INJURY PREVENTION IN YOUNG TENNIS PLAYERS
Compiled by:
Sergio Gomez-Cuesta, MSc, Chartered Physiotherapist, Licensed LTA Tennis
Coach, Strength and Conditioning Coach.
Head of Physiotherapy and Biomechanical Analysis
Gosling LTA International High Performance Centre
Contents
0. Purpose
1. The Development of the Elite Young Athlete: ‘The predisposed young
body’.
1.1 Attaining Expertise
1.2 Growth and Maturation
1.3 Growth and Injuries
2. Risk Factors and Injury Mechanisms
2.1 Growth Related Factors
2.2 Developmental Training Errors
2.3 Suboptimal Strokes Technique and Loading
2.4 Poor levels of Conditioning and Recovery
2.5 Tennis Specific Maladaptations
2.6 Anatomical malalignment and Body Posture
2.7 History of Previous Injury
2.8 Shoe-Surface interaction
2.9 Racket, Strings and Balls (refer to the enclosed book chapter)
3 Common Injuries in Young Tennis Player
3.1 Injury Types
3.2 Injury Incidence, localisation, gender and surfaces
3.3 Common Overuse and Acute Injuries
4 Prevention Strategies
4.1 Technical Strokes Development
4.2 Critical Loading Moments and Common Technical Errors
4.3 Periodization and Strength Training
5.Conclusion: ‘Prepare to Win’.
0. Purpose
This compilation is a review of some of the current concepts and research
in injury prevention in junior tennis players. The purpose of this compilation is
to provide the performance coaching candidates with a good understanding
of:
 the developmental considerations related to injuries when working with
junior tennis players
 the risk factors for injuries in junior tennis players.
 the most common injuries in junior tennis players
 the general injury prevention methods in junior tennis players
This compilation will be supported with a presentation where the practical
coaching implications will be explored through examples of preventative
strategies, case studies and interactive discussion.
1. The Development of the Elite Young Athlete: ‘The predisposed young
body’.
1.1 Attaining Expertise
Continued development of tennis performance in young players
requires optimal and well designed training programmes. Children and
adolescents, like adults, respond to progressive and regular training.
It takes 8 to 12 years of intense and sustained deliberate practice for a
talented young athlete to reach elite levels. This translates to an average of 3
hours of daily practice, the so called 10000 hour rule.
These hours of training will distinguish experts from non-experts.
These experts will have an enhanced ability to interpret meaning from
available information, their detection and recognition of patterns of play are
superior, and they make more rapid and appropriate decisions. Continuous
practice accelerates the ability for complex thinking, learning structures and
processes. Therefore, enhancing the development of the processing
strategies of the chosen skill.
1.2 Growth and Maturation
 Between the ages of 0 and 2 there is an accelerated growth phase
where boys attain approximately 50% of their adult stature. Girls reach
50% of their final stature by 1.5 years. From then on there is a steady
deceleration of growth until the adolescent growth spurt.
 During adolescence the maximum velocity of growth is known as peak
height velocity (PHV).
o Girls onset of PHV: 8.2 and 10.3 years.
o Girls PHV: 11.4-12.2 years
o Boys onset of PHV: 10.0-12.1 years
o Boys PHV: 13.4-14.4 years
 The process of growth and maturation is continuous through childhood
and adolescence, with girls on average, experiencing the onset of
puberty about 2 years before boys
 All young people follow the same pattern of growth however there is
variation in the timing and magnitude of these changes.
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Boys become considerably larger and acquire broader shoulders,
whereas girls enlarge their pelvic diameter and have increased
deposits of fat in various places.
Adolescent males lay down greater amount of lean tissue compared to
girls, this increase in skeletal size and muscle mass leads to increased
strength in males.
Training should be organised so that early, average and late maturers
have their programme tailored for their developmental stage. This way,
training is based on biological age and not chronological age.
Otherwise, under and over training can be induced.
The onset of PHV should be used as a reference point to design the
programmes as it will determine the critical period of adaptation
(window of opportunity) for strength and aerobic training.
1.3 Growth and Injuries
 Injury is an inherent risk of participation in any sport. All elite young
athletes undergo repetitive practice during training, predisposing them
to increased risk.
