🎾 Tennis Injuries Occurrence Aetiology And¶
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Tóm tắt nội dung (trích từ tài liệu gốc): Downloaded from http://bjsm.bmj.com/ on July 30, 2015 - Published by group.bmj.com 415 REVIEW Tennis injuries: occurrence, aetiology, and prevention B M Pluim, J B Staal, G E Windler, N Jayanthi ............................................................................................................................... Br J Sports Med 2006;40:415�423. doi: 10.1136/bjsm.2005.023184 A systematic search of published reports was carried out in the duration and nature of treatment, time lost three electronic databases from 1966 on to identify from sports participation or work, permanent relevant
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415
REVIEW
Tennis injuries: occurrence, aetiology, and prevention
B M Pluim, J B Staal, G E Windler, N Jayanthi
...............................................................................................................................
Br J Sports Med 2006;40:415�423. doi: 10.1136/bjsm.2005.023184
A systematic search of published reports was carried out in the duration and nature of treatment, time lost
three electronic databases from 1966 on to identify from sports participation or work, permanent
relevant articles relating to tennis injuries. There were 39 disability, and cost.9 Another important step is to
case reports, 49 laboratory studies, 28 descriptive determine risk factors and other mechanisms
epidemiological studies, and three analytical that are associated with these injuries.9 10 This
epidemiological studies. The principal findings of the aetiological research entails understanding the
review were: first, there is a great variation in the reported causes of injury, with the goal that modification
incidence of tennis injuries; second, most injuries occur in or removal of these causes can prevent the
the lower extremities, followed by the upper extremities occurrence of the injuries.10 The next step
and then the trunk; third, there have been very few consists of the formulation of preventive mea-
longitudinal cohort studies that investigated the association sures.10 These measures must be evaluated with
between risk factors and the occurrence of tennis injuries regard to their effectiveness before implementa-
(odds ratios, risk ratios, hazard ratios); and fourth, there tion. Ideally, evaluation should include rando-
were no randomised controlled trials investigating injury mised controlled trials.10�12
prevention measures in tennis. More methodologically
sound studies are needed for a better understanding of risk Our aim in this review of published reports
factors, in order to design useful strategies to prevent tennis was to provide an overview of the available
injuries. scientific knowledge on the occurrence, aetiol-
ogy, and possibilities for prevention of tennis
........................................................................... injuries. We asked the following three questions.
First, what are the most common tennis injuries,
See end of article for T ennis is a global sport, with participation in based upon the reported prevalence and inci-
authors' affiliations more than 200 countries affiliated with the dence figures? Second, what associated risk
....................... International Tennis Federation.1 It is also a factors and mechanisms are described with
professional sport in which millions of dollars in regard to the aetiology of tennis injuries? And
Correspondence to: prize money are at stake for both men and third, what is known about the efficacy of
Dr Babette M Pluim, Royal women players. In the Netherlands, it is the prevention efforts designed to reduce the occur-
Netherlands Lawn Tennis second most popular sport, with more than one rence of tennis injuries?
Association, PO Box 1617, million participants from a population of 16
3800 BP Amersfoort, million.2 Among Dutch women it is actually the Another purpose of this review was to identify
Netherlands; bpluim@ most popular sport.3 In other European countries gaps in knowledge with respect to the occur-
euronet.nl tennis also ranks high on the list of popular rence, aetiology, and prevention of tennis inju-
sports.3 ries and to encourage further methodologically
Accepted 22 January 2006 sound epidemiological research in this field.
