Review

Clinician-friendly physical performance tests in

athletes part 3: a systematic review of measurement
properties and correlations to injury for tests
in the upper extremity
Daniel T Tarara,1 Lucas K Fogaca,2 Jeffrey B Taylor,3 Eric J Hegedus3

▸ Additional material is ABSTRACT found little evidence to support their use as either
published online only. To view Objective In parts 1 and 2 of this systematic review, outcome measures or prognostic variables.4 5
please visit the journal online
(http://dx.doi.org/10.1136/
the methodological quality as well as the quality of the Specifically, no test possessed the measurement
bjsports-2015-095198). measurement properties of physical performance tests properties outlined by the IOC to serve as part of a
1 (PPTs) of the lower extremity in athletes was assessed. In musculoskeletal injury screening examination.
Department of Exercise
Science, High Point University, this study, part 3, PPTs of the upper extremity in athletes Further, no single PPT had sufficient measurement
School of Health Sciences, are examined. properties to warrant use in monitoring recovery
High Point, North Carolina, Methods Database and hand searches were conducted and determining readiness for return to play.
USA to identify primary literature addressing the use of upper Therefore, a comprehensive research agenda,
2
Department of Biology, High
Point University, High Point,
extremity PPTs in athletes. The Preferred Reporting Items including a review of literature, on upper extremity
North Carolina, USA for Systematic Reviews and Meta-Analyses (PRISMA) PPTs is needed.
3
Department of Physical guidelines were followed and the Consensus-based In comparison to PPTs that focus on the lower
Therapy, High Point University, Standards for the selection of health Measurement extremity, there are fewer upper extremity PPTs.
School of Health Sciences,
Instruments (COSMIN) checklist was used to critique the This is despite the time lost from sport and long-
High Point, North Carolina,
USA methodological quality of each paper. The Terwee Scale term sequelae that can result from upper extremity
was used to analyse the quality of the measurement injuries.6 To date, such metrics as the reliability,
Correspondence to properties of each test. validity and responsiveness of upper extremity
Daniel T Tarara, Department of Results 11 articles that examined 6 PPTs were PPTs have yet to be comprehensively reported.
Exercise Science, High Point
University, School of Health identified. The 6 PPTs were: closed kinetic chain upper Therefore, the purpose of this study was to system-
Sciences, 833 Montlieu extremity stability test (CKCUEST), seated shot put (2 atically review the literature pertaining to PPTs of
Avenue, High Point 27268, hands), unilateral seated shot put, medicine ball throw, the upper extremity, and to examine the quality of
NC, USA; modified push-up test and 1-arm hop test. Best evidence the literature and measurement properties of estab-
dtarara@highpoint.edu
synthesis provided moderate positive evidence for the lished tests. Our hypothesis was that findings
Accepted 25 November 2015 CKCUEST and unilateral seated shot put. Limited positive would be similar to those of the lower extremity:
evidence was available for the medicine ball throw and limited evidence to support the use of PPTs as
1-arm hop test. screening examinations or outcome measures for
Conclusions There are a limited number of upper musculoskeletal injury.
extremity PPTs used as part of musculoskeletal screening
examinations, or as outcome measures in athletic METHODS
populations. The CKCUEST and unilateral seated shot We framed our research question using the Patient,
put are 2 promising PPTs based on moderate evidence. Intervention, Comparison and Outcome (PICO)
However, the utility of the PPTs in injured populations is method. Our primary research question was: ‘Do
unsubstantiated in literature and warrants further upper extremity performance tests have any rela-
investigation. tionship to upper extremity injuries in athletes of
any age?’ Secondary research questions were
whether PPTs predicted injury, and whether PPTs
Numerous healthcare organisations and sports could be used as an outcome measure in the clinic.
bodies have released consensus statements regard-
ing the importance of the preparticipation screen- Literature search
ing examination to identify athletes at risk of The search was conducted in PubMed and trans-
injury.1 2 Specifically, the IOC has stated that lated with the assistance of a librarian for CINAHL
screening must be reliable, sensitive, specific, inex- and SPORTDiscus databases (see online supple-
pensive, easy to perform and widely available.2 mentary appendix A). All articles were included up
Physical performance tests (PPTs) meet this defin- to 17 April 2015. The search strategy included
ition and go one step further: they are portable and terms pertaining to athletes and injury confined to
can be performed in many different environments the upper extremity, and these were combined with
To cite: Tarara DT, and contexts. terminology relating to performance tests. Results
Fogaca LK, Taylor JB, et al.
Br J Sports Med Published
Despite the obvious benefits of PPTs, little is were limited to English language and humans. In
Online First: [ please include known about whether these tests are appropriate addition, a hand search was conducted based on
Day Month Year] tools for musculoskeletal injury screening, and the identification of review articles using the
doi:10.1136/bjsports-2015- what little is known is uninspiring.3 Two previous ‘Clinical Queries’ function in PubMed. Reference
095198 systematic reviews of PPTs in the lower extremity lists of these reviews were assessed for potentially
Tarara DT, et al. Br J Sports Med 2015;0:1–7. doi:10.1136/bjsports-2015-095198 1
 Review

