ITF Tennis Injury Prevention and Training

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Tennis Injuries
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Tennis Injuries
By :
Mohammed Ahmed Elhamady
Student at Faculty of Sport Education - Mansoura

university
Tennis Injuries
The ITF Injury Clinic provides information on the diagnosis, treatment and rehabilitation of common
tennis injuries .The injuries covered are;
Abdominal Muscle Strain

Achilles Tendon

Ankle Sprain

Calf Muscle Strain

Groin Injury

Hamstring Muscle Strain

Heel Pain

Iliotibial Band Friction Syndrome

Impingement Syndrome

Jumper's Knee

Kneecap Pain

Lower Back Pain

Osgood Schlatter Knee Injury

SLAP Lesion

Tennis Elbow

Wrist Tendinopathy
Abdominal Muscle Strain
Diagnosis
An abdominal muscle strain is a partial tear or pull of one of the
abdominal muscles. The injury usually affects the (non-dominant
side of the) straight abdominal muscles (rectus abdominis)
(figure 1), but the internal and external oblique abdominal
muscles (the obliquus internus abdominis and obliquus
externus abdominis) may also be injured.
Abdominal muscular strains are a common occurrence for tennis

players at all levels. The tennis serve is the movement which
involves the highest risk of sustaining an abdominal muscle
strain.
Just before making the stroke, whilst bending back during the
cocking phase, the abdominal muscles are under a great deal of
tension. As soon as you start to hit the ball, these muscles start
to contract, using the elastic energy stored in the abdominal
muscles.
The power released moves across the body, from the dominant
shoulder to the leg of the non-dominant side of the body. This
movement, whereby the muscles stretch and then contract
(eccentric-concentric contraction), is a high-risk moment for the
abdominal muscles.
When you arch your body back even further than you do for a
standard serve, such as for a kick serve or topspin serve, this
increases the risk of sustaining an abdominal muscle strain even
more.
The open stance forehand, which involves a powerful rotation of
the torso, may also lead to an abdominal muscle strain.
Symptoms of an abdominal muscle strain are a sudden stabbing
pain upon contraction of the injured muscle. This pain is for
example felt during the serve or when doing abdominal muscle
exercises. Furthermore, the injured muscle is sensitive upon
palpation.
What should you do? First Aid!
The first phase of the treatment consists of activity modification
and cooling of the injured area. Once the pain has somewhat
subsided, you can start the rehabilitation process.
Immediate and effective first aid is essential for a rapid recovery.
If the injury seems to be serious or if in doubt, have a (sports)
physician examine you. In certain cases you will be referred to a
(sports) physiotherapist.
How to Ensure the Best Recovery
As soon as the worst of the pain has subsided (after one to five
days), you can start the build-up process. During this build-up
pain is a warning sign to stop and rest.
Be careful: do not exceed your pain threshold, as this will only
delay the healing process! The build-up consists of three stages,
ranging from easy to demanding. Here are the exercises, along
with some tips.
Stage 1. Improvement of Normal Function
Gentle stretches and isometric contractions of the abdominal

muscles will stimulate the natural recovery process.
- Stretching the abdominal muscles. Lie down on your stomach
with your hands in the push-up position (figure 2). Slowly push
yourself up with your hands so that your shoulders are raised
from the ground, while hips and legs maintain contact with the
ground. Hold this position for 15 to 20 seconds and then return
to the original position. Try to ensure that your back and buttock
muscles remain relaxed throughout this exercise.
- Isometric contraction of the right abdominal muscles. Lie down
on your back with bent knees and your feet placed flat on the
floor. Tense your stomach muscles and press your back into the
floor. Hold this position for five seconds and release.
- Isometric contraction of the oblique abdominal muscles. Stand
in front of a door opening, with your right hand on the door
frame. Push your right hand against the door frame very gently,
until you feel tension in the abdominal muscles. Keep your upper
body straight and keep looking straight ahead
Pushing away your finger tips. Gently push the finger tips of both
hands into your abdomen, by a few centimetres. Push your fingers
outwards by tensing the stomach muscles, whilst your fingers continue
to apply counter-pressure. Hold this position for five seconds and then
release.
Stage 2. Returning to Training
As soon as all of the above exercises can be performed confidently and
free of pain, you may start training again.
- Strengthening the straight abdominal muscles (straight crunch,

figure 3). Lie on your back with your knees bent and your feet
flat on the ground. Place your finger tips behind your head, so
that your elbows are pointing outwards. Look straight ahead and
try to relax your head and neck. Contract your abdominal
muscles and ensure that your back maintains contact with the
floor. Raise your torso to the point whereby your shoulders are
just off the ground. Hold this position for a few seconds and
slowly return to the original position. Keep your lower back on
the ground throughout the entire exercise. Repeat the exercise
as often as you possibly can.
- Strengthening the oblique abdominal muscles (oblique crunch,
figure 4). Lie on your back withyour knees bent and your feet flat
on the ground. Place your left foot across your right knee. Place
your finger tips behind your head, so that your elbows are
pointing outwards. Look straight upwards and try to relax your
head and neck.
Contract your abdominal muscles and curl your body up with a
twisting motion. Now bring your right elbow towards your left
knee, to a point whereby your right shoulder blade just comes off
the ground. Hold this position for a few seconds and slowly
come back down. Repeat the exercise as often as you can.
Then change legs (right foot across left knee) and repeat the
exercise for the oblique muscles on the other side.
- The next step is to start running. Start off at a slow pace,
followed by faster pace work, and then include pivots and turns.
Finally, start introducing short sprints.
Stage 3. Return to Play

With an abdominal muscle strain you can sometimes just continue to
play tennis. However, whilst it is still painful it is best if you avoid
serves and overhand strokes.
- Start off by playing against the practice wall or with a game of mini tennis, which will allow you to move
backwards slowly. Avoid serves, smashes, high forehand and backhand strokes and high volleys.
- Strengthening the abdominal muscles. Up to this point, the abdominal muscles have been trained in a
normal position, whereby they contracted during the exercise. It is important for them to also
be strengthened in a slightly stretched position, like in a serve, so that they are able to cope with the
strain when performing this movement. Sit down on a bench which is either straight or tilted slightly
backwards. Lean back slightly, hold this position for a few seconds and slowly come back to the original
position. Maintain the contraction in the abdominal muscles and repeat the movement. Do three sets of
10 to 20 repetitions.
- Medicine ball exercises (Figure 5). In this exercise muscles undergo a rapid stretch and contraction
('stretch-shortening'), similar to the action when performing a serve. Hold a medicine ball above your
head with two hands (figure 5). Throw the ball to your partner and then catch it above your head. Slightly
spring back with the ball and then throw the ball back in one go. Start by using a relatively light weight
ball (0.5 1 kg), and slowly build it up over several weeks. Repeat three sets of six to eight repetitions.
- You can now start performing second serves, smashes, and high forehand and backhand strokes
during play.
- Once this is going well, you can start performing some first serves. Gradually increase the frequency
and speed of the serve.
- You can now start playing practice sets and practice matches. Once you have played practice matches
for two weeks without pain, you can start playing competition matches again.
Preventing Re-injury
Unfortunately, abdominal muscle strains cannot always be avoided.

However, you can
minimise the risk by observing the following guidelines:
- Ensure that you have good basic fitness.
- Strengthen your abdominal muscles.
- Ensure you have a good service technique, with a regular ball toss.
- Ensure that you rest sufficiently between training sessions, games,
competitions and matches.
Achilles Tendon
Diagnosis
An injury of the Achilles tendon is a degenerative condition of

the tendon, not an inflammatory process. It is therefore incorrect
to describe this as tendinitis. Tendinopathy is a better term.
The injury is caused by chronic repetitive movements during
running and jumping. It occurs mainly in recreational tennis
players aged between 35 and 45. The symptoms are a gradual
increase of pain, initially only in the morning and at the start of
the training. In later stages, the pain may be continually present
during exercise and even at rest. The pain is felt in the Achilles
tendon, 5-7 cm above the heel (Figure 1 and 1a). Continued
exercise carries the risk of a gradual worsening of the injury,
which makes recovery more difficult.
First aid
As a rule of thumb, first aid involves modification of activity (less
tennis and running).
Cooling with ice, stretching exercises and wearing firm, good shoes
are also important measures.
When there is swelling and pain, ice massage may alleviate
symptoms. Use a melting ice cube or a paper cup with ice. Massage the
painful spot. In general, 5 to 8 minutes will be sufficient. Repeat this
several times a day.
Use special (visco-elastic) inlays or an Achilles tendon bandage.
These provide good shock absorption and because of the increase in
height, they artificially lengthen the tendon, reducing the stress on it.
Replace running exercises with cycling or swimming.

Exercises can start when the worst pain and swelling have disappeared.
During these exercises, pain is a signal to reduce the training load.
Do not surpass the pain threshold, as this will impair recovery.
The build-up of the training load takes place in three stages, as
described below, together with some practical tips.
Stage 1. Improving Normal Function

Stretching the long calf muscles (Figure 2). Take a step forward with
the unaffected leg, keeping the heel of the back leg on the floor. The
knee of the affected leg is kept straight.
Shift the weight of the back leg to the front leg and press the heel of
the back leg firmly into the floor. Rest the hands on a stationary object
(no bouncing). The stretch should be felt high in the calf. Hold the
stretch for 15 to 20 seconds, followed by a rest period of 10 to 20
seconds, and repeat three times.
Stretching of the short calf muscles (Figure 3). Start from the same
position as above, but now bend the knee of the back leg, while
keeping the heel on the floor. The stretch is felt low in the calf. Hold
the stretch for 15 to 20 seconds, followed by 10 to 20 seconds rest, and
repeat three times.
Strengthening the foot muscles. Sit on a chair. Write the alphabet in

the air with the foot of the injured leg. Fold a towel by grasping it with
the toes of the injured leg. Perform this for 15 to 20 seconds, followed
by 10 to 20 seconds rest, and repeat 10 to 20 times.
Strengthening the calf muscles (Figure 4). Stand on your toes on a
stair or bench and move up and down. It is best to use both legs while
going up, and to lean on the injured leg only when going down. This
exercise needs to be repeated seven days a week, twice a day for five
minutes, for twelve weeks. The exercise should be performed both
with an extended knee as with a slightly bent knee. You
should continue the exercise, even if you

