Introduction
Tennis is a demanding sport that requires a blend of strength, flexibility, and endurance. One common challenge for tennis players is shoulder injuries, particularly due to repetitive overhead serves. On average, players perform around 40 serves per set (Myers et al., 2016), placing significant stress on their shoulders. Understanding the mechanics behind these movements and the factors contributing to shoulder injuries is crucial for prevention and treatment. In this blog, we explore the anatomy of the shoulder, scapular movement, and the kinetic chain's role in shoulder injuries among tennis players.
The Unique Demands on the Shoulder
The shoulder is the most mobile joint in the human body, designed to balance stability with a wide range of motion. However, this balance is particularly strained in tennis players (Van Der Hoeven & Kibler, 2006). Tennis involves many overhead actions, which are dynamic and unnatural. Powerful serves, in particular, push the shoulder beyond its normal range, making it prone to injury (Van Der Hoeven & Kibler, 2006). For optimal performance, tennis players rely on balanced rotator cuff muscles, stable scapular movement, and a well-coordinated kinetic chain.
Maintaining Shoulder Stability
Shoulder stability is key to ensuring smooth and controlled movement while preventing injury. This stability comes from a combination of static and dynamic stabilisers, which work together to keep the humeral head centred on the glenoid during various shoulder movements (Renström, 2002):
Static Stabilisers: These include the shoulder’s bony architecture and ligaments, which provide a strong structural foundation (Renström, 2002).
Dynamic Stabilisers: These include the rotator cuff muscles, which actively stabilise the joint during movement (Renström, 2002).
The rotator cuff is a group of four muscle-tendon units essential for shoulder stability: the subscapularis, supraspinatus, infraspinatus, and teres minor (Renström, 2002):
Subscapularis: Originates from the anterior portion of the scapula and inserts onto the lesser tuberosity of the humerus. It accelerates the arm during internal rotation and provides anterior stability, especially during the cocking phase of a serve (Renström, 2002) (Figure 1)
Supraspinatus, Infraspinatus, and Teres Minor: These muscles originate from the posterior scapula and share a tendon inserting onto the greater tuberosity of the humerus. They assist in arm elevation and external rotation, enabling smooth and controlled shoulder movement (Figure 2) (Renström, 2002).
Adequate strength and range of motion (ROM) in the rotator cuff muscles are crucial for preventing overuse injuries, especially during the extreme motions experienced during tennis strokes, such as serving. Therefore, it is recommended that tennis athletes include both concentric and eccentric shoulder training in their routines to enhance performance (Kovacs, 2006). Playing tennis alone is insufficient to improve shoulder ROM, so players should follow a dedicated shoulder ROM programme during both the pre-season and competitive season (Kovacs, 2006).
Figure 1. Subscapularis muscle |
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Reproduced from BioDigital Human https://www.biodigital.com/ |
Figure 2. Supraspinatus, Infraspinatus and Teres Minor muscles | |
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Reproduced from BioDigital Human https://www.biodigital.com/ |
Shoulder Rotational Changes in Tennis Players
Tennis players often experience changes in the rotational arc of their dominant shoulder, typically with increased external rotation and reduced internal rotation (Van Der Hoeven & Kibler, 2006).
Figure 3. Internal (IR) and External (ER) rotation of the shoulder |
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Lubis, A.Mt., Wisnubaroto, R.P., Ilyas, E.I. and Ifran, N.Npps., 2020. Glenohumeral internal rotation deficit in non-pitcher overhead athletic athletes: case series analysis of ten athletes. Annals of Medicine and Surgery, 58, pp.138–142 |
This is commonly linked to tightness in the posterior capsule of the shoulder (Perkins & Davis, 2006). Such changes can compromise shoulder stability and increase the risk of impingement and reduced ROM (Di Giacomo, De Gasperis, & Costantini, 2016).
