Introduction
Tennis is a popular international sport with more than 75 million tennis players worldwide (35). The majority of tennis players participate at an adult recreational league level, which can be defined as skill levels of National Tennis Rating Program (NTRP) ratings (United States) 5.0 and below as suggested by a previous article by Jayanthi et al. (20). Using Strength of Recommendation Taxonomy (SORT) criteria (7) and a case-based approach, this article focuses on evidence-based recommendations for the medical evaluation of the adult recreational tennis player and does not address elite or junior level tennis players.
For consistency, this article will use the NTRP ratings as able. For comparison to other international standards of play for tennis, see Table (18). Although the International Tennis Number (ITN) ratings define the recreational level athlete differently (NTRP 2.5 and below) (18), we propose that the definition used by Jayanthi et al. (20) more accurately encompasses the majority of regular adult recreational tennis players and better reflects the existing medical literature.
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Table:
NTRP ratings.a
Of note, a recent consensus statement on epidemiological studies of medical conditions in tennis recommends collecting baseline information on tennis players that includes skill level or “standard of play,” such as an NTRP rating. This should help standardize study populations in the future; however, few previous studies mention specific ratings (35).
Epidemiology
Case 1
“A 43-yr-old male is interested in starting with a regular tennis league but has concerns about injuries. What recommendations can you give him regarding the risk of injury?”
Although there are many epidemiologic studies on injuries in elite and junior level tennis players, there are few studies on the adult recreational tennis player. Of the existing studies, they tend to be limited by recruitment and difficulties with data collection. Generally speaking, tennis is considered a low-risk sport with minimal risk of severe injury in adults (19). However, despite the small number of studies in the adult recreational player, there is a wide variety of reported injuries due to varied definitions of “injury” and means of data collection. Incidence of injury ranges between 0.04 and 3.0 per 1000 h of play (37). Most epidemiology studies on tennis players focus on musculoskeletal injury, and there is little data on medical conditions in the adult recreational tennis player other than a study that included sunburns, abrasions, and blisters as reportable injuries (22).
One of the first studies on epidemiology of tennis injuries was a retrospective study of racket injuries presenting to a sports medicine clinic (3), but did not describe injury rates and the study population included some junior athletes in addition to adult recreational players. The authors found that lower-limb injuries (45%) were more common than upper-limb injuries (35%). Overuse injuries were common (30%). Since the study was published in 1987, racket technology and stroke technique has changed substantially at the elite level, though it is unclear if this influences injury patterns at the recreational level (28).
A more recent study performed by Jayanthi et al. (20) surveyed 529 recreational athletes participating at NTRP levels 2.5 to 5.0 to collect self-reported injury data. The injuries in the adult recreational population — average age of 46.9 yr — were predominantly upper extremity overuse injuries. Risk of injury increased with skill level. Acute injuries were more common in the lower extremity and among higher-level players. This study reported 3.0 injuries per 1000 h of play and a prevalence of 52.9 injuries per 100 players. No differences were found by gender or age. Interestingly, injury levels decreased with the amount of hours played per week. Players with less than 4 h·wk−1 had a higher incidence of injury 4.90/1000 h compared with those with >6 h·wk−1 with an incidence of 1.66/1000 h; however, this difference was not statistically different. The most common sites of injury were the elbow (20%), shoulder (15%), knee (12%), and back (10%) (20).
A 2006 systematic review by Pluim et al., (37) which included junior and elite level players, concluded that most tennis injuries occur in the lower extremities, followed by upper extremities, then trunk. Of the lower extremity injuries, these tend to be acute injuries, though the upper extremity injuries tend to be chronic. Of the adult recreational players mentioned in this review, 21% to 45% of injuries occurred in the upper extremity, 31% to 67% of the injuries occurred in the lower extremity, and 3% to 20% of the injuries occurred in the trunk/head (37).
Finally, a 2014 study on tennis-related injuries presenting to the emergency department from 1990 to 2011 provided a U.S. national estimate of approximately 347,958 injuries per year in athletes ages 19 yr and older (13). The majority of these were assumed to be adult recreational athletes, but data were not provided on the skill level of these athletes. Across the entire study, which included junior tennis players, 42.1% of injuries were lower extremities injuries, 26.7% were upper extremity injuries, and 9.2% were trunk injuries (13).
