Upper Extremity Musculoskeletal Profiles in Tennis Players: A Systematic Review.

CONTEXT: Tennis-specific musculoskeletal (MSK) screening can assess range of motion (ROM) and muscular imbalances. Identifying normative values before implementing a MSK screen is essential in contributing to athlete performance and injury risk profiles. OBJECTIVE: To review upper extremity MSK data in healthy tennis players across age, sex, and level of play. DATA SOURCE: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this review. A search was conducted in MEDLINE, SPORTDiscus, Embase, and CINAHL. STUDY SELECTION: This review included shoulder, elbow, and wrist ROM, isometric strength, or isokinetic strength in a tennis population. Each article was critically appraised to help identify the internal and external validity of each study. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: A total of 41 studies met the search criteria. Each contributor organized the data elements of interest into data tables, with a second contributor assigned for review. Data elements of interest included player and study characteristics: ROM, isometric dynamometry, and isokinetic strength. RESULTS: A total of 3174 players were included in the final studies. Most of the players included were competitive adolescents and young adults; 15 studies included ROM data. Male tennis players consistently had more external rotation (ER) gain (range, 1.8º to 8.8º) and internal rotation (IR) loss (range, -15.3º to -3.0º) when compared with their female counterparts (ER range, -2.5º to 5.8º; IR range, -10.4º to -3º). Shoulder IR and ER strength were measured in the majority of all the strength studies, with the external rotators generating at least two-thirds the strength of the internal rotators. CONCLUSION: Overall MSK data of tennis players indicate that shoulder strength values are often larger than nontennis players, but equal to or slightly lower than comparable athletes in other overhead sports. Adaptive changes of the glenohumeral joint and subsequent rotational motion are similar to those of other overhead athletes.

Return to Sport and Clinical Outcomes Following Osteochondral Autograft Transplantation in Baseball Players and Gymnasts With Unstable Osteochondritis Dissecans: A Critically Appraised Topic.

CLINICAL SCENARIO: Osteochondritis dissecans (OCD) of the capitellum is a condition occurring at the elbow and often seen in both baseball players and gymnasts due to the repetitive loading of the radiocapitellar joint. Treatment options for OCD vary and are dependent on lesion presentation, elbow motion, and growth plate maturity. OCD lesions categorized as unstable can be treated with an osteochondral autograft transplantation surgery (OATS). FOCUSED CLINICAL QUESTION: In an adolescent population, what are the return to sport rates and clinical outcomes following OATS in baseball players and gymnasts with unstable OCD lesions? SUMMARY OF KEY FINDINGS: Three articles met the inclusion criteria for this appraisal, and all indicate an OATS procedure should be considered in the management of unstable OCD lesions. Return to play outcomes were favorable for both baseball players and gymnasts. Self-reported patient function and elbow extension all improved following an OATS. CLINICAL BOTTOM LINE: An OATS procedure is a favorable option for the management of OCD lesions of the elbow in baseball players and gymnasts. STRENGTH OF RECOMMENDATION: There is level B evidence to support return to sport and clinical outcomes in baseball players and gymnasts following an OATS procedure. This score is directly related to the quality of evidence that currently exists on the topic.

Does humeral torsion play a role in shoulder and elbow injury profiles of overhead athletes: a systematic review.

BACKGROUND: Humeral retrotorsion (HRT) is one bony adaptation that occurs in overhead athletes. This bony adaptation often leads to bilateral changes in range of motion at the glenohumeral joint. Because HRT can create different stress environments on the surrounding tissue, it may play a role in upper-limb injury and pain profiles. Therefore, the aim of this review was to examine whether HRT plays a role in shoulder and elbow injury profiles. METHODS: Two separate critical appraisal tools were administered: the Newcastle-Ottawa Scale (case control) and the Appraisal Tool for Cross-sectional Studies. The primary author extracted all data and obtained means and standard deviations for each outcome. Cohen d effect sizes (ESs) were calculated (ES [95% confidence interval]) for all HRT measurements including nondominant, dominant, and side-to-side differences. Finally, the Strength of Recommendation Taxonomy was used to evaluate the overall strength of the recommendation. RESULTS: Nine articles were included in this review. Large ESs were present in 2 studies on examination of symptomatic and asymptomatic dominant HRT and ranged between 0.83 (0.08-1.55) and -2.57 (-3.66 to 1.99). The majority of all ESs for all HRT measurements were moderate or low, rendering comparisons between asymptomatic and symptomatic cohorts that were not clinically meaningful. CONCLUSION: The Strength of Recommendation Taxonomy rating was C based on inconsistent findings. Differences in sports populations and definitions of injuries across studies may be one reason for the varying ESs. HRT does occur in the overhead population, but the degree to which this HRT starts to affect upper-limb injury is unknown and is more than likely player specific and multifactorial.

