🎾 Rotator Cuff Injuries In Tennis Players¶
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Tóm tắt nội dung (trích từ tài liệu gốc): Current Reviews in Musculoskeletal Medicine (2020) 13:734�747 https://doi.org/10.1007/s12178-020-09675-3 SPORTS INJURIES AND REHABILITATION: GETTING ATHLETES BACK TO PLAY (R GALLO, SECTION EDITOR) Rotator Cuff Injuries in Tennis Players Rami G. Alrabaa1 & Mario H. Lobao1 & William N. Levine1 Published online: 22 August 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract Purpose of Review This review presents epidemiology, etiology, management, and surgical outcomes of rotator cuff injuries in tennis players. Recent Findings Rotator cuff injuries in tennis players
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Current Reviews in Musculoskeletal Medicine (2020) 13:734�747
https://doi.org/10.1007/s12178-020-09675-3
SPORTS INJURIES AND REHABILITATION: GETTING ATHLETES BACK TO PLAY (R GALLO, SECTION
EDITOR)
Rotator Cuff Injuries in Tennis Players
Rami G. Alrabaa1 & Mario H. Lobao1 & William N. Levine1
Published online: 22 August 2020
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Purpose of Review This review presents epidemiology, etiology, management, and surgical outcomes of rotator cuff injuries in
tennis players.
Recent Findings Rotator cuff injuries in tennis players are usually progressive overuse injuries ranging from partial-thickness
articular- or bursal-sided tears to full-thickness tears. Most injuries are partial-thickness articular-sided tears, while full-thickness
tears tend to occur in older-aged players. The serve is the most energy-demanding motion in the sport, and it accounts for 45 to
60% of all strokes performed in a tennis match, putting the shoulder at increased risk of overuse injury and rotator cuff tears.
Studies have shown deficits in shoulder range of motion and scapular dyskinesia to occur even acutely after a tennis match. First-
line treatment for rotator cuff injuries in any overhead athlete consists of conservative non-operative management with appro-
priate rest, anti-inflammatory drugs, followed by a specific rehabilitation program. Operative treatment is usually reserved for
older-aged players and to those who fail to return to play after conservative measures. Surgical options include rotator cuff
debridement with or without tendon repair, biceps tenodesis, and labral procedures. Unlike rotator cuff repairs in the general
population, repairs in the elite tennis athlete have less than ideal rates of return to sport to the same level of performance.
Summary Rotator cuff injuries are a common cause of pain and dysfunction in tennis players and other overhead athletes. The
etiology of rotator cuff tears in tennis players is multifactorial and usually results from microtrauma and internal impingement in
the younger athlete leading to partial tearing and degenerative full-thickness tears in older players. Surgical treatment is pursued
in athletes who are still symptomatic despite an extensive course of non-operative treatment as outcomes with regard to returning
to sport to the same pre-injury level are modest at best. Debridement alone is usually preferred over rotator cuff repairs for partial
tears in younger players due to potential over-constraining of the shoulder joint and decreased rates of return to sport after rotator
cuff repairs.
Keywords Tennis . Shoulder . Rotator cuff . Tear . Impingement
Introduction
This article is part of the Topical Collection on Sports Injuries and Tennis players are susceptible to upper extremity injuries as
Rehabilitation: Getting Athletes Back to Play chronic repetitive supraphysiologic forces are generated at the
shoulder and elbow throughout a typical match. The shoulder
* Rami G. Alrabaa is involved in all strokes in the sport and is particularly prone
ra2830@cumc.columbia.edu to injury during the serve and overhead. Similar to other over-
head sports, upper extremity injuries are chronic and second-
Mario H. Lobao ary to repetitive microtrauma and overuse, while lower ex-
mhl2155@cumc.columbia.edu tremity injuries in tennis athletes tend to be acute injuries [1,
William N. Levine 2]. Multiple epidemiologic studies have noted that the most
wnl1@cumc.columbia.edu common injuries in tennis athletes are lower extremity inju-
ries, closely followed by upper extremity injuries that typical-
1 Department of Orthopedic Surgery, Columbia University Medical ly involve the shoulder and elbow and lastly the trunk which
Center, 622 W 168th Street, PH-11, New York, NY 10032, USA commonly involves injuries to the lower back [3�5].
Curr Rev Musculoskelet Med (2020) 13:734�747 735
The overall prevalence of shoulder injuries among tennis cause of rotator cuff injury shifts from microtrauma due to
players of all levels ranges from 4 to 17% [6, 7]. A recent posterosuperior internal impingement causing partial-
study noted that apart from lower extremity injuries, shoulder thickness cuff tears to degenerative changes leading to full-
injuries were the most common cause of professional tennis thickness tears. Partial-thickness rotator cuff tears in the over-
player departure from the sport [8]. The spectrum of shoulder head athlete mostly affect the articular side of the tendon and
pathology includes chronic rotator cuff inflammation are known as PASTA (partial articular-sided tendon avulsion)
(tendinosis), subacromial bursitis, partial-thickness rotator lesions. Bursal-sided tears are less common in the overhead
cuff tears, posterior capsule contracture, long head of biceps athlete and are associated with subacromial impingement.
