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Tóm tắt nội dung (trích từ tài liệu gốc): Author Manuscript HHS Public Access Author Manuscript Author manuscript Author Manuscript Hand Clin. Author manuscript; available in PMC 2018 February 01. Author Manuscript Published in final edited form as: Hand Clin. 2017 February ; 33(1): 175�186. doi:10.1016/j.hcl.2016.08.009. Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment, and Management Kevin C. Chung, MD, MS1 and Meghan E. Lark, BS2 1Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, Michigan 2Research Associate, Section of Plastic Sur
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Author Manuscript HHS Public Access
Author Manuscript Author manuscript
Author Manuscript Hand Clin. Author manuscript; available in PMC 2018 February 01.
Author Manuscript Published in final edited form as:
Hand Clin. 2017 February ; 33(1): 175�186. doi:10.1016/j.hcl.2016.08.009.
Upper Extremity Injuries in Tennis Players: Diagnosis,
Treatment, and Management
Kevin C. Chung, MD, MS1 and Meghan E. Lark, BS2
1Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of
Michigan Medical School, Ann Arbor, Michigan
2Research Associate, Section of Plastic Surgery, Department of Surgery, University of Michigan
Health System, Ann Arbor, Michigan
Synopsis
Upper extremity tennis injuries are most commonly characterized as overuse injuries to the wrist,
elbow and shoulder. The complex anatomy of these structures and their interaction with
biomechanical properties of tennis strokes contributes to the diagnostic challenges. A thorough
understanding of tennis kinetics, in combination with the current literature surrounding diagnostic
and treatment methods, will improve clinical decision-making.
Keywords
upper extremity; tennis; shoulder; treatment; wrist; elbow; treatment
INTRODUCTION
Tennis is one of the most popular sports in the world, owing to the unique combination of
aerobic and anaerobic activity that is enjoyable for all ages and skill levels. At the
competitive level, tennis is showcased through the dynamic exchange of intricate strokes and
serves by some of the world's most versatile athletes. However, the physical demands of this
sport are known to put athletes at risk for a variety of musculoskeletal injuries1. A recent
study of professional tennis competitions found that over 50% of men's and women's
departures from competition could be attributed to injury.2 Although specific injury
incidence varies by age, sex, and experience level, studies of the general tennis population
report that incidence can range from 0.05 � 2.9 injuries per player per year.1 This observed
high prevalence of injury has led many researchers to study how tennis mechanics contribute
to the profiles of various musculoskeletal injuries.
Corresponding Author: Kevin C. Chung, MD, MS, Section of Plastic Surgery, University of Michigan Health System, 2130
Taubman Center, SPC 5340, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5340, kecchung@umich.edu, Phone
734-936-5885, Fax 734-763-535.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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Disclosure: The authors do not have a conflict of interest to disclose.
Chung and Lark Page 2
Author Manuscript Descriptive epidemiological studies of tennis injuries have found that injuries occur most
frequently in the lower extremity, followed by the upper extremity, then trunk.1-3 Although
Author Manuscript the upper extremities are not the most prevalent injury site, a recent study investigating the
epidemiology of NCAA men's and women's tennis injuries suggested that tennis has a
higher proportion of upper extremity injuries than other NCAA sports3. Additionally,
distinct patterns of injury are observed among sites of occurrence. Lower extremity tennis
injuries are mostly acute and result from traumatic events, whereas upper extremity injuries
are mostly chronic and result from repetitive overuse. To better understand these findings,
risk factors for upper extremity overuse injuries have been widely presented in the literature
for the overhead throwing and striking athlete population. These studies proposed that the
excessive loading of upper extremity contributes significantly to soft tissue problems4,
revealing the important role that technique modification of joint biomechanics can have in
both injury prevention and treatment.
Physicians are confronted with a variety of challenges in the management of injuries
sustained in the upper extremity joints of the wrist, elbow, and shoulder. These challenges
are intensified in the overhead athlete, as the complex anatomical interactions of these joints
often produce a spectrum of pathology.5 This article aims to review concepts related to the
biomechanical origin, diagnosis, treatment, and prevention of common upper extremity
tennis injuries in an effort to guide clinical decision-making. With knowledge of tennis
biomechanics and their relation to injury, physicians can provide patients with informed
opinions and make treatment recommendations that fit the individual needs and expectations
of each athlete.
Author Manuscript BIOMECHANICS
Author Manuscript Similar to other racket sports, tennis is comprised of diverse strokes and serves, each
consisting of different biomechanical factors that could contribute to the spectrum of upper
extremity injury. The tennis serve is the most energy-demanding tennis motion, and has been
shown to comprise nearly 45-60% of all strokes performed in a tennis match.6 The serve is
characterized by five different phases of motion:
(1) wind-up,
(2) early cocking,
(3) late cocking,
(4) acceleration, and
(5) follow through.