....................... Like many other sports, playing tennis--at
either a recreational, collegiate, or professional METHODS
level--places participants at risk of injury. We undertook a literature search to retrieve
Though many injuries that occur in tennis are potentially relevant articles published since 1966.
common to other sports, tennis does have a The following electronic databases were
unique profile of injuries.4 Differences in equip- explored: Pubmed (from 1966 to October 2005),
ment, biomechanics, and physical demands Embase (from 1989 to October 2005), and
result in an injury profile that differs from other Cumulative Index to Nursing and Allied Health
racquets and throwing sports.4 Sports injuries, Literature (CINAHL) (from 1982 to October
including tennis injuries, are a common cause of 2005). A priori defined search terms (Medical
disability and, in some cases, absence from subject heading (Mesh) and text words) that
work.5�7 This can have substantial socioeconomic were used in this search were: ``injury'', ``inju-
consequences, both on a personal and a societal ries'', ``prevalence'', ``incidence'', ``incidence
level.8 For these reasons it is important to density'', ``proportion'', ``distribution'', ``popula-
develop effective measures for the prevention of tion'', ``aetiology'', ``etiology'', ``mechanism'',
tennis injuries. ``risk factor'', ``risk factors'', ``prevention'' and
``intervention''. These terms were combined with
To develop prevention strategies, both the ``tennis''. Reading titles and abstracts identified
incidence and severity of tennis injuries must potentially relevant articles. Citation tracking of
be determined. The severity of an injury can be the articles retrieved was also performed to
described on the basis of the nature of the injury, identify additional relevant articles.
To be included in this review studies had to
meet the following inclusion criteria: they must
contain data on tennis injuries; they must
investigate the frequency of tennis injuries, the
aetiology (for example, risk factors) of tennis
injuries, the efficacy of prevention strategies, or a
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416 Pluim, Staal, Windler, et al
combination of these purposes; and they must have been Vascular injury in the upper extremity was mentioned four
published in English, German, or Dutch. Studies focusing on times.32�35 Though an uncommon injury, it has also been
treatment for tennis injuries and literature reviews were reported in overhead batting and racquet sports. Vascular
excluded. For the purpose of this review we defined a tennis injury may result from compression of the large vessels in the
injury as a musculoskeletal problem requiring reduction or axilla during the service motion, resulting in aneurysm
interruption of tennis activity for any length of time, with or formation.35 Distal embolisation may occur.34 Endothelial
without evaluation or treatment by a health care provider.13 injury caused by repeated microtrauma to the hand by the
racket was also reported.32 33
We did not expect to find many cohort or randomised
controlled studies in this field. Furthermore, with the Regarding the lower extremity, injuries were more equally
expected heterogeneity in study designs and methods, we distributed and included case reports on tendon injuries,46 48
elected not to follow a formal meta-analytic approach. The plantar fascia tears,49 52 muscles tears,45 stress fractures,47 50
studies retrieved were classified as case reports, laboratory and intra-articular knee injury.51
studies, descriptive epidemiological studies, analytic epide-
miological studies, or intervention/prevention trials. A similar Laboratory studies
approach was conducted earlier by Pollack et al14 15 with Forty nine laboratory studies were identified: 36 involved the
regard to the available evidence for the prevention of softball upper extremity,55�90 six the lower extremity,91�96 three the
injuries. For reasons of clarity we defined descriptive trunk,97�99 and four the whole body.100�103 In the upper
epidemiological studies a priori as cohort studies (either extremity articles, the following topics were discussed most
cross sectional or longitudinal), describing the frequency often: range of motion (seven studies)55 58 61�65 and strength
(that is, prevalence or incidence or both) of tennis injuries in (nine studies)55�60 62 65 66 of the shoulder, and biomechanical
a cohort or subcohort. Analytic epidemiological studies were analysis of the stroke (six studies).69�71 74 75 77
defined as cohort studies (either cross sectional or long-
itudinal) which aimed to estimate a measure of association In the studies examining range of motion of the shoulder,
(that is, odds ratio, risk ratio, hazard ratio) between risk internal and external rotation was measured using a
factors and the occurrence of tennis injuries. The results of goniometer. In six58 61�65 of seven studies55 58 , 61�65 a significant
the selected studies will be described and summarised to decrease of internal rotation and total range of motion was
formulate answers to the research questions posed above. The demonstrated in the dominant arm. Kibler et al64 showed that
emphasis lies on the results of descriptive and analytic the loss of total range of motion was progressive with age and
epidemiological studies, and intervention/prevention studies years of tournament play.
rather than laboratory studies or case series and reports.
