Prevention of the Most Common Shoulder Injuries in Tennis Players
By Mara Argyriou, SPT, CSCS
Background:
I played competitive and collegiate tennis prior to attending physical therapy (PT) school where I witnessed countless of tennis injuries, especially of the shoulder. The lack of awareness and knowledge of preventive strategies available to athletes of all levels has driven me to explore this area in more depth to help athletes enhance their performance. My passion for the prevention of tennis-related injuries continues to grow as I continue to be involved in tennis as a coach and continue to see the devastating effects injuries can have on a player’s career.
Given my passion for tennis and prevention, during the Evidence-Based Practice II course, I completed a critically appraised topic regarding the effectiveness of a shoulder injury prevention program compared to standard training alone for reducing shoulder injury rate in overhead (OH) athletes. To my surprise I found minimal high-quality evidence on this topic, which motivated me to seek a deeper understanding for shoulder prevention for OH athletes, with a focus on the risk factors and screening methods for the most common shoulder injuries in this population.
Statement of Need:
Elite tennis players are at high risk of shoulder injury due to the extensive forces associated with the OH motions in the sport.1 Internal impingement and posterosuperior RC tears are identified as the leading causes of chronic shoulder pain in the OH athlete.2,3 At the professional level it has been reported that over 50% of withdrawals and retirements from competition, including both the Association of Tennis Professionals (ATP) and Women’s Tennis Association (WTA) is a result of injury, with shoulder injuries being the second most frequent cause.4 In addition, evidence suggests that the incidence of tennis injury ranges from 0.05-2.9 injuries per player each year and overuse shoulder injuries contribute to 4-17% of all tennis injuries.5,6 Looking at OH sport in general, the incidence of shoulder injury is between 0.2/1000 hours and 1.8/1000 hours.7
Shoulder pain and/or injury can greatly impact an athlete’s career and limit his or her participation in the sport. This can further lead to physical, psychological and financial challenges. There is a need to increase awareness of the importance of shoulder preventive interventions and educate coaches who are the first line of defense on preventive strategies.
Purpose:
The primary focus of my capstone project was to provide evidence for the need for preventive interventions for the OH athlete, specifically a tennis player, as well as identify risk factors for shoulder injuries seen in OH athletes, screening methods for early detection and preventive strategies that can aid in reducing shoulder injury rate. This paper and power point will serve as a framework for shoulder prevention programs for PTs and PT students. The capstone project also intends to increase awareness of the importance of preventive interventions for OH athletes and provide coaches with preventive strategies to implement in the athlete’s training program to help reduce shoulder injuries and ultimately enhance performance.
Products:
- Literature review paper on the “Prevention of the Most Common Shoulder Injuries in Tennis Players.” This paper addresses relevant anatomy of the shoulder complex, biomechanics and pathomechanics of the OH motion, as well as screening and diagnostic tools for early detection. It also provides evidence-based information on conservative and surgical management of shoulder injuries and preventive strategies to help reduce shoulder injury rate.
- Power point presentation designed to serve as a clinical resource for PTs and PT students. The presentation consolidates the evidence and information from the literature review. I plan to present my Power Point as an inservice during my last clinical rotation at a sports PT clinic.
- Feedback form for the PTs and PT students to complete following my presentation. I plan to utilize this feedback to make appropriate changes and improve my presentation for future use.
- Shoulder Injury Prevention handout designed for coaches. This handout contains exercises and stretches that can easily be administered by the coach and implemented during the OH athlete’s warm-up.
Self-Reflection:
Through this project I have learned way more than I thought I would. I have expanded my knowledge and understanding on the biomechanics and pathomechanics of the OH motion, which has helped me tremendously when considering and implementing preventive interventions. I have also increased my knowledge regarding high-quality diagnostic screening tools, as well as cut-off values that can be utilized for early detection. Additionally, I feel confident in my ability to implement a wide variety of preventive strategies based on the identified limitations found that can aid in reducing shoulder injuries and enhancing performance.
I am very excited to present my power point in a sport PT clinic. I believe the information I present will be highly valued and useful in this setting and will provide me with the opportunity to increase awareness and receive more feedback. Overall, I am very pleased with the final products of this project and thankful for the personal learning experience it has provided. I plan to continue to enhance my learning regarding preventive interventions throughout my career and continue to seek feedback for improvement.
