nutrients

Review
Nutritional Ergogenic Aids in Racquet Sports:
A Systematic Review
Néstor Vicente-Salar 1,2, *,† , Guillermo Santos-Sánchez 3,†,‡ and Enrique Roche 1,2,4
1 Biochemistry and Cell Therapy Unit, Institute of Bioengineering, University Miguel Hernandez,
03201 Elche, Spain; eroche@umh.es
2 Department of Applied Biology-Nutrition, Alicante Institute for Health and Biomedical
Research (ISABIAL-FISABIO Foundation), University Miguel Hernandez, 03201 Elche, Spain
3 Departamento de Tecnología de la Alimentación y Nutrición, Universidad Católica de Murcia,
30107 Murcia, Spain; gsantos-ibis@us.es
4 CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII),
28029 Madrid, Spain
* Correspondence: nvicente@umh.es
† To be considered as equal first author.
‡ Present Address: Departamento de Bioquímica Médica y Biología Molecular e Inmunología,
Universidad de Sevilla, 41009 Seville, Spain.




Received: 27 August 2020; Accepted: 15 September 2020; Published: 17 September 2020


Abstract: A nutritional ergogenic aid (NEA) can help athletes optimize performance, but an
evidence-based analysis is required in order to support training outcomes or competition performance
in specific events. Racquet sports players are regularly exposed to a high-intensity workload
throughout the tournament season. The activity during a match is characterized by variable durations
(2–4 h) of repeated high-intensity bouts interspersed with standardized rest periods. Medline/PubMed,
Scopus, and EBSCO were searched from their inception until February 2020 for randomized controlled
trials (RCTs). Two independent reviewers extracted data, after which they assessed the risk of bias
and the quality of trials. Out of 439 articles found, 21 met the predefined criteria: tennis (15 trials),
badminton (three trials), paddle (one trial), and squash (two trials). Among all the studied NEAs,
acute dosages of caffeine (3–6 mg/kg) 30–60 min before a match have been proven to improve specific
skills and accuracy but may not contribute to improve perceived exertion. Currently, creatine, sodium
bicarbonate, sodium citrate, beetroot juice, citrulline, and glycerol need more studies to strengthen
the evidence regarding improved performance in racquet sports.

Keywords: racquet sports; ergogenic aid; performance; sport supplement

1. Introduction
Racquet sports are included in the family of ball sports and more specifically, among those using
an implement. They are characterized by the use of a manual racquet to propel an implement (a ball,
shuttlecock, etc.) between two or four players with the objective of placing it in a position with no
return possibilities for the opponent. There are two different game formats: (a) passing the implement
over a net in a divided field (tennis, badminton, paddle and table tennis) or (b) hitting the implement
onto a wall in a shared field (squash and racquetball) [1].
Racquet sports are acyclic disciplines with very intense workload cycles, which are interrupted
by small pauses that allow for an incomplete recovery. Therefore, metabolic demands in racquet
sports alternate between both anaerobic and aerobic energy sources. Anaerobic energy comes from
intramuscular ATP and phosphocreatine (PC), as well as from anaerobic glycolysis, the three of which
are used during high intensity, short duration points, changes of direction, and hits. On the other hand,

Nutrients 2020, 12, 2842; doi:10.3390/nu12092842 www.mdpi.com/journal/nutrients

Nutrients 2020, 12, 2842 2 of 20

the aerobic system is involved during long points of moderate intensity, playing a primary role in
delaying fatigue, and indirectly, favoring concentration, technical skills, and maintaining workload
during a match [2–5].
As a result of this fact, the average heart rate (HR) during a match reaches up to 60–80% of HR maximum
(HRmax), increasing to 90% of HRmax in high-intensity situations [6–8]. Nonetheless, HRmax does not
provide clear information regarding real energy demands or the metabolic pathways involved, since this
parameter is affected by dehydration, heat stress, age, and playing techniques [9]. Measuring blood
lactate concentration during a match could report more accurately the energetic pathways used by
racquet sports players. Ranges vary from 1.0–4.0 mmol/L to 8.0–12.0 mmol/L during prolonged
high-intensity matches [2,10–12], supporting the key role of glycolytic pathways during the match.
An ergogenic aid is any training method, mechanical device, nutritional or pharmacological
approach, or psychological technique that can improve exercise performance capacity and/or improve
training adaptations [13]. Therefore, a nutritional ergogenic aid (NEA) is defined as those nutritional
supplements taken orally containing a nutritional ingredient that intends to complement diet.
The objective of these supplements is to improve sports performance without exerting harmful
effects on the individual [14].
The consumption of NEAs has been increasing in recent years around the world, which has
led to a great variety of research with the aim of estimating their intake and use. In fact, sales of
dietary supplements grew 6.1% in 2017, achieving an income of 39.8 billion dollars in the US [15].
A meta-analysis published in 2015 concluded that elite athletes used many more dietary supplements
than non-elite athletes, and the prevalence of use was similar in men and women [16]. The NEAs
most frequently used by high-level tennis players tend to be creatine and caffeine [17] while among
international rank squash players, sodium bicarbonate is also frequently consumed in addition to
the two aforementioned NEAs [18]. Normally, NEA recommendations in high-level racquet sports
players are directed by personal trainers, coaches, or sports dietitian–nutritionists. However, proper
counseling based on current scientific evidence is required.
In this line, several organizations such as the Australian Institute of Sport (AIS) or the World
Anti-Doping Agency (WADA) propose classifications of sports supplements grouped into different
categories according to effectiveness, legality, and safety. Nevertheless, there are not policies regarding
the regulation of alleged benefits and safety claims [19,20]. Thus, athletes find themselves under the
influence of companies’ advertising, which claims improved performance and recovery through the
consumption of a wide range of products without scientific evidence regarding their effect, dosage,
or instructions for use.
The main aim of this systematic review was to evaluate the scientific evidence concerning NEAs
in the improvement of performance of racquet sports athletes specifically through published RCTs.

