Shoulder pain in tennis players

Shoulder pain is the most common upper limb injury in tennis players and caused by service action. Almost all tennis players have a difference in range of motion when the dominant shoulder is compared to the non-dominant side. If players examine themselves, they will realize that if they try to tough their fingers behind their backs, (with one hand above the shoulder and one hand at the waist) that there is a difference between the 2 sides. This is caused by tightness of structures at the back (posterior) part of the dominant shoulders and bony adaptation of the humerus due to years of high intensity training. This difference in range of motion, GIRD (gleno-humeral internal rotation deficit) is also found in baseball pitchers.

Shoulder pain will affect a large percentage of tennis players and in most cases there will be no specific anatomical cause. Service induced shoulder pain in the majority of cases is caused by muscle imbalances, wrong shot technique or overuse. In the past all sports induced shoulder pain were thought to be the same, but advances in imaging techniques ( MRI and high resolution ultrasound) have confirmed that shoulder pain needs to be treated differently for each particular sport.

Basics of shoulder anatomy

The shoulder joint is a ball (femoral head) and socket (glenoid) joint where the socket is flat to allow a large arc of movement. The glenoid is part of the shoulder blade (scapula) which attaches to the ribcage (thorax) with muscles. 66% of shoulder movement takes place in the gleno-humeral (shoulder joint) and 33% scapulathoracic movement ( shoulder blade on ribcage). The joint between the collar bone and shoulder blade ( acromioclavicular or AC joint) can also become injured in overuse injuries. Stability of the shoulder joint and shoulder blade depend on stabilizer muscles of which the rotator cuff muscles are the most important. The rotator cuff muscles supraspinatus, infraspinatus, teres minor and subscapularis plays an important role in stabilizing the humeral head on the relatively flat small glenoid. These stabilizer muscles work mostly eccentrically and especially in deceleration.

The glenohumeral joint has 3 important ligaments in the front (anterior) part of the joint. Laxity of these important ligaments can lead chronic instability which can end an overhead athletes’ career. Although laxity or stiffness depend on each individual’s genetic makeup it also can be acquired through the wrong training techniques or neglect.

Basic biomechanics of service action

The rotator cuff muscles play an important role in stabilizing the ball into the socket, but also slowing down (deceleration) the shoulder in the late cocking phase during the throw (or service) action. Injuries to the shoulder can happen when deceleration is insufficient, leading to excessive external rotation that leads to intra-articular (inside joint) injuries. In tennis deceleration when the racket connects to the ball happens naturally, unlike in throwing. Scapular stability is important in all high demand sport. Scapular dysfunction can lead to stabilizer inhibition (sick scapula as named by Dr Ben Kibler)

The body position with uncoiling if a player wants to increase serve velocity rotates the trunc away from the dominant arm and thereby increasing external rotation of the arm. By starting in a closed position, back nearly facing the net, and keeping the shape as long as possible, the forces on the shoulder can be decreased.

It is important to protect the shoulder by starting with the right technique, using the legs, core muscles to generate speed of the service. External rotation of the forearm also allow for better synchronicity with the service action. “Hip over hip”, body rotation, toss position, grip, and full follow through is important different parts of the service motion that play a role in maintaining a healthy shoulder and also effective shot. It is also important to be patient in developing a good service action.

Good core training from early in career is important to avoid shoulder injuries. Eccentric and isometric rotator cuff exercises will prevent capsule and ligaments overstretching which, can lead to functional impairment.

Imbalances from wrong technique and core weakness is the cause for most shoulder pain in tennis players

Treatment of acute shoulder pain in tennis players

Prevention with correct technique, core muscle training, recovery and scapula and shoulder stability training. Soft tissue treatment including posterior capsule stretches, trigger point treatment, massages and rotator cuff exercises. Non-steroidal medication and rest

Diagnosis of shoulder pain in tennis players

Physical examination looking at shot technique, grip used for service action, scapula rhythm, range of movement differences and normal clinical examination of rotator cuff muscles as well as possible ligamentous laxity.

Causes for shoulder pain in tennis players

  • Scapula thoracic pain
  • Rotator cuff impingement and biceps tendon subluxation/tendinitis
  • Stress fractures including atraumatic osteolysis of claivicle
  • Internal shoulder impingement and instabilities
  • Rotator cuff tears
  • Osteoarthritis of glenohumeral joint or acromioclavicular joint in older patients
  • Humerus stress fractures in younger patients

Special investigations

X rays to exclude bony pathology, soft tissue calcifications and can be indicative of osteo arthritis Diagnostic high resolution ultrasounds provide a dynamic test for subacromial bursa thickening, status of rotator cuff and biceps tendon Magnetic Resonance Imaging scans for detecting intra articular pathology

Surgical treatment

With the advances of knowledge of causes of shoulder pain in tennis players and special investigations, it is possible to be accurate with expected outcomes, if surgery is indicated. Most shoulder surgeries can be done with keyhole (arthroscopic) techniques.

It must be taken into consideration that the intricacies of the shoulder movement during a high speed service action is such, that return to competitive tennis after shoulder surgery is a lengthy process.

Advances in reconstructive shoulder surgery (replacement for Osteoarthritis) have improved to such an extent, that players can return to tennis, but unlikely to pre-injury levels.