Muscular strength of the shoulder was determined by
RESULTS isokinetic testing. Five58�60 62 65 of seven studies55 56 58�60 62 65
Our search in the Pubmed, Embase, and Cinahl databases showed an imbalance of muscle strength, with significantly
resulted in, respectively, 1368, 1617, and 2460 potentially greater isokinetic strength in the dominant arm than in the
relevant hits. To identify appropriate papers for the present non-dominant arm for internal rotation, leading to a reduced
review, the titles and abstracts were read and, if considered external/internal rotation ratio. Both the loss of internal
relevant, selected by two persons (BMP and JBS). In cases of rotation motion and the muscle strength imbalance were
disagreement further discussion was undertaken to achieve hypothesised to increase the risk of shoulder injuries.
consensus. We found 39 case reports, 49 laboratory studies,
28 descriptive epidemiological studies, three analytic epide- In three91 95 96 of the six articles91�96 focusing on the lower
miological studies, and no intervention study which met the extremity, the interaction between shoe and court surface
inclusion criteria of the present review. Table 1 provides an was examined. The main conclusion of these studies was that
overview of the distribution of study type and body region lateral stability of the shoe is important in the prevention of
within the relevant articles. injuries.
Case reports Descriptive epidemiological studies
Of the 39 case reports, 29 dealt with injuries of the upper Twenty eight descriptive epidemiological studies were identi-
extremity,16�44 eight with injuries of the lower extremity,45�52 fied, including 19 on tennis injuries in general,104�124 seven on
and two with the trunk.53 54 Of the case reports, the most injuries of the upper extremity,125�132 one on the lower
common condition in the upper extremity injury section was extremity,133 and one on the trunk.134
stress fractures (14 case reports).16�29 Stress fractures in the
upper extremity included the metacarpals, hamate bone, Injury incidence
radius, ulna, and humerus. The suggested causal mechanism Injury incidence varied from 0.05122�124 to 2.9119 injuries per
involved repeated loading on the upper extremity during the player per year (table 2). Per hour of play, the reported
tennis stroke,27 28 and included the impact of the racket butt incidence varied from 0.04 injuries/1000 hours108 to 3.0
against the palm of the hand,16�18 and high torsional injuries/1000 hours.105 Incidence and prevalence rates for
stresses.25 27 28 tennis elbow were quite high, with reported incidence
varying from 9%128 to 35%130 and prevalence varying from
14%128 to 41%.131 132
Table 1 Distribution of identified studies by type of study and body region
Descriptive Analytical Intervention and
prevention
Case studies Laboratory epidemiological epidemiological
0
General 0 4 19 1 0
Upper extremity 29 36 0
Lower extremity 7 0 0
Trunk 8 6 0
Total 2 3 1 1
39 49
1 1
28 3
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Table 2 Characteristics and results of included descriptive epidemiological studies Tennis injuries
Study* Study design Study population Injury definition General incidence Upper Lower Trunk/ Type of injury Severity
Vriend104 ext (%) ext (%) head (%) reported
Jayanthi105 Cross sectional study: General population: in All acute and chronic injuries 1.1/1000 h: O/D 52% required medical
Ku�hne106 telephone interviews, with each of the 5 y, 10 000 people or ailments that developed as a 0.9/1000 h; I/D 29.1 53.6 10.2 (not NR treatment (O/D 49%, I/
Da Silva107 recall period of 3 m were interviewed, of whom result of or during sports 1.6/1000 h defined D 59%, NS)
LIS 1999�2003108 (2000�2004) ,50% were sports participants participation in the past 3 m 3.7)
Schmikli109
Cross sectional, questionnaire; 140 M, 388 F recreational Any injury or pain the player 3.0 inj/1000 h; 41 49 3 Overuse injuries NR Downloaded from http://bjsm.bmj.com/ on July 30, 2015 - Published by group.bmj.com
Sallis110 recall period 1 y league players (International had experienced in the past prevalence 52.9
