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Training, Biomechanical Factors and Injuries Associated with Tennis

By Christopher J. Couture, MD, Wentworth Health Partners Seacoast Orthopedics & Sports Medicine

It has been said that tennis players are among the best all-around athletes on the planet. Yes, I’m the one who said it, and I might be a bit biased as someone who has been playing tennis for almost 40 years! However, it is true that tennis requires a unique blend of high-level aerobic conditioning, flexibility, strength, and coordination. The sport is also associated with several specific injuries, and preventing those injuries demands specific attention to the factors that can cause them. In this article, I’ll discuss those factors and provide some tips on how you can stay healthy during the tennis season, get the most out of your game, and keep playing this wonderful sport for life.

Tennis-specific conditioning and body mechanics

A typical tennis match requires 300-400 bursts of effort - obviously more so and with more sustained efforts in singles than in doubles. A typical 2-hour match features approximately 30 minutes of actual play: 5-10 seconds per point with 20-30 seconds of “rest” between points. During those bursts of effort, aerobic performance level averages 60-70% of maximum predicted heart rate (HR) for singles, 40-50% for doubles. A well-conditioned tennis player needs strength and efficiency of form for each burst of effort, sustained throughout the match, without fatiguing at the end. Movements require side-to-side as well as back-to-front-and-back sprinting, jumping, as well as the strokes themselves.


Tennis conditioning requires a strong focus on lower extremity strength and coordination, as well as high intensity interval training to train for the quick bursts of effort required. Strengthening should involve progressive resistance to prepare muscles for each type of stroke and should also include balanced conditioning of agonist and antagonist muscles to maintain joint stability.

Tennis form

A well-executed and efficient serve mirrors a typical throwing motion and includes the following phases:

  • Wind-up - Hips, knees, ankles flex for recoil; abdominal muscles set
  • Cocking - Ball toss and recoil of serving arm; shoulder muscles at maximum stretch
  • Acceleration - Energy release from lower extremity drive, abdominal flexion and then arm swing
  • Deceleration of service arm

Groundstrokes (forehands & backhands) are comprised of the following phases:

  • Preparation - Trunk rotation, run/jump to set point, racket pull-back
  • Acceleration - Lower extremity and abdominal energy release, arm swing
  • Deceleration - Lower extremity and trunk rotation toward net

Back and trunk motion
Primary concern as a potential source of injury is lower back hyperextension during serve and overhead strokes. This can be mitigated by directing the ball toss slightly ahead of the service line and launching the serve upward and into the court, driving from the legs.

Excessive back motion can also affect groundstrokes and can result from compensation for shoulder girdle, hip & lower extremity inflexibility. Spine (i.e., torso) rotation during groundstrokes also requires appropriate strength, flexibility & coordination.

Shoulder motion
Primary concern is overloading of shoulder girdle during serve and overhead strokes. This can lead to several types of overuse injuries discussed in more detail below.

Elbow and wrist motion
Elbow & wrist of the athlete are fixed during groundstrokes. In other words, the power from a tennis stroke should come from trunk rotation and lower extremity spring/recoil, rather than arm swing or elbow & wrist snap. Overuse injuries can result from excessive snapping of wrist, most commonly during the backhand stroke.

Hip, knee, and ankle motion
Stresses on quads, hamstrings, knees, calves, Achilles are like those seen in sprinting and therefore require a similar approach to training and conditioning. The proper set-up for each stroke includes a partial squat & adequate trunk rotation, again with most of the power of the stroke coming from lower extremity recoil rather than arm swing.


Obviously, the racket is the tool of the tennis player’s trade and is an extension of his or her arm. Several factors go into proper racket choice and set-up:

Proper grip sizing - When gripping a racket, it should feel like a handshake. A properly sized grip should allow a small amount of space between the tips of your fingers and the heel of your hand. If your fingertips run into the heel of your hand, you need a larger grip.

That said, many players opt for a slightly smaller grip to generate more topspin on their groundstrokes while avoiding the excessive wrist action that can create overuse injuries. Most adult females have grip size 2 (4-1/4”) and most males are size 3 (4-3/8”).