Other stroke types include the forehand or backhand groundstroke, which each have three
different phases of motion:
(1) racket preparation,
(2) acceleration, and
(3) follow through.
Hand Clin. Author manuscript; available in PMC 2018 February 01.
Chung and Lark Page 3
Author Manuscript Specific and dynamic upper extremity positioning can account for large amounts of the
speed at impact and varies by stroke type.
Author Manuscript
When investigating the production of high-energy tennis strokes and their contribution to
tennis injury etiology, the kinetic chain concept of motion cannot be ignored. The kinetic
chain describes the route and direction of energy flow in tennis strokes and serves. In this
process, musculoskeletal joints such as the knee, shoulder, and elbow serve as links in the
kinetic chain by absorbing, generating, and transmitting energy to the next link, completing
a cycle of energy from the ground to the tennis ball at impact with the racket. In a single
tennis match, this cycle is repeated numerous times and relies heavily on an athlete's
strength, endurance, flexibility, and technique.6,7 If energy transfer in one joint is not
efficiently coordinated, subsequent joints can easily become overloaded. For example, a
biomechanical study of the tennis serve found that the mechanical loads transmitted to the
shoulder and elbow increased by 17% and 23% in the absence of proper knee flexion when
attempting to produce a velocity similar to that of a serve performed with correct knee
flexion.8,9 Additionally, a tennis player's ability to use the kinetic chain is often dependent
upon experience level. Several studies have found that advanced players are more efficient at
manipulating the kinetic chain to reduce the impact forces transmitted to upper extremity
joints. In turn, novice or recreational tennis players often use excessive and uncoordinated
strength in the absence of efficient technique, which does not translate into increased ball
velocity and rather overload the joint and increases risk of injury.10,11These results imply
that optimal technique can contribute immensely to maximizing injury prevention and
minimizing loads placed on each joint.
Author Manuscript WRIST INJURIES
Author Manuscript In tennis, wrist injuries are most commonly experienced as ulnar pathology related to the
extensor carpi ulnaris (ECU) tendon and occur during forehand groundstrokes. The forehand
stroke is the most frequently utilized groundstroke in tennis and is performed with the
dominant forearm in full supination and the wrist flexed in ulnar deviation.6 Wrist flexion
and extension are important components of ball velocity after ball-racket impact. For
example, a study by Seeley et al. determined that increasing tennis ball velocity from
medium to fast during the forehand stroke required 31% greater angular velocity of the wrist
joint at impact.12 Therefore, dynamic repetition of this stroke depends largely on the
integrity of the ECU and its ability to contribute to wrist flexion and extension.
Injury risk to both the ECU tendon and its fibro-osseous sheath increases when the tendon is
overloaded by strong forces transmitted to the wrist at impact. A major component of the
forehand stroke that is associated with wrist extensor and flexor overload is the generation of
top-spin, which can be accomplished through using specific racket grip techniques. The
contribution of grip techniques to wrist injury was studied by Tagliafico et al. in 370
nonprofessional tennis players.13 These authors found that utilization of Western and semi-
Western grip types, which are most effective in generating top-spin rotation in the forehand
stroke, were associated with ulnar-sided wrist injuries that almost exclusively pertained to
ECU tendinopathy. Additionally, the non-dominant wrist in the two-handed backhand stroke
can be subjected to the same harmful forces as that of the forehand stroke. This observation
Hand Clin. Author manuscript; available in PMC 2018 February 01.
Chung and Lark Page 4
Author Manuscript is most likely attributed to the extensive ulnar deviation experienced by the non-dominant
wrist at stroke impact.14 These studies indicate that athletes utilizing the Western or semi-
Author Manuscript Western grip types of the forehand stroke, as well as those utilizing the two-handed
backhand stroke are at higher risk of experiencing ulnar wrist symptoms and can benefit
from prevention exercises aimed at strengthening the wrist extensor and flexor units of both
arms.
Although less prevalent than ECU tendinitis, tennis players can also experience acute ECU
injury as a result of traumatic subsheath rupture or attenuation. Disruption of the ECU
subsheath leads to a loss of tendon stabilization and can result in painful subluxation or
snapping of the ECU tendon over the ulnar groove.15 Specifically, acute ECU subluxation is
connected with performance of the low forehand stroke. In this stroke, sudden hyper-
supination of the forearm occurs with the wrist in flexion and ulnar deviation, generating a
traumatic force capable of disrupting subsheath integrity. The physicians treating tennis
players with ECU pathology should distinguish between these chronic and acute injuries to
make informed treatment decisions.