Steinbru�ck111 Tennis Number 3 to 8); mean 12 m preventing play for >7 d inj/100 players predominated, most
Weijermans112 age 46.9 y
in upper extremity
Prospective study, follow up 60 competitive, 50 recreational The injuries and problems that 1.5 inj/player/y 25 64 11 Cramps, strains, 3.3% of acute and 2.2%
6 months players; C range 16�35 y, the player experienced during
mean 25; R range 40�68 y, the tennis season and sprains were of chronic injuries were
mean 53
most common eventually operated
Prospective study with 1 y Elite junior players, participating Any consultation and/or 6.9 medical treatment/ NR NR NR Cramps (muscle NR
follow up; all medical in the national circuit in Brazil treatment given to a player 1000 games played
treatments required during in the ,12, ,14, ,16, during a tournament on site contracture) were
tournament and ,18 age categories 0.04 inj/1000 h
Prospective study of injuries General population; 7700 Injuries requiring treatment at most common
treated at the first aid tennis players the first aid department of the
department of 15 selected hospital 28 59 13 Acute, more severe Costs per injury J830;
hospitals in Netherlands
type of injuries; 5% hospitalised for an
sprains most average of 5 d
common (59%)
Cross sectional study: General population, 1982�83; Injuries or ailments newly 1986�87: I/D 1.8/ NR NR NR NR Medical treatment
telephone interviews; recall 67 139 persons, of whom developed as a result of or 1000 h; O/D 1.2/ required: O/D, 27%,
periods 1 month (1986�87), 31 688 played sports during sports participation in 1000 h; 1992�93: 34%, and 39% of
1 month (1992�93), and the past 4 wk (3 m); chronic I/D 2.9/1000 h; injuries; I/D, 57%, 60%,
3 months (1997�98) injuries not recorded O/D 1.2/1000 h; and 66%
1997�98: I/D 1.0/
1000 h; O/D 0.5/
1000 h
Retrospective cohort study of College players; range 18�22 y; Medical problem as a result 0.456 M; 0.425 F 23.1 M; 62.2 M; 14.6 M; NR No ACL injuries,
injury reports compiled by per player/y 21.9 F 70.7 F 7.2 F otherwise NR
athletic trainers with a 15 y 3767 participants, divided over of sport participation requiring
follow up period
sports, including tennis visit to training room
Prospective longitudinal study General population; 1257 M Not defined: any medical NR 21 60 19 Knee 25%; NR
with 25 y follow up; visits to and 858 F tennis players problem that required a visit ankle 23%
sports orthopaedic and to the sports medicine clinic
trauma OPD was registered as an injury
www.bjsportmed.com Prospective cohort study of 179 club players Tennis related problem resulting 0.11/1000 h NR 67 NR Mostly acute For the 5 most common
46 tennis clubs; follow up in loss of practice or match
6 months (O/D tennis time, need for medical injuries; tennis leg injuries, 60% needed
season); injuries reported consultation, or negative social/
to contact person economic consequences and sprained ankle medical consultation,
(absence from school/work)
most common and 20% absence from
school/work
417
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Table 2 (Continued)
Study* Study design Study population Injury definition General incidence Upper Lower Trunk/ Type of injury Severity
Hutchinson113 Prospective cohort 1440 male participants ext (%) ext (%) head (%) reported
study, with follow at the USTA National Any medical problem requiring 21.5/1000 athletic One athlete transported
Baxter-Jones114 up of 6 y Boys Championships physical or medical assistance exposures; 9.9/100 26 51 22 Sprains 58% to hospital for heat
Lanese115 1986�1988; 1990�1992 players exhaustion
Prospective 156 elite players in five 2-y
cohort study age groups from 8�16 y Any injury resulting in 0.52 inj/player/y NR NR NR Osteochondrosis Acute injuries 13 d lay- Downloaded from http://bjsm.bmj.com/ on July 30, 2015 - Published by group.bmj.com
discontinuation of training NR 26% off time; chronic injuries
Prospective cohort 12 M, 11 F college players, and/or medical treatment 1.6 inj/1000 h (M); NR NR 11 20 d
study 18�22 y 1.0 inj/1000 h (F), 19.3 NR
Traumatic medical problem p = 0.37 2.42 (0.57) disability d
Elite players: 61 M, mean due to sports participation per 100 person h