2. Materials and Methods

The conduct and reporting of the current systematic review conform to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) [21]. Five racquet sports were analyzed
regarding the effectiveness of certain nutritional ergogenic aids: tennis, badminton, squash, table tennis,
and paddle.

2.1. Systematic Search

Relevant articles were identified by title and abstract in the electronic databases Medline, Scopus,
and EBSCO (since inception to 20 February 2020) using the search strategy in Table 1. The electronic
search was supplemented by a manual review of reference lists from relevant publications and reviews
to find additional publications on the subject.
Nutrients 2020, 12, 2842 3 of 20

Table 1. Combined terms used in the search for studies in the database. 1 Mesh terms were used in the
search; 2 Term not included in the Mesh search; 3 nutritional ergogenic aid (NEAs) filed in the A group
of the Australian Institute of Sport (AIS).

Pubmed 1 Scopus and EBSCO

NEA Sport NEA 3 Sport
Dietary
Dietary supplements Racquet Sports Racquet Sports
supplements
Caffeine Tennis Ergogenic aid Tennis
Creatine Caffeine Badminton
Beta-alanine Creatine Table tennis
AND AND
Sodium Bicarbonate Beta-alanine Squash and sport
Sodium
Ergogenic aid 2 Paddle
Bicarbonate
Nitrate
Beetroot juice
Glycerol

2.2. Data Extraction

Two reviewers (N.V.-S. and G.S.-S.) independently extracted the following data from each study
using a predefined Microsoft Excel data extraction form including the number of participants within
each group, participant characteristics, racquet sport discipline, and supplementation intervention
characteristics, end points, measurement methods, and results in order to produce an overview table
of all eligible studies.

2.3. Study Selection

Studies were eligible for inclusion if they met each of the following criteria: (a) not using any
doping substances established by the World Anti-Doping Agency (WADA), (b) using a randomized
controlled trial (RCT) design that included one group taking supplementation and 1+ groups receiving
a placebo or not taking supplementation, (c) not including any ergogenic aids classified within group A
by the Australian Sports Commission (AIS) because of their high evidence grade [22], (d) not presenting
supplementation as a source of nutrients, such as bars, gels, or drinks rich in carbohydrates and
electrolytes, and (e) not being gray literature (abstracts, conference proceedings, or editorials) or reviews.

2.4. Quality Assessment and Publication Bias

Characteristics of the retrieved RCTs were evaluated using the ‘risk-of-bias’ assessment tool following
the recommendations by the Cochrane Handbook for Systematic Reviews of Interventions [23,24].
This evaluation was carried out by two reviewers (N.V.S. and G.S.S.) working independently in order
to present bias comprehensively. The following criteria were analyzed: randomized treatment order
and carry-over effect (selection bias), blinding of participants and research staff to group allocation
(performance bias), blinding of outcome assessor (detection bias), incomplete outcome data (attrition
bias), selective reporting (reporting bias), and other bias (it was assessed if there was controlled diet,
exercise use of supplements or drugs, and sport stratification when a mixture of disciplines was
analyzed). Then, the retrieved RCTs were classified as being of “high”, “unclear”, or “low” risk of bias.
Effect size was calculated using Cohen´s d test.

3. Results

3.1. Included Studies

A total of 438 studies were screened by title and abstract, and 377 were assessed for eligibility
criteria (full-text screening). From the retrieved articles, twenty-one met all the inclusion criteria
and were included in the systematic review (Figure 1, Tables 2 and 3). Thirteen RTCs were found
 A total of 438 studies were screened by title and abstract, and 377 were assessed for eligibility
criteria (full-text screening). From the retrieved articles, twenty-one met all the inclusion criteria and
were included in the systematic review (Figure 1, Tables 2 and 3). Thirteen RTCs were found in the
Medline database (eleven for tennis and two for badminton), seven were found in the Scopus
Nutrients 2020, 12, 2842 4 of 20
database (three for tennis, one for badminton, two for squash, and one for paddle) where one article
was not available despite requesting it from its main author; and none were retrieved from the
EBSCO in database
the Medline database
(because all(eleven for tennis
those found andwere
there two for badminton),
repeated). seven wereone
Additionally, found in the
article Scopus
that was not
database (three for tennis, one for badminton, two for squash, and one for paddle)
found through the initial search but was found in a review published in the Medline database was where one article
addedwas fornotfull-text
availableanalysis.
despite requesting it from its
The PRISMA main author;
flowchart wasand none were
applied to retrieved
illustratefrom
the the EBSCO
step-by-step
database (because all those found there were repeated). Additionally, one article that was not found
exclusion of unrelated/duplicate retrieved records, leading to the final selection of twenty-one RCTs
through the initial search but was found in a review published in the Medline database was added
that met the predefined inclusion criteria (Figure 1).
for full-text analysis. The PRISMA flowchart was applied to illustrate the step-by-step exclusion of
unrelated/duplicate retrieved records, leading to the final selection of twenty-one RCTs that met the
predefined inclusion criteria (Figure 1).

