1. Stephan Esser USPTA, MD
Mayo Clinic Sports Medicine Fellow
Tennis for the Sports Medicine
Provider: from Contact Point to
Match Point
2. • Disclosures:
– Received free product from Head/Pro-Penn
Raquet Sports for a recent Tennis Injury Study
Tennis is my favorite sport
Tennis is my favorite sport
4. Goals
• Introduce the basics of tennis
• Equip you with the tools to understand
benefits of the sport and risk of injury
• Review the most common tennis injuries
• Introduce/Discuss concepts related to tennis
injury prevention
• Equip you with tools to care for and
appropriately refer your players
6. By the end of our time
• Understand the basics of tennis
• Be literate in basic “tennis lingo”
• Know the Health benefits of tennis
• Understand the epidemiology of tennis injuries
• Be aware of common technical errors that
predispose to injury
• Be prepared to address these issues and guide
rehabilitation and referral
7. Tennis
• Raquet Sport
• Played on a “court”: 78 x 36 (27)
• Net: 3ft high
• Surface: Clay, Hard, Grass, Modular
• Type: Singles(2) vs Doubles(4)
• Scoring: 15’s (each point)
– Best 2/3 sets first to 6 games, 7 or 10 point tie
breaker
– Love: Not what it means at home
9. Few Basics
• Sweet Spot
• Contact Point
• Strike Zone
• Kinetic Chain
• Stance
• Etc
10. Tennis Lingo
• Rally = hitting a ball back and forth multiple
times without missing it
• Volley = hitting a ball out of the air before it
bounces
• Ace = A winning serve the opponent doesn’t
even touch
11. Tennis “Lingo”
• “Sticks” = Raquets
• “Bagel” = 6-0 win “Breadstick” = 6-1 win
• “Shank” = an off center hit
• “Hacker” = someone who has really bad form
• “Slice and Dice” = what a winning hacker does
• “Pusher” = someone who hits the ball with minimal pace
• “Grinder” = someone who runs down every ball
• “a-Bomb” = Ace
• “Chip n Charge” = hit a slice and run to net
• “Up a Tree” = hitting shots and winners that are way better than their regular
playing.
• “Hook” = an intentionally bad call
• “Deef” = to default a match
• “Tweener” = to hit a shot between your legs
12. Tennis Equipment
• Tennis Shoes: Non-Marking soles
• Raquet:
– Length
– Head Size
– Weight
– Grip Size
– String type
– String Tension
http://www.fangcan.com/upload/200908011249121171562.jpg
http://www.holabirdsports.com/tennis-tech-center/select-grip.html
13. String Basics
Diameter: 15-18g = thinner (durability,
elasticity, spin, feel, comfort)
Type
• Natural Gut: pricey, sensitive
• Synthetic:
– Nylon: single core or multi-layered overlap
– Polyester: Mono or polyfilament
– Hybrid
– Other: Steel, Titanium, Metal Coated etc
www.tennisrackethq.com
14. String Basics
Tension
• Low: More Power, Less Control, More Durability, More
Feel, More Comfort
• High: Less Power, More Control, Less Durability, Less
Feel, Less Comfort
http://online.wsj.com/article/SB10001424052970203370604577265832373170456.html
16. Health Benefits of Tennis
• CV, strength, coordination, balance, plyometrics,
speed, flexibility
• METs:
– Doubles Tennis: 5
– Singles Tennis: 7-12
• “improved aerobic fitness, a lower body fat percentage, a more favorable
lipid profile, reduced risk for developing cardiovascular disease, and
improved bone health.’ Pluim et al 2007
• Cognitive function, neural connectivity, mood, Social engagement,
PA efficacy, problem solving, test scores
17. Changes from Tennis
• 2010: SJMSS: 15 professional tennis players
– DXA, MRI, biopsy
– Dominant: 11-15% inc LMM UE and VL
• 2006: BJSM: torque, power in dom. Forearm
• 2004: MSSE: Core Rotational Strength, equal in elite boys, Inc in
backhand side in girls 4-8%
• 1990: AMJSM: Non-Dominant Lumbar Extensor musculature
stronger than dominant side
• 2006: BJSM: OA of the dominant shoulder in elite players (18)
– 1996: Art Rheum: rates of OA in hips/knees (TF)
• 2005: CJAP: bone mineral density dom. UE
– 1998 CJI: BMD 10-15%in L2-L4/GT/Fem Head/Neck
– 2012: J Osteop: Fem neck BMD in adolescent female TP’s
18.