 Up to half of all sports injuries in the young are overuse injuries. These
overuse injuries are most likely to be sports specific as a result of
extensive periods of specialized repetitive practice.
 Overall tennis injuries in children are uncommon however incidence
increases with age towards adolescence. It is important that we aim to
limit injuries without losing the competitive enjoyment and maximising
the performance potential.
2. Risk Factors and Injury Mechanisms
A good understanding of the risk factors by everyone involved in the
development of a tennis player is the cornerstone of prevention.
Risk factors can be divided into two main categories: internal (playerrelated) such as strokes technique and conditioning levels of the player and
external (environmental factors) such as the equipment and the competition
schedule.
Recently, It has been advocated that sports injuries may result from a
complex interaction between internal and external risk factors. However,
merely addressing the internal and external factors is not enough: ‘the final
mechanism of injury’ by which they occur must also be identified.
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Figure 1. Interaction between internal and external risks factors leading to an inciting
event and resulting in injury.
As can be seen in figure 1 the internal risk factors will ‘predispose the
player’ the external factors will make him ‘more susceptible’ and a series of
final ‘inciting events’’ will cause the injury. Therefore, in order to prevent
injuries we need to address the internal factors, external factors and the final
inciting events (Table 1).
The internal factors will mainly determine the load tolerance of the body
(how much the body can cope with). The external factors will determine the
load that the player is exposed to. In general terms, when the load exceeds
the body load tolerance tissues will fail and injury will occur.
Internal Risk Factors
(load tolerance)
Fixed
Modifiable
External Risk Factors
(load)
Fixed
Modifiable
Inciting Events
(load)
All Modifiable
Growth factors
Age
Weight
Genetics
Environment
Surface
Weather…
Opponent
Training load
Competition Schedule
Skill Performance
Body conditioning
Malalaigment
Poor posture
Muscle
imbalances
Skill level
Technique
Prior Injury
Conditioning
Recovery
Mental
toughness
Training load
Technical load
Competition load
Equipment
Table 1. Risk factors and inciting events for junior tennis players.
2.1 Growth Related Factors
Generally, injuries occur at the peak of the growth rate (Peak Height
Velocity). Failure occurs when excessive load is applied in excess to the load
tolerance of the tissues. These are the main anatomical sites that are more
vulnerable:
 With growth spurts (after the onset of PHV, particularly in the summer
seasons) there is a decrease in muscle flexibility as the muscles elongate
passively in response to the bones growth. As muscles become
progressively tighter they can be pulled from their attachment to the bone.
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(These injuries are called traction apophysitises i.e. Osgood –Schlatters
Disease. Apophysis means muscle insertion to the bone).
The growth plate of the bone (or epiphysial cartilage plate where the bone
grows) and the joint cartilaginous surfaces are other structures that can be
injured. These thin vulnerable layers of bone are less resistant to repetitive
stresses than in adults.
Bones in children are more porous than adults and may fail with
compression or rotational forces.
Finally, ligaments in children can be stronger than the growth plate where
they attach, excessive forces may result in growth plate fracture.
Coaching Implications:
Children evolve at different rates. The growth rate of their bones, muscles,
organs, and nervous systems are different from stage to stage, and
these developments largely dictate their performance capabilities.
2.2 Developmental Training Errors
 Well organized and systematic training usually accomplish the best future
performances. Applying correct training principles and considering the
different stages of athletic development will produce healthy and
outstanding athletes and tennis players.
 Abrupt changes and unsound increases in intensity and volume of training
clearly predispose to overuse injury.
2.3 Suboptimal Strokes Technique and Loading
Tennis strokes places a large demand on a player’s body. The
powerful modern strokes are linked to increased load in the body. The link
between this load and injuries must always be treated seriously (Elliot et al.
2003). Coaches and support staff who understand this link are able to
enhance the strokes performance in an injury-free environment.
Faulty technique is a major risk factor for overuse injuries. The repetitive
demands placed upon the body could gradually overload the tissues and
contribute to injury. Some of the suboptimal mechanical features that could
increase the loading in the tissues are:
 If there is an Ineffective leg drive during the serve action, it will place 23%
greater load on the shoulder and 27% greater load on the elbow to
achieve the same serve velocity.