Records identified through Additional records identified

Identification

database searching (n=438) through other sources (n=1)

Records excluded (n=62)

Reasons:
Screening

-Repeated (61)
- Not available (1)

Full-text articles assessed

for eligibility (n=377)

Full-text articles excluded (n=356)

Reasons:
Eligibility

- Included doping substances (27)

- Included supplements with CHO
and/or isotonic drinks (15)
- Did not include nutritional ergogenic
aids (127)
- Did not include racket sports (139)
- Other motives (Review, Book Chapter
or Congress abstract) (48)
Included

Studies included in qualitative

synthesis (Systematized
review) (n=21)

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow
chartprocess.
chart [21] of the study selection [21] of the study selection process.
Nutrients 2020, 12, 2842 5 of 20

Table 2. Included studies on nutritional ergogenic aids in tennis. BCAAs: Branched-chain amino acids; FFA: Blood free fatty acids; Glu: Blood glucose; Gly: Blood
glycerol; HR: Heart rate; Lac: Blood lactate; LTPT: Leuven Tennis Performance Test; LTST: Loughborough Tennis Skill Test; NO; Nitric oxide; Pl: Placebo;
RSA: repeated-sprint ability shuttle test; STPT: Skill Tennis Performance Test; Trp/BCAAs: Blood tryptophan/branched-chain amino acids ratio; u-EPI: Urine
epinephrine; u-NE: Urine norepinephrine. ↑: Significant increase compared to placebo/control group; ↓: Significant decrease compared to placebo/control group;
↔: without changes compared to placebo/control group.

Blinded/Double
Study NEA Dosage/Time Participants Age (yrs) Level Duration Exercise Protocol Measurements Main Outcomes
Blinded
- Lac ↔ Lac
- Glu ↔ Glu
3 matches (2 of
- 0.2 75 min/match and - Gly ↔ Gly
(women)–0.25 1 of 90 min/match - FFA ↔ FFA
(men) mg/kg/0 National
16 (8 men/ 25.4 ± 1.9/ with only rest
[25] Caffeine min before ranking DB 1 day - u-EPI ↑ u-EPI
8 women) 20.4 ± 2.8 between match 2
match and every (Germany)
and 3 of 30 min) + - u-NE ↔ u-NE
15 min during a Accuracy and
match - Sprints ↔ Sprints
sprint test
- Accuracy hit ↔ Accuracy hit
- Perceived exertion ↔ Perceptual training intensity
- Sprints ↔ Sprints
- 5 mg/kg/60 min
before pre-test. - Serve quality ↔ Serve quality
- 0.75 National LTPT + Sprint test - Backhand stroke quality ↑ Backhand stroke
[26] Caffeine mg/kg/Each 1 h 13 men 20.4 ± 0.9 ranking DB 1 day + Court session
- Volley errors and fatigue ↑ Volley errors and fatigue
after start (Belgium) (120 min) + LTPT
pre-test and - HR ↔ HR
during protocol
- Perceived exertion ↔ Perceptual training intensity
- Lac ↔ Lac
- Glu ↔ Glu
- CK ↔ CK
- Prolactin ↔ Prolactin
National
- 3 mg/kg/30 min 1 match of - Fluid loss ↔ Fluid loss
[27] Caffeine 12 men 18.3 ± 3.0 ranking B 1 day
before match 160 min/match - Serve and stroke velocity ↑ Serve velocity in 4th set
(Australia)
- Serve kinematics ↔ Serve kinematics
- Perceptual skills ↔ Perceptual skills
- HR ↔ HR
- Perceived exertion ↔ Perceptual training intensity
Nutrients 2020, 12, 2842 6 of 20

Table 2. Cont.

Blinded/Double
Study NEA Dosage/Time Participants Age (yrs) Level Duration Exercise Protocol Measurements Main Outcomes
Blinded
Intermittent - Successful shots ↑ Total shot successes
- 6 mg/kg/60 min 16 (8 men/8 National treadmill exercise
[28] Caffeine 20.7 ± 1.7 DB 1 day - HR ↔ HR
before test women) ranking (45 min) + Tennis
skills test - Perceived exertion ↔ Perceptual training intensity
(USA)
University 3 days of sleep
- 80 mg/30 min 12 (6 men/6 players restriction follow
[29] Caffeine 18–22 DB 1 day - Accuracy serve ↔ Accuracy serve
before test women) (UK) a day of accuracy
serve test
- Handgrip force ↑ Handgrip force
- Serve velocity ↔ Serve velocity
Tennis specific test - Running speed ↑ Only in high intensity
Elite-level
+ Simulated
- 3 mg/kg/60 min 14 (10 men/4 Junior - Number of sprints ↑ Number of sprints
[30] Caffeine 16.4 ± 1.2 DB 1 day Match of
before test women) players
best-of-3-sets - Distance ↔ Distance
(Spain)
system
- HR ↔ HR
- Sweat rate ↑ Sweat rate
↑ Accuracy serve (depending of
- Tennis serve trial - Accuracy serve
National conditions of time and distance
- 6 mg/kg/60 min 10 (5 men/5
1 day + Shuttle run
[31] Caffeine 19.9 ± 1.8 ranking DB
before test women) sprint + Tennis - Shuttle run time ↔ Shuttle run time
(USA)
serve trial - Likert scale ↔ Feelings
- Quality of 1st and 2nd
- 20 g/day ↔ Service quality
National service
(4 × 5g/day)/ LTPT + Shuttle
[32] Creatine 8 men 20.4 ± 0.9 ranking DB 5 days
During 5 days run sprint - Stroke quality ↔ Stroke quality
(Belgium)
before test - Sprint power ↔ Sprint power
- Lac ↔ Lac