In summary, using these limited-quality (level 2) studies, we concluded that most lower extremity injuries are acute injuries, and most upper extremity injuries are chronic injuries (SORT B). Data were mixed on whether lower-extremity or upper-extremity injuries were more common in the adult recreational tennis player. We advocate that more good-quality epidemiological studies of skill level-related injuries in the adult recreational tennis athlete are needed.
Medical Evaluation
Case 2
“A 51-yr-old female NTRP 3.5 tennis player was recently diagnosed with hypertension and hyperlipidemia. What recommendations can you give her regarding tennis and her chronic medical conditions?”
There are several studies that evaluate common medical conditions in the tennis athlete and review articles have summarized these previously (26,36). The majority of these studies were performed in adult tennis players without mention of elite or professional tennis background and are assumed to be adult recreational players if not otherwise mentioned. Although tennis has never been studied as an intervention for hypertension, two small studies on adult recreational tennis players demonstrated that regular tennis playing resulted in similar blood pressure numbers compared to a moderately active control group (43) while another study showed improved blood pressure numbers compared to a randomly selected comparison group (SORT B) (45,47). Cholesterol profiles, specifically High-Density Lipoprotein levels, of the adult recreational player generally improved with regular tennis playing, but these small studies limited the ability to make any conclusions about the effects on total cholesterol, Low-Density Lipoprotein, or triglyercides compared to control subjects (SORT B) (10,46).
Case 3
“A 68-yr-old male NTRP 3.0 tennis player with diabetic neuropathy was recently diagnosed with a myocardial infarction that was treated with coronary revascularization after developing chest pain while playing tennis. What recommendations can you give him regarding tennis and his chronic medical conditions?”
Although exercise, including tennis, poses risk for sudden cardiac death in the acute setting (25), the general cardiovascular benefits of tennis support playing tennis for cardiovascular health. In a randomized study, as an intervention for post myocardial infarction in 79 low-risk patients, a modified tennis program compared similarly with a traditional bicycling program for rehabilitation on several physiologic and metabolic parameters. After a 3-month training program, lipid profiles, quality-of-life measurements, and METs improved in the intervention groups (both tennis and biking) compared with the control group (SORT B) (12).
Although several small studies attempted to evaluate tennis as an intervention for diabetes, there were no significant reductions in hemoglobin A1C (16,32). However, skin and nail injuries are common in adult recreational tennis players (1,22). The authors’ opinion is that adult recreational tennis players with diabetes should have reinforcement on regular foot checks and proper footwear due to the regular overuse and trauma to the skin and nail (SORT C).
Musculoskeletal Evaluation
When evaluating the adult recreational tennis player for musculoskeletal injury, there are two major tennis-focused considerations for the clinician to keep in mind: 1) the overhead athlete and 2) the asymmetric athlete. The asymmetric tennis athlete is well documented; asymmetries have been found consistently across quality studies with both muscular and bony hypertrophy of the dominant upper extremity and nondominant lower extremity and trunk compared with the contralateral sides (SORT A) (19,36,39). Asymmetries in bone mineral density are found across all levels with junior, elite and recreational level players, though are more pronounced with younger starters compared to older starters and with length of participation in tennis (36). These asymmetries can predispose players to injury due to musculoskeletal imbalance (6,9,19). Beyond typical rehabilitation programs for musculoskeletal injuries, recommendations for stroke modifications from clinicians can aid the adult recreational player in managing many tennis-related overuse injuries.
Shoulder
Case 4
“A 41-year-old male 4.5 NTRP tennis player complains of shoulder pain particularly while serving for 2 months. What nonoperative and operative treatment options are available to return to tennis, and what tennis stroke modifications can assist in this return to play?”
