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09-09-2010, 02:03 PM
September 8, 2010, 12:01 am Phys Ed: How to Fix a Bad Tennis Shoulder

By GRETCHEN REYNOLDS (http://well.blogs.nytimes.com/author/gretchen-reynolds/) Thomas Northcut/Getty Images
For a study published a few years ago (http://bjsportmed.com/content/40/5/447.abstract) in the British Journal of Sports Medicine, researchers at the High Performance National Training Center in Argentina X-rayed the shoulders of 18 elite older tennis players, both men and women. Each of the 18, between the ages of 51 and 75, had at one time played professionally, and all were still active in tennis, as either competitors or teachers. None had experienced any unusual shoulder pain or problems. But when radiologists reviewed the players’ X-rays, they found signs of osteoarthritis, or loss of joint cartilage, in a third of the players’ dominant shoulders (generally the right). Shoulder X-rays from an age-matched group of Argentines who didn’t play tennis turned up arthritic changes in only 11 percent of the group. With understandable circumspection, the authors, operating under the auspices of the Argentine Tennis Association, concluded that years of “intensive tennis practice may be a predisposing factor for the development of mild degenerative articular changes in the dominant shoulder.” Playing tennis, in other words, might be gnawing away at the joint.
Shoulder problems may not be the most talked-about condition in tennis. Most of us are more familiar with tennis elbow, tennis knee, tennis toe and, lately, Serena Williams’s lacerated foot. But aching shoulders are actually among the most common overuse tennis injuries, being both democratic and insidious, robbing professionals and duffers of playing time and comfort. “Tennis is pretty hard on the shoulder,” said Todd Ellenbecker, a physiotherapist in Scottsdale, Ariz., and director of sports medicine for the ATP World Tour, the men’s professional tennis circuit.
The difficulty lies in the joint’s construction and the demands placed on it by the modern ballistic tennis serve. A 2009 review article in Sports Medicine (http://www.ncbi.nlm.nih.gov/pubmed/19530752) reported that, according to electromyographic measurements of the forces generated during overhand motions, like the baseball pitch or tennis serve, up to 120 percent of a person’s body weight can slam through the rotator cuff, located at the back of the shoulder, during a pitch or serve. The rotator cuff then has to work as “the brakes of the shoulder,” said Paul Borsa, an associate professor in the department of applied physiology and kinesiology at the University of Florida in Gainesville who has studied shoulder injuries (http://www.ncbi.nlm.nih.gov/pubmed/18081365), absorbing these forces and slowing the lacerating forward momentum of the serving arm.
Unfortunately, many tennis players have relatively weak rotator cuff muscles. “Playing tennis builds up the muscles in the front of the shoulder, but it doesn’t build up those in the back very much,” Mr. Ellenbecker explained.
Trips to the gym don’t help either. “The usual bench presses, overhead presses and rowing” exercises “won’t necessarily work the rotator cuff muscles,” Professor Borsa said. “They’re small and hard to isolate.”
In many dedicated tennis players, one result can be “muscle imbalances,” Mr. Ellenbecker said, with the front muscles becoming much more powerful than those in the back, leading, ultimately, to an extremely common type of injury that “we now call Toyota shoulder — all acceleration and no brakes.”
The symptoms of the condition, more formally referred to as shoulder instability, may well be familiar to anyone who’s played tennis for any length of time. “The soreness in the shoulder starts slowly,” Professor Borsa said. “You may ignore it at first, but then it starts lingering after a match. The pain may wake you at night. Nocturnal pain is definitely a symptom to pay attention to.”
Another is “dead-arm syndrome,” a feeling that “your arm is just too heavy to lift, let alone to serve,” said Dr. Babette Pluim, a sports physician for the Royal Netherlands Lawn Tennis Association and an expert on tennis injuries.
Professional players, like those pounding the courts this week at Flushing Meadows, rarely suffer from this particular type of shoulder problem, “because they have trainers and coaches checking to make sure that they’re strengthening their rotator cuffs,” Mr. Ellenbecker said. Local club players typically do not have such resources, even the best, most dedicated players, who, paradoxically, are at greatest risk. Players who lose in the first rounds of tournaments probably don’t need to worry much, Dr. Pluim said. They’re not hitting enough serves to endanger their shoulders. Tournament winners and runners-up are.
It may behoove anyone who plays competitive tennis to consider adopting the rotator-cuff strengthening routines long common in the pro ranks. Their programs typically involve simple exercises like holding an anchored exercise band and rotating your raised arm away from your body or using elastic tubing to simulate the rowing motion. “You don’t need to use a lot of resistance,” Mr. Ellenbecker said. “You want to build endurance more than power” in those tissues. (For examples of suggested exercises from Mr. Ellenbecker, see the slide show below.)

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But will such regimens protect shoulders from the silent, accumulating damage suggested by the findings of the Argentinian study? Dr. Pluim says she is confident that it will. If a player doesn’t develop an actual injury and subsequent shoulder instability, she said, there’s little evidence that tennis contributes to overt shoulder arthritis. Even in the Argentinian study, she pointed out, the arthritic changes were mostly mild and asymptomatic, meaning that they hadn’t been causing pain. The incipient changes hadn’t even kept the players, some in their 70s, from the courts. “You could read that,” she concluded, “as an endorsement of the benefits of the sport.”