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Side dominance does not affect dynamic control strength ratios in the shoulder
Dawn T. Gulick , Chrisa S. Dustman, Laura L. Ossowski, M. Duncan Outslay, Christine P. Thomas and Sean Trucano
Purpose: To examine the normal strength relationship between eccentric external rotation (EccER) and concentric internal rotation (ConIR) strength ratios of the shoulder in the dominant and non-dominant extremities of healthy subjects. Methods: Fourteen men and sixteen women were tested in the scapular plane using two angular velocities: 90 and 120 /s. The dependent variables were: peak torque (PT), work per repetition (W/rep), and total work (TW) ratios. Results: The EccER: ConIR ratio in a non-athletic population was signicantly greater (p < 0.05) for the dominant than the non-dominant extremities for PT, W/rep, and TW. There was no signicant difference in torque production between the two-isokinetic velocities. W/rep and TW ratios were signicantly higher in females than in males. Although PT was not statistically signicant, a similar relationship existed (p = 0.069). Conclusion: In a healthy, non-athletic population, when tested at 90 or 120 /s, the EccER is just slight greater than its ConIR counterpart in women and men alike. Keywords: Isokinetic, torque ratios, shoulder strength

1. Introduction Shoulder rotation is frequently evaluated in research because of its importance in overhead functional activities, i.e. baseball pitching, tennis, water polo, and swimming [2,6,13,18,26,36,43]. Typically the purpose of overhead activities is to propel an object, such as a ball in pitching, a racket in tennis, a ball in water polo, or the individuals hand in swimming [21]. It has been reported that concentric shoulder ER and IR strength
for correspondence: Dr. Dawn T. Gulick, Widener University, Institute for Physical Therapy Education, One University Place, Chester, PA 19013, USA. Tel.: +1 610 499 1287; Fax: +1 610 499 1231; E-mail: Dawn.T.Gulick@Widener.edu. Isokinetics and Exercise Science 9 (2001) 7984 ISSN 0959-3020 / $8.00 ! 2001, IOS Press. All rights reserved
Address

ratios range between 0.6:1.0 in water polo players and swimmers [3,27] to 0.75:1.00 in control subjects [27, 42]. The differences between dominant and non-dominant shoulders have been examined in non-athletes, runners, tennis, and baseball players [7,15,30]. The dominant ER: IR ratios ranged from 0.57 to 0.78:1.00 while the non-dominant ER: IR ratios ranged from 0.66 to 0.85:1.00. In each of the studies, the non-dominant ratios were greater than the dominant ratios for all velocities tested. In addition, there was a tendency for the overhead athlete to have lower ER: IR ratios in both dominant (0.57 to 0.71:1.00) and non-dominant (0.66 to 0.76:1.00) as compared to non-overhead athletes and non-athletes (dominant 0.71 to 0.78:1.00; non-dominant 0.76 to 0.85:1.00) [7,15,30]. Given the strength of the IR in the overhead athlete, these relationships would be expected. This conventional ER: IR strength ratio has been based upon concentric ER and concentric IR [2]. However, during ballistic overhead movements, eccentric ER is needed to decelerate the humerus on the scapula [2,28,29]. A more functional ER: IR strength ratio would be expressed as the ratio between eccentric ER and concentric IR strength where the acceleration and deceleration phases of movement are both addressed [2]. This functional ER: IR ratio was compared in one previous study [2] and found to be 0.89 to 1.08:1.00 in the shoulder. An understanding of the normal strength relationship that exists between the two sides of the body is critical for the clinician to set reasonable rehabilitation goals. Our study examined the EccER: ConIR ratios for PT, W/rep, and TW measurements in non-symptomatic subjects to determine if there is a difference between the dominant and non-dominant shoulders at two different velocities. Such a determination will provide a framework by which clinicians can establish appropriate goals for muscle strengthening of the shoulder joint.

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D.T. Gulick et al. / Side dominance does not affect dynamic control strength ratios in the shoulder

2.2. Data analysis PT, W/rep, and TW data were collected. EccER: ConIR ratios were calculated and compared between the dominant and non-dominant extremities for each velocity using a 2 (gender) 2 (dominant vs. nondominant) 2 (90 vs. 120 /s) analysis of variance. 3. Results The means, standard deviations, and ratios of EccER to ConIR for dominant and non-dominant extremities at 90 and 120 /s for PT, W/rep, and TW are displayed in Table 1. A summary of the ANOVAs performed for PT, W/rep, and TW are displayed in Table 2. There were no interactions found.

