and transverse plane for the scapulothoracic muscles, in particular the rotator cuff muscles, to enhance the shoulder and scapular movement, as well as to improve the scapular kinematics [33]. Exercises commonly performed to improve the strength of the rotator cuff and periscapular deltoid muscles include internal and external rotation, abduction, extension, and flexion, and pulley exercises to improve/restore the functioning of the infraspinatus and teres minor and improve the passive and active range of motion of the shoulder [34,35,36,37,38].

2.3. Data Analysis

The statistical analysis was performed using R version 3.5.1. The data were analyzed using R v3.5.1 (USA-2018) and tested for normality using the Shapiro–Wilk normality test. We used the median and interquartile range to describe the nonparametric data. We ran a Wilcoxon signed-rank test to test the significance. The parametric data were reported as means ± SD and tested with Student’s t-test and an analysis of variance. We utilized G*Power for a post hoc power analysis.
We assessed the reliability of the protocol through the intraclass correlation coefficient (ICC). The intra-subject reliability was estimated using the ICC (3,1) of three trials for the left and right sides from the first session. The inter- and intra-rater reliability were calculated with ICC (3.1) using the average data (the means of three trials per session). Furthermore, the 95% confidence interval (CI) of the ICC values was calculated. The following interpretation of the ICC values was considered: poor was below 0.20; fair was from 0.21 to 0.40; moderate was from 0.41 to 0.60; good was from 0.61 to 0.80; and very good was from 0.81 to 1.00.

3. Results

Thirty-two male subjects, (age: 22 ± 4 years, height: 183 ± 3.2 cm, BMI: 23 ± 0.96 kg/m2), including sixteen for Group A and sixteen for Group B, were enrolled in this study. There was no statistical significance between the group differences at T0, as seen in Table 1.

3.1. Reliability

The intra-subject reliability was very high (>0.90) for all scapulothoracic joint angles. The intra- and inter-rater reliability of the scapular kinematics during shoulder flexion showed good reliability.

3.2. Kinematic Analysis

The values of the shoulder range of motion at T0 and T1 for Group B are shown and compared with the reference range calculated for healthy subjects in Table 2.
The KJOCSE score was significantly higher (p < 0.001) at T1 (92 ± 6.4) compared to T0 (75 ± 4.5), with an average increase of 23% in the score for each item of the questionnaire.
There were no differences in the range of shoulder movement between the dominant and non-dominant shoulders (p > 0.05) at T0. The movement of the scapulothoracic joint during flexion (Fl-STJ) of the upper limbs was significantly smaller (p = 0.035) at T0 (33° ± 8.36°) than at T1 (40.5° ± 10.6°).
The abduction of the glenohumeral joint (Ab-GHJ) was significantly lower (p < 0.001) at T0 (113° ± 19.98°) than at T1 (140.35° ± 12.11°); similar results were seen for the extension of the upper limbs (T0: 69.68° ± 9.62°; T1: 82.06° ± 6.66°) (p < 0.001).
The movement of the scapulothoracic joint during the abduction of the upper limbs (Ab-STJ) was significantly lower (p = 0.028) at T0 (38.93° ± 9.8°) than at T1 (47.75° ± 8.1°).
The extra-rotation was significantly smaller (p < 0.001) at T0 (73.18° ± 6.92°) than at T1 (85.56° ± 4.1°); the intra-rotation did not show any differences (Figure 4).
The muscle activity measured using sEMG was significantly decreased at T1 compared to T0 (p = 0.02). A diminution in the sEMG signal of the examined muscles was recorded at T1 (28 ± 3% of MVIC) compared to at T0 (30 ± 4% of MVIC).
In particular, a reduction in the activity of the teres minor (T1: 31 ± 6% of MVIC; T0: 28 ± 4% of MVIC) and pectorals major (T1: 6 ± 3% of MVIC; T0: 4 ± 3% of MVIC) was observed during the movement of external rotation and a reduction in the activity of the trapezius (T1: 33 ± 7% of MVIC; T0: 29 ± 6% of MVIC) was observed during the movement of abduction of the upper limb.
No shoulder injuries were recorded in the group of athletes during the competitive season.