Burkhart, Morgan, and Kibler (2003) explained that during the follow-through phase of overhead motions, significant distractive forces are applied to the posterior shoulder capsule (Figure 4). These forces are countered by the posteroinferior capsule and the rotator cuff muscles, particularly the infraspinatus. However, the eccentric activity of the infraspinatus leads to adaptive changes, including decreased active tension, increased passive tension, and impaired proprioception. This causes the posterior capsule to stiffen and shorten (Van Der Hoeven & Kibler, 2006). Regular stretching of these shortened structures is crucial to maintain flexibility, reduce the risk of impingement, and preserve shoulder function (Van Der Hoeven & Kibler, 2006).
Figure 4. Posterior shoulder capsule |
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Reproduced from BioDigital Human https://www.biodigital.com/ |
The Role of the Kinetic Chain
Understanding shoulder injuries also requires an examination of the kinetic chain, which describes how energy flows through the body during tennis strokes and serves. The chain involves several joints, including the knee, shoulder, and elbow, which work together to transfer energy from the ground to the racket and, ultimately, to the ball (Chung & Lark, 2017).
Inefficiencies at any joint can overload others, increasing the risk of injury. For example, improper knee flexion during a serve can raise mechanical loads on the shoulder and elbow by 17% and 23%, respectively (Chung & Lark, 2017). Similarly, a 20% reduction in hip force requires the arm to generate 34% more speed or the shoulder to increase mass by 80% to transfer the same force to the ball (Peterson & Renström, 2017).
Problems anywhere in the kinetic chain can lead to shoulder injuries, making the shoulder a victim rather than the source of the problem (Di Giacomo, De Gasperis, & Costantini, 2016). Even after surgical repair, if the kinetic chain dysfunction isn’t addressed, injuries are likely to recur (Di Giacomo, De Gasperis, & Costantini, 2016).
Conclusion
Understanding the complex relationship between shoulder anatomy and the kinetic chain is essential for preventing and managing shoulder injuries in tennis players. By focusing on shoulder stability, incorporating strength and ROM training, and addressing any inefficiencies in the kinetic chain, players can minimise injury risk and improve their on-court performance. Consistent conditioning, proper technique, and attention to body mechanics are key to keeping the shoulder healthy and supporting a long and successful tennis career.
References
Burkhart, S.S., Morgan, C.D. and Ben Kibler, W., 2003. The disabled throwing shoulder: spectrum of pathology part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 19(6), pp.641–661. https://doi.org/10.1016/S0749-8063(03)00389-X.
Chung, K.C. and Lark, M.E., 2017. Upper Extremity Injuries in Tennis Players. Hand Clinics, 33(1), pp.175–186. https://doi.org/10.1016/j.hcl.2016.08.009.
Di Giacomo, G., De Gasperis, N. and Costantini, A., 2016. Tennis: Epidemiology and Injury Mechanism. In: P. Volpi, ed. Arthroscopy and Sport Injuries. [online] Cham: Springer International Publishing. pp.19–23. https://doi.org/10.1007/978-3-319-14815-1_3.
Myers, N.L., Sciascia, A.D., Kibler, W.B. and Uhl, T.L., 2016. Volume-based Interval Training Program for Elite Tennis Players. Sports Health: A Multidisciplinary Approach, 8(6), pp.536–540. https://doi.org/10.1177/1941738116657074.
Perkins, R.H. and Davis, D., 2006. Musculoskeletal Injuries in Tennis. Physical Medicine and Rehabilitation Clinics of North America, 17(3), pp.609–631. https://doi.org/10.1016/j.pmr.2006.05.005.
Renström, P. ed., 2002. Handbook of sports medicine and science. Tennis. Handbook of sports medicine and science. Malden, MA: Blackwell Science.
Van Der Hoeven, H. and Kibler, W.B., 2006. Shoulder injuries in tennis players. British Journal of Sports Medicine, 40(5), pp.435–440. https://doi.org/10.1136/bjsm.2005.023218.
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