Tennis is an outstanding sport with a low risk of injury. However there are real risks of injury and this presentation was provided to Tennis Teaching professionals to guide them in developing an injury prevention program.

1. Injury Prevention in the
Recreational Tennis Player
Stephan Esser USPTA, MD, STMS

2. Case 1
• Tuesday Ladies doubles clinic
• 44 y/o RH 3.0 rated player: Rt Shoulder pain
• What do you do?

3. Case 2
• Annual Club Championship
• 100+ people watching
• Suddenly one of your members runs up saying
“Some old guy by court ten says his chest is
hurting.”
• What do you do?

4. Goals
– Know the rates/types of injuries commonly seen
in recreational tennis players
– Highlight some Common Injury types and basic
management
– Tips and tools to apply to your setting and players
– Consider a framework for developing and
implementing a comprehensive injury prevention
and management program at your facility

5. Tennis Injury
• BJSM 2006: 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)

6. Tennis Injury
• Abrams et al BJSM 2012
– Lower extremity > Upper Extremity
– Back

7. Lower Extremity Injury
– Ankle Sprains
– “Tennis Leg”
– Knee Pain

8. Ankle/Foot
• Ankle Sprains
– #1 injury in the lower limb
– Ligament Strain/Tear
– Bone Injury? / Age ?

9. Ankle Sprain
• Treatment:
• PRICE: Protect, Rest, Ice, Compression, Elevation
• 3-7 days before protected / progressive return
– Consider MD referral if severe swelling/major
bruising/significant pain “on the bones,” inability to walk
without severe pain after 30 minutes
• Things to have in the Shop:
• Ice/Plastic Bags/Plastic Wrap
• Bracing: ACE wrap/Air Splint/Ankle Brace
• Old walking Boot
• Crutches

10. Ankle Sprain
• Prevention:
– Extrinsic:
• Court Maintenance:
Material/Cracks/Lines/Water/Algae/Balls
• Apparel: Shoe-wear (type, age), Bracing, Orthotics
– Intrinsic:
• Conditioning: Flexibility/Balance/Reaction Time/CV
• Adequate Warm Up
http://www.itftennis.com/scienceandmedicine/injury-clinic/tennis-injuries/ankle.aspx

11. “Tennis Leg”
• Medial Calf Tear
– Player pushes off to run for ball and “feels a pop”
or like someone “hit or shot” them in the leg

12. “Tennis Leg”
• Treatment:
• PRICE: Protect, Rest, Ice, Compression, Elevation
• Refer to a sports Doc’
• Expect 1-6 weeks before full tennis participation
• Things to have in the Shop:
• Ice/Plastic Bags/Plastic Wrap
• ACE wrap
• Old walking Boot
• Crutches

13. Tennis Leg
• Prevention:
– Extrinsic:
• Apparel: Shoe-wear (type, age), Bracing
– Intrinsic:
• Conditioning: Flexibility/Balance/Reaction Time/CV
• Adequate Warm Up: 10 min dynamic
• Nutrition/Smoking Exposure
• Neurologic/Spine Issues

14. Knee Pain

15. 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

16. Knee Pain
• Things you/the player can handle:
– Mild Intermittent Discomfort
– Previously Diagnosed low grade pain
• You need a Doc:
– Acute Trauma
– Moderate to Extreme Persistent Pain
– Severe Swelling
– Catching, Popping, Clicking, Locking, Grinding,
Instability without a diagnosis

18. Knee Pain
• Things you/the player can handle:
– Mild Intermittent Discomfort
– Previously Diagnosed low grade pain
• You need a Doc:
– Acute Trauma
– Moderate to Extreme Persistent Pain
– Severe Swelling of the knee or calf
– Catching, Popping, Clicking, Locking, Grinding,
Instability without a diagnosis

19. Knee Pain
• Treatment:
– PRICE: 3-7 days
– Strengthening and Muscle Balance
– Guided or personal Physical Therapy Program
– NSAIDs
– Cortisone injections
– Cartilage Supplementation to the joint
– Platelet Rich Plasma/Stem Cells
– Surgery

