Abdominal Muscle Strain

Figure 1. The abdominal muscle injury

Figure 2. Stretching the abdominal muscles

Figure 3. Exercising the straight abdominal muscles

Diagnosis

Figure 4. Exercising the oblique abdominal muscles

An abdominal muscle strain is a partial tear or pull of one of the abdominal muscles. The injury usually affects the (non-dominant side of the) straight abdominal muscles (rectus abdominis) (figure 1), but the internal and external oblique abdominal muscles (the obliquus internus abdominis and obliquus externus abdominis) may also be injured. Abdominal muscular strains are a common occurrence for tennis players at all levels. The tennis serve is the movement which involves the highest risk of sustaining an abdominal muscle strain. Just before making the stroke, whilst bending back during the cocking phase, the abdominal muscles are under a great deal of tension. As soon as you start to hit the ball, these muscles start to contract, using the Figure 5. Throwing the medicine ball elastic energy stored in the abdominal muscles. The power released moves across the body, from the dominant shoulder to the leg of the non-dominant side of the body. This movement, whereby the muscles stretch and then contract (eccentric-concentric contraction), is a high-risk moment for the abdominal muscles. When you arch your body back even further than you do for a standard serve, such as for a kick serve or topspin serve, this increases the risk of sustaining an abdominal muscle strain even more. The open stance forehand, which involves a powerful rotation of the torso, may also lead to an abdominal muscle strain. Symptoms of an abdominal muscle strain are a sudden stabbing pain upon contraction of the injured muscle. This pain is for example felt during the serve or when doing abdominal muscle exercises. Furthermore, the injured muscle is sensitive upon palpation. What should you do? First Aid! The first phase of the treatment consists of activity modification and cooling of the injured area. Once the pain has somewhat subsided, you can start the rehabilitation process. Immediate and effective first aid is essential for a rapid recovery. If the injury seems to be serious or if in doubt, have a (sports) physician examine you. In certain cases you will be referred to a (sports) physiotherapist. How to Ensure the Best Recovery As soon as the worst of the pain has subsided (after one to five days), you can start the build-up process. During this build-up pain is a warning sign to stop and rest. Be careful: do not exceed your pain threshold, as this will only delay the healing process! The build-up consists of three stages, ranging from easy to demanding. Here are the exercises, along with some tips. Stage 1. Improvement of Normal Function Gentle stretches and isometric contractions of the abdominal muscles will stimulate the natural recovery process. y Stretching the abdominal muscles. Lie down on your stomach with your hands in the push-up position (figure 2). Slowly push yourself up with your hands so that your shoulders are raised from the ground, while hips and legs maintain contact with the ground. Hold this position for 15 to 20 seconds and then return to the original position. Try to ensure that your back and buttock muscles remain relaxed throughout this exercise. . y Isometric contraction of the right abdominal muscles. Lie down on your back with bent knees and your feet placed flat on the floor. Tense your stomach muscles and press your back into the floor. Hold this position for five seconds and release. y Isometric contraction of the oblique abdominal muscles. Stand in front of a door opening, with your right hand on the door frame. Push your right hand against the door frame very gently, until you feel tension in the abdominal muscles. Keep your upper body straight and keep looking straight ahead

y Pushing away your finger tips. Gently push the finger tips of both hands into your abdomen, by a few centimetres. Push your fingers outwards by tensing the stomach muscles, whilst your fingers continue to apply counter-pressure. Hold this position for five seconds and then release. Stage 2. Returning to Training As soon as all of the above exercises can be performed confidently and free of pain, you may start training again. y Strengthening the straight abdominal muscles (straight crunch, figure 3). Lie on your back with your knees bent and your feet flat on the ground. Place your finger tips behind your head, so that your elbows are pointing outwards. Look straight ahead and try to relax your head and neck. Contract your abdominal muscles and ensure that your back maintains contact with the floor. Raise your torso to the point whereby your shoulders are just off the ground. Hold this position for a few seconds and slowly return to the original position. Keep your lower back on the ground throughout the entire exercise. Repeat the exercise as often as you possibly can. y Strengthening the oblique abdominal muscles (oblique crunch, figure 4). Lie on your back with your knees bent and your feet flat on the ground. Place your left foot across your right knee. Place your finger tips behind your head, so that your elbows are pointing outwards. Look straight upwards and try to relax your head and neck. Contract your abdominal muscles and curl your body up with a twisting motion. Now bring your right elbow towards your left knee, to a point whereby your right shoulder blade just comes off the ground. Hold this position for a few seconds and slowly come back down. Repeat the exercise as often as you can. Then change legs (right foot across left knee) and repeat the exercise for the oblique muscles on the other side. The next step is to start running. Start off at a slow pace, followed by faster pace work, and then include pivots and turns. Finally, start introducing short sprints. Stage 3. Return to Play With an abdominal muscle strain you can sometimes just continue to play tennis. However, whilst it is still painful it is best if you avoid serves and overhand strokes. y Start off by playing against the practice wall or with a game of mini tennis, which will allow you to move backwards slowly. Avoid serves, smashes, high forehand and backhand strokes and high volleys. y Strengthening the abdominal muscles. Up to this point, the abdominal muscles have been trained in a normal position, whereby they contracted during the exercise. It is important for them to also be strengthened in a slightly stretched position, like in a serve, so that they are able to cope with the strain when performing this movement. Sit down on a bench which is either straight or tilted slightly backwards. Lean back slightly, hold this position for a few seconds and slowly come back to the original position. Maintain the contraction in the abdominal muscles and repeat the movement. Do three sets of 10 to 20 repetitions. y Medicine ball exercises (Figure 5). In this exercise muscles undergo a rapid stretch and contraction ('stretch-shortening'), similar to the action when performing a serve. Hold a medicine ball above your head with two hands (figure 5). Throw the ball to your partner and then catch it above your head. Slightly spring back with the ball and then throw the ball back in one go. Start by using a relatively light weight ball (0.5 1 kg), and slowly build it up over several weeks. Repeat three sets of six to eight repetitions. y You can now start performing second serves, smashes, and high forehand and backhand strokes during play. y Once this is going well, you can start performing some first serves. Gradually increase the frequency and speed of the serve. y You can now start playing practice sets and practice matches. Once you have played practice matches for two weeks without pain, you can start playing competition matches again. Preventing Re-injury Unfortunately, abdominal muscle strains cannot always be avoided. However, you can minimise the risk by observing the following guidelines:

y Ensure that you have good basic fitness. y Strengthen your abdominal muscles. y Ensure you have a good service technique, with a regular ball toss. y Ensure that you rest sufficiently between training sessions, games, competitions and matches.

The Achilles Tendon Injury

Figure 1. The Achilles Tendon injury

Figure 1a.

Diagnosis An injury of the Achilles tendon is a degenerative condition of the tendon, not an inflammatory process. It is therefore incorrect to describe this as tendinitis. Tendinopathy is a better term. The injury is caused by chronic repetitive movements during running and jumping. It occurs mainly in recreational tennis players aged between 35 and 45. The symptoms are a gradual increase of pain, initially only in the morning and at the start of the training. In later stages, the pain may be continually present during exercise and even at rest. The pain is felt in the Achilles tendon, 5-7 cm above the heel (Figure 1 and 1a). Continued exercise carries the risk of a gradual worsening of the injury, which makes recovery more difficult.
Figure 2. Stretching the long calf muscles

First aid y As a rule of thumb, first aid involves modification of activity (less tennis and running). y Cooling with ice, stretching exercises and wearing firm, good shoes are also important measures. y When there is swelling and pain, ice massage may alleviate symptoms. Use a melting ice cube or a paper cup with ice. Massage the painful spot. In general, 5 to 8 minutes will be sufficient. Repeat this several times a day. y Use special (visco-elastic) inlays or an Achilles tendon bandage. These provide good shock absorption and because of the increase in height, they artificially lengthen the tendon, reducing the stress on it. y Replace running exercises with cycling or swimming. How to Ensure the Best Recovery Exercises can start when the worst pain and swelling have disappeared. During these exercises, pain is a signal to reduce the training load. Do not surpass the pain threshold, as this will impair recovery. The build-up of the training load takes place in three stages, as described below, together with some practical tips. Stage 1. Improving Normal Function
Figure 4. Strengthening the calf muscles

Figure 3. Stetching the short calf muscles

y Stretching the long calf muscles (Figure 2). Take a step forward with the unaffected leg, keeping the heel of the back leg on the floor. The knee of the affected leg is kept straight. Shift the weight of the back leg to the front leg and press the heel of the back leg firmly into the floor. Rest the hands on a stationary object (no bouncing). The stretch should be felt high in the calf. Hold the stretch for 15 to 20 seconds, followed by a rest period of 10 to 20 seconds, and repeat three times. y Stretching of the short calf muscles (Figure 3). Start from the same position as above, but now bend the knee of the back leg, while keeping the heel on the floor. The stretch is felt low in the calf. Hold the stretch for 15 to 20 seconds, followed by 10 to 20 seconds rest, and repeat three times. y Strengthening the foot muscles. Sit on a chair. Write the alphabet in the air with the foot of the injured leg. Fold a towel by grasping it with the toes of the injured leg. Perform this for 15 to 20 seconds, followed by 10 to 20 seconds rest, and repeat 10 to 20 times. y Strengthening the calf muscles (Figure 4). Stand on your toes on a stair or bench and move up and down. It is best to use both legs while going up, and to lean on the injured leg only when going down.

