Musculoskeletal injuries in tennis

In recent decades, tennis, in particular, and racquet sports in general, have experienced a significant increase in fans, remaining in the top ten most practiced sports in our country. Musculoskeletal pathologies associated with tennis are highly varied and, although they can manifest acutely, are usually caused by repetitive microtrauma:

• The upper limb is by far the anatomical area where most injuries are found, and within this group, the shoulder is the joint with the highest incidence of injuries.
• Possibly the second most frequently affected area is the spine. Playing tennis subjects the spine to hyperflexion, hyperextension, and rotation, which often cause various types of injuries.
• Other joints, such as ankles, knees, feet, and hips, will also be subjected to overload and therefore experience various injuries.

UPPER LIMB PATHOLOGY

A) SHOULDER

Various pathologies can affect it, most of which are the repetitive microtraumas to which the shoulder joint is subjected, primarily due to the demands and importance of one of its fundamental aspects in the game: service (Figure 1).

Figure 1: Different phases of service

Although the most common conditions are tendonitis and acute inflammatory processes, we describe below four important injury conditions that occur in both professional and amateur tennis players:

• Impingement syndrome or subacromial syndrome, perhaps the most common, causes shoulder pain due to a space conflict between its container (acromiocoracoid space) and its contents (rotator cuff and bursa). This condition is clinically diagnosed with pain and functional impairment of varying degrees and supported by tests such as X-rays, ultrasound, or MRIs.Initial treatment is conservative, with sports rest, anti-inflammatory drugs, physical therapy, and functional rehabilitation, reserving infiltration therapy for those who fail to improve with these initial measures.A high percentage will respond to this initial treatment. In cases where there is no improvement, arthroscopic surgery may be indicated.
• Acromioclavicular arthropathy: The acromioclavicular joint is compromised by high-range movements performed at high speed and repetitively. It almost always affects the dominant shoulder and occurs after the age of 25. Three movements during tennis practice can lead to damage to this joint.

Diagnosis is primarily clinical and supported by radiological X-rays and ultrasound. Treatment is the usual treatment of rest and anti-inflammatory drugs, and in some cases, ultrasound-guided intra-articular corticosteroid injections. Few cases require surgical intervention.

• Anterior shoulder subluxation: Repetitive trauma in the smash or serve causes weakness of the anterior shoulder complex and can lead to injuries to the glenoid labrum or the anteroinferior border of the glenoid. It manifests as severe pain at the end of the stroke with a sensation of loss of strength. Treatment is usually conservative.

• Long Thoracic Neuropathy: A long nerve originating in the cervical spine and responsible, among other nerves, for innervating the serratus anterior muscle. Again, the smash and the serve are two tennis movements that can cause neuropathies due to repetitive microtrauma. It manifests as pain and functional weakness in the shoulder with a sensation of loss of strength and scapula alata, which appears when the medial border of the scapula lifts off during active raising and lowering of the arm. (Figure 2)

Physiotherapy will focus on targeted active therapy of the shoulder girdle and functional recovery of the serratus anterior muscle.

Figure 2: Raising and abrupt lowering of the arm during service and smash

• Neuropathy of the suprascapular nerve, which innervates the supraspinatus and infraspinatus muscles, can be affected by smash and serve shots (again, the most technically and anatomically demanding). Three movements can compromise this nerve:

  -Horizontal adduction.
  -Horizontal retropulsion of the shoulder plus external rotation.
  -Anterior propulsion plus internal rotation.

The suprascapular nerve passes through two notches (the suprascapular notch, before which it gives its innervating branch to the supraspinatus muscle, and the spinoglenoid, after which it gives innervation to the infraspinatus. It is for this reason that the clinical symptoms of this neuropathy can vary depending on the location of the nerve injury. Sports rest, ultrasound-guided infiltration therapy and, in cases resistant to conservative treatment, surgical release of the nerve can restore functionality, complementing the treatment with active and progressive re-education at the first signs of reinnervation.

B) ELBOW

Few joints are as directly related to sports as this one. The term epicondylitis or tennis elbow refers to epicondylar pain, which encompasses a series of conditions affecting the anterolateral aspect of the elbow, which can radiate down the forearm. There are several conditions that cause pain in this area:

• Insertion pathology. Alterations in the insertion of the forearm extensor muscles into the epicondyle.
• Radiohumeral joint injuries.
• Radial nerve neuropathies.
• Pain radiating from the cervical spine.

Most of these are due to repetitive movements and repeated microtrauma caused by backhand hitting. Other factors, in this case extrinsic, may include technical or material defects, racquets, string tension, etc.

Figure 3: Phases of the one-handed backhand

In the backhand stroke, we go from an extended elbow and wrist flexion with maximum tension to a position of elbow extension and maximum wrist extension, causing overload of the extensor muscle insertion. (Figure 3)

Treatment will depend on the diagnosis. In cases of insertional pathology, rest, anti-inflammatory treatment, and in some cases ultrasound-guided corticosteroid injections, physical therapy (stretching, eccentric exercises, etc.), followed by re-education and correction of the factors involved (selection of materials and improvement of the hitting technique) are recommended. In epicondylitis that has lasted more than three months and does not respond to conservative treatment, ultrasound-guided platelet-rich plasma (PRP) injections may be indicated. (If you want to learn more about this condition: https://drjordijimenez.com/es/dr-jordi-jimenez/blog-cuida-tu-salud/epicondilitis-y-prp

 

Mention should be made of cases of epitrochleitis (the same pain as the elbow, but on the inside). Although not typical of this sport, it can also occur in tennis players (at the end of the serve and on the forehand).