- 0.3 g/kg in - Serving velocity ↔ Serving velocity

- Service test + Ball
loading phase DB - Stroke velocity ↔ Stroke velocity
22.5 ± machine ground
(6 days)
[33] Creatine 36 men 4.9–28.8 ± ITN 3 5 weeks stroke drill + - Sprinting velocity ↔ Sprinting velocity
- 0.03 g/day in
4.8 Intermittent sprint
maintenance - Strength ↔ Strength
test + Strength test
phase (28 days)
- HR ↔ HR
- Perceived exertion ↔ Perceptual training intensity
Nutrients 2020, 12, 2842 7 of 20

Table 2. Cont.

Blinded/Double
Study NEA Dosage/Time Participants Age (yrs) Level Duration Exercise Protocol Measurements Main Outcomes
Blinded
- Lac ↑ Lac
- pH ↔ pH
Keeps serve consistency while
- Serve consistency
Pl ↓
- 0.3 g/kg/70 min College
- LTST + Keeps stroke consistency while
Sodium before test Tennis - Stroke consistency
[34] 9 men 21.8 ± 2.4 DB 1 day Simulated match Pl ↓
Bicarbonate - 0.1 g/kg/During players
(50 min) + LTST
test (Taiwan) - Serve Accuracy ↔ Serve Accuracy
- Stroke Accuracy ↔ Stroke Accuracy
- HR ↔ HR
- Perceived exertion ↔ Perceptual training intensity
- Lac ↑ Lac
- pH ↑ pH
Junior STPT + RSA + - Stroke consistency ↑ Stroke consistency
Sodium - 0.5 g/kg/120 National Simulated match - Stroke accuracy ↔ Stroke accuracy
[35] 10 men 17.0 ± 1.0 DB 1 day
Citrate min before test Ranking (60 min) + STPT +
(Brazil) RSA - Number strokes ↔ Number strokes
- Time of sprints ↔ Time of sprints
- Perceived exertion ↔ Perceptual training intensity
- Serve velocity ↔ Serve velocity
- Serve velocity
test + Counter - Jump height ↔ Jump height
- 70 mL ATP and
Beetroot movement jump + - Handgrip force ↔ Handgrip force
(6.4 mmol of National 1 day
[36] juice 13 men 25.4 ± 5.1 DB Isometric
NO3− )/3 h ranking
handgrip strength
- Agility ↔ Agility
before test (Spain)
+ Agility and - Sprint velocity ↔ Sprint velocity
sprint test
- Perceived exertion ↔ Perceptual training intensity
- Handgrip force ↑ Handgrip strength
- Isometric - Peak vertical power ↔ Jump power
Masters handgrip strength
- Anaerobic capacity ↔ Anaerobic capacity
Citrulline- - 8 g/60 min ranking in
1 day + Counter
[37] 17 women 51.0 ± 9.0 DB
malate before test USTA movement jump + - Relative peak power ↑ Relative peak power
(USA) Wingate cycling - Explosive power ↑ Explosive power
test
- Sustained power ↔ Sustained power
Nutrients 2020, 12, 2842 8 of 20

Table 2. Cont.

Blinded/Double
Study NEA Dosage/Time Participants Age (yrs) Level Duration Exercise Protocol Measurements Main Outcomes
Blinded
- Lac ↔ Lac
- Gly ↔ Gly
- Glu ↔ Glu
- FFA ↔ FFA
- 0.17 g/kg Perceptual-motor
BCAAs performance test - NO ↑ NO
(Leu–Ile–Val = (LTST modified) + - Trp/BCAAs ↓ Trp/BCAAs
BCAAs + National
10:7:3) + 0.05 Simulated match
[38] Arginine + 9 men 25.6 ± 0.7 Ranking B 1 day - HR ↓ HR
g/kg Arginine + (120 min) +
Citrulline (Taiwan)
0.05 g/kg Perceptual-motor Prevents a high decrease in
Citrulline/80 performance test - Stroke Accuracy stroke accuracy compared
min before test (LTST modified) with Pl
Keeps stroke consistency
- Stroke consistency
while Pl ↓
- Stroke velocity Keeps stroke velocity while Pl ↓
- Perceived exertion ↓Perceptual training intensity
- Change in body ↑ Body weight vs. Pl
Weight
↑ Plasma osmolality vs. Pl
- Plasma osmolality
(only pre- and post-exercise)
↑ Plasma volume vs. Pl (only
- Change in plasma
pre- and post-exercise)
- 1 g/kg/150 min Ranking Tennis specific test
before test 4–5 in + Simulated match volume
[39] Glycerol 11 men 27.0 ± 2.0 DB 1 day
- 0.5 g/kg/15 min USTA (75 min) + Tennis - Electrolytes ↔ Electrolytes
after test (USA) specific test
- Urine volume ↓ Urine volume
- Sprint velocity ↔ Sprint velocity
- Agility ↔ Agility
- Stroke accuracy ↔ Stroke accuracy
- Serve accuracy ↔ Serve accuracy
Nutrients 2020, 12, 2842 9 of 20

Table 3. Included studies on nutritional ergogenic aids in badminton, squash, and paddle. Glu: Blood glucose; HR: Heart rate; Lac: Blood lactate. ↑: Significant
increase compared to placebo/control group; ↓: Significant decrease compared to placebo/control group; ↔: without changes compared to placebo/control group.

