Watch this video of Ms Ruth Delaney, Consultant Orthopaedic Surgeon specialising in shoulder injuries at UPMC Sports Surgery Clinic.
This video was recorded as part of SSC’s Online Evening for Tennis in April.
Good evening everybody, and welcome to our UPMC Sports Surgery Clinic webinar and evening for tennis players.
I know that everybody has been off-court for a long time, with the lockdown and restrictions and this week everybody is getting excited to get back on court, so it is probably a good time to talk about some tennis-related things.
My name is Ruth Delaney, and I am a shoulder surgeon here at UPMC Sports Surgery Clinic. We are going to talk a bit about some things that pertain to tennis and shoulder injuries. My colleague Neil Welch, who is a strength and conditioning coach, is going to speak to you about also some low back issues.
Everybody has been off court for quite a long time with lockdown and restrictions and only this week getting excited to get back on court. One of the most important things is going to be warming up and stretching properly and Neil is going to take you through some exercises that are going to help with all of that.
I am going to talk about a few other things to do with Tennis, and then we will get into some shoulder things.
So let’s talk about Tennis and where better to talk about Tennis than from Wimbledon, although I wish I was actually there – who knows if anybody will get to be there this year.
Tennis has been part of my life for a long time – my parents took us to Garryduff, which was up the road from where we grew up and put us on the tennis courts there. We were really lucky to get this background in Tennis, lucky that there was a young coach there named Declan Gray, who was willing to teach some kids how to play Tennis. It was for quite a number of years a big part of life, and it is really a great sport, so I am glad that we can do this evening, and talk about Tennis and the shoulder.
I did most of my shoulder training in Boston, having graduated from UCC and got to train at Massachusetts General Hospital on the Harvard Orthopaedic training programme. Then as a shoulder fellow in my last year of training doing just shoulder surgery, I spent time in France in Annecy and Lyon before coming back to Dublin in 2014.
Shoulder pain is really common – up to 70% of us are going to experience shoulder pain at some point in our lives, and about a quarter of people who have shoulder pain, it is not their first time having it. It can have a significant effect on people’s lives in terms of sleep disturbance and work absences, and so it is something that is a really important part of musculoskeletal medicine.
One of the things if you are dealing with a shoulder or arm injury and playing tennis or if you are trying to prevent running into trouble with your shoulder is to have your equipment optimised as best as you can and so talking to your tennis coach or club pro about that is really helpful as well. So with tennis rackets – everyone has their own preference. I have had these tennis rackets for a long time, and they suit me really well.
The grip size is really important, and that is something that is worth taking a bit of time to talk to whoever you are buying a tennis racket from, talk to your coach and have a look – because if you have a grip size that is too small, then you are going to be gripping your racket really tightly because you have to in order to hold on to it. That is going to lead to strain coming up here, which is where we get problems with tennis elbow and can lead to problems with your shoulder.
If you have a grip that is too big, you are not going to be able to get your hand all the way around it, and you may run into trouble with your wrist. Having the right grip size is a really important place to start to prevent injuries and not to aggravate any underlying issues that you might have.
One of the simplest ways that I was taught when I was growing up playing tennis to figure out what grip size I should have, was just to have my hand on the racket in my regular forehand grip or semi-western grip or whatever you like and then see when I fit my thumb in between my fingers and sort of the heel of my hand here what we call the thenar eminence, put my thumb right here. If that fits nicely there and there isn’t a huge overlap or big gap, then I have got about the right size grip for me because all of us obviously have slightly different sized hands, so finding the right grip size for your tennis racket is going to make your arm, your elbow your shoulder much more comfortable when you are playing.
The other thing with your racket is obviously your strings – I am guilty of this, I have not restrung this racket in ages, and that is because we have not been playing a lot in a long time, and I think most of you out there are probably the same. So before getting back on court, it is good to check-in and get your racket restrung.
Your club coach will be able to advise you on whether there is someone in your club who can restring your racket for you and get advice about the type of string and the tension that you want to put in it, depending on whether you are somebody who needs help generating more power, so you might want to go down on the tension a little bit, so that you are not trying to use your shoulder and elbow to generate all of the power, or if you are going to go higher on your tension that is going to give you a bit more control and there are lots of other things about the type of string and all sorts of variations.
