Kinetic Chain Concepts and Exercise Progression for Tennis Players

Kinetic Chain Concepts and Exercise Progression for Tennis Players

Mijo Tomislav Cotic, SPT

Overview

My interest in overhead athletes and the sports medicine setting of physical therapy stems from my experience as an NCAA tennis student-athlete. I experienced numerous injuries throughout my athletic career including a debilitating shoulder injury that affected my performance and participation in the sport. For my culminating capstone project, I decided to explore the literature and investigate injury prevention and rehabilitation concepts associated to the tennis athlete population. More specifically, I strived to research the theoretical framework of the kinetic chain and it’s value in exercise development and prescription for tennis players. I started researching the subject in the Evidence-Based Practice II course in the Fall semester, and further investigated the concept through the completion of my capstone.  The overall objective of the project was to demonstrate the importance of incorporating the lower extremities and trunk/core into conditioning or intervention planning for tennis players versus the “traditional” dominant upper extremity approach to therapy which focuses solely on the upper quadrant.

The Tennis Serve Biomechanics:

Here is a slow-motion replay of tennis professional Roger Federer during his tennis serve :

[youtube]https://www.youtube.com/watch?v=InYd8IrFnkU[/youtube]

Introduction: 

Tennis is truly a global sport, with millions of yearly participants worldwide and over 200 nations possessing an active involvement with the International Tennis Federation (ITF).^1,2 It is estimated that tens of millions of Americans play tennis, both recreationally and competitively.² The increased popularity of professional tennis has resulted in an exponential rise in the amount of tennis participants from the general public, along with a parallel increase in tennis related injuries.^1,3,4 The demands of the sport can affect the upper and lower extremities, the most common being the shoulder, elbow and knee,¹² as well as the trunk and can dispose an athlete to characteristic injury patterns and musculoskeletal adaptations.^5,6 Tennis players are susceptible to developing shoulder injuries due to muscular imbalances and altered length-tension relationships, secondary to the repetitive stress and loading associated with the game.^5-9

A tennis-specific strategy for screening, evaluating, and conditioning can play a key role in preventing and rehabilitating common injuries in tennis players.  Current research correlating specific techniques and exercises to successful injury prevention in tennis players is limited.⁵ The present literature has associated specific resistive and flexibility exercises with performance enhancement in tennis players.^10,11 However, further investigation is needed to determine the role specific exercises and intervention strategies possess in preventing common tennis injuries. While studies have shown that acute injuries tend to occur in the lower extremity, chronic injuries usually affect the dominant upper extremity and trunk.^3,4,12,13 Upper extremities tend to be more troublesome and lead to longer delays in return to sport and will therefore be highlighted in this discussion.¹⁴

The Kinetic Chain Model:

Dynamic dominant upper extremity activities such as serving and throwing arise from the tandem activation of a muscle system along with an integrated, multisegmented, sequential joint motion.¹⁵ The dominant upper extremity is of critical importance throughout these complex tasks; however, overhead activities require “link sequencing,” which is the proximal to distal delivery of velocity, energy, and force to the terminal link of the system, the dominant arm.^15,16 The sequencing and theoretical framework is termed the “kinetic chain.”^15,16 The effective and efficient  use of the kinetic chain starts at the ground and permits maximal velocity, energy, and force to be developed in the lower extremity and core musculature which is then transferred to the dominant upper extremity.¹⁵ The largest proportion of kinetic energy and force is derived from the larger proximal body segments. Current literature demonstrates that 51% of the total kinetic energy and 54% of the total force generated in the tennis serve are created by the lower legs, hip, and trunk.¹⁶

Conclusions:

A tennis-specific conditioning program, designed in the context of the kinetic chain, can potentially play a critical role in preventing common dominant upper extremity injuries to which tennis players are currently predisposed. The development and creation of preventative programs can assist in the education of tennis athletes and coaches through exercise prescription that includes conditioning of all the involved segments of the body, as well as result in potential performance enhancement on the court. A thorough understanding of the kinetic chain model, normal biomechanics and pathomehanics, and common upper extremity pathology and mechanisms of injury, can assist sports medicine professionals in developing intervention strategies to prevent and rehabilitate injuries, as well as enhance performance in tennis players. The physical demands of overhead tennis activity can affect the upper and lower extremities, as well as the trunk of players, and lead to characteristic injury patterns and musculoskeletal adaptations across the body. The repetitive stressors and distinctive loading sequences can create muscular imbalances and altered length-tension relationships, which require preventative interventions to reduce the potential for injury. A better understanding of kinetic chain mechanics, and their association with these forces and loads throughout the musculoskeletal tissue, can allow clinicians to design more effective injury prevention and rehabilitation programs and perhaps improve performance as well. The implementation of various conditioning and resistive training programs have shown to improve motor performances in this athletic population; however, further research is needed to provide evidence for kinetic chain-designed intervention strategies to strive for optimal exercise prescription for tennis players and the overhead athletic shoulder to fulfill ultimate goals of injury prevention and performance enhancement.