Badminton
Blinded/Double Exercise
Study NEA Dosage/Time Participants Age (yrs) Level Duration Measurements Main Outcomes
Blinded Protocol
- Handgrip maximal force ↔ Handgrip force
- Smash jump
- Squat jump ↔ Smash jump
↑ Squat jump
Handgrip force - Countermovement
height/power
National + Jump tests +
- 3 mg/kg/60 min
[40] Caffeine 16 men 25.4 ± 7.3 ranking DB 1 day Agility Test + Jump (CJ) ↑ CJ height/power
before test (Spain) Simulated - Agility ↔ Agility
match (45 min)
- Number of impacts ↑ Number of impacts
- HR ↔ HR
↔ Perceptual training
- Perceived exertion
intensity
- Lac ↔ Lac
- Glu ↔ Glu
↓ Errors in
- 4 mg/kg/60 min Badminton - Errors in anticipation
anticipation
before exercise National specific test +
- Accuracy serve ↔ Accuracy serve
- 4 mg/kg ranking Fatigue protocol
[41] Caffeine 12 men 28 ± 9 DB 1 day
/during 2nd (United (33 min) + - Reaction time ↓ Reaction time
Badminton Kingdom) Badminton
- Time sprints ↓ Time sprints
specific test specific test
- HR ↔ HR
↓ Perceptual training
- Perceived exertion
intensity
- pH ↑ pH
Student Treadmill
Sodium - 300 mg/kg/90 1 day - Lac ↑ Lac
[42] 30 men 21 players ? testing to
bicarbonate min before test
(Indonesia) exhaustion - Time to exhaustion ↑ Time to Exhaustion
- pH ↓ pH
Student Treadmill
Sodium - 300 mg/kg/90 1 day - Lac ↑ Lac
[42] 30 men 21 players ? testing to
citrate min before test
(Indonesia) exhaustion - Time to exhaustion ↑ Time to Exhaustion
Nutrients 2020, 12, 2842 10 of 20

Table 3. Cont.

Squash
Blinded/Double Exercise
Study NEA Dosage/Time Participants Age (yrs) Level Duration Measurements Main Outcomes
Blinded Protocol

- 0.3 g/kg/day - Lac ↔Lact

(4 × 0.075 g National - Sprint time ↓ Sprint time
9 (8 men/1 Court set sprint
[43] Creatine /kg/day)/during 21.3 ± 0.3 ranking DB 5 days
woman) test - Likert scale ↔ Feelings
5 days (UK)
before test - HR ↔HR
- Peak Power ↑ Peak power
- 1000 mg - Fatigue ↓ Fatigue
creatine + Cognitive tests +
1500 mg Cycle ergometer - Reaction time ↔Reaction time
guarana + National sprint test + - Reaction time under ↓ Reaction time under
Creatine +
[44] 133 mg 8 18.2 ± 3.7 ranking ? 1 day Cognitive tests + pressure time pressure
Guarana
Caffeine/Half (France) Submaximal test
dosage at 30 min with cognitive - Visual response reaction ↓ Visual response
and rest at 0 min test time reaction time
before test. - Ocular motility response ↓ Ocular motility
time response time
Paddle
- Isometric handgrip
↔ Handgrip strength
strength
Specific paddle
- Volley precision ↑ % Correct hits
training (45 min)
6 mg/Kg /30 min Amateur
1 day + Handgrip - HR ↓ % Errors
[45] Caffeine 12 men 27.7 ± 3.7 B
before test (Brazil)
strength and - Perceived exertion ↔ HR
Volley test
↔ Perceptual training
intensity
 Nutrients 2020, 12, 2842 11 of 20

3.2. Risk of Bias and Quality Assessment of Studies

The risk of bias of the included studies is illustrated in Table 4. The RCTs of Pluim; 2006 [33]
and Hartono; 2017 [42] were parallel group trials, so the criteria of random sequence generation
and allocation concealment were used instead of randomized treatment order and carry-over effect
respectively. Most of the trials assessed showed an unclear level in the criteria of selection bias, both
in the randomized treatment order and in the evaluation of the carry-over effect. Only the trials by
Vergauwen; 1998, [26] Lopez-Samanes; 2020 [36] and Abian; 2015 [40] suitably described the tools
used for randomization treatment, while trials by Wu; 2010 [34], Yang; 2017 [38], Abian; 2015 [40] and
Muller; 2019 [45] used tests to check if the washout time between conditions was suitable. Moreover,
most of the studies also showed a high risk of detection bias except for trials by Gallo-Salazar; 2015 [30]
and Abian; 2015 [40], which specifically indicated that blinding was kept until the statistical analysis
was performed. Five studies [27,38,42,44,45] were at a high risk of performance bias due to incomplete
blinding or a lack of blinding.

Table 4. Quality assessment of the included studies. Cross-over studies where A = Randomized
treatment order; B = Carry-over effect; C = Performance bias; D = Detection bias; E = Attrition bias;
F = Reporting bias; G = Other bias. * Parallel studies where A = Random sequence generation and
B = Allocation concealment.
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Nutrients 2020, 12, 2842 13 of 20

handgrip strength and relative peak power, and citrulline + arginine + BCAAs avoided the decrease of
stroke accuracy and kept stroke consistency and stroke velocity.
Lastly, regarding hydration agents, glycerol was the only NEA found in just one study [39].
The consumption of 1 g/kg glycerol 150 min before the trial and 0.5 g/kg 15 min after it increased body
weight, plasma osmolality, and plasma volume, and decreased urine volume.

