Tennis is considered the most popular international racket sport, and it is estimated that there are 27 million players in the United States alone. Tennis originated from other racket sports such as badminton and squash, and officially began as “lawn tennis” in 1874 in England (20). It is played now throughout the world on multiple surfaces and by players of all ages and levels.
Tennis has many health benefits, including improved aerobic fitness, lowering body fat percentage, developing a more favorable lipid profile, reducing the risk for developing cardiovascular disease, and improving bone health in young tennis players (37). However, especially at the elite level, training has become more intense, specialized, and volume dependent (33). Patterns of injury reflect the changes in training, more aggressive styles of play, grip modifications and open stance forehands, as well as improved physical abilities of the players. When evaluating injury risk and type, it is important to review these risks and to distinguish the adult recreational player from the junior and elite tennis player.
In this article, we explore the epidemiology of tennis injuries based on the type of player and review the most common musculoskeletal adaptations seen and the tennis-specific injuries and patterns. Additional recommendations on treatments and return-to-play strategies that are unique to tennis athletes is explored, as well as a brief review of injury patterns of other racket sports.
Safran (41), Silva (44), and Hutchinson et al. (15) analyzed medical consultations during junior national tournaments and reported from 21.5 to 35.5 medical consultations per 1000 match exposures, which may be similar to other competitive sports. We previously evaluated 28,336 match exposures in 4 United States Tennis Association (USTA) supernational junior tournaments in 1 year and found higher medical withdrawal rates in boys, singles players, and older age divisions (17). Most importantly, there was a significant increase in medical withdrawal risk beyond the fourth match within a tournament, suggestive of a cumulative match volume risk within tournaments.
Prospective evaluations of junior tennis players have identified prior injury as a risk factor for new injury (P < 0.001; odds ratio (OR), 8.8) (14) and increased future risk of a medical withdrawal in a tournament (P < 0.001; OR, 6.27) (33). We also found, in a prospective evaluation of 519 competitive midwest junior tennis players, that 70% specialized in tennis at an average age of only 10.4 years old, and they were 1.6 times more likely to report an injury (P < 0.05) than multisport athletes (33). Players had a median weekly volume of 11 to 15 h·wk−1 of exposure to tennis and competed in 11 to 25 tournaments a year, whereas those who played 16 h·wk−1 or more trended toward being more likely to experience a tournament medical withdrawal.
Training for success
Carlson (6) found that elite professional players had less hours of training prior to 15 years old than near-elite players; however they had more hours of training after 15 years old. Near-elite players had greater demands for success, larger group classes, shorter relationships with their coaches, and less access to courts than elite players. A separate study found that the top 10 players in the world had played in an average of only 11.0 tournaments a year when they were 17 years old and 15.2 tournaments a year when they were 18 years old (38). A recent study demonstrated that performances at U14 youth elite level European tournaments had weak correlation with later professional success (2). These data suggest that early, high-volume, tournament-focused play may not be necessary for later success at the elite level and may in fact promote injury.
Training techniques may influence risk of injury and should be specific to the sport. Competitive tennis players play at work-rest intervals of 1:2 up to 1:5, with an average of 6.36 seconds per point; therefore the most effective tennis-specific training should use those parameters (22). Speed and agility correlate closely with tennis performance in junior players, and such training should be at most the distance of the court (22).
Adult recreational player
Tennis in general is considered a low-risk sport with minimal incidence of severe injury in adults. Reported injury rates vary from 0.05 to 2.9 injuries per player per year (36). This wide variance may be due to varied definitions of “injury” and variability in the age, gender, and ability level of the cohorts studied. There is some evidence for more acute lower extremity injuries in studies that involved acute presentation in clinic or at clubs (5). Meanwhile there also is evidence for more overuse upper extremity injuries by retrospective evaluations of the players (18). In a cross-sectional survey study of 529 recreational players with an average age of 46.9 years, Jayanthi et al. (18) reported 3.0 injuries per 1000 h of play and a prevalence of 52.9 injuries per 100 players. Overuse injuries predominated, and 49% of injuries were in the lower extremities. These risk factors and rates of injury are similar to other individual recreational sports such as golf and running.