4. Discussion

Shoulder injuries in water polo athletes occur as a result of repetitive excessive movements, characterized by kinematics that go beyond the physiological forces involved in the throwing action [10]. Functional alterations, such as scapular muscle imbalance, are the first signs of overuse injuries and increase glenohumeral contact and the impingement of the rotator cuff [2]. Most alterations appear during the first phase of the throwing motion, when the arm is raised, while dyskinesia of the scapula in the kinetic chain increases the mechanical stress on the glenohumeral joint [39].
In the literature, there are different protocols for the kinematic analysis of the shoulder with various techniques, but none of these has become an industry standard because of their own limitations, i.e., the complexity of the protocols requiring up to 24 cameras and 53 markers [40]. The level or timing of the muscle activity is mostly recorded by sEMG which is an accurate, reliable, and non-invasive method for measuring muscle activity and the muscle timing of superficial muscles when it is coupled with inertial sensors, but it may be necessary to use up to 13 surface electrodes to analyze the scapular behavior [41], which is not practical in clinical applications.
For these reasons, it is important to evaluate the behavior of the muscles during shoulder movement with an easy-to-use protocol that couples sEMG and kinematic analysis to detect functional alterations of the shoulder. We evaluated the shoulders of 16 healthy subjects to test the reliability of the functional evaluation protocol and to develop a set of reference data regarding the shoulder’s ROM. The kinematic protocol tested has shown a good reliability in water polo players and can provide a new insight into medical practice since it allows the use of kinematic analysis and sEMG simultaneously to relate muscle activation to a range of voluntary movements of the shoulder muscles. Previous studies have analyzed either the movement or the activation of the muscle, but this protocol can provide more detailed information on the status of the activation of the muscles. The combination of sEMG and the quantification of the movement of the marker with kinematic analysis helps the physician detect aberrant movements caused by altered muscle recruitment patterns, force imbalance, muscle fatigue, poor thoracic posture, and scapular dyskinesis and allows a reduction in the number of markers and sEMG probes used during the examination. Another advantage of this protocol is the lower number of cameras utilized, which simplifies the testing procedure and reduces the cost compared with methods already described in the literature. Based on these considerations, applications of this proposed kinematic analysis protocol could play a role the in future.
Moreover, we analyzed the effect of a preventive exercise protocol on water polo athletes. In particular, we found that scapular upward rotation during the abduction and flexion of the upper limb and the abduction and external rotation of the glenohumeral joint were significantly higher at T1, after the application of a specific protocol of exercises performed during the agonistic season. Biomechanically, a reduction in the scapular upward rotation has been postulated to reduce the subacromial space, leading to a mechanical compression of the supraspinatus tendon and subacromial bursa [42]. Thus, an increase in the scapular upward rotation during the elevation of the arm could potentially reduce the risk of the development or progression of impingement syndrome [43]. Interestingly, it was associated with lower activation of the upper trapezius sEMG activity during the elevation of the upper limb at T1, confirming that the greater activation of the upper trapezius is a key element to focus on since it is a predictive factor for shoulder injuries [43]. Namely, the increased sEMG activity of a muscle could be considered a compensatory strategy [29], correlated to an altered scapula movement and the overuse of the glenohumeral joint.
The reduction in the activation of the pectoralis major during external rotation at T1, and, consequently, a greater muscle flexibility lead to a decreased activation of the external rotatory muscles, such as the minor teres, and an improvement in the external glenohumeral rotation, reaching a new balance between the agonist muscles and antagonists at a lower energy level.
These findings confirm that a specific protocol of exercises, performed using elastic—which is a low-cost device and easy to handle—and specific techniques to improve the perception of arm and movement positioning could play a role in the harmonization of the sequence of movements and restore dynamic scapular stability [44,45], with an improvement in the performance and function of the upper limb [46,47]. Based on the results of our study, this protocol of exercises could be considered for use during the warm-up stage for water polo players and overhead athletes.
However, this study is not free of limitations. One limitation of the optoelectronic systems is linked to the positioning of the markers on the skin of the patient. The reduction in the laboratory settings and number of cameras could have affected the marker acquisition. The integration of the proposed warm-up protocol during the sport season could have been influenced by the sport activity. We did not perform an assessment of the muscle length. Finally, the limited sample size may have affected the study results and limited their generalizability.

5. Conclusions

The proposed protocol of kinematic analysis integrated with sEMG has shown high reliability for the functional evaluation of the shoulder in water polo athletes. Thanks to the data obtained, this analysis can help physicians and kinesiologists design specific exercise protocols able to produce an improvement in the kinematics of the shoulder by concurrently reducing the risk of injury. Moreover, it is recommended that the warm-up be integrated with a specific protocol of exercise, to improve shoulder function and prevent injuries.

