tennis, exercises to eliminate these weaknesses must
also be addressed.- Rotator cuff rehabilitation includes all shoulder arcs
of motion including abduction, adduction, external,
and internal rotation. Scapular stabilizer strengthen-
ing is critical and elimination of any abnormal tho-
racic kyphosis, if possible, is addressed. Full shoulder
flexibility is a necessity in this endeavor. - Control of force loads:The basic tenet of overall
treatment is a balance between improving the muscu-
loskeletal system (e.g., rehabilitation or surgery) and
controlling any injury producing overuse imposed by
the sport (in this instance, tennis).
•Tennis stroke mechanics of good quality are essential
to controlling any injury producing overuse injuries to
the rotator cuff, as well as lateral and medial tennis
elbow. - Integral to quality tennis ground stroke mechanics are
to use the lower body often (e.g., running to achieve
ideal body position and forward weight transfer at the
time of ball impact) and the upper body little (e.g., use
wrist and forearm for ball control rather than as a
power source).
•Traditional lateral tennis elbow is primarily associated
with poor backhand technique (e.g., the power source
is the forearm and elbow rather than the shoulder,
trunk rotation, and body weight transfer). Conversely,
a quality single hand or two-handed backhand stroke
minimizes arm use. - Medial tennis elbow from groundstrokes or the volley
is commonly associated with a late forehand stroke.
The lower body mechanics include poor weight trans-
fer and body position. In these poor mechanics the
wrist must snap (flex) to bring the racquet head in a
perpendicular position to the incoming ball. This tech-
nique results in overuse of the common flexor origin
at the medial elbow. As in lateral elbow, quality
mechanics include proper body position as well as
trunk and shoulder rotation and a firm, not flexing,
wrist at the time of ball impact. - Medial tennis elbow from serve and overhead may
occur from quality stroke mechanics. At the interface
of the serve cocking motion and backscratch and as
acceleration is initiated the medial elbow is subject to
valgus stress. In addition, at ball impact, snapping
wrist flexion stresses the common flexors and pronator
teres further challenging their origins at the medial epi-
condyle. Subtle changes in grip position and wrist
mechanics often aid medial elbow stress but the gross
kinesiology of a quality tennis serve may still be
stressful. Medial elbow stresses are exaggerated fur-
ther in a serve and volley player playing on a slow and
watered down clay surface (e.g., a wet heavier tennis
ball).- Rotator cuff:The rotator cuff is primarily stressed
with the tennis serve and overhead. The basic shoul-
der position of 90°of abduction and full external rota-
tion at the backscratch followed by racquet head
acceleration is a major stressor by increasing tension
forces on the rotator cuff. The shoulder, in contradis-
tinction to the elbow is vulnerable with both a quality
and inexperienced low quality tennis serve. In addi-
tion, the constant stretching of scapular muscle groups
in at the deceleration phase of the serve, especially
after ball impact, fatigues and weakens the posterior
shoulder muscles placing the cuff at further risk sec-
ondary to muscle imbalance. - Shoulder:Although the primary pathology is rotator
cuff tendinosis, companion issues such as shoulder
labral tearing and instability, bursitis, and aggravation
of AC osteoarthritis may occur. These tissues are chal-
lenged in similar shoulder positions of back scratch
and acceleration. The extreme of external rotation at
90 ° of abduction is most stressful. Quality tennis
serve technique, unlike baseball pitching, rapidly pro-
gresses to full extension and is therefore somewhat
protective. The volume of use in tournament class
players often, however, ultimately takes its toll.
Inexperienced serve mechanics conversely tends to
maintain the more punishing 90°abduction position at
ball impact thereby increasing the stresses on the
shoulder. This troublesome stroke pattern combined
with an age related rotator cuff vulnerability of the
older recreational player often incites rotator cuff
symptoms. - Force load control:Control of force loads can occur
in a variety of ways. Alteration of frequency, intensity,
and duration of tennis activity is the initial approach
(e.g., relative rest). Tennis instruction, including hit-
ting with a ball machine and against a backboard,
increases ball impact per unit of time and is often an
inciting factor in the onset of tennis elbow symptoms
and is best avoided when the arm is sensitive. - Equipment:Increased force loads have been empir-
ically noted with unduly rigid racquets with tight
stringing. In addition, gut strings by anecdotal obser-
vation are more forgiving and more protective than
synthetic strings. Light racquets (under 10 oz) as
well have more limited racquet mass resulting in
excess torque forces with off center tennis ball hits.
Conversely, ball impacts in the center of percussion,
with any racquet (e.g., the sweet spot), are protec-
tive. - Counter force functional bracing:For tennis elbow,
the counter force concept, introduced by the author in
1972, is to diffuse the concentration of forces from a
small to a large area. A wide brace (2 3/4 in. or above)
is more protective. Since the forearm is conical in
- Rotator cuff:The rotator cuff is primarily stressed
536 SECTION 6 • SPORTS-SPECIFIC CONSIDERATIONS