The Project:

My final clinical rotation will take place in a sports medicine/advanced orthopedic therapy setting: Athlete’s Performance in Raleigh, NC. My clinical instructor has informed that the overhead athlete population encompasses a significant portion of the associated caseload. Thus, I have decided to present my capstone project during my final clinical rotation in order to further educate sports medicine professionals on a topic that would be useful and beneficial to the types of patients they encounter. I will have a 60-90 minute Powerpoint Presentation Lecture to demonstrate and emphasize the value of designing intervention and conditioning exercises and programs in the context of the kinetic chain in comparison to the “traditional” approach or therapies associated to dominant upper extremity injury in tennis players. My presentation provides clinicians with the evidence-based “traditional” approach to treatment and injury prevention and then transitions into the rationale behind the kinetic chain model. All members of the audience will be asked to complete the Evaluation Form at the conclusion of the discussion.

I have also created a kinetic chain exercise video (below) that will provide sports medicine professional with examples of kinetic chain exercises that can be incorporated into injury prevention and conditioning programs for tennis players. I decided to omit commentary during the video in order to promote discussion with the audience during the lecture.

Here is the video:

[vimeo]https://vimeo.com/92191367[/vimeo]

Exercises were designed in the context of the kinetic chain with consideration of all the musculoskeletal structures involved in the overhead tennis serve. This promotes proper deployment of the kinetic chain as successful transmission of kinetic energy relies on optimal integrity of all the “links in the chain.”

Additional Products:

The Capstone References were listed along with the presentation in case there was any special interest in an article I mentioned or any desire to learn more about this topic. My Evidence Table and Literature Review  were also part of this process in order to ensure I included current evidence-based practice to support these intervention ideas and provide the rationale associated to the theoretical kinetic chain model.

Acknowledgments:

I would like to thank my advisor Mike Gross and committee members Mike McMorris, Matthew Medlin, Marija Cotic, and Ryan Mulligan for all of their valuable feedback, advice, and resources. Another special thank you to fellow class of ’14 DPT student Kenneth Ngwu for his A/V expertise with creating the kinetic chain exercise video. Thank you for visiting my capstone web page, please do not hesitate to contact me at mcotic@med.unc.edu, if you have any further questions.

References:

1. Bylak J, et al. Common sports injuries in young tennis players. JSM. 1998 Aug;26(2):119-32.

2. International Tennis Federation. History of the ITF. ITF Web Site. http://beta.itftennis.com/about/organisation/history.aspx. Date Accessed: October 8, 2013.

3. Perkins R, et al. Musculoskeletal Injuries in Tennis. Phys Med Rehabil Clin N Am. 2006; 17: 609–631

4. Kocher M, et al. Upper Extremity Injuries in the pediatric athlete. Am Journ Sports Med. 2000; 30(2): 117-135.

5. Ellenbecker T, et al. Common Injuries in Tennis Players: Exercises to Address Muscular Imbalances and Reduce Injury Risk. Journal of Strength and Conditioning. 2009; 31(4) 50-58.

6. Ellenbecker T, et al. Age specific isokinetic glenohumeral internal and external rotation strength in elite junior tennis players. J Sci Med Sport. 2003; 6: 63–70.

7. Kibler W, et al. Shoulder range of motion in elite tennis players. Am J Sports Med. 1996; 24:279–285.

8. Cools A, et al. Trapezius activity and intramuscular balance during isokinetic exercise in overhead athletes with impingement symptoms. Scand J Med Sci Sports. 2007;17:25-33.

9. Nodehi-Moghadam A, et al. A Comparative Study on Shoulder Rotational Strength, Range of Motion and Proprioception between the Throwing Athletes and Non-athletic Persons. Asian J Sports Med. 2013;4(1):34-40.

10. Treiber F, et al. Effects of Theraband and Lightweight Dumbell Training on Shoulder Rotation Torque and Serve Performance in College Tennis Players. Am J Sports Med. 1998; 26(4): 510-515.

11. Fernandez J, et al. Effects of A 6-Week Junior Tennis Conditioning Program on Service Velocity. Journal of Sports Science and Medicine. 2013;12(2):232-239.

12. Renstrom P, et al. Overuse injuries in sport. Sports Med. 1995; 2: 316-333.

13. Kibler W, et al. Pathophysiology of tennis injuries: An overview. In: Tennis. Renstrom P, ed. Oxford, United Kingdom: Tennis Blackwell Publishing Company, 2002. pp. 147–154.

