Shoulder injuries make up around 17% of all injuries related to tennis, which makes it the second most common injury site, and the most common chronic (long-term) injury site in tennis. At a young age, pain and dysfunction are apparent in approximately 20-25% of dominant shoulders in tennis players. As we age, that number increases significantly. It is reported that approximately 50% of middle-aged tennis players report significant shoulder pain in their dominant arm. We are a long lived generation, with some playing well into their 5th or 6th decade.
Types of Injury
There are a few different types of shoulder injuries that can occur in the overhead athlete:
Some shoulder pain can actually be referred from the neck. Nerves from the neck run through the shoulder and so pain can commonly be referred to the shoulder, with no neck pain as a clue to the actual source of the pain.
- Tendons connect muscle to bone. They can be injured through a sudden acute force, such as falling on an outstretched arm and forcing the shoulder back, or more commonly in tennis, through repetitive micro-trauma.
- Tendon injuries requires lightly loaded exercises in order to remodel the tendon. They DO NOT get better with rest. Evidence has shown that both underuse and mechanical overuse of the tendon will be detrimental to healing. Talk to your physiotherapist about the amount and type of exercise suitable for your injury.
- For prevention of rotator cuff tendon injury, try to load the muscles eccentrically – that is, ‘strengthening while lengthening’. A great eccentric exercise is the ‘drawing the sword exercise’, shown below.
For this exercise, start with your hand at your opposite hip, holding the resistance band in your hand with your thumb pointing down. Bring your whole arm up and across your body in a smooth motion, rotating as you do, so when your arm is in the end position above your head, the thumb is pointing up. The eccentric part of this exercise is slowly returning it to the start position – making sure the movement is smooth and controlled. Repeat this approximately 8-12 times for 3 sets.
Draw the Sword
- This includes injuries to the capsule-labral complex, which is the socket of the shoulder joint and the surrounding ligaments and various other tissues. Again, this complex can be injured acutely, through direct trauma, or chronically, through repetitive micro-trauma.
Mechanism of injury
During the overhead tennis serve there are five different phases:
- Wind up
- Early cocking
- Late cocking
- Acceleration phase
- Follow through
During the late cocking phase of the serve, the shoulder is in maximal external rotation in an abducted position.
This position puts huge amounts of stress through the front of the shoulder joint capsule, which can then create elongation of the front structures, leading to subtle instability of the shoulder joint. This change in position created by the instability leads to pain and impingement.
If there is any evidence of instability found in your shoulder by a physiotherapist, a good stabilising exercise is outlined below:
For this exercises, place one hand in the centre of the Swiss ball and slowly increase the pressure exerted through the straight arm by walking out from the ball, until your hand starts moving small amounts due to slight instability. Hold this position for 30-60 seconds, keeping your arm as stable as possible.
Swiss Ball Stability
The scapula (or shoulder blade) has a huge role in the function of the shoulder. Part of the scapula is the glenoid fossa, which forms the socket for the shoulder joint.
Muscular imbalances can cause the scapula to sit incorrectly, this can lead to incorrect movement patterns and repetitive wear when the humeral head rubs against parts of the glenoid fossa (the socket) and surrounding tissues it shouldn’t. This can contribute to shoulder pain in the overhead athlete due to the repetitive movements essential in tennis.
A sign that your scapula may have something to do with your shoulder pain is by observing a ‘winging’ in the shoulder blade. This when all or part of the medial part of the shoulder blade sits further off of the ribcage than it should. This can be caused by muscle weakness.
Some great exercises to strengthen your scapula stabilisers are outlined below.
For the first exercise, bend your elbow and bring your shoulder to 90 degrees abduction. Hold onto a resistance band and slowly punch forward, keeping the arm stable and upper shoulder relaxed. At the end of the movement make sure to go as far as possible, pulling the shoulder blade forward. Slowly return to start position. Repeat approximately 8-12 times.
Serratus Anterior Punch
For the next exercise, we will be working the rhomboid muscles. For this exercise, wrap the band around a pole above chin height, or trap it in a door. Grab hold of both ends, stand up straight and set your shoulder blades into a good position. Slowly pull back on the ends of the resistance band, keeping your elbows close to your sides. As your arms come back, squeeze your shoulder blades together, careful not to arch the back. Slowly return to starting position, repeat 10-15 times.
High Rope/Band Pull
Commonly tennis players can find themselves with an increased external rotation range of motion, and a decreased internal rotation range of motion. This is due to a toughening of the posterior capsule due to an increased load placed through it secondary to tightening of the posterior rotator cuff muscles.
Usually, this is not a problem, as the increase in external rotation will most often equal the decrease in internal rotation, leaving the total rotation range of motion the same. But occasionally, the internal rotation deficit will be larger. The shortening of the posterior structures in the shoulder can lead to a change in position of the humeral head, which again can lead to shoulder pain through repetitive micro-trauma and tears in the shoulder joint.
You can usually tell if you have a significant decrease in internal range of motion by placing your hand behind your back as far up as possible, and comparing it to the other side. A great stretch to increase internal rotation mobility of the shoulder is the sleeper stretch, shown below.
If you are experiencing any shoulder pain with any overhead activities, especially tennis, make sure you visit us here at Absolute Health and Performance to get it checked out. 199 William Street, Melbourne CBD 3000. It could be something as simple as changing your technique, or adding an exercise into your routine!
Written by Physiotherapist Kristin Cameron | Absolute Health & Performance- Physiotherapy Services Melbourne CBD.