Author Manuscript Diagnosis
Author Manuscript In many cases of ECU subluxation, the patient may report painful snapping over the ulnar
styloid of the wrist that limits athletic participation. A detailed physical examination starts
with discussion of both mechanism of injury and symptom history. Next, physicians should
careful palpate the dorsoulnar wrist, specifically assessing the scapholunate, triquetrolunate,
distal radio-ulna, and ulnocarpal joints. Additionally, the hook of the hamate, flexor, and
extensor tendons are examined and the Finkelstein test for DeQuervain tenosynovitis is
performed. Plain radiographs in three views should be ordered to rule out osseous
pathologies such as fractures or distal radio-ulna joint (DRUJ) arthritis.
Although various physical tests for ECU pathology exist, the intricate structures of the wrist
are often difficult to isolate. For this reason, results of clinical maneuvers can often be
elusive and contradictory, further complicating the diagnostic process. Recently, in an effort
to better distinguish ECU tendinitis from ECU subluxation, Ruland and Hogan16 developed
the ECU Synergy Test. This key provocative maneuver relies on synergistic muscle activity
to achieve isometric contraction of the ECU tendon and discern between intra-and extra-
articular ECU pathology (Table 1). This test has proven useful in clinical settings and should
be used prior to imaging studies. In the case of an ambiguous diagnosis or recurrent
symptoms, MRI and dynamic ultrasound studies can supplement physical examination. MRI
can be useful for visualization of ECU tendinitis or confirmation of other soft tissue
abnormalities such as scapholunate ligament or TFCC tears.17 Dynamic ultrasound is an
effective method for identification of ECU subluxation.18-20 These differing findings
highlight the clinical importance of performing the ECU Synergy Test prior to selecting an
imaging modality, in an effort to gain information about injury type and minimize the
unnecessary use of imaging studies.
Hand Clin. Author manuscript; available in PMC 2018 February 01.
Chung and Lark Page 5
Treatment
Author Manuscript ECU tendonitis is treated with nonoperative methods such as rest, NSAIDs, splinting, and
technique modification. If symptoms are persistent, corticosteroid injections into the ECU
Author Manuscript sheath may be useful. For the treatment of ECU subluxation, cast immobilization with the
wrist pronated and extended for 6 weeks can be considered prior to operative treatment.15 If
symptoms persist after conservative treatment, surgical reconstruction of the fibro-osseous
tunnel of the sixth extensor compartment is recommended. Typically, this reconstruction can
be performed by wrapping a strip of the extensor retinaculum around the ECU and suturing
the tendon in place. A recent study by MacLennan et al.18 investigating outcomes of ECU
tendon sheath reconstruction in 21 patients diagnosed with ECU subluxation observed a
significant improvement in postoperative grip strength, flexion-extension, pronation-
supination, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores at long term
follow-up. Another study that evaluated surgical outcome in a sample consisting of 10
professional athletes (7 tennis players) found that the athletes were able to return to previous
levels of play after an average of 8 months (range 3-21).21 These study results indicated that
excellent surgical outcomes facilitating a return to previous level of play are achievable in
both operative and nonoperative treatments for ECU wrist pathology.
Author Manuscript ELBOW INJURIES
Author Manuscript Elbow pathology in tennis players frequently differs by level of play. Less experienced or
recreational tennis players typically experience elbow injury as a result of incorrect
technique or equipment, whereas professional tennis players may injure the elbow as a result
of more subtle incorrect technique. With this, physicians can tailor medical treatment and
recommendations to fit the tennis player's experience level for both the treatment and
prevention of elbow injury.
Lateral epicondylitis
One of the most prevalent tennis injuries presenting to general and specialty clinicians is
lateral epicondylosis, commonly termed "tennis elbow". Epidemiological studies estimated
that up to 50% of tennis players will develop lateral elbow symptoms throughout their tennis
career, with a primary population consisting of recreational tennis players.22,23 Consensus
on cause of lateral epicondylitis does not exist; however, many different etiologies have been
proposed. In addition to anatomical predisposition of the extensor carpi radialis brevis
(ECRB) tendon to irritation, overloading of wrist extensors during the backhand tennis
stroke is thought to be a key contributor to the prevalence of the condition.24-26 Despite
lower utilization compared to forehand strokes and serves, the backhand stroke is important
skill for tennis players. It can be performed using a one-hand or two-handed approach;
however the one-handed approach is more commonly associated with elbow pathology. This
stroke is accomplished with the elbow extended and the wrist supinated, applying stress to
the forearm extensor unit and transmitting particularly large forces to the ECRB at the lateral
epicondyle. Numerous studies have identified both intrinsic technical skill factors and
extrinsic equipment variations that contribute to the high prevalence of this condition in the
recreational tennis player.