This exercise needs to be repeated seven days a week, twice a day for five minutes, for twelve weeks. The exercise should be performed both with an extended knee as with a slightly bent knee. You should continue the exercise, even if you feel pain and stop only if the pain becomes really severe. The exercise can be made harder by carrying a filled knapsack. y Cycling or swimming for 15-30 minutes every day to preserve general fitness. Stage 2. Build-up As soon as the Stage 1 exercises can be performed well and the patient can walk without pain, work can start on a return to sport. y Take small, quick steps on the spot, alternating the left and the right leg. y If this goes well, start with easy jogging. Take small steps and use the entire foot. y Now you are ready for some easy running. y The next step is to include some sprinting exercises, starts, stops and turns in the training. y This can be followed by jumping exercises Step 3. Return to play y A return to the tennis court should now be possible. Start against the practice wall or with mini-tennis and gradually increase the distance to the wall, or use a full court. Make sure you position yourself well for the ball by taking small steps. y A start can now be made with volley exercises. y The next step is some easy hitting from the baseline. y In the course of the next two weeks, gradually incorporate exercises that require running longer distances to the ball (tennis drills from side to side). y Next, include low volleys and overheads. y Start playing points, then games, and then a full practice match. Once practice matches have been completed for two successive weeks without problems, the player is ready for match play. Preventing Re-injury It is not always possible to prevent a reoccurrence of an Achilles tendon injury, but the risk can be reduced by paying attention to the following: y Perform a complete warm-up before play and cool down afterwards, for approximately 10 to 15 minutes each. y Improper footwear is one of the main causes of an overuse injury of the Achilles tendon. Stability around the ankle joint is essential. Make sure the shoe fits well around the heel and that the base of the heel is wide enough. The heel cap should be stable. You can test this by pressing the heel cap with your thumb. It should be very difficult to compress. The sole of the shoe should be supple, with a normal unrolling from the ball of the foot to the toes. The flex point of the shoe should be located under the ball of the foot and not under the middle of the foot. Do not throw old shoes immediately away, but gradually break in shoes of another type of brand. A good tip is to walk around in new shoes before wearing them when playing. y During the unrolling of the foot a certain amount of pronation is necessary. Excessive pronation, however, can be found with a flat foot, cavus foot, and a leg length discrepancy. When misalignments are present, have customised inlays or a heel lift made by a podiatrist. y After a heavy practice or match a massage may help to relax the calf muscles and to relieve the

tension of the Achilles tendon. In addition, blood flow of the tissues is increased, which will reduce muscle cramp and enhance recovery. y Do not increase the frequency or duration of the practice too quickly. If there are any drastic changes, such as new shoes or a change of playing surface, the body must be given enough time to become accustomed to the change. y During the recovery period after an ankle injury there may be temporary Achilles tendon problems. This may be caused by the fluid around the Achilles tendon and increased instability of the ankle, which increases the load on the Achilles tendon. These complaints can be overcome by temporary use of an ankle brace.

Ankle Sprain

Figure 1. Ankle sprain

Figure 1a.

Figure 1b.

Figure 2. Mobilising the ankle

Figure 3. Balance excercises are very useful

Figure 4. Strengthening the muscles

around the ankle

Diagnosis A sprained or twisted ankle is the most common tennis injury. In most cases, the injury is caused by landing on the outside of the foot, with the foot turning too far inwards. The relatively weak lateral ankle ligaments are then injured (Figure 1, 1a and 1b). An injury of the much stronger ligament on the inside of the ankle (medial ankle ligament) is far less common (5-10% of cases). Depending on the severity of the injury, the ligaments may be overstretched or torn, resulting in instability of the ankle. The symptoms are pain and swelling around the ankle, mainly on the outside, later followed by discoloration of the skin. First aid Perform the following as quickly as possible, during the first 48 hours: y Rest (immobilisation). Do not play tennis and do not lean on the ankle. y Cool the painful area directly with ice, a cold pack or cold running water for 10 to 15 minutes. Repeat this several times a day (aim for 20 minutes every 2 hours). Do not place the ice directly on the bare skin, but cover the ice or cold pack with a towel. y Apply a compressive bandage immediately. This is even more important than cooling with ice, as it will stop the bleeding and prevent severe swelling of the ankle due to an accumulation of blood. The ankle cannot be taped until the swelling subsides. y Elevate the lower leg and the ankle above the heart whenever possible (i.e. lie on the floor and place the entire leg on several pillows to decrease swelling). Immediate and adequate first aid is important to ensure fast healing. In more serious cases, a visit to the doctor is recommended to rule out a fracture and to determine whether crutches or a boot are necessary. The doctor may refer the patient for physiotherapy. How to Ensure the Best Recovery Rehabilitation can begin when most of the pain and swelling have disappeared (after 2 to 5 days). During the build-up phase, pain is a signal to rest. Do not cross the pain threshold, as this will slow down the healing process. The build-up of the training load takes place in three stages, as described below, together with some practical tips. Stage 1. Improvement of Normal Function y As much as the pain allows, you may stand on the foot. Crutches can be used to support the ankle/foot during the first week, but try to walk normally, from heel to toe. y Sit down in a chair. Lift the injured foot and circle the ankle 10 to 20 times. Make the circles slow and wide, first with a clockwise set, then an anti-clockwise set. y Sit on a smooth surface. Lay a towel on the floor in front of you. Put the injured foot on the towel, with both the heel and the toes touching it (Figure 2). Move the feet with the towel alternately forwards (extend the knees) and back (bend the knees). Both the heels and the toes should stay in touch with the ground. y Stand straight and walk on your heels. The forefoot and mid-foot must not touch the ground. Take small steps. Then walk on your toes. Finally, walk on the inside of your feet, pressing the big toe firmly into the ground. y Stand on the injured foot, with arms spread to keep your balance (Figure 3). Shut your eyes and try to still keep your balance. y Sit on a chair with your feet on the floor (Figure 4). Tie one end of an elastic tube to the chair. Wrap the other end of the tube under the middle of the injured foot. Bend the knees 90 degrees. Move the foot against the resistance of the elastic tubing outwards and try to keep the outer side of the foot facing up. Repeat 10 to 20 times. Try to hold the knee and upper leg stable. y Swim or cycle for 15-30 minutes each day to preserve overall physical fitness.

Stage 2. Build-up As soon as the player can perform the above exercises well and can walk without pain, he/she can start building up strength for a return to sport. y Slowly rise onto your toes and hold this position for 10 to 20 seconds. Return to the starting position. Perform this exercise with first with both feet together, then using the injured leg only. y Stand on the injured leg. Bounce a tennis ball against a wall or on the floor and catch it again without losing your balance. Try to vary the point of the bounce as much as possible. A variation on this exercise is to stand on one leg and try to juggle with one, two, three or even more balls. y Take quick, small steps, alternating the injured and uninjured legs. y A very good exercise for the muscles around the ankle and foot is skipping. This should be done with care, however. It is important to build up this exercise gradually, from one minute a day to 10-15 minutes daily. Use a soft surface, such as grass or carpet, and wear either tennis or running shoes. y If this goes well, you can start jogging. Start with an easy warm up, then progress to straight running, followed by the introduction of starts and stops into your running exercises. y Finally, include sprints and jumping exercises. Stage 3. Return to Play y Now you are ready to go back on court again. Initially, the ankle should be taped or lace-up brace should be used, to help prevent re-injury of the ankle ligaments. y Start against the practise wall or with mini-tennis (playing within the service lines). Gradually increase the area of play and move back towards the baseline. Make sure you use small steps to position yourself correctly for the ball. y This can be followed by volley exercises. y After 1-2 weeks, you can start including exercises in which you run longer distances to the ball (tennis drills, from side to side). y Include low volleys, followed by the serve and overhead. y As soon as you can hit a jump smash without problems, you can start playing practice matches. y Take care with explosive or unexpected movements, or strokes in which your foot is perpendicular to the running direction, such as wide backhands. y In this phase, it is important to increase the loading capacity of the ankle, to regain your rhythm and to win confidence. y Once you have been able to play practice matches for two successive weeks without problems, you will be ready for match play again. Preventing Re-injury It is not always possible to prevent an ankle sprain, but the risk can be reduced by paying attention to the following: y Perform a complete warm-up before each practice or match, and a cool-down afterwards, both lasting 10-15 minutes. Pay attention to the correct performance of stretching exercises. Stretching exercises for the calf muscles are especially important. y Ensure a gradual build-up of training, so the body can get used to the extra load.

