Shoulder imbalances can occur in 8- to 11-year-old junior tennis players and continue with competitive play, along with upper limb asymmetry (3,7,14). A glenohumeral internal rotation deficit (GIRD) was seen in 27 professional tennis players (42). Additional changes may include scapular dyskinesis and dominant side weakness in external rotation. It is believed that this may increase the risk of impingement of the subacromial space, internal impingement of the posterior glenohumeral joint, or acromioclavicular joint impingement as well as superior labrum, anterior to posterior (SLAP) (47). Excess upper extremity load primarily on the serve can lead to stress injury to the humeral shaft (43), limiting play for 2 to 12 wk depending on severity.
Tennis players may develop adaptations in the elbow, including loss of terminal extension and increased size of the forearm; however it is unclear if these influence injury risk. The elbow is the most common site of injury in adult recreational players (18) and lateral epicondylosis, or “tennis elbow” is the leading overuse injury of the upper extremity in tennis players (36). There is a 50% incidence of elbow injuries in club players 30 years or older, with a fourfold increase in players over 40 years old (13). In a series of more than 700 players (including seniors) from the French Open, only one had a diagnosis of lateral epicondylitis (31), suggesting that this type of problem occurs predominately in the recreational player and may be a product of improper technique, combined with older age and volume of play.
Elbow issues in junior tennis players tend to have more concerning pathologies such as valgus extension overload, osteochondral lesions, and ulnar collateral ligament insufficiency. These conditions may be increased potentially with excess valgus on strokes such as forehands and serves (Table 1).
Muscular adaptations of the wrist were seen in a study of 32 female elite USTA junior tennis players who were found to have significantly greater dominant wrist and forearm pronation strength and also dominant forearm weakness in supination (10). Aggressive topspin groundstrokes may increase risk of injury to the ulnar wrist, resulting in extensor carpi ulnaris (ECU) tendon injuries, triangulofibrocartilage complex (TFCC) tears, and ulnar impaction. In the higher level player, overuse and traumatic injury of the ECU are common and are treated frequently successfully with conservative care (32) (Table 1). ECU tendon subluxation may be treated with an ulnar gutter splint for 3 to 4 months (32), whereas rupture requires surgery. Stress injuries to the lunate also have been reported in elite level players with dorsal wrist pain. These players may be returned to playing tennis with conservative treatment at about 14 wk (26).
Rehabilitation and return-to-play principles
Most tennis-related injuries are treated nonsurgically, and the rehabilitation principles should be functional and specific to the tennis player’s deficits and adaptations. In addition, recommendations should include acute, recovery, and functional rehabilitation phases (4). During the acute phase, rehabilitation is performed in pain-free planes. The player may be removed from the sport, or modifications may be made, for example, temporarily hitting without serves or overheads. Recovery phase includes more advanced rehabilitation such as closed kinetic chain strengthening, core stabilization, and scapular stabilization. Functional rehabilitation of the upper quarter should include tennis-specific eccentric strengthening (including deceleration) and proprioception while incorporating the kinetic chain. Return-to-play recommendations may include an on-court progression that is sequenced and should include specific technique changes as well (Table 1).
Routine conservative therapy (including eccentric strengthening) with instruction on stroke modification (in office or 1 h on court) resulted in 90% resolution of elbow pain in tennis players with less than 6 months of pain, and it obviated the need for surgery in any of the players (16). Alterations of grip and wrist motion may be necessary before successful return to play for ulnar wrist pain (Table 1).
Adherence to the training volume principles is important, and individualized training with diagnosis-specific stroke modifications (Table 1) should occur before match play, and then tournament play. Return to play after arthroscopic rotator cuff repair has been reported at 9.8 months, although return to play after total shoulder arthroplasty has been reported but not generally recommended (45). Arthroscopic drilling of the lateral epicondyle and surgical debridement may result in >95% good results with return to play in 3 months in experienced hands (34).
Back pain is common in adult and junior players, with increases in incidence with age in adults. Renkawitz (39) noted that more than 50% of amateur German tennis players experience low back pain during and after tennis, and the back is the most common cause of withdrawal on the men’s professional tour.
Back injuries were more likely when play exceeded as few as 6 h·wk−1 (OR, 4.7, P < 0.04) in junior tennis players (14), although elite national junior tennis players with spondylolysis all trained >15 h·wk−1 (40). Serial magnetic resonance imaging investigations of the lumbar spine in elite junior tennis players reveal abnormalities in the majority of the players (85%), with injuries to the pars interarticularis being the most common, followed by lumbar disc degeneration and facet joint arthropathy (11).