 If trunk rotation is ineffective during the serve action it will require 28%
more load in the elbow and 34% increase in shoulder velocity to achieve
the same ball velocity.
 If the dominant arm and shoulder don’t have an optimal coordination
action the muscles in the forearm would have to be 60% larger in size to
protect the elbow against injuries.
 Players with abbreviated backswing serves recorded higher force levels at
the shoulder than those players with a full backswing serve.
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Loading increase with an increase in service speed. Optimal physical and
technical preparation to prepare the body for high speed serves is
paramount.
2.3 Poor levels of Conditioning and Recovery
 Players that lack the appropriate levels of strength, speed and stamina to
cope with the demands of the game are at high risk of injuries
 Players that don’t have the proprioceptive, agility and speed skills to get in
and out of the high speed situations of the game may be unable to
withstand the forces of training.
 Young tennis players tolerate gradual training progressions well followed
by scheduled recovery periods. Lack of appropriate recovery strategies will
increase the risk of developing fatigue, overtraining and burnout. It will
increase the risk of injury, reduce the quality of training and reduce the
competitive performance.
2.4 Tennis Specific Maladaptations
Performance tennis training and competition cause changes in
flexibility and strength on those areas of the body subject to repetitive tensile
overload. These maladaptations increase with years of training. They will alter
joint optimal function and alter the way muscles operate around the joint .
These changes are seen as risk factors for injury and decrease the force
production therefore affecting performance.
The most commonly involved areas and deficiencies include:
 The lead hip rotation and flexion flexibility and stability
 Shoulder rotation flexibility, rotational strength and neural
tightness
 Scapula stability
 Elbow and wrist flexibility and neural tightness
 Trunk strength, flexibility, stability and neural tightness
 Neck and thoracic spine flexibility
 Ankle ligaments stability, flexibility and strength
Interestingly, these adaptations occur in areas of high incidence of
injury, indicating a relationship between these changes and injury patterns.
2.5 Anatomical malalignment and Body Posture
Malalignment refers to the abnormal position of bones and joints in
relation to others. It can be genetic, due to poor posture or caused by an
injury. Malalignment has been suggested as a contributory factor to overuse
injuries in young athletes. Examples of malalignment are:
-Spine: scoliosis
-Hip rotation abnormalities
-Feet: over pronated or high arched
Promoting proper body posture is widely recommended whether the
athlete is sitting or moving on court. Sub-optimal body posture will increase
the chances of developing muscle imbalances and therefore increasing the
risk of injury. A stable and balanced posture will enhance the transfers of
forces during strokes and on-court movement. Furthermore, good posture will
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provide a stable platform for the head for accurate processing of visual
information.
2. 6 History of Previous Injury
This is one of the strongest injury predictors. Injuries can leave residual
effects that will predispose the tissues and surrounding areas to some level of
chronic residual weakness.
Appropriate rehabilitation should minimize any residual effects.
Furthermore, taking in consideration any past injuries, through a
comprehensive injury history recording during screenings, should be a priority.
Any area that has been injured before should be carefully monitored and may
be addressed on the prehabilitation programme.
2.4 Shoe-Surface interaction (refer to section 3.3.2)
2.5 Racket, Strings and Balls (refer to the enclosed book chapter)
3 Common Injuries in Young Tennis Player
3.1 Injury Types
Young tennis players, as with all young athletes involved in organized sports,
are subject to two basic types of injuries (09-8):
 Acute injuries (sprains, muscle pulls, fractures,etc) are the result of
single macrotrauma event (i.e. a player runs to get a wide ball whilst
playing tripping over and spraining his ankle)
 Overuse injuries (strains, tendynopathies, shoulder impingement, low
back pain,etc…) previously rare in young tennis players, are due to
repetitive microtrauma over a extended period of time (i.e. a player
reports shoulder pain that was due to a combination of muscle
imbalances and poor strokes mechanics)
Coaching Implications:
The recognition and treatment of acute injuries is well established therefore it
will be easier for the players support team to deal with them. The majority are
minor and long-term effects of these injuries are minimal.
However, overuse injuries require careful evaluation and a good
understanding of the possible multiple causal mechanism. Their rehabilitation
could be lengthy.
