GENERAL OVERVIEW Description

• More than 20 million people in the United States participate in tennis at least once a year.

• Five million people play tennis at least twice a month. • More than 500,000 adolescents participate in tennis. • Roughly 650,000 people in the United States play at the com-

petitive level.

Epidemiology of Tennis Injuries • Injuries to the lower extremity and spine account for 50% to

75% of all tennis injuries. • Elite players tend to have more injuries to the lower extremi-

ties and spine, whereas recreational players incur more inju-ries to the lower extremities.

• The majority of injuries are sprains or repetitive trauma over-load injuries.

Physiology • Intermittent high-intensity exercise that requires aerobic and

anaerobic fi tness. • Tennis is a noncyclical anaerobic sport (10% to 30%) with an

aerobic recovery phase (70% to 90%). • Single rallies may last only 3 to 8 seconds, but complete

matches may last 3 hours. • Over the course of a match, 300 to 500 bursts of effort may be

expended. • Tennis requires elements of quickness, endurance, strength,

fl exibility, reaction time/speed, agility, and coordination. • Movements include sprinting, twisting, side-to-side running,

sliding, jumping, lunging, and quick stops. • Heart rate for singles tennis can average more than 160 beats

per minute and average more than 80% of the player’s maxi-mal heart rate.

• Depending on conditioning, age, gender, intensity of play, hydration status, and environment, a player may lose 0.5 to 2.5 liters of water per hour of play.

• Conditioning includes both aerobic fi tness and anaerobic fi t-ness. Progressive resistance strengthening of key muscle groups is important, including strengthening of the core and scapular stabilizers.

Equipment/Facilities Racket composition: Change in manufacturing materials has re-

sulted in rackets that are larger, lighter, stiffer and more power-ful than rackets of the past, though the effect of these variables in injury prevention and production is unclear.

Court surfaces: Play a role in types of injuries seen. Include clay, hard, grass, and indoor.

Clay surface: Loose surface causes the ball to lose speed rapidly and bounce higher. Allows increased time for opponent to reach/return the ball. Considered a “slow” surface. This allows for longer rallies and matches, resulting in overuse injuries. The forgiving surface is more gentle on lower extremity joints. How-ever, due to loss of speed of the ball, power to hit the ball hard must come from the kinetic chain, resulting in upper body and back overuse injuries as well.

Hard surface: Concrete, coated asphalt, Rebound Ace. Balls bounce low, giving hard-hitting players an advantage. Consid-ered a “fast” surface. Harder impact to the lower extremities,

with stress fractures of the lower extremities and other injuries such as patellofemoral pain more prevalent. Sudden stops and starts make tennis toe and ankle sprains more common on this surface. Because powerful serve more important on this surface, injuries related to serving are more common.

Grass surface: Grass grown on hard, packed soil. Balls tend to slide and bounce low, making returns diffi cult. Favors the serve-and-volley player. Considered the “fastest” surface. However, uneven-ness of the surface may result in slipping and sprains.

Indoor courts: Allow for year-round play. Usually hard court type surface.

MECHANICS OF TENNIS Kinetic Chain

• The kinetic chain is the transference of force effi ciently from the ground to the racket through the coordinated sequencing of the legs, hips, trunk, and upper extremity.

• Each segment transfers more energy than the previous one, resulting in maximal racket acceleration.

• Fluid motion through the kinetic chain is essential to generate a powerful swing and minimize the risk of injury.

Strokes • 75% of play involves the forehand and serve.

The Serve • Considered the most important stroke of the game, and also

the most commonly associated with injury. • The service motion puts signifi cant stress on the lower ex-

tremities, spine, abdomen, and shoulder, though certain phases of the serve are more apt to cause injury than others.

• Four phases: wind-up, cocking, acceleration, and follow-through ( Fig. 69-1 ).

PHASES OF SERVE

Wind-up: From the standstill (ready) position, this phase is the initiation of the serving motion; it ends with the toss of the ball by the contralateral extremity (when the ball leaves the hand). The lower extremities prepare for the buildup of power that oc-curs in the cocking phase, as the knees and hips bend. The hips and back rotate toward the dominant extremity (see Fig. 69-1 ).