feel pain and stop only if the pain becomes really severe. The exercise
can be made harder by carrying a filled knapsack.
Cycling or swimming for 15-30 minutes every day to preserve
general fitness.
Stage 2. Build-up
As soon as the Stage 1 exercises can be performed well and the patient
can walk without pain, work can start on a return to sport.
Take small, quick steps on the spot, alternating the left and the right
leg.
If this goes well, start with easy jogging. Take small steps and use
the entire foot.
Now you are ready for some easy running.
The next step is to include some sprinting exercises, starts, stops and
turns in the training.
This can be followed by jumping exercises
Step 3. Return to play
A return to the tennis court should now be possible. Start against the
practice wall or with mini-tennis and gradually increase the distance to
the wall, or use a full court. Make sure you position yourself well for
the ball by taking small steps.
A start can now be made with volley exercises.
The next step is some easy hitting from the baseline.
In the course of the next two weeks, gradually incorporate exercises
that require running longer distances to the ball (tennis drills from side
to side).
Next, include low volleys and overheads.
Start playing points, then games, and then a full practice match. Once
practice matches have been completed for two successive weeks
without problems, the player is ready for match play.
It is not always possible to prevent a reoccurrence of an Achilles
tendon injury, but the risk can be reduced by paying attention to the
following:
Perform a complete warm-up before play and cool down afterwards,
for approximately 10 to 15 minutes each.
Improper footwear is one of the main causes of an overuse injury of
the Achilles tendon. Stability around the ankle joint is essential. Make
sure the shoe fits well around the heel and that the base of the heel is
wide enough. The heel cap should be stable. You can test this by
pressing the heel cap with your thumb. It should be very difficult to
compress. The sole of the shoe should be supple, with a normal
unrolling from the ball of the foot to the toes. The flex point of the
shoe should be located under the ball of the foot and not under the
middle of the foot. Do not throw old shoes immediately away, but
gradually break in shoes of another type of brand. A good tip is to walk
around in new shoes before wearing them when playing.
During the unrolling of the foot a certain amount of pronation is
necessary. Excessive pronation, however, can be found with a flat foot,
cavus foot, and a leg length discrepancy. When misalignments are
present, have customised inlays or a heel lift made by a podiatrist.
After a heavy practice or match a massage may help to relax the calf
muscles and to relieve the tension of the Achilles tendon. In addition,
blood flow of the tissues is increased, which will reduce muscle cramp
and enhance recovery.
Do not increase the frequency or duration of the practice too quickly.
If there are any drastic changes, such as new shoes or a change of
playing surface, the body must be given enough time to become
accustomed to the change.
During the recovery period after an ankle injury there may be
temporary Achilles tendon problems. This may be caused by the fluid
around the Achilles tendon and increased instability of the ankle,
which increases the load on the Achilles tendon. These complaints can
be overcome by temporary use of an ankle brace.
Ankle Sprain
Diagnosis
A sprained or twisted ankle is the most common tennis injury. In

most cases, the injury is caused by landing on the outside of the
foot, with the foot turning too far inwards. The relatively weak
lateral ankle ligaments are then injured (Figure 1, 1a and 1b).
An injury of the much stronger ligament on the inside of the

ankle (medial ankle ligament) is far less common (5-10% of
cases). Depending on the severity of the injury, the ligaments
may be overstretched or torn, resulting in instability of the ankle.
The symptoms are pain and swelling around the ankle, mainly
on the outside, later followed by discoloration of the skin.
First aid
Perform the following as quickly as possible, during the first 48

hours:
Rest (immobilisation). Do not play tennis and do not lean on the

ankle.
Cool the painful area directly with ice, a cold pack or cold running
water for 10 to 15 minutes. Repeat this several times a day (aim for 20
minutes every 2 hours). Do not place the ice directly on the bare skin,
but cover the ice or cold pack with a towel.

Apply a compressive bandage immediately. This is even more
important than cooling with ice, as it will stop the bleeding and prevent
severe swelling of the ankle due to an accumulation of blood. The
ankle cannot be taped until the swelling subsides.
Elevate the lower leg and the ankle above the heart whenever
possible (i.e. lie on the floor and place the entire leg on several pillows
to decrease swelling).
Immediate and adequate first aid is important to ensure fast healing. In
more serious cases, a visit to the doctor is recommended to rule out a
fracture and to determine whether crutches or a boot are necessary. The
doctor may refer the patient for physiotherapy.
Rehabilitation can begin when most of the pain and swelling have
disappeared (after 2 to 5 days). During the build-up phase, pain is a
signal to rest. Do not cross the pain threshold, as this will slow down
the healing process. The build-up of the training load takes place in
three stages, as described below, together with some practical tips.

As much as the pain allows, you may stand on the foot. Crutches can
be used to support the ankle/foot during the first week, but try to walk
normally, from heel to toe.
Sit down in a chair. Lift the injured foot and circle the ankle 10 to 20
times. Make the circles slow and wide, first with a clockwise set, then
an anti-clockwise set.
Sit on a smooth surface. Lay a towel on the floor in front of you. Put
the injured foot on the towel, with both the heel and the toes touching it
(Figure 2). Move the feet with the towel alternately forwards (extend
the knees) and back (bend the knees). Both the heels and the toes
should stay in touch with the ground.
Stand straight and walk on your heels. The forefoot and mid-foot
must not touch the ground. Take small steps. Then walk on your toes.
Finally, walk on the inside of your feet, pressing the big toe firmly into
the ground.
Stand on the injured foot, with arms spread to keep your balance
(Figure 3). Shut your eyes and try to still keep your balance.
Sit on a chair with your feet on the floor (Figure 4). Tie one end of
an elastic tube to the chair. Wrap the other end of the tube under the
middle of the injured foot. Bend the knees 90 degrees. Move the foot
against the resistance of the elastic tubing outwards and try to keep the
outer side of the foot facing up. Repeat 10 to 20 times. Try to hold the
knee and upper leg stable.

Swim or cycle for 15-30 minutes each day to preserve overall
physical fitness.
Stage 2. Build-up
As soon as the player can perform the above exercises well and can
walk without pain, he/she can start building up strength for a return to
sport.
Slowly rise onto your toes and hold this position for 10 to 20
seconds. Return to the starting position. Perform this exercise with first
with both feet together, then using the injured leg only.
Stand on the injured leg. Bounce a tennis ball against a wall or on the
floor and catch it again without losing your balance. Try to vary the
point of the bounce as much as possible. A variation on this exercise is
to stand on one leg and try to juggle with one, two, three or even more
balls.
Take quick, small steps, alternating the injured and uninjured legs.
A very good exercise for the muscles around the ankle and foot is
skipping. This should be done with care, however. It is important to
build up this exercise gradually, from one minute a day to 10-15
minutes daily. Use a soft surface, such as grass or carpet, and wear
either tennis or running shoes.
If this goes well, you can start jogging. Start with an easy warm up,
then progress to straight running, followed by the introduction of starts
and stops into your running exercises.
Finally, include sprints and jumping exercises.
Now you are ready to go back on court again. Initially, the ankle
should be taped or lace-up brace should be used, to help prevent re-
injury of the ankle ligaments.
Start against the practise wall or with mini-tennis (playing within the
service lines). Gradually increase the area of play and move back
towards the baseline. Make sure you use small steps to position
yourself correctly for the ball.
This can be followed by volley exercises.
After 1-2 weeks, you can start including exercises in which you run
longer distances to the ball (tennis drills, from side to side).
Include low volleys, followed by the serve and overhead.
As soon as you can hit a jump smash without problems, you can start
playing practice matches.
Take care with explosive or unexpected movements, or strokes in
which your foot is perpendicular to the running direction, such as wide
backhands.
In this phase, it is important to increase the loading capacity of the
ankle, to regain your rhythm and to win confidence.
Once you have been able to play practice matches for two successive
weeks without problems, you will be ready for match play again.
It is not always possible to prevent an ankle sprain, but the risk can be
reduced by paying attention to the following:
Perform a complete warm-up before each practice or match, and a
cool-down afterwards, both lasting 10-15 minutes. Pay attention to the
correct performance of stretching exercises. Stretching exercises for
the calf muscles are especially important.
Ensure a gradual build-up of training, so the body can get used to the
extra load.
Wear firm, stable, well-fitting tennis shoes and pay attention to how
the shoelaces should be tied. An ideal tennis shoe should have good
shock absorption, sideways stability, feeling with the surface (grip) and
optimal comfort.
Remove all the balls from the tennis courts, to avoid tripping over
them.
Improve your physical condition with regular jogging or cycling.
Most injuries tend to occur towards the end of the match or at the end
of the day, when you are getting tired. The better your physical
condition, the lower the risk of injury.
Improve proprioception and strength of the muscles around the ankle
with co-ordination and balance exercises. Standing on one leg is a
particularly useful exercise. The exercises can be made more difficult
by using a wobble board.
A tape, brace or high shoe will help protect the ankle ligaments,
especially during the first three months after the injury, and have been
shown to reduce the risk of re-injury. Contrary to common belief, this
does not weaken the ankle.
Calf Muscle
Strain
Diagnosis
Tennis leg is an incomplete rupture of the inside of the calf

muscle (Figure 1 and 1a). It is a typical tennis injury that often
occurs in players in the 35 to 50 age group. This muscle injury
may occur as a result of a sudden contraction of the calf
muscles, for instance during a sprint.

Symptoms are a sudden, sharp or burning pain in the leg,
sometimes accompanied by an audible sound. In most cases,
the player is unable to continue play because of the severe pain.
Depending on the severity of the injury, recovery may take
between a few days and six weeks.
First Aid
The following action should be taken as quickly as possible,

certainly within 48 hours.
Rest (immobilisation). Stop playing tennis and do not lean on the

foot.
Cool the painful area directly with ice, a cold pack, or cold running
water for 10 to 15 minutes and repeat this several times a day. Do not
place ice on the bare skin. Place a towel between the skin and the ice
pack to avoid injury from the ice pack.
Apply a compression bandage. This is important, as it compresses
the small vessels in the calf and limits the bleeding.
Elevate the lower leg.
Fast and adequate first aid is of major importance
for a quick recovery. In severe cases, or if in doubt, the injury should
be evaluated by a physician, who may make a referral for
physiotherapy.
When the worst pain and swelling have subsided (after 1 to 2 days),
start to build-up the training load. During this period, pain is a signal to
rest.
Do not to cross the pain threshold, as this will slow down the
healing process. The training load is built up in three steps.
These are described below, with several tips.
If the pain allows it, you may put weight on the foot, if necessary
using elbow crutches during the first week. The foot should be used in
a normal fashion.
A heel lift (with shock absorption) in both shoes for one to two
weeks may help to ease the load on the calf muscles during walking.
Viscoheels are very useful for this purpose.
Swimming or cycling for 30 minutes every day increases the blood
flow to the calf muscles and enhances

recovery.
Stretching the long calf muscles (Figure 2). Step forward with the
unaffected leg, keeping the heel of the back leg on the floor. The knee
of the affected leg is kept straight. Shift the weight of the back leg to
the front leg and press the heel of the back leg firmly into the floor.
Rest with your hands on a stationary object. The stretch is felt high up
in the calf. Hold the stretch for 15 to 20 seconds without bouncing,
followed by a rest period of 10 to 20 seconds. Repeat 3 times.
Stretching the short calf muscles (Figure 3). Start from the same
position as described above, but now bend the knee of the hind leg,
while keeping the heel on the floor. The stretch is felt low in the calf.
Again, hold the stretch for 15 to 20 seconds (no bouncing), followed
by 10 to 20 seconds rest, and repeat 3 times.
the air with the foot of the injured leg. Fold a towel by grasping it with
the toes of the injured leg. Perform this for 15 to 20 seconds, followed
by 10 to 20 seconds rest, and repeat 10 to 20 times.
Stage 2. Build-up
As soon as all the above exercises can be performed and walking is
possible without pain, a return to tennis and other sports can be
considered.
Start by strengthening the calf muscles (Figure 4). Slowly rise onto
your toes and hold this position for 10 to 20 seconds. Then return to the
starting position. Perform this exercise with both feet at the same time,
then when leaning on the injured leg only. If using body weight is too
painful or difficult, elastic tubing may be used to work the plantar
flexors (i.e. push the toes and forefoot down against the resistance of
the elastic tubing).
leg.
If this goes well, you can begin jogging. Start with an easy jog, then
include some sprints and straight running, followed by quick turns,
starts, and stops.
Finally, you can include jumping exercises.