Rehabilitation and return-to-play principles
Adults with low back pain who have discogenic pathology should limit initial flexion, and then incorporate eccentric extensor spine control in multiple planes. A 7-wk home back exercise program of 20 min daily was successful in improving pain ratings, trunk extension strength, and performance in adult amateur tennis players (39).
In a retrospective review of 66 cases of spondylolysis in elite young tennis players, tennis was resumed at 4.5 months in patients with developing lysis, 3.9 months in active lysis, and only 1.7 months in established lysis, where there was an average of 24.6 d of pain (40). Posterior element problems such as facet syndrome and spondylolysis initially should limit extension, and then incorporate multiple planes of motion only when pain has subsided. Delaying the age of introduction to the kick serve until 13 years old or later also may help limit this extension stress (Fig. 2 and Table 2).
There is known asymmetric hypertrophy of the contralateral rectus abdominis in experienced tennis players. Injuries are reported on the contralateral rectus abdominis more often during the serve (27). Return-to-play rehabilitation must include both decline eccentric strengthening and rotation, thereby mimicking many of the forces experienced during tennis serves (27).
Asymmetric stress also may occur along the pubic symphyseal joint, resulting in osteitis pubis. Rehabilitation of this type of injury has been described in tennis players in a progressive manner (unload the tissue, concentric and then eccentric strengthening of adductors) (49).
Lower extremity injuries are common in tennis players, tend to be more acute in nature, and occur in more elite players (18,36).
Muscular injuries to the lower extremity
Thigh/adductor injuries were common in elite level junior tournaments due to rapid directional changes (15). Adult recreational players may get a strain or rupture of the musculotendinous junction of the medial gastrocnemius during rapid push off while the medial gastrocnemius is loaded eccentrically, or “tennis leg.”
With loss of lead hip rotation due to open stance forehands (46), progression to femoroacetabular impingement or labral tears may occur.
Common knee injuries still include meniscus tears and osteoarthritis in adults, and patellar tendinopathy, patellofemoral pain, and tibial tubercle apophysitis in junior/elite athletes. The clinician should be mindful of atypical patterns of pain that may suggest osteochondritis dissecans.
Plantar pressures are higher in the forefoot and central midfoot in tennis players. These forces are lower on clay court surfaces (12). Overuse injuries, including Achilles tendinopathy, plantar fasciitis, and specifically forefoot overload, may occur. Forefoot overload may predispose to sesamoid injuries, flexor hallucis longus tendonitis, and Morton’s neuroma. Elite tennis players had a stress fracture incidence of 12.9%, with the majority being at the lower extremity (metatarsal, tarsal, navicular, and tibia) (25).
Clay court surfaces have lower knee ratings than hard court surfaces for recreational players and may be the “gateway” surface for return to play after lower extremity injury. At the elite level, there are fewer treatments on the ATP tour on clay court versus other surfaces. In addition to court surface, structured tennis-specific on-court progression beginning at the service line is recommended also during return-to-play protocols.
Anterior cruciate ligament (ACL) injuries have a relatively low incidence in tennis players; however tennis-specific limitations for ACL-deficient individuals such as reduced rapid directional changes and playing a maximum of 3 sets of singles over a 24-h period may be considered (28). Specific play recommendations after joint replacement also may be recommended. Fifty-eight USTA members with a mean age of 70 years were able to return to tennis with improved pain and function after total hip replacement surgery, with only 3 revisions required at 7-year follow-up (29). Thirty-three USTA members with a mean age of 57 were able to return to tennis after total knee replacement surgery (30). Twelve percent of players complained of pain and stiffness. General recommendations following total hip and knee replacement are that doubles play is acceptable and singles play is not recommended (30).
Dynamic warm-up before play is considered the optimum method, followed by postexercise stretching. Sport-specific risks may be reduced also through the modification of equipment or technique. For example, the use of protective eyewear in racket sports has been shown to reduce rate of eye injury. Serial musculoskeletal screening may identify areas at risk that allow sports medicine providers to intervene before injury occurs. A posterior capsule stretching program, “sleeper stretch” has been shown to reduce GIRD, but its reduction in shoulder injury risk is still unclear.