Cocking: From the release of the ball for the toss, through the point where body motion stops moving backward, toward the dominant extremity side. The arm holding the racket appears to be in maximal external rotation ( Fig. 69-1 ). This phase is char-acterized by the building up of power. Energy is stored by pre-stretching of the muscles. Subject to injury: • Anterior shoulder capsule is tensioned to its physiologic limit

with the shoulder in maximum external rotation. • Glenoid labrum serves to help prevent shoulder subluxation

during external rotation and translation. • With abduction and external rotation of the humerus, internal

impingement may occur. • Muscles of the lower extremity during extension. • Intervertebral disc, pars interarticularis with hyperextension/

rotation of the spine. • Wrist extensors.

Acceleration: This phase is characterized by the body moving forward and up, as the dominant shoulder appears to be in even greater (maximal) external rotation initially and ends at ball

69 Tennis

Robert E. Mayle, Jr , Todd Ellenbecker , and Marc Safran

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impact (see Fig. 69-1 ). High muscular activity is noted with peak activity prior to ball impact as energy is transferred along the kinetic chain. Internal rotation of the humerus is responsible for 40% of the racket speed at impact. Fluid motion through the kinetic chain is crucial. Injury to one segment will lead to a loss of power and place another segment at risk for injury. Subject to injury: • Muscular overload of the rectus abdominus, obliques, hip ad-

ductors and rotators, rotator cuff, glenohumeral internal rota-tors and adductors, elbow extensors, and wrist fl exors may occur.

• Superior labrum with extreme abduction and internal rotation of the humerus.

• Ulnar lateral collateral ligament and the fl exor-pronator mus-cles of the elbow secondary to valgus stress.

• Extensor carpi ulnaris tendon at the wrist with hypersupi-nated, ulnarly deviated wrist (for topspin/slice).

Follow-through: Ball impact through completion of the stroke. Activation of shoulder musculature is required to decelerate the humerus to maintain glenohumeral stability. Long axis rotation through the arm, via shoulder internal rotation and forearm pronation, help in the dissipation of forces. Subject to injury: • The posterior shoulder muscles contract eccentrically to slow

the internal rotation of the shoulder. • The rotator cuff acts to maintain the humeral head within the

glenoid. • The biceps function to slow forearm pronation, elbow exten-

sion, and assist in stabilizing the glenohumeral joint. • The posterior capsule is placed under tension as it counters

distraction forces. • Scapular motion combined with contraction of the infraspina-

tus muscle places the suprascapular nerve, located in the spi-noglenoid notch, at risk for injury.

KINEMATICS

• Racket speeds reach a peak velocity of 62 to 83 mph. • Ball velocities reach 83 to 153 mph. • Above speeds are achieved in 0.2 to 0.3 seconds from the end

of the cocking phase until ball contact. • Shoulder internally rotates at 1100 to 1700 degrees per

second. • Elbow fl exes to 120 degrees during late cocking and extends

to 15 to 20 degrees of fl exion at ball impact, resulting in an extension velocity of 900 to 1000 degrees per second.

• Forearm pronation has been recorded at 350 to 900 degrees per second prior to ball impact and has been documented to increase to 1300 degrees per second, 0.1 seconds after impact.

• Wrist speeds approach 1000 degrees per second, 0.1 seconds prior to ball impact; range of motion (ROM) of wrist during a serve is 90 to 100 degrees.

Ground Strokes • Forehand and backhand. • Each stroke has three phases: preparation, acceleration, and

follow-through. • Each stroke may be hit open stance (lead foot more parallel to

the net) or closed stance (lead foot toward the net).

Backhand • The backhand swing may be performed one-handed or two-

handed. The one-handed backhand stroke allows the player to have a better reach and the ability to slice the ball. The two-handed backhand stroke requires less arm strength, but re-quires more trunk rotation and may result in greater power.

• There is an increased incidence of lateral elbow pain in novice players in the backhand stroke, particularly the one-handed

This view of service wind-up illustratesthe addition of 30� lateral thoracic tilt tothe 90� to 100� of scapulohemeral abduction.

30�

90� to 100�

Service ball toss in front of service line ensureshyperextension is avoided.

Back and neck hyperextension should be avoidedduring the service motion.

Figure 69-1 Phases of Serve.

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backhand. This is attributed to not using the trunk and shoul-der musculature properly, placing more stress across the el-bow joint, and from hitting the ball with the wrist in fl exion (versus extension). Players should strive to hit the ball in front of their body to reduce injury to the elbow.

