Prevalence of Postural Deviations and Their Association with Shoulder Pain in Adolescent Handball Players

Authors

  • Sakhira Tariq Department of Physical Therapy, Government College University, Faisalabad, Pakistan Author
  • Nida Afzal Department of Physical Therapy, Government College University, Faisalabad, Pakistan Author
  • Ali Raza Department of Physical Therapy, Government College University, Faisalabad, Pakistan Author
  • Muzamil Abbas Department of Physical Therapy, Government College University, Faisalabad, Pakistan Author

DOI:

https://doi.org/10.61919/h1sqzb35

Keywords:

shoulder pain, postural deviations, scapular dyskinesis, pelvic tilt, adolescent athletes, handball.

Abstract

Background: Shoulder pain is a common complaint in overhead athletes and has been increasingly linked to postural deviations affecting the cervical spine, trunk, and scapular complex. Adolescent handball players, exposed to repetitive throwing and high training loads, may be particularly vulnerable to such biomechanical imbalances, yet evidence addressing posture–pain associations in this population remains limited. Objective: This study aimed to determine the prevalence of postural deviations and assess their association with shoulder pain in adolescent handball players. Methods: A cross-sectional observational study was conducted among 109 male handball players aged 18–25 years in Faisalabad, Pakistan. Eligibility required regular training for ≥3 months, with exclusion of those with spinal, neurological, or surgical histories. Posture was evaluated using a standardized posture grid, while shoulder pain was quantified with the Numeric Pain Rating Scale. Associations were tested using chi-square analysis, and odds ratios with 95% confidence intervals were calculated. Results: Shoulder pain was reported by 66.1% of players, predominantly of moderate intensity. High prevalence of anterior pelvic tilt (65.1%), scapular abnormalities (58.7%), and forward head posture (32.1%) was observed. Significant associations with pain were found for scapular malalignment (OR 40.0, 95% CI 11.9–134.0, p<0.001), pelvic tilt (p=0.042), and head posture (p=0.041). Foot posture showed no association. Conclusion: Postural deviations, particularly scapular malalignment and pelvic tilt, are strongly associated with shoulder pain in adolescent handball players. Early screening and kinetic chain–based corrective strategies are warranted to reduce injury risk and support long-term musculoskeletal health.

 

References

1. McCausland C, Sawyer E, Eovaldi BJ, Varacallo M. Anatomy, Shoulder and Upper Limb, Shoulder Muscles. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.

2. Okwumabua E, Black AC, Thompson JH. Anatomy, Shoulder and Upper Limb, Nerves. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.

3. Carini F, Mazzola M, Fici C, Palmeri S, Messina M, Damiani P, et al. Posture and Posturology, Anatomical and Physiological Profiles: Overview and Current State of Art. Acta Biomed. 2017;88(1):11-6.

4. Rosario L. What Is Posture? A Review of the Literature in Search of a Definition. EC Orthop. 2017;6(3):111-33.

5. Grabara M. The Posture of Adolescent Male Handball Players: A Two-Year Study. J Back Musculoskelet Rehabil. 2018;31(1):183-9.

6. Kim EK, Kim JS. Correlation Between Rounded Shoulder Posture, Neck Disability Indices, and Degree of Forward Head Posture. J Phys Ther Sci. 2016;28(10):2929-32.

7. Hunter DJ, Rivett DA, McKiernan S, Smith L, Snodgrass SJ. Relationship Between Shoulder Impingement Syndrome and Thoracic Posture. Phys Ther. 2020;100(4):677-86.

8. Malmström EM, Olsson J, Baldetorp J, Fransson PA. A Slouched Body Posture Decreases Arm Mobility and Changes Muscle Recruitment in the Neck and Shoulder Region. Eur J Appl Physiol. 2015;115(11):2491-503.

9. Shin YJ, Kim WH, Kim SG. Correlations Among Visual Analogue Scale, Neck Disability Index, Shoulder Joint Range of Motion, and Muscle Strength in Young Women With Forward Head Posture. J Exerc Rehabil. 2017;13(4):413-7.

10. Singla D, Veqar Z. Association Between Forward Head, Rounded Shoulders, and Increased Thoracic Kyphosis: A Review of the Literature. J Chiropr Med. 2017;16(3):220-9.

11. Wilczyński J, Cieślik M, Maszczyk A, Zwierzchowska A. The Importance of Posture and Body Composition for the Stability and Selected Motor Abilities of Professional Handball Players. J Hum Kinet. 2022;82:264-73.