age 28 y; 28 F, mean resulting in time loss from
Winge116 Prospective study, age 22 y practice or competition 0.52 inj/player/season; 45.7 39 Shoulder injuries Mean injury period
follow up 6 months 2.3 inj/1000 h (M 2.7, 17% 44.5 d; absence from
(O/D tennis season) 78 M + 49 elite players, Every problem that appeared F 1.1) work practically 0
age range 15�46 y in connection with tennis,
Krause117 Cross sectional 78 M + 53 recreational handicapped the player 0.7 inj/player/y 36.4 44.3 Shoulder, back, NR
Chard118 players, age range 8�66 y during play, and/or required
Longitudinal study, special treatment
8 y follow up; visits to 24 M + 21 F elite players at
sports medicine clinic Australian Institute of Sport, NR
aged 16�20 y, mean 17.6
and ankle 85%
15 elite M players, 1�15 in
German National ranking; Medical problem related to NR 35 45 20 PF problems 44%; NR
mean age 28 y; range 15�43 acute injuries 70%,
tennis that required a visit to chronic injuries 30%
100 M and 26 F recreational
players, mean age 43 y the sports injury clinic (self
203 M, 72 F high level referral for acute injuries;
competitive players; mean
age 28 y referral by GP for chronic
injuries)
Reece119 Retrospective cohort Any injury that required 2.5 inj player/y (M); 20 59 21 Ankle sprain most 2 conditions required
study: injuries requiring common, followed by surgical intervention
attention of medical attention from the medical 2.9 inj/player/y (F) calf and quadriceps
officer or physiotherapist strain
officer or physiotherapist
Von Salis-Soglio120 Cross sectional study: NR NR NR NR NR Shoulder and elbow Small risk for long term
interview and medical problems (tennis problems
examination elbow) most
common
Von Kra�mer121 Retrospective study, Complaints and diseases NR 47.5 31.1 16.6 Tennis elbow 39%; NR Pluim, Staal, Windler, et al
follow up 17.5 y which resulted from 0.05 inj/player/y Achilles tendon
playing tennis 15%)
Biener122�124 Cross sectional NR 48.6 43.4% 2/6 Tennis elbow 36%; NR
sprains 21%; strains
14%
*First author and reference number.
ACL, anterior cruciate ligament; ; d, days; ext, extremity; F, female; I/D, indoor; inj, injury; h, hours; m, months; M, male; NR, not reported; O/D, outdoor; OPD, outpatient department; PF, patellofemoral joint; wk, weeks; y, years.
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Tennis injuries 419
Table 3 Characteristics and results of included analytic epidemiological studies
Study* Study design Study population Risk factors Outcomes Adjustment for
Llana137 Discomfort confounders Results
Cross A sample of 146 tennis Perceived design
sectional players in Spain selected errors No Significant correlation (p = 0.02)
study from a sample of 4000
who had completed a between incorrect arch support
questionnaire on
``discomfort'' associated and plantar discomfort
with tennis shoes
Spector135 Retrospective Long term weight Pain Yes The ex-athletes had greater rates
cohort study 81 female ex-elite athletes bearing sports OA as defined
(67 middle and long activity by radiological of radiological OA at all sites. This
distance runners, and 14 changes (joint
tennis players), aged space narrowing association was strongest for the
40�65, recruited from and osteophytes)
original playing records, in hip joints, PF presence of osteophytes at the TF
and 977 age matched joints, and TF
female controls from joints joints (OR = 3.57 (95% CI, 1.89
London UK
to 6.71)), at the PF joints
(OR = 3.50 (1.80 to 6.81)),
narrowing at the PF joints
(OR = 2.97 (1.15 to 7.67)), femoral
osteophytes (OR = 2.52
(1.01 to 6.26)), and hip joint
narrowing (OR = 1.60 (0.73 to
3.48)), and was weakest for
narrowing at
the TF joints (OR = 1.17 (0.71
to 1.94)). The tennis players
tended to have more osteophytes
at the TF joints and hip
Nigg136 Prospective 171 members of Shoe, temperature, Pain No Stiffness of shoe and subjective
cohort study tennis clubs type and duration
(2 m follow of match play, evaluation of frictional properties
up) subjective
assessment of shoe of the shoe were significantly
comfort, sole grip
and lateral stability associated with pain
Only statistically significant results are reported.