Shoulder injuries are common in the adult recreational tennis player and are generally isolated to the serve and overhead strokes in the dominant arm (20). Cools et al. and Ellenbecker et al. (4,9) both provide recommendations for overhead athletes that can be applied to the adult recreational tennis player to help prevent shoulder injuries; athletes should be assessed for glenohumeral internal rotation deficit (GIRD), scapular dyskinesis, and rotator cuff strength, especially the external rotators (SORT C). During evaluation of the adult recreational tennis player, pain during the cocking and loading phase of a serve often points to rotator cuff pathology while pain during the deceleration or follow-through phase of the serve points to injuries in the biceps/labral complex (19). Although decreases in both GIRD and total range of motion are common in the dominant arm in elite and junior players (37), one study of female recreational tennis players did not demonstrate any deficit in range of motion (42). Ellenbecker et al. recommend applying exercises for the rotator cuff that are at submaximal intensity levels to allow for rotator cuff activation; eccentric exercises should be performed using a multiple set (two to three sets) and high repetition based (15–20 repetitions per set) paradigm to promote local muscular endurance. Providers should focus on exercises to increase posterior rotator cuff and scapular stabilization (SORT C). We outline an evidence-based algorithm for nonoperative management in the adult recreational player in Figure 1.
Figure 1:
Management of tennis shoulder in the adult recreational tennis player.
For return to play, stroke modifications can often help prevent reinjury. For players with rotator cuff pathology, players should focus on retracting the scapula during the loading and cocking phase while also using the lower body to generate force during the serve. For players with biceps/labral injuries, players should focus on decreasing rapid internal rotation during follow-through while also using the lower body to generate force during the serve (SORT C) (19).
For players who failed nonoperative management, several studies exist on return to sports participation after rotator cuff repair and shoulder arthroplasty, though fewer studies are specific to the adult recreational tennis player (2,8,21). An early study by Bigiliani et al. (2) evaluated 9 “competitive” and 14 “recreational” players; all 23 players underwent anterior acromioplasty and rotator cuff repair in the dominant shoulder. Of the four players with decreased return to play, all had massive (>8 cm) tears. Overhead strokes were not allowed until at least 1 yr postoperatively. A study by Sonnery-Cottet et al. (41) reported on 51 middle-aged tennis players; 40 players (78.4%) were able to return to tennis at an average of 9.8 months after rotator cuff repair or debridement with or without biceps tenodesis. Based on these small case series, it is our opinion that adult recreational players will likely be able to return to tennis activities after rotator cuff repair; however, the size of the tear is likely a major contributing factor to the ability to return to tennis (SORT C).
Most studies on shoulder hemiarthroplasty, arthroplasty, and reverse total shoulder arthroplasty include return to play outcomes on a variety of sports, rather than focusing on tennis only. In one study on hemiarthroplasty, 57% of players returned to doubles tennis; average return to sports across all athletes was 6.5 months (11). McCarty et al. (27) reported a case series for total shoulder arthroplasty on 75 patients who participated in sports; 21 (75%) of 28 tennis players reported a return to tennis. Finally, in one study on activity recommendations, more surgeons allowed doubles tennis compared with singles tennis after hemiarthroplasty and total shoulder arthroplasty. European surgeons were more conservative than American surgeons in their recommendations after hemiarthroplasty and total shoulder arthroplasty, but good agreement between the two groups was noted regarding restrictions after reverse total shoulder arthroplasty (SORT C) (23).
Elbow
Case 5
“A 48-yr-old female 3.5 NTRP tennis player complains of right dominant lateral elbow pain particularly topspin forehands and one-handed backhands for 3 months. What risk factors are there to develop tennis elbow, and what tennis-specific treatment options and modifications are available for a successful return to tennis?”
Lateral epicondylosis (common extensor tendinopathy or “tennis elbow”) is uncommon in elite players; however, this injury represents one of the most common injuries in the adult recreational player (19). This likely reflects a combination of improper technique, age and volume of play. A self reported study of injuries in adult recreational players found that there is a 50% incidence of elbow injuries in club players 30 yr or older, with a fourfold increase in players older than 40 yr (20). Adult recreational players with more than 10 h of play per week are at higher risk for a new diagnosis of lateral epicondylosis than those with less than 10 h of play per week (14).