Serious injuries, such as fractures, ligament, tendon, joint, spinal injuries can
leave permanent damage and/or residual symptoms.
3.2 Injury Incidence, localisation, gender and surfaces
3.2.1 Incidence
Tennis appears to have a lower injury rate in comparison with contact
and with non-contact individual sports such as golf or running. The rate is
approximately 0.5 to 1.0 injury per player per year.
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3.2.2 Localisation
Young players seem to be more susceptible to overuse injuries than
their adult counterparts.
The majority of the injuries are acute (60%-70%) versus overuse (3040%).Most injuries occur in the lower extremities, followed by the upper
extremities and the trunk. Most acute injuries occur in lower extremities,
whereas most overuse injuries are located in the upper extremities.
A specific study in juniors looked at the injury incidence during 5 years of
USTA boys Championships.
The distribution of injuries was 51% lower extremities, 26% upper
extremities and 22% the trunk. Back pain is the most common ailment
preventing juniors from playing (~25%)
3.2.3 Gender
Another study comparing male and female elite tennis players showed
that females had a significantly higher rate of injuries on the front of the
shoulder, and in their dominant and non-dominant wrists than males, as well
as more lower extremities injuries.
It could be hypothesised that one of the contributing factors is the
prevalence of the ‘unit ‘ forehand coordination in women tennis versus the
‘multisegment’ forehand in the men s game.
Generally speaking female players have more knee problems, less
upper body strength and start competition at a lower level of conditioning than
men. Extrapolating this to junior girls experts advocate that we should expect
more over-use injuries, more upper body injuries and more knee problems in
female juniors.
3.3.3 Surfaces
In general, the repetitive and multilateral nature of tennis movement
together with the associated twisting and turning movements predisposes the
lower extremities to a greater risk of injury than other sports.
A study on ATP players indicates that the treatments received on the
lower body and back were higher on grass (0.42 treat x match) than hard
court (0.37) and that clay court (0.20). This study seems to indicate that clay
has a positive effect on the reduction of load on the lower extremities in tennis
players. The lower injury pattern on clay is probably due to the lower frictional
resistance of this surface when compared to grass or hard courts
Recently, another study has demonstrated that the surface significantly
affects the foot loading. On hard courts the foot presented higher loads
making it very prone to ‘blocking type’ injuries (i.e. knee sprains). By contrast,
on the slower clay court surface the lower friction leading to longer sliding
movements tends to predispose the player to muscle strains, spasms and
tears.
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3.3 Common Overuse and Acute Injuries
3.3.1Common Overuse Injuries
Table 3 shows the most common overuse injuries
Injury Location
Shoulder
Type
Rotator cuff impingement
Shoulder instability
Frequency
Common
More common than
impingement
Elbow
Tennis elbow
Golfers elbow
Common in children
More common in
adolescence than
children
Rare
Growth plate injury
Wrist/hand
Tendinopathies
Stress fractures
Trunk/Spine
Lower back strains
Abdominal strains
Stress fractures
Groin
Strains
Thigh
Strains
Knee
Osgood-Schlatter’s
Common:
females>males
Rare
Most common
Common
Rare bur more common
in adolescences<18 than
adults>18.
Common Male>female
Common
Very common
Female>male
More common in females
Common
Patella-femoral pain
Rare
Leg
Shin splints
Ankle
Growth plate injury
(Sever’s)
Rare.
Foot
Stress fractures
Most common stress
fracture in juniors
Table 3. Common overuse injuries in junior tennis players.
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3.3.2 Common Acute Injuries
Table 4 shows the most common acute injuries
Injury Location
Type
Frequency
Lower Extremities
Hamstring, groin and calf tear
Common
Ankle
Ligament Sprains
The commonest acute injury
Less common
Knee
Ligament Sprains
Patellar dislocations
Table 4. Common acute injuries in junior tennis players.
4 Prevention Strategies
4.1 Technical Strokes Development
An understanding of the biomechanical principles of strokes production
and the most common technical errors associated with overuse injuries is
important to minimize the risk of injury.