Also consider string tension - Aim for the lower range of racket manufacturer recommendations to reduce rigidity and impact forces. However, looser strings can reduce control.

“Swing weight” and stiffness of the racket are a bit more of a personal preference - Generally, a somewhat heavier racket (10-11 oz.) will absorb more impact force and be “easier” on the arm, as will a racket whose weight is evenly balanced or more balanced toward the head of the racket (which prevents torsion or twisting of the racket on impact). However, such rackets also require more strength and endurance to consistently swing through the course of a match without fatiguing.

Many players prefer the quickness and maneuverability of a lighter racket (8-1/2 to 9-1/2 oz.) with a more head-light balance. Similarly, the stiffness of racket is also a matter of preference. A more flexible racket absorbs more impact force and thus would seem to reduce the risk of injury, but that comes at the cost of a loss of power and control in the shot, thus requiring a harder swing to generate the same power.

Lastly, pay attention to proper footwear - Tennis specific shoes have snug fit and a robust heel counter to provide side-to-side stability and wear resistance.

Overuse injuries

With all of this in mind, we can think about the types of injuries commonly seen in tennis. The predominant mode of injury is overuse stress to soft tissues (muscles, tendons, ligaments) - and in growing kids and adolescents, the growth plates.


  • “Tennis elbow” - overuse/strain of wrist extensor tendon at its attachment point on the lateral elbow, usually combined with age-related degenerative changes
  • Risk factors: age > 30, improper grip sizing, tight strings, rigid racket, form - tight grip and/or excessive wrist snap on backhand strokes
  • “Golfers elbow” - similar injury on medial/inner elbow; usually associated with excessive wrist snap on serves and aggressive topspin forehands


  • Rotator cuff overuse/impingement - usually associated with improper shoulder blade “glide” with overhead movements
  • Instability of glenohumeral (“ball & socket”) joint can lead to injuries of the labrum (cartilage ring inside the joint)
  • Biceps strain & tendinitis

Wrist and hand

Uncommon, but overuse injuries can occur to ligaments and joints

Neck and back

Excessive hyperextension often related to service ball toss behind the head or inadequate trunk rotation from poor flexibility or coordination of movement


Hip flexor & adductor (inner thigh) overuse/strain injuries, often associated with lower abdominal strains (so called “sports hernia” injuries)


  • Knee extensor mechanism - quadriceps, patella (kneecap) and patellar tendon overuse from aggressive side-to-side and jumping movements
  • Calf strains (including “tennis leg”) - especially in age > 40
  • Achilles tendinitis and ruptures - especially in age > 40
  • Ankle sprains - “rollover” injuries from side-to-side movements, especially on hard courts if footwear does not provide appropriate stability

Growth plate injuries in adolescents

  • Upper arm/shoulder - associated with aggressive serves with improper mechanics
  • Inner elbow - associated with aggressive topspin forehand.
  • Knee - Osgood-Schlatter disease at attachment site of patellar tendon on upper shin
  • Heel - Sever’s disease at Achilles tendon attachment

If you experience any of these injuries, be sure to collaborate with your athletic trainer. He or she will guide your recovery and rehabilitation so that you can return to tennis safely and can help determine if you should also work with a physical therapist or be seen by a sports medicine physician.

With appropriate attention to conditioning, form, and equipment factors essential to the game, tennis is a sport that can be enjoyed for life. See you on the court!

About Dr. Christopher J. Couture, MD

Dr. Couture is certified in Family Medicine by the American Board of
Family Medicine and is a member of the American Medical Society for
Sports Medicine. He specializes in the evaluation and non-surgical
treatment of musculoskeletal injuries, as well as the full range of non-
musculoskeletal sports medicine conditions. He is also proficient in the
use of ultrasound for musculoskeletal diagnosis and procedures and is
Registered in Musculoskeletal Sonography.

Dr. Couture serves as the Head Team Physician at the University of New
Hampshire. Dr. Couture is also an avid tennis player.

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