Fig. 1. Testing position on the BIODEX isokinetic unit.

2. Methods 2.1. Subjects Thirty healthy subjects (16 females, 25.5 2.5 years, 1.67 0.07 m, 68.9 11.8 kg and 14 males, 27.5 2.5 years, 1.78 0.06 m, 81.2 13.6 kg) signed an informed consent form approved by the Investigational Review Board for the Protection of Human Subjects. Each individual served as his/her own control so the need for comparisons of torque with lean body mass or total body weight is eliminated [14]. Dynamometer: A BIODEX (Model #900-350) isokinetic dynamometer was used to collect data on PT, W/rep, and TW for concentric shoulder IR and eccentric shoulder ER. Warm-up and positioning: A ve-minute warm-up exercise using the upper body ergometer at 60 revolutions per minute preceded the test. Each subject was then seated at the dynamometer in a standardized position (Fig. 1) with the trunk and upper extremities stabilized to avoid substitution. The testing range covered 90 of motion. Thus, the forearm moved from the vertical position (ER) to the horizontal position (IR) in the plane of the scapula. The subject performed ve sub-maximal repetitions at each of the two testing velocities (90 and 120 /s) to increase familiarity with the machine. The commands given to each subject at each stage were standardized by using videotape. The dominant upper extremity was tested rst for all subjects. Each test consisted of ve maximal repetitions with the mean values of repetition 3, 4, and 5 used for data analysis. Subjects were given a one-minute rest period between velocities. The order of side testing was dominant rst and within each side the order of the individual tests were follows: concentric (IR) at 90 /s, concentric (IR) at 120 /s, eccentric (ER) at 90 /s, eccentric (ER) at 120 /s.

4. Discussion Various studies have attempted to describe the role of muscle strength and muscle balance across extremities. Electromyographic studies have demonstrated that during activity the internal rotators of the shoulder function concentrically to initiate and maintain motion, whereas the external rotators function eccentrically to decelerate and stop the motion [35]. Scoville et al. [35] stated that eccentric ER should be sufciently strong to overcome and decelerate the motion, thus a force production ratio of greater than 1:1 would be expected to avoid pathology. Traditionally, the majority of isokinetic shoulder testing has examined the concentric motion and discounted the eccentric phase. Even when the eccentric phase was addressed, the eccentric: concentric ratio was analyzed within the same muscle. To date, ratios reported have involved ConER: ConIR, EccER: ConER and EccIR: ConIR. The functional ratio calculated in the present study involves eccentric to concentric muscular activity of muscles that are coupled in functional activity, i.e. EccER and ConIR of the shoulder. This ratio has more clinical relevance. A source of the variability in prior studies has been the choice of testing position. Some studies have placed the shoulder in a neutral shoulder position [18,26,27], others the 90/90 position [1,2,6,8,10,13,15,20,28,35, 36,43], and still others in the plane of the scapula [12, 24,29,42].

D.T. Gulick et al. / Side dominance does not affect dynamic control strength ratios in the shoulder Table 1 Means, standard deviations, and eccentric external rotation to concentric internal rotation strength ratios for peak torque, work per repetition, and total work Testing method Peak torque Mean standard Ratio deviation 35.3 14.7 1.23:1.00 41.5 15.6 33.9 14.3 40.7 15.8 35.1 13.9 37.1 15.3 33.6 13.5 36.8 14.3 1.13:1.00 1.08:1.00 1.22:1.00 Work per repetition Mean standard Ratio deviation 39.3 18.0 1.18:1.00 43.7 14.7 38.5 17.2 42.7 14.1 36.7 15.2 38.0 14.4 36.1 15.3 38.4 14.2 1.10:1.00 1.06:1.00 1.18:1.00 Total work Mean standard Ratio deviation 185.2 88.1 1.18:1.00 206.1 74.3 180.2 83.7 200.6 66.9 172.2 74.6 177.9 70.4 172.2 73.5 175.3 66.1 1.05:1.00 1.06:1.00 1.19:1.00

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Dominant Con IR 90 /s Dominant Ecc ER 90 /s Dominant Con IR 120 /s Dominant ER 120 /s Non-Dominant Con IR 90 /s Non-Dominant Ecc ER 90 /s Non-Dominant Con IR 120 /s Non-Dominant Ecc ER 120 /s