20. Knee Pain
• Prevention:
– Extrinsic:
• Court Maintenance: Lines/Water/Algae/Balls
• Apparel: Shoe-wear (type, age), Bracing
– Intrinsic:
• Maximize Muscle Balance: Quad: Hamstring
• Maximize Flexibility Hips/Quad/Hamstrings/Calves
• Exercise Form/On-Court Form (Video/Muscle Memory)
• Achieve “Ideal Body Weight”
• Diet/Smoking?

21. Upper Extremity Injury
– Rotator Cuff Injury
– Tennis Elbow

22. The Science
• 310 Recreational Tennis Players
• 24% had arm injury from tennis in 6 months
– 13% Shoulder Injury
– 13% Elbow Injury
– 7% Wrist Injury
– 4% Hand/Finger/Thumb

25. Rotator Cuff Injury
• Pain in the shoulder, possibly radiating to the
mid/arm (NOT past the elbow)
• Worse with reaching overhead, follow
through, putting on/taking off shirts etc,
laying on the painful side at night

26. Rotator Cuff Injury
Prevention:
Intrinsic:
– Technique
• Service Ball Toss Height and Location
• Kinetic Chain: “Ground up”
• Forehand Grip Type: Eastern/Semi-western are
preferred
• Forehand Contact Point and Follow-through
– Muscle Balance: Increase Back/Stretch front
– Maintain Shoulder range of motion

27. Rotator Cuff Injury
• Treatment:
– 5-7 days
• Rest, Ice, Short Course of OTC NSAIDs
• Home Exercise Rotator Cuff Program
– Persistent Pain
• Sports Doc’ or PT Referral

28. Rotator Cuff Injury
• In the Shop
– Ice/Plastic Bags
– Kinesio Tape
– Handouts from local Doc/PT on Rotator Cuff
Exercises
– Elastic Bands to perform them

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 Forehand Grip use
– Late contact in Backhand stroke

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. Tennis Elbow
• Treatment:
– Rest, Ice, deep tissue massage
– Avoid:
• Steroid Injections
• NSAIDs?
– Send to PT for manual therapies/ Active Release
Therapies, strengthening
– Send to MD if not getting better or also have
numbness, tingling, neck pain etc

33. Developing a Comprehensive
Injury Prevention and Response
Program at your Facility

34. PLAN
• Identify the Need
• Know your Resources
• Develop relationships and a plan
• Discuss with your staff, GM etc
• Consider a run through for emergency issues
• Re-visit: Adjust and Adapt

35. Identify the Need
• Extrinsic
• Intrinsic

36. Preventing Injury
• Extrinsic: Walk the Grounds 3 times per year
– Court: Algae, potholes, cracks, lines, net cranks, fencing
(sharp edges, loose fence bottoms etc)
– Seating Areas: steep steps, slick surfaces, broken
furnishings, exposed sharp edges
– Walkways: Uneven stones, slick surfaces, unmarked stairs,
poorly lit walkways, guardrails, signage
– Parking/Entry: Markings, stop signs, uneven surfaces, blind
spots
– Ambient Weather: Heat, Cold, Sun, Rain, Lightening, Snow
etc
– Lessons: Carts, Balls, Other players

37. Preventing Injury
• Intrinsic:
– Personal Disease: Previous surgeries, Major Heart,
Lung issues, Joint or Muscle/Tendon Problems,
Seizures
• Consider a notebook for serious stuff with Emergency
Contact numbers
• Consider “PAR-Q for you”
– Conditioning: Strength, Cardiovascular Fitness,
Flexibility, Balance
– On Court Technique
– Hydration/Nutrition

38. Know Your Resources
• Learn about your
– Players/Members: Healthcare Providers?
• Consider a referral list for the front desk
– Docs’, therapists etc (added value)
– Neighbors
• Which healthcare providers are nearby
• Can call or give player contact for quick access

