Shoulder pain in young female athletes: volleyball, swimming and the load nobody counts

In elite youth handball, almost one athlete in four (23%) had substantial shoulder problems over a single season, and girls had a prevalence 1.46 times higher than boys. Among adolescent swimmers the available review reports the highest shoulder-pain rate of any age group (91.3%), against 17 hours a week in the pool. The shoulder is the one joint that works overhead every day in girls' sport — and the one nobody keeps count of.

In girls' sport the shoulder is the most-used joint and the least-watched. Volleyball is the most played team sport among girls in Italy; swimming is among the most widespread of all. In both, the defining movement — spike, serve, stroke — happens overhead, thousands of times a season, on a joint that at 14 is still growing. Yet almost no club keeps count of how many times that arm went over the head this week, and shoulder pain remains the quietest of all overuse injuries: it does not swell, it does not make anyone limp, it cannot be seen from the sideline.

In brief

  • In elite handball at 15-18 years, 23% have substantial shoulder problems in one season; 43% of them for at least 3 consecutive weeks (Asker et al., 2018; 471 athletes monitored weekly).
  • Girls have a prevalence 1.46 times higher than boys (95% CI 1.04-2.06) in the same sample.
  • In swimming, adolescents aged 15-17 report the highest shoulder-pain rate of any age group (91.3%), with 17.27 ± 5.25 hours in the pool per week (Feijen et al., 2020; 12 studies, 1,460 swimmers).
  • The proximal humeral growth plate provides roughly 80% of the humerus's growth in length and closes between 18 and 21: until then it is the mechanically weakest point in the chain (Casadei and Kiel, StatPearls).
  • Screening does not predict well: on scapular dyskinesis one meta-analysis estimates +43% risk (Hickey et al., 2018), a larger one finds no significant association at all (Hogan et al., 2021).
  • The prevention programme with the strongest evidence cuts shoulder problems by 28% — but it was tested on ADULT elite players (Andersson et al., 2017).

How common is shoulder pain in young female athletes?

Common enough to affect almost one athlete in four over a season. The best data for this age group comes from a Swedish prospective study of 471 elite handball players aged 15-18 (mean age 16.4, 54% female), monitored every week for a full season. 23% reported «substantial» shoulder problems — the threshold used is problems that genuinely reduce participation or performance — and among those, 43% had them for at least three consecutive weeks. The weekly prevalence of substantial problems was 6% (Asker et al., 2018).

That weekly 6% is the number that matters most to a coach: it means that in a squad of twenty, on any given Monday of the year, more than one athlete is playing with a shoulder that is limiting something. And that in most cases nobody knows, because a shoulder does not stop anyone training: it only changes how they train.

In swimming the picture is starker still. The systematic review of 12 studies and 1,460 swimmers finds that the adolescent group (15-17 years) reports the highest shoulder-pain rate of all ages considered: 91.3%, against 20.0% in swimmers under 15 and 19.4% in masters (Feijen et al., 2020). It should be read for what it is — self-reported prevalence of «pain», not clinical diagnoses, with large differences in definitions between studies — but the direction is unambiguous and it coincides with the phase of the career when volume explodes.

Do girls have more shoulder problems than boys?

In the available data yes, and here the difference is not inferred: it is measured inside the same sample. In the study of 471 adolescent athletes — 256 girls and 215 boys, same training, same level, same monitoring system — the prevalence of substantial shoulder problems was 1.46 times higher in girls (95% CI 1.04-2.06). The second associated factor was playing position: backcourt players, the ones who throw most, had a prevalence 1.58 times higher (Asker et al., 2018).

Among adults the figure is high too: of 179 players in the Norwegian top division, 36% reported shoulder pain on the test day and about a third had missed matches because of the shoulder; in two-thirds of cases the pain had come on gradually, not through trauma (Myklebust et al., 2013 — a sample of adult elite athletes).