In children ages 9 to 13, keep in mind PANNER disease (osteonecrosis of the humeral condyle).

C) WRIST

The increased power of the shot and the topspin drive (Figure 4) have led to an increase in pathologies in this sport, most of which are usually mild tendonitis or overload. Furthermore, synovial cysts on the back of the wrist and fractures of the uncinate process of the hamate bone are not uncommon. The latter presents as pain in the ulnar border of the hand and wrist, with prior trauma (fall with wrist hyperextension) or without prior trauma as a result of repetitive microtraumas in the drive or smash. Once again, conservative treatment is essential.

Figure 4: Top-spin drive
 

D) SPINE

Although all vertebral segments can be affected, the lumbar spine is by far the most affected. The abruptness of rotations, flexions, and extensions of the lumbar segment, combined with factors such as age, lack of training, previous lumbar pathologies (spondylosis, degenerative disc disease, vertebral listhesis), associated with technical defects, and demanding movements such as those in service, explain the vulnerability of this area and the predisposition to injury. (Figure 5)

          Figure 5: Anterior flexion, hyperextension and lumbar rotation movements.

 

E) MUSCULOTENDONE INJURIES

Regarding musculotendinous injuries, two deserve special mention due to their specific nature: tennis leg and contralateral rectus abdominis injury (Figure 6).

Tennis leg: The sudden and forceful start with the knee fully extended and the ankle dorsiflexed causes disinsertion of the medial gastrocnemius. This injury typically affects people over 40 years of age, associated with other factors such as poor prior training, environmental factors, dietary factors, etc.

Clinically, there is a sudden pain (the stone-hit sign), often with an audible click, and severe functional impairment. Radiological tests confirm the diagnosis, primarily ultrasound, which also allows for follow-up and prognosis. Treatment is conservative in the vast majority of cases, with immobilization for 3-4 weeks, followed by physical therapy and subsequent rehabilitation.

 

Figure 6: Mechanisms of tennis leg production and rectus abdominis injury.
 

• Contralateral rectus abdominis muscle injury: This occurs due to a sudden contraction of the contralateral abdominal muscles during the final phase of exercise. It is sometimes preceded by overexertion, lack of warm-up, etc. The pain presents as a muscle strain or tear in the contralateral lower abdominal region. Ultrasound will assist with clinical diagnosis.
   

F)TENDON PATHOLOGY

High physical demands, prolonged exertion, and constant changes in rhythm and acceleration make tendon strains and injuries very common in tennis.

At the level of the upper extremity, the smash and the serve are the two technical movements that most compromise the supraspinatus tendon and the long head of the biceps brachii. The topspin forehand frequently causes radial styloiditis and tendonitis of the first extensor compartments, and the forehand backhand and volley cause ulnar styloiditis and strain of the ulnar margin of the wrist. Likewise, triceps brachii tendonitis is associated with the slice backhand (Figure 7).

Figure 7: Mechanisms of production of radial styloiditis, tricipital tendonitis and ulnar styloiditis.
 

Upper and lower body disproportions associated with a lack of elasticity lead to adductor tendonitis, especially during forced lateral movements (Figure 8).

Other common tendon conditions include patellar tendonitis, pes anserinus tenosynovitis, insertional tendonitis of the peroneal tendons, posterior tibial tendonitis, and Achilles tendon tendinopathies (partial/complete ruptures of this tendon are not uncommon).

G) JOINT PATHOLOGY

Having already discussed joint pathology in the upper extremity, we now focus on the lower extremity. While the hip joint is more prone to periarticular involvement due to muscular and tendon processes, and the knee is not particularly exposed (meniscal injuries, chondropathies, etc., are evident), the ankle joint is particularly affected in tennis players. External ligament involvement due to forced varus torsades de pointes (Figure 8), osteochondral talar injuries, etc., is common.

Figure 8: Mechanisms of external lateral ankle ligament injuries and adductor injuries.

Regarding the foot, there are various processes, all related to overload, structural alterations of the foot, footwear, and playing surfaces, such as plantar fasciitis (if you want to learn more about this pathology: https://drjordijimenez.com/en/dr-jordi-jimenez/blog-take-care-of-your-health/plantar-fasciitis), and stress fractures (which occur primarily at the level of the 2nd and 3rd metatarsals).

Without a doubt, all these injuries are preventable by building a baseline physical capacity, avoiding overload (a frequent source of injury), creating recovery periods between workouts, regulating the intensity, frequency, and duration of workouts, and compensating for the asymmetry inherent in tennis as much as possible through complementary exercises.

ACKNOWLEDGMENTS
We would like to thank David Alfaro and Rafael Baena, managers and coaches of Club Tenis Delta, for their collaboration and technical and iconographic advice in the production of this publication.