Hand Clin. Author manuscript; available in PMC 2018 February 01.
Chung and Lark Page 6
Author Manuscript Differences in the backhand technique of experienced and recreational tennis players can be
observed in kinematic studies of forearm muscle coordination during backhand stroke
Author Manuscript production. Grip tightness is a key feature of a powerful backhand stroke; however it must
be coordinated appropriately with phases of the backhand serve to prevent injury to the
Author Manuscript elbow. For example, a kinematic study of the backstroke performed by Wei et al.10 found
that experienced tennis players employ a tight grip at ball-racket impact, then immediately
decrease their grip tightness in the follow-through phase. This study found that use of this
quick-release grip reduced 89.2% of the impact force transmitted to the lateral epicondyle
region of the elbow. However, when grip force was quantified in recreational players, these
researchers found that the tight grip was incorrectly retained throughout both ball impact and
follow-through phase, resulting in reduction of only 61.8% of impact force transmitted to the
elbow. Electromyography studies of the same test groups revealed similar results when
forearm muscle activity was quantified, finding that the wrist extensors of recreational
players exceeded maximal contraction levels at both ball impact and follow-through phase,
whereas those of experienced players reached maximal activity at ball impact and were sub-
maximal in the follow-through phase. From this, physicians and rehabilitation specialists
should communicate the importance of decreasing grip strength and relaxing forearm
muscles in the follow-through phase of the backhand stroke. These modifications have
serious implications for lateral epicondylitis prevention in recreational tennis players.
Overloading of the elbow joint can also occur as a result of equipment-dependent factors,
such as racket size or quality. Incorrect grip size of the racket handle has recently been
associated with increased force transmission to the elbow. A study by Rossi et al. quantified
the forces acting on the dominant tennis arm with varying racket handle grip sizes, finding
that grip size significantly influenced the impact forces transmitted to the forearm extensor
muscles, particularly when the grip was too small or large.27 These researchers observed that
when racket handles were not the appropriate size for a tennis player's hand, the players
increased grip force on the racket, which in turn increased harmful force transmission to the
elbow. This study highlights the benefits of properly fitting equipment, of which less
experienced tennis players may not be familiar with.
Author Manuscript Diagnosis--Patients with lateral epicondylitis typically present with pain and tenderness
over the lateral epicondyle, which may radiate distal to the forearm throughout the extensor
muscle area. Patients usually experience discomfort with passive flexion and resisted wrist
extension, as well as pain with grasping objects firmly. A variety of physical tests can be
performed to aid diagnosis, including the Cozen test, Mill's test, and Maudsley test (Table
1). The differential diagnosis includes radial tunnel syndrome and posterior interosseous
nerve entrapment. In cases where the diagnosis is unclear, MR imaging can be used to
confirm and plan treatment; however, clinical tests and physical examination are typically
sufficient for diagnosis28.
Treatment--There is no standard protocol for treatment of lateral epicondylitis.
Nonoperative therapy is recommended before operative intervention. In the majority of
cases, symptoms will resolve without treatment within 6 to 12 months. In the tennis athlete,
the wait-and-see approach is not always a realistic option, as athletes often need to return to
Hand Clin. Author manuscript; available in PMC 2018 February 01.
Chung and Lark Page 7
Author Manuscript play quickly. When conservative treatment is selected by the patient and physician,
nonsteroidal anti-inflammatory drugs (NSAIDS) are typically the first approach and are
Author Manuscript often recommended with splinting, stretching, and strengthening exercises. Additionally,
physiotherapy that combines elbow manipulation and strengthening exercises targeting the
extensor muscles of the forearm have proven to provide short term symptom relief.29 If
symptoms do not improve with NSAIDS or therapy, corticosteroid or platelet-rich plasma
injections may be considered, although there is a lack of evidence supporting the use of
injections over other nonoperative treatments. A recent randomized control trial conducted
by Coombes et al.30 compared 1-year postoperative outcome measures of three groups of
lateral epicondylitis patients: those receiving physiotherapy with corticosteroid injection,
those receiving physiotherapy only, and those receiving injection only. These researchers did
not observe a clear benefit when comparing these groups to control lateral epicondylitis
patients, and in turn found that corticosteroid treatment resulted in less improvement and
greater 1-year recurrence. Similar studies of conservative treatments have failed to find long
term benefits.29,31-35
In the case of nonoperative treatment failure surgical release of the ECRB at the lateral
epicondyle can be performed with an arthroscopic or open approach provides safe and
effective relief of symptoms with minimal complications36-38. Recent literature has focused
on exploring outcomes of arthroscopic release and has contributed to the growing support of
arthroscopy as a viable method of ECRB release for recalcitrant cases39-42. Studies of
functional recovery after surgical ECRB release indicated that patients can typically return
to play within 3-6 months after surgery 43.