So again, get advice from the professionals who can help you with that, and that will not only help your tennis but help keep you out of trouble with injury as well. Some players used to like shock absorbers on their strings – that is a personal preference, a lot of us find they just damp the feeling, and it is sort of a different sensation when you are playing. They have kind of gone out of vogue a little bit, but some people still like them if they have trouble with tendonitis issues in the wrist & elbow, and the vibrations coming through the racket. Your strings are important as well, and your grip size and getting good advice on all of that before you get back out on court can really help.
So this week, everybody is looking forward to getting back on court. Some people have maybe already gotten back on court since Monday. I think there are lots of different aspects to that.
Adult players and seniors who like to play doubles all the time are maybe feeling a bit upset that doubles is only possible with people in your own household, and maybe not so comfortable playing singles. But if you’re smart about it, everybody can play singles. Maybe you just play in half the court and use the tramlines. Maybe you realize that for the sake of your shoulder or the rest of your body that you’re not going to serve overarm all the time because remember when you’re playing singles, you’re going to hit double the number of serves, but everybody can get back out and play singles in a way that works for them.
I think a lot of the juniors have been very frustrated with all the time away from courts or maybe trying to find some ways to hit on court somewhere, but it is okay if you went a few months without hitting – it will all come back, it will all catch up. For the juniors, too, being smart in terms of warming up properly and being patient to get back into your rhythm, and everything will start to happen again.
One of the other things about gear that we sometimes forget about is the tennis balls that we’re using, and especially in our Irish weather, it doesn’t take long for the tennis balls to get damp and wet, particularly if there’s a bit of rain out there, so depending on your tennis balls, this one’s been used a bit it’s kind of starting to fade it’s still perfectly fine to play with, but after a while, tennis balls may start to get wet, and there’s absolutely nothing wrong with opening new tennis balls halfway through your session.
It is not just the pros who get to say new balls please every seven games – okay, it adds expense, but if you’re somebody who has trouble with your shoulder or elbow playing tennis, then it’s something to be conscious of if it’s a wet evening and you are playing tennis. It might be an idea to bring an extra set of balls and halfway through just to open a new set of balls so you have a nice, light, dry set of tennis balls, particularly to be serving with so you’re not putting extra stress down through your shoulder when you’re hitting.
Tennis & The Shoulder
The serve is probably the best example of the complex biomechanics involved in tennis and how when they don’t happen the way they should, and the shoulder can get in trouble. This is from a recent article published by Alan Curtis and his team from the New England Baptist Hospital in Boston. This diagram shows us the phases of the serve and starts to get us thinking about what we call the kinetic chain.
There are a couple of things about your technique when you play tennis that can help save your shoulder as well. I’m no tennis coach. When I did my level one coaching qualification as it was called back then (it was quite a while ago, so I’m pretty sure it’s out of date) – your tennis coach in your club and your own tennis coach can work a lot with you on things that can help if you have an injury or if you’re trying to prevent an injury.
There are a few basic things that we’ll mention tonight just to have you think about as you get back on court – one of them is footwork.
It’s easy to get lazy about footwork and not get your feet in the right position so that if the ball is out there, we’re doing something like this instead of actually getting our feet there, and that’s going to help you in terms of saving your shoulder and your arm so getting yourself in the right position early whether it’s singles or doubles that you’re playing, that’s going to be important.
|The other things that can help in terms of shoulder is that we need to remember not to let the shoulder always be taking the brunt of what we’re doing on the tennis court because the shoulder’s part of what we call the ‘kinetic chain’, which includes your legs, your hips, your trunk and then your shoulder, your elbow, your wrist and your hand and that goes for every shot that we play.|
So if you’re hitting a forehand, that will often start from the ground up, whether it’s an open stance or more closed stance, you’re still going to get yourself ready and have that body rotation and lead with your hip rotation so that it’s not all coming from the shoulder and so that if you do have any issues in your shoulder, you are protecting your shoulder by actually using the rest of your body. The same applies to your backhand; whether it’s a one or two-handed backhand, or whether you’re hitting a serve, it is going to come from the ground up, legs, hip rotation, trunk and only then your shoulder and arm and so that is something to work on with your tennis coach at your club.