the wall or your opponent on the court. Make sure you position
yourself well for the ball by taking small steps.
In this phase you can also include volley exercises.
Gradually (in the course of one to two weeks) include more exercises
that involve moving longer distances towards the ball.
Next, include low volleys, followed by overheads and services.
As soon as you can hit a smash with footwork without problems, you
are ready to start playing points, games and a practice match.
Once you have played practice matches for two weeks in succession
without problems, you can start playing matches again.
It is not always possible to prevent tennis leg, but the risk can be
reduced by paying attention to the following points:
Perform a complete warm-up before play and a cool down
afterwards, for approximately 10 to 15 minutes each. Pay close
attention to correct stretching exercises. Stretching exercises for the
calf muscles are particularly important.
Build up training gradually, so that the body can slowly adapt to the
increased load.
Adapt clothing to the weather conditions. Particularly at the start of
the season or if there is a biting wind, it may be wise to keep the track
suit or running tights on during the warm up. Well-warmed muscles
and tendons are better able to withstand pulling and traction forces than
cold muscles.
Wear properly fitting tennis shoes with good shock absorption,
sideways stability, feeling with the playing surface (grip) and optimal
comfort.
Massage calf muscles if they feel stiff and tense.
Maintain strong calf muscles, with adequate rest in your training
programme. Steps, cycling and running are ideal exercises for calves.
Groin Injury
Diagnosis
A groin injury is a strain or (partial) tear of one of the adductors,

the inner thigh muscles (Figure 1). The injury usually occurs at
the junction between the muscle and tendon or at the tendon
attachment to the pelvic bone.
The adductor langus is the

muscle which is most frequently affected. Groin injuries often
occur when playing tennis, as the side to side movements and
sudden stops and changes of direction require a strong
contraction of the adductors. One of the main causes is losing
ones step when reaching out for a ball on a surface which is too
slippery, which can result in a player performing the splits and
over-extending the groin muscles.
A sudden sharp pain may be felt in the groin area or inner thigh.
There may be tightening and hardening of the groin muscles.
The adductor tendons or the pubic bone feel tender upon
palpation. Contracting the groin muscles (pressing the legs
against one another) is also painful. There may be bruising or
swelling, although this might not occur until a couple of days
after the initial injury. With a severe injury, a small dip may be
visible or felt.
Muscle tears are classified according to their severity as grade

1, 2 or 3. A grade 1 tear is a mild muscle tear. There is a slight
tear without being obviously visible (its size is microscopically
small). There is usually no significant loss of strength. A grade 2
muscle tear is a moderate muscle tear. There is clear tearing of
some of the muscle fibres and a loss of strength.
A grade 3 tear is when the entire muscle has been torn.

Fortunately this is not very common. Healing may take between
two and 20 or more weeks, depending on the severity of the
injury and the players age. In the case of players over 30 years
of age, tissue quality diminishes and the healing process often
takes longer. Tendon attachment injuries in particular may
sometimes be very persistent.
What should you do? First aid!
Do the following as soon as possible, for 48 hours:
Ice
Cool the painful area directly with ice or a cold pack for 10 to 15
minutes and repeat this several times a day. Do not place ice on bare
skin, but place a towel between the skin and the cold pack. Men should
take care not to freeze the scrotum
Immobilisation
Stop playing any kind of sport and avoid putting weight on the leg.
Compression
Apply a compression bandage. This will help deter minor bleeding
caused by the muscle tear in the thigh. Remove the bandage if it starts
feeling too tight or if the calf starts swelling.
Immediate and effective first aid is essential for a rapid recovery. Have
a (sports) physician examine the injury if it seems serious or if in
doubt. In some cases the player will be referred to a (sports)
physiotherapist.
As soon as the worst of the pain and swelling have subsided (between
several days and a week) you can start building up strength. If you feel
pain during the build-up, this is a warning sign to stop and rest. Be
careful: do not exceed your pain threshold, as this will only delay the
healing process! The build-up consists of three stages, ranging from
light to demanding. Here are the exercises, along with some tips.
Carefully put weight on the leg, as long as it is not painful. If
necessary, use an elbow crutch for the first few days.
When the leg stops hurting in the course of your daily activities, you
can become more active, for example by cycling. This stimulates
circulation in the thigh muscles and will assist the healing process..
Muscle strengthening (short adductors): Lie down on your back with
your knees bent and feet flat on the ground. Squeeze a ball between
your knees. Press the ball with your legs for five seconds, release and
repeat. Do one set of 10 repetitions.
Muscle strengthening (long adductors): Lie down with your legs
extended in front of you; squeeze a ball between your ankles. Press the
ball with your ankles for 30 seconds, release and repeat. Do one set of
10 repetitions.
Muscle strengthening (short adductors): Lie down on your back with
your knees bent and your feet flat on the ground. Slowly move one
knee outwards towards the ground and slowly bring it back up again.
Stretching the inner thigh muscles (short adductors, figure 2). Sit
cross-legged on the ground. Place the soles of your feet together. Sit up
straight and gently push your knees towards the ground with your
elbows until you feel a stretch. Hold this position for 20 to 30 seconds,
followed by a 20 to 30 second rest. Repeat this three times.
Stretching the inner thigh muscles (long adductors, figure 3). Stand
up straight and take a long step sideways with your right leg. Bend the
right knee and shift your body weight above this knee, thereby
stretching the left knee. Bend the knee until you feel the stretch in the
left groin. Hold this position for 20 to 30 seconds, followed by a 20-30
second rest, and repeat three times. Repeat this exercise for the other
leg.
Stage 2. Return to Training
As soon as all of the above exercises can be performed confidently and
free of pain, you may consider returning to sport
Take small, quick steps on the spot, alternating the left and right leg..
Muscle strengthening (long adductors, figure 4): Lie down with your
legs extended in front of you; squeeze a ball between your ankles.
Press the ball with your ankles for 30 seconds, release and repeat. Do
one set of 10 repetitions.
Muscle strengthening (Long adductors, figure
5 ): Attach one end of an exercise band to a

secure object and tie the other end around your ankle. Stand in a
position whereby the outer side of the leg which requires strengthening
is facing the secure object and move the leg against the resistance of
the exercise band across the front of your body. Do five sets of 10
repetitions, and then change legs. You can make this exercise harder by
gradually increasing the number of repetitions and/or by stretching or
folding the exercise band.
Muscle strengthening (Abductors, figure 6): Turn around so that your
inner leg is now facing the secured end of the exercise band. Move the
leg slowly outwards against the resistance of the band. Do five sets of
10 to 15 repetitions. Repeat the exercise with

the other leg. The exercise can be made more difficult by gradually
increasing the number of repetitions and/or stretching or folding the
exercise band.
Lunges. Place your feet shoulder width apart. Take a long step
sideways with one leg, whereby you bend your knee at a 90 angle, and
it does not protrude beyond your foot. Keep your back straight. Lower
yourself gently, release and come back to standing. This exercise can
be made more difficult by holding a small weight or by doing the
exercise at a quicker pace. Start off with two to three sets of 10
repetitions.
The next step is to start jogging. Start off at a
slow pace, followed by sideways hops. Once

you have practised this several times, you can step up the pace, adding
pivots, turns and short sprints.
Finally you can start doing jumping exercises, such as leaps, side
steps, hops and lunges.
You are now ready to go back to the tennis court. Start off by playing
against a practice wall or with a game of mini-tennis, which will allow
you to move backwards slowly
Start off by playing against the practice wall or with a game of mini-
tennis, which will allow moving backwards slowly.
At this stage you can also practice volleys.
Proceed by gradually doing more exercises (over one or two weeks),
whereby you have to move greater distances to reach the ball (tennis
drills from corner to corner).
The next step is to include lower volleys and smashes.
When you are able to perform smashes and the combined volley
smash confidently, you can start playing practice sets.
Once the practice sets have been going well for two weeks, you are
ready to start playing matches again.
Unfortunately groin injuries cannot always be avoided. However, you
can minimise the risk by observing the following guidelines:
Do a thorough warming-up before, and cooling-down after a training
session or a match for about 10 to 15 minutes each. Make sure the
stretching exercises are performed correctly. In particular, the
stretching exercises for the adductors are important.
Make sure you have properly fitting tennis shoes which have good
lateral support and an appropriate sole for the court surface you are
playing on.
Avoid being insufficiently prepared for a tennis match or game,
resulting in playing too many games in too short a period. Fatigue
plays an important role in the occurrence of this kind of injury. Regular
games of tennis, jogging, on-line skating, fitness or cycling can reduce
your chance of sustaining an injury.
Adapt your clothing to the weather. Especially at the beginning of
the season, or when there is a strong wind, it is advisable to wear a
track suit at least during the warm-up. An elastic bandage can be
worn to protect the thighs and keep them warm. Muscles and tendons
that have been warmed up properly are more resistant to stretching and
pulling than cold muscles.
When you return to play after an injury consider taping your thigh
for the first few games, as a preventative measure.
Heel Pain
Diagnosis
Plantar fasciitis is an overuse injury at the point where the
plantar fascia anteromedial attaches to the heel (Figure 1 and
1a). Degenerative changes of the plantar fascia occur at the
attachment site to the bone, as a result of repetitive micro
ruptures.
A heel spur is calcification caused by repeated pulling away of
the periosteum from the calcaneus. This can be demonstrated
by X-rays. However, heel spur itself is not the cause of the pain.
Plantar fasciitis is common among players who perform a great
deal of jumping and sprinting.
Common symptoms are a localised, sharp pain and/or swelling
at the inside of the heel, deep under the fat pad of the
calcaneus, as well as pain during exercise. Rest gives
immediate pain relief, although there may be some nagging pain
after exercises or at night.
There is generally pain and stiffness in the morning and at the
start of exercise, when the area around the heel is cold and
contracted.
First Aid
Fast and adequate first aid treatment is very important to ensure
a speedy recovery. In serious cases or when in doubt, the injury
should be evaluated by a physician. He/she may refer the
patient to a physiotherapist for further treatment.
The following general measures can be taken to ease the pain:
activity modification, unloaded exercise, cooling with ice, stretching
and wearing firm, well-cushioned, orthotically-designed shoes.
When there is pain and swelling, ice massage can be helpful. Use a
melting ice cube or a polystyrene cup filled with ice. Massage the
painful spot. Five to eight minutes of massage will generally be
sufficient. Repeat this several times a day.
Massaging the soles of the feet by rolling the feet over a can or bottle
will also help to relax the fascia and the muscles.
In feet with a collapsed arch (flat feet) or excessive pronation, the
plantar fascia may become overloaded during running and tennis.
When the plantar fascia is very tight, as in cavus feet, there may also
be considerable pressure at the attachment to the heel bone. Make sure
the feet receive adequate support by using an inlay, shoes with sturdy
soles or tape.
Temporary use of a shock absorbing heel lift can be useful. The
advantage of a heel lift is that there is less tension on the plantar fascia,
because the calf muscles are more relaxed.
When the initial pain and swelling have disappeared, the player can
start to build up the volume and/or intensity of training. However, the
onset of pain during this period is a signal to take some rest. If players
go beyond their pain threshold, this is likely to slow the healing
process.
Training load should be increased in three stages, as follows:

Stretching the foot muscles. Kneel on one knee, with the toes on the
floor (Figure 2). A stronger stretch can be felt by grabbing the toes of
the foot with one hand and pulling the toes and feet as far backwards as
possible (Figure 3).
Stretching of the long calf muscle. Take one step forward with the
uninjured leg. The knee of the injured leg is kept straight. Shift the
weight of the back leg to the front leg and press the heel of the back leg
firmly into the floor. Rest with the hands on a stationary object (no
bouncing). The stretch is felt high in the calf. Hold the stretch for 15 to
20 seconds and follow this with a rest period of 10 to 20 seconds.
Repeat three times.
Stretching the short calf muscles. Start from the same position as
described above, but now bend the knee of the back leg, while keeping
the heel on the floor. The stretch is felt low in the calf. Hold the stretch
for 15 to 20 seconds, then rest for 10 to 20 seconds. Repeat three times.

the air with the injured foot. Fold a towel by grasping it with the toes
of the injured leg. Perform this for 15 to 20 seconds, then rest for 10 to
20 seconds. Repeat 10 to 20 times.
A night splint with the ankle in a neutral position and the toes
maximally bent backwards/upwards reduces the healing time. The
night splint is applied with an elastic band.
Cycling or swimming for 15 to 30 minutes every day preserves
general fitness.
Stage 2. Build-up
As soon as the player can perform the above exercises well and can
walk without pain, he/she can start building up strength for a return to
tennis.
Slowly rise to your toes and hold for 10 to 20 seconds, then return to
the starting position. First perform the exercise with both feet at the
same time, then with the injured leg only.
Walk on your toes, then on your heels.
leg.
If this goes well, introduce easy jogging. Take small steps and use
the entire foot.
This can be followed by some easy running.
The next step is to include sprinting exercises, starts, stops and turns
in the training.
Jumping exercises are the final step in the build-up stage.
the wall, or use a full court. Make sure you position yourself well for
the ball by taking small steps.
A start can now be made with volleys.
In the course of the next two weeks, gradually incorporate exercises
that require running longer distances to the ball (tennis drills from side
to side).
Next, include low volleys and overheads.
Start playing points, then games, and then a full practice match. Once
practice matches have been completed for two successive weeks
without problems, the player is ready for serious tournament play.
It is not always possible to prevent the recurrence of an injury to the
heel, but the risk can be reduced by paying attention to the following:
Perform a complete warm-up before play and cool down afterwards,
for approximately 10 to 15 minutes each.
Use correct form when stretching. Stretching exercises for the foot
and calf muscles are of particular importance.
Ensure a gradual build-up of the training programme, so that the
body can slowly adapt to the extra training load. Many players suffer
injuries when they switch from a clay court to a hard court or during
the transition from outdoor to indoor play. After a holiday, illness or
when practising on a hard court, gradually increase the training load
over the course of one to two weeks.
Wear well-fitting tennis shoes with a firm heel cap and adequate arch
support.
Use proper shoes during off-court (conditioning) training. In casual
settings, firm walking shoes are more comfortable than unstable, light
shoes or high heels. A sudden decrease in heel height can increase the
potential for heel injury if a players tendons and muscles lack
flexibility.
Do not throw out old shoes immediately. Break in new shoes
gradually and walk around in them for a day or two first, to help wear
them in.
Improve the co-ordination (proprioception) and strength of the
muscles around the ankle. Performing exercises on one leg is an
effective way to do this. Additional complexity (difficulty) can be
added to these exercises if the player stands on a wobble board
Iliotibial Band Friction Syndrome
Description
Iliotibial band friction syndrome is an overuse injury of the
iliotibial band, the broad tough band of fibers that runs down the
outside of the thigh passing the knee. This injury is caused by
the fibres of the band rubbing on the femur bone, just above the
knee joint where there is a bony prominence (figure 1).
The iliotibial band is an extension of the tensor fascia lata

muscle which is located at the side of the hip. Risk factors are
bow legs, over pronation, worn out shoes and running on
cambered surfaces. These factors all cause extra tension on the
iliotibial band which leads to more friction.
A weakness of the hip and buttock muscles can also contribute
because the opposite side of the pelvis will dip down more also
pulling on the iliotibial band (figure 1). A tight iliotibial band and
sharp increase in the amount of training can also contribute to
this injury.
Symptoms
The symptoms are pain and swelling located at the side of the
knee (the outside) and the pain can sometimes radiate up the
outside of the thigh. Players tend to have more pain while
jogging than while playing tennis. The pain usually starts after a
fixed distance (2 to 3km) and will force the player to reduce the
speed or walk.
First Aid
It is advisable to modify activities (reduce playing and training but
you do not have to stop altogether), use ice to cool the area, stretch the
thigh and hip muscles and make sure that the shoes are not worn and
offer good support.
Cooling can also be done by performing ice massage. To do this use
an ice cube or a paper cup with ice. Rub the ice on the painful area for
ten to fifteen minutes. If using a cool pack be sure to place a towel
between the cool pack and the skin to prevent freezing injury.
Immediate and effective first aid is essential for a speedy recovery.
Have a (sports) physician examine the injury if it looks serious or if
there is any doubt. In some cases the player will be referred to a
(sports) physiotherapist.
Pain is an important signal. If pain occurs do not play or train
through the pain, because this will delay

recovery.
Rehabilitation progresses in three steps, from light to demanding.
Here is a list with descriptions and tips for doing these exercises.
Stretching the muscle (tensor fascia lata) at the side of the hip
together with the iliotibial band will reduce the tension or decrease the
amount of friction (figure 2). Stand with the left leg crossed behind the
right. Bend your body as far as possible to the right. Reach up with
your left arm past your left ear and then over your head to the right to
give an extra stretch. Hold the stretch for fifteen to twenty
seconds and then rest for fifteen to twenty

seconds. Repeat this three times on both sides.
Strengthen the buttock muscles (gluteus medius, figure 3). Use a step
(20 to 30cm) or stand on the stairs. Stand with one foot on the step and
keep the other foot on the ground. The thigh of the leg up on the step
should now be horizontal with the floor. Lift the front foot up off the
step and concentrate on keeping your balance. Stop your pelvis from
dipping to the side or wobbling. Hold the foot up for three seconds and
then lower it slowly. Perform ten to fifteen repetitions on each leg. You
can make it more difficult by using ankle weights.
Strengthening the hip muscles (abductors, figure 4). Lie on your right
side with your legs straight. Contract the muscles in the thigh and pull
your toes up. Lift the left leg, keeping the knee straight, until the foot is
20 to 30cm off the ground. Hold the leg in this position for three
seconds and then lower it slowly. Perform this exercise slowly and
build up to three sets of fifteen repetitions. Perform this exercise for the
other leg too. To make it harder support yourself, using your elbows
and ankles, so that your body does not touch the ground (figure 5) or
use an ankle weight.
Stage 2. Returning to Training

