This document discusses injury prevention in tennis athletes. It provides data on common tennis injuries, their causes, and recommendations for reducing risks. Some key points include: - Tennis involves high physical demands that can lead to injuries if proper precautions aren't taken. - Common injuries include shoulder issues like rotator cuff tears, elbow issues like tennis elbow, and knee/back pain. - Injury risks can be reduced through proper warmups, stretching, strength training, technique, hydration, nutrition, and avoiding overuse or fatigue. - Specific recommendations include dynamic warmups, rotator cuff exercises, stretching chest and shoulders daily, and addressing biomechanical flaws or muscle imbalances.

1. Preventing Injury in
The Tennis Athlete
Stephan Esser MD, USPTA
Follow Me @EsserHealth or
@EsserSports
on
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2. Goals
• Introduce injury types, trends and risks in the tennis athlete
• Provide you tangible tools to reduce the most common injuries in
your athletes

3. Tennis
• 10,680 steps in an hour of singles tennis
• 100-200 serves per match
• 200-300 ground strokes per match
• 400-600 calories per hr of play
• Bake in the Sun
• Sweat up to 2.0-3.0L/h. (6.6lbs of fluid)

4. Tennis Injury
• BJSM: Pluim et al
• Injury incidence 0.05- to 2.9 per player per year
• Per hour of play 0.04- 3.0 injuries/1000 hours
• Junior Rugby 56.8/1000hrs JSMS Gabbett 2008
• Gender: slight inc in men > women
• Age: as age increases, risk of injury increases
• Volume: Unclear risk (tennis elbow)

5. Coach Goals
• Maximize Performance
• Minimize Injury
• Accelerate Recovery

6. Hydration

7. Hydration
• > 2% of weight loss impairs performance (Thirst??)
• blood volume, decreased skin blood flow, decreased sweat rate, increased
core temperature, and an increased rate of muscle glycogen use
• Increases risk of cramping
• Increases risk of delayed onset muscle soreness
• Impairs skin, tendon, cartilage and ligament health

8. Signs of Inadequate Hydration ??
• Headaches
• Fatigue
• Reduced Effort
• Slowed speed
• Prolonged recovery
• Negative Attitude
• Slowed Cognitive reaction/planning

9. Hydration

10. Hydration
• Pre-hydrate
• 20 ounces 2 hrs before sport
• 20 ounces 15 minutes before
• Maintain
• Drink 10oz every 15 minutes ( 4-6 big gulps)
• Consider electrolyte/carb(6-8%) beverage if high risk of cramping or high heat
and prolonged play > 1.5 hrs
• Rehydrate
• Weighing themselves before and after practice. For every kilogram (pound)
lost during the workout, drink ~1.5 liters (~three cups) of fluid in order to
rehydrate the body.
• Monitor Urine Changes

11. Hydration

12. Hydration

13. Tips
• ”Eat your water”
• Make Water readily accessible
• Remind to Pre-hydrate and to drink during play
• High level or high risk players consider pre and post weigh ins
• Educate, Remind, Educate again, Remind again
• Performance vs Pain vs Recovery

14. “Food is Medicine”

15. Food as Medicine
The effect of dietary anthocyanins on
biochemical, physiological, and subjective
exercise recovery: a systematic review and
meta-analysis CRFSN 2021
• To summarize, ACN were shown to have an overall
beneficial effect on reducing CK, muscle
soreness, strength loss and
improving power after exercise. This
was accompanied by attenuated inflammation and
increased antioxidant capacity/status following the
intake of ACN, suggesting a potential causal link.