So thinking about all of that, then it is the legs from the ground up, the trunk, the shoulder girdle and then the upper extremity or the arm. We run into trouble if it is all coming from the shoulder. The legs and core should provide a stable base. The shoulder blade is key – it is a stable platform for the shoulder to function in general, not just in tennis. It protects the rotator cuff if the shoulder blade is working properly, and something that we call scapular dyskinesis, or basically the shoulder blade not moving the way that it is supposed to, gives a really high increased risk of shoulder pain in overhead athletes, including tennis players.
There are these key points during a serve action, for example, that are referred to as nodes when we are talking about Biomechanics. If any one of those isn’t happening correctly, then it can lead to another downstream effect that can result in injury and overuse and again, this is from Curtis’ paper. I think it is interesting to just think about this – that your foot position can affect what is happening with your hip and your trunk, same with your knee motion as you go into a knee bend and then extension through contact with the ball and all the way up.
The scapula and the shoulder are almost like a funnel directing all that force from the ground up towards the arm and then finally into the racket and into your serve. All of these things are important in protecting the shoulder when you play tennis, and that is why the tennis coaches spend so much time getting all of these things right for their tennis players.
In terms of shoulder symptoms that we see – a lot of times, it is shoulder pain as the main reason why people come to see us. It can also be stiffness or weakness. Sometimes it can be an issue with shoulder instability.
It’s also possible that some symptoms that you feel around your shoulder can be coming from a problem with the neck, and there can be overlap between a shoulder problem causing neck pain or a neck problem causing shoulder pain. Sometimes we end up looking at both.
When we assess shoulder problems, we take a history, try to figure out the pattern of what’s happening, and then examining the shoulder gives us a lot of really useful information. Usually, we will want some imaging – sometimes X rays are more useful, sometimes an MRI is helpful. It depends on what’s going on with the shoulder, and sometimes we use other things like CT scans.
Four of the main things that we see with shoulder problems are the rotator cuff that you’ve probably heard of, frozen shoulder, which is quite common, arthritis of the shoulder and often in younger, overhead athletes, there can be issues with instability or tears of the labrum, which is the cartilage bumper around the socket of the shoulder.
In Tennis players, there can be very particular patterns of those labral issues in younger tennis players – often those are things that we do not treat with surgery.
When there are problems that we consider shoulder surgery for, I think it’s important to get advice from a shoulder specialist, there are a lot of things on the internet out there, and you have to be careful where you get your information.
A shoulder specialist will walk you through the risk/benefit balance of considering surgery or non-operative management for a problem.
What’s really important for active people like tennis players is, of course, the recovery time, the rehabilitation involved, how long you’re going to be out of action and preparation for the surgery is important as well.
Knowing some of the background of what’s involved in your surgery is the job of the shoulder specialist to show you and teach you.
At our practice, we like to be really meticulous about following up the outcomes of our shoulder surgeries as well, based on the principles of Ernest Amory Codman, who was a shoulder surgeon from over 100 years ago at Mass General who actually got thrown out of Mass General for having the ‘cheek’ to suggest that surgeons should be held accountable for their outcomes. Now over 100 years later, that’s something that I think the whole world of surgery embraces.
So if we do a shoulder surgery, the patient fills out surveys at various points after surgery, and that shows us if that patient is on track compared to our averages and the averages of a whole load of other practices all over the world – so that keeps our standards on a par with everywhere else.
To go back to these specific problems that we see in the shoulder, if we talk about the rotator cuff. A lot of people hear about the rotator cuff, and a lot of times, any kind of shoulder pain is called a rotator cuff problem, which may or may not be the case, but the rotator cuff are these four muscles that are deep inside the shoulder. This shows the front and back view of those four muscles. Their job is to help compress the shoulder in its socket and to help raise the arm as well as obviously perform rotation, so the rotator cuff does a lot of work when we’re playing tennis.
These tendons haven’t got a great blood supply, and they do tend to wear over time. There’s a certain element of normal wear in the rotator cuff, so if you get an MRI scan of any shoulder over the age of about 40, you’ll see some normal wear and maybe even partial tears; those are often not things that we have to fix surgically, but they may cause pain or inflammation. Full-thickness tearing where the tendon tears away from the bone is something that we sometimes consider surgery for.
Things that cause inflammation and pain will often be treated with physiotherapy. An injection may have a role in it – things like steroid injection or cortisone, or sometimes some other types of injections, and those may help settle things down, so you can then work on your physiotherapy, retrain the muscles around the shoulder blade to get back to that shoulder blade control and again enable you to get back on the tennis court, without necessarily having surgery.
