Last week, we looked at the importance of a post-match recovery routine for the tennis shoulder.  This is based on a couple key factors. First, the current trend of modern tennis is heavily reliant on successful serving. And second, scientific evidence points to losses in both range of motion (ROM) and strength, along with shoulder/arm soreness, post matchplay. If you haven't read that post, take a look at it here as it helps provide the framework for this week's follow-up article. 

Below, we'll look at the various recovery modalities players can employ after tennis, both from a research and practical perspective. 

Strengthening Exercises 

When touring with a WTA player, we often ran or biked after every match. Now why would anyone get on a bike after playing high-intensity sport for a few hours? The answer, active recovery (AR). AR has been proven to accelerate recovery better than passive recovery (PR), post-exercise (Martin et al 1999). PR could include sitting, lying down and passively stretching. AR, on the other hand, is characterized by submaximal exercise (jogging, light biking). AR is proposed to increase blood flow in an attempt to remove blood lactate. Research suggests that this enhanced lactate clearance (along with improvements in other biomarkers) is better than passive measures when it comes to recovery post exercise. Don’t get me wrong, passive recovery is also important - remember, sleep is a form of passive recovery - but we’re going to be investigating the shoulder, and as you’ll see, active measures are better. The question remains, if jogging and light biking benefit the legs, lungs, heart etc., would some form of activity in the arm/shoulder have similar benefits? Let’s take a closer look.

You wouldn’t normally think of performing more shoulder work after training or competition, but based on the evidence, that’s exactly what I’m proposing. I’m not saying go into the gym and bench press after a marathon match; I’m merely saying that LIGHT upper body exercises SHOULD be performed after matchplay. If you recall from last week’s post, light strengthening exercises of the shoulder post pitching were better than ice (or no intervention) in restoring both ROM & strength and decreasing DOMS (Yanagisawa et al 2003). Like jogging, light shoulder exercises probably have benefits in clearing metabolites - this is perhaps one reason DOMS is attenuated with light exercise.

What about strength? Both pitching and serving require heavy deceleration (Ellenbecker et al 2002) - which is referred to as the most damaging aspect of each activity. It puts tremendous stress on the rotator cuff muscles, in an eccentric manner. And although we won’t get into the details here, trust me when I say that eccentric contractions produce more muscle damage than other contraction types. So the rotator cuff muscles helps stabilize the glenohumeral joint, which it is in itself an unstable joint. Because serving is a high-velocity movement, after tennis, we lose strength in the dynamic stabilizers and this MUST be restored. According to Kawamura (2015), here’s what happens after a 100 pitch outing in baseball:

“After a number of pitches (7 ± 2 innings, 99 ± 29 pitches), there’s a loss of 15% shoulder flexion, 12% abduction, 6% abduction in the scapular plane with internal rotation, 18% internal rotation, 11% external rotation, 11% adduction strength, and 4% grip strength”

Although research is scarce in this area, leaders in the baseball world, like Mike Reinold (creator of Optimal Shoulder Performance) and Kyle Boddy, founder of Driveline Baseball, advise in favor of both resistance band and light dumbbell exercises post pitching. Boddy even has his athletes perform light plyometric drills post throwing (video below). These exercises should target eccentric/deceleration phases, along with the restoration of internal and external rotation strength. I would also recommend doing mobility exercises - combination of flexibility and strength - as they would theoretically help restore ROM and strength simultaneously. CARs (controlled articular rotations), are best for this - refer to Functional Anatomy Seminars for more info 

Post-tennis shoulder exercise examples:

Assessment & Stretching of the Tennis Shoulder

In both baseball pitching and tennis, we know that these athletes lose ROM in internal and external shoulder rotation. Pitchers see a decline of about 10.7° of total ROM after one outing and this can last up to 24 hours (and in some cases longer). The shoulder isn’t the only joint that loses range after overhead activities. Pitchers can lose between 3-5° of elbow extension - loss of elbow extension has been correlated with ulnar collateral ligament (UCL) tears. UCL tears aren’t common in tennis but elbow issues (both medially and laterally) are. Here’s what Reinold et al (2008) had to say about these losses in range post pitching:

“The causes of stiffness of anatomical motions include inflammation and soft tissue edema in the perimysial and/or epimysial connective tissue elements from eccentric muscle activity. Pitching before the recovery from acute muscle damage and loss of shoulder and elbow ROM places the pitcher at risk of injury.”

Shoulder ROM is obvious, but I’ve personally seen players lose elbow extension (and flexion) post tennis. This can cause elbow, bicep and tricep weakness, numbness and pain. So, first thing’s first, every player should have a baseline assessment done for both external, internal and total GH ROM along with elbow extension and flexion. Although values will vary depending on each player, total range of motion of the shoulder (both internal and external combined) should be NO LESS than 150° . This value is already cutting it close. Also, there shouldn’t be more than a 10° difference between dominant and non dominant shoulders - with the non dominant shoulder having greater range of the two.