y Wear firm, stable, well-fitting tennis shoes and pay attention to how the shoelaces should be tied. An ideal tennis shoe should have good shock absorption, sideways stability, feeling with the surface (grip) and optimal comfort. y Remove all the balls from the tennis courts, to avoid tripping over them. y Improve your physical condition with regular jogging or cycling. Most injuries tend to occur towards the end of the match or at the end of the day, when you are getting tired. The better your physical condition, the lower the risk of injury. y Improve proprioception and strength of the muscles around the ankle with co-ordination and balance exercises. Standing on one leg is a particularly useful exercise. The exercises can be made more difficult by using a wobble board. y A tape, brace or high shoe will help protect the ankle ligaments, especially during the first three months after the injury, and have been shown to reduce the risk of re-injury. Contrary to common belief, this does not weaken the ankle.

alf Muscle Strain ('Tennis Leg')

Figure 1. Calf muscle strain ('Tennis Leg')

Figure 1a.

Diagnosis Tennis leg is an incomplete rupture of the inside of the calf muscle (Figure 1 and 1a). It is a typical tennis injury that often occurs in players in the 35 to 50 age group. This muscle injury may occur as a result of a sudden contraction of the calf muscles, for instance during a sprint. Symptoms are a sudden, sharp or burning pain in the leg, sometimes accompanied by an audible sound. In most cases, the player is unable to continue play because of the severe pain. Depending on the severity of the injury, recovery may take between a few days and six weeks. First Aid The following action should be taken as quickly as possible, certainly within 48 hours. y Rest (immobilisation). Stop playing tennis and do not lean on the foot. y Cool the painful area directly with ice, a cold pack, or cold running water for 10 to 15 minutes and repeat this several times a day. Do not place ice on the bare skin. Place a towel between the skin and the ice pack to avoid injury from the ice pack. y Apply a compression bandage. This is important, as it compresses the small vessels in the calf and limits the bleeding. y Elevate the lower leg. Fast and adequate first aid is of major importance for a quick recovery. In severe cases, or if in doubt, the injury should be evaluated by a physician, who may make a referral for physiotherapy. How to Ensure the Best Recovery When the worst pain and swelling have subsided (after 1 to 2 days), start to build-up the training load. During this period, pain is a signal to rest. Do not to cross the pain threshold, as this will slow down the healing process. The training load is built up in three steps. These are described below, with several tips. Stage 1. Improvement of Normal Function y If the pain allows it, you may put weight on the foot, if necessary using elbow crutches during the first week. The foot should be used in a normal fashion. y A heel lift (with shock absorption) in both shoes for one to two weeks may help to ease the load on the calf muscles during walking. Viscoheels are very useful for this purpose. y Swimming or cycling for 30 minutes every day increases the blood flow to the calf muscles and enhances recovery. y Stretching the long calf muscles (Figure 2). Step forward with the unaffected leg, keeping the heel of the back leg on the floor. The knee of the affected leg is kept straight. Shift the weight of the back leg to the front leg and press the heel of the back leg firmly into the floor. Rest with your hands on a stationary object. The stretch is felt high up in the calf. Hold the stretch for 15 to 20 seconds without bouncing, followed by a rest period of 10 to 20
Figure 2. Stretching of the long calf muscles

Figure 3. Stretching of the short calf muscles

Figure 4. Strengthening of the calf muscles

seconds. Repeat 3 times. y Stretching the short calf muscles (Figure 3). Start from the same position as described above, but now bend the knee of the hind leg, while keeping the heel on the floor. The stretch is felt low in the calf. Again, hold the stretch for 15 to 20 seconds (no bouncing), followed by 10 to 20 seconds rest, and repeat 3 times. y Strengthening the foot muscles. Sit on a chair. Write the alphabet in the air with the foot of the injured leg. Fold a towel by grasping it with the toes of the injured leg. Perform this for 15 to 20 seconds, followed by 10 to 20 seconds rest, and repeat 10 to 20 times. Stage 2. Build-up As soon as all the above exercises can be performed and walking is possible without pain, a return to tennis and other sports can be considered. y Start by strengthening the calf muscles (Figure 4). Slowly rise onto your toes and hold this position for 10 to 20 seconds. Then return to the starting position. Perform this exercise with both feet at the same time, then when leaning on the injured leg only. If using body weight is too painful or difficult, elastic tubing may be used to work the plantar flexors (i.e. push the toes and forefoot down against the resistance of the elastic tubing). y Take small, quick steps on the spot, alternating the left and the right leg. y If this goes well, you can begin jogging. Start with an easy jog, then include some sprints and straight running, followed by quick turns, starts, and stops. y Finally, you can include jumping exercises. Stage 3. Return to Play y A return to the tennis court should now be possible. Start against the practice wall or with mini-tennis and gradually increase the distance to the wall or your opponent on the court. Make sure you position yourself well for the ball by taking small steps. y In this phase you can also include volley exercises. y Gradually (in the course of one to two weeks) include more exercises that involve moving longer distances towards the ball. y Next, include low volleys, followed by overheads and services. y As soon as you can hit a smash with footwork without problems, you are ready to start playing points, games and a practice match. y Once you have played practice matches for two weeks in succession without problems, you can start playing matches again. Preventing Re-injury It is not always possible to prevent tennis leg, but the risk can be reduced by paying attention to the following points: y Perform a complete warm-up before play and a cool down afterwards, for approximately 10 to 15 minutes each. Pay close attention to correct stretching exercises. Stretching exercises for the calf muscles are particularly important. y Build up training gradually, so that the body can slowly adapt to the increased load. y Adapt clothing to the weather conditions. Particularly at the start of the season or if there is a biting wind, it may be wise to keep the track suit or running tights on during the warm up. Well-warmed muscles and tendons are better able to withstand pulling and traction forces than cold muscles.

y Wear properly fitting tennis shoes with good shock absorption, sideways stability, feeling with the playing surface (grip) and optimal comfort. y Massage calf muscles if they feel stiff and tense. y Maintain strong calf muscles, with adequate rest in your training programme. Steps, cycling and running are ideal exercises for calves.

Groin Injury (adductor muscle tear)

Figure 1. The Groin injury

Figure 2. Stretching the short adductors

Figure 3. Stretching the long adductors

Diagnosis A groin injury is a strain or (partial) tear of one of the adductors, the inner thigh muscles (Figure 1). The injury usually occurs at the junction between the muscle and tendon or at the tendon attachment to the pelvic bone. The adductor langus is the muscle which is most frequently affected. Groin injuries often occur when playing tennis, as the side to side movements and sudden stops and changes of direction require a strong contraction of the adductors. One of the main causes is losing ones step when reaching out for a ball on a surface which is too slippery, which can result in a player performing the splits and overextending the groin muscles. A sudden sharp pain may be felt in the groin area or inner thigh. There may be tightening and hardening of the groin muscles. The adductor tendons or the pubic bone feel tender upon palpation. Contracting the groin muscles (pressing the legs against one another) is also painful. There may be bruising or swelling, although this might not occur until a couple of days after the initial injury. With a severe injury, a small dip may be visible or felt. Muscle tears are classified according to their severity as grade 1, 2 or 3. A grade 1 tear is a mild muscle tear. There is a slight tear without being obviously visible (its size is microscopically small). There is usually no significant loss of strength. A grade 2 muscle tear is a moderate muscle tear. There is clear tearing of some of the muscle fibres and a loss of strength. A grade 3 tear is when the entire muscle has been torn. Fortunately this is not very common. Healing may take between two and 20 or more weeks, depending on the severity of the injury and the players age. In the case of players over 30 years of age, tissue quality diminishes and the healing process often takes longer. Tendon attachment injuries in particular may sometimes be very persistent. What should you do? First aid! Do the following as soon as possible, for 48 hours: y Ice Cool the painful area directly with ice or a cold pack for 10 to 15 minutes and repeat this several times a day. Do not place ice on bare skin, but place a towel between the skin and the cold pack. Men should take care not to freeze the scrotum y Immobilisation Stop playing any kind of sport and avoid putting weight on the leg. y Compression Apply a compression bandage. This will help deter minor bleeding caused by the muscle tear in the thigh. Remove the bandage if it starts feeling too tight or if the calf starts swelling.
Figure 5. Strengthening the long adductors