39. Develop Relationships
• You are a resource
– Players
– Healthcare Providers
• Reach out, develop relationships
– Mixers
– Health Committee
– Healthy on the Court Newsletter

40. PLAN
• Identify the Need
• Know your Resources
• Develop relationships and a plan
• Discuss with your staff, GM etc
• Consider a run through for emergency issues
• Re-visit: Adjust and Adapt

41. Framework
INJURYINJURYNON-
EMERGENT
NON-
EMERGENT
TRANSFER
CARE
TRANSFER
CARE
EMERGENTEMERGENTNew
Unknown
New
Unknown
Old
Chronic
Old
Chronic
Follow upFollow up
Mild
discomfort,
Clear cause,
no Abnormal
symptoms
Mild
discomfort,
Clear cause,
no Abnormal
symptoms
Return to the
CourtSevere
Pain/Numb
ness/Tinglin
g/Swelling/I
nability to
walk etc
Severe
Pain/Numb
ness/Tinglin
g/Swelling/I
nability to
walk etc
Encourage
MD/PT visit
Encourage
MD/PT visit
Follow upFollow up
PRICE
3-7 days of rest
Home Exercise
Technique Modifications
PRICE
3-7 days of rest
Home Exercise
Technique Modifications
Symptoms Resolved
SymptomsResolved
Resolved
Sym
ptom
s
Cleared for Sport
ClearedforSport

42. Take-Aways
• Risk of Injury is real
• Intrinsic and Extrinsic Factors affect risk
• Pro-active approaches can help prevent injury
• Developing an effective Injury prevention and
management program:
– Awareness/Education
– Plan Development
– Execute
– Re-evaluate/Dynamic Modification

43. Thank You!
Stephan Esser MD, USPTA
www.tennismedicine.com

44. The Science
• 310 Recreational Tennis Players
• 24% had arm injury from tennis in 6 months
– 13 % Shoulder Injury
– 13% Elbow Injury
– 7% Wrist Injury
– 4% Hand/Finger/Thumb

45. • A summary of general player characteristics is
provided in Table 1. Median age was 51 years
(Range: 22 – 79 years) and 127 players (41%)
were male. The majority of players used their
right hand for their forehand groundstroke
(93%), had played tennis for more than 10 years
(61%), typically played between 1 and 5 times per
week (89%), and typically played between 1 and
2 hours at a time (82%). The Continental grip
(28%) and Eastern grip (55%) were most
common, and 43 players (14%) had a loss of
elbow extension on their forehand arm

46. • Risk of forehand shoulder injury was significantly lower for players
using an Eastern grip compared to a Continental grip (OR: 0.33,
P=0.004) and risk of forehand elbow injury was significantly higher
for players who played more than 5 times per week (OR: [vs. 0-3
times per week]: 3.53, P=0.021). For the outcome of forehand wrist
injury, this occurred more often in players with a high volume of
play score (OR [vs. low]: 4.09, P=0.007). When evaluating risk
factors for any forehand upper extremity injury (Table 4), in
multivariable analysis there was a significantly increased risk of this
outcome for players who played more often per week (OR [3-5
times vs. 0-3 times]: 1.93, P=0.025; OR [>5 times vs. 0-3 times]:
3.37, P=0.010), and for players with a high volume of play score (OR
[vs. low]: 2.49, P=0.018). No other factors were significantly
associated with risk of upper extremity injury, though several
additional non-significant trends were observed (Tables 3-4).

47. • risk of forehand elbow injury was significantly
higher for players who played more than 5
times per week (OR: [vs. 0-3 times per week]:
3.53, P=0.021). Forehand wrist injury,
occurred more often in players with a high
volume of play score (OR [vs. low]: 4.09,
P=0.007).

