Racket Sports After Shoulder Replacement Surgery: Will I Play Tennis/Pickleball Again?

Patients in the United States are living longer and remaining more active into their 60’s and beyond than ever before. As the population continues to age and the indications for shoulder replacement continue to expand, a greater amount of shoulder replacements are occurring every year. In the United States, more than 50,000 shoulder replacements are performed annually in patients of all ages. Although most patients undergoing shoulder replacement in this country are in their late 60’s and early 70’s, patients as young as 40 and as old as 90 may undergo this procedure as well. These shoulder replacements are performed for many reasons, including shoulder osteoarthritis (wear-and-tear), rheumatoid arthritis (inflammatory arthritis), fracture of the shoulder, or irreparable (non-fixable) rotator cuff tears. Regardless of the reason for shoulder replacement, the end goal remains the same; to get our patients back to living life and doing the activities that make them happy.

These goals differ for each patient. Some simply wish to hold their grandchild without pain. Others seek to return to high levels of competitive recreational sports that require extensive use of the arm, such as tennis, pickleball, racquetball, and squash. Tennis is a popular sport in the United States played by more than 20 million Americans last year alone, a large portion of whom are over the age of 60. Pickleball is one of the fastest-growing sports in the nation, with reports citing over 36 million players in the United States in 2023, more than 25% of whom are over the age of 55. These racket sports are clearly very popular amongst the age group of patients who commonly undergo shoulder replacement. This leaves us with a very important question to answer:

Can patients receiving a shoulder replacement ever get back to enjoying their favorite racket sport?

Shoulder Replacement Surgery: What Exactly Is It?

To better understand what you can do after a shoulder replacement, you must first understand what happens in a shoulder replacement. The shoulder is a ball-and-socket joint, with the ball arising from the arm bone (humerus) and the socket (glenoid) arising from the shoulder blade. A smooth layer of cartilage lines the shoulder joint and allows the ball to glide smoothly over the socket for a pain-free range-of-motion. In shoulder arthritis, the cartilage lining is worn away, leaving the rough bony surfaces of the ball and socket to rub together, causing pain and stiffness. In a shoulder replacement, the arthritic ball and socket are replaced with a combination of metal and plastic implants allowing for an improved, pain-free range-of-motion.

There are multiple types of shoulder replacements, including anatomic total shoulder arthroplasty, reverse shoulder arthroplasty, and hemiarthroplasty. In an anatomic shoulder arthroplasty, the arthritic ball is replaced with a metal ball and the arthritic socket is replaced with a plastic socket. This recreates your normal anatomy and is performed for patients with shoulder arthritis and a normal rotator cuff. In a reverse shoulder arthroplasty, the arthritic ball is replaced with a metal stem and plastic socket and the arthritic socket is replaced with a metal baseplate and metal ball. This is performed for patients with an irreparable rotator cuff tear, a fracture of the upper arm bone (proximal humerus), or a patient with a socket that has been worn away leaving very little bone behind. The reverse shoulder replacement changes the anatomy of your shoulder, allowing it to work well even when you do not have a normal or intact rotator cuff, unlike the anatomic shoulder replacement. In addition, the ball is attached to the socket using a metal baseplate and metal screws, providing better fixation onto the bone in patients with a worn-down socket. A hemiarthroplasty is when only half of the joint is replaced. This involves replacing only the ball (humerus) with a new metal ball and leaving the socket alone. This may be done for a young patient (often less than 50 years old) with arthritis or a young patient with a fracture. For more information on shoulder replacements and the differences between each type, please visit Rothman’s Shoulder Replacement Surgery page.

