Shoulder pain in archers: Kim 2021 study

Fifty-eight archers from Gwangju, South Korea, aged 13 and over (29 men and 29 women, from middle school, high school, university and club teams) filled in an injury questionnaire and were examined with ultrasound, two shoulder function scores and a strength measurement. The shoulder was the most common site: 38 of the 58 (65.5%) had been injured there, followed by the hand (16 archers, reported as 29.3%) and the neck (13, or 22.4%). The shoulder came first in all four age groups, and in the university team it reached 9 archers out of 10.

Forty of the 58 reported shoulder pain: mild in 30 (51.7%), moderate in 8 (13.8%) and severe in 2 (3.5%). Where the side was recorded, the pain was in the drawing arm in 33 cases out of 41 (80.5%), in the bow arm in 5 and in both in 3. It appeared mostly during the draw (48.8%), then at full draw (36.6%) and at release (14.6%). In 56.1% the pain had come back more than once, 75.9% had had some non-surgical treatment in the previous year and 3 archers (5.2%) had had surgery; 86.7% were back in training within a week, and only 4 of 47 (8.5%) thought the injury had affected their results. On ultrasound, 22.4% had biceps tendinosis and 10.3% subacromial bursitis.

Archers with pain scored lower on both shoulder function questionnaires: 83.81 against 85.25 on the Constant-Murley score (p = 0.048) and 82.97 against 99.71 on the ASES score (p < 0.001). Abduction strength of the drawing arm did not differ (14.56 against 14.20, p = 0.606). None of the training habits examined (length and frequency of sessions, minutes of warm-up, injury prevention courses, supplements) was significantly linked to having pain.

The study is cross-sectional: a single assessment, with questions asking archers to recall past injuries (the authors call it a retrospective cohort study). There were 27 archers from a middle school team (aged 13 to 15), 12 from a high school (16 to 18), 10 from a university (19 to 22) and 9 from club teams (23 or older), with a mean age of 17.3, 7.5 years of practice and about 101 minutes of team training a day. The paper does not name the bow division, but it describes shooting with a clicker, so this is Olympic recurve. Archers who had not completed the questionnaire were excluded.

The questionnaire followed the Oslo Sports Trauma Research Center model for overuse injuries. An injury was pain in a specific area that came on with training or was being treated for that reason, and one archer could report more than one. Pain was rated on a visual scale from 0 to 10 (mild 1 to 3, moderate 4 to 6, severe 7 to 10). Shoulder function was assessed with the Constant-Murley score and the American Shoulder and Elbow Surgeons score, both from 0 to 100, and strength with a dynamometer during abduction of the drawing arm. Two specialists scanned the painful area with ultrasound, or the drawing arm in archers without pain. The groups with and without pain were compared with t-tests, Mann-Whitney tests, chi-squared or Fisher's exact tests.

The authors themselves point to the small sample, which leaves groups of 9 to 27 archers once it is split by age, and to the risk of inaccurate recall when injuries are counted through a questionnaire. The cross-sectional design cannot show whether pain lowers the function scores or whether the two go together for other reasons; both function questionnaires also include questions about pain, so they partly measure the same thing. The difference on the Constant-Murley score is 1.4 points out of 100, only just under the significance threshold.

All the archers come from one city and almost half are middle school pupils, so calling them all elite archers makes sense in the Korean context rather than as a description of each individual's level. Draw weight, arrows per day and technique were not measured, so the study can say nothing about what causes the pain. In the discussion the authors recommend more warm-up and injury prevention courses, yet in their own data neither warm-up time (p = 0.617 in the table) nor the courses (p = 0.337) were linked to pain.

Some figures do not add up: 16 archers out of 58 is 27.6%, not the 29.3% given for the hand; the summary gives 65.6% for the shoulder and the table 65.5%; and the discussion says pain appeared mostly at full draw, while the table puts the drawing phase first. The unit of the strength measurement is not stated.

For archers, the most solid finding is the distribution: in this Korean group the shoulder is by far the most affected area, and in four cases out of five the pain is in the drawing arm, appearing while the string is being drawn or held at full draw. This is the same picture other studies of archers describe, found here in 13 to 15-year-olds as well. That 69% of the participants reported shoulder pain, mostly mild and with a quick return to training, shows how common it is to train with this kind of discomfort; the ultrasound shows, however, that some of them also had a visible sign in the biceps tendon or the bursa under the acromion.

The study does not say what causes the pain or how to prevent it. The training habits the authors put forward as helpful are not linked to pain in their own data, so they cannot be read as a conclusion of the paper. Abduction strength was the same in archers with and without pain, so these data do not support the idea that a weaker arm is the cause: they describe how widespread the problem is, not how to deal with it.