I njur y Pat terns a nd

Biome cha nic s of the

Athlete’s Shoulder
Dave Lintner, MDa,*,Thomas J. Noonan, MDb, W. Ben Kibler, MDc

KEYWORDS
 Kinetic chain  Biomechanics  Evaluation

Although shoulder injury patterns vary by sport and position, overhead sports, such as
baseball, swimming, tennis, and volleyball, share a common dependence on the integ-
rity of the kinetic chain. Disruption of this critical mechanism predisposes to injury and
deserves attention as the most important of the biomechanical principles required to
help evaluate and manage problems of the athlete’s shoulder.
The term ‘‘kinetic chain’’ refers to the conceptual framework for understanding the
mechanisms by which athletes accomplish the complex tasks required for function in
sport. Alteration in the sequential activation, mobilization, and stabilization of the body
segments occurs commonly in association with sport dysfunction, either decreased
performance or injury. This kinetic chain ‘‘breakage’’ has been demonstrated in
both young and older athletes in many anatomic areas and as a result of repetitive,
vigorous activities. It is usually acquired and can be created from many factors—
remote injury, incompletely healed or rehabilitated injury, muscle weakness or imbal-
ance, muscle inflexibility or joint stiffness, or improper mechanics. Kinetic chain
breakage creates increased distal physiologic or biomechanical requirements
(increased muscle activation or increased distal segment velocity, acceleration, or
mass to ‘‘catch up’’ and develop the same kinetic energy or force at the distal seg-
ment); changes the interactive moment at the distal joint (increasing the forces that
must be absorbed at the joint); or decreases the ultimate velocity or force at the distal
segment.
Thus, an understanding of biomechanics is actually fundamental for the practicing
clinician in the evaluation and treatment of the athlete’s shoulder and in injury preven-
tion. It permits a broad-based perspective from which we can better understand the
pathophysiology responsible for observed injury patterns. The paradigm of the
‘‘victim’’ distally at the site of clinical symptoms and the responsible ‘‘culprit’’

a
Methodist Sports Medicine, 6560 Fannin Street, Suite 400, Houston, TX 77030, USA
b
Steadman Hawkins Clinic, Denver, CO, USA
c
Lexington Clinic Sports Medicine Center, Shoulder Center of Kentucky, 1221 S. Broadway,
Lexington, KY 40504, USA
* Corresponding author.
E-mail address: dlintner@tmh.tmc.edu (D. Lintner).

Clin Sports Med 27 (2008) 527–551

doi:10.1016/j.csm.2008.07.007 sportsmed.theclinics.com
0278-5919/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
528 Lintner et al

proximally may be useful to enhance our diagnostic acumen. With the importance of
the kinetic chain in mind, this article intends to provide the reader with clinically
relevant biomechanics and injury patterns seen in baseball throwing and batting
and tennis.

THE PRACTICAL BIOMECHANICS OF THROWING

Repetitive throwing of a baseball at high velocity places tremendous stresses on the

upper extremity. Given the popularity of youth baseball, the advent of year-round play,
and the seeming increase in elbow and shoulder injuries in throwers of all ages, it is
incumbent on the sports medicine physician to understand the basic mechanics of
the overhand throwing motion to help diagnose and treat these injuries. In addition,
an understanding of these mechanics is helpful when educating parents and coaches
about the interplay of poor mechanics and injury.
By understanding the biomechanics of throwing, the physician will have an under-
standing of how the details of the patient’s history help make the diagnosis. Similarly,
knowledge of the mechanics of throwing can help the physician fine-tune the physical
examination to clarify the diagnosis. For example, medial elbow pain during the throw
may originate from pathology of the ulnar collateral ligament (UCL), common flexor
tendon, or ulnar nerve, among other structures. By knowing which phase of the throw
is painful and correlating this with the structure under the most stress during that
phase, the physician can narrow the diagnosis through the history. Similarly, by mim-
icking, during examination, the stresses on specific structures during the painful
phases of throwing, the player’s symptoms can often be reproduced and traced to
a structure.

Phases of Throwing
The phases of overhand throwing have been well described.1,2 Because of the consis-
tency from player to player, the baseball pitch is used to illustrate these phases.
The 6 phases of throwing are separated by distinct changes in the throwing motion,
and these motions have direct impact on the stresses applied to the musculoskeletal
system and thus implications for injury.
The windup commences with the first movement of the pitcher and ends when the
hand leaves the glove. The stride phase begins when the hand leaves the glove and
ends with the lead foot striking the ground (Fig. 1). The cocking phase then begins.
Cocking ends when the shoulder has reached its maximal ER. Early acceleration
begins when the shoulder has maximally externally rotated (Fig. 2A) and transitions
into late acceleration, which ends when the ball leaves the hand (Fig. 2B). The decel-
eration phase starts when the ball leaves the hand and ends when the shoulder has
reached its maximal internal rotation (IR) (Fig. 3). The final phase, follow-through,
ends when the pitcher has reached a balanced fielding position (Fig. 4).
The stresses on the shoulder, elbow, trunk, and legs are highest in the cocking and
acceleration phases.3–6 In particular, the transition from cocking to acceleration is the
most dangerous stage and is when most upper extremity injuries occur. The next most
dangerous phase is just after ball release.5 Applying the principles of biomechanics to
throwing explains why.
It is important to realize that the overhand throw is a sequential motion of a kinetic
chain. Each body segment accelerates in order from lower to higher. Each lags behind
the adjacent lower segment, then accelerates past it at even higher velocity. This has
been compared with a ‘‘double pendulum’’ or a child’s ruler composed of 2 rigid seg-
ments hinged in the middle (Fig. 5).7 As the lower segment moves forward, the upper
 Injury Patterns and Biomechanics 529

Fig.1. Stride phase. At the end of the stride phase, the pitcher’s stride forward coupled with
the extension of the hand behind the center of rotation lengthens his body along the
horizontal axis. This maximizes the rotational torque available to be applied to the ball.
(Courtesy of Kimberly A. Yee, MD.)

segment lags behind. As the lower segment nears the end of its arc, the upper
segment accelerates and moves past the lower segment at an even faster rate. The
overhand throwing motion is also similar to the cracking of a whip. The whip is cocked
with a slower backward movement of a rigid handle with the velocity of the whip
increasing through the principles of leverage. Around that stable base, the whip handle
changes direction and moves suddenly forward while the tail is still moving backward.
The relative velocity of the proximal and distal segments thus increases suddenly, and
the tip will snap from a backward to forward direction. It will accelerate forward from
this maximally extended position to catch up to and pass the handle as it moves
toward its target. The stress on the whip is greatest at the moment of direction change,
creating the characteristic cracking sound.