12. Ohlendorf D, Salzer S, Haensel R, Rey J, Maltry L, Holzgreve F, et al. Influence of Typical Handball Characteristics on Upper Body Posture and Postural Control in Male Handball Players. BMC Sports Sci Med Rehabil. 2020;12:28.

13. Između P, Držanja P, Ruke TID, Tjelesnim SS, Rukometaša DK. Connection Between Body Posture Indicators and Dominant Hand With Scoliotic Body Posture in Handball Players. [Journal Unknown; details incomplete].

14. Vila H, Barreiro A, Ayán C, Antúnez A, Ferragut C. The Most Common Handball Injuries: A Systematic Review. Int J Environ Res Public Health. 2022;19(17):10688.

15. Barroqueiro C, Morais NV. The Effects of a Global Postural Reeducation Program on an Adolescent Handball Player With Isthmic Spondylolisthesis. J Bodyw Mov Ther. 2014;18(2):244-58.

16. Forthomme B, Croisier JL, Delvaux F, Kaux JF, Crielaard JM, Gleizes-Cervera S. Preseason Strength Assessment of the Rotator Muscles and Shoulder Injury in Handball Players. J Athl Train. 2018;53(2):174-80.

17. Landreau P, Zumstein MA, Lubiatowski P, Laver L. Shoulder Injuries in Handball. In: Handball Sports Medicine: Basic Science, Injury Management and Return to Sport. Berlin: Springer; 2018. p. 177-95.

18. Koester MC, George MS, Kuhn JE. Shoulder Impingement Syndrome. Am J Med. 2005;118(5):452-5.

19. Sayampanathan AA, Andrew THC. Systematic Review on Risk Factors of Rotator Cuff Tears. J Orthop Surg. 2017;25(1):2309499016684318.

20. Graham P. Rotator Cuff Tear. Orthop Nurs. 2018;37(2):154-6.

21. Horowitz EH, Aibinder WR. Shoulder Impingement Syndrome. Phys Med Rehabil Clin N Am. 2023;34(2):311-34.

22. Garving C, Jakob S, Bauer I, Nadjar R, Brunner UH. Impingement Syndrome of the Shoulder. Dtsch Arztebl Int. 2017;114(45):765-76.

23. Fares MY, Salhab HA, Khachfe HH, Kane L, Fares Y, Fares J, et al. Upper Limb Injuries in Major League Baseball. Phys Ther Sport. 2020;41:49-54.

24. Takeno K, Ingersoll CD, Glaviano NR, Khuder S, Norte GE. Upper Extremity Neuromuscular Function Can Distinguish Between Individuals With and Without Glenohumeral Labral Repair. J Electromyogr Kinesiol. 2024;79:102935.

25. Sheean AJ, Kibler WB, Conway J, Bradley JP. Posterior Labral Injury and Glenohumeral Instability in Overhead Athletes: Current Concepts for Diagnosis and Management. J Am Acad Orthop Surg. 2020;28(15):628-37.

26. DeFroda SF, Goyal D, Patel N, Gupta N, Mulcahey MK. Shoulder Instability in the Overhead Athlete. Curr Sports Med Rep. 2018;17(9):308-14.

27. Skjaker SA, Enger M, Engebretsen L, Brox JI, Bøe B. Young Men in Sports Are at Highest Risk of Acromioclavicular Joint Injuries: A Prospective Cohort Study. Knee Surg Sports Traumatol Arthrosc. 2021;29:2039-45.

28. Gismervik SØ, Drogset JO, Granviken F, Rø M, Leivseth G. Physical Examination Tests of the Shoulder: A Systematic Review and Meta-Analysis of Diagnostic Test Performance. BMC Musculoskelet Disord. 2017;18:41.

29. Dai L, Zeng R. Physical Examination of the Musculoskeletal System. In: Handbook of Clinical Diagnostics. Singapore: Springer; 2020. p. 241-53.

30. Singla D, Veqar Z, Hussain ME. Photogrammetric Assessment of Upper Body Posture Using Postural Angles: A Literature Review. J Chiropr Med. 2017;16(2):131-8.

31. Ghervan P. Prevention and Correction of Handball Players' Lumbar Spine Injuries. Ann Dunarea de Jos Univ Galati Fascicle XV Phys Educ Sport Manag. 2017;1:107-12.

32. Jandrić SĐ. Differences in Postural Disturbances Between Female Adolescents Handball Players and Nontraining Peers. Vojnosanit Pregl. 2016;73(4):337-42.