48. Tennis Injuries
Back Pain

49. Back Pain
• > 80 % of Americans in a lifetime
• ≈ 30 % at any given time
• 2nd
leading reason to see a doctor
• Spending in 2005 = $85.9 billion
• Among Athletes highest rates:
– Football, gymnastics, wrestling etc.

50. 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
– Guilodo et al 1999: 633 subjects, No difference in rates of low
back pain between recreational players and non players or in
recreational players based on volume of play
– 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
• 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
Kjaer et al. Spine, 2005: 13 y/o MRI 33% with disc dessicationKjaer et al. Spine, 2005: 13 y/o MRI 33% with disc dessication

51. Tennis Injuries
http://2.bp.blogspot.com/-VuCL0SXN-Rs/T58nY7UYTYI/AAAAAAAAAHY/BAn1vaVu_JA/s1600/Andy+Roddick+Serve.jpg
www.tennisforyou.com

52. Tennis Injuries
• Limited Evidence for Prevention
• Perhaps: ?
– Start later with spin serves
– Focus on kinetic chain: legs, core
• Advance the research

53. Tennis Injuries
Hip Pain

54. Tennis Injuries
• Hip:
– Tommy Haas, Gustavo Kuerten, Magnus Norman, David Nalbandian,
Lleyton Hewitt
– JSMS 2003: Loss of IR at the Hip in ATP players
– FAI, Labral Tear, Gluteal Tendinopathy, Rectus
Strain, Adductor Strain, Iliopsoas Strain, Hamstring
Strain, LBP, OA, etc
• Predisposing:
– Technique (open stance, late contact)
– Conditioning (Hamstring tightness, Abductor
weakness, inadequate Quad/Hamstring balance)

55. Hip Take-Aways
• The Hip is a complex region
• Identifying if the pain is local or referred, traumatic
or degenerative, acute or chronic, temporally or
functionally associated, intra-articular or extra-
articular is crucial
• Excellent clinical exam skills are imperative to
guiding imaging and treatment
• Injections and surgery have their place
• Evidence for therapeutic modalities is limited

56. Tennis Injuries
• Lower Extremity:
– Knee: PFS, Meniscal Tears, Patellar Tendonitis,
ACL, MCL, OA
– Leg: “Tennis” Leg (strain or partial tear of medial
gastroc),Achilles Tendonitis, Shin Splints
– Foot/Ankle: Ankle Sprains, Plantar Fasciitis, Stress
Fractures, Tennis Toe

57. Tennis Injuries
• LE Injury Prevention:
• Conditioning
• Sport-specific training and Cross Training
– Shorter bursts, Rapid directional changes, Lateral movement
• Technique, technique, technique
• Shoe Wear
• Surface of play

58. Conclusion
• Tennis Specific Questions to ask?
– R or L Handedness
– Racquet Variables: Oversize, midsize, string
tension, type
– Grip Type: Continental, Eastern, Semiwestern,
Western
– Volume of Play: years, per week, hours per time
– Type of Play: Doubles vs Singles
– Surface: Clay, Hard, Grass, Modular

59. Conclusion
• Tennis Specific Questions to Ask?
– When does it hurt most?
• Which stroke?
• What phase of the stroke?
• During/after play etc?
• Do you have a tennis pro?
– Any red flags?
• Neurologic dysfunction
• Persistent swelling, catching, instability
• Acute trauma, onset

60. Take Aways
• Open Communication
– With Players
– With Team: Pros, Assistants,
– With PT/MD/ATC/CPT
• Preparation
– Knowledge/Equipment
• Prevention:
– Complete Warms Ups/Promote
Conditioning/Healthy habits

61. Conclusion
• The sport of tennis places sport-specific
stresses on the UE, Spine and LE
• Tennis results in unique, sport specific
physiologic adaptations in the athlete
• Technique and conditioning may alter some of
these forces but whether this reduces injury
risk is anecdotal at best
• Much research remains to be done
• Identify excellent referral sources: Pros, Docs,
Therapists, Trainers
Tennis
Rocks!
Tennis
Rocks!

62. Thank you!