Acknowledgments:
I would first like to thank my committee advisor, Dr. Mike Gross, PT, PhD for your professional guidance, availability and patience. You have provided me with direction and feedback throughout this project and I am very appreciative for everything you have done and continue to do for me and other students. I would also like to thank Dr. Michael McMorris, PT, DPT for your honest feedback and for helping me present the evidence in an effective and efficient manner. Lastly, I want to thank Chad Ownbey, PT for your time, support and clinical expertise in the prevention of shoulder injuries in OH athletes.
References:
- Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of shoulder injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2015;43(10):2379-2385.
- Lin DJ, Wong TT, Kazam JK. Shoulder Injuries in the Overhead-Throwing Athlete: Epidemiology, Mechanisms of Injury, and Imaging Findings. Radiology. 2018;286(2):370-387.
- Peduzzi L, Grimberg J, Chelli M, et al. Internal impingement of the shoulder in overhead athletes: Retrospective multicentre study in 135 arthroscopically-treated patients. Orthop Traumatol Surg Res. 2019;105(8S):S201-S206.
- Okholm Kryger K, Dor F, Guillaume M, et al. Medical reasons behind player departures from male and female professional tennis competitions. Am J Sports Med. 2015; 43(1):34–40.
- Lynall RC, Kerr ZY, Djoko A, Pluim BM, Hainline B, Dompier TP. Epidemiology of National Collegiate Athletic Association men’s and women’s tennis injuries, 2009/2010-2014/2015. Br J Sports Med. 2015.
- Pluim BM, Staal JB, Windler GE, Jayanthi N. Tennis injuries: occurrence, aetiology, and prevention. Br J Sports Med. 2006; 40(5):415–423.
- Asker M, Brooke HL, Waldén M, et al. Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best-evidence synthesis. Br J Sports Med. 2018;52(20):1312-1319.
9 Responses to “Prevention of the Most Common Shoulder Injuries in Tennis Players”
argyriou
Emma and Anjali, thank you both for your very kind words and your valuable feedback. I’m glad to hear that you may one day be utilizing these materials in the clinic as that was one of my hopes!
Emma – I know exactly what presentation you are referring to and you pose very good questions regarding the hypermobile athlete. Surprisingly, throughout my tennis career I have not seen any of my teammates or other tennis players I know experience hypermobility. The literature I read did not specifically discuss hypermobility in overhead athletes, however, anterior laxity is a risk factor for shoulder injury in this population that we must evaluate and address as appropriate. It is important to remember that most of these athletes have adaptive laxity that is actually normal and advantageous. This does make screening challenging, however, according to my literature search the apprehension/relocation test is an effective tool that can aid in diagnosis, with a positive test defined by apprehension rather than pain. Comparing side-to-side differences is also found to be effective. Lastly, I did not find any research linking tennis injuries with hypermobility. I believe there is a paucity of evidence regarding this topic and it would be interesting to see future research evaluate this area in more depth.
Anjali – I am glad to hear that you found my materials beneficial for individuals without a tennis background. It is definitely challenging to truly understand the biomechanics and pathomechanics of different sports, however, I think it’s crucial we do to implement an optimal rehabilitation plan, as well as to gain the athlete’s trust and increase buy-in. I agree with you, I definitely want to make it known to the coach/trainer/parent/athlete that this is an evidence-based handout. I made some adjustments to include it in the title in hopes to make it known right away that this is an evidence-based program.
Thank you both again for taking the time to read and review my project!
Anjali
Mara,
I am thoroughly impressed by your capstone project. Your unique passion for this topic is reflected in the thorough and engaging materials that you have produced. Your literature review is comprehensive, well written, non-tennis player-friendly, and clinically useful. I was surprised to learn that evidence is lacking regarding shoulder prevention programs for overhead athletes. I also really appreciated the images and descriptions you chose to include in the appendices – these were clear and clinically useful. Your PowerPoint presentation is impressive, concise, and very pertinent for physical therapists who treat tennis players. All of your images serve to augment understanding of the concepts you present. Slide 14 is slightly busy, but I assume you will be systematically walking PTs through this information. Your audience may feel less overwhelmed if this slide’s contents were broken up into multiple slides.
Your evidence-based overhead athlete shoulder injury prevention program is clear and concise with the images and visuals that you have included. The “key features” and “important to note” sections of the handout answer many of the questions and concerns that coaches, parents, and players may come across while implementing the program. One suggestion would be to somehow make it known that this program is evidence-based (perhaps this information could be included in the “key features” section). Overall, this is an incredible, impactful capstone project. The education that you provide helps translate research into practice as well as into the community to ultimately improve the shoulder health of overhead athletes.
Thank you!