Fig. 2. Acceleration: (A): The lower extremity, pelvis, and chest rotate toward the target as
the shoulder lags behind. (B): The lumbar spine is in extension, increasing the lever arm
further. (Courtesy of Kimberly A. Yee, MD.)
530 Lintner et al

Fig. 3. Deceleration: The lower extremities and pelvis provide a stable base for continued
trunk and shoulder rotation. Note the lack of change in the position of the belt buckle.
In addition, the lower extremities have changed little other than straightening of the
knee as the pitcher vaults over this lever while the shoulder has internally rotated almost
180 degrees. (Courtesy of Kimberly A. Yee, MD.)

Biomechanics of Throwing
The act of throwing is essentially the development of potential energy, its transforma-
tion into kinetic energy, and its application to the ball to deliver it at a high velocity. This
energy is created as the kinetic chain coils (windup), elongates forward and is then
firmly anchored to the ground (stride), and then further elongates rearward (cocking).
The conversion to kinetic energy begins as the hips, trunk, and then the arm move
forward in sequence (acceleration), rotating around a stable axis toward the target
through ball release.
The highest forces and the highest risks of injury occur during the transition from
late-cocking to early-acceleration phases. This is marked by a sudden transition

Fig. 4. Follow-through: By allowing the arm to fully pass across the body during the follow-
through phase, the pitcher allows the deceleration forces to dissipate through the large
muscles of the trunk and scapular rotators over a longer period of time. This is thought
to protect the posterior cuff muscles. (Photograph courtesy of Steve Wilson, MD.)
 Injury Patterns and Biomechanics 531

Fig. 5. A hinged ruler: rigid segments connected by a hinge. As the lower segment moves
forward, the upper lags behind, then moves forward and past the lower at an even greater
speed. (Courtesy of Kimberly A. Yee, MD.)

from ER of the shoulder to IR, and this transition places high stresses on the shoulder
and elbow. Therefore, our attention will focus on this stage.
While the thrower progresses through the stride phase, the hips and trunk are
sliding, rotating, and forward flexing toward home plate (see Fig. 1). Once the foot
is securely fixed to the ground, this hip and trunk movement accelerates into the
last stages of cocking. The pelvis rotates toward the target at approximately 600
degrees/second.4 The trunk follows, with the upper torso rotating at approximately
1000 degrees/second.4 This velocity is almost twice that of the pelvis and demon-
strates the whip-like mechanics of the overhand throw—as you move up the kinetic
chain, each segment of the chain moves faster than the one before.
While cocking continues, there is a maximal elongation around a vertical axis as the
hand continues to move away from the target as the hips and trunk move toward it (see
Fig. 1). From a bird’s eye view, this maximal length is created by the sequential rota-
tion of the hips, pelvis, then torso, plus the hyperextension of the lumbar spine.8
Essentially, the pelvis is thrust forward as it turns toward the target, and the trunk
follows. While this occurs, the shoulder is still horizontally abducting and externally
rotating, causing the hand to move away from the target while the body moves toward
it. This creates an increase in the velocity of ER at the shoulder compared with the
movement of the trunk. However, this abruptly changes as the thrower enters early
acceleration (see Fig. 2) and the shoulder begins to rotate internally.5 This places
the maximal ER torque on the shoulder, which must be matched by the body’s appli-
cation of IR torque forces. This IR torque is supplied by the major internal rotator mus-
cles of the shoulder girdle: pectoralis major, anterior deltoid, latissimus dorsi, and
subscapularis.4 These muscles begin firing eccentrically during the late cocking phase
as they work to decelerate the shoulder’s ER. As the trunk moves forward, the pector-
alis, anterior deltoid, and subscapularis exert an anteriorly directed pull on the
humerus to keep it moving forward and not lagging behind the trunk. This action,
plus the centering effect of the rotator cuff, minimizes shear and translation of the
humerus on the glenoid.4
During late cocking, as the trunk moves forward, the arm lags behind as it horizon-
tally abducts and externally rotates. The shoulder abducts to 94 degrees, externally
rotates 165 degrees, while horizontal adduction approaches approximately 11 de-
grees.5 The elbow flexes to approximately 95 degrees. Once the shoulder reaches
its maximum ER (MER) and reverses direction into the acceleration phase, the shoul-
der rotates internally (Figs. 2 and 3), creating an IR torque of approximately 67 Nm at
the shoulder during the transition from ER to IR. Similarly, this sudden change in direc-
tion creates a high valgus torque of approximately 64 Nm at the elbow, which must be
532 Lintner et al

resisted by the tissues of the elbow.5 This results in a distraction force medially and
a compression force laterally, the magnitude of which is determined by the angular
velocity of the shoulder and the lever arm of the forearm at the elbow.
This has important implications for mechanisms of injury. An increased amount of
ER correlates with increased throwing velocity7,9,10 as well as to the amount of stress
on the anterior shoulder and anterior elbow.2 The transition from rapid ER to IR puts
a ‘‘slingshot’’ or whip-like stress on the passive and dynamic restraints of the shoulder.
The angular velocity of the IR of the shoulder is approximately 7000 degrees/second
and is the fastest human motion recorded.1,2,4,5,11,12 Shear forces of 310 N anteriorly
and 250 N superiorly develop at the glenohumeral (GH) joint surfaces.5 The rotator
cuff, capsule, and labrum must counter these shear forces. Failure to maintain the
humeral head centered on the glenoid is thought to lead to shear injuries of the anterior
labrum because it is entrapped beneath the subluxed humeral head under high com-
pressive and shear forces. This, in turn, diminishes the centering capability of the static
restraints, which leads to increased stress on the rotator cuff, which is already over-
whelmed. This may lead to intrinsic failure of the rotator cuff itself. Similarly, increased
ER coupled with a tight posterior-inferior capsule may result in increased posterior-
superior translation of the humeral head and contribute to posterior-superior labral
‘‘peel back’’ lesions.12,13
The elbow sees considerable forces as well, with an estimated 34.6 Nm with each
throw being borne by the UCL.14 Intriguingly, cadaveric studies of the UCL of the
elbow have shown a maximum load bearing capacity of 32 Nm.14 Thus, with each
throw, the UCL is theoretically loaded beyond it s capacity. According to Morrey
and An15 the UCL provides 54% of the total varus torque at the elbow (resisting the
applied valgus load), with the lateral compartment bearing the remainder as a com-
pression load. While the strength of the UCL in cadaveric studies may underestimate
its strength in vivo, the dynamic stability contributed by the flexor mass and joint com-
pression from the bicep and tricep may help shield the UCL. Nonetheless, the UCL is
under a high load with each throw.
The position of the elbow contributes to the force on the shoulder and humeral shaft
as well as on the UCL, by determining the length of the lever arm through which axial
torque is applied to the humerus. This axial torque determines the risk of torsional frac-
tures of the humerus6,16 and the magnitude of the ER torque applied to the shoulder and
valgus applied to the elbow. With the elbow at 90 , the lever arm is maximal because the
forearm is perpendicular to the axis of humeral/shoulder rotation. If the elbow is ex-
tended or flexed beyond 90 degrees, the lever arm diminishes. In most experienced
pitchers, the elbow begins to extend just before the end of cocking, diminishing the tor-
que on the humerus and shoulder. A delay in this elbow extension is a common
mechanical flaw that may increase the risk of injury.4,17 Sabick and colleagues6 calcu-
lated the typical peak axial torque applied to the humerus during baseball pitching as 92
Nm. This axial torque exceeds the maximal torque strength of adult cadaveric humeri.
Professional pitchers have been found to have hypertrophic humeral cortices, with the
calculated stress of each pitch being approximately 48% of the maximal torque load of
the humerus. However, in some pitchers, the peak torque has been calculated at 128
Nm, thus approaching catastrophic failure.6,16 Also, submaximal rotational torque
loads are thought to play a role in proximal humeral physeal ‘‘stress’’ injuries (‘‘Little
League shoulder’’) and acquired humeral retroversion in youth pitchers.18,19 Though
it may seem intuitive that a prior stress reaction or stress fracture may lead to or corre-
late with later catastrophic humeral fracture, there are no published data to support this.
In fact, Ogawa and Yoshida16 notes in their series of 90 recreational throwers with hu-
meral shaft fractures that none had a prior history or prodrome before their injury.
 Injury Patterns and Biomechanics 533