All measurements of torque are in foot-pounds. Table 2 Summary analysis of variance table for peak torque, work per repetition, and total work Source Extremity Velocity Gender Extremity * Velocity Extremity * Gender Velocity * Gender Extremity * Velocity * Gender
Signicant

Peak torque F p 5.751 0.018* 0.077 0.782 3.376 0.069 0.520 0.472 1.407 0.238 1.015 0.316 0.546 0.462

Work per repetition F p 7.137 0.009* 0.383 0.537 18.030 0.000* 0.382 0.538 2.961 0.088 0.316 0.575 0.033 0.857

Total work F p 9.998 0.002* 0.004 0.949 11.936 0.001* 0.030 0.862 2.541 0.114 0.676 0.413 0.278 0.599

at p = 0.05 level.

4.1. Dominance The current study examined the functional ER: IR ratio in a non-athletic population. There was a signicant difference (p < 0.05) between EccER: ConIR of the dominant and non-dominant extremities for PT (dominant = 1.22: 1.00; non-dominant = 1.10: 1.00), W/rep (dominant = 1.18: 1.00; non-dominant = 1.08: 1.00) and TW (dominant = 1.18:1.00; non-dominant = 1.05:1.00). The higher ratios for the dominant versus non-dominant extremity are a result of higher torque production for EccER in the dominant extremity as compared to the non-dominant extremity. Bak and Magnuson [2] examined this functional ER: IR ratio in healthy and injured elite swimmers at a velocity of 30 /s. They reported ratios of 1.08: 1.00 and 0.89: 1.00 for the injured and healthy shoulders, respectively. In a different study, Sirota et al. [36] pub-

lished torque values of dominant and non-dominant extremities for concentric and eccentric force production at 60 /s and 120/s. Although ER: IR ratios were not included, calculations of dominant and non-dominant EccER: ConIR ratios were performed by the current authors from the raw data. At 60 /s the dominant EccER: ConIR ratio was 1.06:1.00 and at 120 /s was 1.19:1.00. The non-dominant EccER: ConIR ratios were 0.97:1.00 at 60 /s and 1.17:1.00 at 120 /s. Hence, these results were consistent with the present study in spite of the fact that the data was collected on professional baseball pitchers in 90 of shoulder abduction and 90 of elbow exion (90/90 position). According to Nirschl and Sobel [31] the dominant upper extremity (UE) should be approximately 5% stronger than the non-dominant UE in recreational tennis players and 10% stronger in competitive players. Ivey et al. [20] examined the non-athletic population and found a pattern of a stronger dominant UE in com-

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D.T. Gulick et al. / Side dominance does not affect dynamic control strength ratios in the shoulder

parison to the non-dominant. Likewise, Codine et al. [7] showed signicantly higher force production of the dominant versus non-dominant extremity in baseball players. Our ndings were consistent with these studies in that the dominant UE EccER ranged from 9.6% to 13.7% stronger than the non-dominant and the dominant ConIR ranged from 0% to 7% stronger than the non-dominant UE for all modes of testing. Albeit, the question must be asked; why was torque production of EccER lower in the non-dominant extremity? When performing functional overhead activities, i.e. reaching overhead, throwing a ball, or playing racquet sports, the dominant UE tends to be used more frequently. Hence, naming the extremity the dominant one. Also, these movements tend to have a high eccentric component [14]. Throughout the literature, there are few studies that examined eccentric strength of the shoulder rotators [2,13,28,36] in particular ER. Sirota et al. [36] tested professional baseball pitchers and found no signicant difference between dominant and non-dominant UEs but they reported a trend toward stronger EccER in the dominant UE. Mikesky et al. [28] found no signicant difference between dominant and non-dominant strength but conversely there was a trend toward stronger EccER in the non-dominant UE. On the other hand, there are numerous studies that have shown signicantly stronger ConIR in the dominant UE, the majority of which involve competitive athletes. Collegiate tennis players [9], high school baseball [18], collegiate baseball [8,28] and professional baseball pitchers [6,15] have all shown greater ConIR strength of the dominant UE. Likewise, Ellenbecker and Bleacher [12] have shown greater ConIR strength of the dominant UE in non-athletic females. Therefore, it is the impression of the current authors that the decrease in EccER torque in the non-dominant extremity is a result of less eccentric activity in tasks of daily living. The ConIR torque production was within the range of variability of prior studies. 4.2. Velocity Previous literature has stated that concentric PT should decrease with increasing velocities [32]. Whereas Ellenbecker et al. [13] stated that eccentric PT should increase or stay the same with increasing velocity. Unlike concentric muscle activity, eccentric activity involves muscle lengthening under a loading force via the breaking or releasing of sarcomere cross-bridges. Releasing of the cross-bridges occurs in order of weakest to strongest regardless of velocity. When lengthening