eligible articles, as were the reference lists of any article that we (HR-PROs)10 and adapted for performance measures,14 final
read in full. Finally, Google Scholar was searched using the COSMIN quality scores were not based on sample size to avoid
names of known upper extremity PPTs. automatic exclusion of small (n<30) studies.15 The COSMIN’s
original scoring guidelines sets a minimal threshold for adequate
Eligibility criteria sample size at >30 (fair quality).13 Automatically disqualifying
Two authors (DTT and LKF) reviewed the titles and abstracts of small studies (<30) as poor quality may unnecessarily exclude
all studies identified during the literature search to generate a studies that report large effect sizes for physical performance
list of selected articles to read in full. Discrepancies were measures.14 Following the recommendation by Bartel et al,14
resolved via consensus discussion, and a third author (EJH) ref- studies scored as poor quality based solely on small sample sizes
ereed if disagreements could not be resolved. (n<30) and without formal power analysis were retained, and
The inclusion criteria were: accounted for in the best evidence synthesis as limited evidence.
▸ Analysed at least one upper extremity PPT that was accessible The lowest score methodology was used; poor quality studies
across settings (clinic, courtside, field side), and feasible were eliminated, as recommended previously, to contextualise
( portable, affordable and easy to administer). best evidence.4 14 The grading key4 for the best evidence
▸ (1) Studied an exclusive population of organised profes- summary was:
sional, collegiate or high school sports athletes (eg, baseball, ▸ Unknown: investigated in studies of exclusively poor meth-
volleyball, tennis, javelin); (2) used terms ‘elite athlete’, ‘pro- odology or not investigated in any study.
fessional athlete’, ‘semi-professional athlete’, ‘club sport’, ▸ Conflicting: contradictory findings.
‘intramural athlete’, ‘recreational athlete’ or ‘sport partici- ▸ Limited: one study of fair methodological quality.
pant’; or (3) when 50% of study’s participants had a physical ▸ Moderate: multiple studies of fair methodological quality or
activity level 5 or high based on the Tegner scale.7 one study of good methodological quality.
▸ Original, primary research (reviews were excluded). ▸ Strong: multiple studies of good methodological quality or at
We operationally defined PPT as a subset of functional assess- least one study of excellent methodological quality.
ments8 used by sports medicine clinicians to discern aspects of
athleticism ( power, agility, endurance, flexibility), injury risk and RESULTS
return-to-play readiness.4 PPTs were accepted as upper extrem- Description of included studies and PPTs
ity if they tested the region of the body from shoulder girdle, The database searches identified 1021 studies for preliminary
including the scapula, and supporting structures to the end of title/abstract screening. A majority (n=854) of studies were
the fingers. eliminated for not meeting the inclusion criteria of PPT, athletic
We excluded studies of PPTs that used equipment for three- population or upper extremity (UE) body region. In addition, 4
dimensional motion capture, upper body ergometers, rowing summary abstracts, 114 case reports, 17 narrative reviews and
ergometers, or other technology-dependent instrumentation, 19 systematic reviews were excluded. Thirteen studies were eli-