As acceleration continues, the rotator cuff supplies a compression force at the GH

joint of approximately 480 N.5 The lead knee straightens to brace the hips and trunk,
which flex forward leading the arm toward the target. The majority of trunk rotation has
occurred by this time, and the legs and pelvic muscles provide a stable platform for the
trunk to move forward and rotate, followed in sequence by the shoulder, elbow, and
hand.8 Though the sideways tilt of the trunk may make it seem that the arm angle
relative to the torso has changed, in fact the arm stays at approximately 90 to
94 degrees abduction throughout.4 The shoulder internally rotates from 165 degrees
to approximately 64 degrees at ball release with an angular velocity of approximately
7000 degrees/second (Figs. 3 and 4).5
As the arm moves forward, the elbow extends to about 25 degrees at ball release.
The bicep eccentrically resists elbow extension and provides a compression force
across the GH joint.19 The shoulder remains at approximately 93 degrees of abduction
and almost in the coronal plane (6 degrees adduction).5 The arm may appear more ad-
ducted than this, but this is the result of the torso continuing to rotate past the target
(counterclockwise in a right-handed pitcher viewed from above). Compression of the
GH joint is maximal at ball release, reaching approximately 1100 N.5 Anterior shear
diminishes to 80 N, and mild inferior shear develops (110 N).5 Near ball release, the
compressive force on the glenoid approximates the body weight and is 2 to 3 times
greater than the other forces applied to the shoulder.4 The wrist flexors and pronator
teres are very active at ball release as the pitcher ‘‘finishes’’ his pitch by applying spin
as he releases. This final force application to the ball comes from the wrist and finger-
tips as backspin (4-seam fastball), topspin (curveball), or sideways spin (slider) is
applied.
The elbow flexors decelerate the elbow just short of full extension (fastballs)4 except
on curveballs where the pitcher will ‘‘snap off’’ his curve by allowing his elbow to
(hyper)extend to generate additional topspin. This is associated with posteromedial
pain as synovial impingement and/or valgus extension overload can occur.
During the deceleration phase, the trunk and hips continue to flex, braced by the
extended knee. The shoulder continues to internally rotate to approximately 0 degrees
and horizontally adduct. The rotator cuff and shoulder girdle musculature apply a pos-
terior and abduction force to slow the arm’s movement. The infraspinatus, teres minor
and major, latissimus dorsi, and posterior deltoid are all quite active in this stage, the
teres minor most of all. These are eccentric loads that may result in tensile injury to the
posterior rotator cuff.4,5,20,21 At this time the shoulder is in maximal IR while adducted
in front of or across the chest. This resembles the Hawkins impingement position and
the greater tuberosity may impinge under the coracoacromial arch.22
By definition, the follow-through phase begins at the time of maximal shoulder IR.
During follow-through, the trunk flexes and the shoulder moves through horizontal
adduction. The serratus anterior, middle trapezius, and rhomboids are most active
at this stage: the serratus isometrically/concentrically stabilizing the scapula against
the chest while the trapezius and rhomboids decelerate the scapula (Fig. 4).4 For
a given arm velocity, a longer follow-through will dissipate the stresses over more
time, decreasing the peak load on the posterior rotator cuff. It is accepted by baseball
athletic trainers and pitching coaches that a short or abrupt deceleration phase is as-
sociated with shoulder injuries. Clinically, these are seen as tensile failure injuries to
the posterior rotator cuff or traction injuries to the superior labrum through the eccen-
tric load on the biceps (eg, superior labrum from anterior to posterior [SLAP]).23,24
Studies have shown that the hand and ball velocity are due primarily to leg, hip, and
trunk movement.7,25–27 The velocity of rotation is magnified as each link in the kinetic
chain rotates on the adjacent segment, which is itself rotating. At maximum velocity,
534 Lintner et al

they all rotate toward the target. The pelvis rotates at 600 degrees/second, starting
before trunk rotation. The pelvis essentially pulls the trunk toward the target by leading
the way. The trunk rotates at 1000 degrees/second, pulling the shoulder toward the
target.4 The shoulder at its peak rotates at approximately 7000 degrees/second,
pulling the elbow toward the target, which then hinges toward the target at a velocity
of approximately 4000 degrees/second5,11 on top of the already rapidly moving hu-
merus much like a child’s segmental ruler. At times of maximum stress, the segments
rotate in opposite directions with the peak stress at the time of transition from opposite
to same directions like a whip snapping from a backward to forward position or a ball
bouncing off a wall.

Throwing Biomechanics Summary

The overhand throw is similar to the cracking of a whip. The handle of the whip (the
trunk of the athlete) starts by moving back and away from the target until the tip of
the whip (the hand holding the ball) has passed behind the handle. After a brief pause,
the handle moves forward while the tip is still moving backward until the maximum
length is achieved. At this point, the tip violently reverses direction and accelerates
forward in segmental fashion, each segment moving on the fast-moving preceding
segment, creating maximum velocity at the tip.
In the human throw, the windup and stride phases represent the loading of the whip.
The potential energy is stored as the arm is loaded. Once late cocking has occurred,
the direction of shoulder rotation changes abruptly from external to internal. As in the
whip, this is a violent transition and places high stresses on the shoulder and elbow. At
this stage, the anterior capsule of the shoulder and the UCL of the elbow are under
maximal stress. Thus, anterior shoulder pain is typically related to instability or anterior
labral pathology, and medial elbow pain at this phase is most likely due to UCL pathol-
ogy. At ball release, stress on the UCL is less, and the flexor pronator group is active
because the pitcher applies spin to the ball. Medial pain during this phase is more
commonly from pathology of the common flexor tendon. During deceleration, the pos-
terior rotator cuff muscles are under high eccentric loads, and posterior shoulder pain
during deceleration may indicate pathology of the teres minor and/or infraspinatus.
An understanding of the fundamental mechanics of throwing can aid the physician
in making an accurate diagnosis of the painful thrower’s shoulder and elbow. The
details of the history indicate which structures are most likely to be involved, and
the physical examination can be tailored to more closely mimic the positions during
the throw to further narrow the diagnosis.

