After an evaluation of his shoulder and elbow I explained to his coach, Terick that the real problem was muscle imbalances surrounding Andy’s shoulder. The muscle imbalances resulted in structural changes caused by muscle weakness and muscle tightness. This imbalance caused joint restrictions and the need to compensated during specific movement patterns such as the serve and ground strokes. In this case Andy’s elbow was hurting because of the above problems. I then proceeded to treat some of the joint restrictions by with soft tissue mobilization techniques and developed a specific strengthening program to improve performance.

Athletes overuse muscles with high velocities repetitive movements, such as throwing a baseball or the tennis serve. Some muscles respond to this trauma by becoming tight and others respond by becoming weak. This is referred to as a muscle “imbalance”. Muscles work in pairs while one is contracting the other needs to relax or slow down the movement. (Agonist vs. Antagonist) The treatment approach must include a combination of stretching techniques and specific strengthening exercises to get the athlete back to the high level of performance that is necessary to compete.

I have heard coaches, athletes, trainers, and medical practitioners over emphasize the need to stretch. There are two basic reasons to stretch, increase range of motion of the joint and/or to increase the flexibility of muscle and other soft tissues, attempting to prevent injuries. The literature shows us that raising the core body temperature prior to athletic activities can be just as effective in preventing certain muscle strains then if we stretched prior to the activity.

In rehabilitation we use several different kinds of stretching techniques such as, low load prolonged stretch, continuous passive stretch, stretch relaxation techniques, and manual therapy which is a very specific method of stretching soft tissues, in order to over come shortened muscles and other soft tissues surrounding joints. In Andy’s case the rotators of the shoulder, which include the rotator cuff and the shoulder blade rotators were asymmetrical causing instability of the shoulder and trauma to the elbow. Some of the muscles were tight causing structural asymmetries and others were weak causing inefficient movement patterns. My job was to mobilize the restricted tissues and strengthen the weak muscles, in order to re-establish a symmetrical and stable shoulder.
Be sure to take a look at the following TennisMD video for an effective shoulder stretch
Flexibility Test, Shoulder/Posterior Capsular

After working with Andy and his coach we have eliminated his shoulder pain for the past year. Last season he won the most matches on the ATP tour, without shoulder pain. Andy has worked hard at maintaining the strength and flexibility of his shoulder. He has been pain free for the past 3 years and increased his velocity from 139mph to 155mph. He broke the serve velocity record by 8 mph, 3 years ago.

Strength training has not been widely accepted in the game of tennis. Former champions such as Jimmy Conners and John MacEnroe probably never lifted a weight in their entire tennis career. Then how did they prevent the injuries to their shoulder that we see today? First, no one was capable nor were they interested in hitting a serve 139mph. The game of tennis was different then, serve and volley was the emphasis. I have young tennis players, at the ripe old age of 12-16, coming into my office on a regular bases complaining of pain in their shoulder or elbow or both. I usually ask if they changed any thing prior to the development of pain? Often times they say yes, I increased the tension of my racquet strings to enable me to increase the velocity of my serve and forehand. Or my coach told me I needed to hit the ball harder so I changed to a heavier racquet. No one tested the strength of the shoulder rotators to determine if their muscle strength was sufficient enough to generate greater speeds or with stand the stress of greater torsional forces to the shoulder and elbow.

Several studies have been published in the American Journal of Sports Medicine, on the influence of resistance training and periodization weight training to improve muscle strength and performance in collegiate women tennis players. They reported that a high-volume, variable repetitions, multiple –set resistance training program produced superior increases in muscular strength, power, lean body mass, tennis performance, and decrease in percent body fat over a 9 month training period. The exercises performed in this study included all the major muscle groups of the upper and lower extremity important to tennis activities. Another study using Isokinetic training to strengthen the shoulder rotators demonstrated an average of 11mph increase in the velocity of the tennis serve. (Mont, Am J Sports Med.)

Weight training was thought to be a remote form of exercises that was designed to create big muscles that caused abnormal movements, which were appropriate for bodybuilders and strength athletes, not for the average person or athlete. Through a better understanding of muscle physiology and research those old ideas have changed dramatically. Weight training is viewed as a frontline type of exercise that improves bone density, reduces heart disease and improves performance.

Furthermore, muscle strength equals improved performance and reduced risk of injury. Any serious athlete needs to strength training during the off-season in order to recuperate the muscle strength losses during the season. When I evaluate an athlete at any age the parents and/or athlete is surprised that the dominant shoulder is the weaker one. They thing by playing tennis or throw a baseball the shoulder should be stronger on their dominant side, because the activity strengthens the muscles. On the contrary the certain muscles break down if not allowed to recuperate. Andy was surprised that his right shoulder was so much weaker than is left. He said it felt strong and he said he lifted weights. However, when I did specific testing to the muscles that were important to tennis, it was obvious he was not lifting weights to improve his game, but more so to look good on the beach.

Be sure to take a look at the follwing TennisMD videos below for two good shoulder strengthening exercises.

Strengthen Your Shoulders: External Rotators
Quick Shoulder Strength 2, Serratus "Reach".

Before starting a strength-training program it is very important to be evaluated by a health professional that specializes in the musculoskeletal system e.g. a medical doctor to make sure you have no medical limitations. The physical therapist can evaluate muscle strength deficits and/or muscle imbalances and flexibility. Recently, more and more physical therapist are offering sports specific rehabilitation and training to assist the athlete in returning to their sport pain free. Without the assessment of the musculoskeletal deficits or imbalances the exercise program may be less effective.