When you can perform all the exercises in stage 1 easily and without
problems it is time to think about playing again. Here are some
exercises to help during this stage.
Strengthening the thigh muscles: Half squats. Stand with the feet
shoulder-width apart. Bend the knees while keeping your back straight.
Hold your arms out in front of you. Do not bend the knees further than
90 degrees or allow the knees to go further forward than the toes. Build
up to three sets of fifteen repetitions.
Strengthening the thigh muscles: Single leg step. Stand on the
involved leg facing sideways on a step leaving the other leg hanging
over the edge. Bend the involved leg and point the toes of the other
foot towards the ceiling. Touch the step below you with the heel of the
other leg and then straighten the involved leg. Start with one to two
sets of ten to fifteen repetitions and build up to three sets of fifteen
repetitions.
Make small quick steps on the spot, shifting support between the left
and right leg.
Strengthening the thigh muscles: Lunges. Place the feet shoulder-
width apart. Bent the leg until the knee is bent at a 90-degree angle. Do
not let the knee protrude in front of the foot. Keep your back straight.
Bend further into the knee and then step backwards. You can make the
exercise more difficult by holding a weight or by performing the
exercise more quickly. Build up to two to three series of ten to fifteen
repetitions.
In the event of a mild injury, there is no need to stop playing tennis
altogether, as long as you adapts your game to the restrictions imposed
by the injury. In general continuous jogging is worse for iliotibial band
friction syndrome than playing tennis.
Adapt your training program, allowing you to start off hitting the ball
from an area measuring two square meters (approx. two square yards).
In this way you can continue practicing your footwork (taking small
steps, positioning yourself correctly to hit the ball) without putting
excess strain on the knee.
Initially, you should limit activities that will put excess strain on the
knee, such as sprints, jumping exercises, low volleys, intensive left-
right exercises and serve and volley training.
If the adapted training goes well you can gradually start doing more
exercises, and increasing the distance you have to run to reach the ball
(tennis drills from corner to corner).
After this, low volleys and smash hits can be added to the training
program.
If this goes well then you can start running again. Start slowly with a
warming-up after which you can do several interval accelerations. Do
some turning and twisting movements while running. If this goes well
you can progress to several short sprints.
After this jump training should be included such as: hopping,
bounding and sideways jumps.
Do not increase your running time or distance by more than 10%
each week.
Unfortunately it is not always possible to prevent recurrence of
iliotibial band friction syndrome. The risk can be reduced following
this advice:
Be sure to perform a thorough warming-up and cooling down which
should last at least ten minutes. Pay attention to stretches, especially
the stretch for the tensor fascia lata muscle and the iliotibial band
(figure 2).
If you ride a bike make sure that the saddle is not too high or too far
back.
Increase the intensity and the extent of the exercise gradually in
order to avoid straining. This is especially important if you are
planning to run hilly routes.
Wear properly fitting tennis shoes when playing tennis, and properly
fitting trainers when working out. It is essential for the shoes to be
adapted to your weight and to the surface you will be playing on.
If you have knock knees, bow legs, flat feet or high arches consult a
shoe expert or podiatrist to see whether shoe orthotics are needed.
If you run on a cambered surface the downside leg is put under extra
strain be sure to change direction regularly to even out the load.
Impingement Syndrome
Diagnosis
Impingement syndrome causes pain in the shoulder, when lifting
the arm between 60 and 120 degrees sideways, or when
rotating the lifted arm inwards. The nagging pain occurs
because the supraspinatus tendon (the muscle under the roof of
the shoulder) and/or the bursa are pinched and aggravated
when lifting and rotating the arm.
The two most common areas where impingement occurs are:
a. Subacrominal or external impingement: between the roof of
the shoulder and the head of the upper arm.
The space between the roof of the shoulder and the head of the
upper arm is quite narrow, and becomes smaller when the arm
is lifted between 60 and 120 degrees sideways. If the
supraspinatus tendon and bursa become thicker than usual
(because they have been strained or aggravated), or the space
becomes more narrow than usual (due to bony structures or
projections) this may result in impingement (figures 1 and 2).
b. Internal impingement: between the shoulder socket and the

head of the upper arm.
When the arm is in the overhead position and rotated outwards
(the position the arm is in when preparing for a serve), the arm is
put in the maximum position for the shoulder joint, causing the
supraspinatus tendon and upper edge of the shoulder socket to
come into contact. If this is repeated continuously, the edge of
the shoulder socket as well as the supraspinatus tendon may
become impinged (figures 1 and 2).
Impingement is most commonly caused by straining (due to
performing many serves and high forehands), an imbalance of
the muscles around the shoulder (the front shoulder muscles are
much stronger than the back ones) and when shoulder blade
movements change pace (for example due to tiredness, weak
shoulder muscles or instability).
Symptoms
These include pain around the shoulder, often at the outer
portion of the upper arm. The pain is worse with overhead
activities such as serving, hitting high tops spin forehands or
hitting overhead smashes. There may be an aching pain after
play. The pain may make it difficult to sleep, especially when
lying on the affected shoulder.
Sometimes there is loss of strength, usually due to pain, though
in later stages a rotator cuff tear may develop which may also be
responsible for shoulder weakness. There may be limited
mobility of the shoulder, especially when reaching behind (back
pocket, bra) or across the body, or a catching or grinding
sensation.
Occasionally, the athlete will also note pain in the front of the
shoulder, that is worse with bending the elbow or lifting due to
involvement of the biceps tendon in the impingement process.
What should you do? First Aid!
Play less tennis and certainly perform fewer serves and
smashes. Try to minimise any movements above shoulder level!
If you absolutely must reach out for something or lift something,
rotate your arm outwards whenever possible (with the palm of
your hand turned up).
The next step is to start an exercise programme, monitored by a
(sports) physician or a (sports) physiotherapist, and thus treat
the cause of the impingement.
Cortisone injections may help in the short term as they reduce
the swelling and the worst of the pain. However, a side effect is
that they weaken the tendon tissue. When tennis is resumed,
the pain often returns, especially if the underlying cause is not
taken care of. We recommend limiting these injections,
especially for competition tennis players.
Surgery is generally only considered if, after intensive remedial
therapy, pain has not clearly subsided or disappeared and/or
there is an anatomical impediment which causes the pain to
persist.
Posterior shoulder stretch. Extend your injured arm in front of you to
shoulder level and take hold of your elbow with your other hand. Draw
your elbow in towards you until you feel a stretch at the back of your
shoulder (figure 3). Do this for 20 to 30 seconds, followed by a 10 to
20 second rest. Repeat three times.
Also do muscle strengthening exercises to strengthen the muscles
which stabilise the shoulder blade. Gradually build up the exercises. It
is alright to feel something in your shoulder whilst performing these
exercises, however the pain should have dissipated once you have
finished them. Start with a set of 10 to 15 repetitions per exercise, with
a 60 second rest between each set. An exercise band or small free
weight can be purchased in a sports shop.

Protraction and retraction of the shoulder (figure 4). Attach an
exercise band to a fixed sturdy object. Stretch out your injured arm and
pull the exercise band back, whilst keeping your arm straight. This is
done by moving your shoulder forwards (rounding your
shoulders) and then back again (straightening your shoulders)
Protraction and retraction of the shoulder (figure 4). Attach an
exercise band to a fixed sturdy object. Stretch out your injured arm and
pull the exercise band back, whilst keeping your arm straight. This is
done by moving your shoulder forwards (rounding your
shoulders) and then back again (straightening your shoulders).
Sawing (figure 5). Attach an exercise band to a fixed sturdy object.
Using a sawing motion, pull the exercise band towards your waist, and
back again.
Extension (figure 6). Attach the middle of the exercise band to a fixed
sturdy object in front of you. Hold on to the ends and stretch both arms
along the side of your body. Keeping your arms straight, stretch them
against the resistance of the band, and then back again.
Stage 2. Strengthening the Rotator Cuff
As soon as you are able to perform the exercises described above
confidently and you can stabilise the shoulder blade, you can start
performing muscle strengthening exercises

for the actual rotator cuff.
These exercises are quite tough, so do not perform them every day and
incorporate a day off. This will enable the muscles and tendons to heal
and adapt. Gradually build up to three sets of 15 to 20 repetitions per
day, with a 60 second rest between each set.
Exercising the front of the shoulder: attach an exercise band to a
fixed sturdy object to the right hand side of your body. Place your right
elbow on your side so that your forearm is pointing forward.
Remaining in this position, rotate your arm towards your stomach.
Repeat on the left side.
Exercising the back of the shoulder: attach the end of an exercise
band to a fixed sturdy object to the left hand

side of your body. Place your right elbow on your side so that your
forearm rests on your stomach. Remaining in this position, rotate your
arm outwards by 70 degrees and back again. Repeat on the left side
(figure 7).
Wall push-ups: lean your hands against a wall, standing at a distance
of approximately one metre. Now do wall push-ups, changing the
position of your hands (hands closer together, hands further apart, one
hand above the other, using only one hand etc.). The closer you stand
to the wall, the easier the exercise is. You can increase the difficulty by
standing further away from the wall. You can target the specific
muscles which need to be strengthened even more in this exercise by
pushing yourself even further away from the wall whilst rounding your
shoulders (push up plus).
Rowing: attach the middle of an exercise band to a fixed study object
in front of you. Grasp each end of the exercise band and pull your
elbows back. Hold for a few seconds and then slowly release the band.
Maintain a constant and even tension, and tuck in the abdominal
muscles.
When you can do all of the exercises confidently and without pain, you
are ready to play tennis again.
At first avoid any overhand strokes. Start off by playing against a
practise wall or by playing mini-tennis, gradually taking small steps
back. Use an underhand serve, delivering the ball below shoulder level
as much as possible.
Subsequently step up baseline speed, only hitting the ball flat. Only
play low volleys when using a net.
You may gradually start including topspins and higher volleys.
The next step is to throw a ball over the net. Standing at the service
line, throw the ball overhead to the other side of the net. Once this is
going well, gradually increase distance and speed.
You can now start incorporating serves. The first time you do so,
serve without using a ball. Then serve standing at the service line.
Gradually increase distance and speed. You may also perform a gentle
smash. Pay close attention to technique and timing.
The next step is to play points, and then a game, a practice set and a
practice match. Once practice matches have been completed for two to
four weeks pain free, you can sign up to play a match!
Shoulder injuries cannot always be avoided. However, you can
minimise the risk by observing the following guidelines:
Regularly stretching the back of the shoulder minimises the chance
of sustaining (another) impingement.
Be sure to perform a thorough warm-up before playing and a cooling
down after the training or match, for a minimum of ten minutes each.
Ensure that shoulder stretching exercises are performed correctly.
Make sure your transversus abdominis muscle is strong and that you
have good shoulder muscle balance by performing shoulder muscle
stretching exercises at least twice a week.
Build up training gradually, so that muscles and tendons can adapt to
the increased load. Allow for a sufficient recovery period between
training sessions and matches.
Jumper's Knee
Description
Jumpers knee (patellar tendinopathy) is an overuse injury of the
patellar tendon. The patellar tendon is the tendon between the
underside of the patella (knee cap) and the tibia (shin). In the
area just underneath the patella there are microscopic tears and
degeneration in the tendon (figure 1).