THE BIOMECHANICS OF BATTING

Despite an interest in hitting dating back to the beginning of baseball, there has been
little scientific research on this topic. This is especially true in contrast to pitching and
is probably due to the preponderance of upper extremity injuries from pitching.
Nonetheless, hitting is clearly important from a performance standpoint, and is still
a source of injury. Injuries emanating from batting more often involve the trunk—the
thoracolumbar spine and supporting musculature. The lower extremities are also
integrally involved in the hitting motion—though they are less commonly injured, their
function is critically important to performance.
One of the first scientific studies performed on hitting was conducted by Race28 in
1961. With the aid of a 26-mm movie camera, he studied the swings of 17 minor league
players and presented one of the first qualitative and quantitative analyses of the
baseball swing. More recently, Welch and colleagues29 more precisely defined the
 Injury Patterns and Biomechanics 535

biomechanics of the baseball swing. They studied 7 professional male baseball

players at an indoor biomechanics facility. Reflective markers were placed on the hit-
ter, bat, and ball, and the movement of these markers was then captured by 6 cameras
at a rate of 200 frames/second. In addition, the 3-dimensional ground reaction forces
were measured for each foot using force plates.
The reference frame was defined as the 3-dimensional system in which the relative
movement of the body was measured (Fig. 6). The positive X axis was defined as the
direction from home plate to the pitching rubber and parallel to the surface of the bat-
ter’s box. For a right-handed batter, when looking in the positive X direction, positive Z
was defined as pointing superiorly and positive Y was defined as pointing to the left.
The relative movement of the center of pressure between the 2 feet and the body’s
calculated center of mass in the global X direction was measured as an indication
of dynamic balance and forward momentum. Three body segments were defined:
hips, shoulders, and arms. The hips were defined as a vector from the right hip to
the left hip. The shoulders were defined as a vector from the right shoulder to the
left shoulder, and the arms were defined as a vector from mid-shoulders to mid-wrists.
The axis of rotation was defined as the axis of the trunk from mid-hips to mid-
shoulders, and the rotation was measured with respect to the X axis.
In an earlier study,30 the swing was divided into 4 phases (Fig. 7): 1. Windup—
begins as the lead heel leaves the ground and ends as the lead toe recontacts the
ground; 2. Pre-swing—begins as the lead forefoot strikes the ground and ends as
the swing begins; 3. Swing—early swing from initiation of bat movement until the
bat is perpendicular with the ground; middle swing until the bat is parallel with the
ground; late swing until ball contact occurs; 4. Follow-through—begins with ball
contact and ends as the lead shoulder reaches maximum abduction and ER.
In the study by Welch and colleagues, 3 key events were chosen for the identifica-
tion of key mechanical transitions. The first was foot off, defined as the instant the front
foot broke contact with the ground and began to stride (the beginning of windup). The
second was foot down, defined as the instant the front foot made full contact with the

Fig. 6. Batter orientation and movement. (A) Global reference frame. (B) Stride parameters.
(C) Segmental rotation around the axis of the trunk (AOT) (From Welch MW, Banks SA, Cook
FF, et al. Hitting a baseball: A biomechanical description. J Orthop Sports Phys Ther
1995;22(5):193–201; with permission.)
536 Lintner et al

Fig. 7. Phases of batting swing. (From Shaffer B, Jobe FW, Pink M. Baseball batting. An elec-
tromyographic study. Clin Orthop Relat Res 1993;292:285–93; with permission.)

ground, ending stride (the beginning of pre-swing). The third was ball contact, defined
as the instant the bat made contact with the ball (the beginning of follow-through).
The swing initiates with a weight shift toward the back leg. At roughly the same time,
the upper body rotates in a clockwise direction (for a right-handed batter) around the
axis of the trunk, initiated by arms and shoulder and followed closely by the hips. This
begins the coiling process.
Immediately following the initiation of coiling, the front leg lifts, and the front foot
breaks contact with the ground, increasing the total force applied by the back foot
to a value of 102% of body weight. As a result, any injury to the back leg would impair
this critical function. Part of the total force applied by each foot is shear force acting
parallel to the ground in the X and Y directions. At foot off, the center of pressure
moves in the negative X direction toward the back foot to a point 20 cm behind the
center of mass. At foot off, the arms in a right-handed batter rotate 150 degrees clock-
wise, the shoulders 30 degrees, and the hips 18 degrees.
As the stride continues toward foot down, the hips rotate to a maximum rotation of
28 degrees, 0.350 seconds before ball contact. At that instant, they change direction
and begin to rotate counterclockwise. The shoulders continue to rotate clockwise,
reaching a maximum rotation of 52 degrees, 0.265 seconds before ball contact. The
shoulders then change direction and follow the lead of the hips in a counterclockwise
rotation toward the ball. The arms, at the same time, continue in a clockwise rotation
around the axis of the trunk, increasing the coil of the upper body against the move-
ment of the hips and shoulders.
At foot contact, the front foot touches the ground and defines stride length. In the
study by Welch and colleagues,29 the mean stride length was 380% of hip width. At
this point, the arms reach full clockwise rotation and begin counterclockwise rotation.
Weight shifts forward as the heel of the front foot makes contact with the ground. The
total force applied to the back foot decreases to 58% of body weight. The center of
pressure makes a dramatic shift forward in the X direction to a point 20 cm ahead
of the center of mass. The front leg extends at the knee, pushing the front hip back-
ward, while the back leg pushes the back hip forward. This creates a counterclockwise
acceleration of the hips around the axis of the trunk. The rotational velocity of the of the
hips increases to a maximum of 714 degrees/second, at 0.075 seconds before ball
 Injury Patterns and Biomechanics 537