• Using a two-handed backhand reduces the risk of elbow in-jury, because of the greater need for trunk rotation to hit the backhand while maintaining proper elbow and wrist posi-tion.

• Wrist pain is also common with the two-handed backhand stroke, as players “fl ick” the racket at ball contact. Proper technique, taping of the wrists, and strengthening exercises will reduce injury to the wrist during this stroke. The non-dominant wrist is more often injured in those using a two-handed backhand, during the preparation phase when this wrist is in an extended and supinated position.

Forehand • Players may hit the forehand shot with a Western grip or an

Eastern grip. • The Western grip allows for the production of topspin, and

is more suitable for play on clay or slow hard courts. This style, however, places more of a valgus stress on the elbow.

• The Eastern grip allows for the player to slice the ball and is used on grass or carpet surfaces by serve-and-volley type players.

• The forehand shot has three phases: preparation, accelera-tion, and follow-through.

SPECIFIC INJURIES Upper Extremity Shoulder Overview: 35% of junior tennis players complained of shoulder

pain at some point. More than 50% of older players and elite athletes note shoulder pain at some point in their career. A ma-jority of their shoulder pain is caused by impingement and insta-bility.

King Kong arm: Drooping and hypertrophy of the musculature of the shoulder girdle of the dominant upper extremity from repetitive use. This is attributed to eccentric stretching of the posterior shoulder and scapular stabilizers.

Rotator cuff infl ammation: One of the more common causes of shoulder pain, attributed to the chronic, repetitive swinging of the racket. Rotator cuff infl ammation in the young player is more often due to instability, where posterior capsular tightness, impingement, and instability are factors in the older player. De-creased strength of the scapular stabilizers and external rotators and decreased fl exibility with internal rotation are associated with shoulder instability. Impingement of the rotator cuff be-tween the acromion and humeral head is more likely to occur with serves, overhead shots, and high volleys as opposed to ground strokes ( Fig. 69-2 ). Players will present with subacromial pain and referred pain to the lateral arm. They may claim that their arm “feels dead” during play. Persistent infl ammation may lead to tears of the rotator cuff (see Fig. 69-2 ). Avoid activities that may further aggravate shoulder symptoms/pathology.

Acromion

Deltoidmuscle

Supraspinatus tendon

Rotator Cuff Disease, Tears and Ruptures

Capsule

Scapula

Abduction of arm causes repeated impingement of greatertubercle of humerus on acromion, leading to degenerationand inflammation of supraspinatus tendon, secondaryinflammation of bursa, and pain on abduction of arm.Calcific deposits in the supraspinatus tendon may progressto acute calcific tendinitis and sudden onset of severe pain.

Subacrominalbursa

Extensive rupture of left cuff. To bring aboutabduction, deltoid muscle contracts strongly

but only pulls humerus upward towardacromion while scapula rotates

and shoulder girdle is elevated.45° abduction is thus possible.

Test for partial tearof cuff is inability to maintain 90°

abductionagainst mild

resistance.

Repair. If freshened edges of tearcannot be brought together, notchis created in humerus just beneatharticular surface to allow attachmentof tendon through drill holes inbone, using strong sutures.

Infraspinatusmuscle

Bicepsbrachiitendon

Humerus

Communication between shoulder joint and subdeltoid bursa on arthrogramis pathognomonicof cuff tear.

Subscapularismuscle

Supraspinatusmuscle

Acute rupture (superior view). Often associatedwith splitting tear parallel to tendon fibers. Furtherretraction results in crescentic defect as shownat right. Retracted tear, commonly found in

surgery. Broken line indicates extentof debridement of degenerated tendon for repair.

Thickened, edematousbiceps brachii tendon

Figure 69-2 Rotator Cuff Injuries. Having the racket hand high above shoulder level, such as to serve or hit an overhead, puts the subacromial space and rotator cuff at risk for impingement.

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Strengthen weak muscles; external rotators tend to be weaker than internal rotators. Increased rotator cuff strength is associ-ated with increased velocity of serve. Additionally, strengthen latissimus dorsi, serratus anterior for all strokes, deltoid for overhead and backhand strokes, and rhomboids to counter drooping of the shoulder girdle. Maintaining fl exibility of the posterior shoulder is important in prevention of injury.

