By Patrick Aubone, CTPS & Dr. Mark Kovacs, CTPS, MTPS

             
Headed into the professional clay court season, common perception is that in tennis surface matters. As we get older, clay courts are the surface of choice. “It’s easier on the body” is the most repeated phrase. “Hard courts hurt my knees and my back” is often heard. But what if the injuries were not a result of the playing surface?  Most players over time get some type of overuse injury. Whether it’s the playing arm, the back, or the knees and ankles, everyone gets “niggles.”
           
A recent 2016 study in Netherlands evaluated 4 different surfaces and their injury rates over a 6 month period. Hard courts, clay courts, sand filled artificial grass and red sand filled artificial grass were used. The average age of the participants was 49 years old. 20,000 adults were invited to participate, 18% (3656) participated. There were 4047 injuries (53%) reported by 1957 participants. 80% of the injuries were overuse injuries and 20% were acute injuries. Participants who played on multiple surfaces suffered from overuse injuries compared to those who played on one surface. The researchers concluded that there was no significant injury prevalence of injury with the different surfaces.
 
This study shows that unless a player suffers a freak injury such as Bethanie Mattek-Sands at the 2017 Wimbledon or David Goffin at the 2017 French Open, the grand majority of injuries are due to overuse and not surface type. Essential to maintaining a healthy body is rehabbing minor injuries and strength training to prevent injuries. Rest is vital for the body. More is not always better.
           
Another study evaluated the influence of tennis court surfaces on player perception and biomechanical response. The researchers noted that there was a difference in the way players stood on a hard court compared to a clay court. Players on a hard court were in a more upright position. This allowed the athlete to be more on their toes in anticipation of sliding. They did note that players with previous clay court experience may experience a reduction of injury as a result of reduced loading on the knees and lower limbs.
           
Research is clearly showing that playing surface has limited correlation with injuries in tennis. The injuries reported were preexisting injuries. Past injuries from other sports or accidents can be exacerbated because of the start/stop nature of the sport. The forces generated can place extra stress on the body and cause flare ups in injuries that were not properly rehabbed
So how much is too much in professional and recreational tennis?
           
Professional players travel 25-35 weeks a year between tournaments, preseason camps, and home visits. Recreational players play between 2 and 3 times a week. While some individuals can argue that Courier, McEnroe and Lendl all played 85+ matches in the past, there are many variables that have changed. For recreational players, you have to worry about outside stress from home and work. The professional athletes are stronger, faster and fitter than ever. Matches are going 4+ hours in Grand Slams with the winner having 36 hours to recover before playing again. The physical toll on the athlete’s body after these matches is tremendous. In recreational players recovery can take a few days depending on how much outside weight lifting and endurance training is done. Technology has played a part in developing more powerful racquets allowing players to hit harder and add more spin to the ball.  
 
3 Takeaway points

1. Injury prevention begins before you step on court and does not stop when you leave the court. Stretching, foam rolling, dynamic warmup all help.
   1. Basic Injury Prevention Exercises for Tennis http://itpa-tennis.org/itpa-blog/basic-injury-prevention-exercises-for-tennis
2. Stress Management – outside stressors such as work and family can have a negative impact on the body. Meditation, reading a book or any activity that activates the parasympathetic nervous system will greatly reduce stress levels.
3. Technology- USE IT! With the advances in technology today there are a lot of tools that can speed recovery not just from an injury standpoint but also after a practice or match. Just make sure you use technology that has a track record of success and has evidence based support.

​Here are another few nice resources from the iTPA
Are You Helping or Hurting Your Young Tennis Players? - http://itpa-tennis.org/itpa-blog/april-19th-2013
 
Sources:
The influence of tennis court surface on player perceptions and biomechanical response
https://www.ncbi.nlm.nih.gov/pubmed/26699792
 
Injury rates in recreational tennis players do not differ between different playing surfaces
https://www.ncbi.nlm.nih.gov/pubmed/28209569

Common sports injuries in young tennis players
https://www.ncbi.nlm.nih.gov/pubmed/9777684


Alternating Hot and Cold Water Immersion for Athlete Recovery: A Review
http://www.sciencedirect.com/science/article/pii/S1466853X03001226

Preventing overtraining in athletes in high intensity sports and stress recovery management
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0838.2010.01192.x/full

A common problem seen in tennis players is cramping.  Cramping is seen during Grand Slams tournaments when matches are played in hot and humid conditions. They are very common to see in longer physical matches. In lower levels of tennis such as league or recreational play it is common due to lack of practice time during the week or lack of fitness.  A lot of the time cramping is preventable with proper hydration, nutrition and physical preparation leading into a match or tournament.