*First author and reference number.
CI, confidence interval; m, months; OA, osteoarthritis; OR, odds ratio; PF, patellofemoral; TF, tibiofemoral.
Injury localisation players. This was not a statistically significant difference
(p = 0.37).
Ten of 13 studies 104�106 108 110�113 117 119 104�106 108 110�113 116 117 119 121�124
Sallis et al110 studied injury patterns in 18�22 year old
showed a preponderance of injuries of the lower extremity tennis players. This was a retrospective cohort study of injury
reports compiled by certified athletic trainers. The incidence
compared with the upper extremity. was 0.46 injuries per male player per year and 0.42 injuries
per female player per year. The differences was not
Injury type statistically significant.
Four108 112 113 118 of six studies105 108 112 113 116 118 reported more
acute than chronic injuries. Most acute injuries occurred in Hutchinson et al113 compared injury patterns in elite junior
the lower extremities, whereas most chronic injuries were players (male and female) during a three year period (1996�
located in the upper extremities. Injuries to the trunk 1998) at the United States Tennis Association (USTA) tennis
comprised 5% to 25% of all injuries.104�106 108 110 111 113 116�119 121�124 championships. There was no significant difference in the
overall rate of injury (new and recurrent) between male and
Injury severity female players.
Injury severity was expressed in various ways in the different
studies, including number of injuries requiring hospital Winge et al116 found a higher injury rate in men (2.7 injuries
admission108 113 or operative treatment,106 average medical per 1000 hours) than in women (1.1 injuries per
costs per injury,108 time loss,114 115 or the percentage requiring 1000 hours). This was a statistically significant difference
medical treatment.104 109 112 Injuries sustained while playing (p,0.05).
indoors tended to be more severe than outdoor injuries, with
a higher percentage requiring medical treatment.104 109 In the Age
study by Kuhne et al, 3.3% of acute and 2.2% of chronic The Letsel Informatie Systeem108 is a continuous registration
injuries required surgery.106 Five per cent of the injuries in the of injuries treated in the emergency departments of a
Letsel Informatie Systeem (LIS) study required an average of selection of 15 hospitals and medical centres in the
five days of hospital admission.108 In the studies on juniors, Netherlands. These injuries are generally acute and more
injury severity was significantly less, with only one player of serious. In this study, injury risk in tennis has been shown to
1440 being taken to hospital and two injuries of 176 requiring gradually increase with age, from 0.01 injuries per player per
surgery.113 year in the 6�12 year age group to 0.5 injuries per player per
year in those over 75 years of age. An increased incidence
Sex with age was consistently shown for tennis elbow.127�132
Injury rates between men and women were compared in a
prospective cohort study of intercollegiate tennis.115 In this Level of play
study, 1.6 injuries per 1000 hours were recorded for male In these general descriptive epidemiological studies, the
tennis players versus 1.0 injury per 1000 hours in female study populations can be characterised as recreational/
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420 Pluim, Staal, Windler, et al
general, elite, or junior competitive. The studies include a more acute and serious injuries will be reported, as players with
wide distribution of retrospective, cross sectional, pro- less serious and chronic injuries are more likely to visit their
spective cohort, and prospective longitudinal study designs. general practitioner, physiotherapist, or sports physician. The
There were nine studies104�106 108 109 111 112 118 121 involving other study with a relatively low injury rate (0.11/1000 hours of
recreational players or the general population, seven play) was by Weijermans et al.112 In that study, injuries sustained
studies110 115�117 119 120 122�124 involving elite players, and three by tennis players at a club had to be reported to a contact person
studies107 113 114 relating to junior tournament players. Study in order to be recorded. This may have resulted in under-
designs of junior and elite players often involved recording of reporting of injuries. Biener et al122�124 also reported a very low
injuries as medical consultations at tournaments or training injury rate, which can be explained by their long recall period of
centres. This method of injury reporting may inflate injury 17.5 years.