19. 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)
20. Tennis Injury
• Abrams et al BJSM 2012
– LE>UE
– LE: ankle sprains, thigh strains, GS strain, Achilles
– UE: lateral epicondylitis, rotator cuff
– Back
22. Tennis Injuries
• Elbow:
– Most common UE injury in tennis players
– Lateral Epicondylitis:
• 35-51% lifetime incidence Abrams et al 2012
• Prevalence 14-41% Pluim et al 2006
– Pathophysiology:
• Excessive loading of the ECRB results in microtears and
failure to heal results in tendinosis
• Degenerative vs inflammatory
http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/extensor-carpi-radialis-
brevis/atlasImage
23. Tennis Injuries
• Elbow, Lateral Epicondylitis:
– Risk Factors:
• Technique, Technique, Technique, Technique,
“Experienced athletes reduced the racket impact to the elbow joint by 89.2%, but
“Experienced athletes reduced the racket impact to the elbow joint by 89.2%, but
Technique
recreational players reduced it by only 61.8%. The largest EMG differences were
recreational players reduced it by only 61.8%. The largest EMG differences were
found in the follow-through phase (P<0.05). Experienced athletes showed that
found in the follow-through phase (P<0.05). Experienced athletes showed that
• Muscle Strength and Balance
their extensor and flexor EMGs were at submaximal level for follow-through
their extensor and flexor EMGs were at submaximal level for follow-through
• whereas recreational players maintained their flexor and extensor EMGs
phase,Frequency of Play
phase, whereas recreational players maintained their flexor and extensor EMGs
at either supramaximal or maximal level.” Wei et al CJSM 2006
at either supramaximal or maximal level.” Wei et al CJSM 2006
• Change
• String Tension
• Racquet Stiffness
• Grip Size
24. Preventing Elbow Pain
• Technique
• Technique
• Technique
• Avoid Sudden Variation:
– Play Frequency / Racquet Width, Weight, Length /
String Type and Tension
• Conditioning
• Flexibility
26. Tennis Injuries
• Shoulder:
– 4-17% at any given time Abrams et al BJSM 2012
– Impingement, Instability, RTC –itis/tear, Labral
injury, Scapular Dyskinesis
– Predisposing:
• Relative RTC deconditioning, Excessive IR and ADD
strength and ER weakness, GIRD
• GIRD: >25 ° total difference (ER + IR)
28. Tennis Injuries
• Shoulder:
– During follow through, eccentric loading of the
external rotators
– If insufficient strength in the dynamic stabilizers,
the passive stabilizers of the shoulder and elbow
take up the slack, (capsule, GHL, labrum, UCL etc.)
– As a result, microtears occur in the capsule, with
reactive fibrosis and posterior capsular tightening
29. Tennis Injuries
• Shoulder:
– Presence of GIRD may predict risk of shoulder
injury Van der Hoeven BJSM 2006, VB Vad JSMS,2003
30. Preventing Shoulder Pain
• Conditioning
– Muscle Balance ER > IR Kibler et al 2008
– Flexibility: PC, IR/Add
• Pec minor?
• Technique
– FH follow through elbow, serve toss, contact
• Equipment
– Strings, raquet, grip?
31. Managing Shoulder Pain
• Thorough H and P: Know their strokes
• Understand the etiology
• Back to Basics
• Rule out masqueraders
• Combination approaches add value
• Refer when appropriate
• Identify educated pros in the area
33. 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.
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
– 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 al. Spine, 2005: 13 y/o MRI 33% with disc dessication
Kjaer et G1 and G2 –listhesis y/o MRI 33% with disc dessication
Kjaer et al. Spine, 2005: 13
• 2 acute/5 chronic stress reactions of the pars
• 13 with disc dessication, disc bulging
36. Tennis Injuries
• Limited Evidence for Prevention
• Perhaps: ?
– Start later with spin serves
– Focus on kinetic chain: legs, core
• Advance the research
38. 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)
39. 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
40. 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
41. 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
42. 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
43. 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
44. Conclusion
• The sport of tennis places sport-specific
stresses on the UE, Spine and LE
• Tennis results in unique, sport specific
Tennis
physiologic adaptations in the athlete
• Technique and conditioning may alter some of
Rocks!
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
Previous 60’s and even 70’s……..now top players strining in the low 50’s…..federe in the mid-50’s to as low as 47…..