occurs, the tension at any point is simply the yield point of the next weakest sarcomere. Thus, the next weakest sarcomere will be stronger than the last, so the muscle tension should continue to rise. Our study revealed no signicant difference in PT, W/rep, or TW between the two-isokinetic velocities. Dominant and non-dominant ConIR PT was the same at each velocity, however dominant EccER PT was greater than non-dominant EccER PT at each velocity. This resulted in the dominant ratio of ER: IR being greater than the non-dominant ratio at 90 /s (41.5:35.3 vs. 37.1:35.1) and at 120 /s (40.7:33.9 vs. 36.8:33.8). When comparing the velocities of 90 and 120 /s, both the dominant and non-dominant extremities experienced a decrease in PT for the ER and IR movements. Both extremities had a larger decrease in PT with ConIR than with EccER. However, this difference was not great enough to yield statistical signicance. Perrin et al. [32] found that PT in eccentric activity may stay the same as velocity increases. In an unpublished study by Smith et al. [37], researchers found that as velocity increased, PT decreased in both concentric and eccentric activities. In the current study, eccentric PT did not change with increasing velocity. There are at least two possible explanations for these results. First, exercising eccentrically for the rst few times can be difcult. Concentric testing requires the subject to initiate the movement, whereas eccentric testing requires the subject to rapidly respond to a movement initiated by the machine. Smith et al. [37] termed this phenomenon catching the machine. As the velocity increases, the ability to catch the machine becomes increasingly more difcult and may delay torque generation. The longer the delay, the further the movement progresses into the range of motion. If the mid-range of the movement is passed, maximum torque production will be compromised. Becoming familiar with the workings of an isokinetic unit could help an individual learn how to catch the machine. In the current study, a single practice session of ve repetitions may not have been sufcient to teach the subjects how to properly exert resistance against the force of the machine. Second, ber type of the muscle tested may have an effect on the ability to generate force [9]. Fast twitch bers can continue to produce more concentric torque at the faster velocities while the contribution of slow twitch torque declines [9]. Ivey et al. [20] studied average peak torque for concentric IR and ER. They found that ER:IR concentric PT ratios were 0.66:1.00 for both slow (60/s) and fast movements (180 /s). They also found no signicant differences between dominant and

D.T. Gulick et al. / Side dominance does not affect dynamic control strength ratios in the shoulder

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non-dominant concentric PT ratios at these velocities. Our study had similar results in that PT ratios were not signicantly different between velocities. Though this has only been studied in concentric actions, the types of bers used in EccER may also affect the ability to generate torque. Generally, differences begin to occur at or above velocities of 120 /s. Since the maximum velocity for eccentric activity on the Biodex model used in this study is 120 /s, it was not possible to examine higher velocities. With a 30 /s physiological overow through the velocity spectrum [9], the velocities used in this study may not have been different enough to detect a change in performance. It has been recommended that testing velocities need to differ by 50 /s to detect a signicant difference in torque production [6]. 4.3. Gender The relationship between velocity, dominance, and test mode by gender was examined. Analysis of the data indicates that at a given velocity,the difference in torque between eccentric and concentric output was larger for the female subjects than for the male subjects. This statement holds true for both W/rep and TW (p < 0.05) in this population. Although PT was not statistically signicant, a similar relationship existed (p = 0.069). Therefore, when comparing W/rep and TW, the values in the female subject pool had a signicantly higher ratio than their male counterparts. An explanation for this relationship eludes the current authors, however it would behoove clinicians to recognize the difference in the ratios between genders.

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5. Conclusion In summary, this study attempted to address an unexplored relationship between EccER and ConIR of the shoulder. In a healthy, non-athletic population, this ratio was found to be slightly greater than 1.00:1.00 for both velocities, both dominant and non-dominant extremities, and across both genders.

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