3.5. Nutritional Ergogenic Aids and Intervention Characteristics in Badminton, Squash, and Paddle
Caffeine was tested in badminton male players 60 min before exercise protocol with a dosage
ranging from 3 to 4 mg/kg [40,41]. It showed improvements in jumps and the number of impacts
accompanied with a decrease in errors in anticipation, reaction time, and time of sprints (Table 3).
In addition, in paddle, caffeine showed ergogenic effects. The intake of 6 mg/kg caffeine 30 min
before the exercise protocol in twelve amateur male players increased the percentage of correct hits,
diminishing errors [45].
Different plasma buffers were evaluated by one study in badminton male players [42]. A load of
0.3 g/kg sodium bicarbonate or 0.3 g/kg sodium citrate 90 min before the test showed an increase in
time to exhaustion with both supplements (51.3 and 44.4% respectively). Both NEAs increased plasma
lactate, but only sodium bicarbonate showed an increase in plasma pH.
Finally, the effect of creatine was evaluated in squash players by two studies, one of them with a
load of 0.3 g/kg/day for 5 days before test [43], and the other with acute supplementation of a mixed
product composed by 1 g creatine + 1.5 g guarana + 133 mg caffeine [44]. The creatine loading protocol
showed a decrease in sprint time, while acute supplementation with guarana and caffeine increased
peak power and decreased fatigue, reaction time under pressure, and time visual response.

4. Discussion

4.1. Effects of Caffeine in Racquet Sports

Caffeine has shown to be an effective ergogenic aid for aerobic and anaerobic exercise with
improvements in performance and the perceptions of exertion and muscle pain with dosage ranging
from 2.35 to 5 mg/kg [46,47]. A similar dosage range was used in most of the racquet sports studies that
showed positive effects and a low risk of bias [26,30,40,41] with the exception of Hornery; 2007 [27] due
to its methodology of randomization and blinding. Even using higher doses (6 mg/kg), the positive
effects are verified [28,31,45] but with a moderate risk of bias due to aspects of randomization
or blinding.
In tennis, caffeine improved power skills such as backhand stroke, serve velocity, handgrip force,
and the number and velocity of sprints, as well as mental aspects such as the accuracy serve or total
number of successful shots. Lower dosages such as 0.2–0.25 mg/kg before and during a tennis match
or approximately 1 mg/kg 30 min before a serve test only increased epinephrine levels in urine but
they have not shown any performance improvements [25,29]. Moreover, both studies have a moderate
risk of bias since the control of randomization, the carry-over effect, the differences in caffeine dosage
between sexes, and the lack of certain control groups could be affecting the results. In another study [26],
it was shown that the use of a carbohydrate drink with or without caffeine showed improvements in
sprints and serve quality compared with the placebo group. As there were no differences between
both conditions, it is not possible to evaluate the real effect of caffeine in this study. Furthermore,
although an increase in sweat rate has been observed with low caffeine dosages (3 mg/kg) in junior
tennis players [30], several studies have disproved a dehydration risk [14].
On the other hand, handgrip force was not affected in badminton and paddle [40,45], but squat
and counter jump height or power were significantly better than in the placebo group in badminton [40],
offering a specific advantage in this discipline due to the net height in this sport.
In short resistance training, positive results have been observed regarding caffeine consumption in
the reduction of perceived exercise exertion [47]. However, no changes were observed in racquet sports
Nutrients 2020, 12, 2842 14 of 20

(long duration intermittent sports) with the only exception of using two intakes of 4 mg/kg caffeine
before and after the first half of a badminton specific test and combining them with carbohydrates [41].
Despite these null effects, the number of total successful shots (with medium effect size (d = 0.57)) and
volley precision (high effect size (d = 0.86)) were improved in tennis and paddle respectively using a
high caffeine dosage (6 mg/kg) [28,45].
Therefore, the use of an acute ergogenic dosage of caffeine (3–6 mg/kg) 30–60 min before a
match is better than the intake of smaller concentrations, despite its continuous use during the
match. Due to the large seasons with accumulative long duration matches such as tennis, caffeine
consumption could be a useful aid for all competitive levels, since it may maintain physical and mental
conditions. More studies with a high caffeine dosage during long periods of intermittent exercise
and in combination with carbohydrates are needed in order to prove caffeine capacity to elicit high
accuracy and synergetic effects.

4.2. Effects of Creatine Monohydrate in Racquet Sports

Commonly, creatine monohydrate supplementation has been used as a strategy to increase muscle
mass and strength during training, but it has been also reported to improve power and anaerobic
capacity [48–50]. Thus, the use of creatine in intermittent sports such as racquet sports is of high
interest since about 75% of top 100 rank tennis players take it [17]. However, up to the present, there is
no evidence for recommendation.
Neither specific tennis skills, such serve or stroke, nor general physical aptitudes, such as sprints
or strength (typical short-duration high-intensity movements), were improved with different protocols
involving only a creatine load (20 g/day for 5 days) or load and maintenance (0.3 g/day for 6 days
and 0.03 g/kg for 28 days) [32,33]. Both creatine protocols were used in two studies that had a low to
moderate risk of bias.
On the contrary, in one study on squash, the intake of 0.3 g/kg creatine for 5 days was capable of
improving the sprint time in a specific test on court [43]. Due to the heterogeneity of sprint protocols,
it is not possible to reach a solid conclusion regarding its effect and the effect of moderate bias due
to lack of information about the randomization method, carry-over effect and missing information
about placebo composition. Moreover, the combination of 1 g of creatine + 1.5 g of guarana + 133 mg
of caffeine in an acute dosage improved several physical and alertness aptitudes in squash players,
but it has not been ruled out that the stimulant effect of guarana and caffeine were behind them [44].
Therefore, this fact—together with the lack of blinded groups—led to a high risk of bias.
Further studies should evaluate the sprint capacity or service and stroke skills with a high dosage
(16 g/day or 0.3 g/kg/day) for a longer period (at least 14 days), as has been shown in previous
works [49,50]. Further studies should also consider protocols that emulate long games. In addition,
despite not showing any clear improvements in specific tennis skills, creatine consumption during the
pre-season could be beneficial for the maintenance or increase of lean mass [50].

