Sports Presentation Tennis Injuries

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Sports PresentationTennis Injuries

• Au Ching Man (2)
• But Wai Man (3)
• Chan Yee Wah (17)
• Chui Pui Yu (44)
• Tung Shui Ping (126)

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Presentation outline

• Physiological and physical requirements
• Prevalence
• Common injury
• Shoulder injury
• Elbow injury
• Back injury
• Conclusion

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Physiological Characteristics (Konig, 2001)

• VO2 Max 60-70
• Mean HR 140-160/min
• HR affected by psychological stress and
  Temperature
• 70 alactic anaerobic, 20 lactic anaerobic, 10
  aerobic
• Recovery from anaerobic work is aerobic
• Require good cardiovascular endurance

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Physical Requirements(Chandler, 1995)

• Good agility
• Maintain balance and control to hit the ball
  effectively
• Power and strength
• Sprinting, stopping, starting and bending
• Muscle Endurance
• Repetitive demand on the bones, ligaments, and
  muscles to absorb the shear force

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Demands on different parts of body(Chandler,
1995)

• Shoulder high loading, high velocity and large
  ROM
• Elbow, forearm and wrist high load and absorb
  rotational torque
• Hip and trunk
• center of rotation
• Transfer force produced by the legs to the
  shoulder
• Abdominal muscles generate, transfer and
  decelerate forces in the trunks

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Prevalence(Bylak, 1998)

• LL injuries 2 X UL or spine injury
• Ankle injury is the most common
• E.g. sprain ankle
• Gender
• junior female gt junior males
• LL injuries
• wrist and hand injuries
• Males has more shoulder and elbow injuries

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Common injuriesin different parts of body

• Rotator Cuff Tendinitis
• Impingement
• Shoulder Instability

Chronic stress and compressive injuries
Tennis elbow (Lateral and medial)
Abdominal Strain Repetitive and compressive stress
Tendinitis of extensor carpi radialis longus and
brevis
Adductor strain
Anterior knee pain Hamstring strain
Sprain ankle Calf strain Achilles Tendinitis
Plantar fascitis Stress fracture Tennis toe
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Prevalence of shoulder pain in tennis players

• Incidence rate of shoulder pain
• 10 -30 among elite junior players (Todd S.
  1995)
• 74 of men and 60 of women world-class tennis
  players have a Hx of shoulder or elbow injury
  (Todd S. 1995)
• 3 common causes of shoulder pain
• Subacromial impingement as most common shoulder
  injury
• 97 of junior tennis players w/ shoulder symptom
  have subacromial impingement (Richard C. Lechman
  1988)
• rotator cuff tendinitis
• Shoulder instability

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Risk Factors That Contribute to shoulder pain in
Tennis

• Intrinsic
• Biomechanics of tennis playing
• Weakness in humeral/ scapular stabilizers
• Muscle imbalance
• Inflexibility
• Age difference
• Neck pain

• Extrinsic
• Poor techniques
• Tennis racquet
• Grip
• String
• Tennis ball

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Tennis Biomechanics in Shoulder region

• Serving
• Hitting an overhead smash
• .
  
• 
  

Cocking phase90o abduction max ER0o forward
flexion Full retraction Ant. Capsule and internal
rotators maximally stretchedExternal rotators
maximally contracted.
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Tennis Biomechanics in Shoulder region

• Acceleration phase
• ER ? IR
• Abduction ? Forward flexion Lati dorsi, Pect
  maj, and Teres maj contract maximally
• External rotators maximally lengthened.

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Tennis Biomechanics in Shoulder region

• Follow-through phase
• Rapidly IR of shoulder
• Eccentric contraction of the external rotators
• Full protraction of scapula

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Mal-adaptation of tennis players

• Muslce imbalance
• Post. capsule tightness
• Droop shoulder

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Cocking phase
Follow-through phase
Eccentric overloading of ER
Lengthening of Scapular stabilizer
Repetitive eccentric overload of IR HF
Weakness/ fatigue of rotator cuff
Drooping of dominant shoulder
Overstretch sh. ant. capsule
Overstretch and microtrauma of post. Sh. capsule
Altered Scapular humeral rhythm
Post. Capsule tightness
shoulder instability
Rotator cuff tendinitis/Impingement
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Age

• Older tennis player
• Actual impingement or degeneration
• X-ray change in AC jt, narrower subacromial
  space, or increase size in greater tuberosity due
  to chronic wear

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Neck problem

• Neck pain will cause compensatory movement of GH
  and scapulo-thoracic joint
• Cause myotomal change can alter the strength and
  endurance of the cervical, scapular and GH joint
  muscle

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Extrinsic factor-Tennis Racquet

• Size
• Mid-sized (90-1002 inches)

Handle -Y-shaped throat configuration -Largest
grip comfortable
Weight heaviest racquet (without sacrificing
technique)
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Extrinsic factor-String

• String type
• - high quality synthetic (Pluim B.M., 2000)
• - thinner (Pluim B.M., 2000)
• String tension
• -?? by 3 5 pounds (Lehman RC, 1988)
• string pattern
• -High-density
• (Pluim B.M., 2000)