The Association Between Noncontact Injuries and the Acute-Chronic Workload Ratio in Elite-Level Athletes: A Critically Appraised Topic.

Clinical Scenario: Workload monitoring and management of an athlete is viewed by many as an essential training component to determine if an athlete is adapting to a training program and to minimize injury risk. Although training workload may be measured a variety of different ways, session rate of perceived exertion (sRPE) is often used in the literature due to its clinical ease. In recent years, sports scientists have been investigating sRPE as a measure of internal workload and its relationship to injury in elite-level athletes using a metric known as the acute:chronic workload ratio (ACWR). This critically appraised topic was conducted to determine if internal workload using the ACWR is associated with injury. Focused Clinical Question: In elite-level athletes, is there an association between the ACWR for sRPE and noncontact injuries? Summary of Search, Best Evidence Appraised, and Key Findings: The literature was searched for studies investigating the association between noncontact injuries and the sRPE ACWR in elite athletes. Three prospective cohort studies were included. Two studies found that high ACWR led to 2.0 to 4.5 times greater injury risk compared with a more balanced ACWR. One study found that low chronic workloads coupled with a low ACWR were associated with injury. Clinical Bottom Line: The majority of evidence suggests that when the acute workload exceeds the chronic workload, there is an increase in injury risk. The evidence also supports that a low chronic workload with a low ACWR should be considered as an injury risk factor. Strength of Recommendation: Based on the American Family Physician's Strength of Recommendation Taxonomy, there is level A evidence to support the sRPE ACWR as a risk factor for noncontract injuries in elite athletes.

The Acute: Chronic Workload Ratio Is Associated with Injury in Junior Tennis Players.

PURPOSE: Session RPE (sRPE) is used to track internal training/competition load in athletes using a metric known as the acute to chronic workload ratio (ACWR). Research that reported on team sports has determined that if the acute load is higher than the chronic load, athletes are likely to sustain injury. No studies, however, have attempted to investigate internal load and injury in a tennis population despite the rigorous training loads. Therefore, the purpose of this study was to investigate if sRPE ACWR is associated with injury in junior tennis players over a 7-month time period. METHODS: Forty-two junior tennis players were recruited to participate, 26 were included in the final analysis. Players provided a rating of RPE as an estimate of training intensity every day after training/match sessions. sRPE, a measure of internal and external training load was calculated by multiplying the training/match sRPE by the session duration in minutes. Players self-reported all injuries. The ACWR was the primary independent variable. Acute load was determined as the total sRPE for 1 wk, whereas a 4-wk rolling average sRPE represented chronic load. RESULTS: Seventeen players sustained injuries. The model indicated that ACWR from the previous week (P < 0.001) and previous injury history (P = 0.003) were significant predictors of injury the following week. In the week preceding injury, the average ACWR was 1.57 (SD, 0.90). CONCLUSION: Injured players had on average 1.5 times more training load in the past week compared with the previous 4 wk. A majority of players who went on to sustain an injury were not prepared for the load endured. These results were similar to previous studies investigating ACWR where an acute increase in load was associated with increased injury risk.

RELIABILITY AND VALIDITY OF A BIOMECHANICALLY BASED ANALYSIS METHOD FOR THE TENNIS SERVE.

