Impingement Syndrome of the Shoulder: Tennis Shoulder

Years back, a friend of a former colleague came to see me with left shoulder pain. I had helped him resolve prior issues in this other shoulder, so I took it as a compliment that he came back to see me when a new problem arose on the opposite side.

Given that his case was fairly typical, I think it provides a helpful example of how to quickly and properly manage acute “tennis shoulder.”

The Athlete:

  • Approximately 38 years old
  • Active military, excellent health, top-notch strength and conditioning
  • Right-hand dominant (with a history of impingement syndrome in the right shoulder), but favors his left arm when playing tennis

The Symptoms:

  • Significant sharp shoulder pain in the left AC joint
  • Approximately 50% strength loss in functional activities such as turning the steering wheel in car or holding something away from the body
  • Shoulder pain while lifting the arm
  • Inability to sleep on the left shoulder due to pain

The History:

  • No falls, accidents or episodes that would lead to shoulder symptoms
  • Competitive tennis player in his youth; recent tennis activity with his daughter on a frequent basis
  • Over the last two weeks, an increase in localized shoulder pain while lifting his arm, along with more intense point tenderness on the AC joint (tip of the shoulder)

The Examination:

  • Point tenderness, approximately the size of a dime, was easily located at the end of the left collarbone on the front of the AC joint.
  • Intense pain occurred with active motion when attempting to reach across the body with the left hand to touch the back of the right shoulder.
  • Passive extension of the shoulder, with the elbow extended and wrist pronated, maximized the stretch on the longhead of the biceps brachii muscle.
  • Manual muscle tests used to assess shoulder strength with motions including external rotation, flexion, abduction, supraspinatus elevation and extension demonstrated approximately 70% less strength than observed in the right shoulder.
  • Other tests performed to rule out issues such as shoulder joint instability, AC joint separation, nerve pathologies and an SC joint sprain were normal and symptom-free.

The Diagnosis:

Acute Impingement Syndrome of Shoulder, aka Tennis Shoulder

The Plan:

  • Discontinue tennis and all other activities that lead to shoulder symptoms for two weeks.
  • Perform consistent pendulum swings with a light weight.
  • Implement an aggressive one-week strengthening routine for external rotation (ER).
  • If strength in ER returns to approximately 90% in one week, resume pain-free weight training while continuing to avoid all overhead lifting and exercises involving the left arm crossing the midline of the body.
  • Improve posture with pain-free chest and anterior shoulders stretches.
  • Consistently massage chest muscles immediately before exercising the upper-mid back with shoulder blade retraction or “pulling together” exercises.
  • Ice the shoulder three to five times per day.
  • Consume over-the-counter anti-inflammatory medicine for a short period of time, only as needed for pain.
  • Avoid sleeping on left shoulder for two weeks.
  • Nail down a successful pre-tennis routine that will:

> Warm up the shoulder joint, AC joint and surrounding musculature

> Allow for normal mechanics and patterns for movement

> “Fire up” the shoulder’s external rotators to help decelerate the arm during the follow-through phase of the tennis swing

It was a pleasure working with this gentleman, who understood he may need to permanently limit his overhead lifting and consistently focus on the strength of his external rotators bilaterally based on his history. More imminently, I expected him to be able to return to his normal activities as an active military specialist and tennis vet within three weeks following his exam. Game, set, match!