conference proceedings, dissertations and theses, case studies, gible for full-text review. The preliminary article selection
and case series. All articles were read in full by two authors process yielded a moderate16 correlation (κ=0.55) with 99.2%
(EJH and DTT) to further include or exclude them for scoring agreement. The full-text article screening process eliminated 11
of methodological quality and quality of measurement proper- studies for not meeting inclusion criteria as a feasible PPT or
ties. Any discrepancies were resolved via consensus discussion being administered in an athletic population. Hand searching
or consultation with a third author (LKF) if consensus could not identified nine additional articles for inclusion. The outline of
be reached. study selection and inclusion is in figure 1. The preliminary ana-
lysis consisted of 11 studies (table 1). Online supplementary
Data extraction, summaries and best evidence synthesis appendix B provides the COSMIN scoring tables.
Included studies were summarised based on population, injury
classification, sport, PPT description and study results. PPTs Summary of methodology quality (COSMIN) of included
were grouped based on testing procedures to determine whether studies
the naming of PPTs and their conduct was consistent across Reliability
studies. Finally, we summarised the methodological quality of Based on two reliability studies of upper extremity PPTs, there
the literature and the quality of the measurement properties of is poor25 to good20 evidence of test-retest reliability. Both
the PPTs and combined them using a best evidence synthesis.9 studies reported good to excellent interclass coefficient correl-
One author scored the methodological quality and measurement ation (ICC) values (>0.75). A small sample size was used for
properties (DTT). the one-arm hop test,25 which resulted in a poor quality rating.
A modified version of the Consensus-based Standards for the There was good methodological quality evidence for the reliabil-
selection of health Measurement Instruments (COSMIN) ity of the closed kinetic chain upper extremity stability test
tool10 11 was used to assess the quality of methodology of all (CKCUEST).20
included articles. Our version of the COSMIN tool consisted of
five categories (reliability, agreement, hypothesis testing, criter- Agreement/measurement error
ion validity and responsiveness). The methodological quality of Measurement error of UE PPTs was analysed in one study of
each categorical property was individually scored on a scale of good methodological quality, which reported measurement
excellent, good, fair and poor. To determine the quality of PPT error (SE measurement (SEM)) and minimal detectable change
measurement properties, the Terwee Scale of positive (+), inde- (MDC) with 95% CIs for the CKCUEST.20
terminate (?) and negative (−) was used.12
For the best evidence synthesis, we combined the results of Hypothesis testing/construct validity
the COSMIN tool assessment13 and the Terwee Scale12 for each There was conflicting evidence from two studies for hypothesis
article. Since the COSMIN scoring guidelines were originally testing24 27 and consistent evidence from two studies of con-
designed for health-related patient-reported outcomes struct validity.20 21 Hypothesis testing of the unilateral seated
2 Tarara DT, et al. Br J Sports Med 2015;0:1–7. doi:10.1136/bjsports-2015-095198
 Review