BACKGROUND: An observational tennis serve analysis (OTSA) tool was developed using previously established body positions from three-dimensional kinematic motion analysis studies. These positions, defined as nodes, have been associated with efficient force production and minimal joint loading. However, the tool has yet to be examined scientifically. PURPOSE: The primary purpose of this investigation was to determine the inter-observer reliability for each node between two health care professionals (HCPs) that developed the OTSA, and secondarily to investigate the validity of the OTSA. METHODS: Two separate studies were performed to meet these objectives. An inter-observer reliability study preceded the validity study by examining 28 videos of players serving. Two HCPs graded each video and scored the presence or absence of obtaining each node. Discriminant validity was determined in 33 tennis players using video taped records of three first serves. Serve mechanics were graded using the OSTA and categorized players into those with good ( ≥ 5) and poor ( ≤ 4) mechanics. Participants performed a series of field tests to evaluate trunk flexibility, lower extremity and trunk power, and dynamic balance. RESULTS: The group with good mechanics demonstrated greater backward trunk flexibility (p=0.02), greater rotational power (p=0.02), and higher single leg countermovement jump (p=0.05). Reliability of the OTSA ranged from K = 0.36-1.0, with the majority of all the nodes displaying substantial reliability (K>0.61). CONCLUSION: This study provides HCPs with a valid and reliable field tool used to assess serve mechanics. Physical characteristics of trunk mobility and power appear to discriminate serve mechanics between players. Future intervention studies are needed to determine if improvement in physical function contribute to improved serve mechanics. LEVEL OF EVIDENCE: 3.

Volume-based Interval Training Program for Elite Tennis Players.

BACKGROUND: A sport-specific conditioning program can help tennis players train for competition or return to play from injury. This study determined the actual tennis serve volume in elite play and used these data to construct an interval training program based on stroke volume. HYPOTHESIS: There will be no differences in serve volume between male and female tennis players at the professional and junior levels. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Game day statistic scorecards were provided to the research team from the 2013 and 2014 United States Open and the 2014 Metropolia Orange Bowl International Tennis Championships. Serve volume data for both male and female players were extracted from the scorecards. Data included serves per match and per set. These data were used to construct a sport-specific tennis program to meet the demands of the serve. RESULTS: Professional male players serve 63 more serves per match than junior male players because of the greater number of sets played ( P < 0.01). Professional female players serve 10 more serves per match than junior female players playing the same number of sets ( P = 0.01). All male players hit 2 more total serves per set than all female players ( P < 0.01). Regardless of sex, professional players serve 4 more serves per set than junior players ( P < 0.01). The typical number of serves per set was 40 in elite-level tennis players, resulting in a 3:1 ratio of first to second serves. CONCLUSION: These data establish the "unit dose" of serves per match and/or per set for each group. CLINICAL RELEVANCE: Coaches and health care providers may use these data in estimating loads per tournament/season and to prepare tennis athletes for individual competition and/or as they return to play after an injury.

ACUTE CHANGES IN PASSIVE GLENOHUMERAL ROTATION FOLLOWING TENNIS PLAY EXPOSURE IN ELITE FEMALE PLAYERS.

BACKGROUND: Alterations in glenohumeral (GH) rotation especially internal rotation and total range of motion have been associated with altered GH kinematics and susceptibility to injury. Researchers have evaluated long-term change in baseball and tennis players, and short-term changes in baseball players. However, acute (short-term) changes in GH rotation have not been evaluated in tennis players. HYPOTHESES/PURPOSE: The purpose of this study was to quantify short-term glenohumeral rotational changes within a group of professional women's tennis players following competitive play. It was hypothesized that there would be acute alterations in passive glenohumeral internal rotation and total range of motion following episodes of tennis play. STUDY DESIGN: Cohort Study. METHODS: Passive glenohumeral external rotation (GER), glenohumeral internal rotation (GIR), and total range of motion (TROM) were evaluated in a cohort of 79 professional adult female tennis players. Measurements were taken at three different time points (TP): baseline before match play (TP1), immediately after match play (TP2), and 24-hours after baseline (TP3). RESULTS: There was a statistically significant decrease in the mean GIR from TP1 (43 ± 11 °) to TP2 (39 ± 9 °) (p=0.002) and from TP1 to TP3 (38 ± 10 °) (p=0.001). All measures were at the level of minimal detectable change (MDC) (4 °) indicating clinical significance. There was a decrease in mean TROM from TP1 (146 ± 11 °) to TP2 (142 ± 12 °) (p=0.04), which was not above MDC (7 °). Subgroup analysis showed that 47% of the players demonstrated a decrease in GIR beyond MDC, and 37% demonstrated a decrease in TROM beyond MDC. GER remained unchanged across all time points (p>0.05). CONCLUSION: Both GIR and TROM were reduced after acute exposure to tennis play. In a large subgroup of the cohort, the changes were clinically significant and approached values previously demonstrated to be associated with increased injury risk. Given the changes in glenohumeral motion following acute exposure to tennis, evaluation of players for significant motion alterations following overhead activity and intervention strategies to minimize such alterations in these players are recommended for high level tennis players. LEVEL OF EVIDENCE: Level 3.