Figure 4. Strengthening the long adductors

Figure 6. Strengthening the abductors

Immediate and effective first aid is essential for a rapid recovery. Have a (sports) physician examine the injury if it seems serious or if in doubt. In some cases the player will be referred to a (sports) physiotherapist. How to Ensure the Best Recovery As soon as the worst of the pain and swelling have subsided (between several days and a week) you can start building up strength. If you feel pain during the build-up, this is a warning sign to stop and rest. Be careful: do not exceed your pain threshold, as this will only delay the healing process! The build-up consists of three stages, ranging from light to demanding. Here are the exercises, along with some tips. Stage 1. Improvement of Normal Function y Carefully put weight on the leg, as long as it is not painful. If necessary, use an elbow crutch for the first few days. y When the leg stops hurting in the course of your daily activities, you can become more active, for example by cycling. This stimulates circulation in the thigh muscles and will assist the healing process.. y Muscle strengthening (short adductors): Lie down on your back with your knees bent and feet flat on the ground. Squeeze a ball between your knees. Press the ball with your legs for five seconds, release and repeat. Do one set of 10 repetitions. y Muscle strengthening (long adductors): Lie down with your legs extended in front of you; squeeze a ball between your ankles. Press the ball with your ankles for 30 seconds, release and repeat. Do one set of 10 repetitions. y Muscle strengthening (short adductors): Lie down on your back with your knees bent and your feet flat on the ground. Slowly move one knee outwards towards the ground and slowly bring it back up again. y Stretching the inner thigh muscles (short adductors, figure 2). Sit cross-legged on the ground. Place the soles of your feet together. Sit up straight and gently push your knees towards the ground with your elbows until you feel a stretch. Hold this position for 20 to 30 seconds, followed by a 20 to 30 second rest. Repeat this three times. y Stretching the inner thigh muscles (long adductors, figure 3). Stand up straight and take a long step sideways with your right leg. Bend the right knee and shift your body weight above this knee, thereby stretching the left knee. Bend the knee until you feel the stretch in the left groin. Hold this position for 20 to 30 seconds, followed by a 20-30 second rest, and repeat three times. Repeat this exercise for the other leg. Stage 2. Return to Training As soon as all of the above exercises can be performed confidently and free of pain, you may consider returning to sport y Take small, quick steps on the spot, alternating the left and right leg.. y Muscle strengthening (long adductors): Lie down with your legs extended in front of you; squeeze a ball between your ankles. Press the ball with your ankles for 30 seconds, release and repeat. Do one set of 10 repetitions. y Muscle strengthening (Long adductors, figure 5): Attach one end of an exercise band to a secure object and tie the other end around your ankle. Stand in a position whereby the outer side of the leg which requires strengthening is facing the secure object and move the leg against the resistance of the exercise band across the front of your body. Do five sets of 10 repetitions, and then change legs. You can make this exercise harder by gradually increasing the number of repetitions and/or by stretching or folding the exercise band. y Muscle strengthening (Abductors, figure 6): Turn around so that your inner leg is now facing the secured end of the exercise band. Move the leg slowly outwards against the resistance of the band. Do five sets of 10 to 15 repetitions. Repeat the exercise with the other leg. The exercise can be made more

difficult by gradually increasing the number of repetitions and/or stretching or folding the exercise band. y Lunges. Place your feet shoulder width apart. Take a long step sideways with one leg, whereby you bend your knee at a 90 angle, and it does not protrude beyond your foot. Keep your back straight. Lower yourself gently, release and come back to standing. This exercise can be made more difficult by holding a small weight or by doing the exercise at a quicker pace. Start off with two to three sets of 10 repetitions. y The next step is to start jogging. Start off at a slow pace, followed by sideways hops. Once you have practised this several times, you can step up the pace, adding pivots, turns and short sprints. y Finally you can start doing jumping exercises, such as leaps, side steps, hops and lunges. Stage 3. Return to Play You are now ready to go back to the tennis court. Start off by playing against a practice wall or with a game of mini-tennis, which will allow you to move backwards slowly y Start off by playing against the practice wall or with a game of mini-tennis, which will allow moving backwards slowly. y At this stage you can also practice volleys. y Proceed by gradually doing more exercises (over one or two weeks), whereby you have to move greater distances to reach the ball (tennis drills from corner to corner). y The next step is to include lower volleys and smashes. y When you are able to perform smashes and the combined volley smash confidently, you can start playing practice sets. y Once the practice sets have been going well for two weeks, you are ready to start playing matches again. Preventing Re-injury Unfortunately groin injuries cannot always be avoided. However, you can minimise the risk by observing the following guidelines: y Do a thorough warming-up before, and cooling-down after a training session or a match for about 10 to 15 minutes each. Make sure the stretching exercises are performed correctly. In particular, the stretching exercises for the adductors are important. y Make sure you have properly fitting tennis shoes which have good lateral support and an appropriate sole for the court surface you are playing on. y Avoid being insufficiently prepared for a tennis match or game, resulting in playing too many games in too short a period. Fatigue plays an important role in the occurrence of this kind of injury. Regular games of tennis, jogging, on-line skating, fitness or cycling can reduce your chance of sustaining an injury. y Adapt your clothing to the weather. Especially at the beginning of the season, or when there is a strong wind, it is advisable to wear a track suit at least during the warm-up. An elastic bandage can be worn to protect the thighs and keep them warm. Muscles and tendons that have been warmed up properly are more resistant to stretching and pulling than cold muscles. y When you return to play after an injury consider taping your thigh for the first few games, as a preventative measure.

Hamstring Muscle Strain

Figure 1. The Hamstring muscle strain

Figure 2. Stretching the hamstrings

Figure 3. The half squat

Figure 4. The lunge

Description A hamstring strain is the most common injury of the thigh (Figure 1). Symptoms are pain, tenderness, swelling, warmth and/or redness over the hamstring muscles at the back of the thigh. The pain is worse during and after strenuous activity. The player notes muscle spasms in the back of the thigh over the area of the strain. Symptoms are pain and/or weakness during running, jumping or bending the knee against resistance. With acute severe strains, the player may note bruising in the thigh within 48 hours following the injury. Occasionally there will be loss of fullness of the muscle or muscle bulging with complete rupture. A hamstring strain may occur from overuse, or from a sudden eccentric contraction of the muscle, as occurs during sprinting, sliding, and lunging. Other factors that increase the risk of hamstring strains in athletes include tight or shortened hamstrings, hamstring muscle weakness relative to the quadriceps muscles, and previous injury of the thigh, knee, or pelvis.

Figure 5. The step-ups

Muscle strains can be classified based upon their severity. A grade 1 strain is a slight pull without obvious tearing (it is microscopic tearing). There is mild pain, which may Figure 6. Good mornings prevent the player from continuing to play. There is usually no significant loss of strength. A grade 2 strain results in tearing of some of the fibres within the substance of the muscle. There is significant pain, which usually causes the player to stop playing. There may be difficulty bearing full weight on the affected leg and there is decreased strength. Swelling and bruising may develop within 2448 hours following the injury. A grade 3 strain is a tear of all the fibres of the muscle. There is marked pain with difficulty or inability to bear weight on the leg. Swelling and bruising develops within 24-48 hours. There is significant loss of strength and a gap in the muscle can often be felt at the site of injury. Grade 1 and grade 2 strains are most common. Muscle strains may take days to weeks to heal, depending on the severity of the injury. Ultrasound or MRI may be helpful, especially in high level players, in determining the severity of the injury and estimating the time until return to competition. First Aid The following action should be taken as quickly as possible, certainly within 48 hours. y Rest (immobilisation). Stop playing tennis and avoid leaning on the leg. y Cool the painful area directly with ice or a cold pack for ten to fifteen minutes and repeat this several times a day. Do not place ice on the bare skin. Place a towel between the skin and the ice pack to avoid injury from the ice pack. y Apply a compression bandage. This will help deter minor bleeding caused by the muscle tear in the thigh. Immediate and effective first aid is essential for a speedy recovery. Have a (sport) physician examine the injury if it looks serious or if there is any doubt. In some cases the player will be referred to a (sport) physiotherapist. How to Ensure the Best Recovery As soon as the worst of the pain and swelling have subsided (several days to a week) you can resume training. Pain is a warning to stop and rest. Be careful; exceeding the pain threshold will only prolong the healing process! The build-up consists of three phases, from light to demanding. Here is a list with descriptions and tips for doing these exercises.