Reliance on forearm musculature for power generation is a common mistake that can lead to elbow pathology in tennis players. Eccentric wrist and forearm exercises to increase strength and muscular endurance should be the focus of any rehabilitation program in the elbow of the adult recreational player. In addition, stroke modification with a focus on power generation through the kinetic chain should be recommended to avoid overreliance on the wrist and forearm musculature (9). Stroke modification typically involves limiting wrist extension during a one handed backhand with contact and follow-through for lateral epicondylosis. Similarly, players also can consider changing to a two-handed backhand to limit excessive wrist extension (19). In a small observational study, stroke modification and conservative therapy led to resolution of symptoms in 90% of players with symptoms less than 6 months; 82% of players with symptoms more than 6 months reported good or excellent results (SORT B) (17). We outline an evidence-based algorithm for nonoperative management of lateral epicondylosis in the adult recreational player in Figure 2.
Figure 2:
Management of lateral epicondylosis in the adult recreational tennis player.
Use of shock absorbers and grip size does not have published data to support the use for treatment of lateral epicondylosis; however, many sports physicians and tennis professionals will continue to recommend use of a proper grip size determined by Nirschl criteria (grip size is equal to the distance from the middle of the proximal palmar crease to the tip of the ring finger) (SORT C) (33).
Medial epicondylosis is typically noticed during the forehand and serve in players hitting with excessive topsin. Stroke modification can include limiting extreme degrees of a “Western” forehand grip, heavy topsin, and slice serves (SORT C) (19).
Wrist
Case 6
“A 25-yr-old male 4.0 NTRP former high school tennis player complains of right dominant ulnar wrist pain particularly with aggressive topspin forehands for 2 yr. What type of grips and strokes put him at risk to develop this pain, and when should surgery be considered?”
Tagliafico et al. (44) evaluated 320 Italian division III and IV players (NTRP >4.0) for wrist injuries by tennis grip. Thirteen percent of the players reported injuries, the majority of which affected the extensor carpi ulnaris (ECU) tendon (30/50). Ulnar-sided injuries were found more commonly with western or semiwestern grips; radial-sided injuries were associated with eastern grips. Average time lost from injury was 69 d. Wrist injuries represented 6% of the total number of injuries in the study by Jayanthi et al. (20) of adult recreational players described earlier. Although most of these injuries are ECU tendon injuries; triangular fibrocartilage complex (TFCC) tears, and ulnar impaction affect the ulnar wrist as well (19).
A study of elite tennis players by Montalvan et al. (31) provides some insight into treatment for ECU tendon injuries in the adult recreational player. Typically, ECU tendon pain develops in the nondominant hand of a player with a two handed backhand. ECU tendon subluxation can be treated with an ulnar gutter splint for 3 to 4 months; ruptures typically require surgery (31). Players can be instructed to reduce aggressive ulnar deviation, extension, and supination during the affected strokes. In addition, late wrist rotation instead of early wrist rotation can help reduce pain (SORT C) (19).
Trunk
Case 7
“A 50-yr-old male 4.5 NTRP tennis player complains of low back pain when serving and also throughout the day for 6 months. What evidence-based recommendations are available for him to independently reduce his low back symptoms and also to prevent future symptoms?”
Lumbar back pain is common in tennis due to twisting during the forehand, backhand, serve, and overhead strokes and due to the flexion and extension motion with these strokes. In the adult recreational player, 10% of injuries were associated with back injuries. This was the fourth most common injury behind, shoulder, elbow, and knee injuries (20). Pain related to lumbar disk disease is often worse during the acceleration and follow-through phases of the serve as the spine flexes forward. Players can limit the forward flexion and rotation to minimize pain (19).
Asymmetry in the tennis athlete can predispose to lumbar neuromuscular imbalances. Renkawitz et al. (38) demonstrated that a daily home back exercise program was successful in improving pain ratings, trunk extension strength, and performance in adult amateur players; these exercises focused on triplanar lumbar spine stabilization and lumbar back extension (SORT B). Ellenbecker et al. (9) provided guidelines for prevention of tennis injuries in elite players to prevent common injuries due to muscular imbalance; the authors’ opinion is that many of these can be applied to the adult recreational player as well (SORT C). Core and pelvis stabilization programs are the main focus to prevent trunk injuries. We outline an evidence-based algorithm for management of lumbar back pain in the adult recreational player in Figure 3.