Biceps tendinitis: Overuse injury, leading to pain in the front of the shoulder with activities that fl ex the arm at the elbow, rotate the forearm, and accelerate/decelerate the arm, such as hitting a high topspin forehand. Activity modifi cations, antiinfl ammato-ries with eventual strengthening of the muscles of the shoulder, elbow, and scapula are recommended to prevent persistent ten-donitis or tendon rupture. Need to rule out SLAP lesions.

SLAP (superior labrum, anterior to posterior) lesions: Two theories on etiology: First, tightness of the posterior inferior capsule leads to peeling off of the posterior superior labrum when the arm is abducted 90 degrees and externally rotated. Second, tension placed on the biceps tendon with repeated in-ternal and external rotation of the shoulder leads to avulsion of the labrum from the superior glenoid.

Osteoarthritis (OA): In a recent study of senior elite tennis play-ers, there was a statistically signifi cant increase in mild osteoar-thritis of the glenohumeral joint in the player’s dominant shoul-der. Increased instability as the result of high demands placed on the shoulder during tennis play may be the underlying cause for the development of OA.

Elbow Overview: Biceps/triceps strengthening with improve control over

the elbow, helping to reduce injury risk. Full pronation of the arm after impact will reduce excessive load and stress on the elbow.

Lateral tennis elbow: 50% of recreational players sustain injury to the origin of the extensor carpi radialis brevis (ECRB) tendon (and sometimes the extensor digitorum communis [EDC]) at the lateral epicondyle ( Fig. 69-3 ). Microtears in the tendon lead to the formation of granulation tissue and adhesions, which cause pain. Risk factors include age above 30, improper grip size, tight strings, use of a metal racket, incorrect technique, inadequate conditioning, practice more than 2 hours daily. Improper tech-nique: wrist-fl exed backhand, premature trunk rotation, leading with the elbow during the backhand. Correction of technique in addition to rest, rehabilitation, bracing, antiinfl ammatories is recommended.

Medial tennis elbow: Less common than lateral tennis elbow in the general tennis playing population, but more common than lateral in professional tennis players (see Fig. 69-3 ). Usually caused by strain at the origin of the common fl exor tendon at the medial epicondyle. Competitive players are prone to this injury from repeated wrist fl exion from overhead serves or from prona-tion stress associated with placing topspin on the ball. Degen-erative changes can be seen in FCR, PL, FDS, and FCU.

Medial and lateral elbow tendinosis: Respond more to physical rehabilitation though injections may help by reducing the pain while rehabilitating. Suspect radial nerve entrapment in a player with refractory tennis elbow.

Posterior impingement syndrome of the elbow: Impaction of olecranon into the olecranon fossa of the humerus with repeti-tive, forceful extension of the elbow. Pain and tenderness occur about the elbow with repeated boney/soft tissue impingement. Activity modifi cation to avoid leaning on the elbow and hitting the ball with the arm in full extension (e.g., Western forehand with fully extended arm) is recommended. Players should strengthen the biceps, triceps, and wrist fl exors/extensors.

Ulnar collateral ligament (UCL) sprain: Over time, repetitive valgus stress to the elbow may stretch the UCL. This may lead to increased contact and cartilage wear on the lateral side of the elbow (between the radial head and the capitellum) and to a

stretch injury of the ulnar nerve. A ruptured UCL is rare and would require surgery. Players may avoid this injury by using proper technique. Avoid hitting the Western forehand with the arm fully extended. Exercises to strengthen the biceps, triceps, wrist extensors/fl exors are recommended.

Epicondylitis (tennis elbow). Exquisite tendernessover lateral or medial epicondyle of humerus.

Tendon of extensor carpiradialis brevismuscle(cut away)

Capitulum of humerus

Radial collateral ligament

Head of radius

Technique for injection of tennis elbow.

Lateralepicondyleof humerus

Tendon ofextensordigitorumcommunismuscle(cut away)

Figure 69-3 Tennis Elbow. A degenerative process of the elbow. Lateral epicondylitis is seen in recreational tennis players who are aged 30 to 50, play three to fi ve times a week, and more often have a one-handed backhand with poor mechanics. Racket factors have also been implicated. Medial epicondylitis is seen more commonly than tennis elbow in the high-level tennis player. Factors associated with this overuse injury include hitting a lot of topspin on the fore-hand and the wrist snap in serving.

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Wrist/Hand De Quervain’s stenosing tenosynovitis: Irritation to the abduc-

tor pollicis brevis and extensor pollicis brevis rubbing over the radial styloid with excessive ulnar deviation of the hand during grasping and swing of the racket ( Fig. 69-4 ).