injuries, labral tears, scapular dyskinesia, and superior labrum Tears in athletes can also exhibit extension into an
anterior-to-posterior (SLAP) tears. This review will focus on intratendinous or intralaminar portion of the tendon and are
rotator cuff tears, but it is important to keep in mind that tennis referred to as PAINT (partial-thickness articular surface
players often present with concomitant pathologies. intratendinous tears) lesions [13, 16]. Partial-thickness tears
can be classified according to Ellman [17] in 3 grades based
Rotator Cuff Injuries in Tennis Players on tear depth (grade 1, < 3 mm deep or 25% of tendon width;
grade 2, 3�6 mm or 50%; grade 4, > 6 mm or > 50%). This
The overall injury incidence in tennis players across all com- classification was revised by Snyder [18] to include location
petitive levels is estimated to be between 0.05 and 2.9 injuries (bursal or articular) and tear severity.
per player per year and ranges from 0.04 to 3.0 injuries per
player per 1000 h played [3]. In elite adolescent athletes, over- Several mechanisms have been described to cause rotator
all injury rates are higher ranging from 2 to 20 injuries per cuff injuries in overhead athletes, including tensile overload,
1000 h played [6]. Overuse injuries to the shoulder have been internal rotation deficit, internal impingement, scapular dyski-
shown to contribute to nearly 4 to 17% of all tennis injuries [1, nesia, and less commonly external impingement [19].
2, 4, 6, 7], but the true incidence of rotator cuff tears in tennis Repetitive and rapid eccentric contraction of the rotator cuff
athletes remains unclear [9]. The prevalence of rotator cuff to decelerate the arm during the follow-through phase of the
tears in overhead athletes may be underreported as many cuff throw generates tensile forces that progressively overload the
tears are asymptomatic in athletes. Connor and colleagues rotator cuff tendons leading to hypertrophy, microtrauma, and
[10] reported on imaging findings in completely asymptom- eventual failure of the tendon fibers [20]. These injuries have
atic shoulders of overhead athletes, and they found that 40% been well studied in professional baseball pitchers with liter-
of dominant shoulders had MRI findings consistent with par- ature reporting compressive loads as high as 860 N across the
tial or full-thickness rotator cuff tears, while none of the non- glenohumeral joint and humeral angular velocities up to
dominant shoulders had any significant MRI findings. 8000�/s during the throwing motion; the rotator cuff muscles
Another study imaged asymptomatic elite adolescent tennis act to offset these extreme forces to keep the humeral head
players and found higher frequency of rotator cuff tendinosis stable and centered on the glenoid [21, 22]. During the tennis
on MRI of the dominant shoulder when compared with the serve, there is major stress across the posterosuperior rotator
non-dominant shoulder [11]. Rotator cuff injuries have also cuff tendons from eccentric contraction to decelerate the arm
been extensively studied in baseball pitchers. Lesniak and from its maximum angular velocity [23].
colleagues [12] imaged the dominant shoulder in professional
baseball pitchers who were completely asymptomatic and Competitive tennis players and overhead athletes frequent-
found that around half of the pitchers had partial or full- ly develop excessive shoulder external rotation that seems to
thickness rotator cuff tears. Moreover, the authors reported be an adaptation to the repetitive external rotation involved in
that pitchers with higher cumulative innings pitched had in- the late cocking phase of the throwing motion. This leads to a
creased likelihood of rotator cuff tears on MRI even though corresponding glenohumeral internal rotation deficit (GIRD)
they were asymptomatic. These findings suggest that rotator as repeated microtrauma to the posterior capsule during the
cuff injuries in overhead throwing athletes may be an adaptive deceleration phase of the throw leads to scar formation and
response in order to accommodate the extremes in range of subsequent posterior capsule contracture. As shoulder internal
motion required for success in the sport [13�]. rotation is essential in tennis especially for high velocity serv-
ing strokes and forehand ground strokes [24], GIRD alters the
Rotator cuff pathology is common in the general elderly shoulder kinematics increasing the risk of shoulder injuries in
population in the form of degenerative tears to the tennis players and overhead athletes [25, 26].
anterosuperior rotator cuff with increasing prevalence with
age [14]. Full-thickness tears are uncommon in the athlete During the late cocking phase of the serve, maximal exter-
under 35 years of age, but the rate increases in players older nal rotation and abduction of the shoulder cause abutment
than 50 years of age [15]. As tennis players age, the primary between the greater tuberosity of the humerus and the
posterosuperior glenoid labrum. This abutment increases the
contact pressure in the articular surface of the posterosuperior
rotator cuff leading to a characteristic bipolar injury to the
736 Curr Rev Musculoskelet Med (2020) 13:734�747
posterosuperior labrum and the articular aspect of the posterior serving, suggesting that heavy serving activity during tourna-
supraspinatus and anterior infraspinatus tendons (Fig. 1). ments acutely leads to abnormal scapular movement patterns
Walch and colleagues [27] dubbed this "internal impinge- that can play a role in long-term rotator cuff injuries. The
ment" and described arthroscopic findings of fraying of the authors recommend close monitoring of scapular upward ro-
posterosuperior labrum and partial-thickness tearing of the tation in tennis players returning to play after shoulder
undersurface of the rotator cuff. GIRD and internal impinge- injuries.
ment seem to be intimately associated with one another.