Emma Shirley
Hi Mara,
I really enjoyed this project, particularly that it is sport-specific, and obviously something you care deeply about. Your passion for tennis really shines through in the high quality of the work and these products. I personally would love to work in orthopedics with athletes of all levels; however, it is really difficult for one person to know the ins-and-outs of the biomechanics of every sport out there! This material was comprehensive, yet concisely summarized tennis-related movement patterns related to shoulder pathology and gave me appropriate knowledge to implement shoulder injury prevention strategies for tennis players that I may see one day in the clinic (despite not being a tennis player myself). Throughout reviewing your material, I frequently thought back to a presentation I saw at CSM in 2019 about hypermobility and the female collegiate athlete. During this presentation, they discussed how hypermobile females in sport may show athletic advantage in excess range than then can eventually lead to injury down the road; I could see this being an issue in the shoulder in tennis, due to the range demands as well as the biomechanical wear and tear you discussed in your materials. Anecdotally, have any of your previous teammates been hypermobile and suffered a shoulder injury? Did the literature discuss hypermobility in female tennis players at all? Are there any instances of injuries in professional tennis secondary to hypermobility?
Thanks Mara! Excellent work. I’m keeping these materials bookmarked to hopefully implement one day in clinic!
argyriou
Debbie, Gabe and Kristen – thank you for taking the time to go over my capstone materials, for the encouraging words and your valuable feedback. I greatly appreciate it.
Gabe – I thought you would be one of the people to truly appreciate the need for preventive care in this population knowing your baseball background. To answer your questions: yes, serve velocity is associated with an increased risk for shoulder injury as it results in an increase in distraction forces during the deceleration phase, ultimately increasing risk of internal impingement and RC tears. A decrease in serve velocity may also be an identification of a shoulder discomfort or potential upcoming injury, which should be observed as a screening strategy for prevention. Regarding different racquets types and string tension, there is no evidence to suggest an association with shoulder injury, however, I did find that string tension is associated with elbow injuries, specifically tennis elbow. Higher string tension increases the load placed at the elbow, which increases risk of injury. While a lower string tension reduces the elbow load during strokes. So that is definitely another thing to evaluate for prevention of elbow injuries.
Kristen – I am glad to hear that you found my material useful and easy to follow despite not having a tennis background. That was definitely something I wanted to achieve in this project as any one of us may see a tennis player in clinic. Regarding the handout, yes I definitely wanted to include the fact that it is evidence based and I see how having that noted at the top will help attract attention from the beginning and may potentially help increase adherence to the program – thank you! When I played for CofC we did not have a comprehensive shoulder prevention program. We definitely had some of the exercises/stretches I mention as part of our warm-up or sometimes during our lifts, which is what you commonly see happening in college sports. The problem is that this is not enough. After reading the literature I realized the importance of having a comprehensive shoulder prevention program that targets all the key areas, as well as being consistent and compliant with such a program, rather than implementing some exercises every other week. Another common thing you will see in college sports is implementing excellent programs and exercises, but only after the athlete complains of pain, which may be too late.
Thank you all again. I enjoyed reading everyone’s projects and learning so much on so many different topics!
Kristen Massey
Mara, you should definitely be proud of this product! The language and descriptions you used in your manuscript were clear and concise. I was able to visualize the shoulder anatomy as I read through this section, and the pictures in your appendices contributed further to this. I especially appreciate how you discuss all of the possible joints or problems that could be causing pain or injury (i.e. scapulothoracic, GH, thoracic, etc.). This is a great reminder to us as therapists to include screening of all these areas.
Your organization of your paper made this information very accessible to someone like me with limited knowledge of a tennis serve/stroke or other sports with overhead motion. I learned a great deal.
I believe that your handout is also very clear with the descriptions and visuals. In addition, because the information that it contains is evidence based, I think you did a great job eliminating possible barriers for coaches to not want to use this tool. I see that you say “references upon request” at the end of the handout. I wonder if you have any ideas for ways to make it clear earlier in the handout that this injury prevention program is evidence based. That way, as I go to read this (if I were a coach), I know right away that this is evidence based and not just something someone made up from experience. Maybe include something after the title? Not sure.
Lastly, I was just wondering, as a student athlete at College of Charleston, did your coach implement any sort of injury prevention program with you all?
