How to Reduce Your Risk of Tennis Shoulder Injuries: What the Research Says

If you have had one bout of shoulder trouble and would rather not have another, or you are adding tennis days and quietly wondering whether your shoulder will keep up, you are asking the right question at the right time. Tennis shoulder injury prevention is worth taking seriously — and it is also more modest than most programs claim.

Let us start with the least comfortable finding, because it is also the most useful. Across the research on overhead athletes, every single study that looked at previous injury found it predicted future injury. Every study that looked at training load found the same. Those two factors are more consistent than anything else in the field — and both are things you can actually do something about.

The good news? You do not need a magic drill. You need a system, and most of it is unglamorous: build strength, watch your workload, respect the shoulder that has already been hurt once.

At Rooted Motion Physical Therapy, we believe honest prevention advice beats confident prevention advice. Here is what the evidence supports, and where it is thinner than the internet suggests.

Can You Actually Prevent a Shoulder Injury?

Not reliably, and it is worth saying so plainly. Injury is shaped by training load, previous injury, anatomy, age, strength, movement, fatigue and technique. The largest review in this area screened more than 3,000 papers and found only 25 worth analyzing, eleven of them in baseball. Its authors state that the risk factors are still not fully established, and that whether prevention programs genuinely reduce shoulder injuries has itself not been firmly proven.

So the honest goal is risk reduction: change what you can change, build capacity, and manage how much you ask of the shoulder. That is a smaller promise than most programs make, and it is the one the evidence will actually support.

Imagine a Bank Account

Think of your shoulder as an account. Strength, endurance and recovery are deposits. Serves, matches and tournaments are withdrawals. You do not get into trouble because of any single withdrawal — you get into trouble when the withdrawals outpace the deposits for long enough.

The key idea: almost everything below is either a way to make bigger deposits or a way to space the withdrawals out. That is the whole of prevention, and it is why the same advice keeps appearing in different words.

1. Build Strength That Lasts a Whole Match

This is the most consistent finding in the research. Every study examining muscle weakness and imbalance found it raised risk. Weakness before the season even started predicted later shoulder injury in high school pitchers.

For tennis this means more than light band work. The recommendation is to train the muscles that rotate your arm outward in both directions of effort — shortening under load and lengthening under load — and the inward rotators in the lengthening direction, because that combination is what steadies the shoulder during fast overhead movement. Bands and dumbbells do the job.

The cuff also needs endurance in positions that resemble serving, not just at your side. Many players can produce a few clean repetitions in a clinic and cannot hold their mechanics in the third set. That gap is the whole point.

2. Is Losing Shoulder Rotation a Warning Sign?

Overhead athletes commonly gain outward rotation and lose inward rotation in the dominant shoulder. Some of that is a normal, useful adaptation, and it can appear after a single season.

Where it becomes a warning sign is genuinely unsettled — two of the four studies supported movement loss as a risk factor and two did not. What the supporting studies found is still striking: in adolescent baseball pitchers, a side-to-side difference of more than 13 degrees in inward rotation came with roughly six times the risk of shoulder injury.

Two cautions travel with that number. It comes from baseball, not tennis. And an older rule of thumb held that losing under 20 degrees was fine, which the 13-degree finding directly undercuts. So clinicians watch trends rather than cutoffs: is it getting worse, does it hurt, and does your shoulder still suit what you ask of it?

If stiffness at the back of the shoulder is the problem, regular stretching there is reasonable. If the problem is the opposite — too much movement — the answer is control work, not more stretching. Those two players need close to opposite programs.

3. Look at the Shoulder Blade, Without Blaming It

Altered shoulder blade movement is common in overhead athletes: roughly 61 percent, against 33 percent in athletes who do not play overhead sports.

But three studies supported it as a risk factor and two argued against, and the authors themselves call the question controversial. Plenty of players have a visibly uneven shoulder blade and no pain whatsoever. So it is worth assessing as part of how your whole shoulder moves, and not worth treating as the villain in every story.

4. How Fast Is Too Fast to Add Load?

Training load has the cleanest signal in the entire review: six studies out of six found it mattered. The specifics come from other sports, but they are instructive.

• Youth pitchers throwing more than 100 innings in a year had roughly three and a half times the risk of shoulder injury.

• Throwing more than 75 pitches in a single match was a risk factor in high school pitchers.

