Lobbing injury out of tennis: a review of the literature

Monash University Accident Research Centre – Report #144 - 1999

Authors: E. Cassell & A. McGrath

Abstract:

Over 362,000 Australians over the age of 15 years participate in tennis. It is the third most popular sport and physical activity in Australia behind aerobics and golf. Participation provides physical fitness either in a highly competitive or social atmosphere. The public exposure that professional tennis receives and the vast amount of money involved impact upon young tennis players. This leads to great pressure to practice, high expectations of performance and increasing demands on the human body. Tennis requires a variety of physical attributes (speed, power, endurance, strength and balance) and specific playing skills. Therefore, participants should train and prepare to meet at least a minimum set of physical, physiological and psychological requirements to cope with the demands of play and reduce the risk of injury.

Emergency department presentation data collected by the Victorian Injury Surveillance System (VISS) indicate that 69% of adult tennis injury cases and 40% of child injury cases occurred during formal competition. Injuries to adults in formal play were predominantly to the lower limb (55%), particularly sprains and strains to the ankle (15% of all injuries) and knee (12%). Overexertion was the most common cause of adult tennis injury during formal play. Forty-five percent of all child tennis injuries in formal play were to the upper extremities, particularly fractures of the radius/ulna (7% of all injuries) and sprain/strains of the wrist (4%). Most child injuries in formal play were caused by falls.

The overall aim of this report is to critically review both the formal research literature and informal sources that describe measures to prevent tennis injury together with an assessment of the extent to which they have been formally demonstrated to be effective. Countermeasures to injury include pre-season conditioning, warm-up programs, attention to environmental conditions, prevention and management of overuse injuries, appropriate footwear, modified rules, education and coaching, first aid and rehabilitation. Recommendations in this report include: extension of pre-participation evaluation; the further development of equipment innovations that protect against injury; improvements to education and training for players and coaches, particularly at the wider community level; promotion of modified games for children; provision of appropriate and prompt first aid by trained personnel; improvements to injury data collections; and further epidemiological, biomechanical and laboratory research into the causes of tennis injuries and measures to prevent them.

Executive Summary

Tennis is one of the most popular sports in the world. Every day it is played by millions of people of all ages at various standards. Participation in tennis provides physical fitness either in a highly competitive or social atmosphere. The public exposure of professional tennis and the vast amount of money involved has impacted upon young tennis players, leading to great pressure to practice, high expectations of performance and increasing demands on the human body (Mothadi and Poole 1996). Tennis requires a variety of physical attributes including speed, power, endurance, strength and balance and specific playing skills. Tennis places acute physical demands on players, requiring them to move quickly in all directions, change directions often, stop and start, while maintaining sufficient balance, control and upper body strength to hit the ball effectively (Chandler 1995). Therefore, participants should train and prepare to meet at least a minimum set of physical, physiological and psychological requirements to cope with the demands of play and reduce the risk of injury.

The aim of this report is to provide advice on the prevention of tennis injuries, through a critical review of the formal and informal research literature relevant to injury prevention. An overview of the epidemiology of tennis injury and a discussion of common tennis injuries are given to provide a background to the review of potential countermeasures to injury.

The recommendations have been based on the literature review and discussions with the experts acknowledged in this report. Many of the recommended countermeasures must be regarded as promising, rather than proven, and more controlled field evaluations of their effectiveness are needed. For example, the evidence on whether warm-up and stretching prevents injury remains equivocal. More research effort needs to be directed to epidemiological studies to determine the risk factors for injury and the role of the identified risk factors in causation and basic scientific studies to better understand the biomechanics of tennis and the mechanisms of injury.

Participation and Injury Data

A population household survey conducted by the Australian Bureau of Statistics (ABS) in 1995/1996 reported that 362,000 Australians over the age of 15 years participate in tennis. This ranked tennis as the third most popular sport and physical activity in Australia, behind aerobics and golf. More females (57%) than males (43%) play tennis. Over one-third (37%) of players are over the age of 45 years. Over one-half of all participants (55%) indicated that they participate in tennis once a week. The survey estimated that 114,300 Victorians participate in tennis (46% males and 54% females).