Tennis rackets ideally maximize performance while theoretically limiting vibrations to avoid injury. Nirschl criteria may be used to assess appropriate grip size, which is the measurement (in inches) from the distal tip of the ring finger to the proximal palmar crease (20). Lower tennis string tension typically imparts more power with less control, and it is accepted generally that this also may reduce recurrence of injury due to reduction of swing speed. Counterforce braces (tennis elbow straps) have been effective in decreasing forces to the ECRB in cadaver studies and to the forearms in tennis players, but these are not necessarily effective in injury reduction. Vibration dampeners are used to decrease string vibrations in the racket but do not result in any reduced racket frame vibration to the forearm as the strings only weigh 1/20th of the weight of the racket (24).
Squash originated in the 19th century in England. During play, the ball may reach speeds in excess of 170 mph. Compared with tennis, squash strokes have limited follow through and accentuate wrist and forearm acceleration. Most of the injuries in squash are acute or traumatic events, and a relatively small proportion is from overuse. There was an overall injury rate of 35.5/100,000 players requiring hospitalization between 2000 and 2001 (9). Sixty-eight percent of the injuries involved the lower extremity; 80% were men, and eye injuries were the most common reason (32.7%) for presentation to the emergency department. In a retrospective study of racket sport patterns of injuries, Chard and Lachmann (5) noted that squash players sustained more injuries, at 59% compared with 21% for tennis players and 20% for badminton players. Squash players sustained more knee, lumbar region, and ankle injuries, whereas upper extremity injuries were more common in tennis.
Badminton has both Greek and Roman origins as the child’s game “battledore and shuttlecock.” Badminton players use the terminal upper extremity like a whip during play to a greater extent than tennis players, accounting for faster racket head velocity. Kroner et al. (23) studied badminton injuries seen in a Denmark hospital during a 12-month period in 1986. A total of 217 injuries in 203 patients were seen. Joints and ligaments were injured in 58.8% of badminton players/patients, and the injuries most commonly were located in the lower extremities. Yung et al. (50) reported an injury incidence rate of 5.04/1000 player-hours in elite Hong Kong Badminton athletes. Most new injuries were strains, and the back, shoulder, thigh, and knee were involved most commonly.
Racquetball is a blend of squash, handball, and paddleball with shorter rackets and a larger ball with a more dynamic bounce. The incidence of ocular injuries has been reduced effectively with the use of protective eyewear, but upper extremity tendinopathies and acute sprains and cartilage injuries of the lower extremity are not infrequent (5).
Risks of adult recreational, junior, and elite tennis players vary based on volumes of exposure as well as the types of injury. Junior players may increase injury risk with 16 h·wk−1 training, while this may occur with as low as 6 to 10 h·wk−1 in adults. Changes to training and style of the modern game have led to various overuse injuries in the upper extremity and trunk. Return-to-play recommendations vary based on the ability level and age of the player. Upper extremity injuries typically require a structured three-phase rehabilitation program, including core stabilization, kinetic chain integration, and functional strengthening. Lumbar spine injuries should involve rehabilitation in the pain-free direction and instruction on limiting extension in younger players. Lower extremity injuries may be related generally to higher acuity, trauma, and higher level players. Most conditions allow a successful return to play in tennis without surgical intervention. Other racket sports have more acute injuries and less overuse injuries.
Summary of Tennis Training Recommendations
Junior/elite training and competition recommendations:
- Exercise caution in junior tournament players competing in their fifth match and beyond, particularly in older age divisions (17) (SORT Level B).
- Caution with history of prior injury, particularly in the low back and before a tournament (11,14,33,40) (SORT Level B).
- Keep exposure to tennis training <16 h·wk−1 (or even less hours per week than age), and take off more than 1 d from tennis training per week (33,40) (SORT Level C).
- Consider playing <18 tournaments annually in the 18 and under division (and potentially less tournaments per year than age). Under-14 tournament success is not necessary to develop later elite level success (2,38) (SORT Level B).
- Consider delaying specialization in tennis until middle or late adolescence for injury prevention as well as for successful performance (7,33) (SORT Level B).
- Intensify training in late adolescence, and make attempts to have consistent coaching, less demands for success, and facilities to ensure optimum success (6) (SORT Level B).
Adult recreational player recommendations:
- Caution when exceeding >6 to 10 h·wk−1 (13,18) (SORT Level B).