contact. The shoulders and arms follow, accelerating to a maximal rotational velocity
of 937 degrees/second and 1160 degrees/second, respectively, 0.065 seconds be-
fore ball contact. At the same time, the bat moves around the axis of the trunk, increas-
ing in both angular velocity and linear velocity.
The two main components of linear movement are anterior (away from the body in
the negative Y direction) and downward (in the negative Z direction). The anterior
velocity of the bat away from the body increases to 19 m/secondat 0.040 seconds
before ball contact. At the same time, the downward movement of the bat increases
to a maximum velocity of 16 m/second. The linear motion of the bat then becomes
dominated by an increase in the positive X direction toward the ball, while the Y and
Z components of linear velocity decrease in magnitude. Nearing the point of impact,
the speed of the bat reaches its maximum value of 1588 degree/second at
0.020 seconds before ball contact.
At ball contact, the front leg acts as a block, flexing 15 degree at the knee and
applying a total force to the ground equal to 84% of body weight. The back leg acts
in a support role, flexing 45 degree at the knee and applying a total of 16% of body
weight to the ground. After ball contact, the body acts to slow itself and the bat
through eccentric contraction using the larger muscle groups. These eccentric con-
tractions generate significantly higher forces than concentric contractions and act
as a potential source of injury. For example, the most common cause of shoulder injury
in batting is an attempted check swing. In doing so, the batter enters the follow-
through phase abruptly and attempts to rapidly decelerate the bat. The rear shoulder
generates large muscular forces, which can posteriorly subluxate the shoulder and
tear the posterior labrum.
An additional, but unrelated, source of shoulder injury in the follow-through phase is
experienced by the lead shoulder in batters who release the top hand. In doing so, the
lead shoulder can be forcefully propelled into a position of extreme abduction and ER,
increasing forces in the anterior capsulolabral structures. Anterior subluxation and
labral tearing can result.
Thus, much like a golfer, a hitter generates bat speed using a kinetic link,31,32 in
which large base segments pass momentum to smaller adjacent segments. When
a large base segment decelerates, the velocity of the remaining system increases
as it receives the momentum lost by the base segment.
The hitting motion can be broken down into 2 components of motion: rotational and
linear. The rotational component involves the movement of segments around the axis
of the trunk. A hitter starts the swing with clockwise rotation (right-handed hitter) of the
arm, shoulder, and hip segments, while shifting weight toward the rear foot. This
action can be considered the act of loading or coiling. It is important that the hip
segment starts counterclockwise rotation before the shoulder segment, which, in
turn, should start before the arm segment. This sequence allows the kinetic link sys-
tem to incorporate the musculature of the trunk and upper extremity through preload.
The linear component is the forward movement (positive X direction) of the body. By
shifting weight to the rear foot, the hitter moves the center of pressure behind the
position of the center of mass. As the swing progresses, the center of pressure moves
toward the center of mass and propels the body forward.
As the hitter’s stride foot makes contact with the ground, the linear component and
the rotational components interact with each other. The interaction of the two compo-
nents determines how the kinetic link is used. At foot down, the center of pressure
moves ahead of the center of mass. The application of shear forces by the feet pro-
duces a force couple at the hip segment, facilitating its counterclockwise rotation
around the axis of the trunk. At this point, the hitter can emphasize either the rotational
538 Lintner et al

or the linear component. If the rotational component is emphasized, the center of

pressure aligns itself with the center of mass between both feet. This allows significant
shear force to be applied by each foot and increases the force couple applied to the
hip component. If the linear component is emphasized, then the center of pressure
stays in a forward position at the lead foot, and the center of mass moves to align itself
over the lead leg. In this case, the only significant shear force is produced by the lead
foot, reducing the force couple applied to the hip segment for acceleration.
Regardless of individual mechanics, the hip segment accelerates around the axis of
the trunk to a maximum velocity. The hip segment then decelerates as the shoulder
segment accelerates. Timing is critical for the most efficient acceleration of each
successive segment, culminating with the bat. Proper timing leads to successively
higher rotational velocities, which, in turn, produce bat speed and power. These
high rotational velocities create a lot of torsional stress on the thoracolumbar spine.
Though acute disk rupture is uncommonly seen, degenerative changes in this region,
especially in veteran players, commonly occur.
Muscle activity during the baseball swing has also been investigated. Shaffer and
colleagues30 studied 18 professional baseball players using electromyography.
Fine-wire electrodes were placed into the supraspinatus, triceps, posterior deltoid,
and middle serratus anterior of each subject’s lead arm and the lower gluteus maxi-
mus of their back leg. Surface electrodes monitored right and left erector spinae,
abdominal obliques, vastus medialis obliques (VMOs), the semimembranosus, and
the biceps femoris of the back leg.
Activity levels during windup are relatively low except in the back leg hamstrings.
During this period of single-leg stance, hamstring activity maintains hip extension as
weight shifts to the back leg in preparation for swing. In the pre-swing phase, the ham-
strings and lower gluteus maximus have a high level of activity, indicating their role in
hip stabilization and initiation of power. Both lead and trail erector spinae and abdom-
inal oblique muscles are also active at this time for trunk stabilization and power
generation. As the body lowers during pre- and early swing, posterior deltoid and
triceps activity increase to maintain lead shoulder elevation.
During pre-swing and early swing, there is increased activity in the VMO, which pre-
vents collapse of the flexed back leg and promotes push-off to facilitate force transfer.
When the weight transfers to the lead leg, hamstring and gluteus maximus activity in
the back leg declines. Trunk activity, in both erector spinae and the oblique muscles,
remains high throughout swing, with erector spinae activity declining just before ball
contact. This demonstrates the importance of the trunk in power transmission as
the body uncoils. This further explains why the trunk is a source of injury from batting.
The triceps and posterior deltoid show decreasing yet persistently high activity,
throughout the swing, which suggests that they play a positioning role. Although
they may contribute to power generation, their decreasing levels suggest they are
not the main drivers. Activity levels in the lower and upper extremities were low during
follow-through, except for the VMOs, which maintained an extension force on the
flexed back knee. Back and abdominal oblique activity levels remained high, maintain-
ing trunk rotation and stabilization.
In summary, lower-extremity groups appear important in early pelvic stabilization
and power generation. The hamstrings maintain hip stabilization in addition to initiating
rotation in the uncoiling mechanism. VMO activity increases throughout the swing, as
the lower extremity pushes against the ground to contribute to the forward thrust of
the pelvis and trunk. The posterior deltoid and triceps appear to be more important
in positioning than power generation. The middle serratus anterior and supraspinatus
do not significantly contribute to the swing.
 Injury Patterns and Biomechanics 539

The uncoiling of the wound-up pelvis, trunk, and upper extremities on a stable base
provides the power of the baseball batting swing. There is a sequence of activity, from
the lower extremities (the most active group in pre-swing) to the trunk (highest in early
swing), to the upper-extremity muscle groups. This observation correlates with the
kinematic findings previously discussed in which the swing is generated by the kinetic
chain composed of the hips, shoulders, and arms.

INJURY PATTERNS AND BIOMECHANICS OF THE TENNIS PLAYERS’ SHOULDER

Introduction
Tennis is a violent game to the shoulder. It requires multiple repetitions of large ranges
of motions and high forces during all strokes. These stresses place high demands on
the intrinsic and extrinsic force generation and musculoskeletal constraint systems as
the athlete strives for maximal performance with minimal injury risk. Because of its
central location in the kinetic chain, the shoulder is the focal point for force transfer
and experiences the highest loads of any individual kinetic chain segment.33 This
frequently results in injury, loss of performance, and/or adaptations in the shoulder
and its surrounding structures. The shoulder is a crucial link in efficient kinetic chain
function. However, the shoulder, because of its inherent instability and relatively small
musculature, is dependent on the kinetic chain to minimize the forces that can disrupt
the joint structures. This article reviews shoulder injuries in tennis, describes the
known forces on the shoulder, provides an overview of kinetic chain strategies for
responding to the demands, and suggests methods of evaluation and treatment of
shoulder injuries.