rates, therefore making it difficult to make direct compar-
isons with studies involving recreational players that often The highest injury rates were found by Hutchinson et al113
involve self reporting of their injuries. and Silva et al.107 This is undoubtedly related to their rather
inclusive injury definitions: ``any medical problem that
We were able to identify only two studies that compared required physical or medical assistance''113 and ``any con-
injury rates between players of different ability. Baxter-Jones sultation and/or treatment given to a player during a
et al114 studied elite young athletes. They found that tournament on site'',107 respectively. Using these definitions,
performance success was significantly related to injury rate. injuries which may not have had any effect on tennis play,
Jayanthi et al105 described the incidence and prevalence of time loss, or work were also included. Kuhne et al addressed
injuries in recreational players of different skill levels, this problem by making a separate category for
ranging from International Tennis Number 3 to 8. Despite ``Bagatellverletzungen'' (minor injuries), which included
trends, there were no statistical differences in overall injury sunburns, abrasions, and blisters. We were not able to find
incidence and prevalence rates across all skill levels. any study that identified the relation of match volume within
a tournament or through a season and the risk of injury.
Volume of play Prospective studies of independent risks associated with
Studies describing the risks associated with volume of play increased playing time in junior tournament players are
are scarce. Increased playing time was associated with lacking and necessary in order to counsel parents, coaches,
increased incidence of new cases of tennis elbow in and tournament directors with appropriate evidence based
recreational players playing more than two hours a day recommendations.
versus those playing less than two hours a day.128 However,
total incidence and prevalence of all tennis related injuries Despite the wide variation of reported injury rates and
was not different among recreational players who played less study designs, comparisons of injury rates in tennis can be
than four hours a week, four to six hours a week, or more made with the rates in other sports. In order to make optimal
than six hours a week.105 comparisons, similar study designs and injury definitions
should be used. There were 377 injuries in 456 matches
Analytic epidemiological, and intervention studies involving all team sports studied during the 2004 summer
Three studies were found that investigated risk factors for Olympic Games.138 There was a total injury incidence of 0.8
tennis injuries (table 3). Two of these135 136 had a longitudinal injuries per match and 54 injuries per 1000 player matches,
study design and one137 was cross sectional. Adjustments for where injury was defined as any physical complaint incurred
confounding variables was made in one longitudinal cohort during the match that received medical attention regardless
study.135 The type of sports injury described in the investi- of consequence. Handball players (114/1000 player matches)
gated studies was variable and consisted of discomfort or and soccer players (108/1000 player matches) had the highest
pain from wearing tennis shoes, sport related injuries in injury rates, while volleyball players (7.7/1000 player
general, low back pain, and osteoarthritis. matches) had the lowest. With a similar definition of injury
and comparable study design, Hutchinson et al113 reported
Llana et al137 described in a cross sectional study a 21.5 injuries/1000 athletic exposures and Silva et al107 reported
significant correlation (p = 0.02) between perceived incorrect 6.9 medical appointments/1000 games in prospective studies
arch support and plantar discomfort. Spector et al135 found of junior national tournament tennis players.