Before turning any of this into a rule, the limit has to be stated: the systematic review of risk factors for shoulder injury in overhead sports examined 17 studies of sufficient quality and concludes that the evidence for all risk factors is «limited or conflicting», and that most of the factors identified are non-modifiable characteristics such as sex (Asker et al., 2018, British Journal of Sports Medicine). Knowing that girls have more shoulder problems tells nobody what to do on Monday. Knowing how many times the arm went overhead does.

Why the shoulder, and why now?

Because at 13-16 the shoulder has not finished building itself. The proximal humeral growth plate — the physis just below the head of the humerus — contributes roughly 80% of the humerus's growth in length and closes completely between 18 and 21. While open it is largely cartilaginous, which makes it mechanically weaker than the ligaments and musculotendinous structures around it. It is the same logic as the growth spurt and bone stress injuries: in a growing body, the part that gives way first is almost never the part that gives way in an adult.

Hence the picture described in clinical literature as proximal humeral epiphysiolysis, known in the English-speaking world as little league shoulder: a repetitive-overload problem of the growth plate, typically presenting between 11 and 16 years (Casadei and Kiel, StatPearls — a clinical reference text, not a primary study; the original literature is mostly on male youth baseball).

The practical point is not the diagnosis, which is not made courtside and is not made in this article. It is the reversal of the most common phrase: in a still-growing athlete, shoulder pain that lasts weeks is not «growth» — it is a reason to have it looked at.

Volume: the variable nobody adds up

In adolescent swimmers the review reports 17.27 ± 5.25 hours in the pool per week: the highest volume of their career so far, exceeded only by adults. In the same work, among adolescents, weekly volume and years of competitive swimming correlated with supraspinatus tendon thickness, and every swimmer with tendon thickening reported pain (Feijen et al., 2020).

These are associations, not proof of causation, and the overhead-sports review classifies external workload among the factors where evidence is still limited (Asker et al., 2018, BJSM). But in youth sport there is a more basic problem than dosage: nobody adds up. A 14-year-old can play club volleyball four times a week, plus PE, plus a school tournament, plus a regional selection camp — and each of those settings sees only its own slice. It is the same mechanism as early specialisation: the load is not high on any single calendar; it is high only in the sum, which is written down nowhere.

Can you predict which shoulder will break down?

Not reliably — and it is worth knowing before investing in a pre-season screen. The most popular candidate is scapular dyskinesis, altered movement of the shoulder blade during arm elevation. The literature has split on its predictive value:

Meta-analysis Studies / athletes Result
Hickey et al., 2018 (BJSM) 5 prospective studies, 419 athletes +43% risk of shoulder pain at 9-24 months (RR 1.43; 95% CI 1.05-1.93); pain in 35% with dyskinesis vs 25% without
Hogan et al., 2021 (AJSM) 7 studies, 923 athletes, 212 injuries No significant association (RR 1.07; 95% CI 0.85-1.34; p=0.59)

The prudent reading is the second: the larger review, with more than twice the athletes, finds only a non-significant trend. Scapular dyskinesis on its own does not identify who will get injured.

The same goes for GIRD (glenohumeral internal rotation deficit), the loss of internal rotation in the dominant shoulder. In a case-control study of 123 high-school volleyball players (63 male, 60 female, mean age 15.8), 38.2% had GIRD by the definition used — and in that same sample no relationship emerged between GIRD and history of shoulder injury. One interesting finding by sex in the same work: males tended towards hypomobility, females towards hypermobility, with total rotation above 180° in the girls (Mizoguchi et al., 2022).

Translated: measuring degrees of rotation in September is useful for knowing the athlete, not for predicting her season. The variable you can govern is load, and all it takes to govern it is for somebody to record it.

Does prevention work? Yes — but the evidence is on adults

The programme with the strongest evidence is the Oslo Sports Trauma Research Center's. In a cluster-randomised trial of 45 teams and 660 elite handball players followed for one season (7 months), the group doing the programme 3 times a week inside the warm-up — glenohumeral internal rotation, external rotation strength, scapular muscle strength, kinetic chain and thoracic mobility — had a shoulder-problem prevalence of 17% against 23% in controls: 28% lower risk (OR 0.72; 95% CI 0.52-0.98; p=0.038). For substantial problems the estimated reduction was 22%, but not statistically significant (OR 0.78; 95% CI 0.53-1.16; p=0.23) (Andersson et al., 2017).