Triangular fi brocartilage complex (TFCC) tears: Painful or painless clicking noted on the ulnar side of the wrist due to tear in the TFCC. Increased association with ulnar positive variance (increased length of the ulna relative to the radius). Prevent by decreasing twisting motion at the wrist, functional bracing, and wrist strengthening exercises.

Hamate fracture: Rare injury caused by the impaction of the butt end of the racket handle into the hook of the hamate ( Fig. 69-5 ). May require excision of the fracture fragment.

Wrist ganglion cysts: May cause pain predominately in the dor-sum of the wrist. Treated with drainage, compression, antiin-fl ammatories, splinting, and surgically. These may recur.

Extensor carpi radialis brevis/longus, fl exor carpi ulnaris ten-donitis: Result from poor form, overstretching of the muscles during serve, and eccentric muscle contraction to stabilize wrist during off-center shots.

Wrist sprains: Acute overstretching or tearing of one or more ligaments of the wrist as the result of an unexpected twist, bend, or impact to the wrist. Taping, bracing, splinting of the wrist should be done until the player is completely pain free.

Recurrent dislocating extensor carpi ulnaris: Tears or stretch-ing of the extensor retinaculum allow for subluxation of the tendon in and out of its normal groove. This commonly occurs when players hit a forehand shot with the wrist in ulnar devia-tion and supination imparting slice to the ball. Symptoms in-clude painful snapping sensation over the dorsum of the wrist with rotation of the forearm and wrist. Treatment includes im-mobilization of the wrist for 6 weeks in supination. If nonopera-tive treatment fails, surgery may be necessary to repair the reti-naculum. Injury prevention techniques include strengthening exercises of the wrist extensors and application of support braces, tape, or elastic bandages.

Neurovascular injury: May include ulnar nerve (cubital tunnel syndrome or entrapment at Guyon’s canal), median nerve (pro-nator teres syndrome, carpal tunnel syndrome), radial nerve entrapment (radial tunnel syndrome), suprascapular nerve in-jury, or injury to palmar arteries.

Lower Extremities Muscle strains: Partial muscle tears or pulls affecting the quadri-

ceps, hamstrings, adductors, gastrocnemius, and soleus are com-mon. Injury most commonly occurs at the muscle-tendon (myo-

tendinous) junction. Muscles that span two joints are more susceptible to injury (hamstrings, gastrocnemius, and quadriceps).

Labral injuries: External rotation and hyperextension of the hip has been suggested to cause tearing of the anterior acetabular labrum ( Fig. 69-6 ). Increased prevalence of these injuries occur in players that hit with an open stance stroke. Additionally, labral tears occur more commonly in players with hip dysplasia and femoroacetabular impingement. To confi rm a diagnosis, magnetic resonance imaging (MRI) arthrogram (with Marcaine injection) is the diagnostic tool of choice. Surgical treatment via hip arthroscopy is advocated for treatment of labral injuries (see Fig. 69-6 ).

Knee injuries: Common in tennis due to the side-to-side, pivot-ing, twisting, jumping, bending, rapid acceleration and decelera-tion nature of the game. Most common knee injuries include patellofemoral syndrome, patellar tendonitis, meniscal injuries, and bursitis. In a survey of the U.S. Tennis Association (USTA) national team, 19% of all injuries were knee related. Of these, 70% were traumatic and 30% were from overuse. An uncom-mon injury that is seen more commonly in tennis is popliteus tendonitis.

Tennis leg: Incomplete/complete rupture of the medial head of the gastrocnemius. Injury is often incurred with a forceful con-traction of the gastrocnemius when the knee is extended and the foot is dorsifl exed. Players aged 35 to 50 are at increased risk for this injury.

Medial tibial stress syndrome (shin splints): Periostitis along the posterior medial border of the distal one-third of the tibia from repetitive shock to the lower extremity. Muscles that nor-mally absorb the shock in the leg fatigue, transferring the energy to the adjacent periosteum/bone. Rest, arch supports, taping, and antiinfl ammatories may alleviate symptoms.

Achilles tendon rupture: More commonly seen in the player over age 40 and is associated with movements that require a quick burst of speed. Incidence is roughly 5.5%.

