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Tennis Injuries
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The ITF Injury Clinic provides information on the diagnosis, treatment and rehabilitation of common
tennis injuries .The injuries covered are;
Achilles Tendon
Ankle Sprain
Calf Muscle Strain
Groin Injury
Hamstring Muscle Strain
Heel Pain
Iliotibial Band Friction Syndrome
Impingement Syndrome
Jumper's Knee
Kneecap Pain
Lower Back Pain
Osgood Schlatter Knee Injury
SLAP Lesion
Tennis Elbow
Wrist Tendinopathy
Abdominal Muscle Strain
Diagnosis
An abdominal muscle strain is a partial tear or pull of one of the
abdominal muscles. The injury usually affects the (non-dominant
side of the) straight abdominal muscles (rectus abdominis)
(figure 1), but the internal and external oblique abdominal
muscles (the obliquus internus abdominis and obliquus
externus abdominis) may also be injured.
strain.
Just before making the stroke, whilst bending back during the
cocking phase, the abdominal muscles are under a great deal of
tension. As soon as you start to hit the ball, these muscles start
to contract, using the elastic energy stored in the abdominal
muscles.
The power released moves across the body, from the dominant
shoulder to the leg of the non-dominant side of the body. This
movement, whereby the muscles stretch and then contract
(eccentric-concentric contraction), is a high-risk moment for the
abdominal muscles.
When you arch your body back even further than you do for a
standard serve, such as for a kick serve or topspin serve, this
increases the risk of sustaining an abdominal muscle strain even
more.
The open stance forehand, which involves a powerful rotation of
the torso, may also lead to an abdominal muscle strain.
Symptoms of an abdominal muscle strain are a sudden stabbing
pain upon contraction of the injured muscle. This pain is for
example felt during the serve or when doing abdominal muscle
exercises. Furthermore, the injured muscle is sensitive upon
palpation.
What should you do? First Aid!
The first phase of the treatment consists of activity modification
and cooling of the injured area. Once the pain has somewhat
subsided, you can start the rehabilitation process.
Immediate and effective first aid is essential for a rapid recovery.
If the injury seems to be serious or if in doubt, have a (sports)
physician examine you. In certain cases you will be referred to a
(sports) physiotherapist.
How to Ensure the Best Recovery
As soon as the worst of the pain has subsided (after one to five
days), you can start the build-up process. During this build-up
pain is a warning sign to stop and rest.
Be careful: do not exceed your pain threshold, as this will only
delay the healing process! The build-up consists of three stages,
ranging from easy to demanding. Here are the exercises, along
with some tips.
Stage 1. Improvement of Normal Function
- Medicine ball exercises (Figure 5). In this exercise muscles undergo a rapid stretch and contraction
('stretch-shortening'), similar to the action when performing a serve. Hold a medicine ball above your
head with two hands (figure 5). Throw the ball to your partner and then catch it above your head. Slightly
spring back with the ball and then throw the ball back in one go. Start by using a relatively light weight
ball (0.5 1 kg), and slowly build it up over several weeks. Repeat three sets of six to eight repetitions.
- You can now start performing second serves, smashes, and high forehand and backhand strokes
during play.
- Once this is going well, you can start performing some first serves. Gradually increase the frequency
and speed of the serve.
- You can now start playing practice sets and practice matches. Once you have played practice matches
for two weeks without pain, you can start playing competition matches again.
Preventing Re-injury
Diagnosis
First aid
As a rule of thumb, first aid involves modification of activity (less
tennis and running).
Cooling with ice, stretching exercises and wearing firm, good shoes
are also important measures.
When there is swelling and pain, ice massage may alleviate
symptoms. Use a melting ice cube or a paper cup with ice. Massage the
painful spot. In general, 5 to 8 minutes will be sufficient. Repeat this
several times a day.
Use special (visco-elastic) inlays or an Achilles tendon bandage.
These provide good shock absorption and because of the increase in
height, they artificially lengthen the tendon, reducing the stress on it.
Replace running exercises with cycling or swimming.