- Increased risk of injury with match play versus recreational play (48) (SORT Level B)
- Higher NTRP level may be associated with injury (18) (SORT Level B).
- Caution when over 40 years old, particularly when developing symptoms in the elbow (13,18,19) (SORT Level B).
The authors declare no conflicts of interests and do not have any financial disclosures.
1. Abrams GD, Harris AHS, Andriacchi TP. Biomechanical analysis of three tennis serve types using a markerless system. Br. J. Sports Med
2. Brouwers J, De Bosscher V, Sotiriadou P. An examination of the importance of performances in youth and junior competition as an indicator of later success in tennis. Sport Manage. Rev
. 2012; 15: 461–75.
3. Brown G. Do pre-adolescent performance tennis players show signs of shoulder imbalances compared to post-adolescent tennis players? A pilot study. J. Med. Sci. Tennis
. 2008; 13: 22–5.
4. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy
. 2003; 19: 641–61.
5. Chard MD, Lachmann SM. Racquet sports — patterns of injury presenting to a sports injury clinic. Br. J. Sports Med
. 1987; 21: 150–3.
6. Carlson. The socialization of elite tennis players in Sweden: an analysis of the players’ backgrounds and development. Sociol. Sport J
. 1988; 5: 241–56.
7. Cools AM, Declercq G, Cagnie B. Internal impingement in the tennis player: rehabilitation guidelines. Br. J. Sports Med.
2008; 42: 165–71.
8. De Smedt T, de Jong A, Van Leemout W, et al. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. Br. J. Sports Med
. 2007; 41: 816–19.
9. Eime R, Finch C, Wolfe R, et al. The effectiveness of a squash eyewear promotion strategy. Br. J. Sports Med
. 2003; 10: 243–5. 2005;39:681–5.
10. Ellenbecker TS, Roetert EP, Riewald S. Isokinetic profile of wrist and forearm strength in elite female junior tennis players. Br. J. Sports Med
. 2006; 40: 411–4.
11. Faisal A, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br. J. Sports Med
. 2007; 41: 836–41.
12. Girard O, Eicher F, Fourchet F. Effects of the playing surface on plantar pressures. Br. J. Sports Med
. 2007; 41: 733–8.
13. Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am. J. Sports Med
. 1979; 7: 234–8.
14. Hjelm N, Werner S, Renstrom P. Injury profile in junior tennis players: a prospective two year study. Knee Surg. Sports Traumatol. Arthrosc
. 2010; 18: 845–50.
15. Hutchinson MR, Laprade RF, Quinter MB, et al. Injury surveillance at the USTA boys’ tennis championships: a 6- year study. Med. Sci. Sports Exerc
. 1994; 27: 826–30.
16. Ilfeld FW. Can stroke modification relieve tennis elbow? Clin. Orthop. Relat. Res
. 1992; 276: 182–6.
17. Jayanthi NA, Boyle J, Durazo-Arvizu RA. Risk factors for medical withdrawals in United States Tennis Association Junior National Tennis Tournaments: a descriptive epidemiologic study. Sports Health
. 2009; 1: 231–5.
18. Jayanthi NA, Sallay P, Hunker P. Skill level related injuries in competition tennis players. Med. Sci. Tennis
. 2005; 10: 12–5.
19. Kibler WB. Clinical biomechanics of the elbow in tennis: implications for evaluation and diagnosis. Med. Sci. Sports Exerc
. 1994; 26: 1203–6.
20. Kramer J, Sloane S, Campbel J, et al. The Complete Guide to USPTA Membership
. Houston: U.S. Professional Tennis Association, 2005.
21. Kovacs M, Ellenbecker T. An 8-stage model for evaluating the tennis serve implications for performance enhancement and injury prevention. Sports Health
. 2011; 3: 504–13.
22. Kovacs MS. Applied physiology of tennis performance. Br. J. Sports Med
. 2006; 40: 381–6.
23. Kroner K, Schmdit SA, Neilson AB, et al. Badminton injuries. Br. J. Sports Med
. 1990; 24: 169–72.
24. Li FX, Fewtrell D, Jenkins M. String vibration dampers do not reduce racket frame vibration transfer to the forearm. J. Sports Sci
. 2004; 22: 1041–52.
25. Maquirriain J, Ghisi JP. The incidence and distribution of stress fractures in elite tennis players. Br. J. Sports Med
. 2006; 40: 454–9.