4.3. Effects of Buffering Supplements in Racquet Sports

High-intensity intermittent exercise tends to accumulate acid (H+ ) and carbon dioxide (CO2 ) in the
muscle and blood. Bicarbonate coming from CO2 acts as the primary mechanism to counteract plasma
acidification. The efficiency of acute sodium bicarbonate supplementation is influenced by exercise
duration. Specifically, extended duration (>4 min) sports have shown diverse results, with sodium
bicarbonate improving performance in running and cycling, but not in rowing, rugby, water polo,
or basketball [51].
An acute dosage (0.3 g/kg) and a continuous intake for a >4 min specific tennis test (0.1 g/kg)
did not improve accuracy or perceptual exercise exertion but kept serve (small effect size (d = 0.42))
and stroke consistency (small effect size (d = 0.09)), which decreased in placebo condition [34] with
a low risk of bias. On the other hand, in badminton players, only an acute dosage of 0.3 g/kg
increased time to exhaustion in a treadmill test, but not in a specific test in a high risk of bias
Nutrients 2020, 12, 2842 15 of 20

study, since the randomized method, allocation concealment, blinding method and control of diet,
other supplementation consumption, and exercise load were poorly controlled [42]. Although the
blood lactate level was higher than in the placebo groups in both studies, this could be due to the
carboxylate co-transporter, which extracts lactate and H+ from working muscle cell to circulation
after an increase in extracellular pH [52] and an increase of glycolytic activity. Despite no changes
observed in extracellular pH between placebo and sodium bicarbonate before and after tests in tennis
players [34], changes between pre- and post-tests with supplementation may be enough to activate
lactate extrusion due to an enhance of glycolytic metabolism.
Other buffer supplements such as sodium citrate, used for causing less gastrointestinal distress
than other supplements, also showed significant high values of blood lactate compared to placebo
after an acute dosage (0.3–0.5 g/kg) 90–120 min before exercise [35,42]. Nevertheless, an increase in
extracellular pH was observed in tennis players, [35] which decreased in badminton players [42],
but there are contradictions about it, since the text of the study indicates otherwise. On the other hand,
sodium citrate was able to increase stroke consistency (high effect size (d = 1.41)) in junior tennis
players, just as sodium bicarbonate did, but it did not present effects in accuracy and perceptual exercise
exertion in protocols of >4 min duration [35]. With a non-specific badminton test, sodium citrate was
able to improve the time to exhaustion in a treadmill test [42]. Both studies have a moderate to high risk
of bias due mainly to the blinding methodology and the control of the intake of other supplementation.
More studies with a higher number of subjects would be needed with the aim of achieving strong
evidence about improvements in tennis skills as well as evidencing possible synergies between different
buffers (for example, beta-alanine) and other NEAs.

4.4. Effects of Nitric Oxide (NO) Precursors in Racquet Sports

It is well known that NO plays a relevant role as a second messenger. Its production is also
related to an increase in blood flow, which enhances nutrient and hormone delivery. NO also has a
favorable impact on resistance and endurance training adaptations [53,54]. Recent systematic reviews
and meta-analysis about NO synthase-independent pathway supplements showed that potassium
nitrate and sodium nitrate were less effective than beetroot juice on endurance exercise. The use of
beetroot juice supplementation containing 12–6 mmol nitrate displayed significant improvements in
time to exhaustion in a cycling race of 5–30 min duration but slightly non-significant improvements in
time trial or graded-exercise performance [55,56].
In intermittent sports such as tennis, beetroot juice containing 6.4 mmol nitrate did not show
any improvements in either explosive movements (serve velocity, jump, sprint, handgrip force)
or perceptual exertion in high-level tennis players [36] with a low risk of bias. These results are
similar to the ones found in recent studies in which short and high-intensity movements (such as
countermovement jump, isometric strength, or muscular movement concentric velocity) were evaluated
after the consumption of beetroot juice containing 6.4–17.7 mmol nitrate [57–59]. It seems that the
effect of beetroot juice could be beneficial in endurance performance due to nitrate conversion to NO,
affecting improvement in aerobic adenosine triphosphate (ATP) synthesis due to a reduction of VO2 .
In intermittent and short-term exercise, where the anaerobic alactic system is the main source of energy,
the effects are less clear. Only one-third of the studies evaluated in a recent systematic review of
intermittent exercise protocols [60] showed significant results in different variables of power compared
with the placebo group during repeated-sprint tests.
On the other hand, NO synthase-dependent pathway supplements, such as arginine or citrulline,
have shown different results. While arginine supplementation has demonstrated improvements in
both aerobic and anaerobic performance with acute (0.15 g/kg) or chronic (1.5–2.0 g/day for 4–7 weeks
or 10–12 g/day for 8 weeks) protocols [61], acute protocols of citrulline supplementation (3–6 g) showed
a small effect size (0.2) on high-intensity strength and power performance in resistance exercise [62].
In master female tennis players (51.0 ± 9.0 years), acute protocol with 8 g of citrulline improved
handgrip strength and power peak in a specific anaerobic test, but not the capacity of sustained
Nutrients 2020, 12, 2842 16 of 20