Stage 1. Improvement of Normal Function y Put as much weight on the leg as (lack of) pain allows. If necessary, use elbow crutches for the first few days after injury. y Once the leg does not hurt (any more) in the course of your daily activities, you can become more active; by going cycling, for example. This serves to stimulate circulation in the thigh muscles and will help the healing process. y Muscle strengthening: (half squats, figure 2). Stand with the feet shoulder-width apart. Bend the knees slightly and then stretch them. Do the same exercise again, but this time on one leg. You can make this exercise more difficult by kicking a ball at the same time or by closing your eyes. y Stretch the hamstrings regularly as follows (figure 3). Stand straight up. Place the heel of the involved leg in front of you, with the heel on the ground. Keep your back straight and bend forward slowly from the hips until you feel a slight pull. Do this for 20 to 30 seconds, followed by 10 to 20 seconds rest. Repeat three times. y Bouncing forward and backward (figure 4). Place your feet shoulder-width apart from each other. Take a large step forward until the knee is bent at a 90-degree angle. Do not let the knee protrude in front of the foot. Bounce gently in this position, shifting the weight from the front to the back leg, without stepping back. Start off with two to three reps. y Co-ordination training: Stand on the injured leg with the arms extended to maintain balance. Close your eyes and try to keep your balance. Stage 2. Returning to Training As soon as all the above exercises can be performed and walking is possible without pain, a return to sports can be considered. y Take small, quick steps on the spot, alternating the left and the right legs. y Muscle strengthening exercises.

Lunges. Place the feet at shoulder-width from each other. Bent the leg until the knee is bent at a 90-degree angle. Do not let the knee protrude in front of the foot. Keep your back straight. Bend further into the knee and then step backwards. You can make the exercise more difficult by holding a weight or by doing the exercise more quickly. Start off with two or three series of repetitions.

Step ups (figure 5). Stand in front of a bench or a stairs step. Step up on the bench with your right leg, step up with the left leg and then step back down with the left leg. Continue, starting with the left leg. Start off with two to three series of ten repetitions.

Good mornings (figure 6). Stand up straight, with legs shoulder-width apart. Place your hands behind your head, with the elbows protruding sideways. Keep your back straight and bend slowly from the hip until you are nearly parallel with the ground. Look straight ahead throughout the exercise. Start off with two to three series of ten reps.

y The next step is to start running. The first few times out, run at a slow pace. After a few training sessions you can start introducing some faster paces, followed by turning and pivoting exercises. Conclude with short sprints. y After this you can do jumping exercises, such as bounding, lateral jumps (skaters jumps) skipping and lunging. Stage 3. Return to Play

y You are now ready to go back to the tennis court. Start off by playing against the practice wall or with a game of mini-tennis, which will allow moving backwards slowly. y At this stage you can also practice volleys. y Proceed by gradually doing more exercises (in the course of one or two weeks), so that you have to move greater distances to reach the ball (tennis drills from corner to corner) y You can now practice low volleys and hitting some smashes. y As soon as you are able to execute a jump smash and the combined volley-smash without problems, you are ready to play a practice match. y If the practice matches proceed without any problems for a period of two weeks, you are ready to play matches again. Preventing Re-injury Unfortunately it is not always possible to avoid hamstring injuries. You can decrease the risk by observing the following guidelines: y Do a thorough warming-up before and cooling-down after training or a match, doing each for no less than fifteen minutes. Make sure the exercises are performed correctly. y Sprinting exercises are especially risky where hamstring injuries are involved and are often responsible for overexertion and injuries. Build up your sprint training gradually and make sure you give your body enough rest to allow it to recover. y Avoid playing matches you have not trained for sufficiently so that you do not end up playing (far) too many games in a (far) too short a period. Fatigue plays an important role in the occurrence of this kind of injury. Regular games of tennis, jogging, on-line skating, fitness or cycling can reduce your chance of injury. y Adapt your clothing to the weather conditions. Especially at the beginning of the season, or when there is a strong wind, it is advisable to wear a training suit at least during warm-up. An elastic bandage can be worn to protect the thigh and to keep it warm. Muscles and tendons that have undergone a proper warm-up have a better defence against the forces of stretching and pulling than do cold muscles. y Consider taping the hamstrings as a preventative measure for the first few games when you resume play after an injury.

Iliotibial Band Friction Syndrome

Figure 1. Iliotibial band friction syndrome

Description Iliotibial band friction syndrome is an overuse injury of the iliotibial band, the broad tough band of fibers that runs down the outside of the thigh passing the knee. This injury is caused by the fibres of the band rubbing on the femur bone, just above the knee joint where there is a bony prominence (figure 1). The iliotibial band is an extension of the tensor fascia lata muscle which is located at the side of the hip. Risk factors are bow legs, over pronation, worn out shoes and running on cambered surfaces. These factors all cause extra tension on the iliotibial band which leads to more friction. A weakness of the hip and buttock muscles can also contribute because the opposite side of the pelvis will dip down more also pulling on the iliotibial band (figure Figure 2. Stretch of the tensor fascia lata muscle and the iliotibial band 1). A tight iliotibial band and sharp increase in the amount of training can also contribute to this injury. Symptoms The symptoms are pain and swelling located at the side of the knee (the outside) and the pain can sometimes radiate up the outside of the thigh. Players tend to have more pain while jogging than while playing tennis. The pain usually starts after a fixed distance (2 to 3km) and will force the player to reduce the speed or walk. First Aid y It is advisable to modify activities (reduce playing and training but you do not have to stop altogether), use ice to cool the area, stretch the thigh and hip muscles and make sure that the shoes are not worn and offer good support. y Cooling can also be done by performing ice massage. To do this use an ice cube or a paper cup with ice. Rub the ice on the painful area for ten to fifteen minutes. If using a cool pack be sure to place a towel between the cool pack and the skin to prevent freezing injury. Immediate and effective first aid is essential for a speedy recovery. Have a (sports) physician examine the injury if it looks serious or if there is any doubt. In some cases the player will be referred to a (sports) physiotherapist. How to Ensure the Best Recovery y Pain is an important signal. If pain occurs do not play or train through the pain, because this will delay recovery. y Rehabilitation progresses in three steps, from light to demanding. Here is a list with descriptions and tips for doing these exercises. Stage 1. Improvement of Normal Function
Figure 5. Strengthening the hip muscles (hard) Figure 3. Strengthening the buttock muscles

Figure 4. Strengthening the hip muscles (light)

y Stretching the muscle (tensor fascia lata) at the side of the hip together with the iliotibial band will reduce the tension or decrease the amount of friction (figure 2). Stand with the left leg crossed behind the right. Bend your body as far as possible to the right. Reach up with your left arm past your left ear and then over your head to the right to give an extra stretch. Hold the stretch for fifteen to twenty seconds and then rest for fifteen to twenty seconds. Repeat this three times on both sides. y Strengthen the buttock muscles (gluteus medius, figure 3). Use a step (20 to 30cm) or stand on the stairs. Stand with one foot on the step and keep the other foot on the ground. The thigh of the leg up on

