Over the last two months we have examined general shoulder rehabilitation and prevention recommendations, and most recently, specifics for throwing and swimming. This month we will continue the discussion with a focus on tennis and golf. Although these two sports are worlds apart with regard to technique, aerobic demands, and muscular effort, they do have in common the use of an apparatus which increases the lever arm of the upper extremity for the purpose of increasing impact to a ball.
In elite junior players, the overall incidence of shoulder injury ranged from 10-30%, 80% of which is overuse injury.3 It is interesting to note that the shoulder and elbow are often both injured. Of those with tennis elbow, one study indicated a 63% higher incidence of shoulder injuries. The shoulder is injured alone more often with the serve than with other strokes.
Muscular Demands
There are in essence three main strokes in tennis: (1) the serve; (2) the backhand groundstroke; and (3) the forehand groundstroke. The serve is divided into four phases: (1) windup; (2) cocking; (3) acceleration; and (4) follow-through (similar divisions for throwing). Unlike pitching which involves throwing down, serving requires the ball to go up and arc over the net. During windup, the arm is positioned by the body with little shoulder muscle activity required. In the cocking phase, glenohumeral stability is provided by a sharp increase in rotator cuff and biceps activity supported by the scapular positioning function of the serratus anterior, which by far demonstrates the highest level of activity.4
The acceleration phase is characterized by a peak in internal rotator muscle activity from the subscapularis, pectoralis major, and latissimus dorsi, while the serratus anterior continues to maintain proper scapular positioning. The biceps functions eccentrically during acceleration (an important point for rehabilitation and training). During follow-through, the posterior rotator cuff, serratus anterior, latissimus dorsi, and biceps are all quite active (mainly eccentric contractions). The amount of activity appears to be increased in the recreational player as compared to the professional player pointing to an uncoordinated performance; less lower body force causes more shoulder participation, and therefore, predisposes to overuse.
The forehand and backhand are divided into three phases: (1) preparation; (2) acceleration; and (3) follow-through. Muscular activity is highest in the acceleration phase. With the forehand the highest activity is found with the subscapularis, biceps, pectoralis major, and the serratus anterior. With the backhand, the peak contributors were the middle deltoid, supraspinatus, and the infraspinatus. Some activity is also noted for the biceps, latissimus dorsi, and serratus anterior. The follow-through for the forehand is characterized by high activity of the serratus anterior, subscapularis, infraspinatus, and biceps. For the backhand, follow-through is characterized by moderate activity of the biceps, middle deltoid, supraspinatus, and infraspinatus. It appears that the follow-through for the backhand is more a body controlled event, relying less on the decelerator function of the anterior musculature.
Training and Rehabilitation
Most serious injury occurs with serving. The repetitive nature of the act coupled with the overhead position sets up a potentially harmful scenario. Couple with these inherent positional demands underlying capsular laxity (often increased by the act of serving itself) or underlying acromial pathology, and the stage is set for injury. Laxity is more often a younger player's fatal flaw, while underlying acromial or subacromial degenerative changes are the older player's. These should be focused on in the evaluation process for each group. Laxity is a clinical assessment, whereas acromial involvement is primarily radiographic.
Shoulder injury with groundstrokes is generally from overuse or misuse. Some of the general recommendations include specifics for the body, and racquet guidelines:5
It appears there may be an age-related phenomenon with shoulder injury in golf as noted above in tennis. Older players are more common in golf than in most any other sport. Accumulative degenerative changes may predispose these individuals to impingements of the rotator cuff, bursa, or AC joint, in particular at the extremes of motion. In younger players, it appears that instability may be a factor in overuse injury.
Muscular Demands
The golf swing is generally divided into the: (1) takeaway (backswing); (2) forward swing; (3) acceleration; and (4) follow-through.5 Forward swing and acceleration are often combined into a stage called impact. As with throwing sports, golfing requires substantial lower body contribution to the development of a powerful swing. The lower body and pelvis rotate ahead of the upper body during acceleration. For the left arm (right-handed golfer), the main muscle for the takeaway is the subscapularis. For the forward swing, the main muscle activation is the latissimus dorsi, with assistance from the pectoralis major and rotator cuff. Acceleration demonstrates an increased activity of the subscapularis and infraspinatus. There is a dramatic increase in pectoralis major firing. During follow-through, the infraspinatus demonstrates a marked increase in activity. The pectoralis major, subscapularis, supraspinatus, and latissimus dorsi all participate. It is interesting to note that the supraspinatus is less important in golfing than with other sports, primarily due to the fact that golfing requires so little overhead movement.
Training and Rehabilitation
The biomechanics of the swing may give clues as to muscular or joint damage. The following is a discussion of left shoulder pain in a right-handed golfer. If pain is felt anteriorly at the left shoulder at the top of the backswing, either AC compression or anterior labrum impingement are likely. If the pain is felt posteriorly in the left shoulder, capsular tightness or capsulitis is likely. If pain is felt during the downstroke, an underlying cause may be scapular lag, where the scapula does not keep up with the movement. Primarily, the serratus anterior and the rhomboids should be strengthened. If pain is felt with follow-through at the left shoulder, consider posterior labral or posterior rotator cuff impingement.
A summary of observations recorded by Mann8 on 52 professional golfers may assist with recommendations regarding do's and don'ts:
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