Tennis Injuries
Are You an Ace on the Court?

Tennis is a complex physical sport requiring hand-eye coordination and full body participation to run, position, swing, and hit. Because of these demands, endurance, flexibility, and muscle-conditioning exercises are important to prevent injuries. Some tennis injuries may be random occurrences (such as those that are the result of a fall). However, most can be minimized or prevented entirely by proper conditioning, proper technique, appropriate equipment, and seeking medical attention for persistent, painful conditions in a timely fashion.

Types of injuries
The most common injuries associated with tennis are rotator cuff tendinitis, tennis elbow, wrist strains, back pain, anterior (front) knee pain involving the knee cap, calf and Achilles tendon injuries, ankle sprains, and tennis toe.

Rotator cuff tendinitis
The rotator cuff consists of muscles and tendons that originate from the scapula (shoulder blade) and attach to the humerus (upper arm bone). These muscles and tendons allow the shoulder to move in many directions. As a result of overuse, you can develop tendinitis, or inflammation of the tendons. Rotator cuff tendinitis in recreational tennis players usually results from excessive overhead serving. This is more likely to occur if you hold your arm at a 90-degree angle from your side while you are serving (Fig. 1). Changing your technique to increase the angle between your arm and side to more than 90° (ideally 135°) will lessen the chance of injury to your rotator cuff.

Treatment for this condition is rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. If symptoms persist after 7 to 10 days of this treatment, see your physician. If symptoms resolve only to recur when you return to play, lessons from a tennis professional to modify your technique may help to prevent recurrence.

Tennis elbow
Tennis elbow, or lateral humeral epicondylitis, is a painful condition caused by inflammation or small tears of the forearm muscles and tendons on the lateral side (outside) of the elbow. Most experts believe that tennis elbow is caused by overloading of the forearm muscles due to faulty backhand technique. Improper body positioning with the elbow leading the racquet, combined with late strokes and "wristy" impacts seem to cause this overloading. The two-handed backhand relieves stress on the muscles that attach to the lateral epicondyle of the humerus at the elbow (Click to enlarge Fig. 2).

Proper racquet selection and grip size play a significant role in preventing tennis elbow. Smaller heads and excessive string tightness require the forearm muscles to exert more force, which can lead to tennis elbow. Stiffer graphite-type racquets with large heads that expand the impact area, or "sweet spot," are preferred. String tension should be at the manufacturer's lowest recommendation. The grip should be comfortable and not too small. The best way to choose grip size is to measure the distance from the crease of your palm to the tip of the ring finger.

The treatment of tennis elbow involves rest, ice, compression, and elevation (RICE) and perhaps NSAIDs. Often, the condition becomes chronic (long lasting) and is difficult to resolve. Other available treatments include decreasing playing time, counterforce braces (tennis elbow supports), and rehabilitation programs. If all types of treatment fail, surgery may be considered.

Wrist strain
Wrist strains seem to be related to the "laid-back" grip position: rotating the palm upward and quickly turning your wrist over as you hit the ball in order to achieve topspin. The best grip position for preventing wrist and elbow injuries is the "hand-shake" grip, with the racquet making an "L" position with the forearm (Fig. 3).

Back pain
Back pain seems to be related to an exaggerated arched, or swaybacked, posture used for power production during service strokes (Fig. 4). This exaggerated position stresses the small joints and soft tissues of the spine. Older tennis players seem to have the most back pain due to progressive stiffness and degenerative disease, such as arthritis. A conditioning program designed to strengthen abdominal and back muscles and to increase flexibility can minimize back pain associated with tennis.

Knee pain
The most common knee problem in tennis players is anterior (front) knee pain. This is due to either chondromalacia (softening of the cartilage) of the patella (knee cap) or tendinitis, especially at the patellar tendon. Elite and highly ranked recreational tennis players seem to encounter these injuries more frequently than others. This is thought to be related to the "spring-up" action of the knees on the serve (Fig. 5). Treatment of acute anterior knee pain involves the usual RICE, but frequently needs to be complemented with NSAIDs and a short-arc knee strengthening program to build up the innermost quadriceps muscle in the thigh.

Calf and Achilles tendon injuries
The common underlying cause in both calf muscle and Achilles tendon injuries is a tight calf muscle-Achilles tendon unit. This muscle-tendon unit crosses both the knee and the ankle. You can tell your calf muscle-tendon complex is tight if you cannot raise the ball of your foot higher than the heel of that foot with the leg extended (straight). A sudden overload from pushing off your foot while your leg is fully extended is the usual cause of injury.

Achilles tendinitis involves inflammation of the Achilles tendon as a result of overuse (Click here for details - Fig. 6). To treat Achilles tendinitis, decrease playing time, take NSAIDs, use heel lifts in your regular shoes, and diligently stretch the calf muscles with your leg straight.

A ruptured Achilles tendon is more severe than tendinitis. You may feel a sudden snap in the lower leg, as if someone has kicked you in the back of the foot. This is not a particularly painful injury, and a player may be lulled into thinking that the injury is not as severe as it really is. After an Achilles tendon rupture, a player will be able to walk flat-footed, but will not be able to stand up on his or her toes on the affected side. Treatment can consist of casting or surgery, but surgery is recommended for most Achilles tendon ruptures, especially for athletes.

With tennis leg (a tear of the calf muscle on the inside of the leg) (Click her for details - Fig. 6), you may feel as if you have been shot in the upper calf by a pellet gun. This muscle tear can be quite uncom-fortable. It is important to stop playing immediately and treat the calf muscle with RICE. Tennis leg may take several weeks to resolve.

Ankle sprains
Sprains of the outer ligaments of the ankle are common in tennis (Click here for details - Fig. 7). You can minimize the risk by selecting shoes that are specifically designed for tennis and that have substantial support built into the outer counter of the shoe. The most effective treatment for ankle sprains is the usual RICE for 24 to 36 hours, then walking with an appropriate support on the ankle. If the swelling, pain, and bruising are severe, see your physician. Even after the most minor sprain, some sort of stabilizing ankle support is recommended during play for 6 weeks.

Tennis toe
Tennis toe can occur as the toes are jammed against the toebox of the shoe during tennis's quick starts and stops. Tennis toe is a hemorrhage under the toenail that can be quite painful. Your physician will treat this by drilling a hole in the toenail and relieving the pressure. Prevent tennis toe by keeping your toenails cut short and wearing shoes that provide adequate toe space.

Nicholas E. Mihelic, M.D.
Hilton Head, South Carolina