the step should now be horizontal with the floor. Lift the front foot up off the step and concentrate on keeping your balance. Stop your pelvis from dipping to the side or wobbling. Hold the foot up for three seconds and then lower it slowly. Perform ten to fifteen repetitions on each leg. You can make it more difficult by using ankle weights. y Strengthening the hip muscles (abductors, figure 4). Lie on your right side with your legs straight. Contract the muscles in the thigh and pull your toes up. Lift the left leg, keeping the knee straight, until the foot is 20 to 30cm off the ground. Hold the leg in this position for three seconds and then lower it slowly. Perform this exercise slowly and build up to three sets of fifteen repetitions. Perform this exercise for the other leg too. To make it harder support yourself, using your elbows and ankles, so that your body does not touch the ground (figure 5) or use an ankle weight. Stage 2. Returning to Training When you can perform all the exercises in stage 1 easily and without problems it is time to think about playing again. Here are some exercises to help during this stage. y Strengthening the thigh muscles: Half squats. Stand with the feet shoulder-width apart. Bend the knees while keeping your back straight. Hold your arms out in front of you. Do not bend the knees further than 90 degrees or allow the knees to go further forward than the toes. Build up to three sets of fifteen repetitions. y Strengthening the thigh muscles: Single leg step. Stand on the involved leg facing sideways on a step leaving the other leg hanging over the edge. Bend the involved leg and point the toes of the other foot towards the ceiling. Touch the step below you with the heel of the other leg and then straighten the involved leg. Start with one to two sets of ten to fifteen repetitions and build up to three sets of fifteen repetitions. y Make small quick steps on the spot, shifting support between the left and right leg. y Strengthening the thigh muscles: Lunges. Place the feet shoulder-width apart. Bent the leg until the knee is bent at a 90-degree angle. Do not let the knee protrude in front of the foot. Keep your back straight. Bend further into the knee and then step backwards. You can make the exercise more difficult by holding a weight or by performing the exercise more quickly. Build up to two to three series of ten to fifteen repetitions. Stage 3. Return to Play In the event of a mild injury, there is no need to stop playing tennis altogether, as long as you adapts your game to the restrictions imposed by the injury. In general continuous jogging is worse for iliotibial band friction syndrome than playing tennis. y Adapt your training program, allowing you to start off hitting the ball from an area measuring two square meters (approx. two square yards). In this way you can continue practicing your footwork (taking small steps, positioning yourself correctly to hit the ball) without putting excess strain on the knee. y Initially, you should limit activities that will put excess strain on the knee, such as sprints, jumping exercises, low volleys, intensive left-right exercises and serve and volley training. y If the adapted training goes well you can gradually start doing more exercises, and increasing the distance you have to run to reach the ball (tennis drills from corner to corner). y After this, low volleys and smash hits can be added to the training program. y If this goes well then you can start running again. Start slowly with a warming-up after which you can do several interval accelerations. Do some turning and twisting movements while running. If this goes well you can progress to several short sprints. y After this jump training should be included such as: hopping, bounding and sideways jumps. y Do not increase your running time or distance by more than 10% each week. Preventing Re-injury Unfortunately it is not always possible to prevent recurrence of iliotibial band friction syndrome. The risk can be reduced following this advice:

y Be sure to perform a thorough warming-up and cooling down which should last at least ten minutes. Pay attention to stretches, especially the stretch for the tensor fascia lata muscle and the iliotibial band (figure 2). y If you ride a bike make sure that the saddle is not too high or too far back. y Increase the intensity and the extent of the exercise gradually in order to avoid straining. This is especially important if you are planning to run hilly routes. y Wear properly fitting tennis shoes when playing tennis, and properly fitting trainers when working out. It is essential for the shoes to be adapted to your weight and to the surface you will be playing on. y If you have knock knees, bow legs, flat feet or high arches consult a shoe expert or podiatrist to see whether shoe orthotics are needed. y If you run on a cambered surface the downside leg is put under extra strain be sure to change direction regularly to even out the load.

Heel Pain: Plantar Fasciitis and Heel Spur

Figure 1. Heel pain: plantar fasciitis and heel spur

Figure 1a.

The plantar fascia is the strong tissue under the foot that connects the toes to the heel. In conjunction with the muscles and bones, it forms the arch of the foot. Diagnosis Plantar fasciitis is an overuse injury at the point where the plantar fascia anteromedial attaches to the heel (Figure 1 and 1a). Degenerative changes of the plantar fascia occur at the attachment site to the bone, as a result of repetitive micro ruptures. A heel spur is calcification caused by repeated pulling away of the periosteum from the calcaneus. This can be demonstrated by X-rays. However, heel spur itself is not the cause of the pain. Plantar fasciitis is common among players who perform a great deal of jumping and sprinting. Common symptoms are a localised, sharp pain and/or swelling at the inside of the heel, deep under the fat pad of the calcaneus, as well as pain during exercise. Rest gives immediate pain relief, although there may be some nagging pain after exercises or at night. There is generally pain and stiffness in the morning and at the start of exercise, when the area around the heel is cold and contracted. First Aid Fast and adequate first aid treatment is very important to ensure a speedy recovery. In serious cases or when in doubt, the injury should be evaluated by a physician. He/she may refer the patient to a physiotherapist for further treatment.
Figure 3. Stretching the foot muscles y The following general measures can be taken to ease the pain: slightly further activity modification, unloaded exercise, cooling with ice, stretching and wearing firm, well-cushioned, orthotically-designed shoes.

Figure 2. Stretching the foot muscles

y When there is pain and swelling, ice massage can be helpful. Use a melting ice cube or a polystyrene cup filled with ice. Massage the painful spot. Five to eight minutes of massage will generally be sufficient. Repeat this several times a day. y Massaging the soles of the feet by rolling the feet over a can or bottle will also help to relax the fascia and the muscles. y In feet with a collapsed arch (flat feet) or excessive pronation, the plantar fascia may become overloaded during running and tennis. When the plantar fascia is very tight, as in cavus feet, there may also be considerable pressure at the attachment to the heel bone. Make sure the feet receive adequate support by using an inlay, shoes with sturdy soles or tape. y Temporary use of a shock absorbing heel lift can be useful. The advantage of a heel lift is that there is less tension on the plantar fascia, because the calf muscles are more relaxed. How to Ensure the Best Recovery When the initial pain and swelling have disappeared, the player can start to build up the volume and/or intensity of training. However, the onset of pain during this period is a signal to take some rest. If players go beyond their pain threshold, this is likely to slow the healing process. Training load should be increased in three stages, as follows: Stage 1. Improvement of Normal Function y Stretching the foot muscles. Kneel on one knee, with the toes on the floor (Figure 2). A stronger stretch can be felt by grabbing the toes of the foot with one hand and pulling the toes and feet as far backwards as possible (Figure 3). y Stretching of the long calf muscle. Take one step forward with the uninjured leg. The knee of the

injured leg is kept straight. Shift the weight of the back leg to the front leg and press the heel of the back leg firmly into the floor. Rest with the hands on a stationary object (no bouncing). The stretch is felt high in the calf. Hold the stretch for 15 to 20 seconds and follow this with a rest period of 10 to 20 seconds. Repeat three times. y Stretching the short calf muscles. Start from the same position as described above, but now bend the knee of the back leg, while keeping the heel on the floor. The stretch is felt low in the calf. Hold the stretch for 15 to 20 seconds, then rest for 10 to 20 seconds. Repeat three times. y Strengthening the foot muscles. Sit on a chair. Write the alphabet in the air with the injured foot. Fold a towel by grasping it with the toes of the injured leg. Perform this for 15 to 20 seconds, then rest for 10 to 20 seconds. Repeat 10 to 20 times. y A night splint with the ankle in a neutral position and the toes maximally bent backwards/upwards reduces the healing time. The night splint is applied with an elastic band. y Cycling or swimming for 15 to 30 minutes every day preserves general fitness. Stage 2. Build-up As soon as the player can perform the above exercises well and can walk without pain, he/she can start building up strength for a return to tennis. y Slowly rise to your toes and hold for 10 to 20 seconds, then return to the starting position. First perform the exercise with both feet at the same time, then with the injured leg only. y Walk on your toes, then on your heels. y Take small, quick steps on the spot, alternating the left and the right leg. y If this goes well, introduce easy jogging. Take small steps and use the entire foot. y This can be followed by some easy running. y The next step is to include sprinting exercises, starts, stops and turns in the training. y Jumping exercises are the final step in the build-up stage. Stage 3. Return to Play y A return to the tennis court should now be possible. Start against the practice wall or with mini-tennis and gradually increase the distance to the wall, or use a full court. Make sure you position yourself well for the ball by taking small steps. y A start can now be made with volleys. y In the course of the next two weeks, gradually incorporate exercises that require running longer distances to the ball (tennis drills from side to side). y Next, include low volleys and overheads. y Start playing points, then games, and then a full practice match. Once practice matches have been completed for two successive weeks without problems, the player is ready for serious tournament play. Preventing Re-injury It is not always possible to prevent the recurrence of an injury to the heel, but the risk can be reduced by paying attention to the following: y Perform a complete warm-up before play and cool down afterwards, for approximately 10 to 15 minutes each.

y Use correct form when stretching. Stretching exercises for the foot and calf muscles are of particular importance. y Ensure a gradual build-up of the training programme, so that the body can slowly adapt to the extra training load. Many players suffer injuries when they switch from a clay court to a hard court or during the transition from outdoor to indoor play. After a holiday, illness or when practising on a hard court, gradually increase the training load over the course of one to two weeks. y Wear well-fitting tennis shoes with a firm heel cap and adequate arch support. y Use proper shoes during off-court (conditioning) training. In casual settings, firm walking shoes are more comfortable than unstable, light shoes or high heels. A sudden decrease in heel height can increase the potential for heel injury if a players tendons and muscles lack flexibility. y Do not throw out old shoes immediately. Break in new shoes gradually and walk around in them for a day or two first, to help wear them in. y Improve the co-ordination (proprioception) and strength of the muscles around the ankle. Performing exercises on one leg is an effective way to do this. Additional complexity (difficulty) can be added to these exercises if the player stands on a wobble board.