Applied Biomechanical Principles:
 The use of elastic energy: during the stretch-shorten cycle the pre-tension
created on the muscles will create elastic energy. This muscle pre-tension
process is critical for success. During the backswing on groundstrokes and
serve there will be an accumulation of energy in the muscles that needs to
be released on the forward swing. The timing between these two phases is
vital as 50% of the energy stored is lost if there is a pause of 1 second
between the backswing and forward swing phases of the stroke. It is vital
that there is only a very short pause between the back and forward swing.
 Racket displacement. Research has shown that modern players have a
large racket displacement as part of the backswing in all power strokes.
The reason is to increase the distance over which racquet speed can be
developed during the forward swing to the ball. On forehand: 45 degrees
beyond perpendicular to the back fence. On backhand: racket parallel with
the back fence. On 2hbh: racket aligned just perpendicular to the back
fence. On serve: racket parallel to the players back
 Kinetic chain: in order to transfer force efficiently from the different body
segments to the racket these segments must be activated in a
coordinated fashion (kinetic chain). Reduced performance and injury is
often associated with alterations in the flow of energy across segments,
such that if one segment is removed from the chain, then there is a
compensation on the others to accommodate this loss, which may lead to
tissue overload.
4.2 Critical Loading Moments and Common Technical Errors
(This section will be explore in depth on the presentation day)
4.3 Periodization and Strength Training
Research shows that a well designed periodized training and strength
programmes may help prevent injuries.
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Tendons (which anchor muscles to bones) and ligaments (which hold
together the bones that form the joints), are trainable through strength
training, resulting in their enlargement increasing their ability to withstand the
tension and tearing of training and competition.
Overall early strengthening of ligaments and tendons will reduce the
risk of injuries in the future, and will lay a solid athletic foundation for the body
to cope with future loads.
Table 5 summarizes the prevention strategies that need to be
designed, integrated and implemented in relation to the risk factors.
Risk Factor
Growth related factors
Developmental Training errors
Suboptimal Strokes Technique and Loading
Prevention Strategies
 Education parents, players, coaches,
support staff)
 Good understanding of the different
developmental stages..
 Integrate and implement Growth and
Maturation principles into training and
competition programmes.
 Apply performance training principles
 Good understanding of the different
stages of athletic development
 Apply young training programme
principles
 Periodized Training Programmes
 Adequate warm-up

Apply sound strokes technical
development strategies
 Technical analysis
 Good understanding of the mechanical
features that will overload the body.
(see section 4.1)
Poor levels of conditioning and recovery
 Strength and conditioning programmes
 Recovery strategies
 Education parents, players, coaches,
support staff)
 Interval musculoskeletal sreening
 Equipment adjustments
Tennis Specific Malaadptations
 Early Identification through regular
screening
 Prehabilitation programmes
Anatomical malaligment and posture
 Interval screening and prehabilitataion
programmes
 Coaching team understanding and
implementation support
History of previous injury
 Adequate injury rehabilitatation
 Interval screening
 Prehabilitataion programmes
Surfaces
 Functional strength & conditioning and
footwork for different surface types
 Prehabilitation programmes
 Guide the player regarding best types of
shoe for a particular surface
Equipment
 Guide the player regarding equipment
best suit it.
Table 5. Prevention strategies for junior tennis players.
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5.Conclusion: ‘Prepare to Win’.
The LTA vision is to produce more winners. In order to achieve this
tennis players need to start training and competing regularly from an early
age. This scenario will predispose young athletes to very few injuries with little
or not long-term effects.
However, some players will see their careers cut short due to injuries.
50% of the injuries will be overuse injuries, which mean than they are
preventable. Quality coaching and a sound understanding of the risk factors
during the development stages of our juniors is paramount if we want to
ensure the competitive enjoyment and career longevity of our juniors.
Competition is necessary and good; our responsibility is to prepare them
appropriately to win.
Generally speaking, injuries occurred because the loading of the
performance activities exceed the body tissues loading tolerance. Therefore,
in simple terms the main objective in order to ensure the future longevity and
productivity of our junior players will be:
1. To decrease excessive loading with good quality programmes without
compromising the maximisation of potential. This will mean to focus on
reducing the risk of the external risk factors and the inciting events.
2. To increase the loading tolerance of the players, which will mean to
reduce the predisposing internal risk factors as well as prepare them to
compete.
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