1. Hydration - Dehydration is one of the main causes of cramping. The majority of athletes walk into a match or practice already dehydrated. During a match an individual can lose between 1.5 to 3 liters of sweat. The main element lost in sweat is salt. An easy test to see how much an individual sweats is to wear a dark colored shirt. Once the practice or match is complete look for white stains around the shirt, as this is a sign of the amount of sodium lost during the practice or match. The more white (salt) the shirt has is the heavier a sweater he/she is. Consuming a sports drink such as Gatorade will help prevent cramping. If he/she does not like a sports drink, adding salt to your water or drink of choice is a good way to substitute the sodium lost during play. Recent research has shown that drinking Alkaline water also helps keep a higher PH level in the body. This allowed for more efficient utilization of lactate after high intensity exercise. Also remember that hydration begins before the match or practice.
   
   
2. Nutrition – Nutrition plays a big role in an athlete’s performance. Tennis is a high intensity sport with short points (5-20 seconds) and long breaks (20-25 seconds). Carbohydrates are very important for a tennis player. They provide immediate energy during a match. Gel packets and sports drinks are commonly seen being consumed by tennis players because they provide quick energy. Recent research shows that consuming 16g of glucose improved endurance by 14% compared to drinking only water. A suggested consumption of 20-90g of carbohydrates is recommended per hour. This all depends on your ability to digest a gel or sports drink during competition. It is also important to consume enough calories before and after playing. Consuming the right balance of carbohydrates, fats, and protein in your diet is important to have enough energy throughout the practice or match and prevent cramps.

 

1. Physical Preparation – The final piece to the puzzle is fitness. For most professional athletes this is not a problem, but for recreational players it can be. Most recreational players participate in a league or play with friends once or twice a week. The problem is that if they don’t do any work in the gym or supplemental fitness when they aren’t playing tennis they run the risk of cramping during longer matches. Tennis is a high intensity sport. Combined with the pressure of winning and possible hot and humid conditions there is a high risk of cramping no matter the level of he or she competes in. He or she should try and exercise 2-3 times a week outside of a practice or match in order to improve their fitness levels. This will help prevent cramps muscle fatigue which can lead to cramping.

 

1. Emotional & Mental Preparation – Most cramping occurrences happen during matches and competitive environments. Therefore, it is very important to not overlook the stress response and the impact it has on muscle function and physiological responses that contribute to the exercise associated muscle cramping timeline and mechanical process. Working on breathing routines, focusing on the process rather than the outcome and having overall general routines is very beneficial in this perspective. Here is a great resource that has many lesson plans and practical examples on how to improve the emotional and mental skill development  https://www.amazon.com/USTA-Mental-Skills-Drills-Handbook/dp/1606790803
   
   

In conclusion, the 4 main causes of cramping are a lack of hydration, nutritional deficiencies, physical preparation and emotional/mental preparation.

​Here is another great resource from the iTPA on Cramping in Tennis:
Cramping in Elite Level Tennis - http://itpa-tennis.org/itpa-blog/cramping-in-elite-level-tennis
Calambres musculares en el tenis http://itpa-tennis.org/itpa-blog/muscle-cramping-in-tennis-espanol
 
Resources:
https://link.springer.com/article/10.2165/00007256-200434010-00002
https://www.ncbi.nlm.nih.gov/pubmed/29158619
https://link.springer.com/article/10.1007/s40279-014-0148-z
http://www.sciencedirect.com/science/article/pii/S1440244003800051
 

The presentations by Dr.  Neeru Jayanthi focused on an areas of great interest to me which considered injury prevention in elite junior tennis. With my main philosophy being that tennis can help develop young people positively whilst having great interest in talent development, I was intrigued to listen to the session. Indeed one of the first points made was that coaches (45%) have the most influence on players wishing to train at a high level in comparison to the player (35%) and then the parent (15%). This straight away made me think with coaches being the most influential person determining how intensely the player considers to take the game, even with the best intentions are coaches educated to a level where they understand volume, levels of appropriate intensity and how growth effects a young person’s body? Indeed the thoughts of children not being miniature adults sprung to mind. Jayanthi went onto discuss a number of research articles he has published in recent years including considering risk factors for medical withdrawals from USTA National junior tournaments and training and sport specialisation risks in junior elite tennis players. A host of possible conclusions can be made from these two pieces of research. For example cumulative match scheduling and competition without adequate recovery and rest (approximately two hours) can be detrimental for junior tennis players. Despite this many systems across the world which rank and rate players are based on volume such as how many matches you win within a certain time period which ultimately may lead to excessive volume. Other conclusions were that players should consider delaying early specialisation until middle or late adolescence due to a potential increase risk of burnout and injury alongside playing only one or two tournaments per month, having adequate time away and recovery from the sport. Thanks must go to Jayanthi for his passion and drive to delivery outstanding research in this area of youth development.

