Evaluation of the Shoulder and Elbow in the Elite Tennis Player

  • David DinesEmail author
  • Todd S. Ellenbecker
  • Jonathan Berkowitz


The evaluation of the shoulder and elbow in the elite tennis player is of extreme importance to determine the ultimate cause of the injury/pathology and prepares the foundation for the development of evidence-based rehabilitation and treatment programs. The high interplay and close association of the shoulder, scapulothoracic, and elbow articulations in the upper extremity kinetic chain make a thorough evaluation of all three regions of paramount importance regardless of the specific area of injury in the elite tennis player. The purpose of this chapter is to overview key evaluation methods for the shoulder and elbow of particular relevance to the elite tennis player to provide this foundation. Reference to descriptive findings contained in Chap.  10 will also be provided to highlight specific anatomic adaptations and musculoskeletal strength and range of motion profiling inherent in elite-level players.


  1. 1.
    Ellenbecker TS. Clinical examination of the shoulder. St Louis, MO: Elsevier Saunders; 2004.CrossRefGoogle Scholar
  2. 2.
    Ellenbecker TS, Wilk KE. Sport therapy for the shoulder. Champaign, IL: Human Kinetics Publishers; 2017.Google Scholar
  3. 3.
    Priest JD, Nagel DA. Tennis shoulder. Am J Sports Med. 1976;4(1):28–42.PubMedGoogle Scholar
  4. 4.
    Ellenbecker TS. Chap.  10 Musculoskeletal screening for the elite and developing tennis player. In: DiGiacomo G, Ellenbecker T, Kibler WB, editors. Tennis medicine. Cham: Springer; 2018.
  5. 5.
    Young SW, Dakic J, Stroia K, Nguyen ML, Harris AH, Safran MR. High incidence of infraspinatus muscle atrophy in elite professional female tennis players. Am J Sports Med. 2015;43(8):1989–93.PubMedCrossRefGoogle Scholar
  6. 6.
    Piatt BE, Hawkins RJ, Fritz RC, Ho CP, Wolf E, Schickendantz M. Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elb Surg. 2002;11:600–4.CrossRefGoogle Scholar
  7. 7.
    Kibler WB. Role of the scapula in the overhead throwing motion. Contemp Orthop. 1991;22:525.Google Scholar
  8. 8.
    Bourne DA, Choo AM, Regan WD, MacIntyre DL, Oxland TR. Three-dimensional rotation of the scapula during functional movements: an in-vivo study in healthy volunteers. J Shoulder Elb Surg. 2007;16(2):150–62.CrossRefGoogle Scholar
  9. 9.
    Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elb Surg. 2002;11:550–6.CrossRefGoogle Scholar
  10. 10.
    Ellenbecker TS, Kibler WB, Bailie DS, Caplinger R, Davies GJ, Riemann BL. Reliability of scapular evaluation in professional baseball players. Clin Orthop Relat Res. 2012;470:1540–4.PubMedCrossRefGoogle Scholar
  11. 11.
    McClure PW, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis, Part 1: Reliability. J Athl Train. 2009;44:160–4.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Tate AR, McClure P, Kareha S, Irwin D, Barbe MF. A clinical method for identifying scapular dyskinesis, Part 2: Validity. J Athl Train. 2009;44:165–73.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Tate AR, McClure P, Kareha S, Irwin D, Barbe MF. A clinical method for identifying scapular dyskinesis, Part 1. J Athl Train. 2009;44:165–73.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26:325–37.CrossRefGoogle Scholar
  15. 15.
    Kelley MJ, Kane TE, Leggin BG. Spinal accessory nerve palsy: associated signs and symptoms. J Orthop Sports Phys Ther. 2008;38(2):78–86.PubMedCrossRefGoogle Scholar
  16. 16.
    Ellenbecker TS. Shoulder internal and external rotation strength and range of motion of highly skilled junior tennis players. Isokinet Exerc Sci. 1992;2:1–8.Google Scholar
  17. 17.
    Ellenbecker TS, Roetert EP, Bailie DS, Davies GJ, Brown SW. Glenohumeral joint total rotation range of motion in elite tennis players and baseball pitchers. Med Sci Sports Exerc. 2002;34(12):2052–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Chandler TJ, Kibler WB, Uhl TL, Wooten B, Kiser A, Stone E. Flexibility comparisons of elite junior tennis players to other athletes. Am J Sports Med. 1990;18:134–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Wilk KE, Macrina LC, Arrigo C. Passive range of motion characteristics in the overhead baseball pitcher and their implications for rehabilitation. Clin Orthop Relat Res. 2012;470:1586–94.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson CD II, Harker P, Paparesta N, Andrews JR. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39:329–35.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Shanley E, Rauh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med. 2011;39:1997–2006.PubMedCrossRefGoogle Scholar
  22. 22.