The ball and socket of the shoulder joint are surrounded by your rotator cuff muscles and tendons. In a shoulder replacement, the front rotator cuff tendon is typically detached and temporarily moved out of the way so that your surgeon can see and replace the bones of the shoulder. After completing the surgery, this tendon is then put back in place by repairing it to the arm bone. In an anatomic shoulder replacement and hemiarthroplasty, it is critical that this tendon heal in order to provide you with a well-functioning, pain-free shoulder. Much of your shoulder rehabilitation is focused on giving your shoulder time to allow this tendon to heal prior to beginning any active use of the arm. A reverse shoulder replacement does not depend on the rotator cuff in the same way that the anatomic replacement does, and so rehabilitation after this surgery may be somewhat different.

Rehabilitation and Return to Activity After Shoulder Surgery

After a shoulder replacement, patients are often sent home in a sling to protect the arm and keep it immobilized to allow for healing to occur. A typical postoperative rehabilitation course after shoulder replacement includes remaining in the sling at all times for the first 2-3 weeks, then beginning to remove the sling when at home in a controlled environment. The sling is removed at home to start small range-of-motion exercises in the first few weeks following surgery. During this time, you will be working on passive range-of-motion with a therapist, which will then progress to active range-of-motion at around 6 weeks after surgery, followed by strengthening at around 3 months. Patients with a reverse shoulder replacement may sometimes begin active range-of-motion and strengthening before these time points as it is less dependent upon healing of the rotator cuff. However, some surgeons consider placing a weight limit on the arm after this surgery, and this is something you should speak about with your surgeon.

Once full range-of-motion is achieved and strength is improved, return to sport activities can often be started between 4 and 6 months after surgery. When it comes to racket sports, this would include beginning light volleying with a partner near the net in order to train your body and get used to swinging a racket again. You can then advance slowly over the next 2 months by progressively moving farther away from the net as you work on drills with a partner, eventually working your way up to practicing a serve closer to 6 months after surgery. Once you feel comfortable with all aspects of swinging a racket or paddle, return to competition can then begin. Keep in mind, this is a general rehabilitation guideline and may differ depending upon the preferences of your treating surgeon, the type of shoulder replacement you had, and the reason why your shoulder replacement was performed.

Playing Racket Sports After A Shoulder Replacement

Traditionally, the ability to return to any sport after shoulder replacement surgery was based upon the recommendation of the surgeon and willingness of the patient to accept the risks associated with a high-level of activity after surgery. These risks include:

• Instability: dislocation of the shoulder can be more likely after a shoulder replacement
• Rotator cuff tear: whether that be a tear of the tendon that was repaired during surgery or a new tear of a rotator cuff tendon
• Fracture of the arm bone or shoulder blade around the metal implant
• Rapid wearing-out of the plastic socket due to high-demand use of the shoulder

This is true with racket sports specifically, as any patient returning to tennis or pickleball is at risk of these same complications after a shoulder replacement. In spite of these risks, we know that patients can get back to playing these sports at a high-level with minimal pain and improved function. In fact, a group of orthopedic surgeons studied this very question this year (Vegas et al., Return to racket sports after shoulder arthroplasty: Performance and outcome scores 2023)!  

They sought to find out if patients can return to sports such as pickleball, tennis, and racquetball after a shoulder replacement, and if so, how happy were they with their performance? As it turns out, the results were very reassuring! About 90% of patients got back to playing their racket sport of choice, with one-half of patients playing at a high-level by 6 months and 85% by 1-year after surgery. Ninety-percent of patients believed that their performance was as good or improved after a shoulder replacement, and 98% felt that they enjoyed playing their sport either just as much or even more than they did before surgery. Arguably the most important finding was that the average pain level experienced while playing racket sports dropped from a 5 out of 10 prior to surgery, to a 0 out of 10 after a shoulder replacement. These results were seen in patients regardless of the type of shoulder replacement that they received. This experiment helps to prove that the vast majority of patients suffering from this problem can get back on the court with the same (or greater!) level of competition and enjoyment, as well as much less pain, after a shoulder replacement.