There were a host of other fascinating presentations attended by myself and Mike James. Page Love delivered a session on nutrition focusing on recovery and reducing the potential risk of injury for tennis players. Much of the focus was on tart cherry juice and the antioxidant nature of this to reduce muscle soreness and aid recovery. Indeed this would be a very interesting research topic for anyone in tennis considering the benefits of tart cherry juice during intense match play and recovery. Ollie Stephens then considered the important factors when working as a team to develop competitive tennis players and Dr. Larry Lauer discussed bringing back players from injury. This lecture provided a great insight into the stages an athlete goes through when being injured, such as going through the grief stages and how a team can respond in a way to create a supportive, nurturing environment to help get the athlete back to full fitness. This included factors such as clear and transparent communication, education and listening to the athlete. Other excellent sessions discussed injury and illness data from the US Open for the past 15 years and the age eligibility rule and managing WTA players. Both gave a great insight to working with elite professionals.

The practical elements from USTA Head of Strength and Conditioning Satoshi Ochi, Director of Strength & Conditioning at the University of Georgia, Katrin Koch, and Spanish Director of Education for the iTPA Lalo Vicencio gave delegates an opportunity to actively get involved and take home tennis specific drills and exercises. Focus on these areas included the split step and the opening of the hip and initial step, footwork and agility movements and co-ordination exercises to use with both younger and older tennis athletes. It must be said that with the great range and diversity of presentations and break out groups unfortunately we couldn't make each one, but based on other delegates thoughts and reviews every researcher or practitioner must be recognised for their excellent delivery and information either on a coaching, sport science or medicine level.

Away from the presentations the forums provided delegates to ask questions related to tennis science and medicine questions with two themes. The first one focused on developing young healthy tennis athletes. Indeed the topics varied from ways in which to strength train, manage volume and nutrition such as supplementation. The second panel discussed working with elite full time tennis professionals. It was also a pleasure to hear Atlanta based ATP tennis professional Robby Ginepri give his opinions on how tennis has changed over the past decade since he began his career on the tour. There was great acknowledgement that sport science and medicine has a larger part now to play when developing players and this is due to the advancement of the game physically. Ginepri explained that within his academy sport science plays an important role with the use of physical conditioning and performance psychology and nutrition sessions. This gave me great confidence with me recently starting my own business (www.scienceintennis.com) which is a sport science business solely focusing on tennis.

Ultimately both Mike and I feel there were a number of take home messages for practitioners working in tennis to be aware off. First of all you have to know the game, be aware of the common areas of injury, the challenges both junior tennis and senior professional players face alongside understanding the uniqueness of how to train a tennis player. Secondly, every tennis player is different and knowing your athlete and allowing them to feedback to you and the team you work with is essential to develop a strong professional relationship and maximise their potential. Thirdly don't over complicate things, tennis is a difficult sport to plan and periodise for so use the most effective ways of training but keep things as simple as possible. It was clear that educating players, coaches and parents alongside communicating with and understanding the roles of practitioners who can help develop tennis players, reduce injury and enhance performance is essential, the goal of any of us working within tennis. 

Over 11 Hours of Presentations from the 2014 Tennis Medicine & Performance Conference available for download at the iTPA Dartfish Channel

http://www.dartfish.tv/CollectionInfo.aspx?CR=p90378c98277

Heat-related illness and death are on the rise. Each year about 200 people in the US die from heat stroke, making it one of the top three causes of death in athletes - and the leading cause of death among athletes in July and August. Yet heat illnesses and dehydration are largely preventable...

Click on the below link to download the PDF with much more information on this topic. Produced in conjunction with our partner, STOP Sports Injuries.

Hydration Issues in Sports PDF

               Keep Kids in the Game for Life Through the STOP Sports Injuries Campaign

                              Healthcare and, Business Leaders, and Professional Athletes Join Forces to  Help
                                                                    Young Athletes Play Safe and Stay Healthy

Atlanta, Ga. –– Today, leaders at International Tennis Performance Association are coming together with the American Orthopaedic Society for Sports Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Medical Society for Sports Medicine, National Athletic Trainers’ Association, National Strength and Conditioning Association and Safe Kids USA to promote the STOP Sports Injuries campaign. 