testing procedures (see table 1). The quality of PPT measure-

ments, based on the Terwee Scale, is described below.

Reliability
Test-retest reliability was reported for two of the six PPTs. The
studies reporting on one-arm hop test25 and CKCUEST20 were
of positive quality and reported ICC values >0.75.

Agreement/measurement error
One study reported data consistent with agreement/measure-
ment error (SEM and MDC for the CKCUEST).20 Since the
Terwee Scale scores this category based on reported minimal
important change (MIC) and smallest detectable change (SDC)
values,12 we calculated the MIC and SDC. There was positive
evidence for the quality of the measurement properties of agree-
ment/measurement error for the CKCUEST.

Figure 1 Flow chart of study selection and inclusion. Hypothesis testing/construct validity
Hypothesis testing of unilateral seated shot put yielded positive
quality.24 Conversely, the modified push-up test27 was of nega-
shot put test was of excellent quality,24 while the CKCUEST was tive quality. Construct validity of the CKCUEST was of positive
of fair quality.27 Methodological quality was excellent for quality for discriminate validity20 in distinguishing between
hypothesis testing of the unilateral seated shot put test.24 The healthy, active UE recreational sport athletes and sedentary indi-
construct validity was established for the CKCUEST and evi- viduals with a positive history of subacromial impingement syn-
dence was of fair quality.20 21 drome. With respect to convergent validity, the CKCUEST was
rated as negative quality in correlating to upper quarter y
Criterion/predictive validity balance test (UQYBT).21
Two studies, of fair methodological quality, investigated the cri-
terion validity of PPTs of the shoulder.22 23 Both correlated
Criterion/predictive validity
One-repetition maximum (1RM) bench press values to the
The two-hand seated shot put22 23 demonstrated negative
4.5 kg two-handed seated shot put test distance. Predictive val-
quality criterion validity when referenced to 1-RM bench press
idity for the CKCUEST was reported in one study, but was of
values. Criterion validity, in this context, is an indication of how
poor quality due to a small sample size (n=26) and a prediction
a PPT reflects a ‘gold’ or reference standard based on statistical
model based on only six injury cases.18
correlation.13 There was positive quality for predictive validity:
the CKCUEST prospectively predicted in-season shoulder injury
Responsiveness in male, collegiate football players.18
Responsiveness of upper extremity PPTs was reported in two
studies.17 26 The CKCUEST was used to quantify improvement
for SICK (Scapular malposition, Inferior medial border promin- Responsiveness
ence, Coracoid pain and malposition, and dysKinesis) scapula in The responsiveness of the CKCUEST17 and the medicine ball
asymptomatic overhead athletes following a 3-week open kinetic throw26 were both of positive quality, with demonstrated score
chain exercise intervention and was rated as poor quality improvement after following 3-week17 and 14-week26 resistive
because of low sample size (n<30).17 The seated medicine ball exercise programmes, respectively.
throw was used to quantify improvement following traditional
and maximal concentric acceleration strength training pro- Best evidence synthesis
grammes and was rated to be of fair methodological quality.26 The results of the best evidence synthesis are summarised by test
in table 2.
Summary of quality of measurement properties (Terwee
Scale) for included PPTs Closed kinetic chain upper extremity stability test
Ten studies reported measurement properties. One study27 did Several studies reported on the CKCUEST. However, two arti-
not report any measurement properties included to the cles17 18 were eliminated for poor quality evidence and one for
COSMIN tool or Terwee Scale, and was excluded from further not reporting measurement properties.19 The two remaining
analysis. Measurement properties were reported for the follow- studies20 21 provided varied evidence based on measurement
ing six PPTs (online supplementary appendix C provides the properties. There was moderate evidence for reliability and
Terwee Scale scoring tables): agreement,20 fair evidence for discriminate construct validity,20
▸ CKCUEST;17 18 20 21 and limited evidence for convergent construct validity.21 The
▸ Seated shot put (two hands);22 23 CKCUEST discriminated between young (21.7–23.1 years),
▸ Unilateral seated shot put;24 active, recreational athletes and sedentary adults (45.1–
▸ Medicine ball throw;26 49.8 years). With respect to convergent validity, the relationship
▸ Modified push-up test;27 between the UQYBT and CKQUEST had a positive weak correl-
▸ One-arm hop test.25 ation for the dominant (r=0.43) and non-dominant (r=0.49)
The seated shot put (two hands), unilateral seated shot put sides.16 21 The responsiveness, criterion validity and injury pre-
and medicine ball throw were not grouped due to differences in diction in athletic populations is unknown.
Tarara DT, et al. Br J Sports Med 2015;0:1–7. doi:10.1136/bjsports-2015-095198 3
 Review