Again, great job and great capstone!
dimockgj
Mara,
What a wonderful and thorough project you have created! Having battled shoulder injuries throughout my baseball career, I can attest to the need for high-quality, evidence-based prevention and treatment programs for overhead athletes. I was glad to see you mention that GIRD is not always pathological due to the common humeral retrotorsion found in many overhead athletes. Without this knowledge, many clinicians may view this asymmetry as the root of the patient’s symptoms when this is often not the case. Your manuscript provides a great overview that I will refer to frequently in my career when treating overhead athletes. Additionally, your Powerpoint was well-organized and pulled the most applicable and important information out of the literature review. The injury prevention handout is a great resource for coaches as it is a feasible program that can be understood and implemented by coaches at all levels of play! Below are a few questions that came to mind as I was reading based on previous research I have seen regarding baseball throwing injuries. Thank you for a great project and you are going to be an amazing PT!
Questions:
Is there a link between injury rate and serving velocity?
Is there a link between injury rate and racquet type/weight?
argyriou
Jason, I greatly appreciate your feedback and comments, and I’m glad to see that we came to similar conclusions. I especially like your suggestion for the handout. In fact, that is the “protocol” recommended in the literature and I think it’s important to include.
To answer your questions, after reviewing the literature, I saw internal (posterior) impingement as a pathology that is closely associated with RC tears in overhead athletes. Due to the mechanism of internal impingement it definitely increases the risk of posterosuperior RC tears, so in that sense it can also be seen as a mechanism. The two pathologies are often seen together; I found that posterosuperior RC tears are actually one of the hallmarks of internal impingement. I think an accurate diagnosis is important to identify specific limitations that you will address in therapy, but I don’t think the distinction between it being a “pathology” or “MOI” will affect intervention.
Furthermore, the most frequent location of injury in tennis players that led to withdrawal or retirement was the back (for men) and the thigh (in women), including quads and hamstrings. Interestingly, in that same study they found that women were significantly more injured than men.
jbottoms
Mara,
First of all, you’ve developed an incredibly thorough review of the literature and excellent paper on your topic. I enjoyed reading your thorough explanation of biomechanics/pathomenchanics, screening and diagnostic tools and management of shoulder injuries in overhead athletes. As my capstone was on a very similar topic, it was interesting and educational to get your perspective from your research. I thought you did an exceptional job explaining the pathomechanics of shoulder injury. You delve into explaining how overhead throwing/striking contribute to injury. I can commiserate with the challenge of lacking evidence on surgical outcomes and return to sport after shoulder injury. Also, I agree with the your point about the issue with the definition of “return to sport” – many athletes may return but do they return to the same level of play/performance they were at prior to injury? Additionally, your discussion of conservative management of shoulder injuries as well as prevention could be a project all on its own! You give some great, clinically applicable suggestions. Overall your paper was a very interesting and educational read.
Your powerpoint presentation does an excellent job condensing the information into the clinically relevant portions to be conveyed to PTs and/or PT students. Your hand out does a great job of listing 10 exercises that would be effective in preventing shoulder injuries in these athletes. I like that you have ensured that it is short (15 minutes) allowing it to be easily integrated into a warm-up routine. I also like that you note that while this is an easily administered, generalized program, individualized exercise programs are shown to be more effective.
Overall, very well researched and clinically applicable project! You’ve clearly put a lot of time and effort into this.
Question and suggestions:
1. I want to hear your thoughts on internal impingement. I typically saw it as a mechanism of injury rather than a pathology itself. Ex: internal impingement is a MOI for rotator cuff tears, labral injuries, etc. I suppose MOIs and pathologies aren’t necessarily mutually exclusive. I’m wondering if you think this distinction could affect intervention ideas or if it really matters.
2. You note that shoulder injury is the second most frequent injury leading to withdrawal or retirement in tennis players. Just out of personal curiosity, do you know the most frequent injury?
3. For your PowerPoint, I find the slides to be a little bit wordy and busy. I tend to opt for fewer words on the slides. This way your audience is more likely to be listening to you rather than trying to read the slide.
4. On your handout for coaches, I wonder if it would be beneficial to put a box or line on there about being aware of pain. I feel like athletes and coaches typically try to push through and ignore pain. Some of these exercises would probably elicit pain in an athlete that has an undiagnosed shoulder injury (thinking specifically about 3, 9, and 10). Maybe these exercises could also serve as a “down and dirty” screen for shoulder injury. It could be as simple as a line at the top or bottom that reads “Be aware that sharp or consistent shoulder pain with these exercises may warrant a referral to physician, physical therapist or athletic trainer as it may be a sign of injury.”
Deborah Thorpe
Mara
You did a very thorough literature review! Your handout and ppt presentation will be very helpful for PTs who treat tennis athletes and for tennis coaches. As a reviewer it is nice to have all the pictures and diagrams to help with understanding of content. Fantastic job on this capstone project!
Debbie