Injury Patterns
Shoulder injuries are common in tennis players of all ages and skill levels. A compre-
hensive review of published studies in competitive young (12- to 18-year-old) players
revealed that shoulder injuries represented 25% to 47% of all arm injuries and 7% to
16% of all reported injuries, ranking it second among anatomic areas.34 Most of the
injuries were strains, implicating a process of injury over time, with chronic overload
leading to injury.33 Injury surveys in older elite tennis players show the same distribu-
tion and types of injuries, with the shoulder ranking second or third in frequency of
injury and with non-contact overload-type injuries predominating.35 None of the stud-
ies differentiated the injuries into specific diagnostic categories, so the true incidence
of specific injuries is not known. Most commonly surgically treated problems are labral
injuries. Complete data on this subject are being compiled by both the men’s (ATP)
and women’s (SANEX WTA) professional tours.
Based on anecdotal reports from physicians who routinely treat tennis players and
from several studies that have examined the physical characteristics of tennis players,
it appears that the pathologic process that creates most of the shoulder injuries that
limit play is the ‘‘cascade to injury’’ represented by acquisition of a GH IR deficit, scap-
ular dyskinesis, and GH hyperangulation, with eventual production of a superior
glenoid labral lesion, a partial rotator cuff injury, and other pathology, including biceps
tendinopathy and increased GH translation.33,36 This is the same pathologic process
that occurs in baseball pitchers.

Inherent Demands of Tennis at on the Shoulder

The shoulder faces high loads in playing tennis. Elite players reach rotational velocities
of up to 1700 degrees/second, resulting in arm velocities of up to 72 miles/hour on the
serve.37 The 1-hand backhand stroke generates rotational velocities up to
540 Lintner et al

900 degrees/second (arm velocities of 34 miles/hour), whereas the open stance fore-
hand generates 280 degrees/second, which with trunk rotation through the kinetic
chain created arm velocities of up to 46 miles/hour.37
Ranges of motion were found to be correspondingly large. Total arc of rotational
motion (internal 1 ER) was between 160 and 180 degrees, and the highest point of
abduction was between 140 and 160 degrees.37
Torques generated in the serve by these loads and motions were found to be high at
the 2 critical times of MER and acceleration to ball impact (ABI). At MER, males
recorded 65 Nm and females 46 Nm. At ABI, males recorded 70 Nm and females
50 Nm. Torques greater than 50 Nm are considered a significant and potentially
injurious factor in loading of the upper extremity, so those inherent loads have the
potential to create overload injury.38
The deceleration force between the trunk and the arm at ball impact and follow-
through is up to 300 Nm. This is required to stabilize and support the shoulder against
the distraction forces that equal 0.5 to 0.075  body weight.
These loads are placed on the shoulder with every stroke. The numbers of strokes
per match vary greatly, depending on the type of match, skill level, opponent, and
playing surface. The average elite tennis match will involve at least 100 repetitions
of ‘‘game’’ serves and 250 repetitions of ‘‘game’’ ground strokes.39 In junior tennis
tournaments in scholastic or collegiate tennis, these numbers are larger, because
2 to 3 matches may be played per day. These numbers do not include the number
of ‘‘practice’’ strokes, which in most estimates is 4 to 5 times higher.

The Kinetic Chain

The kinetic chain is the biomechanical system by which the body meets the inherent
demands of tennis. It generates the required forces and helps to regulate and modify
loads seen at the joints, especially the high loads at the shoulder.40
In the normally operating kinetic chain, the legs and trunk segments are the engine
for force development and the stable proximal base for distal mobility.37,38,41 This link
develops 51% to 55% of the kinetic energy and force delivered to the hand,41 creates
the back leg to front leg angular momentum to drive the arm forward,40,42 and because
of its high cross-sectional area, large mass, and high moment of inertia, creates an
anchor that allows centripedal motion to occur.38,43
The functional result of this stable base is considered to represent core stability.44 In
addition to generating force in the trunk and leg segments, kinetic chain activation
through the core also generates force in the distal segments through the creation of
interactive moments or forces generated at joints by the position and motion of adja-
cent segments.45 At the shoulder, the interactive moment produced by trunk rotation
around a vertical axis is the most important factor in generating forward arm motion,
and the interactive moment produced by trunk rotation around a horizontal axis from
front to back is the most important factor in generating arm abduction.39
The remaining kinetic chain segments play smaller roles in intrinsic force generation,
mainly due to their smaller cross-sectional area and the production of interactive
moments. The shoulder only produces 13% of the total kinetic energy for the entire
service motion. The high velocities and forces seen at the shoulder are predominantly
produced through kinetic chain activation.
The shoulder functions in the kinetic chain primarily as a funnel, transferring the
forces developed in the engine of the core to the delivery mechanism of the hand.41
Efficient activation of the segments within the kinetic chain regulates the loads seen
at distal joints.40 In addition, the kinetic chain can modify loads at the shoulder by
aligning the bones of the GH articulation so that ball and socket kinematics to produce
 Injury Patterns and Biomechanics 541

concavity/compression and stabilize the joint may be maximized throughout the

majority of the range of motion of the shoulder. Coordinated coupled motions of the
humerus and the scapula (scapulohumeral rhythm—SHR) keep the GH angle within
30 degrees of the plane of the scapula. This angle minimizes muscle activations
required for joint stability,46 keeps the compression forces directed into the concavity
of the glenoid,47 and minimizes strain of the GH ligaments.48 These actions maximize
the shoulder’s role as a funnel for transfer of forces.

Kinetic Chain Activation and Nodes

Kinetic chain activation is required to generate the forces and motions at the shoulder
to produce the 2 most important individual biomechanical functions in the tennis
serve. The first is long axis rotation, coupled with shoulder IR and forearm pronation,
which produces the most force at ball impact.42 The second is maximum shoulder
abduction, which decreases shoulder impingement in acceleration and allows the
hand to go up and through the ball in follow-through to create topspin.
Since the kinetic chain is composed of multiple segments, there are multiple (up to
244) degrees of freedom or possible combinations of segment activations. Efficient
kinetic chain activation requires minimization of the degrees of freedom in the sys-
tem.49 ‘‘Nodes’’ are specific segment positions and motions that are determined to
be fundamental for efficient linkage and sequencing of multiple segments in a kinetic
chain.49 They have the effect of decreasing the degrees of freedom within a linked sys-
tem, creating maximal torques with minimal force development throughout the kinetic
chain. From data compiled from a variety of scientific studies36,38,39,42,50–53 and from
discussions with tennis coaches,53,54 it has been determined that 5 specific nodes
appear to be required in the tennis serve. These nodes are observable in the tennis
serve. In sequential order from the ground up, they are adequate knee flexion in cock-
ing progressing to knee extension at ball impact, hip/trunk counter rotation away from
the court in cocking, coupled scapular retraction/arm rotation to achieve cocking in
the scapular plane, back leg to front leg motion to create a ‘‘shoulder over shoulder’’
motion at ball impact, and long axis rotation into ball impact and follow-through
(Fig. 8). Achievement of the proper sequencing of the nodes implies the most efficient
use of the kinetic chain,40,53 which will minimize the stresses on the shoulder.
Analysis of 2 specific kinetic chain patterns in the serve will show the effect of kinetic
chain activation on the loads and performance of the shoulder. The 2 serve sequences
are ‘‘push-through/pull-through’’ kinetic chains, and traditional versus abbreviated
service motions.