Table 1 Summary of included studies in preliminary analysis

Study Population/UE injury status Description Results

CKCUEST
Jayesh et al17 n=20 healthy; 15 male and 5 From a push-up position with hands 36 inches apart, CKCUEST pretest and post-test scores showed significant
female; asymptomatic SICK shoulders over hands, one submaximal trial; 45 s rest; (p≤0.05) improvement and were 21.6±3.9 and 25.8±4.8,
scapula three maximal effort trials with 45 s rest intervals; respectively
scored based on average of maximal effort trials; score
was normalised based on body height
Pontillo n=26, division I college football From start position, one hand is brought over the CKQUEST was significant at predicting injury with a cut
et al18 players; I (n=6) shoulder injuries opposite tape line, returned and repeated with the score of <21; Sn=0.83, Sp=0.79, +LR=4.47 and
opposite hand; highest number of touches within 15 s; −LR=0.25
two trails with 1 min rest
Roush et al19 n=77 healthy division III Two 1.5 in tape strips, parallel, 36 inches apart. Start in No difference in CKCUEST scores between playing
collegiate baseball players a push-up position with one hand on each piece of position. Average CKCUEST 30.4±3.87 touches
tape. Perform alternating cross-over touches under the
opposing hand for 15 s followed by 45 s rest. Scored
average of three trials
Tucci et al20 n=108 participants; 40 UE Two tape markers 36 inches apart: from push-up Intersession reliability: ICC=0.85 to 0.96; Intrasession
sport-specific recreational position, the number of supporting hand touches with reliability: ICC=0.86 to 0.96. In males and females,
athletes; I; (n=28) Hx of the swing hand during 15 s. For female participants: test touches were greater in active (24.5) vs sedentary (22.6)
subacromial impingement performed from the modified push-up position, from the vs SIS (10.1) and active (27.9) vs sedentary (24.7) vs SIS
syndrome knees. Scored average of three trials (12.2), respectively; SEM ranged from 1.45 to 2.76
touches; MDC ranged from 2.05 to 3.91 touches
Westrick n=30 healthy USMA cadets; 24 Two tape markers 36 inches apart. Start in a push-up Correlation between dominant and non-dominant UQYBT
et al21 males, 6 females; healthy position with one hand on each piece of tape. Perform and CKCUEST, respectively (r=0.43 and r=0.49). Average
alternating hand crosses under the opposing hand. CKCUEST 18.8±3.3 (males) and 15.9±4.5 (females), no
Number of touches for 15 s was recorded. Scored statistical difference based on gender
average of three trials
Seated shot put
Mayhew n=40 division II college football Performed with 4.5 kg medicine ball; seated on the floor Seated shot put correlated to the 1-RM bench press,
et al22 players; injury status not with back against a support; feet flat on the floor with r=0.57
reported knees at 90 degree angle; two hand push from centre of
Mayhew NR, n=64 college female chest. Three trials with 30 s rest, average distance Seated shot put correlated to the 1-RM bench press,
et al23 athletes; Injury status not thrown used for analysis r=0.38
reported
Unilateral seated shot put
Chmielewski n=125 healthy college-aged Performed with a 2.72 kg medicine ball; ball starts at Allometric scaling (exponent of 0.35) accounted for a 5–
et al24 athletes shoulder height; participant pushes (not throws) the 10% greater distance on the dominant side. Males
ball. Scored based on average of three trials produced greater seated shot put distances compared
with women (119.0±9.3 vs 73.3±8.2 cm/kg0.35)
One-arm hop test
Falsone n=26 healthy, 13 wrestlers, 13 Participants allowed a warm-up and practice trial(s); Test-retest reliability was ICC 0.81 in the wrestlers and
et al25 football players from a one arm push-up position, participant completed 0.78 in the football players. No statistically difference
five proper technique one-arm hops onto a 10.2 cm step between dominant and non-dominant arms, with
and scored for time to complete task non-dominant arm values ranging from 1.1% faster to
9.8% slower than the dominant arm
Medicine ball throw
Jones et al26 n=40 college-aged football Seated on a 20-inch bench with back against the wall; Significant training effect for all tests. No significant
players; injury status not using two hands, subjects tossed 12 lb medicine ball at difference between experimental and control groups.
reported a distance. The back and scapula had to maintain Pre-test and post-test medicine ball throw: 7.9±0.5 vs 8.1
contact with the wall; three warm-up throws followed by ±0.6 m
three max effort throws. Scored based on longest throw
Modified push-up
Ambegaonkar n=32 healthy college-aged Participant performed a modified push-up from knees No difference between groups. College-aged dancers 22.2
et al27 female dancers; n=15 female with lower legs together in contact with the floor with ±8.6; physically active college-aged non-dancers 19.9±8.2
physically active non-dancers ankles in dorsiflexion; down position—chin to floor, up
position— full elbow extension; required to maintain
strict form
CKCUEST, closed kinetic chain upper extremity stability test; ICC, interclass coefficient correlation; LR, likelihood ratio; MDC, minimal detectable change; SEM, SE measurement;
SIS, subacromial impingement syndrome; SICK, Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis; Sp, specificity; Sn, sensitivity;
UQYBT, upper-quarter y balance test; UE, upper extremity Hx, history; USMA, United States Military Academy.