Burkhart and colleagues [20] proposed that the posterior cap- External or subacromial impingement as described by Neer
sular contracture may be the primary structural alteration for [30] is a common cause of rotator cuff disease in the older
the development of internal impingement. Repeated eccentric population as the cuff tendons impinge in the coracoacromial
contraction of the posterosuperior cuff leads to hypertrophy arch. Although less common in overhead athletes, external
and subsequent stiffness of the posterior structures limiting impingement can be a cause of rotator cuff disease, bursitis,
anterior translation of the humeral head in abduction and ex- and cuff dysfunction, as well as subscapularis tears due to
ternal rotation ultimately leading to internal impingement. repetitive impingement of the lesser tubercle against the cora-
coid during the follow-through phase of the forehand ground
Altered scapular mechanics also play a role in cuff injuries. stroke. Although several injury mechanisms exist, one mech-
In the late cocking and early acceleration phases of throwing anism alone may not be solely involved in the injury process
when the humerus is maximally abducted and externally ro- as several mechanisms act in a cascade of events overtime
tated, the scapula undergoes upward rotation to help maintain leading to rotator cuff injuries in overhead athletes.
glenohumeral articular congruency [28]. Imbalance or weak-
ness of the periscapular or posterior cuff muscles may disrupt Tennis Specific Considerations
the dynamic relationship of the scapula and is referred to as
scapular dyskinesia. Burkhart and colleagues [20] have de- The serve is the predominant stroke in tennis accounting for
scribed the SICK (scapular malposition, inferior medial bor- 45 to 60% of all strokes in a service game [31, 32]. As most
der prominence, coracoid pain and malposition, and tournaments are composed of 3-set matches and a player av-
dyskinesis of scapular movement) scapula syndrome which erages 120 serves and 210 ground strokes per match [33�], a
comprises a characteristic set of features and findings associ- high-level tennis player can accumulate around 5400 serves
ated with altered scapular kinematics in overhead athletes. during a competitive season (45 matches per year) without
Disruption of the scapulohumeral rhythm may also lead to accounting for ground strokes. In contrast, a Major League
external impingement of the cuff along the coracoacromial Baseball pitcher averages approximately 100 pitches per game
arch and result in rotator cuff injuries [19]. The ability to every 4 days and an overall count of 2655 pitches throughout
maintain scapular upward rotation during serving seems to the season.
be important to prevent chronic injury risk in tennis players.
Rich and colleagues [29�] demonstrated that fatigued tennis Tennis players must use the kinetic chain efficiently to
players had decreased scapular upward rotation during generate power shots. Forces generated at the feet, legs, knees,
and thighs travel through the core (abdomen and trunk) and
Fig. 1 With repetitive abduction and external rotation, the overhead are transmitted to the shoulder, elbow, wrist, hand, and ulti-
athlete can develop internal impingement leading to partial-thickness mately the racket [34]. The shoulder plays a crucial role in this
tearing of the posterosuperior rotator cuff and labrum kinetic chain by transmitting forces while producing a wide
range of motion. This is particularly evident in the serve,
which has been documented to be the most strenuous stroke
on the upper extremity. An explosive contraction of the inter-
nal rotator muscles with the shoulder in abduction and exter-
nal rotation produces an angular velocity of 2420�/s at the
acceleration phase of the serve [31]. Depending on the ath-
lete's strength, endurance, flexibility, and skill level, improper
technique or fatigue disrupts the kinetic chain leading to inef-
ficient energy transfer and overloading across subsequent
joints which can lead to injuries [24]. It has been shown that
inappropriate knee flexion during a serve significantly in-
creases the mechanical loads to the upper extremity [35].
Elite and experienced players seem to have more efficient
energy transfers in their kinetic chain compared with novice
or recreational players who tend to overload the shoulder and
Curr Rev Musculoskelet Med (2020) 13:734�747 737
elbow joints due to improper technique leading to higher in- extremity overuse injuries [32]. In terms of play surface, hard
jury risk [36, 37]. Energy transfer between segments (kinetic courts result in faster ball speeds, which theoretically subject
chain) is a critical concept related to sports injury. An energy the upper extremity to higher forces; however, there is no
flow study comparing injured and uninjured tennis players evidence showing higher injury rates due to a specific playing
showed that with higher quality of energy transfer from the surface [2, 42].
trunk to the hand and racket led to increased ball velocity and
decreased upper limb joint kinetics [38]. Injured players had a Clinical Evaluation
lower overall quality of energy flow through the upper ex-
tremity, lower ball velocity, and higher energy absorbed by History
the shoulder and elbow which likely predisposed them to
overuse injuries. Most overhead athletes and tennis players with rotator cuff
injuries present with progressive dull shoulder pain, early fa-
Three main serve types have been described including flat, tigue, and decreased performance [19]. Pain location is vague
top-spin or kick, and slice. The top-spin serve is commonly and can radiate laterally to the deltoid. Anterior shoulder pain
taught to junior tennis players or shorter athletes so that the may indicate concomitant labral tear, proximal biceps pathol-
ball clears the net while still landing in the service box; the ogy, or anterior instability, while posterior pain suggests pos-
top-spin serve is also commonly used as the second serve terior labral pathology or instability. The onset of symptoms,
because of its reliability. Motion analysis and biomechanical any history of shoulder instability, and other traumatic events
studies have shown that the top-spin serve results in the should be documented. Symptoms are commonly exacerbated
greatest force, while the slice serve had the lowest overall after overhead activities and especially after the serve.
forces and torques generated on the shoulder [39].