It is a common complaint in tennis players due to the explosive
muscle contractions needed for the sprinting, jumping and quick
changes of directions during tennis. Poor flexibility of the
quadriceps (thigh muscles), hamstrings and variations in leg and
foot type (knock knees, bow legs, flat feet etc.) can contribute to
extra load on the tendon and development of jumpers knee.
Symptoms
Typically there is a sharp pain in the tendon below the knee cap
which is present during jumping, sprinting, serving and change
of direction after running wide to reach a ball. Often there is an
aching pain after finishing playing tennis.
First Aid
It is advisable to modify activities (reduce playing and training), use
ice to cool the area, stretch and strengthen the thigh muscles and make
sure that your shoes are not worn and offer good support.
Have a (sports) physician examine the injury if it looks serious (if the
knee gives way due to the pain or if you have a lot of pain even when
not playing tennis) or if there is any doubt. In some cases the doctor
may refer you to a (sports) physiotherapist.
Pain is an important signal and you should only begin with the
exercises when severe pain has subsided. If pain occurs do not play or
train through the pain, because this will delay recovery. Rehabilitation
progresses in three steps, from light to demanding. Here is a list with
descriptions and tips for doing these exercises.
By stretching the muscles at the front and back of the thigh the
tension on the tendon can be reduced.
Stretch for the quadriceps (thigh muscles): Stand up straight and find
support for one hand. Bend one leg, take hold of the ankle and pull the
ankle towards the buttocks until you can feel the strain in the upper leg.
Bringing the upper leg further backwards can increase the stretch. Hold
this position for ten to twenty seconds, followed by ten to twenty
seconds rest and repeat three times.
Stretching exercise for the hamstrings (back of the thigh). Stand up
straight. Place the heel of the leg to be stretched in front of you and
keep the heel on the ground. Keep your back straight and lean forward
slowly from the hips until you feel a slight pull. Hold this position for
ten to twenty seconds, followed by ten to twenty seconds rest and
repeat three times.
Co-ordination training. Stand on the injured leg with arms spread,
then close your eyes and try to keep your balance. Try to hold this
position for 30 seconds.
Swaying lunges. Place the feet shoulder-width apart. Bend the leg
until the knee is bent at a 90-degree angle. Do not let the knee protrude
in front of the foot. Keep your back straight. Sway gently back and
forth transferring your weight but do not step backwards. Build up to
two to three series of ten to fifteen repetitions.
Quadriceps exercise (static). Sit down on the floor with your legs
straight. Place a rolled-up towel under your knee. Try pushing the
towel into the floor by contracting your quadriceps
muscles. Hold for three seconds and relax.

Build up to three series of fifteen repetitions (figure 2).
Cycling. A good exercise in this stage is non-strenuous cycling every
day for 15 to 30 minutes. When cycling be sure to use a bicycle with
gears. Stay in the lowest gear which will allow a high cadence. This
produces the least strain on the knee. Try to avoid headwind and steep
terrain.
Stage 2. Build-up
without discomfort, you can consider resuming your sport. Listed here
below are a few exercises to improve your sport condition.
Quadriceps exercise (static). Sit down on the floor with your legs
straight. Place a rolled-up towel under your knee. Try pushing the
towel into the floor by contracting your quadriceps muscles. Hold for
three seconds and relax. Build up to three series of fifteen repetitions
(figure 2).
altogether, as long as you adapt your game to the restrictions imposed
by the injury. With more serious injuries, training can usually be
resumed after six weeks to three months.
Try to play on clay courts as much as possible, and avoid hard
courts. The peak strain on the knee is less on a surface that allows
some sliding than it is on surfaces where this is not possible.
Adapt your training programme, allowing you to start off hitting the
ball from an area measuring two square meters( approx. two square
yards). In this way you can continue practicing your footwork (taking
small steps, positioning yourself correctly to hit the ball) without
putting excess strain on the knee.
(tennis drills from corner to corner).
program and you can resume playing (practice) matches.
If practice matches can be played without problems, then you are
ready to get back to playing competitively.
Be sure to perform a thorough warming-up. Do, in any case, some
stretching exercises for the quadriceps muscles. In this way your
muscles and the rest of your body are prepared for the work to come.
order to avoid straining. This is especially relevant in the change from
summer season to winter season when clay courts are exchanged for
the harder indoor courts.
Perform muscle strengthening exercises for the thighs to avoid (new)
knee injuries.
adapted to your weight and to the surface you will be playing on.
In the case of (moderate) foot deformities, such as bunion deformity
(hallux valgus) or high arches, it is advisable to buy special, individual
orthotics for the shoe to help correct the form of the foot and to give
arches additional support.
Fatigue will cause your condition to deteriorate and lessen the
strength of the muscles. This increases the chances of stumbling and
straining a muscle. So, make sure to stay in shape!
Regular cycling (low resistance and on flat surfaces) helps the knee
to keep functioning well.

You can try a patellar tendon strap to see if it helps.
Quadriceps exercise (dynamic): Half squats. Stand with the feet
shoulder-width apart. Bend the knees while keeping your back straight.
Hold your arms out in front of you. Do not bend the knees further than
90 degrees or allow the knees to go further forward than the toes. Build
up to three sets of 15 repetitions (figure 3).
Quadriceps exercise (dynamic): Single leg step. Stand on the
involved leg facing sideways on a step leaving the other leg hanging
over the edge. Bend the involved leg and point the toes of the other
foot towards the ceiling. Touch the step below you with
the heel of the other leg and then straighten

the involved leg. Start with one to two sets of ten to fifteen repetitions
and build up to three sets of fifteen repetitions (figure 4).
and right leg.
Quadriceps exercise (dynamic): Lunges. Place the feet at shoulder-
width from each other. Bent the leg until the knee is bent at a 90-
degree angle. Do not let the knee protrude in front of the foot. Keep
your back straight. Bend further into the knee and then step backwards.
You can make the exercise more difficult by holding a weight or by
performing the exercise more quickly. Build up to two to three series
of ten to fifteen repetitions.
Eccentric strengthening exercise for the
quadriceps. Place your feet shoulder-width

apart on an inclined board. Lower yourself while standing on the
injured knee (bend the knee approximately 60 degrees), then raise
yourself while standing on the uninjured knee. Build up to three sets of
fifteen repetitions, twice a day.
If this goes well, you can start jogging. Start off jogging and progress
to short accelerations, followed by turning and pivoting exercises.
Eventually you can include sprints in the exercise.
Following this you can do jumping exercises, such as hopping,
lateral jumps (skating jumps) on alternating legs and skipping.
Kneecap Pain
In tennis, playing serve and volley, pushing off after having hit a
wide ball, and deep bending for low volleys are most painful.
The pain is caused by excessive or abnormal contact of the
under surface of the kneecap with the bone of the upper leg due
to sideward pulling of the kneecap (lateral tracking).
The lateral tracking results in pressure being concentrated on
the outer part of the kneecap (as opposed to being distributed
over the whole kneecap). It may also occur as a result of direct
injury to the kneecap, such as falling on the kneecap or
dashboard injury (figure 1).

Risk factors
The patella has a wedge shape and slides on extension and
flexion of the knee in a groove formed by the femoral condyles.
Static risk factors for increased lateral tracking of the kneecap
include inward rotation of the thighbone, knock knees, outward
rotation of the shin bone, and increased pronation of the foot.
This combination of factors is called the miserable
malalignment syndrome (figure 2). Dynamic risk factors include
insufficiently developed thigh muscles, which deprives the knee
of adequate support; shortened or stiff muscles which causes
the kneecap to be pulled outwards; and too much, too long and
too intensive training in too short a time.
First Aid
Rest from offending activity and stretching and strengthening
exercises will bring about the speediest recovery, though
continued sports activity do not usually lead to irreversible
problems or damage. Intermittent application of ice, particularly
after exercise and at the end of the day, can help reduce pain
and swelling.
In the event of serious injury, have the injury examined by a
(sports) physician, for example when there is swelling of the
knee or when pain is also experienced when not playing tennis.
In some cases the player will be referred to a (sport) therapist for
further examination or treatment.
Once the worst pain has subsided you can gradually start
increasing the load on your knee. In doing these exercises, pain
is a sign that you need to rest. Warning: do not exceed the pain
threshold, as this will only slow down the healing process!
Rehabilitation progresses in three stages from easy to
strenuous.
Rehabilitation should be aimed at improving the maltracking.
Regular stretching of the muscles on the outer side of the leg (m.
tensor fascia lata and tracts iliotibialis) will restrain the lateral tracking
rotation of the kneecap and improve knee alignment. Stretching
exercises should be performed as follows. Stand up straight and cross
your right leg behind your left leg. Bend the upper body slowly left as
far as you can (figure 3). Hold this position for 20 to 30 seconds,
followed for 10 to 20 seconds of rest and repeat three times.
To ensure that the knee works properly, it is important that the

muscles surrounding the kneecap i.e. the quadriceps (inner upper thigh)
and hamstrings (rear upper thigh) are flexible enough.
Stretching exercise for the quadriceps. Stand up straight and
find support for one hand. Bend one leg, take hold of the ankle
and pull the ankle towards the buttocks until you can feel the
strain in the upper leg. Bringing the upper leg further backwards
can increase the stretch. Hold this position for 20 to 30 seconds,
followed by 10 to 20 seconds rest and repeat three times.
Stretching exercise for the hamstrings. Stand up straight. Place
the heel of the leg that will be stretched in front of you and keep
the heel on the ground. Keep your back straight and lean
forward slowly from the hips until you feel a slight pull. Hold this
position for 20 to 30 seconds, followed by 10 to 20 seconds rest
and repeat three times.
Static quadriceps strengthening (emphasis on medial oblique
muscle). Sit down on the floor with your legs straight. Place a rolled-
up towel under your knee. Try pushing the towel into the floor by
contracting your quadriceps muscles. Hold for three seconds and relax.
Start with three series of fifteen repetitions.
Straight leg raise (figure 4). Sit down on the floor with your legs
straight. Bend the unaffected knee. Now