Unilateral seated shot put test comparing dominant to non-dominant arm. The reliability,
There was moderate evidence for hypothesis testing based on a agreement, criterion validity and responsiveness are unknown.
good methodology, and positive quality measurement properties There is no evidence pertaining to athletes with UE injury.
with hypothesis testing in one study.24 Chmielewski et al24
reported that the unilateral seated shot put test should be scored Seated shot put (two hands)
on an allometric scale (exponent of 0.35), and in healthy ath- Two studies22 23 reported fair evidence on the criterion validity
letes, a 5–10% great difference can be accounted for when of the seated shot put test in relationship to 1-RM bench press.
4 Tarara DT, et al. Br J Sports Med 2015;0:1–7. doi:10.1136/bjsports-2015-095198
 Review

Table 2 Best evidence synthesis by PPT

Measurement properties Unknown (???) Conflicting (±) Limited (+)(−) Moderate (++)(−−) Strong (+++)(−−−)

CKCUEST
Reliability ++
Agreement ++
Hypothesis testing ++
Criterion validity ???
Responsiveness ???
Unilateral seated shot put
Reliability ???
Agreement ???
Hypothesis testing ++
Criterion validity ???
Responsiveness ???
Seated shot put
Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity −−
Responsiveness ???
Medicine ball throw
Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness +
One-arm hop test
Reliability +
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness ???
Modified push-up
Reliability ???
Agreement ???
Hypothesis testing −
Criterion validity ???
Responsiveness ???
+, positive rating; −, negative rating; CKCUEST, closed kinetic chain upper extremity stability test; conflicting, contradictory findings; grading key, unknown (???)=investigated in studies
of exclusively poor methodology or not investigated in any study; limited, one study of fair methodological quality; moderate, multiple fair methodological studies or one study of good
methodology; PPT, physical performance test; strong, multiple studies of good methodological rating or at least one study of excellent methodology.

The correlation between the PPT and strength measure was small sample (n=26) of uninjured athletes.25 Test-retest reliabil-
weak (r=0.38) in female athletes and male (r=0.17 to 0.57) ity was established in subset of 13 wrestlers (ICC=0.8) and 13
athletes. There was no evidence for reliability, agreement, con- football players (ICC=0.78). One-arm hop test scores were
struct validity, responsiveness or injury prediction. 4.4% lower in the non-dominant versus dominant arm. The evi-
dence relating to agreement, hypothesis testing/construct valid-
Medicine ball throw ity, criterion validity and responsiveness for the one-arm hop
There was limited evidence for the measurement properties of test is unknown.
the seated medicine ball throw. Jones et al26 reported 2.8–9.4%
improvement in throwing distance following traditional and Modified push-up test
maximal concentric acceleration strength training programmes. The modified push-up test had fair evidence in discriminate con-
These findings reflect positive quality measurement properties struct validly, but was unable to distinguish between healthy
for the PPT, but were only demonstrated in healthy athletes. university-level modern dancers and non-dancers.27 No evi-
The evidence relating to reliability, agreement, hypothesis dence was available for reliability, agreement, criterion validity,
testing/construct validity, and criterion validity for the seated responsiveness and injury prediction.
medicine ball throw are unknown.
DISCUSSION
One-arm hop test This study provided a systematic review of upper extremity
Limited quality evidence is available for the one-arm hop test. PPTs in response to a broader research recommendation specific
One study reported measurement properties for this PPT in a to the use of PPTs in sports medicine.5 The methodology
Tarara DT, et al. Br J Sports Med 2015;0:1–7. doi:10.1136/bjsports-2015-095198 5
 Review