Shift the weight of the back leg to the front leg and press the heel of
the back leg firmly into the floor. Rest the hands on a stationary object
(no bouncing). The stretch should be felt high in the calf. Hold the
stretch for 15 to 20 seconds, followed by a rest period of 10 to 20
seconds, and repeat three times.
Stretching of the short calf muscles (Figure 3). Start from the same
position as above, but now bend the knee of the back leg, while
keeping the heel on the floor. The stretch is felt low in the calf. Hold
the stretch for 15 to 20 seconds, followed by 10 to 20 seconds rest, and
repeat three times.
Diagnosis
First aid
an anti-clockwise set.
Sit on a smooth surface. Lay a towel on the floor in front of you. Put
the injured foot on the towel, with both the heel and the toes touching it
(Figure 2). Move the feet with the towel alternately forwards (extend
the knees) and back (bend the knees). Both the heels and the toes
should stay in touch with the ground.
Stand straight and walk on your heels. The forefoot and mid-foot
must not touch the ground. Take small steps. Then walk on your toes.
Finally, walk on the inside of your feet, pressing the big toe firmly into
the ground.
Stand on the injured foot, with arms spread to keep your balance
(Figure 3). Shut your eyes and try to still keep your balance.
Sit on a chair with your feet on the floor (Figure 4). Tie one end of
an elastic tube to the chair. Wrap the other end of the tube under the
middle of the injured foot. Bend the knees 90 degrees. Move the foot
against the resistance of the elastic tubing outwards and try to keep the
outer side of the foot facing up. Repeat 10 to 20 times. Try to hold the
A very good exercise for the muscles around the ankle and foot is
skipping. This should be done with care, however. It is important to
build up this exercise gradually, from one minute a day to 10-15
minutes daily. Use a soft surface, such as grass or carpet, and wear
either tennis or running shoes.
If this goes well, you can start jogging. Start with an easy warm up,
then progress to straight running, followed by the introduction of starts
and stops into your running exercises.
Finally, include sprints and jumping exercises.
Stage 3. Return to Play
Now you are ready to go back on court again. Initially, the ankle
should be taped or lace-up brace should be used, to help prevent re-
injury of the ankle ligaments.
Start against the practise wall or with mini-tennis (playing within the
service lines). Gradually increase the area of play and move back
towards the baseline. Make sure you use small steps to position
yourself correctly for the ball.
This can be followed by volley exercises.
After 1-2 weeks, you can start including exercises in which you run
longer distances to the ball (tennis drills, from side to side).
Include low volleys, followed by the serve and overhead.
As soon as you can hit a jump smash without problems, you can start
playing practice matches.
Take care with explosive or unexpected movements, or strokes in
which your foot is perpendicular to the running direction, such as wide
backhands.
In this phase, it is important to increase the loading capacity of the
ankle, to regain your rhythm and to win confidence.
Once you have been able to play practice matches for two successive
weeks without problems, you will be ready for match play again.
Preventing Re-injury
It is not always possible to prevent an ankle sprain, but the risk can be
reduced by paying attention to the following:
Perform a complete warm-up before each practice or match, and a
cool-down afterwards, both lasting 10-15 minutes. Pay attention to the
correct performance of stretching exercises. Stretching exercises for
the calf muscles are especially important.
Ensure a gradual build-up of training, so the body can get used to the
extra load.
Wear firm, stable, well-fitting tennis shoes and pay attention to how
the shoelaces should be tied. An ideal tennis shoe should have good
shock absorption, sideways stability, feeling with the surface (grip) and
optimal comfort.
Remove all the balls from the tennis courts, to avoid tripping over
them.
Improve your physical condition with regular jogging or cycling.
Most injuries tend to occur towards the end of the match or at the end
of the day, when you are getting tired. The better your physical
condition, the lower the risk of injury.
Improve proprioception and strength of the muscles around the ankle
with co-ordination and balance exercises. Standing on one leg is a
particularly useful exercise. The exercises can be made more difficult
by using a wobble board.