Therefore, the top-spin serve should be used judiciously in The overhead athlete may have specific complaints related
younger players due to the potential risk of shoulder injuries. to performance, like early fatigue, decreased strength, de-
This biomechanical data is also relevant to rehabilitation of creased throwing or serving velocity, decreased accuracy, or
shoulder injuries, injury prevention, and return-to-play proto- mechanical symptoms. Information about the athlete's train-
cols; players recovering from shoulder injuries or surgery ing regimen, compliance to rest days, and frequency of com-
should start with slice serves as they generate the least forces petition and practice sections is important to assess for over-
and progress top-spin or kick serve at later stages of use. Possible contributing factors include any recent changes
rehabilitation. in strokes or equipment that may suggest improper or less
ideal technique. Finally, the athlete should be screened for
As described earlier, GIRD and internal impingement are other sources of pain including the back, core, and lower ex-
intimately related and contribute to shoulder injuries and ro- tremities as restoring proper technique is the main focus in
tator cuff tears in tennis players [40]. A recent study demon- rehabilitation if a technical deficiency is identified [2, 35].
strated significant decrease in internal rotation of the dominant
shoulder in tennis players after 3 h of play [41�]. These acute Physical Exam
changes in shoulder range of motion influence the serve ki-
netic chain predisposing to shoulder injury during long Detailed physical examination of the shoulder is performed
matches. Tennis players should be encouraged to stretch after beginning with inspection, palpation, range of motion evalu-
matches and allow for adequate time to rest in between ation, strength assessment, and progressing to provocative
matches to restore baseline shoulder range of motion to avoid maneuvers. Inspection of bilateral scapulae from behind the
injury and maintain performance. Another study by Rich and patient with the entire torso exposed is paramount to detect
colleagues [29�] examined healthy tennis players without any differences in scapular motion between sides that may indicate
shoulder injuries and had them undergo a tennis serving pro- SICK scapula. Asymmetric position, protraction, or a deficit
tocol in order to induce fatigue. The study reported that scap- in upward rotation of the scapula with range of motion may
ular upward rotation was significantly diminished after fatigue indicate scapular dyskinesia. Selective atrophy of the
but returned to baseline within 1 day. Similarly, the authors supraspinatus and/or infraspinatus when compared with the
draw attention to the decreased range of motion and altered contralateral shoulder is a sign of suprascapular nerve com-
kinematics of the shoulder after prolonged tennis and caution pression, which can clinically present with weakness and pain
any athlete to return to competition within a day after heavy similar to a rotator cuff tear.
serving.
Palpation proceeds in a systematic fashion assessing for
Tennis rackets have transformed from heavy wooden tenderness of the sternoclavicular joint, acromioclavicular
models to larger yet lighter and stiffer graphite composite joint, proximal biceps tendons, and along the supraspinatus
models [2]. Modern rackets and strings allow for faster balls and infraspinatus fossa. Range of motion is compared with
and increased spin at the expense of higher torques transmitted
to the shoulder and elbow which may account for upper
738 Curr Rev Musculoskelet Med (2020) 13:734�747
the contralateral shoulder in forward elevation in the scapular assess rotator cuff integrity has the benefits of being low-cost,
plane, external and internal rotation with the arm at the side, easy patient tolerance, and dynamic evaluation of the tendons.
abduction, and external and internal rotation in abduction. However, ultrasound remains operator- and facility-dependent
GIRD can be evident in the dominant shoulder in tennis [48]. A meta-analysis on the effectiveness of ultrasound for the
players with increased external rotation in abduction and a diagnosis of rotator cuff injuries showed a sensitivity of 84% and
corresponding decrease in internal rotation. Although there specificity of 89% for partial-thickness tears and a sensitivity of
is increased external rotation and decreased internal rotation 96% and specificity of 93% for full-thickness tears [49].
in the dominant shoulder compared with the non-dominant
arm, the total arc of rotation of both shoulders should be The gold standard to diagnose rotator cuff tears is magnetic
equivalent [25]. Rotator cuff strength is assessed and com- resonance imaging (MRI). Advantages include the ability to
pared with the contralateral shoulder. Subtle differences may evaluate concomitant pathology including the biceps tendon,
not be detected as other more powerful muscles contribute to labrum, capsule and cartilage in addition to less operator-de-
shoulder motion and the cuff muscles are rarely testing in pendency, and high accuracy. A meta-analysis showed a
isolation. While rotator cuff tears in elderly patients may result pooled sensitivity and specificity of 80% and 95%, respective-
in significant objective weakness and lag signs, that is unusual ly, for diagnosing partial-thickness cuff tears on MRI with
in athletes and younger players even in the presence of full- higher sensitivity and specificity values (0.91 and 0.97) for
thickness rotator cuff tears because other powerful muscles full-thickness tears [50]. Higher-field strength MRIs and the
like the deltoid, pectoralis major, and latissimus dorsi com- availability of musculoskeletal radiologists led to improved
pensate for the rotator cuff deficiencies. accuracy. Differentiating between tendinosis and partial-
thickness tears can be difficult using conventional MRIs.
Provocative maneuvers then focus on different structures Enhanced diagnostic accuracy can be achieved for diagnosing
about the shoulder. Classic impingement (external or partial-thickness cuff tears and labral pathology with the use
subacromial impingement) is assessed with the Neer and of MR arthrography (MRA) (Fig. 2), placing the arm in the
Hawkins tests. Since concomitant pathology is common in throwing position in abduction and external rotation (ABER
overhead athletes, maneuvers to identify labral pathology view), and higher-field (3 T) strength magnets [51]. One study
and instability are always performed. Athletes with anterior- of arthroscopically confirmed partial-thickness cuff tears with
inferior instability will demonstrate apprehension with abduc- a horizontal component showed that only 21% of the lesions
tion and external rotation and have positive relocation and were detected on standard coronal oblique MRI images, while
anterior release signs. Superior labral pathology including 100% of the lesions were identified on ABER views [52].