quality (COSMIN) of eight studies and the quality of measure- for comparative analysis. However, this should not be done
ment properties (Terwee Scale) of six PPTs were included in the based on differences in testing procedures relating to the weight
synthesis of best evidence. Consistent with our hypothesis, the of the ball and alignment of the trunk and upper extremity.
evidence relating to upper extremity PPTs is mostly unknown or Despite modest evidence that supports the relationship of these
limited. tests to other measures of strength, there has yet to be any data
The use of upper extremity PPTs as assessment tools must be supporting their inter-relationship. Thus, each test should be
grounded in the tenants of reliability and validity. In general, the considered independently. For example, the unilateral seated
available studies that report UE PPTs in athletic populations fail to shot put may be the best test to quantify performance and out-
provide adequate reliability and validity evidence based on comes in overhead sport athletes (eg, tennis, volleyball, baseball)
COSMIN criteria due to a number of factors. The first issue who rely on dominant arm performance.
relates to studies relying on poor (n<30)17 18 19 25 and fair
(n=30–49)21 22 26 27 quality sample sizes. Small sample sizes affect Limitations
statistical power and limit the generalisability of study results. The Systematic reviews are prone to a number of limitations29 and
exceptions to this were studies reporting on the CKCUEST,20 there a several studies related to this review worthy of consider-
seated shot put23 and unilateral shot put.24 However, the use of a ation. The quality of our systematic review is dependent on the
small subgroup of healthy (n=40) upper extremity sport-specific availability and quality of primary literature catalogued in elec-
athletes (n=40) and upper extremity-injured athletes (n=28) to tronic databases. There is no standard search strategy for PPTs
evaluate the reliability, agreement and construct validity (discrim- in athletic populations,4 nor is there a MeSH (Medical Subject
inate) of the CKCUEST weakened the methodological quality of Headings) term to facilitate the cataloguing and searching of
the study examining the CKCUEST. Collectively, these findings PPTs. The absence of a MeSH term may compromise identifica-
highlight a problematic issue relating to the low quality of research tion of all relevant studies.30 However, to account for this, we
availability on UE PPTs. included empirical31 and manual30 search strategies in addition
Studies reporting strong evidence relating to reliability, agree- to the electronic database searches. Our search was confined to
ment, hypothesis testing/construct validity, criterion validity and English language studies due to language translation limitations.
responsiveness of upper extremity PPTs are lacking. Research Therefore, we may have missed articles that were published in
designs consistent with moderate evidence relating reliability, languages other than English.
agreement and construct validity (discriminate) are only avail- Our operational definition for qualifying PPTs was restricted
able based on two studies reporting on CKCUEST.20 21 One to tests that were portable, affordable and easy to administer in
study presented moderate evidence of criterion validity for the diverse settings, including clinics, courtside or field side. This
unilateral shot put.24 Limited evidence from two studies was eliminated studies and PPTs that required technology (force
available for the one-arm hop test reliability25 and medicine ball plates, three-dimensional motion capture) for data collection or
throw responsiveness.26 Aside from these investigations, the scoring.
quality of research designs for the remaining studies was mostly Methodological quality and PPT measurement properties
rated as unknown due to an absence of research focused on the were assessed with the COSMIN and Terwee Scale, respectively.
constructs of reliability and validity. These tools were originally designed to evaluate the quality of
Beyond the COSMIN criteria, the majority of studies included HR-PROs with respect to reliability, validity and responsive-
in the best evidence synthesis examined healthy athletes21 24 27 or ness.12 13 32 Recently, the COSMIN and Terwee Scale have been
failed to report upper extremity injury history.22 23 26 Tucci et al20 adapted for systematic reviews relating to PPTs.4 5 14 15 33
included an upper extremity-injured group with a history of suba- Although their measurement properties have been ques-