How to Prepare: Equipment, Warm-Ups, and Injury Prevention

A successful return to the tennis or pickleball courts after a shoulder replacement requires appropriate preparation. Just like in a normal shoulder, pregame warmups are key to preventing an additional shoulder injury. It is important to take 15-20 minutes, prior to practice or game-play, to perform exercises like:

• Straight-arm circles (arm extended away from your body and rotated forward and backward)
• Shoulder rolls (rotate your shoulder blades in a circle by lifting them up toward your ears, then backward in a shoulder blade “pinch”, then downward, then forward),
• Resistance-band work
• Shoulder stretches

It is important to stretch the front of the shoulder by rotating the arm and hand away from your body, and then the back of the shoulder by bringing your arm across your body and hugging it against your chest using the opposite arm. This should be done after warming up the muscles of the shoulder so that they are flexible. Allowing your muscles proper time to loosen up by stretching and exercising before play will help prevent muscular injury of the shoulder.

If you are working with a physical therapist or doing exercises at home after surgery, it can be easy to focus solely on the shoulder. However, it is important to remember to work on core strengthening and balance training. After surgery, patients are encouraged to not be very active in order to protect the shoulder and allow for healing. This means that you have likely been more sedentary than normal in the months following surgery, which can result in weakness of your legs and core muscles. These muscles are important for ensuring appropriate balance, especially while playing a sport like tennis, pickleball, or racquetball. One of the most worrisome complications after a shoulder replacement is a fracture of the bone around the shoulder implant, which can often happen after a fall. This can result in severe shoulder pain and even loosening of the shoulder implant, which may require another surgery to fix. The best way to prevent this is by training your leg and core muscles, allowing you to move safely around the court and minimizing your risk of falls. This includes a combination of abdominal muscle strengthening, squats, lunges, calf raises, and lower back strengthening utilizing light resistance.

Preparing your shoulder for a return to play requires having the right equipment. This includes making sure that you are prepared in all aspects of your game, including before, during, and after play. As previously mentioned, warming up before a game is critical. Using equipment including resistance bands or foam rollers to loosen-up your muscles and prepare them for activity can affect your recovery after a game. During the game, it is important to utilize the proper footwear. Shoes specifically made for a tennis or pickleball court provide a great combination of support and grip to make sure that you are not at risk of rolling your ankle or sliding across the court, both of which can result in a fall. Proper recovery after a game is very similar to warming-up. Post-game stretching and a foam roller can help to prevent muscle stiffness and soreness after activity. In addition, making sure to use a large ice pack or ice-machine to help your muscles cool down can help to minimize soreness and maximize recovery.

Finally, when at home between games, it is important that you continue to work on shoulder strengthening and stabilization exercises that are taught to you during physical therapy. These often require a combination of resistance bands and light free-weights providing between 1 and 5 pounds of resistance. Maintaining these exercises will help to keep your shoulder strong and prepared for activity. Only providing your shoulder with exercise on the days that you play your racket sport of choice will often mean that your shoulder will need a greater period of time to warm up and cool down in order to stay game-ready and injury free.

Conclusion

Shoulder pain due to arthritis, fracture, or rotator cuff tearing can be debilitating, especially when it interferes with the activities that you love to do. Shoulder replacement surgery is very effective at decreasing pain and improving function in patients with these problems. Patients may be hesitant to undergo a shoulder replacement if they are concerned about their ability to play their favorite racket sports after surgery. Fortunately, the vast majority of patients can get back on the court with the same (or greater) level of competition and enjoyment and much less pain after a shoulder replacement. If you love playing pickleball, tennis, or racquetball but suffer from shoulder pain making it difficult to play, contact one of our shoulder replacement specialists today and find out if this surgery is an option for you.

Sources:

1. Vegas, A., Cannon, D., Rafael Garcia, J., Rodriguez, H. C., Levy, J., Lapica, H., & Levy, J. C. (2023). Return to racket sports after shoulder arthroplasty: Performance and outcome scores. Seminars in Arthroplasty: JSES, 33(3), 447–454. https://doi.org/10.1053/j.sart.2023.02.006
2. https://www.theapp.global/news/nearly-50-million-adult-americans-have-played-pickleball