Ankle sprains: The most common acute injury in tennis and ac-count for 20% to 25% of all injuries. Inversion injuries pre-dominate. Proper footwear, taping, bracing may serve to prevent injury.

Plantar fascitis: An overuse injury that occurs due to repetitive forefoot push-offs during volleys. Treatment includes activity modifi cation, nonsteroidal antiinfl ammatories (NSAIDs), and evaluation of heel and medial arch support ( Fig. 69-7 ). Change in footwear or use of an insert may be required.

Posterior tibial tendinitis: Pain is noted over the medial aspect of the ankle. Aggravated by jumping and quick starts. Prevention with use of a medial heel wedge, arch supports, and stretching.

The Finkelstein test exacerbates the pain;it is performed by flexing the thumband then placing the wrist in ulnar deviation.

Course of abductor pollicis longus and extensorpollicis brevis tendons through 1st compartment

of extensor retinaculum, transverse incision,and relation of sensory branches of

radial nerve and synovial sheaths.Superficial branchof radial nerve

Skinincision

Extensorretinaculum

Extensorpollicislongus

Point of exquisite tendernessover styloid process of radiusand sheath of involved tendons.

Extensorpollicisbrevis

Abductorpollicislongus tendons

Figure 69-4 De Quervain’s Tenosynovitis. Common in tennis because of the motions required to hit a ball with some spin as well as the grasp-ing necessary to hold the racket.

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Peroneal tendinitis: Frequently encountered in tennis players due to pivoting and rapid change in direction. Players should use tennis shoes appropriate for the surface of the court. Stabilize the ankle with braces, elastic bandaging, tape, or high-top ath-letic shoes. Strengthen peroneal muscles by eversion against resistance. Perform proprioceptive training.

Tennis toe: Repetitive abutment of the toes against the shoe may lead to a subungal hematoma. Players should wear appropriately sized shoes and keep their toenails cut short.

The Trunk Low back pain (LBP): Common in tennis players of all ages: 38%

of professional, 47% of elite junior female, and 31% of elite junior male tennis players have missed a tournament secondary to LBP.

Dislocation of Carpus

Fracture of Hamulus (Hook) of Hamate

25°

Direction ofx-ray beam

Some lunate dislocationsunstable after closed reduction,as in this case. Persistent gapbetween lunate and scaphoid.

Dislocation of lunate plusfracture of styloid process of radius. Initial attemptat manipulative reductionunsuccessful.

Open reduction and pinningrequired. Pins removed in 6 to 8weeks; cast worn up to 12 weeks.

Second closed reduction satisfactory.Styloid process of radius and lunatepinned percutaneously. Somefunctional disability persisted.

Note: If lunate badly comminuted or necrotic, as in Kienböck disease, totalreplacement with Swanson silicone prosthesis may be indicated

Usually caused by impact frombutt end of tennis racket, golfclub, or bat during swing.

Radiograph of carpaltunnel shows fractureof hook of hamate.

Technique. 2-cm thick radiolucentpad placed under metacarpals;patient holds fingers and wristin maximal dorsiflexion withother hand. X-ray beam directed25° from vertical toward baseof 4th metacarpal.

with C.A. Luce

Figure 69-5 Wrist Injuries.

Hip lateral tears are becoming more common due to the open stance used inhitting the ball. The external rotationand extension of the hip result in increasedstresses to the labrum.

Figure 69-6 Arthroscopic Picture of Labral Tear.

Calcaneal spur at attachment of plantar aponeurosis.

Positive bone scan ofcalcaneal stress fracture.

Calcaneal fat pad(partially removed)

Calcaneal tuberosity

Flexorretinaculum

Medialcalcaneal branch of tibial nerve

Medialmalleolus

Plantar apo-neurosis withinflammationat attachmentto calcanealtuberosity

Tender, slightlyred nodule justlateral to calcanealattachment ofAchilles (calcaneal)tendon

Firm, well-fittingheel countermaintainscompactnessof fat pad,which buffersforce of impact.

Loose-fitting heelcounter in runningshoe allowscalcaneal fat padto spread at heelstrike, increasingtransmissionof impact to heel.

Pump bump

Figure 69-7 Plantar Fasciitis Associated with tightness of the calf muscles, and being on the toes for much of play; the plantar fascia may become infl amed, degenerative, and even tear.