26. Maquirriain J, Ghisi JP. Stress injury of the lunate in tennis players: a case series and related biomechanical considerations Br. J. Sports Med
. 2007; 41: 812–5.
27. Maquirriain J, Ghisi JP, Kokalj AM. Rectus abdominis muscle strains in tennis players. Br. J. Sports Med
. 2007; 41: 842–8.
28. Maquirriain J, Megey PJ. Tennis specific limitations in players with an ACL deficient knee. Br. J. Sports Med
. 2008; 40: 451–3.
29. Mont MA, Laporte DM, Mullick T, et al. Tennis After total hip arthroplasty. Am. J. Sports Med
. 1999; 27: 60–4.
30. Mont MA, Rajadhyaksha AD, Marxen JL, et al. Tennis after total knee arthroplasty. Am. J. Sports Med
. 2002; 30: 163–6.
31. Montalvan B, Parier J, Gires A, et al. Results of three years medical surveillance of the international championships at Roland Garros: an epidemiological study in sports pathology. Med. Sci. Tennis
. 2004; 9: 14–5.
32. Montalvan B, Parier J, Brasseur JL. Extensor carpi ulnaris injuries in tennis players: a study of 28 cases. Br. J. Sports Med
. 2006; 40: 424–9.
33. Jayanthi NA, Dechert A, Durazo R. Training and sports specialization risks in junior elite tennis players. Med. Sci. Tennis
. 2011: 16: 14–20.
34. Nirschl RP. Elbow tendinosis/tennis elbow. Clin. Sports Med
. 1992; 11: 851–70.
35. Osborn RQ, Taylor WC, et al. Echocardiographic characterisation of left ventricular geometry of professional male tennis players. Br. J. Sports Med
. 2007; 41: 789–92.
36. Pluim BM, Staal JB, Windler GE, Jayanthi N. Tennis injuries: occurrence, aetiology and prevention. Br. J. Sports Med
. 2006; 40: 415–23.
37. Pluim BM, Staal JB, Marky BL. Health benefits of tennis. Br. J. Sports Med
. 2007; 41: 760–8.
38. Reid M, Quinlan G, Morris C. Periodisation in tennis. ITF Coach. Sport Sci. Rev
. 2010; 50: 26–7.
39. Renkawitz T. Neuromuscular efficiency of erector spinae in high performance amateur tennis players. Med. Sci. Tennis
. 2006; 11: 26–31.
40. Ruiz-Cotorro A, Balius-Matas R, Estruch-Massana A, Vilaro Angulo J. Spondylolysis in young tennis players. Br. J. Sports Med
. 2006; 40: 441–6.
41. Safran MR. Tennis injuries and strategies for prevention: gender differences in the American junior elite tennis player. J. Med. Sci. Tennis
. 2000: 2.
42. Schmidt-Wiethoff S. 2002 Kinematic analysis of internal and external rotation range of motion in professional tennis. Med. Sci. Tennis
. 2003; 8: 18–9.
43. Silva RT, Hartmann LG, Laurino CF. Stress reaction of the humerus in tennis players. Br. J. Sports Med
. 2007; 41: 824.
44. Silva RT, Takahashi R, Berra B. Medical assistance at the Brazilian juniors tennis circuit — a one year prospective study. J. Sci. Med. Sport
. 2003; 6: 14–8.
45. Sonnery-Cottet B, Edwards B, Noel E, et al. Rotator cuff tears in middle-aged tennis players: results of surgical treatment. Am. J. Sports Med
. 2002; 30: 558–64.
46. Vad VB, Gebeh A, Dines D, et al. Hip and shoulder internal rotation range of motion deficits in professional tennis players. J. Sci. Med. Sport
. 2003; 6: 71–5.
47. Van der Hoeven H, Kibler WB. Shoulder injuries in tennis players. Br. J. Sports Med
. 2006; 40: 435–40.
48. Veijgen NK. Injuries: A Retrospective Cohort Study of Risk Factors for Tennis Related Injuries in The Netherlands
. Amsterdam (Netherlands): Free University, 2007.
49. Wood T. Osteitis pubis as a cause of groin pain in tennis players. Med. Sci. Tennis
. 2004; 9: 4–5.
Copyright © 2013 by the American College of Sports Medicine.
50. Yung PS-H, Chan RH-K, Wong FC-Y. Epidemiology of injuries in Hong Kong elite badminton athletes. Res. Sports Med
. 2007; 15: 133–46.