33. Wagner H, Fuchs PX, von Duvillard SP. Specific Physiological and Biomechanical Performance in Elite, Sub-Elite and Non-Elite Male Team Handball Players. J Sports Med Phys Fitness. 2018;58(1-2):73-81.

34. Andersson SH, Bahr R, Clarsen B, Myklebust G. Preventing Overuse Shoulder Injuries Among Throwing Athletes: A Cluster-Randomised Controlled Trial in 660 Elite Handball Players. Br J Sports Med. 2017;51(14):1073-80.

35. da Silva Barros BR, de Barros ACM, da Silva Júnior N, Cavalcanti IBS, de Oliveira Sousa C. Motor Alterations Along the Kinetic Chain in Amateur Volleyball and Handball Athletes With Shoulder Pain: An Observational Comparative Study. J Bodyw Mov Ther. 2024;39:364-72.

36. de Oliveira VM, Pitangui AC, Gomes MR, da Silva HA, Dos Passos MH, de Araújo RC. Shoulder Pain in Adolescent Athletes: Prevalence, Associated Factors and Its Influence on Upper Limb Function. Braz J Phys Ther. 2017;21(2):107-13.

37. Asker M, Waldén M, Källberg H, Holm LW, Skillgate E. A Prospective Cohort Study Identifying Risk Factors for Shoulder Injuries in Adolescent Elite Handball Players: The Karolinska Handball Study. BMC Musculoskelet Disord. 2017;18:1-7.

38. Grabara M. A Comparison of the Posture Between Young Female Handball Players and Non-Training Peers. J Back Musculoskelet Rehabil. 2014;27(1):85-92.

39. Liaghat B, Bencke J, Zebis MK, Sørensen H, Myklebust G, Wedderkopp N, et al. Shoulder Rotation Strength Changes From Preseason to Midseason: A Cohort Study of 292 Youth Elite Handball Players Without Shoulder Problems. J Orthop Sports Phys Ther. 2020;50(7):381-7.

40. Clarsen B, Bahr R, Andersson SH, Munk R, Myklebust G. Reduced Glenohumeral Rotation, External Rotation Weakness and Scapular Dyskinesis Are Risk Factors for Shoulder Injuries Among Elite Male Handball Players: A Prospective Cohort Study. Br J Sports Med. 2014;48(17):1327-33.

41. Giroto N, Hespanhol Junior L, Gomes M, Lopes A. Incidence and Risk Factors of Injuries in Brazilian Elite Handball Players: A Prospective Cohort Study. Scand J Med Sci Sports. 2017;27(2):195-202.

42. Quka N, Shehu M, Kosta O, Selenica R, Sallaku D. The Influence of Sport on Team Sport Athletes' Postural Development. Sci Sports. 2024;39(1):45-52.

43. Salzer S, Haensel R, Rey J, Maltry L, Holzgreve F, Lampe J, et al. Injury Occurrence in Male Handball Players and Its Impact on Physical Constitution. Int J Sports Med. 2020;41(5):328-38.

44. Abdel-Aziem AA, Ameer MA. The Relationship Between Body Height and Plantar Pressure Distribution in Adult Handball Players: A Cross-Sectional Study. J Orthop Trauma Rehabil. 2024;31(2):160-6.

45. Poschl GU, Coskunsu DK, Inal HS. Investigation of the Relationship Between Physical Activity Level and Postural Changes in Adolescents. Sci Res Health Sci. 2019;6(2):23-40.

46. de Carvalho-Nicolau R, Bittar ST, Tilp M, de Azevedo Lago S, dos Santos Oliveira L. Musculoskeletal Symptoms and Training Characteristics Differ Between Sex and Playing Positions: A Cross-Sectional Study Among High-Performance Brazilian Beach Handball Players. Int J Sports Sci Coaching. 2023;18(6):2133-41.

47. Ameer MA, Abdel-Aziem AA, Abd-Eltawab AE. The Impact of Anthropometric Measures on Plantar Pressure Distribution in Male Handball Players and Non-Athletes: A Cross-Sectional Study. J Bodyw Mov Ther. 2023;36:55-61.

48. Barbosa GM, Saccol MF, Pinheiro SM, Costa ID, Camargo PR, Silva RS. Stability, Performance and Upper and Lower Extremities Range of Motion in Elite Beach Handball Athletes: A Cross-Sectional Study. J Bodyw Mov Ther. 2023;36:178-84.