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Lumbar strain: Onset of symptoms often correlated to a change in intensity/duration of play. Repetitive trunk rotation and hy-perextension place the erector spinae and multifi dius muscles at risk for injury. When the player serves the ball, tossing the ball slightly ahead of the service line and use of the lower extremities to launch into the service will decrease the amount of hyperex-tension of the back and neck.

Herniated disc: Repetitive hyperextension and rotational forces applied to the lumbar spine, especially during the serve, subject the annulus to microtrauma that could lead to a tear. Correction of form and biomechanics is important to prevent a recurrence in injury.

Facet syndrome: Repetitive hyperextension, rotation of the trunk, or a combination of both may lead to cartilage wear of the facet joints. Additional load may be placed on the facet when there is loss of disc height, as seen with degeneration of vertebral discs. Players should avoid hyperextension of the lumbar spine to pre-vent acute facet impingement and chronic facet arthropathy.

Rib stress fracture: Repetitive contraction of muscles that have origins or insertions onto the ribs place excessive stress on the ribs and may lead to a stress fracture. Ribs susceptible to stress fracture in the tennis player include the fi rst and fourth through ninth ribs, with the fourth and sixth most commonly affected. This is due to the action of the serratus anterior and external obliques. Players will note pain with deep inspiration, coughing, and overhead activities. Rib fractures are commonly missed on plain x-ray. Bone scans or MRI will make the diagnosis. Rib fractures heal with time, 4 to 6 weeks. Activity modifi cation dur-ing this time is recommended.

Spondylolysis: A result of repetitive hyperextension of the lumbar spine. Prevention is similar to that for lumbar strains, as dis-cussed earlier.

Abdominal muscle strains: Partial muscle tear or pull of the ab-dominal musculature ( Fig. 69-8 ). Nondominant rectus abdomi-nis is predominately affected. The internal and external oblique muscles are also prone to strains (see Fig. 69-8 ). During the cocking phase of the serve, the player is hyperextending the back, placing the abdominal musculature on greatest stretch. In the acceleration phase that ensues, the abdominal musculature is forcefully contracted—placing the muscles at risk for injury. Treatment is ice and rest. Avoid massage over the affected area to minimize risk of the development of myositis ossifi cans.

Injuries Common in the Adolescent Population

• Muscle strains from overuse predominate the injuries in the young player, though the physis is the weakest link and uniquely susceptible in the skeletally immature player.

• Injuries to the lower extremity are twice as common as inju-ries to the spine and upper extremity.

• Injuries to the foot, leg, and wrist prevail in the female adoles-cent player, whereas injuries to the ankle, groin, hand, abdo-men, and back prevail in the male adolescent player.

• Overall predominance of injury pattern, in order of greatest to least: strains, infl ammation, sprain.

Physeal Injuries Wrist epiphysitis: Repeated hyperextension and rotation of the

wrist, causing infl ammation of the distal radius epiphysis. This is commonly seen in adolescent players who attempt to put top-spin on the ball. Premature closure of the growth plate is a po-tential complication of this process. Treatment strategies range from activity modifi cation, wrist immobilization, to surgery for treatment of an associated fracture or for premature physeal closure. Players with wrist epiphysitis should avoid push-ups and fl atten strokes, avoiding topspin.

Extensor muscles Multifidus Longissimus Iliocostalis

Flexor muscles Psoas External oblique Internal oblique Transversus Rectus abdominis

Corset

Figure 69-8 Muscles of Anterior Abdominal Wall. Abdominal muscle injuries are common in tennis as a result of the stretching and then contracting of the muscles to hit the serve and the increased use of the trunk muscles to generate force with the open stance ground strokes common in today’s style of play.

High-power magnification of involved area.

Radiograph shows separation of superficialportion of tibial tuberosity.

Focal radiograph shows fragment at site ofinsertion of patellar ligament.

Normal insertionof patellar ligamentto ossifying tibialtuberosity.

In Osgood-Schlatterlesion, superficialportion of tuberositypulled away, formingseparate bone fragments.

Bone fragment

Separationfilled withfibrous tissueand fibrocartilage

Growth plate

Metaphysis of tibia

In Osgood-Schlatter condition, theapophysis of the tibial tuberosity isprominent and has irregularossification. Fragmentation and separate ossicles may develop.

Figure 69-9 Osgood-Schlatter Lesion. Patellofemoral problems are common in tennis as a result of the repeated bending of the knees (ready position, serving, hitting low balls), lunging for the ball, and sudden stops and starts. In the young player, Osgood-Schlatter dis-ease, infl ammation of the growth plate where the patellar tendon in-serts, is common, whereas in adults, patellar tendonitis or patello-femoral overload may occur.