SLAP tears can be assessed with the active compression and
posterior stress tests. Clinically diagnosing SLAP tears is dif-
ficult as there is no single test with optimal specificity. Despite
the availability of a specific exam maneuver, one study report-
ed that labral lesions were best identified by a combination of
the modified dynamic labral shear and active compression
maneuvers [43]. Posterior labral pathology is examined with
the Jerk and Kim tests. Closely associated proximal biceps
tendon pathology is assessed with the Speed and Yergason
maneuvers. With the emphasis on the detection of internal
impingement in overhead athletes, several examination ma-
neuvers have been developed including the modified reloca-
tion test and the internal rotation resistance test [44, 45].
Imaging
Accurate diagnosis requires correlating a thorough history and Fig. 2 MR arthrogram of the dominant right shoulder of a 20-year-old
physical exam with imaging findings. Plain radiographs are ob- male overhead athlete showing partial articular-sided tearing of the
tained in all patients and include an anteroposterior view of the supraspinatus. The tear appears to involve approximately 75% of the
scapula (Grashey), axillary, and scapular Y views. The morphol- tendon thickness with an intact bursal surface. This patient was treated
ogy of the acromion is assessed on the scapular Y view and with repair of the partial tear with an arthroscopic transtendon repair
classified as flat, curved, or hooked. Hooked acromions are more technique shown in Figs. 3, 4, and 5
often associated with rotator cuff tears [46, 47]. Other radio-
graphic findings that suggest rotator cuff tears include sclerosis
or cysts in the greater tuberosity [9]. Ultrasound imaging to
Curr Rev Musculoskelet Med (2020) 13:734�747 739
The clinician must use caution when interpreting MRI few case series of collegiate athletes show at least temporary
studies. As previously mentioned, several studies have found relief of symptoms with subacromial steroid injections for
abnormalities of the rotator cuff on imaging in completely rotator cuff pathology, but inconclusive results at mid- and
asymptomatic overhead athletes and tennis players [10�12]. long-term [64, 65]. The use of platelet-rich plasma (PRP)
Moreover, the timing of the MRI after injury or onset of symp- has gained popularity for the treatment of various orthopedic
toms is important to consider as there can be signal abnormal- conditions. Although there is no literature on the use of PRP
ities found in overhead athletes after competition, which can specifically in rotator cuff injuries in athletes, general popula-
take up to a week to normalize on imaging [53, 54]. tion studies show no difference in outcomes between patients
who received PRP and controls for the treatment of rotator
Management cuff tendinopathy [66, 67]. Furthermore, significant variabili-
ty in the PRP attainment methods across different systems
Treatment of rotator cuff injuries in tennis players depends on makes it challenging to draw definitive conclusions [68, 69].
several patient- and injury-specific factors including onset of
injury, thickness of the cuff tear, extent of impairment, pres- Treatment in the tennis player should evaluate the athlete's
ence of concomitant injuries, timing within the season or off- serve and stroke mechanics. As discussed previously, the en-
season (in an elite or professional athlete), and response to tire kinetic chain must be assessed, including lower limbs and
non-operative treatment. core because improper technique at any link of the chain may
disrupt the energy transfer downstream in the chain manifest-
Non-operative ing in upper extremity overuse injuries. Therefore, strength
training of the core, lower, and upper extremities as well as
First-line non-operative treatment of rotator cuff injuries in proper serve and stroke mechanics must be emphasized during
tennis players includes rest from the sport and overhead activ- the rehabilitation process to minimize recurrent or new site
ities, physical therapy, and a rehabilitation program. Duration injuries. Physical therapy begins with exercises focused on
of non-operative treatment varies on severity of symptoms, maximizing range of motion followed by strengthening of
pathology, and the individual athlete. Most treatment plans the rotator cuff and periscapular muscles. GIRD should be
involve at least 3 months as a reasonable period for a compre- addressed with sleeper stretches of the posterior capsule
hensive rehabilitation program [9, 54, 55]. Non-operative [20]. Scapular dyskinesia and SICK scapula require progres-
treatment should be exhausted prior to consideration of sur- sive stretching program and integrating scapular strengthening
gery for the elite tennis player as the results of surgical inter- exercises by having the athlete retract the scapula to its normal
vention are unpredictable in terms of resolution of symptoms anatomic position [19]. Once shoulder range of motion im-
and return to previous level of sport. proves and rotator cuff strengthening is enhanced, the last
phase of rehabilitation in non-operative treatment involves a
During the resting phase of treatment, NSAIDs may be gradual return to sport specific exercises and training. Wilk
used to decrease inflammation and pain to assist in the reha- and colleagues [70�] reported on an evidence-based compre-
bilitation phase. Selected athletes may also benefit from a hensive 4-phase rehabilitation program for non-operative
corticosteroid injection to decrease inflammation and facilitate treatment of shoulder issues including rotator cuff tears in
therapy especially if there are signs of subacromial impinge- the overhead athlete. Another review by Cools and colleagues
ment or bursal-sided tearing [13�]. Articular injection is an [71] outlines the rehabilitation guidelines for internal impinge-
option for articular-sided rotator cuff injuries. Corticosteroid ment specifically in the tennis player.