that long term weight bearing sports activity was associated
with the development of osteoarthritis. It may be more appropriate to compare tennis with other
individual non-contact sports rather than contact team
No intervention study was retrieved investigating the sports. A retrospective cohort survey study in golfers reported
effects of prevention measures on tennis injuries. 3.06 injuries/player injured in professional players of average
age 36.5 years, and 2.07 injuries/player injured in amateur
DISCUSSION players of average age 47.2 years.139 This study did not report
The principal findings of our study are first, that there is a the total prevalence of injuries/100 players but had a total of
great variation in the reported incidence rate of tennis 637 injuries in 703 golfers surveyed. In a cross sectional
injuries; second, that most injuries occur in the lower survey of recreational tennis players with an average age of
extremities, followed by the upper extremities and then the 46.9 years, there were 299 injuries in 528 players giving a
trunk; third, that there are very few cohort studies available prevalence of 52.9 injuries/100 players.105 In a cross sectional
that estimate a measure of association between risk factors survey study of recreational runners, 45.8% of 4358 male
and occurrence of tennis injuries; and fourth, that there are joggers sustained jogging injuries in the previous one year
no randomised controlled trials on preventative measures in period.140 A prospective study of recreational runners training
tennis. for a 10 km race reported that 29.5% of runners experienced
an injury that caused at least some pain after exercise.141
The variation in the reported incidence rates of tennis Comparable prospective studies of recreational tennis players
injuries most probably reflects variation in injury definition, over a six month period reported injury rates of 0.11/
study design, populations under study, methods of data 1000 hours played112 and 1.5 injuries/player/year.106
collection, and the duration of follow up or recall period. The
lowest incidence rate (0.04 injuries per 1000 players per year) Despite some variation in study design and definition of
was reported in the LIS study.108 Injuries in this study injury, tennis appears to have lower injury rates than contact
included only those for which the player was treated at a team sports and also in some comparisons with non-contact
hospital casualty department. This implies that predominantly individual sports such as golf and running. However, no
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Tennis injuries 421
known study has made direct comparisons between risks of What is already known on this topic
injury or lifetime prevalence of injury between tennis and
other sports. There is a great variation in the reported incidence rate of
tennis injuries. Most injuries occur in the lower extremities,
Unfortunately, we were not able to identify any interven- followed by the upper extremities and the trunk. Most acute
tion studies on tennis injuries. An intervention study by injuries occur in the lower extremities, whereas most chronic
Kibler et al,142 in which 51 tennis players undertook a specific injuries are located in the upper extremities.
programme of stretching exercises showed that the exercises
improved the range of motion. Although they did not record What this study adds
the rate of injury, the authors hypothesised that this
stretching programme would reduce injury risk. There is By presenting studies with different study designs, a picture
currently no evidence that limited flexibility is associated emerges that represents the current base of knowledge in this
with an increased risk for tennis injuries. In a systematic field. It is clear from the results that further studies on injury
review of intervention studies on the effect of stretching, rates, risk factors, and prevention of tennis injuries are
Herbert and Gabriel143 showed that stretching before exercise needed. A possible standard protocol for future studies is
did not result in a reduction of injury risk. However, they presented.
noted that generalisation of this conclusion required further
testing. It therefore may be worthwhile to investigate the musculoskeletal screening of players to identify problem
effects of the type of programme designed by Kibler et al142 on areas before injuries occur, and adjustment of equipment
the occurrence of tennis injuries. including shoes, racquets, strings, and balls as well as court
surfaces. However, further research is needed to move from a
The aim of the present literature review was to provide an stage of clinical expertise and speculation to real evidence
overview of available knowledge on the occurrence, aetiology, based prevention of tennis injuries.
and prevention of tennis injuries. For practical reasons we
refrained from doing a formal methodological quality .....................
assessment of individual studies or a quantitative data
synthesis. However, by presenting studies with different Authors' affiliations
study designs, a picture emerges that represents the current
base of knowledge in this field. It is clear from the results B M Pluim, KNLTB, Amersfoort, Netherlands
that further studies on injury rates, risk factors, and J B Staal, Department of Epidemiology, Maastricht University,
prevention of tennis injuries are needed. Researchers should, Maastricht, Netherlands
if possible, choose a prospective study design in order to G E Windler, ATP, Ponte Vedra Beach, Florida, USA
decrease the risk of recall bias. N Jayanthi, Loyola University Medical Center, Chicago, Illinois, USA
A comparison of injury rates across studies will be Competing interests: none declared
facilitated when similar definitions of injuries are used and
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Tennis injuries: occurrence, aetiology, and
prevention
B M Pluim, J B Staal, G E Windler and N Jayanthi
Br J Sports Med 2006 40: 415-423
doi: 10.1136/bjsm.2005.023184
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