Two caveats that change how this number should be used:

  1. Those players were elite adults, not 14-year-old girls. Extending it to adolescents is reasonable — the ingredients are the same as in strength work for girls — but it is not proven.
  2. The systematic review on overhead sports, which includes that trial, concludes that the overall evidence on the effect of shoulder injury prevention measures remains limited (Asker et al., 2018, BJSM).

Intellectual honesty here means saying that twenty minutes of scapular work a week is a good bet, not a guarantee — and that the better bet is not reaching the end of the season with an athlete who has been in pain for nine weeks without anyone writing it down.

Why shoulder pain almost never reaches the staff

Because it prevents nothing. A swollen ankle is visible, a concussion has a protocol, a knee that gives way stops play. A painful shoulder, by contrast, still allows training: hit a bit softer, change the angle slightly, do one set fewer. In the weekly study of 15- to 18-year-olds, the share of problems that became substantial was high precisely because the monitoring asked about reduced participation and performance, not about the presence of pain: in that group the shoulder had already changed how 6% of athletes played in any given week (Asker et al., 2018).

It is the same silence already seen with urinary leaks and period pain: the symptom does not stop training, so it never enters any record, so statistically it does not exist. And what does not exist does not get managed.

What changes in the gym and in the pool

This is not a clinical protocol — that is written by whoever assesses the athlete. These are the points the sources above converge on.

Where BAB fits

BAB does not diagnose a shoulder and does not prescribe exercises. It does the thing that is systematically missing outside a research setting in every study cited above: it gives the athlete a way to note privately what she feels — pain, changed movement, skipped sets, energy, recovery — and gives the club aggregate, anonymous signals, never an individual's health data.

In the Swedish study that 23% only emerged because somebody asked every week for an entire season. That is exactly what no club has the time to do by hand — and what a thirty-second question a day can do instead.

Sources

This article is for information only and is not medical advice or a clinical assessment. Shoulder pain lasting more than a few weeks, appearing during the movement itself, reducing strength or range of motion, waking someone at night, or failing to improve when load is reduced should be assessed by a healthcare professional — all the more so in a still-growing athlete.

How common is shoulder pain in young female athletes?

Far more common than the amount of talk about it suggests. In a prospective study of 471 elite handball players aged 15-18 followed weekly for one season, 23% reported «substantial» shoulder problems — meaning problems that actually reduced participation or performance — and 43% of those had them for at least 3 consecutive weeks (Asker et al., 2018). In swimming, a systematic review of 12 studies and 1,460 swimmers reports the highest shoulder-pain rate of all ages considered in the adolescent group (15-17 years): 91.3%, against 20.0% in swimmers under 15 (Feijen et al., 2020). A caveat: these are self-reported prevalences of «pain», not diagnoses, and the ranges between studies are wide.

Do girls have more shoulder problems than boys?

In the available data yes, and the difference is measured directly. In the study of 471 adolescent elite handball players (256 girls, 215 boys, mean age 16.4), the prevalence of substantial shoulder problems was 1.46 times higher in girls (95% CI 1.04-2.06), and also higher in backcourt players (PR 1.58) (Asker et al., 2018). To be honest about it: that is one sport, one study and an elite setting, and the systematic review on overhead sports concludes that the evidence for every risk factor — sex included — is «limited or conflicting» (Asker et al., 2018, BJSM).

Why is an adolescent's shoulder more vulnerable?

Because it has not finished growing. The proximal humeral growth plate contributes roughly 80% of the humerus's growth in length and closes between ages 18 and 21; while open it is largely cartilaginous, mechanically weaker than the ligaments and tendons around it. That is why, at this age, repetitive overhead load can involve the growth plate rather than the soft tissues — the picture described as proximal humeral epiphysiolysis, typically presenting between 11 and 16 years (Casadei and Kiel, StatPearls, 2023 — a clinical reference text, not a primary study). This is not something to diagnose courtside: it is one more reason why a shoulder pain that lasts should not be filed away as «it's just growth».