injections should be used sparingly in the young athlete due to
risks of tendon weakening and rupture [56, 57]. In a meta- Operative
analysis, Boudreault and colleagues [58] reported that oral
NSAIDs and corticosteroid injections may have similar When an athlete is unable to return to tennis despite extensive
short-term efficacy in terms of pain reduction and functional non-operative treatment, surgery can be pursued. It is impor-
improvement in the treatment of rotator cuff tendinopathy. tant, however, to have a frank discussion with the patient,
However, this study was not limited to athletes. Other studies trainers, and managers of elite athletes regarding the unpre-
have shown mixed results with regard to the efficacy of dictability of surgical outcomes in terms of return to sport at a
subacromial steroid injections for rotator cuff pathology in high level. Surgical approaches have evolved from open to
the general population with some studies demonstrating re- mini-open to arthroscopic with limited literature supporting
duction in pain and improved function, while others reported one approach over another, but arthroscopic surgery is most
no difference when compared with NSAIDs or placebo commonly preferred and performed in athletes [13, 55].
[59�63]. There is limited evidence-based literature on the Surgical treatment includes debridement alone, partial or
use of corticosteroid shoulder injections in elite athletes. A full-thickness rotator cuff repair, and treatment of concomitant
740 Curr Rev Musculoskelet Med (2020) 13:734�747
Fig. 3 Transtendon repair technique of the partial articular cuff tear in order to mark the tear from within the joint in order to evaluate its
shown on imaging in Fig. 2 of the patient's right shoulder. Patient is corresponding bursal surface from the subacromial space. (d) The
placed in the lateral decubitus position. (a) Intra-articular view from a arthroscope and shaver are introduced into the subacromial space to
standard posterior portal of the articular surface of the supraspinatus complete a bursectomy and evaluate the bursal side of the cuff. In this
shows partial-thickness tearing and fraying. (b) The undersurface of the case, the bursal side is intact; however, there is significant tearing of the
cuff is debrided with a motorized shaver to stable margins. (c) A spinal articular side estimated to be at least 75% of the tendon thickness, so the
needle can be placed percutaneously through the tear under visualization, decision was made to proceed with transtendon repair (BT, biceps tendon;
and a monofilament suture can be passed through the eyelet of the needle HH, humeral head)
pathology found at the time of arthroscopy (including labral or suggests significantly increased strain with partial articular cuff
SLAP repair, biceps tenodesis or tenotomy, or acromioplasty). tears exceeding 50% of the tendon thickness [72]. However,
there is no technique to accurately determine the thickness of
Ultimately, patient age, preoperative imaging, size and re- the tear, and one study has shown that there is poor interobserver
traction of the tear, tissue quality, and surgeon experience or reliability when estimating the extent of partial-thickness tears
preference play a role in determining the surgical plan. [73]. While the 50% threshold has historically been used for
Surgical treatment begins with debridement to assess tear tendon repair, more recent literature suggests repair only of more
depth and extent. Irregular unhealthy tendon edges and flaps advanced partial-thickness tears exceeding 75% in the young
are debrided. Partial-thickness articular-sided cuff tears are overhead athletic population [9, 55]. This is largely due to un-
debrided from within the joint to a stable margin. Using a predictable outcomes of cuff repair in the athlete and the risk of
spinal needle, a monofilament suture is percutaneously placed over-tensioning the cuff leading to a non-anatomic repair and
to mark the partial-thickness cuff injury. The suture is then possibly functional deficits in the sport.
identified in the subacromial space, and the bursal cuff integ-
rity is examined. Partial-thickness articular cuff tears can be repaired with a
transtendinous approach (Figs. 3, 4, and 5) or by completing
Options for management include debridement alone, the tear creating a full-thickness defect and then proceeding
bioinductive scaffold placement on the bursal cuff, with repair back to the footprint. This is controversial in tennis
transtendinous repair, or conversion to full-thickness tear and players due the concern of over-tensioning, loss of motion,
repair. Historically, recommendations in the general population and inability to return to tennis. The transtendon repair tech-
report that tears under 50% of the tendon thickness can be nique advances the articular fibers to the medial footprint
debrided alone, whereas tears involving more than 50% of the while maintaining the lateral fibers intact. It is essential to plan
tendon should be repaired. This "cutoff" has been propagated in the appropriate placement of the anchors in order to achieve an
the literature, and there is some biomechanical evidence that
Curr Rev Musculoskelet Med (2020) 13:734�747 741
Fig. 4 Transtendon repair technique of the partial articular cuff tear cannula. The monofilament shuttling suture is then retrieved from its
shown on imaging in Fig. 2 of the patient's right shoulder. (a) View percutaneous entry site (where it was placed through the spinal needle),
from a standard posterior portal. The medial footprint is debrided down therefore passing the blue braided suture through the tendon at the desired
to bone with a motorized shared just lateral to the humeral head articular location. (d) The second posterior suture anchor is then placed
surface. (b) Decision was made to place 2 medial anchors for this repair, percutaneously. The location of this posterior anchor was crucial in this
so the first anterior anchor is placed percutaneously, and then sutures are case as it was used to reduce the posterior cable tissue that was detached.