• In young handball players, increasing weekly load by more than 60 percent raised injury risk.

• That risk was higher again in players who also had weak external rotators.

That last point is the one to carry onto the court. Load and capacity are two halves of the same question, and a jump in volume lands hardest on a shoulder that was not strong to begin with. For tennis, the equivalent variables are serves, match hours, tournament density, and how quickly any of them change. Build gradually, and leave room for recovery.

5. Take a Previous Injury Seriously

Seven studies examined a history of shoulder pain or injury. All seven found it predicted future injury. If you have already had shoulder trouble, you may stay vulnerable when strength, endurance or movement deficits outlast the pain.

That is the argument for keeping up maintenance work after you feel normal again. A symptom-free shoulder is not always a prepared shoulder.

6. Train the Whole Body, Not Just the Shoulder

Tennis strokes depend on force passing smoothly up the body. Strong legs and hips, a trunk that rotates well, a mobile upper back and good shoulder blade control all reduce how much the shoulder has to produce for the same shot.

This does not mean every shoulder problem is caused by weak hips. It means a prevention program that stops at the shoulder is an incomplete one.

7. Is Recovery Really Part of Training?

Adequate spacing between heavy tennis days, sleep, hydration, nutrition and total weekly workload all shape how well tissue adapts. The review puts some of this on coaches, who it argues should be measuring training load and adapting it to the individual rather than the group.

There is a specific reason to protect the day after heavy serving: shoulder rotation and shoulder blade movement measurably change after prolonged play, and return to normal with rest. Recovery is not passive time. It is when your shoulder gets its movement back.

What Does a Week Actually Look Like?

Pulling it together, a practical program might include two to three strengthening sessions a week covering rotation in both directions, movement work where your shoulder is meaningfully restricted, progressive overhead endurance, trunk and leg strength, gradual increases in serve volume, and ongoing attention to symptoms and recovery.

The exercises should be chosen for you rather than copied from a list. That is not a sales pitch — it follows directly from the evidence, which shows the stiff shoulder and the loose shoulder need different work.

The Rooted Motion Difference

Care is one-on-one, in your own home, and built around your actual playing week. Here is what you can expect:

• A baseline of your shoulder movement and strength, so changes are visible later.

• A look at your real training load, not an idealized version of it.

• Strengthening for the cuff, the shoulder blade, the trunk and the legs.

• A plan that distinguishes a stiff shoulder from a loose one.

• Honest discussion of what the evidence supports and what it does not.

• Convenient concierge mobile physical therapy delivered where you are.

Because prevention is not just about avoiding injury — it is about still enjoying tennis in twenty years.

Ready to Build a Shoulder That Holds Up?

If you have had shoulder trouble before, or you are about to ask a lot more of your shoulder than you did last season, that is the moment a plan is worth having — not after the pain arrives.

Ready to move better and live rooted? Contact Rooted Motion Physical Therapy to schedule a one-on-one evaluation and begin a personalized shoulder prevention plan.

Research Used for This Article

1. Tooth C, Gofflot A, Schwartz C, et al. Risk Factors of Overuse Shoulder Injuries in Overhead Athletes: A Systematic Review. Sports Health. 2020;12(5):478-487. DOI

2. Hoppe MW, Brochhagen J, Tischer T, et al. Risk factors and prevention strategies for shoulder injuries in overhead sports: an updated systematic review. Journal of Experimental Orthopaedics. 2022;9(1):78. DOI

3. Kekelekis A, Nikolaidis PT, Moore IS, Rosemann T, Knechtle B. Risk Factors for Upper Limb Injury in Tennis Players: A Systematic Review. International Journal of Environmental Research and Public Health. 2020;17(8):2744. DOI

4. Cools AM, Johansson FR, Borms D, Maenhout A. Prevention of shoulder injuries in overhead athletes: a science-based approach. Brazilian Journal of Physical Therapy. 2015;19(5):331-339. DOI

5. Fu MC, Ellenbecker TS, Renstrom PA, Windler GS, Dines DM. Epidemiology of injuries in tennis players. Current Reviews in Musculoskeletal Medicine. 2018;11(1):1-5. DOI

Educational disclaimer: This article is for general education and is not a substitute for an individualized evaluation. Seek prompt medical care after a traumatic injury or dislocation, for a sudden major loss of strength, or for new numbness, tingling or weakness in the arm.