Shoulder Pain (Impingement Syndrome)

Figure 1. When performing underhand strokes there is sufficient space under the roof of the shoulder

Figure 2. When performing overhand strokes, the space under the roof of the shoulder narrows, which may cause the bursa and supraspinatus tendon to become impinged.

Figure 3. Stretching the posterior rotator cuff

Figure 4. Scapular retraction

Figure 5. Sawing

Figure 6. Extension

Diagnosis Impingement syndrome causes pain in the shoulder, when lifting the arm between 60 and 120 degrees sideways, or when rotating the lifted arm inwards. The nagging pain occurs because the supraspinatus tendon (the muscle under the roof of the shoulder) and/or the bursa are pinched and aggravated when lifting and rotating the arm. The two most common areas where impingement occurs are: a. Subacrominal or external impingement: between the roof of the shoulder and the head of the upper arm. The space between the roof of the shoulder and the head of the Figure 7. External rotation upper arm is quite narrow, and becomes smaller when the arm is lifted between 60 and 120 degrees sideways. If the supraspinatus tendon and bursa become thicker than usual (because they have been strained or aggravated), or the space becomes more narrow than usual (due to bony structures or projections) this may result in impingement (figures 1 and 2). b. Internal impingement: between the shoulder socket and the head of the upper arm. When the arm is in the overhead position and rotated outwards (the position the arm is in when preparing for a serve), the arm is put in the maximum position for the shoulder joint, causing the supraspinatus tendon and upper edge of the shoulder socket to come into contact. If this is repeated continuously, the edge of the shoulder socket as well as the supraspinatus tendon may become impinged (figures 1 and 2). Impingement is most commonly caused by straining (due to performing many serves and high forehands), an imbalance of the muscles around the shoulder (the front shoulder muscles are much stronger than the back ones) and when shoulder blade movements change pace (for example due to tiredness, weak shoulder muscles or instability). Symptoms These include pain around the shoulder, often at the outer portion of the upper arm. The pain is worse with overhead activities such as serving, hitting high tops spin forehands or hitting overhead smashes. There may be an aching pain after play. The pain may make it difficult to sleep, especially when lying on the affected shoulder. Sometimes there is loss of strength, usually due to pain, though in later stages a rotator cuff tear may develop which may also be responsible for shoulder weakness. There may be limited mobility of the shoulder, especially when reaching behind (back pocket, bra) or across the body, or a catching or grinding sensation. Occasionally, the athlete will also note pain in the front of the shoulder, that is worse with bending the elbow or lifting due to involvement of the biceps tendon in the impingement process. What should you do? First Aid! Play less tennis and certainly perform fewer serves and smashes. Try to minimise any movements above shoulder level! If you absolutely must reach out for something or lift something, rotate your arm outwards whenever possible (with the palm of your hand turned up). The next step is to start an exercise programme, monitored by a (sports) physician or a (sports) physiotherapist, and thus treat the cause of the impingement. Cortisone injections may help in the short term as they reduce the swelling and the worst of the pain. However, a side effect is that they weaken the tendon tissue. When tennis is resumed, the pain often returns, especially if the underlying cause is not taken care of. We recommend limiting these injections, especially for competition tennis players. Surgery is generally only considered if, after intensive remedial therapy, pain has not clearly subsided or disappeared and/or there is an anatomical impediment which causes the pain to persist. How to Ensure the Best Recovery Stage 1. Improvement of Normal Function y Posterior shoulder stretch. Extend your injured arm in front of you to shoulder level and take hold of

your elbow with your other hand. Draw your elbow in towards you until you feel a stretch at the back of your shoulder (figure 3). Do this for 20 to 30 seconds, followed by a 10 to 20 second rest. Repeat three times. Also do muscle strengthening exercises to strengthen the muscles which stabilise the shoulder blade. Gradually build up the exercises. It is alright to feel something in your shoulder whilst performing these exercises, however the pain should have dissipated once you have finished them. Start with a set of 10 to 15 repetitions per exercise, with a 60 second rest between each set. An exercise band or small free weight can be purchased in a sports shop. y Protraction and retraction of the shoulder (figure 4). Attach an exercise band to a fixed sturdy object. Stretch out your injured arm and pull the exercise band back, whilst keeping your arm straight. This is done by moving your shoulder forwards (rounding your shoulders) and then back again (straightening your shoulders) y Protraction and retraction of the shoulder (figure 4). Attach an exercise band to a fixed sturdy object. Stretch out your injured arm and pull the exercise band back, whilst keeping your arm straight. This is done by moving your shoulder forwards (rounding your shoulders) and then back again (straightening your shoulders). y Sawing (figure 4). Attach an exercise band to a fixed sturdy object. Using a sawing motion, pull the exercise band towards your waist, and back again. Extension (figure 5). Attach the middle of the exercise band to a fixed sturdy object in front of you. Hold on to the ends and stretch both arms along the side of your body. Keeping your arms straight, stretch them against the resistance of the band, and then back again. Stage 2. Strengthening the Rotator Cuff As soon as you are able to perform the exercises described above confidently and you can stabilise the shoulder blade, you can start performing muscle strengthening exercises for the actual rotator cuff. These exercises are quite tough, so do not perform them every day and incorporate a day off. This will enable the muscles and tendons to heal and adapt. Gradually build up to three sets of 15 to 20 repetitions per day, with a 60 second rest between each set.

y Exercising the front of the shoulder: attach an exercise band to a fixed sturdy object to the right hand side of your body. Place your right elbow on your side so that your forearm is pointing forward. Remaining in this position, rotate your arm towards your stomach. Repeat on the left side. y Exercising the back of the shoulder: attach the end of an exercise band to a fixed sturdy object to the left hand side of your body. Place your right elbow on your side so that your forearm rests on your stomach. Remaining in this position, rotate your arm outwards by 70 degrees and back again. Repeat on the left side (figure 7). y Wall push-ups: lean your hands against a wall, standing at a distance of approximately one metre. Now do wall push-ups, changing the position of your hands (hands closer together, hands further apart, one hand above the other, using only one hand etc.). The closer you stand to the wall, the easier the exercise is. You can increase the difficulty by standing further away from the wall. You can target the specific muscles which need to be strengthened even more in this exercise by pushing yourself even further away from the wall whilst rounding your shoulders (push up plus). y Rowing: attach the middle of an exercise band to a fixed study object in front of you. Grasp each end of the exercise band and pull your elbows back. Hold for a few seconds and then slowly release the band. Maintain a constant and even tension, and tuck in the abdominal muscles. Stage 3. Return to Play When you can do all of the exercises confidently and without pain, you are ready to play tennis again. y At first avoid any overhand strokes. Start off by playing against a practise wall or by playing minitennis, gradually taking small steps back. Use an underhand serve, delivering the ball below shoulder level as much as possible. y Subsequently step up baseline speed, only hitting the ball flat. Only play low volleys when using a net.

y You may gradually start including topspins and higher volleys. y The next step is to throw a ball over the net. Standing at the service line, throw the ball overhead to the other side of the net. Once this is going well, gradually increase distance and speed. y You can now start incorporating serves. The first time you do so, serve without using a ball. Then serve standing at the service line. Gradually increase distance and speed. You may also perform a gentle smash. Pay close attention to technique and timing. y The next step is to play points, and then a game, a practice set and a practice match. Once practice matches have been completed for two to four weeks pain free, you can sign up to play a match! Preventing Re-injury Shoulder injuries cannot always be avoided. However, you can minimise the risk by observing the following guidelines: y Regularly stretching the back of the shoulder minimises the chance of sustaining (another) impingement. y Be sure to perform a thorough warm-up before playing and a cooling down after the training or match, for a minimum of ten minutes each. Ensure that shoulder stretching exercises are performed correctly. y Make sure your transversus abdominis muscle is strong and that you have good shoulder muscle balance by performing shoulder muscle stretching exercises at least twice a week. y Build up training gradually, so that muscles and tendons can adapt to the increased load. Allow for a sufficient recovery period between training sessions and matches.