Push-Through/Pull-Through Kinetic Chains

The push-through activation sequence uses knee flexion and back leg drive to maxi-
mize ground reaction forces that push the body upward from the cocking position into
ball impact and create long axis rotation in the arm. Push-through uses the large leg
muscles to provide the majority of the power,40 decreases the IR torques at the shoul-
der,50 produces greater muscle forces at the shoulder,40 allows higher degrees of
shoulder abduction to produce topspin and decrease impingement,51 and generates
greater ball velocities.39,55 This type of activation is the most efficient and is seen more
frequently in elite male players. Figs. 9–11 demonstrate EMG activation patterns in the
lower extremity that are characteristic of the push-through pattern. Figure 9 (elite
player) demonstrates the back leg to front leg progression of activation in the gastroc-
nemius and quadriceps muscles before ball impact,55 while Figs. 10 and 11 demon-
strate back leg hamstring and gluteus medius activation before ball impact (Kibler
542 Lintner et al

Fig. 8. Example of long axis rotation. (From Herbst R, McEnroe P. The interplay of tactics and
techniques. In: Roetert P, Groppel J, editors. World-Class Tennis Technique Human Kinetics.
Champaign; 2001. p. 115–29.)

unpublished data). Figure 12 demonstrates observational characteristics of push-

through activations.
Pull-through activation uses trunk muscles to pull the trunk and arm from cocking
into ball impact and create long axis rotation in the arm. Knee flexion and use of the
legs are minimized. This activation increases IR torques at the shoulder,40 creates
increased scapular protraction and GH ‘‘hyperangulation,’’56 decreases shoulder
abduction and the ability to hit topspin,51 and is associated with lower ball velocities.55
This type of activation results from lack of full use of the proximal kinetic chain seg-
ments and occurs more frequently in female elite players and recreational players. Fig-
ures 9 and 13 demonstrate EMG activation patterns in the lower extremity that are
characteristic of the pull-through pattern. Figure 9 (beginner player) demonstrates
simultaneous minimal activation of both gastrocnemius and quadriceps muscles right
at ball impact, reflecting an attempt to stabilize the body at impact rather than

Elite Beginner
Vastus Lateralis back
Vastus Medialis back

Gastrocmenius back

Vastus Lateralis front

Vastus Medialis front

Gastrocmenius front

Ball Impact

Fig. 9. Differences between beginner and elite tennis players in lower extremity muscle
activation during the tennis serve. (Adapted from Girard O, Micallef JP, Millet GP. Lower-
limb activity during the power serve in tennis: effects of performance level. Med Sci Sports
Exerc 2005;37(6):1021–9; with permission.)
 Injury Patterns and Biomechanics 543

175.00

150.00

125.00
% MVC .
100.00

75.00

50.00

25.00

0.00
-500.00 -300.00 -100.00 100.00 300.00 500.00
Time Relative to Ball Impact
Female Male

Fig. 10. Hamstring activation of non-dominant leg during tennis serve.

generate force from the legs.55 Figure 13 demonstrates nondominant external oblique
activation to pull the trunk and arm into ball impact (Kibler, unpublished data).
Figures 14 and 15 demonstrate observational characteristics of pull-through.
Pull-through activation patterns are shown to develop less stable kinematic patterns
and higher force loads at the shoulder. No epidemiologic studies have looked at the
correlations of shoulder injury with the type of service motion. However, the kinematic
pattern of GH hyperangulation and increased scapular protraction has been impli-
cated in the generation of shoulder injury,36,56 and the pattern of decreased abduction
is known to relate to impingement.57 The inefficiency of the motion is shown by higher
force loads but lower ball velocities.

Traditional versus Abbreviated Service Motions

The most common method of achieving full arm cocking before acceleration is the
traditional method of bringing the racquet and arm down in a rotary fashion and
then up into the service. This rotational path in a continuous loop helps to produce
a forward motion of the arm and racquet toward ball impact. However, there is a longer

100.00

75.00
% MVC

50.00

25.00

0.00
-500.00 -300.00 -100.00 100.00 300.00 500.00
Time Relative to Ball Impact
Female Male

Fig. 11. Gluteus medius activation of dominant leg during tennis serve.
544 Lintner et al

Fig. 12. Observable characteristics of the push-through serve are scapular retraction and
large degrees of knee flexion during cocking.

arc of motion, with the possibility of more degrees of freedom in the kinematic chain,
with more possibility of errors in the motion, especially with fatigue.58
The abbreviated service motion was developed to decrease the arc of motion,
decrease the degrees of freedom, and reduce kinematic errors. The arm and racquet
are taken back in a more vertical fashion, with minimal rotation of the trunk and
shoulder.

100.00

75.00
% MVC

50.00

25.00

0.00
-500.00 -300.00 -100.00 100.00 300.00 500.00
Time Relative to Ball Impact
Female Male

Fig. 13. Non-dominant external oblique activation during tennis serve.

 Injury Patterns and Biomechanics 545

Fig.14. Observable characteristic of the pull-through serve is the lack of knee flexion during
cocking.

Fig. 15. The hip-back position during a pull-through serve.

546 Lintner et al

Both service motions have been found to produce similar torques at the shoulder,
indicating minimal performance advantages between the two motions.53,59 However,
higher force production from the trunk to the shoulder was required in the abbreviated
serve motion to achieve the same service speed.50 In addition, the lack of rotary
motion of the trunk can lead to a hyperangulation at the GH joint as the arm is brought
in the vertical position into cocking. If this motion is used, attention must be paid to
conditioning for extra strength in the shoulder muscles and assuring proper trunk
rotation to avoid GH hyperangulation.