Author Manuscript Medial Epicondylitis
Medial epicondylitis involves tedinopathy of the pronator teres and flexor carpi radialis
muscles in the attachment of the flexor-pronator tendon to the medial epicondyle. This
condition is found in 10-20% of epicondylitis cases and is believed to be a result of
repetitive eccentric loading of the flexor and pronator muscles of the forearm.44 Contrary to
the incidence of lateral epicondylitis, medial epicondylitis is most common among higher-
level tennis players, and can result from advanced technical deficits, such as open-stance
hitting, short-arming strokes, and excessive wrist snapping during serves and forehand
strokes9.
Author Manuscript Diagnosis--Medial epicondylitis patients present with persistent pain and tenderness over
the medial epicondyle, which may radiate distal to the forearm throughout the flexor-
pronator muscle area. Specifically, patients experience pain during the early acceleration
phase of serves and forehand strokes, in which the forearm is pronated with wrist flexion. In
this position, the elbow joint is in valgus stress and the flexor-pronator muscles are
maximally contributing to elbow stabilization.
Physical examination reveals tenderness with resisted wrist flexion and forearm protonation.
Possible differential diagnoses include medial collateral ligament tear, ulnar neuropathy, and
medial elbow instability. Similar to lateral epicondylitis, a medial epicondylitis diagnosis is
usually achieved clinically through physical examination and MR imaging is useful in
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Chung and Lark Page 8
Author Manuscript diagnosis confirmation in cases of ambiguity45. A recent retrospective review of surgical
medial epicondylitis patients conducted by Vinod and Ross emphasized the utility of
clinically evaluating pronator strength to quantify weakness of the forearm and clinically
track pathological changes in flexor pronator tendon injury46. This aspect is useful in
monitoring the clinical course and making treatment decisions for recalcitrant medial
epicondylitis in the tennis player.
Author Manuscript Treatment--Non-operative approaches to treatment such as NSAIDs, strength and
flexibility programs, and rest are utilized prior to operative treatment. Steroid injections may
provide short term symptom relief, yet fail to display significant long term benefits when
compared with control patients47. Conservative treatment is typically effective in symptom
alleviation in 88-96% of cases48. If symptoms persist after 3-6 months of conservative
treatment, operative intervention is considered. Surgical methods can be implemented earlier
in athletes with MR imaging indicating tendon disruption. Open methods of surgical
debridement of the common flexor tendon have continually demonstrated successful in
symptom alleviation.49 Additionally, recent investigations have suggested that suture anchor
fixation of the flexor-pronator mass can also be a method of symptom relief.50 Contrary to
lateral epicondylitis, an arthroscopic approach is typically not recommended in surgical
management of medial epicondylitis, owing to the close proximity of both the ulnar
collateral ligament and the ulnar nerve to the medial epicondyle. Postoperative rehabilitation
is centered on the strengthening and stretching of the flexor-pronator muscles and athletes
can return to play in 3-6 months as tolerated50.
Author Manuscript SHOULDER INJURIES
Author Manuscript The shoulder joint is the most mobile joint in the body and balances both stabilization and
rotational range of motion. In tennis players, this delicate equilibrium is manipulated to
create powerful serves and groundstrokes through external rotation and abduction of the
shoulder. Overuse injuries to the shoulder are prevalent among tennis players of all skill
levels and have been shown to contribute to nearly 4-17% of all tennis injuries3,51. In a
recent study investigating the causes of professional tennis player departures from
competition, Kryger et al. found that shoulder injuries were the second most frequent cause
of departure for both sexes.2 For these reasons, it is not only important that clinicians are
familiar with the intricate pathology, diagnosis, and treatment of athletic shoulder injuries,
but also aware of the mechanical origin of these injuries and how they relate to tennis-
specific movements.