cromial impingement syndrome to determine construct (discrim- tioned,14 15 33 these tools provide an objective means for deter-
inate) validity for CKCUEST scores. However, comparisons were mining quality and evidence relating to PPTs. Lastly, the review
made between an older (41.5–49.8 years) sedentary injured group was based on small number of available PPTs.
and a younger (21.7–23.1 years) upper extremity athletic popula-
tion. The difference in age and athletic status is a confounder Summary
when interpreting the discriminate validity of the CKCUEST for There are a limited number of upper extremity PPTs that can
injury status, and calls into question the validity of this test. The be used as part of a musculoskeletal screening examination or
absence of studies that evaluate the measurement properties of an outcome measure in athletic populations. Based on current
PPTs in injured athletes is problematic for sports medicine practi- evidence, the CKCUEST, unilateral seated shot, one-arm hop
tioners to interpret PPTs in the contact of injury screening, evalu- test and medicine ball throw may have promise as PPTs.
ation and rehabilitation responsiveness. However, the utility of these PPTs in injured populations is
The naming and testing procedures for comparative tests were unsubstantiated in literature and warrants further investigation.
not a matter of concern because of the low number of PPTs in Higher quality research needs to focus on the measurement
the best evidence synthetic. The CKCUEST was performed and properties of upper extremity PPTs across a spectrum of
measured consistently across studies20 21 and was reflective of healthy and injured athletic populations. Considering this,
the original test description.28 In one study, the CKCUEST was future research needs to consider standardisation of PPT
modified for females by allowing a push-up start position for names, descriptions, and testing procedures to ensure best
the knees.20 Although this modification to the original test may methodological quality and appropriate comparisons of meas-
seem like a reasonable accommodation, it is a deviation that urement properties. This is a critical link for reporting PPTs in
may influence scoring and limit generalisability, and warrants sports medicine literature and to support the clinical feasibility
separate reliability and validity assessment. of tests by physiotherapists, athletic trainers, coaches and trai-
The unilateral seated shot put,24 seated shot put22 23 and ners. In the absence of sound evidence relating to reliability
medicine ball throw26 are PPTs designed to measure upper and validity, upper extremity PPTs provide little utility in deter-
extremity power. As these tests may appear to measure the same mining the scope of functional performance or injury status in
construct, it is tempting for clinicians to group them together athletic populations.
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▸ The CKCUEST has moderate test-retest reliability and may 18 Pontillo M, Spinelli BA, Sennett BJ. Prediction of in-season shoulder injury from
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▸ The medicine ball throw is best used to quantify
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Contributors DTT, EJH and LKF planned the study, executed the searches, 23 Mayhew JL, Bemben MG, Rohrs DM, et al. Specificity among anaerobic power tests
examined the articles for quality and edited the manuscript. DTT and JBT wrote the in college female athletes. J Strength Cond Res 1994;8:43–7.
initial version of the manuscript. JBT edited and contributed to all other versions of 24 Chmielewski TL, Martin C, Lentz TA, et al. Normalization considerations for using
the manuscript. the unilateral seated shot put test in rehabilitation. J Orthop Sports Phys Ther
Competing interests None declared. 2014;44:518–24.
25 Falsone SA, Gross MT, Guskiewicz KM, et al. One-arm hop test: reliability and
Provenance and peer review Not commissioned; externally peer reviewed. effects of arm dominance. J Orthop Sports Phys Ther 2002;32:98–103.
Data sharing statement There are additional figures from the meta-analysis that 26 Jones K, Hunter G, Fleisig G, et al. The effects of compensatory acceleration on
the authors are happy to share with receipt of a written request by the upper-body strength and power in collegiate football players./Les effects de l ‘
corresponding author. acceleration compensatoire sur la force et la puissance du corps de joueurs de
football universitaires. J Strength Cond Res 1999;13:99–105.
27 Ambegaonkar JP, Caswell SV, Winchester JB, et al. Upper-body muscular endurance
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