The campaign educates athletes, parents, athletic trainers, coaches and healthcare providers about the rapid increase in youth sports injuries, the necessary steps to help reverse the trend and the need to keep young athletes healthy. The STOP Sports Injuries campaign highlights include teaching proper prevention techniques, discussing the need for open communication between everyone involved in young athletes’ lives, and encouraging those affected to sign The Pledge to be an advocate for sports safety. The campaign website and pledge are available at www.STOPSportsInjuries.org.

Sports injuries among young athletes are on the rise.  According to the national Centers for Disease Control and Prevention (CDC), high school athletes, alone, account for an estimated two million injuries, 500,000 doctor visits and 30,000 hospitalizations every year. 

The iTPA is excited to join this important campaign, as a major emphasis of our education is focused on preventing and limiting injuries in young tennis players,” said Dr. Mark Kovacs, iTPA Executive Director.

The high rate of youth sports injuries is fueled by an increase in overuse and trauma injuries and a lack of attention paid to proper injury prevention. According to the CDC, more than half of all sports injuries in children are preventable.

“Regardless of whether the athlete is a professional, an amateur, an Olympian or a young recreational athlete, the number of sports injuries is increasing – but the escalation of injuries in kids is the most alarming,” said Dr. James Andrews, former president of the American Orthopaedic Society for Sports Medicine (AOSSM) and STOP Sports Injuries Co-Campaign Chair.  “Armed with the correct information and tools, today’s young athletes can remain healthy, play safe, and stay in the game for life.”

Supporting the STOP Sports Injuries campaign are the country’s leading sports medicine organizations along with professional athletes and business leaders who have signed on as members of the campaign’s Council of Champions. This Council will help raise additional awareness about this growing epidemic of youth sports injuries.  Some of the founding members of the Council include former Olympic champions Christie Rampone, Eric Heiden and Bonnie Blair, professional golfer Jack Nicklaus, NFL Hall of Fame quarterback Bart Starr, MLB baseball player John Smoltz, NFL Hall of Fame defensive end, Howie Long, and Heisman Trophy winner and St. Louis Rams quarterback Sam Bradford.

Watch the below video by iTPA Certification Commissioner Dr. Don Chu on Why Plyometric Training is so Important for Tennis Athletes. Also check out the Plyometrics for Tennis DVD course.

 “A growing epidemic of preventable sports injuries is dismantling the hopes and dreams of young athletes at an early age.” – Dr. James Andrews and the STOP (Sports Trauma and Overuse Prevention) Sport Injuries Organization.

As April is National Youth Sport Safety Month, it is important to evaluate the quality and quantity of training and competition that your young athletes are exposed to. Tennis is a sport that typically has a very high volume at a young age, and although tennis is an early initiation sport, it should be a late specialization sport. This means that to be highly successful (i.e. earning a college scholarship or dreams of playing professionally) in the sport an individual needs to be exposed to the sport at a young age – typically before 10 years of age. However, it is a late specialization sport. This means that it is important to learn the sport at a young age, but also participate in multiple sports to at least till 12-14 years of age. Over the past decade a number of studies in different sports have consistently shown that athletes that specialize in one sport from a very young age have a greater number of injuries. Some of the most recent research was presented at the American Medical Society for Sports Medicine (AMSSM) meeting in San Diego in April. The study is titled “Risks of Specialized Training and Growth in Young Athletes: A Prospective Clinical Cohort Study” and was led by Dr. Neeru Jayanthi (iTPA Certification Commission member) http://www.itpa-tennis.org/certification-commission.html.

Below are some of the most relevant notes from the study :

• Between 2010 and 20103, Neeru Jayanthi (iTPA Certification Commission member) and colleagues at Loyola and Lurie Children’s Hospital of Chicago enrolled 1,206 athletes ages 8 to 18 between who had come in for sports physicals or treatment for injuries.

• There were 859 total injuries, including 564 overuse injuries, in cases in which the clinical diagnosis was recorded. The overuse injuries included 139 serious injuries such as stress fractures in the back or limbs, elbow ligament injuries and osteochondral injuries (injuries to cartilage and underlying bone). Such serious injuries can force young athletes to the sidelines for one to six months or longer.