Kinetic Chain Breakage and ‘‘Catch-Up’’

Because of the importance of the proximal kinetic chain in developing force and
protecting the distal joints, deficits in the proximal chain result in either decreased
force delivered to the hand and racquet,41 resulting in decreased ball velocity, altered
interactive moments at the distal joints with increased forces at the joints,45,50 or
increased activation of distal segments to develop maximal forces at the hand.41,60
There are multiple methods by which the deficits may be developed, including poor
stroke techniques,61 previous injury, muscle inflexibility,34,57,62 or muscle weakness
or imbalance.36,44,63 The most common anatomic areas involved are the hip (inflexibil-
ity and decreased strength), trunk (inflexibility and altered strength balance), scapula
(scapular dyskinesis), and shoulder rotation (glenohumeral internal rotation deficit
[GIRD]).
‘‘Catch-up’’ occurs when the athlete tries to compensate for the kinetic chain break-
age by increasing distal segment activation. Deficiencies in the energy of force
production in a segment require more energy or force from other more distal segments
to develop the same force to the end segment and maintain athletic performance. This
means that the mass of the distal segments, which is usually less than that of the prox-
imal segments, must significantly increase, or the velocity of the segment, which is
already high, must increase even more. Neither increase in mass nor velocity is
easy to achieve. In the mathematical model of the kinetic chain of the tennis player,41
a 20% reduction in kinetic energy from the trunk requires a 34% increase in velocity or
a 70% increase in mass to achieve the same kinetic energy to the hand. Alteration of
normal activation sequencing can also place extra loads on distal joints. Inadequate
flexion of the knee (less than 10 degrees at MER) in cocking in the service motion,
breaking the kinetic chain push-through activation sequencing, significantly increases
shoulder IR torque at MER by 17.6% and at ABI by 18.2% in athletes who maintain the
same serve velocity.50

Summary
Tennis requires multiple repetitions of high forces and loads in all strokes, but the
serve requires the highest forces for optimal performance at any skill or age level.
These forces are optimally developed through efficient kinetic chain activation. Ineffi-
cient activation, or breakage of the kinetic chain, increases the loads on multiple distal
joints. The shoulder, because of its central location in the kinetic chain, the high loads
seen at the shoulder, and the role as a funnel for forces, is frequently the ‘‘victim’’ of the
‘‘culprits’’ that occur elsewhere in the kinetic chain. Evaluation of the tennis player with
shoulder injuries must include evaluation of the possible kinetic chain contributions.
 Injury Patterns and Biomechanics 547

CLINICAL EVALUATION
Observation of Stroke Mechanics
Review of the athlete’s stroke mechanics by video or direct observation is very helpful
to check on poor techniques. The ‘‘nodes’’ model gives a framework for the evalua-
tion. Observation of multiple repetitions of the motion and focusing on 1 node per
serve repetition can demonstrate if any of the nodes are not being used. The most
commonly deficient nodes are lack of knee flexion and hip counter-rotation, which
results in the pull-through service motion, and lack of cocking, which results in GH
hyperangulation. The observable characteristics include minimal knee flexion on ball
toss, limited hip rotation, prominence of the back hip as the player moves to ball
impact (the ‘‘hip-back’’ position), and arm position behind the scapular plane at cock-
ing (Fig. 14). If these alterations are observed, coaching techniques to improve the
mechanics can be employed,53,54,61 and physical examination for musculoskeletal
limiting factors, such as knee injury, hip weakness or rotational inflexibility, trunk inflex-
ibility, or scapular dyskinesis, should be done.

Physical Examination
The examination of the tennis player with shoulder symptoms should include evalua-
tion of the proximal factors that may influence shoulder loading. Specific attention
should be paid to evaluation of the scapula, trunk, and hip/leg. In the history, questions
should be asked about prior leg or back injury and any shoulder symptoms. Relatively
common findings include previous ankle sprain, especially on the contralateral (front
foot) side. In addition, many athletes will report previous problems with the shoulder,
contralateral knee injury, and back pain.
In the physical examination, assessment of posture while standing can check for
lumbar lordosis, which is common and decreases core trunk stability. Screening eval-
uation of the hip/leg can be accomplished by the 1-leg stability series, which includes
1-leg stance and 1-leg squat. Inability to achieve balance of the trunk over the planted
leg represents weakness of the gluteus medius and directs attention for further eval-
uation and rehabilitation efforts as part of the treatment. Hip range of motion is
frequently altered, especially in rotation on the contralateral side and can be evaluated
by seated testing of internal/ER. Trunk flexibility in flexion/extension and lateral bend
can also be evaluated by asking the athlete to bend in these directions. Exercises for
core stability, including lunges, rotations, and pelvic stability can correct these
deficiencies.44
Scapular dyskinesis, which results in loss of retraction control and increased pro-
traction, can affect shoulder loads by altering the stable platform for long axis rotation,
by limiting arm horizontal abduction into full cocking, and by creating GH hyperangu-
lation. Scapular assessment can be accomplished by evaluation of resting scapular
position and of dynamic scapular motion on arm motion. Alterations of scapular posi-
tion/motion, termed scapular dyskinesis, are common in association with tennis
injuries and are best assessed by evaluation of the prominence of the medial border
of the scapula with arm elevation and depression. Work from the authors’ laboratory
has demonstrated that the clinical observation of medial border prominence (Fig. 16)
is statistically correlated with the presence of shoulder injury and excessive scapular
IR and retraction. Further confirmation of scapular involvement in the shoulder symp-
toms can be demonstrated by the scapular correction maneuvers, the scapular assis-
tance test (SAT), and the scapular retraction test (SRT).63
The SAT evaluates scapular and acromial involvement in tennis injuries. The SAT
provides assistance for scapular elevation by manually stabilizing the scapula and
548 Lintner et al

Fig. 16. Medial border prominence of the scapula.

rotating the inferior border of the scapula as the arm moves. This procedure stimulates
the force-couple activity of the serratus anterior and lower trapezius muscles. Elimina-
tion or modification of the impingement symptoms indicates that these muscles
should be a major focus in rehabilitation.
The SRT involves manually stabilizing the scapula in a retracted position on the
thorax. This position confers a stable base of origin for the rotator cuff and often will
improve tested rotator cuff strength. The apparent strength generated by isolated
rotator cuff strength testing is improved by retesting in the scapula-retracted position.
The SRT also frequently demonstrates scapular and glenoid involvement in internal
impingement lesions. The positive posterior labral findings on modified Jobe reloca-
tion testing will be decreased with scapular retraction and removal of the glenoid
from the excessively protracted impingement position.64
The shoulder joint itself should also be evaluated closely. Shoulder rotation can be
evaluated by stabilizing the scapula and determining the end ranges of GH internal and
ER motion. Asymmetric loss of IR (GIRD) is defined as absolute IR less than
25 degrees, or side-to-side differences greater than 25 degrees. Range of motion
exercises specific for rotation should be instituted if GIRD is found. The goal is to bring
the side-to-side differences to less than 25 degrees. Rotator cuff strength should be
evaluated, and testing for labral injury and instability should be performed.

SUMMARY

Many of the injury patterns and biomechanical motions in tennis are the same as those
in baseball. However, tennis-specific kinetic chains are required for optimal force pro-
duction and minimal joint loads. As in baseball, the shoulder joint in tennis faces repet-
itive high loads and is a common site of injury. Efficient kinetic chain activation
sequences such as push-through and traditional serve motions minimize loads and
maximize ball velocity. Visual observation of progression through the nodes of the
tennis serve and physical examination for kinetic chain and local shoulder alterations
in flexibility, strength, and strength balance allow a more complete overview of the
anatomic factors influencing kinetic chain biomechanics and injury risk.

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