passed through the tendon. First, a suture limb is retrieved from the (e) Again, sutures from the second anchor are passed through the tendon
anterior cannula. Then a spinal needle is percutaneously placed through in the same manner as described. Once all sutures are passed through the
tendon in anticipation of where the suture must be passed. (c) A tendon, they are tied in the subacromial space. (f) The arthroscope is
monofilament blue suture which is to be used as a shuttling suture is introduced into the subacromial space and a lateral cannula is
passed through the eyelet of the spinal needle and is retrieved out the established. The corresponding suture limbs are tied together using a
anterior portal. The blue braided suture from the suture anchor is then knot pusher to reduce the tear (BT, biceps tendon; HH, humeral head)
looped around the shuttling suture outside the body from the anterior
anatomic repair; any detached rotator cable tissue should be tendon thickness is involved (over 75%), if the quality of the
restored back to the footprint as significant compromise of the intact lateral fibers are poor, or if there is substantial bursal-
cable tissue can alter glenohumeral kinematics [74�]. sided involvement. Full-thickness cuff tears can then be
repaired as they are in the general population using either
Partial articular-sided cuff tears are completed into full single- or double-row techniques. Double-row and
tears and repaired if it is determined that the majority of the
742 Curr Rev Musculoskelet Med (2020) 13:734�747
Fig. 5 Transtendon repair
technique of the partial articular
cuff tear shown on imaging in
Fig. 2 of the patient's right
shoulder. (a) Intra-articular view
from the posterior portal showing
the anterior aspect of the tendon
reduced to the medial footprint.
(b) Intra-articular view from the
anterior portal showing the
posterior aspect of the tendon
reduced. At this point, the
decision was made for placement
of a lateral row anchor
incorporating all the suture limbs
that were tied in order to provide
compression. (c) Subacromial
view showing placement of the
lateral row anchor incorporating
all the suture limbs that were tied.
(d) View from the lateral
subacromial portal showing the
final repair construct (BT, biceps
tendon; HH, humeral head)
transosseous equivalent repairs have been shown to have in- 51) of patients were able to return to tennis at an average of
creased strength, resistance to cyclic loading, and improved 10 months after surgery; the authors reported no difference in
footprint coverage [75, 76]. return to tennis between the repair or debridement cohorts.
Bigliani and colleagues [78] also retrospectively reviewed
Intralaminar tears can occur specifically in overhead ath- their series of rotator cuff repairs in tennis players. They
letes and are termed partial-thickness articular surface reviewed 23 tennis players with an average age of 58 years
intratendinous (PAINT) lesions. These tears can be repaired who underwent repair of cuff tears at an average 39-month
with side-to-side sutures without anchoring the repair back to follow-up. Overall, 22 of 23 patients returned to tennis with 19
the bony footprint in order to avoid excess tensioning of the returning to the same level, while 3 returned at a lower level.
cuff (Fig. 6) [13, 16, 77]. Over-tensioning the repair by pass- Only 1 patient was unable to return to tennis. While these 2
ing sutures to medial on the cuff in a suture anchor repair or studies demonstrated positive outcomes for return to tennis,
not recreating an anatomic footprint during repair can lead to more recent studies in younger athletes show more unpredict-
tightening of the shoulder which will compromise the kine- able results. A recent small case series of 8 professional female
matics of the tennis player and may lead to functional deficits tennis players who underwent shoulder surgery on their dom-
in the sport. inant arm (5 of which were due to rotator cuff injuries) report-
ed that 7 of 8 players were able to return to professional play;
Outcomes however, only 2 of 8 were able to return to the same level of
play and ranking postoperatively [79�].
A few studies investigate the outcomes of rotator cuff repair or
debridement in tennis players specifically. Sonnery-Cottet and Tibone and colleagues [80] also retrospectively reviewed
colleagues [15] retrospectively evaluated 51 tennis players their series of 45 athletes with an average age of 45 years (with
with partial or full-thickness tears. Thirty-two patients were the majority of patients having partial-thickness tears) and
recreational tennis players, while 19 were elite competitive found that only 56% of athletes were able to return to sport
tennis players. The authors reported that full-thickness tears at their pre-injury level. Of the athletes who required maximal
were more common in the older player, while partial- arm abduction and external rotation for their sport, only 41%
thickness tears were more common in the younger player. In (12 of 29) were able to return to play.
their cohort, 42 patients underwent cuff repair, while 9 pa-
tients had debridement alone. Seventy-eight percent (40 of A recent meta-analysis [81�] reviewed 25 studies with 859
patients and assessed return to sport after surgical treatment of
rotator cuff injury. The most common sport was baseball
Curr Rev Musculoskelet Med (2020) 13:734�747 743
followed by tennis. The authors found that the overall rate of majority (88%) of recreational athletes were able to return to
return to sport was 84.7% with 65.9% of patients returning to some sport activity after rotator cuff repair with a decreased
the same level of play. However, when isolating for profession- percentage (68%) returning to the same sport; but competitive
al or competitive athletes, only 49.9% of these athletes were athletes did so at a much lower rate [83]. Another study retro-
able to return to an equivalent level of play. Altintas and col- spectively reviewed 32 adolescent athletes (average age 16)
leagues [82�] showed in a systematic review of 15 studies (486 who underwent arthroscopic rotator cuff repair for mostly par-
patients) that 70.2% of athletes were able to return to pre-injury tial tears. The authors reported that the majority of overhead
level of play after arthroscopic rotator cuff repair. However, athletes (93%) were able to return to sport; however, more than
only 61.5% of elite/competitive athletes did so, and only 38% half (57%) were forced to play a different position in the sport
of overhead athletes returned to the same level of play. These [84�]. Several other studies have shown less than ideal out-
findings are supported by another study that showed the comes for overhead athletes treated operatively for rotator cuff
744 Curr Rev Musculoskelet Med (2020) 13:734�747
Fig. 6 The arthroscopic repair of a laminated rotator cuff tear referred to including rotator cuff tears. MRI remains the gold stan-
dard for imaging of rotator cuff pathology and other
as a PAINT (partial-thickness articular surface intratendinous tear) lesion concomitant injuries about the shoulder. Primary treat-
in a side-to-side fashion to repair the laminated portions without anchor- ment of rotator cuff tears is non-operative with a period
ing back to the footprint in order to avoid over-tensioning of the cuff and of rest followed by progressive rehabilitation. Proper
potential deficits in abduction and external rotation. Patient is a 22-year- technique is emphasized during the rehabilitation pro-
old right-hand-dominant male and high-level overhead athlete with right cess as well as strengthening of the overall kinetic chain
shoulder pain. MRA confirmed partial-thickness articular-sided cuff tear- including the trunk and lower extremities.