SUSTAINED ISOMETRIC SHOULDER CONTRACTION ON MUSCULAR STRENGTH AND ENDURANCE: A RANDOMIZED CLINICAL TRIAL.

BACKGROUND: The Advanced Throwers Ten Exercise Program incorporates sustained isometric contractions in conjunction with dynamic shoulder movements. It has been suggested that incorporating isometric holds may facilitate greater increases in muscular strength and endurance. However, no objective evidence currently exists to support this claim. HYPOTHESIS/PURPOSE: The purpose of this research was to compare the effects of a sustained muscle contraction resistive training program (Advanced Throwers Ten Program) to a more traditional exercise training protocol to determine if increases in shoulder muscular strength and endurance occur in an otherwise healthy population. It was hypothesized that utilizing a sustained isometric hold during a shoulder scaption exercise from the Advanced Throwers Ten would produce greater increases in shoulder strength and endurance as compared to a traditional training program incorporating a isotonic scapular plane abduction (scaption) exercise. STUDY DESIGN: Randomized Clinical Trial. METHOD: Fifty healthy participants were enrolled in this study, of which 25 were randomized into the traditional training group (age: 26 ± 8, height:172 ± 10 cm, weight: 73 ± 13 kg, Marx Activity Scale: 11 ± 4) and 25 were randomized to the Advanced Throwers Ten group (age: 28 ± 9, height: 169 ± 23 cm, weight: 74 ± 16 kg, Marx Activity Scale: 11 ± 5). No pre-intervention differences existed between the groups (P>0.05). Arm endurance and strength data were collected pre and post intervention using a portable load cell (BTE Evaluator, Hanover, MD). Both within and between group analyses were done in order to investigate average torque (strength) and angular impulse (endurance) changes. RESULTS: The traditional and Advanced Throwers Ten groups both significantly improved torque and angular impulse on both the dominant and non-dominant arms by 10-14%. There were no differences in strength or endurance following the interventions between the two training groups (p>0.75). CONCLUSIONS: Both training approaches increased strength and endurance as the muscle loads were consistent between protocols indicating that either approach will have positive effects. LEVEL OF EVIDENCE: Level 2.

Increasing Ball Velocity in the Overhead Athlete: A Meta-analysis of Randomized Controlled Trials.

Overhead athletes routinely search for ways to improve sport performance, and one component of performance is ball velocity. The purpose of this meta-analysis was to investigate the effect of different strengthening interventions on ball and serve velocity. A comprehensive literature search with pre-set inclusion and exclusion criteria from 1970 to 2014 was conducted. Eligible studies were randomized control trials including the mean and SDs of both pretest and posttest ball velocities in both the experimental and the control groups. The outcome of interest was ball/serve velocity in baseball, tennis, or softball athletes. Level 2 evidence or higher was investigated to determine the effect different training interventions had on velocity. Pretest and posttest data were extracted to calculate Hedges's g effect sizes with 95% confidence intervals (CIs). Methodological qualities of the final 13 articles within the analysis were assessed using the Physiotherapy Evidence Database scale. The majority of the articles included in this analysis had an effect on velocity with the strongest effect sizes found in periodized training (Hedges's g = 3.445; 95% CI = 1.976-4.914). Six studies had CI that crossed zero, indicating that those specific interventions should be interpreted with caution. Consistent and high-quality evidence exists that specific resistance training interventions have an effect on velocity. These findings suggest that interventions consisting of isokinetic training, multimodal training, and periodization training are clinically beneficial at increasing velocity in the overhead athlete over different windows of time.