16. Food is Information
Reduce Inflammation Replete Calories

17. Tendon Injury and High Cholesterol
• Serum Lipids and risk of Tendon Injury
• Impaired micro-perfusion
• Increased risk of injury
• Increased risk of re-tear and slowed healing
• Patients with rotator cuff tears were more likely to have hypercholesterolemia when compared with the
control group. The Effect of Hypercholesterolemia on Rotator Cuff Disease Clinical Orthopedics and
Related Research 2010
• The present study found a significant association between moderate and high perioperative total
cholesterol and LDL levels and the rate of revision surgery after primary arthroscopic rotator cuff
repair. Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery Rate After
Arthroscopic Rotator Cuff Repair AJSM 2017
• Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) concentrations of the patients with
ATR were higher (p<0.001), and their high-density lipoprotein cholesterol (HDL-C) was lower than the
control group (p<0.05). Moreover, the concentrations of triglyceride (TG) and very low-density
lipoprotein cholesterol (VLDL-C) were significantly higher than controls (p<0.05). Is high concentration of
serum lipids a risk factor for Achilles tendon rupture?
• People with altered tendon structure or tendon pain had significantly higher total cholesterol, low-
density lipoprotein cholesterol and triglycerides, as well as lower high-density lipoprotein cholesterol. Is
higher serum cholesterol associated with altered tendon structure or tendon pain? A systematic review
BJSM 2015
• One intrinsic factor that appears to have an association with tendinopathy is body composition; more
specifically central adiposity Adiposity and tendinopathy Disability and Rehabilitation 2008

18. Osteoarthritis and High Blood Pressure
• Association of Hypertension with Knee
Pain Severity Among People with Knee
Osteoarthritis 2022
• Zhang YM, Wang J, Liu XG. Association
between hypertension and risk of knee
osteoarthritis. Med (United States).
2017;96:e7584.
• Hypertension meets osteoarthritis —
revisiting the vascular aetiology
hypothesis 2021
• Accumulation of metabolic risk factors
such as overweight, hypertension,
dyslipidaemia, and impaired glucose
tolerance raises the risk of occurrence
and progression of knee osteoarthritis: a
3-year follow-up of the ROAD study.
Osteoarthr Cartil. 2012;20:1217–26.
• Lo GH, McAlindon TE, Katz JN, Driban JB,
Price LL, Eaton CB, et al. Systolic and
pulse pressure associate with incident
knee osteoarthritis: data from the
osteoarthritis initiative. Clin Rheumatol.
2017;36:2121–8
• Association between hypertension and
osteoarthritis: A systematic review and
meta-analysis of observational studies
2022

19. Shoulder Injury

20. Shoulder Injury

23. Rotator Cuff Injury
Prevention:
Intrinsic:
• Technique
• Service Ball Toss Height, Location and Follow Thru
• Kinetic Chain: “Ground up”
• Forehand Grip Type: Eastern/Semi-western are preferred
• Continental Late contact, compensate with “roll over”
• Forehand Contact Point and Follow-through
• Odd mechanical flaws ( Elbow above Wrist)
• The “Too’s”
• Muscle Balance: Increase Back strength/Stretch chest wall
• Maintain Shoulder range of motion

24. Rotator Cuff Injury Prevention
• 3-4 x’s week: Rotator cuff strength program
• Incorporate into lessons, group sessions
• Daily stretch shoulders and chest wall
• Avoid the Too’s
• Posture Training

26. Rotator Cuff Injury Prevention
• 3-4 x’s week: Rotator cuff strength program
• Incorporate into lessons, group sessions
• Daily stretch shoulders and chest wall
• Avoid the Too’s
• Posture Training

28. Rotator Cuff Injury Prevention
• 3-4 x’s week: Rotator cuff strength program
• Incorporate into lessons, group sessions
• Daily stretch shoulders and chest wall
• Avoid the Too’s
• Posture Training

29. Tennis Elbow
http://www.jantoo.com/cartoons/keywords/tennis-elbow

30. Tennis Elbow
• Causes:
• Overuse: Volume > 5 times per week
• Misuse:
• Sudden changes: Frequency, hours played, intensity of play, string
type, raquet type, grip size etc
• Technique:
• Continental Groundstroke Forehand Grip use
• Late contact and single arm Backhand stroke
• Over-gripping the raquet