14. Gregg J, et al. Upper extremity injuries in adolescent tennis players. Clin Sports Med. 1988; 7(2): 371-385.

15. Sciascia A, et al. Kinetic Chain Rehabilitation: A Theoretical Framework. Rehabil Res Pract. 2012; 11(55): 1-9.

16. Kibler W, et al. The role of the scapula in throwing motion. Contemp Orthop. 1991; 22:525–532.

17. McMullen J, et al. A kinetic chain approach for shoulder rehabilitation. Journal of Athletic Training. 2000;35(3):329-337.

18. Kibler W, et al. Muscle activation in coupled scapulohumeral motions in the high performance tennis serve. Br J Sports Med. 2007; 41:745-749

19. Martin C, et al. Upper limb joint kinetic analysis during tennis serve: Assessment of competitive level on efficiency and injury risks. Scand Jour Med Sci Sports. 2013; (Epub ahead of print).

20. Elliot B, et al. Technique Effects on Upper Limb Loading in the Tennis Serve. Journal of Science and Medicine in Sport. 2003; 6(1):76-87.

21. Martin C, et al. Upper limb joint kinetic analysis during tennis serve: Assessment of competitive level on efficiency and injury risks. Scand Jour Med Sci Sports. 2013; (Epub ahead of print).

22. Ryu K, et al. An electromyographic analysis of shoulder function in tennis players. Am J Sports Med. 1988; 16: 481–485.

23. Chow J, et al. Lower trunk muscle activity during the tennis serve. Journal of Science and Medicine in Sport. 2003; 6(4):512-518.

24. Macher R, et al. Lower-Limb Coordination and Shoulder Joint Mechanics in the Tennis Serve. Medicine and Science in Sports and Exercise. 2008; 39(5) 308-315.

25. Leggin B, et al. Rehabilitation After Surgical Management of the Thrower’s Shoulder. Sports Medicine and Arthroscopy Review. 2012;20(1):49-55.

26. Nirschl R, et al. Rotator cuff tendonitis: basic concepts of pathoetiology. In: Barr JS, editor. Instructional course lectures 38. Park Ridge, IL: American Academy of Orthopedic Surgeons; 1989.

27. Maenhout A, et al. Electromyographic analysis of knee push up plus variations: what is the influence of the kinetic chain on scapular muscle activity? Br J Sports Med. 2010;44:1010-1015.

28. Myers J, et al. Scapular position and orientation in throwing athletes. Am J Sports Med. 2005; 33(2): 263-271.

29.  Ludewig P, et al. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80:276–291.

30. Solem-Bertoft E, et al. The influence of scapular retraction and protraction on the width of the subacromial space: an MRI study. Clin Orthop. 1993;296:99–103.

31. Burkhart S, et al. The disabled throwing shoulder: spectrum of pathology, part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19:641–661.

32. Wilmore J, et al. Physiology of Sport and Exercise. 3rd Edition. Windsor, ON: Human Kinetics Publishing; 2005.

33. Behringer M, et al. Effects of Two Differetn Resistance-Training Programs on Mean Tennis-Serve Velocity in Adolescents. Pediatric Exercise Science. 2013; 25: 370-384.

34. Niederbracht Y, et al. Effects of a shoulder injury prevention strength training program on eccentric external rotator muscle strength and glenohumeral joint imbalance in female overhead activity athletes. J Strength Cond Res. 2008;22(1):140-145.

35. Reinold M, et al. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2. Sports Health. 2010;2(2):101-115.

36. Davies G, et al. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Sports Phys Ther. 1993;18(2):449-458.

37. Witt D, et al. EMG of Scapular Muscles during Diagonal Patterns using Elastic Resistance and Free Weights. Int J Sports Phys Ther. 2011;6(4):322-332.

38. Padua D, et al. The effect of select shoulder exercises on strength, active angle reproduction, single-arm balance and functional performance. J Sport Rehabil. 2004;13(1):75-95.

39. Chen S, et al. Glenohumeral kinematics in a muscle fatigue model. Orthop Trans. 1995;18:1126.

40. Joshi M, et al. Shoulder External Rotation Fatigue and Scapular Muscle Activation and Kinematics in Overhead Athletes. J Athl Train. 2011;46(4):349-357.

41. Tripp R, et al. Functional multi-joint position reproduction acuity in overhead-throwing athletes. J Athletic Train. 2006; 41(2): 146-153.

42. Szucs K, et al. Scapular muscle activation and co-activation following a fatigue task. Med Biol Eng Comput. 2009. 47(5):487-495.