Recommendation
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Extrinsic factor-Tennis balls

• new
• pressurized (Field LD et al, 1995, Pluim B.M.,
  2000)

Recommendation
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Rehabilitation of shoulder injury

• Training of scapular stabilizers Rows, shrug and
  wall push up
• minimise stress GH jt ??recruit of scapular
  activity
• (Moesley et al,1992, cited in Ellenbecker,
  1995)
• Training of rotator cuff
• Normalize unilateral 15 -30 of IR dominance
  (Ellenbecker, 1991, cited in, Ellenbecker, 1995)
• -Isokinetic internal and external rotation ex at
  90o abducted position in scapular plan
  (Greenfield et al, 1990, cited in Ellenbecker,
  1995)
• Before return to full competition
• -Com or Cybex compare players strength
  (Plancher et al, 1995)

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Rehabilitation of shoulder injury

• Inflexibility
• - stretching to restore IR ROM
• Tennis-specific training
• Repetitive exercise
• Eccentric training
• Plyometric trainging (tennis stroke include
  prestretch followed by full-range concentric
  contraction)

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Prevalence of elbow injury in tennis player

• Lateral epicondylitis 40 to 50 (Roetert
  EP1995, Field LD et al, 1995)
• Medial epicondylitis less common (Field LD et al,
  1995)
• Lateral Medial 51(Kibler, 1989, Powers,
  1982)
• Age 35-55 most common, (Nirschl, 1988)

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Aetiology of elbow injury

• Intrinsic factors
• Backhand technique
• One-handed
• Two-handed
• Overhead stroke and top spin
• Arm position
• Age
• Skill level

• Extrinsic factors
• Tennis Racquet
• Racquet weight
• Handle of tennis racquet
• String tension
• Tennis balls

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One-handed backhand technique

• Ball contact far from fulcrum lever (shoulder)
• Greater torque
• Rapid arm and shoulder fatigue
• Lateral epicondylitis

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One-handed backhand stroke

• Failure to lock the wrist during one-handed
  backhand stroke
• Eccentric wrist extensor contraction,
• ? stress on the tendinous attachment of muscles
  near the epicondyle

• Recommend one-handed backhand stroke with long
  backswing
• ? ball-and racket impact force,
• ? external torque on the wrist in the one-handed
  backhand stroke
• Wrist extensor muscles are contracted firmly lock
  the wrist during ball-and-racket impact

Recommendation
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Two-handed backhand techique

• Relies on trunk rotation to generate force in the
  forward swing phase of stroke

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Overhead stroke top spin

• Overhead stroke increase valgus load
• lead to medial epicondylitis
• Top spin cause forced pronation
• Aggravate symptoms at pronator muscle origin
  (Field LD et al, 1995)

• Mean elbow joint angle was 15 degrees at ball
  impact instead of full extension (Elliott and
  Christmass, 1995)
• Long backswing during preparation phase will
  significantly reduce the peak resultant impact
  and the risk for tennis-related UL overuse

Recommendation
28
Arm position

• The 90-degree-angle position (Nirschl,1988)
• Forces in the medial elbow are great
• Increase chance of medial elbow injury

• High arm elevations
• (Nirschl, 1988)
• Diminish medial elbow force load

Recommendation
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Skill level

• Lateral epicondylitis in unskilled player gt
  skilled player
• ?kinematics characteristics of unskilled players
  backhand stroke (Nirschl, 1988)

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Skill level

• Skilled player
• Strike the ball with
• center of the head
• of the racquet

• Unskilled player
• More miss-hits near the periphery of the racquet
  gtgtmore racquet vibration, shock, twisting gtgt
  microtrauma

• Oscillations of tennis racquet for
• different ball impact locations
• (Roetert et al, 1995)

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Extrinsic factor-External Support

• Elbow counterforce bracing
• constrain key muscle groups
• Decrease elbow angular acceleration
• Decrease EMG muscle activity (Groppel, 1986)

Recommendation
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Extrinsic factor-Racquet

• Metal racquets are not recommended for players
  with elbow problem (Gruchow and Pelletier, 1979)
• Dont use long-body racquet if having elbow
  problem (Pluim B.M., 2000)
• Heavy racquet head increase torque about the
  elbow joint by shifting moment arm away from the
  elbow (Field LD et al, 1995), it is not
  recommended for players recovering from injury
• Cushion grip bands can further reduce vibration
  transfer to the forearm (Hatze H, 1992)

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TennisBack problem---Back pain

• Unilateral sports
• ?stronger muscles on dominant side
• ?muscle imbalance
• ?mechanical instability
• ? back pain

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Tennis characteristics

• Great Compressive, shearing force act on the
  lumbar spine
• 4 strokes
• Serve, volley,forehand and backhand stroke
• Lumbar Flexion, extension combined with rotation
  
• (Marks
  Wiesel, 1988)

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Serve
Flexion with rotation
Hyperextension with rotation
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Forehand stroke
Shoulder, trunk, and hip rotate together
Minimize the force on the back
Extension of Knees
Back hand
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Intrinsic Players characteristics

