We are well into the tennis season, and we've seen a number of players through the clinic with injuries, so it's a good time to discuss the management of tennis injuries, which broadly speaking, involves three components

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1. Rehabilitation of the specific injury itself
2. Optimisation of kinetic chain mechanics, technique and equipment in order to reduce the risk of recurrence
3. A graduated reintroduction of load so that a player returns to tennis safely

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The rehabilitation of specific injuries is beyond the scope of this article. We will, however, discuss general principles to manage your tennis player back onto the court, and ways in which you can prevent the injury recurring.

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Many injuries will warrant a period of time off the court that may last several weeks. Use this opportunity to biomechanically assess and rehabilitate the kinetic chain. We recommend reading Bruce Elliott’s excellent article Biomechanics and Tennis (cited below).

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Power generation in a tennis stroke begins in the lower leg and is transferred through the thigh, hip girdle, lumbar and thoracic spine before it reaches the upper limb. It is estimated that well over 50% of tennis stroke power comes from this part of the kinetic chain. Lower limb weakness and thoracolumbar stiffness & weakness are areas that should be addressed with appropriate rehabilitation in order to minimise reliance on the upper limb for power generation.

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In players presenting with shoulder problems (commonly rotator cuff tears/tendinopathy or subacromial impingement), looking for and addressing a glenohumeral internal rotation deficit (GIRD) is very important. The Sleeper Stretch, performed morning and night, has been shown to be very helpful in addressing this.

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In all shoulder problems look for and manage scapular dyskinesis, in particular, any imbalance of the force couples about the scapula. Failure to address scapular and other biomechanical issues, and focusing solely on the rotator cuff is a common cause of treatment failure. Common issues encountered include pectoralis minor tightness and weakness of serratus anterior & the lower fibres of trapezius. The reader is directed to any of the excellent articles written by Ben Kibler et al on this subject. Don’t forget to add in proprioceptive exercises when your patient can tolerate these.

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Shoulder external rotators play an important role in power generation and load transfer during tennis strokes. Contracting eccentrically, they decelerate the humeral head during the follow-through phase of serving, and weakness of them may contribute to impingement-related problems. Accordingly, during shoulder rehab they need to be strengthened both concentrically and eccentrically, and in functional positions (from neutral through to overhead).

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Acting concentrically, these muscles are important generators of power during the backhand, and weakness can lead to overload of the forearm extensors during backhand shots. Concentric strengthening of the external rotators of the shoulder girdle is, therefore, an important part of common extensor origin tendinopathy rehabilitation in the tennis player.

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Weakness of trunk rotators and stiffness in the thoracolumbar spine also increase load in the upper limb. Consider adding exercises such as split-stance cable/Theraband twists (perhaps lunging onto a Dura-disk or Bosu ball), and having your player work regularly on improving thoracolumbar rotation and extension.

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The deceleration required when lunging for a ball or during the follow through after serving demands adequate eccentric quadriceps strength, and places a significant load through the knee extensor mechanism. When managing knee injuries (particularly the masters level player with patellofemoral arthropathy or patellar tendinopathy), help the knee extensor mechanism out by eccentrically strengthening the hip extensors (especially gluteus maximus/proximal hamstrings) and soleus.

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Dr Mark Fulcher has discussed the role of equipment with specific regard to elbow injuries in a previous article.

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Your player may also wish to enlist the services of a coach to assess and alter their technique as appropriate.

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Patients with lower limb injuries can be given a series of tennis-specific running drills, emphasising acceleration/deceleration and good quality multidirectional movement, with a graduated increase in duration and intensity.

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Progression back into tennis

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Once your player has a full, pain-free ROM (and in the shoulder, minimal to no GIRD), full strength, normal proprioception and any kinetic chain issues have been addressed, they are ready for an interval tennis programme:

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1. Three sessions (alternate days) per week
2. Start with 15 minutes hitting forehand shots (easy pace to begin with, focusing on technique), then 10 minutes backhand. Repeat after 5-10 minutes rest. Ice & stretch afterwards.
3. Increase each component (FH and BH) by 5 minutes each session to a maximum of 30 minutes each per interval
4. When able to hit FH and BH for 25-30 minutes x2, add 10 minutes overhead shots/serving and increase this by 5 minutes each session
5. Once able to tolerate 15-20 minutes overhead, can begin playing sets
6. Once able to play 3 pain-free sets in training, gradually return to competition

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However please note:

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1. Successful progression requires no pain during or the day after each session
2. Continue strength/ROM work on alternate days
3. Warm up & stretch prior to each session

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Once they have returned to match play, keep your player fit for tennis by:

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1. Maintaining kinetic chain strength with 2-3 home or gym based conditioning sessions per week
2. Performing regular sleeper stretches and other flexibility work as appropriate
3. Avoiding large spikes in load, particularly in masters level athletes

Reference

Elliott B. Biomechanics and tennis. Br J Sports Med. 2006 May; 40(5): 392–396.

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