Emergency department presentations data collected by the Victorian Injury Surveillance System (VISS) indicate that tennis injury amongst adults (aged greater than or = 15 years) and children (aged <15 years) accounts for 2% of all sports injury. Sixty-nine percent of tennis injuries to adults and 40% of injuries to children occurred during formal competition.

Injuries to adults in formal play were mostly to the lower limb (55%), particularly ankle and knee sprains and strains (15% and 12% of all injuries respectively). The upper limbs accounted for another 24% of all injuries, particularly fractures to the wrist (14%) and radius/ulna (9%). Overexertion (causing sprains and strains) was the most common cause of injury among adults during formal play.

Upper limb injuries were more common than lower limb injuries among children. Forty-five percent of all child tennis injuries in formal play were to the upper limbs, particularly fractures of the radius/ulna (7% of all injuries) and sprain/strains of the wrist (4%). Thirty-one percent of injuries were to the lower limbs, particularly ankle sprains/strains (28% of all injuries) and sprains/strains of the knee (24%). Nine percent of injuries were to the head and face.

Falls were the most common cause of injury to children during formal tennis play' accounting for 31% of all injuries. Children are probably more prone to fall injury than adults. Their skills, technique and co-ordination are less well-developed which causes loss of balance and falls, commonly onto an outstretched arm.

The incidence of injury in terms of body region and nature of injury reported from VISS data correlates to a large extent with that reported in the research literature. Sprains and strains are consistently reported to be the most common injury in tennis. Conclusions based on comparisons between the published epidemiological studies on tennis injury must be treated with caution, because of differences in study populations, data collection methods and injury definitions.

Recommendations for Further Countermeasure Implementation, Research and Development

Playing technique

Promote techniques that maximise bio-mechanical advantage and protect from excessive forces and overuse (based on current research evidence) through coaches, trainers and sporting organisations.
Practice sessions should comprise a balanced variety of tennis strokes and other training activities.
Rigorous epidemiological studies are required to adequately describe limb and back injuries in tennis and to investigate potential risk factors including exposure (both to training and play), playing technique and lack of physical conditioning.
Further research is needed to expand current knowledge on the biomechanics of tennis play and associated risk of overuse injuries and investigate the optimal type and duration of training and conditioning that maximises skill development and fitness and minimises overuse injuries.

Physical preparation

Pre-participation evaluation

Extend pre-participation screening and tailored pre-season conditioning programs to a wider group of serious players and evaluate the protective effects of these programs.
Continue to research assessment measures that are tennis specific to improve pre-participation evaluation instruments.
Systematically evaluate the injury prevention efficacy of the current pre-participation evaluation program for elite and squad tennis players.

Training and conditioning

Simple pre-season fitness testing should be conducted on players participating in competitive tennis at the inter-club level, four to six weeks prior to the start of the season.
All competitive and recreational tennis players are advised to undergo a graduated skills development and training program (which includes cross training), guided by results of an initial fitness test.
Players should consult an accredited tennis coach on their individual training requirements.
Initiatives to increase the awareness of players and coaches of the injury consequences of training errors (including over-training) should be continuously developed, and refined as new knowledge becomes available.
Controlled evaluation studies should be conducted to determine 'best practice' conditioning and training programs that develop the skills and fitness necessary for competitive tennis and protect players from injury.

Warm up, stretching and cool down

All players should routinely warm-up, cool down and stretch before and after every game and training session.
The specific needs of the injured tennis player should be considered when warm-up, stretching and cool down regimes are developed.
The injury protective effects of warm-up, stretching and cool-down require evaluation in controlled trials.

Environmental factors

Weather and player hydration

Extreme heat policy and rules need to be developed at the local club and inter-club competition levels.
Clubs should provide umbrellas and ice-chests on-court, and supply water and 'sports' drinks (with 4%-8% carbohydrate content).
Players should learn how to monitor their fluid intake during games by weighing themselves or by noting any reduction in the amount and concentration of urine output in relation to fluid intake (oliguria). Players should replace fluid and electrolyte loss by consuming 400-600 mls of fluid (2-3 standard glasses) at least 30 minutes before play and 200-300 rots (1 -2 glasses) every 15 minutes during play (at change of ends).
Education and signage about measures to prevent heat illness should be provided at the club level.
Players should use a broad spectrum sunscreen.
Research should continue on player diet and hydration issues.