power or jump power [37]. Due to the lack of a washing time between conditions and control of the
consumption of other stimulant substances, the risk of bias is moderate. Further studies are necessary
to analyze the role of citrulline supplementation in the performance of younger racquet sports players.
Yang et al. (2017) [38] showed improvements regarding the prevention of a decrease in stroke
accuracy and keeping stroke consistency and velocity (as opposed to a worsening in the placebo
group) using 0.05/kg citrulline +0.05 g/kg arginine +0.17 g/kg branched-chain amino acids (BCAAs).
The study presented a low risk of bias. Additionally, perceived exertion after the test decreased
significantly. These results appear to be due to a lower plasma tryptophan/BCAAs ratio than placebo,
since theoretically, BCAAs compete for the same tryptophan transporter across the blood–brain barrier,
avoiding serotonin formation and, consequently, central fatigue instauration [63]. It is common to use a
mixture of several NEAs in one product with the objective to obtain a synergic effect, but further studies
are necessary in order to verify the true effects of citrulline or arginine by themselves, without the
presence of the BCAAs being able to distort them.

4.5. Effects of Glycerol Supplementation in Racquet Sports

Finally, glycerol is a naturally occurring metabolite that acts as a plasma expander and could
help athletes prevent dehydration and improve thermoregulatory and cardiovascular changes [14].
Until 2018, the World Anti-Doping Agency (WADA) considered glycerol a banned substance, since
it was hypothesized that it may alter athlete biological passport [64]. In any case, the results of its
supplementation are mixed both in endurance and anaerobic disciplines [14]. In intermittent sports such
as tennis, 1.0 g/kg glycerol before followed by 0.5 g/kg after 75 min of simulated match, in environmental
conditions in the range of 29–38 ◦ C and 50–90% relative humidity (emulating conditions of important
tennis tournaments such as The Australian Open Grand Slam or Miami ATP Masters 1000), was not
capable of improving accuracy in serves or strokes, sprint velocity, or agility, in spite of its effect
increasing pre- and post-exercise plasma volume and osmolality [39]. This study has a moderate risk
of bias, since its randomized method, carry-over effect, blinding method and control of diet, and other
supplementation and drug consumption were poorly controlled. More research is needed to determine
glycerol’s supposed potential efficacy in racquet sports during more time-prolonged matches or during
several matches on the same day or on consecutive days in hot conditions.

5. Conclusions
Caffeine is the NEA showing clearer evidence of benefits for racquet sport players. Acute dosages
(3–6 mg/kg) 30–60 min before a match may improve specific skills and accuracy but may not contribute
to improve perceived exertion. Even though some evidence concludes that other NEAs, such as creatine,
sodium bicarbonate, sodium citrate, beetroot juice, citrulline and glycerol, could play an interesting
role in improving performance, more studies are needed to strengthen the evidence (Table 5).
Nutrients 2020, 12, 2842 17 of 20

Table 5. NEA recommendations from current evidence. Green: High level of recommendation due to
the high number and quality of studies and the effects produced; Orange: Low level of recommendation
due to the low number and/or quality of studies and the effects produced; Red: Not recommended due
to the low number and quality of studies and contradictory or low effects.

NEA Effects Posology

- Improves specific racquet sports skills
- Improves sprints and jumps
Caffeine 3–6 mg/kg 30–60 min before competition
- Improves mental performance and
maybe accuracy
Creatine - May improve sprints 0.3 g/kg for 5 days
- May improve specific racquet
Sodium Bicarbonate sports skills 0.3 g /kg 70–90 min before competition
- May hold up time to exhaustion
- May improve specific racquet
0.3–0.5 g/kg 90–120 min before
Sodium Citrate sports skills
competition
- May hold up time to exhaustion
Beetroot juice - No effects 6.4 mmol 3 h before competition
- May improve handgrip strength
Citrulline-malate 8 g 60 min before competition
- May improve peak power
1 g/kg 150 min before competition and
Glycerol - No effects
0.5 g/kg 15 min after it.

Author Contributions: Conceptualization, N.V.-S. and G.S.-S.; methodology, N.V.-S. and G.S.-S.; protocol drafting,
N.V.-S. and G.S.-S.; risk of bias, N.V.-S. and G.S.-S.; quality assessment, N.V.-S. and G.S.-S.; data extraction, N.V.-S.
and G.S.-S.; literature search, N.V.-S. and G.S.-S.; search flowchart, N.V.-S.; writing—original draft preparation,
N.V.-S. and E.R.; writing—review and editing, N.V.-S., G.S.-S. and E.R. All authors have read and agreed to the
published version of the manuscript.
Funding: This study was supported by the official funding agency for biomedical research of the Spanish
government, Institute of Health Carlos III (ISCIII) through CIBEROBN CB12/03/30038), which is co-funded by the
European Regional Development Fund.
Acknowledgments: CIBEROBN is an initiative of Instituto de Salud Carlos III, Spain.
Conflicts of Interest: The authors declare no conflict of interest.

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