• Young athletes who spent more hours per week than their age playing one sport – such as a 12-year-old who plays tennis 13 or more hours a week – were 70 percent more likely to experience serious overuse injuries than other injuries.

• The study confirmed preliminary findings - that specializing in a single sport increases the risk of overall injury, even when controlling for an athlete’s age and hours per week of sports activity.

• Young athletes were more likely to be injured if they spent more than twice as much time playing organized sports as they spent in unorganized free play — for example, playing 11 hours of organized soccer each week, and only 5 hours of free play such as pick-up games.

• Athletes who suffered serious injuries spent an average of 21 hours per week in total physical activity (organized sports, gym and unorganized free play), including 13 hours in organized sports. By comparison, athletes who were not injured, participated in less activity – 17.6 hours per week in total physical activity, including only 9.4 hours in organized sports.

• Injured athletes scored 3.3 on researchers’ six-point sports-specialization scale. Uninjured athletes scored 2.7 on the specialization scale. (On the sports specialization scale, an athlete is given one point for each of the following:

1. Trains more than 75 percent of the time in one sport;
2. Trains to improve skill or misses time with friends;
3. Has quit other sports to focus on one sport;
4. Considers one sport more important than other sports;
5. Regularly travels out of state;
6. Trains more than eight months a year or competes more than six months per year.

Dr. Jayanthi offers the following tips to reduce the risk of injuries in young adults:

• Do not spend more than twice as much time playing organized sports as you spend in gym and unorganized play.
• Do not specialize in one sport before late adolescence.
• Do not play sports competitively year round. Take a break from competition for one-to-three months each year (not necessarily consecutively).
• Take at least one day off per week from training in sports

The iTPA Parent’s Guide To Basic Injury Prevention

The iTPA has created a Parent’s Guide To Basic Injury Prevention Course which is specifically designed to help the tennis parent to appropriately work with their junior players to help reduce the chance of injury through appropriate prevention exercises. The course comes with over one hour of practical video instruction showing detailed injury prevention exercises and tutorials, in addition to an 85-page color Workbook. Please see the webpage for a detailed description and sample videos of the course http://www.itpa-tennis.org/parentcourse.html

Perspective below from Dr. Ellen Rome, Head of the Center for Adolescent Medicine at The Cleveland Clinic and a Member of the iTPA Certification Commission (www.itpa-tennis.org/certification-commission) and a member of the USTA Sports Science Committee.

• How does the brain develop when an athlete is very young?
• Adolescent age and stage is important.
  
• Understanding the differences between the different stages is important for the Tennis Performance Trainer or Certified Tennis Performance Specialist.

AUDIO clip below:

Short video featuring several basic injury prevention exercises for tennis players. Presented by iTPA Executive Director Dr. Mark Kovacs. Watch in HD!

2. Andy Murray's Blisters

After the hundreds of hours of pre-season work by Andy Murray, he came into the Australian Open in great physical shape and moved through the first few rounds of the Australian in devastating form. He came into the Open final looking good and played well in the first couple of sets. Then he called the trainer to work on a major blister on the inside of his left foot. As most of you are aware, bad blisters can be devastating for a tennis athlete due to the constant stop, start nature and the hundreds of movements that the athlete goes through in every match. Unfortunately, something as simple as blisters derailed Andy's chance of really contending at 100% for the last 2 sets of the final. This is an important lesson to everyone working with competitive athletes. The athlete is only as strong as his or her weakest link. Although every major factor was accounted for in Andy's training leading to the final, the one area that led to his downfall was something as simple as blisters. This is an important lesson to teach all athletes. Everything needs to be accounted for when preparing for a major tournament - including blisters.

3. Serena Williams Injury

Serena was a strong favorite going into the Australian Open this year; she was looking very strong in the lead up tournament in Sydney.  During her first round she rolled her right ankle 19 minutes into the match. On television it appeared to be rather severe, but she was able to still win her match 6-0 6-0 but with very little movement. Even though it was obvious that her movement was impeded, she continued to win through to the Quarterfinals where she faced the young American Sloane Stephens. Midway through the match while running for a short ball Serena aggravated a back injury which was noticeably painful. Although it is impossible to say with certainty,  the weakened ankle likely led to compensation up the leg and lower back, and this weakness and compensatory movements led her back to require movements that were atypical. This atypical movement likely was the cause of the back injury. This is an important concept to remember at any level of the game. It is important to take care of any injury (no matter how small) as an injury in the lower body can, at some point, have a deleterious effect on other parts of the body.