tighten the muscles of the affected knee and point your toes towards
the ceiling. Lift your leg ten to fifteen inches, keeping the leg straight.
Hold for two seconds and return to the starting position. Perform two
to three sets of fifteen repetitions.
Co-ordination training. Stand on the injured leg with arms spread,
then close your eyes and try to keep your balance.
Cycling. The alignment of the kneecap can be improved by non-
strenuous cycling every day for 15 to 30 minutes. When cycling be
sure to use a bicycle with gears. Stay in the lowest gear which will
allow high cadence. This produces the least strain on the knee. Try to
avoid headwind and steep terrain.
Avoid long periods of sitting with bent knees or sitting in the same
position.
Stage 2. Build-up
without discomfort, you can consider resuming your sport. Listed here
below are a few exercises to improve your sport condition.
Double leg squats (figure 5). Stand up straight with your feet at
shoulders width apart. Stretch your hand straight out in front of you.
Bend your knees slowly and keep your back straight. Bend the knees to
a maximum of 110 degrees. The knees must not protrude in front of the
feet.. Start with two to three series of ten repetitions.
Single leg step (figure 6). Stand on the involved leg facing sideways
on a step leaving the other leg hanging over the edge. Bend the
involved leg and point the toes of the other foot towards the ceiling.
Touch the step below you with the heel of the other leg and then
straighten the involved leg. Start with one to two series of ten to fifteen
repetitions.
and right leg.
If this goes well, you can start jogging. Start off jogging and progress
to short accelerations, followed by turning and pivoting exercises.
Eventually you can include sprints in the exercise.
Following this you can do jumping exercises, such as hopping,
lateral jumps (skating jumps) on alternating legs and skipping.
altogether, as long as the player adapts his game to the restrictions
imposed by the injury. With more serious injuries, training can usually
be resumed after six weeks to three months.
Try to play on gravel courts as much as possible, and avoid hard
court. The peak strain on the knee is less on a surface that allows some
sliding than it is on surfaces where this is not possible.
Consult with your trainer and try to get him to adapt your training
program, allowing you to start off hitting the ball from an area
measuring two square meters( approx. two square yards). In this way
you can continue practicing your footwork (taking small steps,
positioning yourself correctly to hit the ball) without putting excess
strain on the knee.
(tennis drills from corner to corner)
program and the player can resume playing (practice) matches.
If practice matches can be played without problems, then the player
is ready to get back to playing competitions.
Be sure to do a thorough warming-up. Do, in any case, some
stretching exercises for the thigh muscles. In this way your muscles
and the rest of your body are prepared for the work to come.
order to avoid straining. This is especially relevant in the change from
summer season to winter season when gravel courts are exchanged for
the harder indoor courts.
Do muscle strengthening exercises for the thighs to avoid (new) knee
injuries.
adapted to the players weight and to the surface he will be playing on.
In the case of (moderate) foot deformities, such as bunion deformity
(hallux valgus) or hollow foot, it is advisable to buy special, individual
reinforcements for the shoe to help correct the form of the foot and to
give arches additional support.
Fatigue will cause your condition to deteriorate and lessen the
strength of the muscles. This increases the chances of stumbling and
straining a muscle. So, make sure to stay in shape!
Regular bicycling (low resistance and on flat surfaces) helps the knee
cap alignment which in turn helps the knee to work efficiently.
You can try taping or knee braces to see if they help.
Lower Back Pain
Description
Low back pain is very common among tennis players. Low back
pain may have various causes, such as postural abnormalities,
muscle dysfunction (imbalances, shortening or weakening of
muscle), overuse, instability, and articular dysfunction in the
lower back. In tennis, the combined rotation, flexion, and
extension of the back during the serve may cause problems
(Figure 1).
In 95% of the cases of low back pain no

specific physical abnormalities are found by additional diagnostic
investigations that may explain the low back pain; this is why it is
called non-specific. This includes muscle strains and back
sprains. Specific low back pain is low back pain caused by
structural abnormalities such as a herniated disc, a fracture, or a
tumour.
Symptoms
Common symptoms are a sudden, sharp, persistent or dull pain
in the lower back, sometimes on one side only, that worsens
with movement. Prolonged standing, sitting, or running may also
provoke pain. The pain may radiate to the hips, buttocks, or
back of the thigh. Often, muscle spasms in the back may
develop.
First Aid
Rest, medications and ice are recommended to relieve pain and
muscle spasm. Bed rest beyond two days is not recommended,
as this can have detrimental effects on bone, connective tissue,
muscle, and the cardiovascular system.
In the event of serious complaints, or if the pain is accompanied
by other symptoms, such as shooting pain in the leg extending
as far as the foot, a tingling sensation, numbness or loss of
strength, consult a (sport) physician. He or she can give you
personal advice and in some cases refer you to a (sport)
physiotherapist for treatment.
As pain and spasm subside, exercises to improve strength and
flexibility (core stability exercises) are started. This build-up
proceeds in three steps, from light to strenuous.
Step 1. Improvement of Normal Function.
As soon as the pain allows, you can start moving your back
again. The mobility and stability of the lower back can be
improved by doing the following exercises.
Lie on your back with bent knees and keep your feet flat on the
ground. Slowly move your knees from left to right, while your feet
keep touching the ground.

Take up a position on your hands and knees. Round your back, like a
cat, arching your back as far as you can. Then make your back as
hollow as you can, letting it sag towards the floor. Lateral mobility can
be improved by moving your hips from left to right.
Stretch the lower back. Especially in the morning, or after a longer
period of over-use, the back will often feel stiff and painful. Stretching
the lower back muscles can offer some relief from the pain. The
simplest stretching method is to assume a relaxed, squatting position
and hang over a table or chair. Hold this position for 20 to 30 seconds
and repeat this two or three times, taking short breaks in between
(Figure 2).
Spinal extensions (Figure 3). Support yourself on hands and knees
and stretch the right arm and the left knee.

Repeat this on the other side. You can make this exercise more difficult
by stretching the arm and leg of the same side.
Step 2. Build-up
Strong abdominal and back muscles (a good abdominal corset) will
protect the back and can help prevent excessive strain to the
intervertebral disks. The following exercises can be done to prepare for
normal training. It is, however, essential that the exercises are carried
out correctly. Abdominal exercises carried out incorrectly can in fact
aggravate the back injury!
Straight crunch. Lie on your back on a firm surface with your knees
bent and your feet flat on the ground. Place the tips of your fingers
behind your head and, let your elbows stick out sideways. Look
straight ahead and make sure your head and neck are relaxed. Tense
the abdominal muscles and raise yourself to a point where your
shoulders are just off the ground. Hold this position for 3 seconds.
Repeat as often as possible.
Oblique crunch. Lie on your back on a firm surface, with your right
knee bent place it across your left knee. Place your fingertips behind
your head, so that the elbows are pointing outwards. Look straight
ahead and make sure your neck and head are relaxed. Tense the
abdominal muscles and curl your body up with a twisting motion,
bringing your right elbow towards your left knee, to a point just above
the ground. Hold this position for 3 seconds and repeat as often as
possible and then repeat the exercise on the other side.
Bridge. In doing this exercise you train your back and abdominal
muscles simultaneously. Lie on your back on

a firm surface, keeping one leg bent. Push your pelvis upwards and
stretch the other leg so that the leg, the pelvis and the torso form one
straight line. You can make this exercise more difficult by taking your
weight on your elbows (Figure 4).
Balance exercises on a gym ball. Sit up straight on a gym ball. Raise
your right leg five centimeters from the ground and hold this for a few
seconds. Repeat this with the other leg. Do it at least 15 times. You can
make this exercise more difficult by stretching your leg, closing your
eyes or by passing a weight (1-2 kg) in circular movements from one
hand to the other behind your back or over
your head (Figure 5). You can also lie on

your back on the gym ball and try to keep your balance.
Step 3. Return to Play
Try to play on clay as much as possible, avoid hard courts. Longer
braking distance on a clay court causes lower peak strain on the back
than is the case on a hard court.
If possible, start off by hitting the ball from an area measuring two
square meters. In doing this you can practice your footwork (taking
small steps, always getting into the right position to hit the ball) so that
your back will not be strained by having to stretch too much.
The following exercises put more strain on the back and must
therefore be built up gradually: the service (particularly the kick
service and the topspin service); powerful topspin open stance
forehands; long series of low or wide volleys; difficult left-right
exercises; and high topspin backhands. In addition to these there are
combinations of volley-overhead drills that involve alternating volleys
and overheads, which are very taxing for the back. It is better to train
these strokes in separate sessions.
Tennis Elbow
Diagnosis
Tennis elbow is the best-known and also the most painful elbow
injury in tennis players. An estimated 50% of all tennis players
will suffer from tennis elbow in the course of their career. Players
aged over 35 are particularly at risk.
Tennis elbow is an overuse injury of the extensor muscles of the
wrist, in which pain and tenderness are felt at the attachment of
these muscles at the outer side of the elbow (Figure 1 and 1a).
The pain may radiate into the arm, wrist and fingers.
The injury usually develops gradually, as a result of multiple

micro ruptures and scar tissue at the muscle attachment. The
injury may also occur suddenly, for instance as a result of miss-
hitting the ball, so that a larger tear develops.
Lifting, gripping, twisting the wrist, shaking hands, washing
dishes or opening a door may all be very painful. During tennis,
hitting backhands usually provokes the pain.
First Aid
Tennis elbow is a common complaint, but as yet, there is no
consensus on the optimal treatment strategy. There are various
therapies, all based on rest, cooling with ice and stretching
techniques. In some cases, rest will mean complete withdrawal
from play.
In others, the complaints can be controlled by training
modification and discontinuation of match play. Physiotherapy
(friction massage, ultrasound, and a standardised exercise
programme aimed at the mobility of the elbow and wrist,
stretching exercises and strengthening of the muscles of the
forearm, upper arm and hand) and manual therapy often have
good effects, if necessary in combination with a brace.
A corticosteroid injection may have a positive effect in the short
term, but the long-term results are less positive than those of
physiotherapy or rest. One negative side effect of corticosteroids
is that they weaken the tendon tissue. A more conservative
approach is therefore taken with this therapy today than in the
past, especially with competitive tennis players.
Surgery is generally advised if the complaints persist, despite
long-term intense therapy for more than a

year.
In this phase, attention focuses on improving flexibility and
strengthening the forearm muscles.
Daily stretching of the forearm extensor muscles. Extend the arm
forward from the shoulders with the palm down and the elbow straight.
The fingers point to the floor. Grasp the wrist and fingers with the
other hand and bend the wrist down, until tension is felt at the outside
of the forearm (Figure 2).
Increase grip strength. This is a general exercise, which can be
performed by squeezing a stress ball or low-

pressure tennis ball.
Strengthening the forearm flexor muscles. Sit on a chair and lean
forward. Rest the forearm with the elbow slightly bent on the knees.
Turn the hand so the palm is facing up. Holding a weight, curl the hand
towards the ceiling. Return to the starting position and repeat 10-15
times (Figure 3).
Strengthening the forearm extensor muscles. Turn the palm of the
hand towards the floor and rest the forearm with the elbow slightly
bent on the knees. Holding a weight, curl the hand towards the ceiling
and return to the starting position. Gradually build up to three series of
10 to 20 repetitions (Figure 4).
To maintain general fitness, running (20-30 minutes) or cycling (30-
60 minutes) three times per week is