Risk Factors
The scapula plays a key role in stabilizing glenohumeral joint mobility during arm motion
by frequently changing positions to promote shoulder movements. In the tennis serve, the
scapula follows distinct patterns of motion, characterized by retraction/protraction as the
serve progresses from early to late cocking stage and upward rotation during the acceleration
phase52. These fine movements are orchestrated by surrounding rotator cuff muscles that
attach to the scapula and other surrounding capsular structures. If shoulder structures
become weak or dysfunctional as a result of chronic overload, tennis players may develop
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Chung and Lark Page 9
Author Manuscript scapular dyskinesis. This condition is characterized by an imbalance of the scapula, leading
to alterations in scapular movement, which produces pain and functional deficiency during
Author Manuscript overhead serving motions. In some cases, the affected scapula may demonstrate a drooping
appearance or inferior medial border prominence at rest when compared with the unaffected
Author Manuscript shoulder, a condition commonly referred to as SICK (Scapular malposition, Inferior medial
border prominence, Coracoid pain, and dysKinesis of scapular movement) scapula. 53 In the
Author Manuscript majority of tennis athletes, the presence of scapular dyskinesis or SICK scapula has been
found to be associated with shoulder injuries,53-57 though the exact interactions of these
conditions with shoulder injuries are largely undefined.58 The scapula's role in optimal
shoulder performance indicates that an assessment of scapular function is crucial in both
pre-participation athletic evaluations and evaluation of tennis athletes presenting with
shoulder pain or dysfunction. Once identified, scapular abnormalities can be corrected with
rehabilitative stretching programs that successfully target the restoration of muscular and
capsular strength and flexibility in the shoulder.59,60
In tennis, internal rotation of the shoulder is considered one of the most important positive
contributors to ball velocity, especially during the serve8. However, repetition of the
abduction-extension motion of tennis serves and other overhead strokes can alter the
rotational arc of the shoulder, producing an increased degree of external rotation at the
expense of posterior capsule tightening. Although increased external rotation produces a
more powerful serve, posterior tightening decreases the degree to which the athlete's
shoulder can internally rotate and can eventually lead to the development of glenohumeral
internal-rotation deficit (GIRD). GIRD is quantitatively characterized by a >18� loss of
internal rotation in the athlete's dominant shoulder compared with the non-dominant
shoulder, as measured during clinical evaluation.61 The presence of this deficit changes the
glenohumeral kinematics of the tennis serve and has also been found to be associated with
higher risks of shoulder injury.62,63 Athletes with GIRD typically present with deep
posterior shoulder pain that is accompanied with a decrease in degrees of internal rotation
and increase in external rotation, as compared to the non-dominant arm and measured by a
goniometer. The progression of GIRD can be reversed by stretching programs that target the
posteroinferior capsule, which have proven to successfully increase internal and total
rotation and reduce GIRD in high-level tennis players.5,64
Internal impingement is another condition that is related to shoulder injury development. It
is defined as the abnormal mechanical impingement of rotator cuff tendons against the
superior glenoid rim and labrum. Internal impingement occurs in healthy shoulders of
athlete65; however it can be injured from increased posterior capsule compression. Continual
compressive forces in the posterior shoulder capsule can cause a shift of the glenohumeral
joint axis.5 Similar to GIRD and scapular dyskinesis, these compressive loads are
experienced during exaggerated external rotation in the late cocking stage of the tennis serve
and patients will present with posterosuperior pain and dysfunction. Posterior internal
impingement has been shown to occur alongside both GIRD and scapular dyskinesis, and
may become increasingly pathologic when associated with these risk factors.55,66
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Author Manuscript Labral Injury
The labrum is a common site of injury for overhead athletes, as it is a key contributor to
optimizing capsular tension in the shoulder. Labral pathology in athletes has been studied
extensively in literature and is often associated with both GIRD and scapular dyskinesis
conditions.55,57,62,67 Superior labral anterior-to-posterior (SLAP) lesions are the most
common labral injuries experienced by athletes. They are characterized by fraying or tearing
of the superior labrum at the site of biceps tendon attachment, disrupting the underlying
interaction with the glenoid. Although different classifications of severity exist, the most
common SLAP lesion involves the detachment of both the superior labrum and the biceps
tendon from the glenoid.68 Biomechanical studies investigating athletic labral injuries have
indicated that the mechanics of the late cocking stage of overhead throws and serves plays
the largest role in the etiology of SLAP lesions69,70.
Author Manuscript Diagnosis--The diagnosis of the SLAP lesion is notoriously difficult for physicians and
requires detailed knowledge of shoulder pathology and careful clinical examination.
Athletes with SLAP lesions will present with deep pain that is accompanied by shoulder
weakness or dysfunction experienced during the external rotation of the cocking stage of the
overhead motion. Some athletes may also report the experience of a popping sensation67.
There are many clinical tests to aid in the diagnosis of a SLAP lesion; however a single test
with optimal specificity does not exist.61 Despite these diagnostic limitations, recent
explorations have indicated that a combination of the modified dynamic labral shear test and
O'Brien active compression test yields the most accurate diagnosis (Table 1).71 MR imaging
has also proven to be a useful modality to rule out the diagnosis of a SLAP lesion, but is not
an accurate clinical diagnostic tool when utilized alone.72
Author Manuscript Treatment--Similar to other chronic soft tissue injuries, nonoperative treatment is utilized
prior to consideration of surgical repair for SLAP lesions. Conservative treatment typically
Author Manuscript encompasses the use of NSAIDs with the same specialized physical therapy programs that
strengthen, stabilize, and increase flexibility of scapular and posterior capsule structures.