A tape, brace or high shoe will help protect the ankle ligaments,
especially during the first three months after the injury, and have been
shown to reduce the risk of re-injury. Contrary to common belief, this
does not weaken the ankle.
Calf Muscle
Strain
Diagnosis
First Aid
Stage 2. Build-up
As soon as all the above exercises can be performed and walking is
possible without pain, a return to tennis and other sports can be
considered.
Start by strengthening the calf muscles (Figure 4). Slowly rise onto
your toes and hold this position for 10 to 20 seconds. Then return to the
starting position. Perform this exercise with both feet at the same time,
then when leaning on the injured leg only. If using body weight is too
painful or difficult, elastic tubing may be used to work the plantar
flexors (i.e. push the toes and forefoot down against the resistance of
the elastic tubing).
Take small, quick steps on the spot, alternating the left and the right
leg.
If this goes well, you can begin jogging. Start with an easy jog, then
include some sprints and straight running, followed by quick turns,
starts, and stops.
Diagnosis
A sudden sharp pain may be felt in the groin area or inner thigh.
There may be tightening and hardening of the groin muscles.
The adductor tendons or the pubic bone feel tender upon
palpation. Contracting the groin muscles (pressing the legs
against one another) is also painful. There may be bruising or
swelling, although this might not occur until a couple of days
after the initial injury. With a severe injury, a small dip may be
visible or felt.
Ice
Cool the painful area directly with ice or a cold pack for 10 to 15
minutes and repeat this several times a day. Do not place ice on bare
skin, but place a towel between the skin and the cold pack. Men should
take care not to freeze the scrotum
Immobilisation
Stop playing any kind of sport and avoid putting weight on the leg.
Compression
Apply a compression bandage. This will help deter minor bleeding
caused by the muscle tear in the thigh. Remove the bandage if it starts
feeling too tight or if the calf starts swelling.
Immediate and effective first aid is essential for a rapid recovery. Have
a (sports) physician examine the injury if it seems serious or if in
doubt. In some cases the player will be referred to a (sports)
physiotherapist.
How to Ensure the Best Recovery
As soon as the worst of the pain and swelling have subsided (between
several days and a week) you can start building up strength. If you feel
pain during the build-up, this is a warning sign to stop and rest. Be
careful: do not exceed your pain threshold, as this will only delay the
healing process! The build-up consists of three stages, ranging from
light to demanding. Here are the exercises, along with some tips.
Stage 1. Improvement of Normal Function
Carefully put weight on the leg, as long as it is not painful. If
necessary, use an elbow crutch for the first few days.
When the leg stops hurting in the course of your daily activities, you
can become more active, for example by cycling. This stimulates
circulation in the thigh muscles and will assist the healing process..
Muscle strengthening (short adductors): Lie down on your back with
your knees bent and feet flat on the ground. Squeeze a ball between
your knees. Press the ball with your legs for five seconds, release and
repeat. Do one set of 10 repetitions.
Muscle strengthening (long adductors): Lie down with your legs
extended in front of you; squeeze a ball between your ankles. Press the
ball with your ankles for 30 seconds, release and repeat. Do one set of
10 repetitions.
Muscle strengthening (short adductors): Lie down on your back with
your knees bent and your feet flat on the ground. Slowly move one
knee outwards towards the ground and slowly bring it back up again.
Stretching the inner thigh muscles (short adductors, figure 2). Sit
cross-legged on the ground. Place the soles of your feet together. Sit up
straight and gently push your knees towards the ground with your
elbows until you feel a stretch. Hold this position for 20 to 30 seconds,
followed by a 20 to 30 second rest. Repeat this three times.
Stretching the inner thigh muscles (long adductors, figure 3). Stand
up straight and take a long step sideways with your right leg. Bend the
right knee and shift your body weight above this knee, thereby
stretching the left knee. Bend the knee until you feel the stretch in the
left groin. Hold this position for 20 to 30 seconds, followed by a 20-30
second rest, and repeat three times. Repeat this exercise for the other
leg.