recommended. Swimming is also acceptable, but should be restricted
to kick-board work to limit stress on the arm/wrist.
In this phase, attention focuses on building up the specific tennis load.
The increase of the load could take place as follows:
Mini-tennis (within the service-lines), both forehands and backhands.
Baseline tennis, hitting only forehands and (double-handed)
backhands. It is preferable to start on a slow court (clay), because on
fast courts there is less time available to perform the strokes well.
Baseline tennis, hitting flat or double-handed backhands only and
gradually introducing slice backhands (no topspin!).
Volleys.
Baseline tennis with all types of backhands.
Smash and service.
Practice match.
Match play.
During Stage 2, it is important to pay close attention to timing and
technique. The sense of timing ensures that renewed mastery and
improvement of the techniques occurs with minimal use of strength.
This is important, because it allows the player to keep the wrist straight
and to hit the stroke fluently.
A few tips for the gradual build-up of the tennis-specific load,
especially the backhand:
Try to hit the ball in front of the body, so it is easier to fully use the
shoulder and trunk and to stabilise the wrist.
When the ball impacts the racket, the wrist should be straight. The
forearm extensor muscles are better able to handle the shock when the
wrist is straight than when it is flexed.
Try to use the forearm for control instead of strength. The application
of strength should come mainly from the shoulder and trunk muscles,
which are much stronger than the forearm muscles.
Try to use the other arm for balance when hitting a one-handed
backhand. The function of the balance arm is to ensure a smooth stroke
(supporting the racket in the starting position, enabling a change of
grip, improving the shoulder turn etc).
If the player cannot develop sufficient strength or co-ordination
during the one-handed backhand stroke, hitting a double-handed
backhand may be considered. The advantages and disadvantages of
double-handed backhands should be discussed with the coach.
In addition to the backhand, the service and overhead may also
provoke pain in the elbow. Try to build up these strokes gradually too.
It is not always possible to prevent tennis elbow. However, risk can be
reduced by measures such as a gradual build-up of the training
programme, warm-up and stretching exercises, suitable equipment (see
below) and the correct technique (hit the ball in front of the body with
a straight, firm wrist).
Tips for Choosing Correct Equipment:
The racket. To prevent tennis elbow, it is best to choose a flexible
racket with a large sweet spot, such as a mid-size or oversize racket.
Even though a stiff racket gives the player more power and control, a
flexible racket is gentler on the arm with off-centre hits, because the
flexion will absorb some of the shock and spread it over a longer
period.
Strings. Relatively low string tension is better for the arm, because it
increases the dwell time of the ball on the strings. The longer contact
time means that the shock of the ball impact is spread over a longer
period of time. Thinner strings are more elastic and have better shock-
absorbing capacities, and are therefore better for the arm than thicker
strings.
The ball. Choose new, pressurised tennis balls. Avoid, old, wet, and
pressure-less tennis balls.
The grip. A grip that is too small or too large may cause problems. In
both cases, the player may have to grip the racket too tightly to prevent
it from twisting, and high grip force may increase the risk of elbow
injury. An easy way to determine the correct grip is by measuring the
distance from the long crease in the palm (the second one down from
the fingers) to the tip of the ring finger.
Do a thorough warming-up before and cooling down after the
training or match- take at least 10 minutes for each. Concentrate on
performing these exercises correctly.
Make sure you have an adequate abdominal corset by doing

abdominal and back exercises at least twice a week
.
Make sure you build up training step by step, so that your body can
get used to the extra exertion gradually.
Make sure you have the right tennis shoe and pay attention to shock
absorption, lateral stability, feeling for the surface (good traction) and
optimal comfort.
Wrist Tendinopathy
Diagnosis
A wrist tendinopathy is an overuse injury of one of the tendons

around the wrist. Usually it involves the extensor tendon, which
is located at the ulnar side of the wrist (Figure 1). Often, the
injury occurs in the non-dominant wrist in players who use a
double-handed backhand.
The flexor tendon is also located lower down on the ulnar side of
the wrist. This injury leads to complaints during serving and
when hitting forehands and forehand volleys. The cause of the
injury is the high loads that the tendons around the wrist have to
deal with when the ball impacts with the racket.
This results in overstretching and micro-tearing of these
tendons. Women are more commonly affected than men,
because they have looser and weaker wrists. The injury is
characterised by pain, swelling, heat and redness at the
insertion point of the tendon in the wrist. Usually, extension and
flexion of the wrist against resistance is painful.
Tendon injuries are slow to heal and may take six weeks or
more.
First Aid
Activity modification (if you do not stop playing completely while
the injury heals, hit mainly shots that do not hurt, such as double-
handed backhands or only forehands and serves depending on the
location of the injury).
Cool the wrist with ice.
Stabilise the wrist with a wristband or tape, so the ligaments and
tendons can heal.
Fast and adequate first aid is very important to ensure good recovery.
In severe cases, or when in doubt, the player should have the injury
evaluated by a physician, who may make a referral for more detailed
diagnosis and prescribe physiotherapy.
The recovery process takes place in three stages, using exercises to
enhance strength. These are described below, with several tips.
At this stage, special attention is paid to enhancing the strength of the
muscles that are responsible for stabilising the

wrist. Players with a double-handed forehand or a double-handed
backhand need to make sure they strengthen both wrists.
Wrist flexor muscles (Figure 2). Start with a light weight (max. 1 kg)
or elastic tubing. Support the forearm with a slightly flexed elbow on
the knee, palm of the hand facing up. Move the wrist up and down,
from a neutral position (2-3 sets of 10-20 repetitions).
Wrist extensor muscles (Figure 3). This exercise is the opposite of
the exercise for the wrist flexor muscles. Support the forearm with a
slightly bent elbow on the knee, but now with the palm of the hand
facing down. Move the wrist up and down from a neutral position. This
can be built up to 2-3 sets of 10-20 repetitions. When starting these
exercises, it is sufficient to simply hold the

weight, without moving the wrist.
Once the wrist flexion/extension exercise is tolerated, progress to
ulnar/radial deviation and pro/supination to further build strength in the
wrist region. Ulnar/radial deviation. Support the elbow on the knee,
palm facing down and light weight in the hand. Move the hand to the
left and right. Pro/supination. From the same starting position, rotate
the hand clockwise and counter clockwise.
Improve grip strength.
This is a general exercise that strengthens al the muscles of the forearm
and hand. Use an older, softer ball (3 sets of 10-20 repetitions).
In this phase it is important to build up the tennis-specific load. The
increase of the load could take place in the following way.
Mini tennis (i.e. half court within the service lines), both forehands
and backhands.
Baseline tennis, with only forehands, slice backhands, or a single-
handed backhand. Be careful of your technique if you use a double-
handed backhand.
A slow court (clay court) is preferable at first, since fast courts afford
less time for a good stroke performance.
Gradually introduce volleys. Do not practice these for too long.
Stabilise the wrist well at the point of impact.
Baseline tennis with all types of backhands. Limit the use of the
short cross-court backhand, because this puts a high strain on the wrist.
Service and overhead.
Practice match.
Match play.
During stage 2 it is important to pay attention to timing and technique.
The feel for the timing ensures that improvements in technique occur
with a minimum use of strength. This is very important for the
maintenance of a correct position of the wrist and a fluent stroke.
Some Tips for the Backhand
Try to hit the ball in front of the body, so it is easier to fully use the
shoulder and trunk and to stabilise the wrist.
Try to use the forearm for racket control only, and not for strength.
Strength should be exerted mainly via the shoulder and trunk muscles
instead of the forearm muscles.
When hitting a backhand, try to use the other arm for balance. The
function of the balancing arm is very important for a fluent stroke. It
supports the racket in the starting position and enables an easy grip
change when preparing for the backhand.
If the injury is the non-dominant hand and persists during the double-
handed backhand, the player could consider switching to a one-handed
backhand. Since there are both advantages and disadvantages to the use
of a single-handed backhand, the player should discuss this with
his/her coach first before making the change.
Since volleys may also provoke the pain, these should be gradually
introduced into the training programme.
Perform a complete warm-up before play and a cool-down
afterwards, for approximately 15 minutes each. This should be
followed by mini-tennis.
Make sure the build-up of the tennis training is gradual, so your body
can adapt to the increased load.
Alternate volley exercises with other strokes, so your wrists have
enough time to recover.
Avoid push-ups with a bent wrist, because this may worsen a wrist
injury. If you do want to perform push-ups, use handlebars or support
yourself on your knuckles (this straightens the wrists) (Figure 4).
Make sure to use the correct grip. If the grip is either too thick or too
thin, you have to squeeze the racket to prevent it from twisting in the
hand. The correct grip can be determined as follows: grip the racket
lightly, as if you were shaking hands. The little finger should fit
between the base of the thumb and the fingertips. Consult your coach
for further details regarding the correct grip size.
Continue to work on wrist strength to stabilise the wrist using the
exercises and a low-resistance, high-repetition format.
References
http://www.itftennis.com/scienceandmedicine/injury-
clinic/tennis-injuries/overview.aspx
By : Mohammed Ahmed Elhamady
Student at Faculty of Sport Education - Mansoura university
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Article April 2016

Mohammed Ahmed Elhamady

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Mohammed Ahmed Elhamady

Student at Faculty of Sport Education - Mansoura

Abdominal Muscle Strain

Abdominal muscular strains are a common occurrence for tennis

Gentle stretches and isometric contractions of the abdominal

- Strengthening the straight abdominal muscles (straight crunch,

Stage 3. Return to Play

Unfortunately, abdominal muscle strains cannot always be avoided.

An injury of the Achilles tendon is a degenerative condition of

How to Ensure the Best Recovery

Stage 1. Improving Normal Function

Strengthening the foot muscles. Sit on a chair. Write the alphabet in

should continue the exercise, even if you

A sprained or twisted ankle is the most common tennis injury. In

An injury of the much stronger ligament on the inside of the

Perform the following as quickly as possible, during the first 48

Rest (immobilisation). Do not play tennis and do not lean on the

but cover the ice or cold pack with a towel.

Stage 1. Improvement of Normal Function

knee and upper leg stable.

Tennis leg is an incomplete rupture of the inside of the calf

muscles, for instance during a sprint.

The following action should be taken as quickly as possible,

Rest (immobilisation). Stop playing tennis and do not lean on the

flow to the calf muscles and enhances

Finally, you can include jumping exercises.

A groin injury is a strain or (partial) tear of one of the adductors,

The adductor langus is the

Muscle tears are classified according to their severity as grade

A grade 3 tear is when the entire muscle has been torn.

What should you do? First aid!

Do the following as soon as possible, for 48 hours:

5 ): Attach one end of an exercise band to a

10 to 15 repetitions. Repeat the exercise with

slow pace, followed by sideways hops. Once

Stage 1. Improvement of Normal Function

Strengthening the foot muscles. Sit on a chair. Write the alphabet in

The iliotibial band is an extension of the tensor fascia lata

through the pain, because this will delay

seconds and then rest for fifteen to twenty

Stage 2. Returning to Training

b. Internal impingement: between the shoulder socket and the

weight can be purchased in a sports shop.

performing muscle strengthening exercises

band to a fixed sturdy object to the left hand

degeneration in the tendon (figure 1).

muscles. Hold for three seconds and relax.

to keep functioning well.

the heel of the other leg and then straighten

quadriceps. Place your feet shoulder-width

dashboard injury (figure 1).

To ensure that the knee works properly, it is important that the

straight. Bend the unaffected knee. Now

In 95% of the cases of low back pain no

keep touching the ground.

and stretch the right arm and the left knee.

muscles simultaneously. Lie on your back on

your head (Figure 5). You can also lie on

The injury usually develops gradually, as a result of multiple

long-term intense therapy for more than a