Second, these ranges need to be tested before and after every match to assess change. Third, and most importantly, RESTORE ROM before they practice and play again! This can be done using the sleeper stretch (which I have outlined in a previous post) along with upper-body multi-joint stretches like the 3 below. Stretching shouldn’t be restricted solely to these movements. Tennis is chaotic, we don’t know which muscles are involved and how much breakdown occurs. To quote Dr. Andreo Spina "tendon, bone, ligament, muscle, facia...all connective tissue, are just a bunch of ‘stuff’ - make that ‘stuff’ work well." This means that we need to stretch in a variety of different ways and a variety of different planes. Do you know how many planes of action the scapula has? Too many to count.... Find the line of tension that’s affected and work on it. Often when I instruct a player to perform a certain stretch, they say they can’t feel anything. That’s normal. We are different. We play differently. Our techniques are different. Our muscle architectures differ. Find the position where YOU feel tension.

Here are a couple stretching suggestions:

Cryotherapy

There’s been controversy surrounding ice application for a number of years now. The mechanisms of cold therapy post activity aren’t completely understood. Some authors (Hohenauer et al 2015) suggest that benefits may be due to reductions in cardiovascular and thermal strain, inflammation, muscle damage responses and perceptual discomfort. While ice therapy may disrupt the body’s natural inflammation response, athletes across many sports still use ice for pain relief & recovery post training/competition.

After scouring the research on the subject, I have yet to find a single study that uses ice as a recovery modality in the tennis player’s shoulder/arm (if I’m wrong please send me a link to the study). Isn’t that crazy? Many tennis & fitness coaches advise their players to place ice on their shoulder or arm after tennis, but there’s no scientific evidence to support this. I came across 1 study (Duffield et al 2014) in which the authors used cold water immersion (CWI) as a recovery modality in tennis (whole body immersion). The results were favorable - players in the treatment condition improved feelings of perceived exertion and muscle soreness more than a control group. That said, on top of CWI, players in the treatment group also wore compression garments and were given specific sleep intervention techniques so it’s impossible to say whether it was the CWI treatment, the compression garment, sleep or a combination of any of these treatments, that made the difference.

To better understand whether cold therapy has any benefit in the recovery of the tennis shoulder, we must look to baseball. Before we do, there’s a couple things you should know about cryotherapy. A review by Hohenauer et al (2015) states that the benefits of cryotherapy are largely due to subjective feelings. In other words, when it comes to decreasing the perception of DOMS, fatigue and exertion, cryotherapy seems to work - at 24h, 48h, 72h (and even 96h) post-exercise. Unfortunately, cryotherapy doesn’t seem to do anything to tissue - in other words, to objective markers of fatigue. Here’s what the authors had to say:

“Tiidus et al. (2015) recently concluded that cryotherapy or icing, as currently practiced, will not likely be successful in cooling human muscle sufficiently to have any significant influence on muscle repair regardless of the degree of injury. Based on studies in animal models, it may be that if sufficient muscle cooling could be achieved in humans, it could actually delay repair and increase muscle scarring following recovery from significant muscle damage.”

This is similar to findings from Tseng et al (2013) who actually saw fatigue increase, and peak, up to 72h post eccentric exercise (a form of resistance training, not sport play). Further, other biomarkers that should decrease for optimal recovery, remained elevated post-exercise. These authors suggest that cold packs actually DELAY recovery, after eccentric exercise. Pitching, however, was not observed.

Two other things you should know about cryotherapy as it relates to recovery. One, cold water immersion seems to be better than other cooling methods, including ice packs, gel packs and cold air. This is likely due to temperature - when cold therapy treatment remains around 10°C (range of 5°C to 13°C), results are most favorable. Second, time also seems to be important. Best results occur around the 13min mark (range of 10 to 24 min).

On to some baseball research. Last week we looked at 2 studies (Kawamura 2015 and Yanagisawa et al 2003). Both studies suggest that ice ALONG WITH other modalities (stretching and light exercises) are best for post-pitching recovery of the shoulder and arm. Yanagisawa et al (2003) also found that ice was still better than no treatment at all in reducing perceived soreness and regaining strength/ROM.

Apart from that, only 2 other studies to my knowledge have looked at icing the shoulder/arm in pitchers. The only issue with these studies was that ice was administered for 4 minutes between innings - not post pitching. What’s fascinating, however, is that both studies found that between inning icing maintained (and in certain innings) improved, throwing velocity. The pitchers even felt like it was easier to throw after icing (i.e. their perception of task difficulty decreased). Could this be something new that tennis players could benefit from on changeovers? Personally, I doubt it. There just isn’t enough long-term evidence to support these findings. Icing provides a numbing effect - hence pitchers likely let loose on their throws with virtually no biofeedback (i.e pain). Long-term, this could present some problems. I’d hold off on between set icing for now.

So cooling doesn’t really have much benefit on physiological (objective) markers, but does that even matter? If it subjectively helps the athlete feel less sore and experience less perceived exertion, wouldn't it be worth it? If you or your players are currently icing after tennis and there aren't any detrimental side effects, continue what you’re doing. What you may want to avoid is ice application in extreme cold conditions, for periods that are very long (more than 20-25min) and after resistance training. Post-tennis might have some benefit, as long as stretching and light exercise are also employed.