Is shoulder pain normal in swimming?

Common does not mean normal. In the systematic review of 1,460 swimmers, adolescents aged 15-17 reported the highest shoulder-pain rate (91.3%) alongside the highest training volumes of their career so far: 17.27 ± 5.25 hours in the pool per week. In adolescent swimmers, weekly volume and years of competitive swimming correlated with supraspinatus tendon thickness, and every swimmer with tendon thickening reported pain (Feijen et al., 2020). The review shows association, not causation: it does not prove the hours cause the pain, but it does say where to look when pain appears.

Can you tell in advance which athlete's shoulder will break down?

Not reliably — and it is worth knowing that before buying a screening protocol. On scapular dyskinesis — altered movement of the shoulder blade — two meta-analyses reach different conclusions: one of 5 prospective studies and 419 athletes estimates a 43% greater risk of shoulder pain in those who have it (RR 1.43; 95% CI 1.05-1.93) (Hickey et al., 2018); a more recent one of 7 studies and 923 athletes, with 212 injuries observed, finds no statistically significant association (RR 1.07; 95% CI 0.85-1.34; p=0.59) (Hogan et al., 2021). The prudent reading is that scapular dyskinesis alone is not enough to identify who will get injured.

Do shoulder prevention exercises work?

The only solid evidence comes from adult athletes, and that has to be said. In a cluster-randomised trial of 45 teams and 660 elite handball players followed for one season, the OSTRC prevention programme — done 3 times a week in the warm-up, working on internal rotation, external rotation strength and scapular muscle strength — reduced the risk of shoulder problems by 28% (OR 0.72; 95% CI 0.52-0.98; prevalence 17% vs 23%); for substantial problems the estimated reduction was 22% but not statistically significant (Andersson et al., 2017). Those players were elite adults: extending this to athletes aged 13-16 is reasonable but unproven, and the systematic review on overhead sports still judges the evidence on prevention «limited» (Asker et al., 2018, BJSM).

How many overhead hours are too many for an adolescent?

There is no validated threshold, and anyone offering a precise one is going beyond the data. What the data do say is that volume is the variable that keeps recurring: in adolescent swimmers, weekly pool hours correlate with supraspinatus tendon thickness, and the highest pain rates coincide with the career peak in volume, 17.27 ± 5.25 hours per week (Feijen et al., 2020). The systematic review on overhead sports lists external workload among the factors studied but concludes the evidence is limited or conflicting (Asker et al., 2018, BJSM). The useful practical question is not «how many hours» but: is anyone adding up this athlete's total overhead hours across club, school and regional squads?

What is GIRD, and how common is it in adolescent volleyball players?

GIRD (glenohumeral internal rotation deficit) is the loss of internal rotation in the dominant shoulder compared with the other side, a typical adaptation in people who work overhead. In a case-control study of 123 high-school volleyball players (63 male, 60 female, mean age 15.8), 38.2% had GIRD by the definition used (internal rotation difference ≥10° and total rotation deficit ≥5°). In the same sample, males tended towards hypomobility and females towards hypermobility, with total rotation above 180° in the girls. Worth noting: in that sample no relationship emerged between GIRD and history of shoulder injury (Mizoguchi et al., 2022). It is an adaptation to know about, not a verdict.

When should shoulder pain be seen by a healthcare professional?

This article is educational and does not replace a clinical assessment. Good reasons to seek professional advice: pain lasting more than a few weeks or returning every time load picks up, pain during the movement itself (spike, serve, stroke) rather than only afterwards, loss of strength or range of motion, night pain, or pain in a still-growing athlete that does not improve when load is reduced. The criterion that matters most in the data is not the intensity of pain but its duration: in the study of 15- to 18-year-olds, 43% of those with substantial problems had them for at least 3 consecutive weeks (Asker et al., 2018).