    Ellenbecker TS, Roetert EP, Piorkowski P. Shoulder internal and external rotation range of motion of elite junior tennis players: a comparison of two protocols (abstract). J Orthop Sports Phys Ther. 1993;17:A65.CrossRefGoogle Scholar
  23. 23.
    Wilk KE, Reinold MM, Macrina LC, Porterfield R, Devine KM, Suarez K, Andrews JR. Glenohumeral internal rotation measurements differ depending on stabilization techniques. Sports Health. 2009;1(2):131–6.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Tyler TF, Roy T, Nicholas SJ, Gleim GW. Reliability and validity of a new method of measuring posterior shoulder tightness. J Orthop Sports Phys Ther. 1999;29(5):262–74.PubMedCrossRefGoogle Scholar
  25. 25.
    Tyler TF, Nicholas SJ, Lee SJ, Mullaney M, McHugh MP. Correction of posterior shoulder tightness is associated with symptom resolution in patients with internal impingement. Am J Sports Med. 2010;38(1):114–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Laudner KG, Stanek JM, Meister K. Assessing posterior shoulder contracture: the reliability and validity of measuring glenohumeral joint horizontal adduction. J Athl Train. 2006;41(4):375–80.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Kelly BT, Kadrmas WH, Speer KP. The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J Sports Med. 1996;24:581–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Daniels L, Worthingham C. Muscle testing: techniques of manual examination. 4th ed. Philadelphia, PA: WB Saunders; 1980.Google Scholar
  29. 29.
    Kendall FD, McCreary EK. Muscle testing and function. 3rd ed. Baltimore, MD: Williams and Wilkins; 1983.Google Scholar
  30. 30.
    Jobe FW, Bradley JP. The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clin Sports Med. 1989;8:419–37.PubMedGoogle Scholar
  31. 31.
    Malanga GA, Jemp YN, Growney E, An K. EMG analysis of shoulder positioning in testing and strengthening the supraspinatus. Med Sci Sports Exerc. 1996;28:661–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Chalmers PN, Cvetanovich GL, Kupfer N, Wimmer MA, Verma NN, Cole BJ, Romeo AA, Nicholson GP. The champagne toast position isolates the supraspinatus better than the Jobe test: an electromyographic study of shoulder physical examination tests. J Shoulder Elb Surg. 2016;25(2):322–9.CrossRefGoogle Scholar
  33. 33.
    Jenp YN, Malanga BA, Gowney ES, An KN. Activation of the rotator cuff in generating isometric shoulder rotation torque. Am J Sports Med. 1996;24:477–85.PubMedCrossRefGoogle Scholar
  34. 34.
    Walch F, Boulahia A, Calderone S, Robinson AH. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator cuff tears. J Bone Joint Surg Br. 1998;80(4):624–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Leroux JL, Codine P, Thomas E, Pocholle M, Mailhe D, Flotman F. Isokinetic evaluation of rotational strength in normal shoulders and shoulders with impingement syndrome. Clin Orthop. 1994;304:108–15.Google Scholar
  36. 36.
    Patte D, Goutallier D, Monpierre H, Debeyre J. Over-extension lesions. Rev Chir Orthop. 1988;74:314–8.PubMedGoogle Scholar
  37. 37.
    Kurokawa D, Sano H, Nagamoto H, Omi R, Shinozaki N, Watanuki S, Kishimoto KN, Yamamoto N, Hiraoka K, Tashiro M, Itoi E. Muscle activity pattern of the shoulder external rotators differs in adduction an abduction: an analysis using positron emission tomography. J Shoulder Elb Surg. 2014;23:658–64.CrossRefGoogle Scholar
  38. 38.
    Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73:389–94.PubMedCrossRefGoogle Scholar
  39. 39.
    Stefko JM, Jobe FW, Vander Wilde RS, Carden E, Pink M. Electromyographic and nerve block analysis of the subscapularis liftoff test. J Shoulder Elb Surg. 1997;6:347–55.CrossRefGoogle Scholar
  40. 40.
    Neer CS, Welsh RP. The shoulder in sports. Orthop Clin North Am. 1977;8:583–91.PubMedGoogle Scholar
  41. 41.
    Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8:151–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Davies GJ, DeCarlo MS. Examination of the shoulder complex, Current concepts in rehabilitation of the shoulder. La Crosse, WI: Sports Physical Therapy Association; 1995.Google Scholar
  43. 43.
    Yocum LA. Assessing the shoulder. Clin Sports Med. 1983;2:281–9.PubMedGoogle Scholar
  44. 44.
    Valadie AL III, Jobe CM, Pink MM, Ekman EF, Jobe FW. Anatomy of provocative tests for impingement syndrome of the shoulder. J Shoulder Elb Surg. 2000;9(1):36–46.CrossRefGoogle Scholar
  45. 45.