Surgical treatment of SLAP lesions is usually deployed if symptoms are not relieved after
4-6 months. Depending on the severity of the SLAP lesion, patients may benefit from either
arthroscopic debridement or repair. However, arthroscopic repair is the standard treatment
for SLAP lesions, especially those that involve the detachment of both the posterior labrum
and the biceps tendon from the glenoid. The arthroscopic approach typically involves
placing multiple suture anchors on the glenoid to secure the attachment of the labrum. A
recent prospective study evaluating this technique found that 87% of patients reported a
good or excellent outcome at a two year follow-up.73 Similar studies on pain and functional
outcome improvement in overhead athlete populations have also supported these
findings.74,75 Alternatively, recent literature has described the utility of biceps tenodesis in
the surgical treatment of SLAP lesions, but outcomes studies have indicated that this
procedure is most effective for an older, nonathletic population.76 The results of these
evaluations indicate that the athletic status of a patient may have a large role in guiding the
treatment decisions being made for SLAP lesions.
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Author Manuscript It is undisputed that athletic activity contributes heavily to the etiology of labral injury in
tennis players. It is also a significant factor in evaluating postoperative outcome, as an
athlete's perception of treatment success is largely based on the ability to return to play.
Functional outcomes and return to play period of both nonoperative and operative SLAP
lesion treatments continue to be a source of controversy in athletic literature. Studies of
overhead athletes have reported inconsistent results regarding return to previous level of
play, reporting successful return in anywhere from 20-94%61,77,78 of overhead athlete
patients. Additionally, literature suggested that the likelihood of overhead athletes returning
to previous levels of play is significantly lower than that of non-throwing athletes.79 These
studies have strong implications for clinicians, in that they suggest postoperative return to
play cannot be guaranteed in the overhead athlete. This observation highlights the necessity
for sufficient physician communication with tennis players about realistic treatment
outcomes that may not satisfy the patient's athletic expectations.
Author Manuscript Rotator Cuff Injury
Rotator cuff injury is frequent in the general population, with a degenerative etiology seen
mostly in older patients. However, these injuries are also prevalent in younger populations of
overhead throwing athletes, occurring as a result of repetitive, high-energy loading of the
shoulder joint. In energetic overhead motions, the muscles and tendons comprising the
rotator cuff are the most important components of dynamic shoulder stabilization. In
athletes, rotator cuff tendinopathy is most often associated with posterior internal
impingement, which can cause fraying or tearing of the rotator cuff tendons with repetition.
Additionally, scapular dyskinesis has been shown to contribute to rotator cuff pathology, as
the rotator cuff muscles synchronicity is disrupted by abnormal scapular range of motion.
Author Manuscript Diagnosis--Patients with rotator cuff injury typically present with pain experienced during
throwing and dysfunction that inhibits peak performance of tennis serves and other overhead
motions, similar to other soft tissue shoulder pathology. If the injury is the result of posterior
internal impingement, the supraspinatus and infraspinatus tendons will be most affected, and
pain will be experienced in the late cocking phase of the tennis serve. Diagnosis can be
achieved during a careful clinical exam that assesses rotator cuff muscle strength, range of
motion, and posterior instability supplemented with imaging studies. In many cases, tests
that evaluate impingement, such as the Neer or Hawkin's test, can be useful for diagnosis
(Table 1). MRI has proven to be a successful supplement to clinical examination and can aid
in rotator cuff tear identification, although ultrasound has also proven to be an effective
diagnostic tool when utilized correctly.
Author Manuscript Treatment--As a mainstay of chronic soft tissue injury, conservative treatment of rest,
NSAIDs, and physical therapy programs focusing on strengthening and stretching of the
rotator cuff muscles are utilized prior to the consideration of surgery. Minor injuries to the
rotator cuff usually respond well to treatment, and often permit return to athletic overhead
activity within approximately 3 months.80 If nonsurgical treatment fails after 3-6 months,
operative treatment is considered via arthroscopy or open methods. Surgical treatment
methods depend on the thickness and location of the muscle tear, as surgical approach is
typically altered to fit individual patient needs. Surgery can be accomplished through open
Hand Clin. Author manuscript; available in PMC 2018 February 01.