• Alignment
• Increased lumbar lordosis
• Weak local spine stabilization muscle
• Local muscle Transverse Abdominals
• Multifidus
  co-contraction

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Extrinsic Training court

• surfaces
• Eg. Composition court
• ? greater impact force to L.L and then
  transmitted to back may cause injury
• Preventive measure
• Court surface for training back pain player
• eg. Clay shock absorption
• ( Watkins,1996)

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Management Recommendation

• -Pain relief
• Prevent recurrence of low back pain
• Stabilization exercise
• Local muscle first Transverse abdominis and
• Multifidus
• ( static ?
  dynamic)
• ?Global muscle rectus abdominus
• obliquus abdominis
  externus and
• internus, etc.

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Conclusion

• Pre-conditioning
• Choosing equipment
• Correct technique
• Rehabilitation

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QA
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References

1. Adelsberg S The tennis stroke An EMG analysis
   of selected muscles with rackets of increasing
   grip size. American Journal of Sports Medicine
   1986 14 139.
2. Bylak J, Hutchinson MR Common Sports Injuries in
   Young Tennis Players. Sports Medicine 1998 26
   119-132
3. Chandler TJ Exercise Training for Tennis.
   Clinics in Sports Medicine 1995 14 33-46
4. Hirsch R.P., 1988, Prevention and treatment of
   elbow and shoulder injuries in the tennis player,
   Clinics in Sports Medicine, vol. 7, No. 2, April
   1988
5. Ellenbecker TS Rehabilitation of shoulder and
   elbow injuries in tennis players, Clinics in
   sports medicine 1995 14 87-107.
6. Field LD et al, Elbow injuries, Clinics in sports
   medicine 14 no. 1, Jan 1995

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References

1. Goldie I. Epicondylitis humeri (epicondylitis or
   tennis elbow) a pathogenetical study. Acta Chir
   Scand Suppl 339 (1964)1 119
2. Groppel J, Nirschl RP A biomechanical and EMG
   analysis of the effects of counterforce braces on
   the tennis player. Am J Sports Med 14 195,
   1986Lehman RC Surface and equipment variables in
   tennis injuries. Clin Sports Med 7 229, 1988
3. Hatze H The effectiveness of grip bands in
   reducing racquet vibration transfer and slipping.
   Med Sci Sports Exerc 24 226, 1992
4. Haake S.J. and Coe A.O., Tennis Science
   technology, p.321-332 Pluim B.M., Rackets,
   strings and balls in relation to tennis elbow,
5. Hennig EM, Rosenbaum D, Milani TL Transfer of
   tennis racket vibrations onto the human forearm.
   Med Sci Sports Exerc 24 1134, 1992Nirschl RP
   Muscle and tendon trauma Tennis elbow, In Morrey
   BF (ed) The elbow and Its Disorders, ed 2.
   Philadelphia, WB Saunders, 1993
6. Kibler WB, Chandler TJ, Uhl TL, et al A
   musculoskeletal approach to the preparticipation
   physical exmination. Preventing injury and
   improving performance. American Journal of Sports
   Medine 1989 17 525-53

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References

• .Konig D et al Cardiovascular, metabolic, and
  homonal parameters in professional tennis
  players. Medicine Science in Sports Exercise
  2001 33 654-658
• Lee HWM Mechanism of Neck and Shoulder Injuries
  in Tennis Players. Journal of orthopedic and
  sports physical therapy 1995 21 28-37
• Lee WM (1995), Mechanisms of Neck and Shoulder
  Injuries in Tennis Players. Journal of
  Orthopedics and Sports Physical Therapy. 21(1)
  28-37
• Lehman RC(1988), Shoulder Pain in Competitive
  Tennis Player. Clinics in Sports Medicine.7(2)
  309-327
• Marks MR, Haas SS, Wiesel SW Low back pain in
  competitive tennis player. Clincs in sports
  medcine 19887277-287.
• Plancher KD, Litchfield R, Hawkins RJ
  rehabilitatiopn of the shoulder in tennis
  players. Clinics in sports medicine 1995 14
  111-137.
• Watkins RG The spine in sports. Ch 46 Tennis.
  New York Mosby, 1996 499-504.

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EMG study of tennis during serving(Glousman,
1993)
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Serving Action
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• Windup
• Minimal low muscle activity of all sh. Girdle
  muscle
• Racket is brought up ? sh. Extend passively by
  weight of racket trunk rot.
• Cocking
• Max. ER (infra teres min.) abduction
• Deltoid activity is low (abd is done by trunk
  rot.)
• Supraspinatus ? stabilization
• Serratus ant. ? rot. And stabilize scapula
• Subscapularis in late cocking ? decelerate ER

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• Acceleration
• Max. IR by subscapularis, pect maj. lati.
  Dorsi.
• Serratus ant. Max. activity ? stabilize scapula
• Follow-through
• activity of IR, peak activity of ER
• Sarratus ant. ? upward rot. and protraction