Stage 2. Return to Training
As soon as all of the above exercises can be performed confidently and
free of pain, you may consider returning to sport
Take small, quick steps on the spot, alternating the left and right leg..
Muscle strengthening (long adductors, figure 4): Lie down with your
legs extended in front of you; squeeze a ball between your ankles.
Press the ball with your ankles for 30 seconds, release and repeat. Do
one set of 10 repetitions.
Muscle strengthening (Long adductors, figure
Diagnosis
Plantar fasciitis is an overuse injury at the point where the
plantar fascia anteromedial attaches to the heel (Figure 1 and
1a). Degenerative changes of the plantar fascia occur at the
attachment site to the bone, as a result of repetitive micro
ruptures.
A heel spur is calcification caused by repeated pulling away of
the periosteum from the calcaneus. This can be demonstrated
by X-rays. However, heel spur itself is not the cause of the pain.
Plantar fasciitis is common among players who perform a great
deal of jumping and sprinting.
Common symptoms are a localised, sharp pain and/or swelling
at the inside of the heel, deep under the fat pad of the
calcaneus, as well as pain during exercise. Rest gives
immediate pain relief, although there may be some nagging pain
after exercises or at night.
There is generally pain and stiffness in the morning and at the
start of exercise, when the area around the heel is cold and
contracted.
First Aid
Fast and adequate first aid treatment is very important to ensure
a speedy recovery. In serious cases or when in doubt, the injury
should be evaluated by a physician. He/she may refer the
patient to a physiotherapist for further treatment.
The following general measures can be taken to ease the pain:
activity modification, unloaded exercise, cooling with ice, stretching
and wearing firm, well-cushioned, orthotically-designed shoes.
When there is pain and swelling, ice massage can be helpful. Use a
melting ice cube or a polystyrene cup filled with ice. Massage the
painful spot. Five to eight minutes of massage will generally be
sufficient. Repeat this several times a day.
Massaging the soles of the feet by rolling the feet over a can or bottle
will also help to relax the fascia and the muscles.
In feet with a collapsed arch (flat feet) or excessive pronation, the
plantar fascia may become overloaded during running and tennis.
When the plantar fascia is very tight, as in cavus feet, there may also
be considerable pressure at the attachment to the heel bone. Make sure
the feet receive adequate support by using an inlay, shoes with sturdy
soles or tape.
Temporary use of a shock absorbing heel lift can be useful. The
advantage of a heel lift is that there is less tension on the plantar fascia,
because the calf muscles are more relaxed.
How to Ensure the Best Recovery
When the initial pain and swelling have disappeared, the player can
start to build up the volume and/or intensity of training. However, the
onset of pain during this period is a signal to take some rest. If players
go beyond their pain threshold, this is likely to slow the healing
process.
Training load should be increased in three stages, as follows:
Description
Iliotibial band friction syndrome is an overuse injury of the
iliotibial band, the broad tough band of fibers that runs down the
outside of the thigh passing the knee. This injury is caused by
the fibres of the band rubbing on the femur bone, just above the
knee joint where there is a bony prominence (figure 1).
Strengthening the hip muscles (abductors, figure 4). Lie on your right
side with your legs straight. Contract the muscles in the thigh and pull
your toes up. Lift the left leg, keeping the knee straight, until the foot is
20 to 30cm off the ground. Hold the leg in this position for three
seconds and then lower it slowly. Perform this exercise slowly and
build up to three sets of fifteen repetitions. Perform this exercise for the
other leg too. To make it harder support yourself, using your elbows
and ankles, so that your body does not touch the ground (figure 5) or
use an ankle weight.
Diagnosis
Impingement syndrome causes pain in the shoulder, when lifting
the arm between 60 and 120 degrees sideways, or when
rotating the lifted arm inwards. The nagging pain occurs
because the supraspinatus tendon (the muscle under the roof of
the shoulder) and/or the bursa are pinched and aggravated
when lifting and rotating the arm.
The two most common areas where impingement occurs are:
a. Subacrominal or external impingement: between the roof of
the shoulder and the head of the upper arm.