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Traction to the apophysis at the greater/lesser tuberosity of the humerus: Akin to Little Leaguer’s shoulder. Rest and activ-ity modifi cation are the mainstays of treatment. Upon return to play, the player should start with ground strokes only. High vol-leys and serves should be gradually incorporated.

Humeral medial epicondyle apophysitis (adolescent medial tennis elbow): Overuse injury resulting from the repetitive muscular contractions of the forearm and wrist fl exors during forehands and serves. Players may sense a decrease in their abil-ity to serve at full speed and to fully straighten the elbow. Use of a racket with vibration-dampening characteristics, an oversized/light/stiff head, fl exible shaft, a large cushioned grip (that is comfortable to the player), and low-tensioned strings of gut or high-quality synthetic strings are recommended. Activity modi-fi cation with limitations on the intensity of conditioning/play and amount of serving/overhead play/throwing/heavy lifting is encouraged.

Osgood-Schlater disease: Footwear modifi cation for increased shock absorption and stability, stretching of the quadriceps and hamstring musculature to decrease the tension of the muscles pulling on the patellar tendon, training on soft surfaces (clay or sandy surfaces), and use of a patellar tendon strap ( Fig. 69-9 ).

Sever’s disease: Most common cause of heel pain in the adoles-cent player. Prevention and treatment entail proper stretching, use of a heel support that provides cushioning, shock absorption, and decreased tension on the Achilles tendon.

SUMMARY • Tennis is a popular sport—worldwide, both genders, all ages. • Tennis requires both aerobic and anaerobic fi tness. • Tennis may result in a variety of unique injuries. • Lower extremity and back injuries predominate, though

shoulder and elbow injuries do occur commonly.

RECOMMENDED READINGS 1. Bylak J, Hutchinson MR : Common sports injuries in young tennis

players. Sports Med 26: 119 - 132 , 1998 . 2. Christmass MA, Richmond SE, Cable NT , et al : Exercise intensity and

metabolic response in singles tennis. J Sports Sci 16: 739 - 747 , 1998 . 3. Kibler WB, Safran M : Musculoskeletal injuries in the young tennis

player. Clin Sports Med 19: 781 - 792 , 2000 . 4. Kibler WB, Safran M : Tennis injuries. Med Sports Sci 48: 120 - 137 ,

2005 . 5. Kibler WB, Safran MR : Tennis injuries. In Caine DJ, Mafulli N (eds):

Epidemiology of Pediatric Sports Injuries, vol 48. Basel, Switzerland: Karger, 2005 , pp 120 - 137 .

6. Maquirrian J, Ghisi JP, Amato S : Is tennis a predisposing factor for degenerative shoulder disease? A controlled study in former elite play-ers. Br J Sports Med 40 ( 5 ): 447 - 450 , 2006 .

7. Pluim B, Safran M : From Breakpoint to Advantage: A Practical Guide to Optimal Tennis Health and Performance. Vista, California: Racquet Tech Publishing, 2004 .

8. Rettig AC : Wrist problems in the tennis player. Med Sci Sports Exerc 26: 1207 - 1212 , 1994 .

9. Safran MR : Biomechanics of tennis strokes and its association with tennis injuries. Am J Med Sci 5: 276 - 284 , 2003 .

10. Safran MR : Injuries sustained in tennis and other racquet sports. In Fu FH, Stone DA (eds): Sports Injuries: Mechanisms, Prevention and Treatment, 2nd ed. Philadelphia: Lippincott, Williams and Wilkins, 2001 , pp 617 - 656 .

11. Safran MR : Tennis injuries and strategies for prevention: Gender dif-ferences in the elite American junior tennis player. In Crespo M, Pluim B, Reid M (eds): Tennis Medicine for Tennis Coaches. London: Inter-national Tennis Federation, 2001 , pp 44 - 46 .

12. Van der Hoeven H, Kibler WB : Shoulder injuries in tennis players. Br J Sports Med 40 ( 5 ): 435 - 440 , 2006 .

13. Zecher SB, Leach RE : Lower leg and foot injuries in tennis and other racquet sports. Clin Sports Med 14 ( 1 ): 223 - 239 , 1995 .

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