An earlier study by Gruchow and Pelletier (13) suggested that individuals who play more than 2 h of tennis per day, 5 d·wk−1 (i.e., 10 h·wk−1), increase their risk of lateral epicondylitis. Other studies examining volume of play and injury risk found no difference in injury rates based on hours of play per day up to 6 h·wk−1 (18). There is however preliminary evidence that increasing skill level, as rated by the USTA’s National Tennis Rating Program (NTRP) scale, may increase injury risk, specifically, acute injuries (18). Tournament play was more likely to result in injury than noncompetitive play (OR, 4.1) (48). Training volumes of 6 h or a week or less, lower skill level, and noncompetitive tennis play may be more protective of injury in adult recreational tennis players.
Tennis-Specific Evaluation of the Injured Player
A comprehensive evaluation of the tennis player should include level, playing history, technique changes, as well as a tennis-specific musculoskeletal evaluation (Fig. 1).
Asymmetric Tennis Player
The unilateral nature of tennis creates certain adaptations over time. The significance of these adaptations as a way to improve performance, or a risk factor for injury, is debatable. Modification of the extremes of adaptation is a typical goal for injury prevention programs and tennis-specific rehabilitation programs. The dominant upper extremity, including the shoulder, elbow, and forearm, demonstrates asymmetries that is highlighted in the succeeding part of this manuscript. Adaptations of the trunk and lower extremity include a loss of internal rotation of the leading hip (46) and asymmetric hypertrophy of the contralateral rectus abdominis in elite tennis players (27).
The tennis serve and overhead involve a patterned, repetitive motion including kinetically linked stages well described by Kibler (19). In the ideal tennis serve, 54% of kinetic chain forces are generated from the hip/trunk with progressively less force generation from the upper extremity (Fig. 2) (19). These numbers tend to be reversed in the adult recreational player or a developing junior player. Kovacs and Ellenbecker (21) recently described an eight-stage model for evaluating the tennis serve, which involves a specific description of the preparation, loading, and acceleration stages. They predict that a breakdown in any of these phases may increase upper extremity injury risk. Balanced range of motion and strength about the shoulder girdle maintains appropriate motion during the serve. When dynamic stabilizers are insufficient to de-accelerate the movements of the upper extremity, static structures such as the glenohumeral ligaments, labrum, rotator cuff, and posterior joint capsule are stressed. Specific serve types also may influence these risks of injury. Abrams et al. (1) used a markerless system to evaluate the tennis serve in elite players and demonstrated that the kick (heavy topspin) serve places higher physical demands on the back and shoulder, while the slice serve demonstrated lower overall kinetic forces. Caution with hyperextension on topspin serves is recommended generally in younger players, especially when this exceeds 20° (Fig. 2).
Groundstrokes (forehand and backhand)
The modern game of more aggressive topspin may cause ulnar wrist problems in adult and elite junior tennis players. Dominant wrist injuries occur on the forehand, while nondominant ulnar wrist injuries occur on the two-handed backhand. Modifications of strokes as well as grip changes may be necessary (Table 1). The open stance forehand is also a part of the modern game, but it may present injury patterns in either the lead hip or the rear hip, particularly during the forehand stroke (Table 2). A comparison of adult tennis players with tennis elbow and unaffected players shows that injured players had greater wrist extensor activity, particularly of the extensor carpi radialis brevis (ECRB) (8). This activity seems to be reduced in a two-handed backhand; however faulty one-handed mechanics leave this stroke susceptible (8). Symptoms also may occur during pronation on the forehand and serves (16) (Table 1).
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:
1. Exercise caution in junior tournament players competing in their fifth match and beyond, particularly in older age divisions (17) (SORT Level B).
2. Caution with history of prior injury, particularly in the low back and before a tournament (11,14,33,40) (SORT Level B).
3. 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).
4. 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).
5. Consider delaying specialization in tennis until middle or late adolescence for injury prevention as well as for successful performance (7,33) (SORT Level B).
6. 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:
1. Caution when exceeding >6 to 10 h·wk−1 (13,18) (SORT Level B).
2. Increased risk of injury with match play versus recreational play (48) (SORT Level B)
3. Higher NTRP level may be associated with injury (18) (SORT Level B).
4. 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.
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