Author Contributions

Conceptualization, A.A. and A.D.; methodology, A.D., N.M. and T.I.; investigation, A.D. and N.M.; data curation, T.I.; writing—original draft preparation, M.L. and G.M.; writing—review and editing, F.S., G.M. and C.C.; supervision, A.A.; project administration, T.I. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Calabria Centrale (protocol code 115/2022 and 21 April 2022) for studies involving humans.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Kinematic shoulder protocol for the right side.
Figure 1. Kinematic shoulder protocol for the right side.
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Figure 2. Kinematic and sEMG raw signals. The graph shows the kinematic analysis and sEMG signals for a healthy subject. It shows the movement of the scapulothoracic joint and the glenohumeral joint (scapulohumeral rhythm) during the abduction of the right upper limb and the activation of the muscle involved.
Figure 2. Kinematic and sEMG raw signals. The graph shows the kinematic analysis and sEMG signals for a healthy subject. It shows the movement of the scapulothoracic joint and the glenohumeral joint (scapulohumeral rhythm) during the abduction of the right upper limb and the activation of the muscle involved.
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Figure 3. Pre-workout exercise protocol.
Figure 3. Pre-workout exercise protocol.
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Figure 4. Fl-GHJ = contribution of the glenohumeral joint during flexion of the upper limb. Fl-STJ contribution of the scapulothoracic joint during flexion of the upper limb. Ab-GHJ = contribution of the glenohumeral joint during abduction of the upper limb. Ab-STJ contribution of the scapulothoracic joint during abduction of the upper limb. NR stands for range of normality. (EXT = extension; INR internal rotation; EXR: external rotation).
Figure 4. Fl-GHJ = contribution of the glenohumeral joint during flexion of the upper limb. Fl-STJ contribution of the scapulothoracic joint during flexion of the upper limb. Ab-GHJ = contribution of the glenohumeral joint during abduction of the upper limb. Ab-STJ contribution of the scapulothoracic joint during abduction of the upper limb. NR stands for range of normality. (EXT = extension; INR internal rotation; EXR: external rotation).
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Table 1. Characteristics of the included subjects.
Table 1. Characteristics of the included subjects.
MeasureGroup AGroup B
n1616
Age (years)20.8 ± 3.423.3 ± 4
Height (cm)182.4 ± 3183.7 ± 3.2
BMI (kg/m2)23 ± 1.122.9 ± 0.928
Table 2. Shoulder range of motion at T0 and T1 for Group B; set of normative data based on healthy subjects (Group A). Mean (sd). Fl: flexion; Ab: abduction; GHJ: glenohumeral joint; STJ: scapulothoracic joint; *: statistically significant.
Table 2. Shoulder range of motion at T0 and T1 for Group B; set of normative data based on healthy subjects (Group A). Mean (sd). Fl: flexion; Ab: abduction; GHJ: glenohumeral joint; STJ: scapulothoracic joint; *: statistically significant.
T0T1T1–T0Group A
FlexionFl-GHJ161.3° (11.78)170.87° (6.99)9.5 (9.84)163.00° (10.17)
Fl-STJ33.31° (8.36)40.5° (10.57)9.0 (12.98) *31.87° (4.84)
AbductionAb-GHJ113.93° (19.98)140.25° (12.1)26.3 (19.0) *126.37° (21.37)
Ab-STJ38.93° (9.84)47.75° (8.16)8.8 (14.58) *37.75° (5.15)
Extension 69.68° (9.62)82.06° (6.67)12.4 (11.24) *75.68° (6.32)
Internal Rotation 68.93° (9.57)71.18° (7.7)8.8 (18.44)67.62° (9.35)
External Rotation 73.18° (6.92)85.56° (4.18)12.4 (7.1) *73.27° (6.96)
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MDPI and ACS Style

Sgrò, F.; Demeco, A.; Marotta, N.; Merati, G.; Lipoma, M.; Ammendolia, A.; Costantino, C.; Iona, T. The Functional Assessment of the Shoulder in Water Polo Players with Surface Electromyography and Kinematic Analysis: A Pilot Study. Appl. Sci. 2024, 14, 7077. https://doi.org/10.3390/app14167077

AMA Style

Sgrò F, Demeco A, Marotta N, Merati G, Lipoma M, Ammendolia A, Costantino C, Iona T. The Functional Assessment of the Shoulder in Water Polo Players with Surface Electromyography and Kinematic Analysis: A Pilot Study. Applied Sciences. 2024; 14(16):7077. https://doi.org/10.3390/app14167077

Chicago/Turabian Style

Sgrò, Francesco, Andrea Demeco, Nicola Marotta, Giampiero Merati, Mario Lipoma, Antonio Ammendolia, Cosimo Costantino, and Teresa Iona. 2024. "The Functional Assessment of the Shoulder in Water Polo Players with Surface Electromyography and Kinematic Analysis: A Pilot Study" Applied Sciences 14, no. 16: 7077. https://doi.org/10.3390/app14167077

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