The space between the roof of the shoulder and the head of the
upper arm is quite narrow, and becomes smaller when the arm
is lifted between 60 and 120 degrees sideways. If the
supraspinatus tendon and bursa become thicker than usual
(because they have been strained or aggravated), or the space
becomes more narrow than usual (due to bony structures or
projections) this may result in impingement (figures 1 and 2).
persist.
How to Ensure the Best Recovery
Stage 1. Improvement of Normal Function
Posterior shoulder stretch. Extend your injured arm in front of you to
shoulder level and take hold of your elbow with your other hand. Draw
your elbow in towards you until you feel a stretch at the back of your
shoulder (figure 3). Do this for 20 to 30 seconds, followed by a 10 to
20 second rest. Repeat three times.
Also do muscle strengthening exercises to strengthen the muscles
which stabilise the shoulder blade. Gradually build up the exercises. It
is alright to feel something in your shoulder whilst performing these
exercises, however the pain should have dissipated once you have
finished them. Start with a set of 10 to 15 repetitions per exercise, with
a 60 second rest between each set. An exercise band or small free
Description
Jumpers knee (patellar tendinopathy) is an overuse injury of the
patellar tendon. The patellar tendon is the tendon between the
underside of the patella (knee cap) and the tibia (shin). In the
area just underneath the patella there are microscopic tears and
In tennis, playing serve and volley, pushing off after having hit a
wide ball, and deep bending for low volleys are most painful.
The pain is caused by excessive or abnormal contact of the
under surface of the kneecap with the bone of the upper leg due
to sideward pulling of the kneecap (lateral tracking).
The lateral tracking results in pressure being concentrated on
the outer part of the kneecap (as opposed to being distributed
over the whole kneecap). It may also occur as a result of direct
injury to the kneecap, such as falling on the kneecap or
Stage 2. Build-up
As soon as you are able to perform the exercises described above
without discomfort, you can consider resuming your sport. Listed here
below are a few exercises to improve your sport condition.
Double leg squats (figure 5). Stand up straight with your feet at
shoulders width apart. Stretch your hand straight out in front of you.
Bend your knees slowly and keep your back straight. Bend the knees to
a maximum of 110 degrees. The knees must not protrude in front of the
feet.. Start with two to three series of ten repetitions.
Single leg step (figure 6). Stand on the involved leg facing sideways
on a step leaving the other leg hanging over the edge. Bend the
involved leg and point the toes of the other foot towards the ceiling.
Touch the step below you with the heel of the other leg and then
straighten the involved leg. Start with one to two series of ten to fifteen
repetitions.
Make small quick steps on the spot, shifting support between the left
and right leg.
If this goes well, you can start jogging. Start off jogging and progress
to short accelerations, followed by turning and pivoting exercises.
Eventually you can include sprints in the exercise.
Following this you can do jumping exercises, such as hopping,
lateral jumps (skating jumps) on alternating legs and skipping.
Stage 3. Return to Play
In the event of a mild injury, there is no need to stop playing tennis
altogether, as long as the player adapts his game to the restrictions
imposed by the injury. With more serious injuries, training can usually
be resumed after six weeks to three months.
Try to play on gravel courts as much as possible, and avoid hard
court. The peak strain on the knee is less on a surface that allows some
sliding than it is on surfaces where this is not possible.
Consult with your trainer and try to get him to adapt your training
program, allowing you to start off hitting the ball from an area
measuring two square meters( approx. two square yards). In this way
you can continue practicing your footwork (taking small steps,
positioning yourself correctly to hit the ball) without putting excess
strain on the knee.
Initially, you should limit activities that will put excess strain on the
knee, such as sprints, jumping exercises, low volleys, intensive left-
right exercises and serve and volley training.
If the adapted training goes well you can gradually start doing more
exercises, and increasing the distance you have to run to reach the ball
(tennis drills from corner to corner)
After this, low volleys and smash hits can be added to the training
program and the player can resume playing (practice) matches.
If practice matches can be played without problems, then the player
is ready to get back to playing competitions.