If there’s a full-thickness tear it might be something that we recommend repair for, depending on the size of it, and that’s usually a keyhole surgery to reattach the tendon but the recovery takes time afterwards – you are probably looking at about five or six months before you get back on the tennis court after a rotator cuff repair. That’s something that we try to take time to explain beforehand, so we set everybody’s expectations appropriately for afterwards.
Frozen shoulder is something that is really common. It’s often poorly understood, but the main problem with frozen shoulder it’s where the capsule or the soft tissue lining around the ball and socket of the shoulder joint becomes inflamed. It’s also called adhesive capsulitis.
It happens often for no good reason, but it is more common in certain groups. These groups can include people who play Tennis.
It’s more common in women typically in their 40’s or 50’s. It’s associated with hormonal things like diabetes, thyroid or around the time of the menopause, but we do see it in people who don’t fall into any of those categories.
Certainly, if you’re developing a frozen shoulder, it will become really difficult to continue playing tennis. Most cases will resolve without surgery – the inflammation of the capsule is the main problem, and that’s what gives the pain, to begin with. Then as the capsule becomes more inflamed, it gets thickened and tight, and shoulder gets really stiff, so we use anti-inflammatory strategies to try to hurry up the natural process of this settling down.
Sometimes oral tablets just aren’t enough because the pain can be quite severe, so we often inject the joint with cortisone – it’s important where that injection goes, so again a shoulder specialist will inject right into the main joint where that capsule is all inflamed. Sometimes we might even use a short course of oral steroid tablets.
We use really gentle stretching – the instinct sometimes when a shoulder is stiff is to push it and try to stretch really hard. But with frozen shoulder, the more you are aggressive with it in these painful stages, often the more that can aggravate it and actually end up as a vicious cycle of just inflammation and pain.
We just use a gentle stretching program and usually avoid formal physiotherapy.
Often when the swimming pools are open, we use swimming pool based stretches as well to help get the range of motion back in the shoulder.
So these are some of the stretches and this is Orla the physiotherapist who works at my practice and who helps patients navigate this.
In a very small number of cases, we consider surgery for frozen shoulder if the symptoms are not resolving, and that’s a keyhole surgery where we release that thick and inflamed capsule.
The old way to do it was to manipulate the shoulder under anaesthesia, but it’s much safer and more controlled now to do it as a keyhole surgery.
You will often use a nerve block as well as the general anaesthetic to allow for immediate stretching afterwards. Once we have released the shoulder, it’s different then – we will be aggressive with physiotherapy because we don’t want that capsule to scar back in.
It’ll take a few weeks for that to settle and to allow somebody start to get back to high-intensity activities like tennis, and obviously, after any intervention on the shoulder, if you’re getting back to tennis, you go back gradually and take it one step at a time, small steps.
This is what the inside of the shoulder looks like if there’s frozen shoulder, the cartilage is on the left. On the left-hand picture, you can see the cartilage of the humeral head and then a really angry red nasty capsule that we’re dividing with a radiofrequency device.
The other diagnosis that we come across in the shoulder quite a bit is arthritis, and this can affect our tennis playing population, particularly in later years, but actually, you can see arthritis, even in slightly younger patients too. That can be a challenge to manage for younger patients.
Shoulder arthritis for us means cartilage wear of the main shoulder joint, which is the ball and socket joint. On almost every MRI scan of the shoulder, there would be some arthritis or wear of the AC joint or the acromioclavicular joint, which is the joint between the end of the collarbone and the point of the shoulder, and often that’s not actually causing any symptoms. So if you have an MRI scan and you have shoulder pain, and it says arthritis of the AC joint, there’s a good chance that’s not actually what’s causing your pain, unless the pain is right at the top of the shoulder if somebody presses on the AC joint.
That’s not what we’re talking about when we’re talking about shoulder arthritis, we’re talking about the main joints and sort of like the hip, the ball and socket part, and that can become arthritic when the cartilage wears.
You see an irregular shape and loss of joint space that can lead to stiffness and difficulty moving, which is a different stiffness than what somebody with frozen shoulder has and unfortunately, with arthritis, there’s not really any way to undo the arthritis; there’s not really any way to put back the cartilage that has been worn away, so we use strategies to try and work around it, and the strategies centre around pain relief. Sometimes with physiotherapy again being gentle with the range of motion – if it seems to be aggravating the shoulder, we will back off on it. Various injections can help with shoulder arthritis, based on steroid injections, or there are what we call viscosupplementation injections.