49. Laver L, Lubiatowski P, Zumstein MA, Landreau P. Shoulder Instability in Handball Players. In: Handball Sports Medicine: Basic Science, Injury Management and Return to Sport. Berlin: Springer; 2018. p. 197-216.

50. Ameer MAM, Abdel-Aziem AA. Relationship Between Anthropometric Measures and Sagittal Spinal Curvatures in Adult Male Handball Players. Hum Mov. 2017;18(4):41-8.

51. Farhani-Sameni N, Sheikhhoseini R, Piri H, Soltani F. The Effect of Reactive Neuromuscular Training Versus General Warm-Up on Proprioception and Balance in Female Handball Players With Rounded Shoulder. J Orthop Spine Trauma. 2024;10(3):105-10.

52. Grabara M. Anteroposterior Curvatures of the Spine in Adolescent Athletes. J Back Musculoskelet Rehabil. 2014;27(4):513-9.

53. Hoppe MW, Brochhagen J, Tischer T, Beitzel K, Seil R, Grim C. Risk Factors and Prevention Strategies for Shoulder Injuries in Overhead Sports: An Updated Systematic Review. J Exp Orthop. 2022;9(1):78.

54. Bauer J, Schedler S, Fischer S, Muehlbauer T. Relationship Between Upper Quarter Y Balance Test Performance and Throwing Proficiency in Adolescent Olympic Handball Players. BMC Sports Sci Med Rehabil. 2020;12:22.

55. Torabi TP, Bencke J, van den Tillaar R. The Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) Performance in Elite Team Handball Players Playing With Shoulder Pain, Previous Pain, or No Pain. Int J Sports Phys Ther. 2024;19(2):189-96.

56. Sinka GC, Mayer Á, Tállay A, Tátrai M, Tábori L, Papp E, et al. Effects of a Specific Trunk and Shoulder Strength Training Program on Throwing Velocity and Accuracy in Hungarian Female Handball Players. Sports (Basel). 2024;12(11):296.

57. Møller M, Nielsen R, Attermann J, Wedderkopp N, Lind M, Sørensen H, et al. Handball Load and Shoulder Injury Rate: A 31-Week Cohort Study of 679 Elite Youth Handball Players. Br J Sports Med. 2017;51(4):231-7.

58. Alghadir AH, Anwer S, Iqbal A, Iqbal ZA. Test–Retest Reliability, Validity, and Minimum Detectable Change of Visual Analog, Numerical Rating, and Verbal Rating Scales for Measurement of Osteoarthritic Knee Pain. J Pain Res. 2018;11:851-6.

59. Wagner H, Finkenzeller T, Würth S, von Duvillard SP. Individual and Team Performance in Team-Handball: A Review. J Sports Sci Med. 2014;13(4):808-16.

60. Samuelly-Leichtag G, Eisenberg E, Zohar Y, Andraous M, Eran A, Sviri GE, et al. Mechanism Underlying Painful Radiculopathy in Patients With Lumbar Disc Herniation. Eur J Pain. 2022;26(6):1269-81.

61. Robinson CM, Akhtar A, Mitchell M, Beavis C. Complex Posterior Fracture-Dislocation of the Shoulder: Epidemiology, Injury Patterns, and Results of Operative Treatment. J Bone Joint Surg Am. 2007;89(7):1454-66.

62. Mary P, Servais L, Vialle R. Neuromuscular Diseases: Diagnosis and Management. Orthop Traumatol Surg Res. 2018;104(1):S89-95.

63. Xie Y, Szeto GP, Dai J, Madeleine P. A Comparison of Muscle Activity in Using Touchscreen Smartphones Among Young People With and Without Chronic Neck–Shoulder Pain. Ergonomics. 2016;59(1):61-72.

64. Borstad JD. Resting Position Variables at the Shoulder: Evidence to Support a Posture-Impairment Association. Phys Ther. 2006;86(4):549-57.

65. Ludewig PM, Cook TM. Alterations in Shoulder Kinematics and Associated Muscle Activity in People With Symptoms of Shoulder Impingement. Phys Ther. 2000;80(3):276-91.

66. Huang TS, Ou HL, Lin JJ. Effects of Trapezius Kinesio Taping on Scapular Kinematics and Associated Muscular Activation in Subjects With Scapular Dyskinesis. J Hand Ther. 2019;32(3):345-52.

67. Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Scapular Position and Orientation in Throwing Athletes. Am J Sports Med. 2005;33(2):263-71.

68. Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular Muscle Recruitment Patterns: Trapezius Muscle Latency With and Without Impingement Symptoms. Am J Sports Med. 2003;31(4):542-9.