Preventing Re-injury
Be sure to do a thorough warming-up. Do, in any case, some
stretching exercises for the thigh muscles. In this way your muscles
and the rest of your body are prepared for the work to come.
Increase the intensity and the extent of the exercise gradually in
order to avoid straining. This is especially relevant in the change from
summer season to winter season when gravel courts are exchanged for
the harder indoor courts.
Do muscle strengthening exercises for the thighs to avoid (new) knee
injuries.
Wear properly fitting tennis shoes when playing tennis, and properly
fitting trainers when working out. It is essential for the shoes to be
adapted to the players weight and to the surface he will be playing on.
In the case of (moderate) foot deformities, such as bunion deformity
(hallux valgus) or hollow foot, it is advisable to buy special, individual
reinforcements for the shoe to help correct the form of the foot and to
give arches additional support.
Fatigue will cause your condition to deteriorate and lessen the
strength of the muscles. This increases the chances of stumbling and
straining a muscle. So, make sure to stay in shape!
Regular bicycling (low resistance and on flat surfaces) helps the knee
cap alignment which in turn helps the knee to work efficiently.
You can try taping or knee braces to see if they help.
Lower Back Pain
Description
Low back pain is very common among tennis players. Low back
pain may have various causes, such as postural abnormalities,
muscle dysfunction (imbalances, shortening or weakening of
muscle), overuse, instability, and articular dysfunction in the
lower back. In tennis, the combined rotation, flexion, and
extension of the back during the serve may cause problems
(Figure 1).
Diagnosis
Tennis elbow is the best-known and also the most painful elbow
injury in tennis players. An estimated 50% of all tennis players
will suffer from tennis elbow in the course of their career. Players
aged over 35 are particularly at risk.
Tennis elbow is an overuse injury of the extensor muscles of the
wrist, in which pain and tenderness are felt at the attachment of
these muscles at the outer side of the elbow (Figure 1 and 1a).
The pain may radiate into the arm, wrist and fingers.
Make sure you have the right tennis shoe and pay attention to shock
absorption, lateral stability, feeling for the surface (good traction) and
optimal comfort.
Wrist Tendinopathy
Diagnosis
double-handed backhand.
The flexor tendon is also located lower down on the ulnar side of
the wrist. This injury leads to complaints during serving and
when hitting forehands and forehand volleys. The cause of the
injury is the high loads that the tendons around the wrist have to
deal with when the ball impacts with the racket.
This results in overstretching and micro-tearing of these
tendons. Women are more commonly affected than men,
because they have looser and weaker wrists. The injury is
characterised by pain, swelling, heat and redness at the
insertion point of the tendon in the wrist. Usually, extension and
flexion of the wrist against resistance is painful.
Tendon injuries are slow to heal and may take six weeks or
more.
First Aid
Activity modification (if you do not stop playing completely while
the injury heals, hit mainly shots that do not hurt, such as double-
handed backhands or only forehands and serves depending on the
location of the injury).
Cool the wrist with ice.
Stabilise the wrist with a wristband or tape, so the ligaments and
tendons can heal.
Fast and adequate first aid is very important to ensure good recovery.
In severe cases, or when in doubt, the player should have the injury
evaluated by a physician, who may make a referral for more detailed
diagnosis and prescribe physiotherapy.
How to Ensure the Best Recovery
The recovery process takes place in three stages, using exercises to
enhance strength. These are described below, with several tips.
Stage 1. Improvement of Normal Function
At this stage, special attention is paid to enhancing the strength of the
Make sure to use the correct grip. If the grip is either too thick or too
thin, you have to squeeze the racket to prevent it from twisting in the
hand. The correct grip can be determined as follows: grip the racket
lightly, as if you were shaking hands. The little finger should fit
between the base of the thumb and the fingertips. Consult your coach
for further details regarding the correct grip size.
Continue to work on wrist strength to stabilise the wrist using the
exercises and a low-resistance, high-repetition format.
References
http://www.itftennis.com/scienceandmedicine/injury-
clinic/tennis-injuries/overview.aspx