Why Does My Shoulder Hurt Playing Tennis?

Shoulder Pain Is a Symptom, Not a Diagnosis

Two tennis players can both say that their shoulder hurts when serving and have completely different problems.

One may have an overloaded but structurally intact rotator cuff. Another may have a rotator cuff tear. A younger competitive player may have internal impingement or labral pathology, while an older recreational player may have arthritis or degenerative cuff disease.

The first step is therefore to determine which structure is actually producing the symptoms.

1. Rotator Cuff Overload

2. Rotator Cuff Tear

3. Subacromial Bursitis and Impingement-Type Pain

The subacromial bursa sits between the rotator cuff and structures above it.

Repetitive overhead movement can irritate this region, particularly when the rotator cuff is fatigued or shoulder mechanics have changed.

Pain is often felt over the lateral upper arm and may occur when raising the arm overhead.

Importantly, the term “impingement” describes a pattern rather than a single disease. Rotator cuff pathology, stiffness, scapular mechanics, and training load may all contribute.

4. Internal Impingement

Internal impingement is particularly relevant to overhead athletes.

During the late cocking position of the serve, the shoulder moves into abduction and substantial external rotation. In this position, the undersurface of the posterior rotator cuff can contact the posterior-superior region of the glenoid and labrum.

Some contact can occur as part of normal overhead mechanics. The problem develops when repetitive loading, instability, stiffness, or altered mechanics create pathologic stress.

Pain is often felt in the posterior shoulder during the cocking phase.

5. Biceps Tendon and SLAP Labral Problems

The long head of the biceps attaches to the superior portion of the labrum inside the shoulder.

Repeated overhead loading can stress this biceps-labral complex.

Symptoms may include deep shoulder pain, anterior pain, painful clicking, discomfort during serving, or pain with certain positions of external rotation.

Labral findings must be interpreted carefully. MRI abnormalities can exist in athletes without symptoms, particularly as players age.

The goal is therefore not simply to identify an abnormal MRI but to determine whether that abnormality explains the player's clinical symptoms.

6. Shoulder Instability

Instability does not always mean the shoulder completely dislocates.

Some athletes develop more subtle excessive translation of the humeral head during overhead activity.

This can produce pain, fatigue, loss of control, apprehension, or a sense that the shoulder is slipping during the serve.

In younger players, especially those with a prior dislocation or traumatic event, instability may be a major contributor to symptoms.

7. Loss of Internal Rotation and Posterior Shoulder Tightness

Overhead athletes frequently develop adaptations in rotational motion.

A dominant arm may gain external rotation while losing some internal rotation.

This is not automatically abnormal. What matters is whether the change is excessive, whether total rotational motion is preserved, and whether symptoms or altered mechanics are present.

When posterior shoulder tightness becomes clinically important, it may alter humeral-head mechanics and increase stress during the serve.

8. Scapular Dyskinesis

The scapula provides the moving foundation for the shoulder joint.

Weakness, fatigue, pain, or altered muscle coordination can change the way the scapula moves around the chest wall during serving.

This may influence rotator cuff loading, glenoid positioning, and the amount of motion required at the glenohumeral joint.

Scapular dyskinesis is not automatically the cause of pain, but it can be an important part of the overall problem.

9. Arthritis

In older recreational players, arthritis becomes an increasingly important cause of shoulder pain.

Glenohumeral arthritis may cause pain, stiffness, grinding, progressive loss of motion, and difficulty generating an efficient serve.

Acromioclavicular joint arthritis can also cause pain at the top of the shoulder, particularly during certain strokes or positions.

10. Training-Load Errors

Not every painful shoulder has a structural injury.

Sometimes the problem is simply that the amount of tennis increased faster than the tissues were prepared to tolerate.

Examples include:

• Returning abruptly after time away from tennis
• Large increases in serving volume
• Multiple tournaments in a short period
• Increasing training intensity without adequate recovery
• Adding strength training while maintaining full tennis volume
• Playing through progressive fatigue

In these situations, temporary load modification and progressive reconditioning may be more important than imaging or invasive treatment.

Does Pain Location Help Identify the Problem?

Why Does My Shoulder Hurt Only When Serving?

The serve places much greater rotational and overhead demands on the shoulder than most groundstrokes.

A player may therefore tolerate forehands and backhands without difficulty while experiencing pain only during the serve.

That pattern can occur with rotator cuff overload, internal impingement, labral problems, instability, or a mismatch between serve volume and shoulder conditioning.

Why Does My Shoulder Hurt After Tennis but Not During?

Delayed soreness often reflects cumulative tissue loading rather than one painful movement.

The rotator cuff and scapular muscles may fatigue during play, while inflammation or soreness becomes more noticeable afterward.

This can occur with relatively minor overload, but persistent post-play pain that becomes progressively worse should not simply be ignored.

What Does Night Pain Mean?

Night pain is common with several shoulder disorders, particularly rotator cuff disease and arthritis.

It does not identify one diagnosis by itself, but pain that regularly wakes a player from sleep is more concerning than mild soreness limited to the hours immediately after tennis.

What Does Weakness Mean?

True weakness deserves particular attention.

A player may feel weak simply because pain inhibits normal muscle activation. But weakness can also occur with a rotator cuff tear, nerve problem, or more significant structural injury.

Loss of serve speed or inability to control the racket may therefore be clinically important even when pain is relatively modest.

When Should I Stop Playing?

There is no universal rule requiring complete rest for every painful shoulder.

However, continuing unrestricted tennis is less appropriate when symptoms are progressively worsening or when the player develops weakness, instability, significant night pain, or loss of motion.

Temporary modification may include reducing serving volume, avoiding high-intensity overhead strokes, shortening practice, or focusing temporarily on lower-demand tennis activities while the shoulder is evaluated.

How Is Tennis Shoulder Pain Diagnosed?

The most useful evaluation usually begins with the history.

Important questions include:

• When did the pain begin?
• Was there a specific injury?
• Which stroke causes symptoms?
• At what phase of the serve does pain occur?
• Is there weakness?
• Is there instability?
• Is motion restricted?
• Does the shoulder hurt at night?
• Has tennis volume recently increased?

Physical examination then helps assess strength, motion, stability, scapular mechanics, and the structures most likely to be involved.

X-rays, ultrasound, or MRI may be useful depending on the suspected diagnosis.

Does Every Player Need an MRI?

No.

Many shoulder problems can be diagnosed initially through history, examination, and appropriate X-rays.

MRI becomes more useful when there is concern for a rotator cuff tear, labral injury, significant structural pathology, or when the diagnosis remains uncertain after initial evaluation.

Imaging should support the clinical diagnosis rather than replace it.

How Is Tennis Shoulder Pain Treated?

Treatment depends entirely on the diagnosis.

Common nonsurgical strategies may include:

• Temporary modification of tennis volume
• Rotator cuff strengthening
• Scapular rehabilitation
• Mobility work when appropriate
• Kinetic-chain strengthening
• Serve-mechanics evaluation
• Gradual return to serving
• Anti-inflammatory treatment when appropriate
• Selective use of injections for certain diagnoses

Surgery is generally reserved for structural problems in which repair or reconstruction is appropriate, or for persistent symptoms that have not improved sufficiently with a well-designed nonsurgical program.

Frequently Asked Questions