Former world no. 27, Laura Robson taking an ice bath to recover her lower body. But does icing the shoulder have similar benefits?

Deep Breathing

While working towards my undergraduate degree in Kinesiology, I was still competing. And like many student-athletes in Kinesiology, I would choose courses based on my needs as a tennis player (pretty sneaky isn't it). Luckily for me, one of the most prominent researchers in relaxation techniques for sport was a prof at my school, so I took both relaxation/self-regulation courses that were offered. I learned a number of techniques which have helped me over the years but all of them are based on a single premise, breathing. More specifically, diaphragmatic breathing.

This is perhaps the least thought of recovery modality yet it could be one of the most effective. I won’t spend much time on this as I’d like to cover more general recovery strategies in another post but it’s worth mentioning here. Diaphragmatic breathing - also referred to as deep breathing - is a method of breathing to reduce sympathetic activity, draw more air into the bottom of the lungs (where blood supply is better) by using the diaphragm. Diaphragmatic breathing is seen in meditation practice, mindfulness, yoga and many other spiritually focused activities. So why would this be important for shoulder/arm recovery post-tennis? It’s quite simple actually. Beyond the overall relaxation benefits, using the diaphragm when inhaling reduces the use of secondary respiratory muscles - chest, shoulders, neck & back. And getting more oxygen into the bottom of the lungs will allow for better blood transport throughout the body, including the areas where it’s needed most - like the shoulder/arm - which is undergoing an inflammatory response because of heavy use.

How to do it?

If you’re new to using your diaphragm, it may feel tricky at first. Many people use shallow breathing for the majority of the day (chest and shoulders) and haven’t used their diaphragm in years.

Here are a few steps:

1.  Lie on your back with your hands on top of your diaphragm (between your rib cage and belly button).

2. When inhaling, attempt to gather air into the diaphragm - your hands act as feedback - when inhaling, they should be rising

3. Open your mouth when exhaling, letting the breath come out

4. The feeling should be as if your muscles are melting into the floor

5. ALWAYS make sure your inhalation is twice as long as your exhalation (8 seconds in, 4 seconds out is ideal but if you’re new to this, you may have to start at 4 IN, 2 OUT and progress from there).

Massage, Electrical Muscle Stimulation (EMS) & Compression Garments

There are perhaps other recovery modalities that may be of benefit - massage (or other manual therapy techniques), compression garments and EMS - to name a few. In the case of massage, evidence suggests that it's no more effective than passive recovery when looking at physiological markers like lactate removal, decreased sympathetic activity and reductions in creatine kinase levels (Ellenbecker 2009). That said, massage may have psychological benefits which could warrant their use. Should you get a massage post-match? It depends on the type of massage, the time in between matches and whether the player is a responder or not. Remember though, massage decreases sympathetic activity, similar to deep breathing, which will contribute to relaxation. A match requires a certain level of intensity, so be weary of massage on the same day as a match (even the night before).

Other than a few occasions where a therapist used some form of EMS on me for shoulder/elbow treatment, I haven’t used electrical stimulation on a regular basis (not on myself nor my athletes). Two reasons why this has been the case - first, because I was uncertain of it’s benefits and second, because of practical/cost reasons. Until recently, electrical stimulation devices have been big, expensive and technical in nature - seen mostly in lab settings & health clinics. Now there are products like Marc Pro that are easy to use and reasonably priced. In baseball, NMES (neuromuscular electrical stimulation) - a form of EMS - has been reported to help pitchers maintain throwing velocity when administered between innings (Warren et al 2011). Other research indicates that active and passive recovery measures are as effective as EMS when it comes to post-exercise recovery (Osterer 2015). Anecdotally, many coaches working with overhead athletes are beginning to employ EMS to help accelerate recovery. This area needs further research and experimentation, especially in tennis, where there are no studies reported to date.

As for compression garments, there is virtually no evidence of their effectiveness in overhead athletes, let alone tennis players. Like we mentioned earlier, one study used compressive gear to improve various recovery markers in tennis players. But because CWI and sleep therapy were also employed, it’s hard to tell which modality works best. In cycling, compressive clothing did improve cycling performance, while other studies have seen positive improvements in measures of soreness. (Kovacs and Baker 2014). So there are potential benefits but the results are still mixed. I wouldn’t invest in this sort of expensive gear just yet.  

Practical Takeaways

1. Light shoulder exercises probably do a good job in helping to restore strength, improve ROM and clear certain metabolites like lactate (which help decrease soreness post-match). After tennis, DO THEM!

2. Restoring ROM is key, primarily glenohumeral shoulder internal and external rotation. But don’t neglect the elbow, wrist and scapula.

3. Ice may have some benefits but mostly when combined with the previous 2 modalities.

4. Breathing exercises will surely help and can even be combined with a post-match stretching routine (each will help the other exponentially).

5. Other modalities like massage, compression gear and EMS are less clear when it comes to scientific evidence. If you do have access to an experienced, reliable therapist, this will DEFINITELY help, otherwise, stay clear.  

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