69. Feijen S, Struyf T, Kuppens K, Tate A, Struyf F. Prediction of Shoulder Pain in Youth Competitive Swimmers: Development and Internal Validation of a Prognostic Model. Am J Sports Med. 2021;49(1):154-61.

70. McGill SM, Childs A, Liebenson C. Endurance Times for Low Back Stabilization Exercises: Clinical Targets for Testing and Training From a Normal Database. Arch Phys Med Rehabil. 1999;80(8):941-4.

71. Barrett E, O’Keeffe M, O’Sullivan K, Lewis J, McCreesh K. Is Thoracic Spine Posture Associated With Shoulder Pain, Range of Motion and Function? A Systematic Review. Man Ther. 2016;26:38-46.

72. Mitchell C, Adebajo A, Hay E, Carr A. Shoulder Pain: Diagnosis and Management in Primary Care. BMJ. 2005;331(7525):1124-8.

73. Ha SM, Kwon OY, Cynn HS, Lee WH, Kim SJ, Park KN. Comparison of Electromyographic Activity of the Lower Trapezius and Serratus Anterior Muscles During Different Exercises in Subjects With and Without Scapular Winging. Phys Ther Sport. 2012;13(2):101-6.

74. Kibler WB, Sciascia A, Dome D. Evaluation of Apparent and Absolute Supraspinatus Strength in Patients With Shoulder Injury Using the Scapular Retraction Test. Am J Sports Med. 2006;34(10):1643-7.

75. Clarsen B, Bahr R, Myklebust G. The Burden of Shoulder Problems Among Elite Male Handball Players: Risks, Mechanisms and Consequences. Br J Sports Med. 2014;48(14):1129-35.

76. Struyf F, Tate A, Kuppens K, Feijen S, Michener LA. Musculoskeletal Dysfunction Associated With Shoulder Pain in Overhead Athletes: A Systematic Review. Br J Sports Med. 2017;51(11):775-80.

77. Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, et al. Should Exercises Be Painful in the Management of Chronic Musculoskeletal Pain? A Systematic Review and Meta-Analysis. Br J Sports Med. 2017;51(23):1679-87.

78. Hickey D, Solvig V, Cavalheri V, Harrold M, Mckenna L. Scapular Dyskinesis Increases the Risk of Future Shoulder Pain by 43% in Asymptomatic Athletes: A Systematic Review and Meta-Analysis. Br J Sports Med. 2018;52(2):102-10.

79. van der Hoeven H, Kibler WB. Shoulder Injuries in Tennis and Volleyball. Sports Med. 2006;36(7):563-77.

80. Kapreli E, Vourazanis E, Strimpakos N. Neck Pain Causes Respiratory Dysfunction. Med Hypotheses. 2008;70(5):1009-13.

81. Comerlato T, Becker RG, de Souza J, da Silva AM, de Abreu DC. Relationship Between Lumbar-Pelvic Posture and Shoulder Pain in Athletes: A Cross-Sectional Study. J Sports Sci. 2019;37(7):782-9.

82. Dill KE, Begalle RL, Frank BS, Zinder SM, Padua DA. Altered Knee and Ankle Kinematics During Squatting in Those With Limited Weight-Bearing Dorsiflexion. J Athl Train. 2014;49(6):723-32.

83. Kebaetse MB, McClure PW, Pratt NA. Thoracic Position Effect on Shoulder Range of Motion, Strength, and Three-Dimensional Scapular Kinematics. Arch Phys Med Rehabil. 1999;80(8):945-50.

84. Struyf F, Nijs J, Mollekens S, Jeurissen I, Truijen S, Mottram S, et al. Scapular Position, Strength, and Movement Performance in Overhead Athletes With and Without Shoulder Impingement Syndrome: A Case-Control Study. Br J Sports Med. 2011;45(4):330-6.

85. Andersson SH, Clarsen B, Myklebust G, Bahr R. Preventing Overuse Shoulder Injuries in Overhead Athletes: A Randomized Controlled Trial. Br J Sports Med. 2017;51(14):1073-80.

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2025-09-20

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Sakhira Tariq, Nida Afzal, Ali Raza, Muzamil Abbas. Prevalence of Postural Deviations and Their Association with Shoulder Pain in Adolescent Handball Players. JHWCR [Internet]. 2025 Sep. 20 [cited 2025 Nov. 29];3(13):e756. Available from: https://jhwcr.com/index.php/jhwcr/article/view/756

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