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Combat Shoulder Pain Before It Starts

Combat Shoulder Pain Before It Starts

By Brent Brotzman, MD

Shoulders are designed to allow our bodies to reach up into trees or into the highest cabinet — but not to generate a 130 mile an hour serve or throw a 100 mile an hour fast ball. Injuries to the shoulder in tennis are a relatively common occurrence in both the professional athletes like Patrick Rafter experienced, as well as the weekend player.

Because of the high angular torsional forces generated on the shoulder during serving and overheads, tennis players are considered "throwing athletes," and resemble the same type of injuries as seen in baseball players, softball players and quarterbacks.

The shoulder joint is the shallowest joint in the body, and it is composed of a very shallow socket with a very large ball. This shallow socket derives some further support from fibrous structures called labrum and the shoulder capsule. These structures act like a suction cup to try to keep the large ball positioned in the very shallow socket.

The combination of forward elevation, side elevation, internal and external rotation of the shoulder area all controlled by the rotator cuff. The rotator cuff consists of four muscles and tendons that blend together to attach on the outer part of the shoulder two or three inches below the point, or acromion, of the shoulder.

The shoulder joint is also intrinsically involved with the shoulder blade, or scapula. As you serve a tennis ball, the shoulder blade also lifts and rotates in concert with the shoulder joint.

Often, you have heard friends say that they have problems with the rotator cuff (also incorrectly referred to as the rotary cup). The rotator cuff complex is probably the most important set of muscles and tendons involved in the art of serving or throwing. They do the vast majority of work throughout the serving process and may be overused. As teenagers, the rotator cuff complex is extremely strong and would be likened to a thick strap of leather. As the athlete ages, the cuff, through a progressive loss of blood supply, becomes much thinner and easier to tear.

Repetitive overuse, such as serving multiple matches within a short period of time, often results in rotator cuff tendonitis. You have probably felt this tendonitis by a burning or stinging pain on the outer portion of your shoulder, approximately two inches down from the tip of your shoulder.

While many people lift weights to strengthen the pectoral, deltoid and bicep muscles, few recreational athletes strengthen the rotator cuff. Rotator cuff strengthening is extremely important because this muscle and tendon group also functions to push the ball portion of the joint downward during throwing to allow more clearance under the arch of the shoulder. If the rotator cuff is weak, the clearance is decreased and the rotator cuff and the ball of the shoulder essentially bang or get pinched underneath the arch of the shoulder during the throwing motion.

This can become a vicious cycle. The rotator cuff is slightly weak, so it does not allow shoulder clearance under the arch of the shoulder during throwing. As a result, the rotator cuff and the ball are repetitively pinched, or impinged. This inflames the rotator cuff and the shoulder joint, which causes more pain, inflammation, and more weakness - and the vicious cycle continues.

Common history given by a patient with a rotator cuff tear is that they hit an overhead or serve and felt a popping sensation and had immediate pain and weakness. Over the course of weeks or months, the pain and weakness have not improved. This is different than the presentation of rotator cuff tendonitis in which the patient progressively developed more pain with continued serving but noticed minimal, if any weakness.

As Patrick Rafter can tell you, even a young, highly conditioned athlete with exceptional tissue strength and exceptional ability can undergo significant injuries to the shoulder. His difficulty was a rotator cuff tear that resulted from a combination of overuse and improper mechanics. As Patrick generates spin on his serve in an effort to get to the net, he throws his ball toss too far to the left. As a result of the ball toss coming back over his head, he places his shoulder in a position in which the spur of the shoulder bangs on the rotator cuff. Eventually, despite excellent tissue strength, he wore a hole in his rotator cuff from repetitive use and improper mechanics. If you notice now, his ball toss is more out to the right than it was prior to his injury.

Our recommendation to our college players and weekend athletes to whom we provide care is to perform the following steps in an effort to try and avoid shoulder injuries:

One - Receive professional instruction to obtain a smooth, easy, fluid, biomechanically correct service motion and overhead motion.

Two - Avoid ball tosses up over the head or too far left (for the right-handed player).

Three - A stretching program before and after tennis.

Four - General, slow warm-up with half-speed serving to progressively harder serves.

Five - Icing the shoulder down after play with a bag of ice wrapped with an Ace bandage around the shoulder to decrease inflammation.

Six - Listen to your body. If you have played three matches on a Saturday and you are having significant burning pain outside of the shoulder, this probably signals overuse and possibly rotator cuff tendonitis. Continuing to play through the pain may increase your risk of having a tear or a recalcitrant tendonitis that takes months to resolve.

Seven - Seek help of a sports medicine orthopedic surgeon who sees throwing athletes. Though your family physician knows much more than we do about your heart, lungs and high blood pressure, for the intricacies and caveats of shoulder injuries, a specialist best helps the throwing athlete.

Eight - Do not stop using your shoulder because it is painful. Putting it down by the side will eventually result in a stiff or frozen shoulder. Seek out consultation for correction of the underlying problem.

Nine - You should work ten minutes a day strengthening you rotator cuff while you are performing the rest of your exercise regimen if you are a throwing athlete. This often ignored muscle and tendon group is much more important than any other upper extremity muscle and tendon for the tennis player or throwing athlete.

Ten - Use of the RICEN regimen is valuable. RICEN stands for rest, ice, compression (such as a light Ace bandage compression wrap with ice), elevation of the extremity, and non-steroidal anti-inflammatories. If you are allowed to take anti- inflamatories, several days of these will help decrease the inflammation. Patients with ulcers, gastrointestinal upset, asthma, aspirin allergy, et cetera, should not take anti-inflammatoires. Obviously, you and your physician will discuss the use of anti-inflammatories

Good luck and have fun on the court! Upcoming segments will discuss other common tennis injuries. Please drop me a line if there is a topic you would like for us to discuss to brent@tennislifemedia.com

*Dr. Brent Brotzman is an orthopedic surgeon who practices in Corpus Christi, Texas. He specializes in sports injuries. Dr. Brotzman writes a nationally best selling textbook entitled "Clinical Orthopedic Rehab" which distributed in eleven languages. He is the team physician for Texas A&M University at Corpus Christi.

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