Those are sort of a gel type injection that mimic the joint fluid and can help lubricate the joint, and some patients get relief from those. We can use something called platelet-rich plasma, which is where your own blood sample is taken and spun down and then the platelet-rich fraction of that is injected into the joint, sometimes in earlier arthritis, that can help.
Then in some cases, a keyhole surgery might be appropriate in shoulder arthritis; again, it depends on the stage of the arthritis, sometimes the arthritis is too advanced to consider that, and we actually think about shoulder replacement, which is something that people hear about less commonly than hip replacement, but it is something that’s really successful for shoulder arthritis – it is the most definitive way to treat the arthritis because it’s the only way we can actually get rid of it.
How long the shoulder replacement lasts can be affected by how you use the shoulder – in terms of how much you do with it and how high impact the activities are that you do, but a lot of sporting and recreational activities are possible with a shoulder replacement including tennis.
I would absolutely let a shoulder replacement patient of mine play tennis. Once they’ve worked through the rehabilitation afterwards, which does take a number of weeks to months, and it’s probably going to be four to six months after a shoulder replacement before we let you back on court, particularly hitting a serve.
When we do a shoulder replacement, we get a CT scan, and we actually plan surgery with 3D software so that we know exactly all of the pitfalls of that individual person’s shoulder before we get in there.
This is a good example of getting back to tennis after a shoulder replacement: Tom Brown was a US professional tennis player. He passed away a few years ago, but he played in the era of Jack Kramer, right before professional tennis came in, and he was a famous doubles partner and also a really accomplished singles player himself, making it to Grand Slam semifinals and finals.
He had a shoulder replacement, and four months afterwards, he was back on court and regained his world rankings in the over 65’s, having had a really successful shoulder replacement with a surgeon named Tom Norris in California. I think most of us would be happy to let a patient with shoulder replacement back on court.
There are two types of shoulder replacement: the anatomic type, which is we replace the joint as it is with the ball and socket, or a reverse type of shoulder replacement where we actually put the ball and socket the other way around.
The two main reasons that we might do this would be if the rotator cuff tendons are no longer there around the shoulder if they’re torn and not working, the regular anatomic type of shoulder replacement can’t function, so the patient needs a reverse or if the socket of the shoulder is so worn that we can’t fit this white plastic socket in there and it’s not going to be stable, then we also would do our reverse shoulder replacement.
They work in very similar ways, there are some minor differences. The rehabilitation is the same, and again, I think a patient with a reverse shoulder replacement can get back out there and play some tennis as well once they’ve recovered.
What a shoulder replacement involves; the patient is usually about two nights in the hospital and four weeks in a sling afterwards. Often, people feel really good, really quickly after a shoulder replacement, because we’ve taken away that arthritic joint, the pain relief can be quite quick. But it’s a case of being patient in terms of working through the rehab and getting back to things like sports.
This is how we do shoulder replacements, how we plan them, and the future is actually here, in the sense that we have this software which allows us to see in 3D our patients shoulder. We can even get a 3D printed guide to help us place our components really accurately.
Now we can actually use this plan in a mixed reality setting where we wear a headset, and that’s projected right in front of us as we operate.
I’ve been really privileged to be one of the first surgeons to be given that headset, and later on this week, we’re going to do the very first case in Ireland this Friday right here in Dublin, where we use this technology and all the time the field of shoulder replacement is advancing.
It hasn’t been around maybe as long as hip and knee replacement, but huge advances are being made, and so that allows it to be a very successful intervention for our patients.
So coming back to tennis, I think all of us know that it’s a sport for life. Kids can take up tennis pretty young, and I have patients in their 80s and 90s who still play tennis.
The benefits of staying active, both the mental and physical benefits, often outweigh any of the wear and tear that’s sustained along the way.
So I think keeping the simple things in mind to preserve your shoulder longevity while you’re out there will make it so much more enjoyable and hopefully avoid you getting into trouble with the shoulder, so the things that we were thinking about, like the kinetic chain, the whole body working together, footwork to make that happen, and some of the things to be smart about with your gear for tennis, and hopefully that keeps you out of trouble, but if you have shoulder trouble then there are plenty of things that we just discussed that we can do to help you out of it.
Thank you very much.