    McFarland EG, Torpey BM, Carl LA. Evaluation of shoulder laxity. Sports Med. 1996;22:264–72.PubMedCrossRefGoogle Scholar
  46. 46.
    Gerber C, Ganz R. Clinical assessment of instability of the shoulder with special reference to anterior and posterior drawer tests. J Bone Joint Surg Br. 1984;66(4):551–6.PubMedCrossRefGoogle Scholar
  47. 47.
    Pagnani MJ, Warren RF. Stabilizers of the glenohumeral joint. J Shoulder Elb Surg. 1994;3:73–90.CrossRefGoogle Scholar
  48. 48.
    O’Brien SJ, Neves MC, Arnvoczky SP, et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med. 1990;18:449–56.PubMedCrossRefGoogle Scholar
  49. 49.
    Hawkins RJ, Mohtadi NGH. Clinical evaluation of shoulder instability. Clin J Sports Med. 1991;1:59–64.CrossRefGoogle Scholar
  50. 50.
    Saha AK. Mechanism of shoulder movements and a plea for the recognition of “zero position” of the glenohumeral joint. Clin Orthop. 1983;(173):3–10.Google Scholar
  51. 51.
    Altchek DW, Dines DW. The surgical treatment of anterior instability: selective capsular repair. Oper Tech Sports Med. 1993;1:285–92.Google Scholar
  52. 52.
    Hawkins RJ, Schulte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the patient under anesthesia. J Shoulder Elb Surg. 1996;5:286–92.CrossRefGoogle Scholar
  53. 53.
    Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Joint Surg Br. 1964;46:40–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51(3):444–53.PubMedCrossRefGoogle Scholar
  55. 55.
    Juul-Kristensen B, Rogind H, Jensen DV, Remvig L. Inter-examiner reproducibility of tests and critera for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology (Oxford). 2007;46(12):1835–41.CrossRefGoogle Scholar
  56. 56.
    Cameron KL, Duffey ML, DeBerardino TM, Stoneman PD, Jones CJ, Owens BD. Association of generalized joint hypermobility with a history of glenohumeral joint instability. J Athl Train. 2010;45(3):253–8.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Itoi E, Kido T, Sano A, Urayama M, Sato K. Which is more useful, the “full can test” or the “empty can test” in detecting the torn supraspinatus tendon? Am J Sports Med. 1999;27(1):65–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Pennock AT, Pennington WW, Torry MR, Decker MJ, Vaishnav SB, Provencher MT, Millet PJ, Hackett TR. The influence of arm and shoulder position on the bear-hug, belly-press, and lift-off tests: an electromyographic study. Am J Sports Med. 2011;39:2338–46.PubMedCrossRefGoogle Scholar
  59. 59.
    Pandya NK, Colton A, Webner D, Sennett B, Huffman GR. Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis. Arthroscopy. 2008;24(3):311–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42:80–92.PubMedCrossRefGoogle Scholar
  61. 61.
    Hegedus EJ. Which physical examination tests provide clinicians with the most value when examining the shoulder ? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012. Scholar
  62. 62.
    Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elb Surg. 2012;21(1):13–22.CrossRefGoogle Scholar
  63. 63.
    Michener LA, Doukas WC, Murphy KP, Walsworth MK. Diagnostic accuracy of history and physical examination of superior labrum anterior-posterior lesions. J Athl Train. 2011;46(6):343–8.PubMedPubMedCentralCrossRefGoogle Scholar
  64. 64.
    Andrews JR, Gillogly S. Physical examination of the shoulder in throwing athletes. In: Zarins B, Andrews JR, Carson WG, editors. Injuries to the throwing arm. Philadelphia, PA: WB Saunders; 1985.Google Scholar
  65. 65.
    Ellenbecker TS. Etiology and evaluation of rotator cuff pathologic conditions and rehabilitation. In: Donatelli RA, editor. Physical therapy of the shoulder. 4th ed. Philadelphia, PA: Churchill Livingstone; 2004. p. 337–58.CrossRefGoogle Scholar
  66. 66.
    Liu SH, Henry MH, Nuccion S. A prospective evaluation of a new physical examination in predicting glenoid labrum tears. Am J Sports Med. 1996;24(6):721–5.PubMedCrossRefGoogle Scholar
  67. 67.
    Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30(6):806–9.PubMedCrossRefGoogle Scholar
  68. 68.
    O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26(5):610–3.PubMedCrossRefGoogle Scholar
  69. 69.
    Magee DJ. Orthopaedic physical assessment. 3rd ed. Philadelphia, PA: WB Saunders; 1997.Google Scholar
  70. 70.
    Kibler BW, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37(9):1840–7.PubMedCrossRefGoogle Scholar
  71. 71.
    Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy. 1995;11(3):296–300.PubMedCrossRefGoogle Scholar
  72. 72.
    Morrey BF, Tanaka S, An KN. Valgus stability of the elbow: a definition of primary and secondary constraints. Clin Orthop Relat Res. 1991;(265):187–95.Google Scholar
  73. 73.
    Regan WD, Korinek S, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res. 1991;(271):170–9.Google Scholar
  74. 74.
    Kibler WB. Clinical biomechanics of the elbow in tennis: implications for evaluation and diagnosis. Med Sci Sports Exerc. 1994;26:1203–6.PubMedCrossRefGoogle Scholar
  75. 75.
    Elliott B, Fleisig G, Nicholls R, Escamilia R. Technique effects on upper limb loading in the tennis serve. J Sci Med Sport. 2003;6(1):76–87.PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Strukel RJ, Garrick JG. Thoracic outlet compression in athletes. Am J Sports Med. 2016;6(2):35–9.CrossRefGoogle Scholar
  77. 77.
    Churchill RW, Munoz J, Ahmad CS. Osteochondritis dissecans of the elbow. Curr Rev Musculoskelet Med. 2016;9(2):232–9.PubMedPubMedCentralCrossRefGoogle Scholar
  78. 78.
    Antuna SA, O’Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001;17(5):491–5.PubMedCrossRefGoogle Scholar
  79. 79.
    Kim DH, Gambardella RA, Elattrache NS, Yocum LA, Jobe FW. Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers. Am J Sports Med. 2006;34(3):438–44.PubMedCrossRefGoogle Scholar
  80. 80.
    Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med. 1992;11:851–70.PubMedGoogle Scholar
  81. 81.
    Hamilton CD, Glousman RE, Jobe FW, et al. Dynamic stability of the elbow: electromyographic analysis of the flexor pronator group and the extensor group in pitchers with valgus instability. J Shoulder Elb Surg. 1996;5:347–54.CrossRefGoogle Scholar
  82. 82.
    Bruce JR, Andrews JR. Ulnar collateral ligament injuries in the throwing athlete. J Am Acad Orthop Surg. 2014;22(5):315–25.PubMedCrossRefGoogle Scholar
  83. 83.
    Dines J, Altchek D, Dines DM. Medial collateral ligament reconstruction of elbow; current concepts in surgical technique. J Shoulder Elb Surg. 2010;19:110–7.CrossRefGoogle Scholar
  84. 84.
    Safran M, Ahmad C, Elattrache N. Ulnar collateral ligament of the elbow. Arthroscopy. 2005;21(11):1381–95.PubMedCrossRefGoogle Scholar
  85. 85.
    Cain EL Jr, Dugas J, Wolf R, Andrews J. Elbow injuries in the throwing athletes; a current review. Am J Sports Med. 2005;33(2):231–9.CrossRefGoogle Scholar
  86. 86.
    O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231–9.PubMedCrossRefGoogle Scholar
  87. 87.
    Calfee RP, et al. Clinical assessment of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms. J Bone Joint Surg Am. 2010;92(17):2801–8.PubMedPubMedCentralCrossRefGoogle Scholar
  88. 88.
    Lasecki M, et al. The snapping elbow syndrome as a reason for chronic elbow neuralgia in a tennis player - MR, US and sonoelastography evaluation. Pol J Radiol. 2014;79:467–71.PubMedPubMedCentralCrossRefGoogle Scholar
  89. 89.
    Brucker J, Sahu N, Sandella B. Olecranon stress injury in an adolescent overhand pitcher: a case report and analysis of the literature. Sports Health. 2015;7(4):308–11.PubMedPubMedCentralCrossRefGoogle Scholar
  90. 90.
    Park JY, Yoo HY, Chung SW, Lee SJ, Kim NR, Ki SY, Oh KS. Valgus extension overload syndrome in adolescent baseball players: clinical characteristics and surgical outcomes. J Shoulder Elb Surg. 2016;25(12):2048–56.CrossRefGoogle Scholar
  91. 91.
    Paulino FE, Villacis DC, Ahmad CS. Valgus extension overload in baseball players. Am J Orthop (Belle Mead NJ). 2016;45(3):144–51.Google Scholar
  92. 92.
    O’Driscoll S, Goncalves L, Dietz P. The Hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • David Dines
    • 1
    • 2
    Email author
  • Todd S. Ellenbecker
    • 3
  • Jonathan Berkowitz
    • 4
  1. 1.Hospital for Special SurgeryNew YorkUSA
  2. 2.ATP World TourPonte Vedra BeachUSA
  3. 3.ATP World Tour and Rehab Plus Sports TherapyScottsdaleUSA
  4. 4.Southern California Orthopedic InstituteVan NuysUSA

Personalised recommendations