Figure 3:
Management of lumbar back pain in the adult recreational tennis player.
Spinal stenosis and facet joint arthritis are often worse during hyperextension with the cocking phase of the service motion. Patients can be instructed to avoid hyperextending the spine and by instructing them to use the lower body to generate force during the serve (SORT C).
Rectus abdominis strains are common in the side contralateral to the dominant arm in competitive tennis players due to the forced contraction of the stretched rectus abdominis muscle during the serve and overhead strokes (24). Rectus abdominis strains should include an eccentric strengthening that includes rotational rehabilitation prior to return to tennis and particularly serving (SORT C).
Hip/Knee
Case 8
“A 65-yr-old male 3.5 NTRP tennis player has moderate to severe knee osteoarthritis and has been unable to play tennis for 1 yr. What evidence is available to suggest whether tennis players can return after total joint arthroplasty?”
Overall, there are limited data on hip and knee injuries in adult recreational tennis players other than the epidemiologic studies listed previously. However, Mont et al. (29,30) evaluated return to tennis for both hip and knee arthroplasty. Both studies were questionnaires of United States Tennis Association (USTA) members. Average return to play was 6.7 months after hip arthroplasty. Mean NTRP rating before onset of symptoms was 4.25 compared with 4.12 after surgery (29). For patients with knee arthroplasty, average return to play was 5.9 months. Mean NTRP rating was 4.35 compared with 4.26 after surgery (30). A review article by Seyler et al. (40) notes that The Hip and The Knee Societies (15) allow return to doubles tennis after hip and knee arthroplasty but do not recommend return to singles tennis. Their review article recommends that returning to high-level activity should be an individual process, but that general recommendations are that these activities should be avoided. They conclude that it may be appropriate to resume both singles and doubles tennis after an intense rehabilitation protocol in the appropriate patient (SORT C) (40).
Calf/Ankle
Case 9
“A 35-yr-old female 2.5 NTRP tennis player complains of lower leg pain What is the most likely anatomic structure that she injured and how should she progress back into tennis to reduce reinjury risk?”
Many of the lower extremity injuries encountered in tennis players are not specific to tennis and are acute injuries. However, “tennis leg” is an injury in tennis players that is relatively uncommon in other sports. This injury to the either the medial head of the gastrocnemius or the plantaris tendon while landing on a plantar-flexed foot often happens during an overhead smash as the player is moving backward (5,34). A diagnostic ultrasound study by Delgado et al. (5) suggests that injuries to the medial head of the gastrocnemius (66.7%) are much more common than injuries to the plantaris tendon (1.4%) presenting with a clinical diagnosis of “tennis leg.” Ankle and Achilles injuries tendon are common in the adult recreational player with ankle injuries representing 8% of injuries in recreational level players and calf/Achilles injuries representing 5% of injuries (20). Other than case reports of stress fractures, there were little data available on stress injuries in the adult recreational tennis player. For players with previous gastrocnemius or plantaris tendon injuries, a dynamic warm up that includes an eccentric load before playing is recommended (SORT C).
Conclusions
Injury patterns differ between elite, junior, and adult recreational tennis players. Although this review provides guidance for clinicians regarding the medical and musculoskeletal evaluation of the adult tennis athlete, further studies are indicated. Specifically, epidemiologic studies on injury patterns, tennis as an intervention for medical disease, rehabilitation and return to play protocols would help clinicians to better guide management decisions for the adult recreational tennis player.
B.C. declares no conflict of interest and does not have any financial disclosures.
N.J. collects royalties from Up To Date as the author of the topic card (epicondylitis) and patient education handout (elbow tendinopathy). N.J. is a consultant with the Player Development Medical Advisory Panel, Woman’s Tennis Association (WTA) and has received money for travel. N.J. is the president of The Society for Tennis Medicine Science (STMS) and has received hotel/registration costs paid for as an invited faculty at a number of tennis medicine conferences.
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