ing at the posterior supraspinatus and anterior infraspinatus junction along
with posterosuperior labral fraying. These findings were consistent with Adequate rest between tennis matches can help minimize
internal impingement in this elite overhead athlete. Patient was placed in injury as studies have shown alterations in shoulder range of
the lateral decubitus position, and diagnostic arthroscopic began from a motion and scapular kinematics after prolonged play that self-
standard posterior portal. (a) View from the posterior portal shows resolve with rest. Rotator cuff injuries in the tennis player are
posterosuperior labral fraying that was debrided. (b) The motorized shav- most commonly partial articular-sided tears. Full-thickness
er is placed in between the laminated flaps to stimulate healing. After tears occur in the older tennis player and are likely due to
debridement of the tear, the arthroscope is introduced into the degenerative changes. If non-operative treatment fails, surgi-
subacromial space to assess the bursal aspect of the cuff which was intact cal treatment can be pursued, but results are modest at best for
in this case. (c) A spinal needle is placed percutaneously to capture both return to sport to pre-injury level of play. Full-thickness tears
layers of the laminated tear. A monofilament suture (blue PDS suture in are treated as they are in the general population with repair
this case) is threaded through the eyelet of the spinal needle to serve as a back to the footprint with suture anchors; however, it must be
shuttling suture. (d) The shuttling suture is retrieved from the anterior recognized that full repair may be difficult for the tennis player
portal. Outside the anterior portal, a braided high tensile strength suture to return to pre-surgical form. Partial-thickness tears can be
is wrapped around the shuttling suture, and the shuttling suture is re- treated with debridement alone or with partial repair; the tear
trieved from its percutaneous entry site in order to pass the suture through can also be completed into a full-thickness tear and then sub-
the cuff tissue. (e) A spinal needle is then percutaneously introduced to sequently repaired to the footprint. In the general population,
pass the cuff posterior to suture that was already passed, and a shuttling partial-thickness articular-sided tears are generally repaired if
suture is again passed through the spinal needle and retrieved from the the tear involves more than half of the tendon thickness. A
anterior portal, and the suture limb from the anterior portal that was higher threshold exists for repair of cuff tears in younger high-
already passed through the cuff is shuttled through. (f) These steps create level athletes as several studies show less than ideal outcomes
a suture in horizontal mattress configuration as shown. This process is in terms of return to sport and return to the same level of play
repeated 3 times in order to create 3 horizontal mattress sutures to repair as compared with the older recreational tennis player. These
the laminated flaps. (g) After all sutures are passed, the arthroscope is decreased outcomes may be related to over-constraint of the
introduced into the subacromial space, and the corresponding suture athlete's shoulder after a cuff repair as several studies have
limbs are tied to each other through a lateral subacromial cannula. (h) shown imaging consistent with partial-thickness cuff tears in
Subacromial view of the final repair construct of the PAINT lesion with- asymptomatic overhead athletes suggesting that the "patholo-
out restoration to the footprint to avoid compromise of abduction and gy" may be an adaptive response to allow for extremes of
external rotation range of motion in abduction and external rotation. Finally,
newer technology including use of a bioinductive scaffold to
tears in terms of return to play to the same level. At the profes- enhance healing may be an option to consider in the future, but
sional level, full-thickness rotator cuff tears may be career- further research is necessary before it can be widely
ending injuries. Mazoue and Andrews [85] reviewed a cohort recommended.
of 16 professional baseball players who underwent repair for
full-thickness cuff tears and noted that only 1 pitcher and 1 Compliance with Ethical Standards
position player were able to return to professional play follow-
ing surgery on their dominant arm. Conflict of Interest Rami G. Alrabaa and Mario H. Lobao declare that
they have no conflict of interest.
In summary, there appears to be a distinction between the
older, recreational tennis player with a full-thickness rotator William N. Levine reports American Shoulder and Elbow Surgeons:
cuff tear and the younger, higher level player with a partial- Board or committee member. Journal of the American Academy of
thickness tear. The outcomes of surgical treatment in terms of Orthopedic Surgeons: Editorial or governing board. Zimmer: Unpaid
return to sport is favorable for the older recreational athlete, consultant.
while several studies in the sports literature show less than
ideal return to sport to the same level of play in the younger Human and Animal Rights and Informed Consent This article does not
more competitive athlete. contain any studies with human or animal subjects performed by any of
the authors.
Conclusions
Tennis players and other overhead athletes are
predisposed to overuse injuries of the shoulder,
Curr Rev Musculoskelet Med (2020) 13:734�747 745
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tional claims in published maps and institutional affiliations.