Playing surface and surrounds

Risk management/sports safety plans, that include measures to eliminate or ameliorate environmental and other injury hazards, should be developed, implemented and monitored by tennis facility owners (including local councils, associations, clubs, schools and churches) and managers. Guidelines and support for the development of these plans should be available.
Equipment, seating and advertising should be kept away from court boundaries, net posts should be padded.
Tennis surfaces should be diligently maintained and regularly checked for hazards such as hollows, cracks and wear.
Further laboratory and controlled field research is needed to determine the optimal safety performance values for tennis surfaces.

Playing equipment

Racquet selection

Players, especially those with arm and shoulder symptoms, should seek professional assistance when selecting a racquet and choosing string tension.
More epidemiological, biomechanical and independent laboratory research is needed to determine the impact of the size, shape, frame material, string material and tension of the racquet on the incidence of upper extremity overuse injury in tennis.

Ball choice

Players should always match the ball type with the playing surface and climatic conditions.
Players with arm symptoms should avoid playing with wet balls and in windy conditions.
Players should limit play with used balls and avoid play with dead balls.

Footwear

Players should choose their shoes carefully, preferably with professional advice on the most appropriate shoe for their foot type and the playing surface on which they mostly play.
Tennis shoe manufacturers should provide more information to consumers at point-of sale on suggested indications and playing surfaces for which their shoes are or are not recommended.
Future research on tennis footwear must adjust for confounding factors, such as previous injury and exposure, when investigating the relationship between shoe construction and injury.
The effectiveness of orthoses in the prevention and treatment of overuse injury should be determined by well-designed controlled studies that involve sufficient subjects to provide definitive results.
Further research is needed to evaluate the protection against foot blisters afforded by the different kinds of tennis socks with the aim of developing design and material criteria.

Protective equipment

Update epidemiological research into the incidence and nature of eye, facial and dental injuries in tennis and investigate risk factors and potential protective measures.

Graduated and modified training and games

Children should be progressively introduced to tennis through the modified games program promoted by Tennis Australia and Tennis Victoria.
Children should play tennis with an appropriate racquet, in terms of size and weight.
As children progress from modified games to regular tennis, guidance should be sought from an accredited coach on a suitable training routine.

Education and coaching

Accredited coaches should be available at every club to advise and monitor the skills development of players at every level (competitive and social).
All coaches should be accredited and undergo the regular training and re-accreditation provided through Tennis Coaches Australia and state divisions.
Continuous systematic evaluation of the effectiveness of education/training programs should be maintained.

Treatment and rehabilitation

Event organisers and tennis clubs should ensure that there are qualified first aid personnel/sports trainers at all events and competition match days.
Clubs should have a well-stocked first aid kit and a supply of ice-packs.
Players should seek prompt attention for injuries from a sports medicine practitioner and allow enough time for adequate rehabilitation before returning to their pre-injury level of activity.
Players with recurrent injuries should seek expert advice on appropriate taping or bracing and rehabilitation.
Further research and evaluation of rehabilitation programs is required, to develop optimal regimes.
Further controlled research is needed to investigate the efficacy of prophylactic taping and bracing in the prevention of ligament injury and re-injury in tennis.

GENERAL RECOMMENDATIONS

In addition to the specific recommendations in this report, the following set of more general recommendations are made:

Improve data collection on the frequency, pattern and contributory factors to tennis injury. All data collections should conform to national guidelines for sports injury surveillance (the Australian Sports Injury Data Dictionary).
Further epidemiological research is needed to determine the risk factors for tennis injury and to evaluate the effectiveness of countermeasures.
Guidelines for minimum safety requirements for organised tennis (including the need for mobile phones, emergency telephone contacts and first aid kits) should be developed and widely disseminated.
A cost of sports injury study is required to determine the overall cost of sports injury and the relative cost of injuries for different sports.

Sponsoring organisation: Sport and Recreation Victoria