31. Tennis Elbow
• Prevention
• Educate: Proper form, technique and the Need for
“rest days”
• When selling new raquets, string etc, encourage a
gradual transition (ie: Like runners with shoes)
• Co-train: Shoulder, Core, hips, forearm and wrist
muscles
• Tips: “Power” comes from the legs/core
• “Don’t kill the hummingbird”

32. Low Back Pain

34. Tennis Injuries
• Is tennis a risk factor for back pain or spondylosis?
• Hutchinson et al 1995:LBP #1 injury over 6 yrs in adol. elite
• Marks et al 1988: 38% of 143 ATP players missed at least 1 tournament due to back pain
• Alyas et al 2007: MRI LS 33 asymptomatic elite juniors < 18 y/o
• 5 normal MRI’s 28 Abnormal
• 23 with early facet arthrosis L5/S1 L4/L5
• 9 Spondys (L5), 2 with G1 and G2 –listhesis
• 2 acute/5 chronic stress reactions of the pars
• 13 with disc dessication, disc bulging

35. Low Back Pain Prevention
• On Court:
• Avoid the Too’s
• 10 minute cardio warmup
• Dynamic Stretching
• Teach Rhythm, Kinetic Chain Loading
• Control Volume and form of serves
• Off Court
• Daily core program
• Strengthen lateral hips and Butt
• Stretch the hip flexors, quads and mid/low back
• Consider cross training like swimming and pilates

36. Heat Illness

37. Heat Illness
Other
Un-Acclimated
Deconditioned
Prolonged Exposure

38. Heat Illness

39. Heat Illness / Cramping
0. Prevention/Pre-Hydration/Acclimitization
1.Stretch the affected area.
2.Re-Hydrate and consider salt tabs/electrolyte replacement
3.Massage the affected area with your hands or a massage roller.
4.Stand up and walk around.
5.Apply heat or ice. Put an ice pack together or apply a heating
pad, or take a nice warm bath.
6.Take painkillers such as ibuprofen and acetaminophen

40. Heat Illness/Dehydration/Fluid Replacement
Water
• 1 quart water
• ¾ teaspoon table salt
• 2 Tablespoons sugar
• Optional: Crystal Light® to taste
(especially lemonade or orange-
pineapple flavors)
Gatorade G2
• 4 cups Gatorade® G2 (or one, 32
ounce bottle)
• 3/4 teaspoon table salt

41. Heat Illness

42. Knee Pain

43. Knee Pain
• Common Pre-disposing Factors:
• Genetics, Family History, Obesity, Trauma
• Muscular De-conditioning / Imbalance
• Causes:
• Arthritis
• Cartilage (Meniscal) Injury
• Ligament Injury: ACL, PCL etc
• Muscle Imbalance eg: Patello-femoral Syndrome

44. Knee Pain Prevention
• On Court:
• Avoid the Too’s
• 10 minute cardio warmup
• Dynamic Stretching
• Teach Rhythm, Kinetic Chain Loading,
• Consider off court impact fitness > on court
• Off Court
• Daily lateral hip and quad firing program
• Stretch the quads, hip flexors, hamstrings
• Consider low impact cross training if OA/Pain

45. Take Aways

46. Take Aways for Injury Prevention
• 10 minute cardio warm up prior to play
• Perfusion/Blood Flow
• 5-10 minutes of dynamic stretching
• Proprioception/Body Awareness
• Maintaining general body flexibility
• Strengthening posterior shoulders and lateral hips/glutes
• 3-4 days per week at least
• Foundational Technique / Adequate Fitness
• Maintaining Hydration and Excellent Nutrition
• Acclimatization and Avoiding the Too’s

47. Thank You!
Stephan Esser MD, USPTA
Follow Me @EsserHealth or
@EsserSports
on
Social Media