One MET: Resting metabolic rate at 3.5 ml O2/kg/min
Scand J Med Sci Sports. 2010 Jun;20(3):524-34. doi: 10.1111/j.1600-0838.2009.00969.x. Epub 2009 Jul 6. The upper extremity of the professional tennis player: muscle volumes, fiber-type distribution and muscle strength.Sanchís-Moysi J, Idoate F, Olmedillas H, Guadalupe-Grau A, Alayón S, Carreras A, Dorado C, Calbet JA.SourceDepartment of Physical Education, University of Las Palmas de Gran Canaria, Campus Universitario de Tafira s/n, Las Palmas de Gran Canaria, Spain.AbstractThe effects of professional tennis participation on dominant and non-dominant upper extremity muscle volumes, and on fiber types of triceps brachii (lateral head) and vastus lateralis muscles were assessed in 15 professional tennis players. Magnetic resonance imaging (MRI, n=8) examination and dual-energy x-ray absorptiometry (DXA, n=7) were used to assess muscle volumes and lean body mass. Muscle fiber-type distribution assessed by biopsy sampling was similar in both triceps brachii (2/3 were type 2 and 1/3 type 1 fibers). The VL was composed of 1/3 of type 2 and 2/3 of type 1 fibers. The dominant had 12-15% higher lean mass (DXA/MRI) than the non-dominant (P<0.05). Type 1, 2a and 2x muscle fibers of the dominant were hypertrophied compared with the non-dominant by 20%, 22% and 34% (all P<0.01), respectively. The deltoid, triceps brachii, arm flexors and forearm superficial flexor muscles of the dominant were hypertrophied (MRI) compared with the non-dominant by 11-15%. These muscles represented a similar fraction of the whole muscle volume in both upper extremities. Dominant muscle volume was correlated with 1RM on the one-arm cable triceps pushdown exercise (r=0.84, P<0.05). Peak power during vertical jump correlated with VL muscle fibers's cross-sectional area (r=0.82-0.95, P<0.05). Med Sci Sports Exerc. 2004 Nov;36(11):1959-63. An isokinetic profile of trunk rotation strength in elite tennis players.Ellenbecker TS, Roetert EP.SourcePhysiotherapy Associates Scottsdale Sports Clinic, Scottsdale, AZ, USA. ellenbeckerpt@cox.netAbstractPURPOSE:The changes in stroke production in the modern game of tennis have increased the demands on trunk rotation in elite tennis players. Unlike the shoulder, where unilateral strength adaptations have been identified, no study to date has objectively quantified side to side rotational trunk strength in elite tennis players.METHODS:One hundred nine elite tennis players were tested using a Cybex isokinetic torso rotation unit at 60 and 120 degrees x s(-1) to measure left and right rotation while stabilized in a seated position. A repeated-measures ANOVA was used with post hoc dependent t-tests where main effect differences were identified to determine side to side rotational differences.RESULTS:No significant difference in trunk rotation strength was measured in the elite male players. Peak torque to body weight ratios averaged 63.7 and 57.5% for forehand rotation (left rotation in right-handed player) and 64.4 and 59.2% for backhand rotation at 60 and 120 degrees x s(-1), respectively. In females, slightly greater (P < 0.001) backhand rotation strength (right rotation in a right-handed player) was measured at both testing speeds with peak torque to body weight ratios ranging between 47.7 and 45.1% for left rotation and 50.8 and 48.3% for right rotation at 60 and 120 degrees x s(-1), respectively. Left rotation/right rotation ratios ranged from 95 to 98% for males and from 94 to 96% for females.CONCLUSIONS:Elite-level male tennis players have symmetric trunk rotation strength. Elite female tennis players have slightly greater backhand rotation strength (by 4-8%) than forehand rotation. Conditioning programs for elite tennis players should include exercises to facilitate and develop bilateral trunk rotation. J Osteoporos. 2012;2012:423910. doi: 10.1155/2012/423910. Epub 2012 Jul 1. Bone mineral density of adolescent female tennis players and nontennis players.Ermin K, Owens S, Ford MA, Bass M.SourceBone Density Laboratory, The University of Mississippi, 215 Turner Center, University, Oxford, MS 38677, USA.AbstractThe purpose of this study was to determine differences in bone mineral density (BMD) among adolescent female tennis players (TPs) and nontennis players (NTPs) and to assess body composition as a predictor variable of BMD. Nineteen female TPs and 19 female NTPs, ages 14 to 18 years, participated in this study. Lumbar spine, total hip, femoral neck, forearms BMD, and body composition were assessed using dual-energy X-ray absorptiometry (DXA). Lumbar spine and total hip BMD measurements for TP were greater than NTP. However, these differences were not statistically significant (P = 0.37 and 0.12, resp.). TP had significantly greater femoral neck BMD than NTPs (P = 0.02). This difference might play an important role in preventing osteoporosis and decreasing the risk of fractures at the hip later in life.
Coracohumeral ligament: external rotation in neutralMedial glenohumeral ligament: external rotation in midelevationAnteroinferior glenohumeral ligament: external rotation in abductionInferior capsule: abduction in neutral rotationPosteroinferior capsule: internal rotationPosterosuperior capsule: internal rotation in abduction
http://drrobertlaprademd.com/publications/pdf/Articles/Pre%202005/1995%20Injury%20surveillance%20at%20USTA%20boys%20tennis%20championships.pdf Five players (15.2%) had a normal MRI examination and 28 (84.8%) had an abnormal examination. Nine players showed pars lesions (10 lesions; one at two levels) predominately at the L5 level (9/10, L5; 1/10, L4). Three of the 10 lesions were complete fractures; two showed grade 1 and one grade 2 spondylolisthesis, both of which resulted in moderate narrowing of the L5 exit foramen. There were two acute and five chronic stress reactions of the pars. Twenty three patients showed signs of early facet arthropathy occurring at L5/S1 (15/29 joints) and L4/5 (12/29 joints). These were classified as mild degeneration (20/29) and moderate degeneration (9/29), with 20/29 showing sclerosis and 24/29 showing hypertrophy of the facet joint. Synovial cysts were identified in 14 of the 29 joints. Thirteen players showed disc desiccation and disc bulging (mild in 13; moderate in two) most often at L4/5 and L5/S1 levels (12 of 15 discs).
