Part 2-Assessment and treatment.

Assessment

The player will usually complain of problems during the late cocking phase of the serve or throw. They may also report loss of power in the serve and may sometimes complain of a feeling of a ‘dead arm’. In some instances the pain is fairly diffuse, but there are localised sites where it is more common. There may be posterior shoulder pain, deltoid pattern pain (due to primary or secondary ‘impingement’ issues), medial border of scapular pain (at the site of insertion of scapular stabilisers e.g. Levator scapulae) and sometimes pain in the region of the coracoid.

Examination of the patient should, as always, begin with the neck to exclude referred cervical or radicular pain as a cause of the shoulder issue. Examination of the shoulder girdle itself begins from behind, firstly assessing the resting position of the scapula. Particular attention should be paid the the amount of retraction/protraction, height and rotation of the scapula as well as any prominence of all or part of the medial scapular border. Both arms should then be taken through full forward flexion range looking for differences in the scapular position and movement through range. This can be repeated bring the arm into the cocking position paying particular attention to the retraction and elevation the scapula (failure of which can lead to hyperangulation). These movements may be performed repetitively to assess for fatigue and deterioration. Next, range of movement is assessed particularly looking for the presence of any internal rotation deficit (GIRD) and any excessive external rotation. Rotator cuff strength is assessed and the presence of pain with resisted testing (particularly of the supra and infraspinatus) is noted. Pain with supraspinatus testing may represent external impingement or articular sided injury from internal impingement. Infraspinatus pain may be as a result of repetitive micro-trauma with development of fibrosis and contracture of the muscle.

Specific tests for glenohumeral instability, SLAP tears, and scapular assistance and scapular stabilisation tests may then be performed. A throwers test (the arm is taken into the cocking phase position and the forward phase of the throw is resisted) may be useful. Away form the shoulder girdle, core stability is assessed, follow by examination for thoracic spinal stiffness and kyphosis. Hip range and function should also be evaluated.

Imaging is usually not required prior to starting treatment, but if performed the investigation of choice is an MR Arthrogram including ABER views. This is to look for labral pathology, and evidence of external and internal impingement (bursal fluid, supraspinatus tendinopathy or undersurface tearing [PASTA lesion])

Treatment

Not surprisingly, treatment of the painful shoulder will need to address any abnormalities seen following assessment of the specific aspects of kinetic chain function, scapular position and kinetics, internal rotation range and finally rotator cuff and peri-scapular muscle function and strength.

Treatment of kinetic chain issues might include, for example, hip range of movement and abduction strength exercises,  thoracic stretches to minimise kyphosis. 

Scapular treatments could include exercises to ensure adequate scapular retraction and elevation not only to ensure adequate energy transfer into the serve but also to prevent superior cuff impingement and  also ‘hyperangulation’ 

Posterior capsular stretches may include sleeper stretches. Cross body stretches may also be performed but are only useful if the therapist stabilises the scapula during the stretch.

Infraspinatus strengthening, particularly with eccentric exercises, should begin after treatment of the above issues has been instigated. In terms of the peri-scapular musculature, weakness of serratus anterior and the lower traps are a common feature in overhead athletes and if present should be treated.

Summary

An awareness of the potential issues causing shoulder dysfunction in the tennis player or overhead athlete can guide the assessment and treatment and also help prevent further problems in this population.