Chung and Lark Page 12
Author Manuscript or arthroscopic methods, offering either debridement or repair to improve symptoms. For
partial thickness tears, repair is recommended if the tear comprises greater than 50% of the
Author Manuscript tendon, whereas debridement is recommended in cases below 50%. For full-thickness tears,
a suture anchor approach has increasingly emerged as viable option for firm restoration of
rotator cuff tendons to the proper anatomical position. These strengths were demonstrated in
a cadaver study conducted by Burkhart et al. that tested the cyclic loading capabilities of
suture anchor fixation compared to transosseous bone tunnel fixation .81 The long term
outcomes of rotator cuff debridement and repair in the overhead athlete are not well defined
in the literature. However, the few studies that have investigated outcomes in this population
reported that satisfactory result of debridement is achieved in anywhere from 66-76 % of
athletes, with roughly 45-85% being able to return to play. 82-84 Whereas debridement
results are somewhat promising, outcomes of surgical partial- and full-thickness repair are
increasingly dismal, with some studies observing an inability to return to play in more than
half of patients. 84,85 These suboptimal results suggest that physicians should approach
surgical repair of rotator cuff tears with caution when considering overhead athletes. Similar
to outcomes of SLAP repair, it is imperative that physicians discuss the realities of surgical
intervention in shoulder pathology and prepare athletes for potential inability to return to
previous levels of play.
Author Manuscript SUMMARY
Tennis is a complex and physically demanding sport that can produce a wide range of
similarly complex injuries. Upper extremity injuries occur from repetitive overloading of
joints, and diagnosis is frequently challenging for physicians, owing to the complex
interaction between soft tissue anatomy and biomechanics of the kinetic chain. Diagnosis
and treatment of common tennis injuries vary by the location of the injury and can depend
on the mechanism of injury, experience level of the athlete, and the presence of physical risk
factors that are affected by muscular strength, flexibility, and coordination. Operative
management is considered after trying conservative treatment, yet should be approached
with caution, in that favorable outcomes may not be realistic and a return to previous level of
play may not be achievable.
Author Manuscript Acknowledgments
Research reported in this publication was supported by a Midcareer Investigator Award in Patient-Oriented
Research (2K24 AR053120-06) to Dr. Kevin C. Chung. The content is solely the responsibility of the authors and
does not necessarily represent the official views of the National Institutes of Health.
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Author Manuscript Chung and Lark Page 17
� Key Points
� Common upper extremity tennis injuries involve soft tissue and are
� usually a result of overuse.
� Tennis injuries have a complex association with biomechanical
properties of tennis strokes and serves.
Injury profile of tennis injuries vary by injury site, mechanism of
injury, athlete experience level, and presence of known risk factors.
Diagnosis can be a challenge and depends on a thorough understanding
of current research topics.
Author Manuscript
Author Manuscript
Author Manuscript
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Chung and Lark Page 18
Author Manuscript Table 1
A summary of physical tests useful for the diagnosis of common upper extremity tennis conditions
Condition Physical Description Positive Result
Test
� Patient rests arm on table with elbow flexed at 90
degrees
Extensor Carpi Ulnaris ECU � Pain experienced
(ECU) Synergy Test � With forearm in full supination, examiner palpates along the dorsal ulnar
the ECU tendon.
Tendinitis/Subluxation wrist
Ensuring that wrist is neutral, use other hand to
grasp patient's long finger and resist patient's
radial abduction of the thumb
� Patient elbow is stabilized by palpation of
examiner's thumb over lateral epicondyle
Cozen test � Pain experienced at
Patient is asked to make a fist and pronate forearm the lateral epicondyle
with radial deviation and extension
Author Manuscript �
Examiner resists patient movement
� Patient arm in passive pronation with wrist flexed
Lateral Epicondylitis and elbow extended
Mill's test � Examiner palpates the lateral epicondyle with Pain experienced at
thumb lateral epicondyle
� Resisted middle digit extension
Maudsley � Specifically target resistance of the middle Pain experienced in
test extensor digitorum communis (EDC) tendon elbow region above
lateral epicondyle
� Patient stands
Modified � Examiner flexes elbow 90 degrees, then abducts Pain experienced
into scapular plane above 120 degrees and along posterior joint
dynamic externally rotated to maximum ability line with or without
labral shear Guide arm into maximal horizontal abduction, and clicking
shear load to joint maintaining this position
test �
Author Manuscript � Patient stands
Labral pathology
Examiner places arm at 90 degrees forward
� flexion, 10 degrees horizontal adduction with
internal rotation
O'Brien's � Pain experienced at
test Place hand over elbow and ask patient to resist joint line during
downward pressure
� internal rotation, yet
Ask patient to externally rotate palms up, place pain improves with
hand over palm and ask patient to resist downward
pressure external rotation
� Patient stands with arm passive at side of body
with elbow extended
Neer test � Pain experienced at
Examiner internally rotates arm through full anterior-lateral area
forward flexion
of shoulder
Author Manuscript Rotator Cuff pathology
� Patient stands
Hawkin's � Examiner places shoulder in 90 degrees of Pain experienced with
test shoulder and elbow flexion, then rotates internally internal rotation
Hand Clin. Author manuscript; available in PMC 2018 February 01.