Jumper's Knee

Figure 1. Jumpers Knee

Description Jumpers knee (patellar tendinopathy) is an overuse injury of the patellar tendon. The patellar tendon is the tendon between the underside of the patella (knee cap) and the tibia (shin). In the area just underneath the patella there are microscopic tears and degeneration in the tendon (figure 1). It is a common complaint in tennis players due to the explosive muscle contractions needed for the sprinting, jumping and quick changes of directions during tennis. Poor flexibility of the quadriceps (thigh muscles), hamstrings and variations in leg and foot type (knock knees, bow legs, flat feet etc.) can contribute to extra load on the tendon and development of jumpers knee. Symptoms Typically there is a sharp pain in the tendon below the knee cap which is present during jumping, sprinting, serving and change of direction after running wide to reach a ball. Often there is an aching pain after finishing playing tennis. First Aid y It is advisable to modify activities (reduce playing and training), use ice to cool the area, stretch and strengthen the thigh muscles and make sure that your shoes are not worn and offer good support. y Have a (sports) physician examine the injury if it looks serious (if the knee gives way due to the pain or if you have a lot of pain even when not playing tennis) or if there is any doubt. In some cases the doctor may refer you to a (sports) physiotherapist. How to Ensure the Best Recovery Pain is an important signal and you should only begin with the exercises when severe pain has subsided. If pain occurs do not play or train through the pain, because this will delay recovery. Rehabilitation progresses in three steps, from light to demanding. Here is a list with descriptions and tips for doing these exercises. Stage 1. Improvement of Normal Function y By stretching the muscles at the front and back of the thigh the tension on the tendon can be reduced. y Stretch for the quadriceps (thigh muscles): Stand up straight and find support for one hand. Bend one leg, take hold of the ankle and pull the ankle towards the buttocks until you can feel the strain in the upper leg. Bringing the upper leg further backwards can increase the stretch. Hold this position for ten to twenty seconds, followed by ten to twenty seconds rest and repeat three times. y Stretching exercise for the hamstrings (back of the thigh). Stand up straight. Place the heel of the leg to be stretched in front of you and keep the heel on the ground. Keep your back straight and lean forward slowly from the hips until you feel a slight pull. Hold this position for ten to twenty seconds, followed by ten to twenty seconds rest and repeat three times.

Figure 2. Static strengthening exercises for the qusdriceps muscles

Figure 3. Quadriceps strengthening exercise: half squats

Figure 4. Quadriceps strengthening exercise: single leg step

Figure 5. Eccentric quadriceps strengthening exercise

y Co-ordination training. Stand on the injured leg with arms spread, then close your eyes and try to keep your balance. Try to hold this position for 30 seconds. y Swaying lunges. Place the feet shoulder-width apart. Bend the leg until the knee is bent at a 90-degree

angle. Do not let the knee protrude in front of the foot. Keep your back straight. Sway gently back and forth transferring your weight but do not step backwards. Build up to two to three series of ten to fifteen repetitions. y Quadriceps exercise (static). Sit down on the floor with your legs straight. Place a rolled-up towel under your knee. Try pushing the towel into the floor by contracting your quadriceps muscles. Hold for three seconds and relax. Build up to three series of fifteen repetitions (figure 2). y Cycling. A good exercise in this stage is non-strenuous cycling every day for 15 to 30 minutes. When cycling be sure to use a bicycle with gears. Stay in the lowest gear which will allow a high cadence. This produces the least strain on the knee. Try to avoid headwind and steep terrain. Stage 2. Build-up As soon as you are able to perform the exercises described above without discomfort, you can consider resuming your sport. Listed here below are a few exercises to improve your sport condition. y Quadriceps exercise (static). Sit down on the floor with your legs straight. Place a rolled-up towel under your knee. Try pushing the towel into the floor by contracting your quadriceps muscles. Hold for three seconds and relax. Build up to three series of fifteen repetitions (figure 2). Stage 3. Return to Play In the event of a mild injury, there is no need to stop playing tennis altogether, as long as you adapt your game to the restrictions imposed by the injury. With more serious injuries, training can usually be resumed after six weeks to three months. y Try to play on clay courts as much as possible, and avoid hard courts. The peak strain on the knee is less on a surface that allows some sliding than it is on surfaces where this is not possible. y Adapt your training programme, allowing you to start off hitting the ball from an area measuring two square meters( approx. two square yards). In this way you can continue practicing your footwork (taking small steps, positioning yourself correctly to hit the ball) without putting excess strain on the knee. y Initially, you should limit activities that will put excess strain on the knee, such as sprints, jumping exercises, low volleys, intensive left-right exercises and serve and volley training. y If the adapted training goes well you can gradually start doing more exercises, and increasing the distance you have to run to reach the ball (tennis drills from corner to corner). y After this, low volleys and smash hits can be added to the training program and you can resume playing (practice) matches. y If practice matches can be played without problems, then you are ready to get back to playing competitively. Preventing Re-injury y Be sure to perform a thorough warming-up. Do, in any case, some stretching exercises for the quadriceps muscles. In this way your muscles and the rest of your body are prepared for the work to come. y Increase the intensity and the extent of the exercise gradually in order to avoid straining. This is especially relevant in the change from summer season to winter season when clay courts are exchanged for the harder indoor courts. y Perform muscle strengthening exercises for the thighs to avoid (new) knee injuries. y Wear properly fitting tennis shoes when playing tennis, and properly fitting trainers when working out. It is essential for the shoes to be adapted to your weight and to the surface you will be playing on. y In the case of (moderate) foot deformities, such as bunion deformity (hallux valgus) or high arches, it is advisable to buy special, individual orthotics for the shoe to help correct the form of the foot and to give arches additional support. y Fatigue will cause your condition to deteriorate and lessen the strength of the muscles. This increases

the chances of stumbling and straining a muscle. So, make sure to stay in shape! y Regular cycling (low resistance and on flat surfaces) helps the knee to keep functioning well. y You can try a patellar tendon strap to see if it helps. y Quadriceps exercise (dynamic): Half squats. Stand with the feet shoulder-width apart. Bend the knees while keeping your back straight. Hold your arms out in front of you. Do not bend the knees further than 90 degrees or allow the knees to go further forward than the toes. Build up to three sets of 15 repetitions (figure 3). y Quadriceps exercise (dynamic): Single leg step. Stand on the involved leg facing sideways on a step leaving the other leg hanging over the edge. Bend the involved leg and point the toes of the other foot towards the ceiling. Touch the step below you with the heel of the other leg and then straighten the involved leg. Start with one to two sets of ten to fifteen repetitions and build up to three sets of fifteen repetitions (figure 4). y Make small quick steps on the spot, shifting support between the left and right leg. y Quadriceps exercise (dynamic): Lunges. Place the feet at shoulder-width from each other. Bent the leg until the knee is bent at a 90-degree angle. Do not let the knee protrude in front of the foot. Keep your back straight. Bend further into the knee and then step backwards. You can make the exercise more difficult by holding a weight or by performing the exercise more quickly. Build up to two to three series of ten to fifteen repetitions. y Eccentric strengthening exercise for the quadriceps. Place your feet shoulder-width apart on an inclined board. Lower yourself while standing on the injured knee (bend the knee approximately 60 degrees), then raise yourself while standing on the uninjured knee. Build up to three sets of fifteen repetitions, twice a day. y If this goes well, you can start jogging. Start off jogging and progress to short accelerations, followed by turning and pivoting exercises. Eventually you can include sprints in the exercise. y Following this you can do jumping exercises, such as hopping, lateral jumps (skating jumps) on alternating legs and skipping.

Anterior Knee Pain (Patellofemoral Pain Syndrome)

Figure 1. Pain behind and around the kneecap

Figure 1a.

Figure 2. 'Miserable malalignment' syndrome. Inward rotation of the thighs, knock-knees and pronated feet

Figure 3. Stretching excercises for the tensor fascia lata and the tractus iliotibialis

Figure 4. Straight leg raise

Description Patellofemoral pain syndrome, also called excessive lateral patellar compression syndrome, is characterised by anterior knee pain that is aggravated by activities such as squatting, downhill running, biking, and descending stairs. In tennis, playing serve and volley, pushing off after having hit a wide ball, and deep bending for low volleys are most painful. The pain is caused by excessive or abnormal contact of the under surface of the kneecap with the bone of the upper leg due to sideward pulling of the kneecap (lateral tracking). The lateral tracking results in pressure being concentrated on the outer part of the kneecap (as opposed to being distributed over the whole kneecap). It may also occur as a result of direct injury to the kneecap, such as falling on the kneecap or dashboard injury (figure 1). Risk factors The patella has a wedge shape and slides on extension and flexion of the knee in a groove formed by the femoral condyles. Static risk factors for increased lateral tracking of the kneecap include inward rotation of the thighbone, knock knees, outward rotation of the shin bone, and increased pronation of the foot. This combination of factors is called the miserable malalignment syndrome (figure 2). Dynamic risk factors include insufficiently developed thigh muscles, which deprives the knee of adequate support; shortened or stiff muscles which causes the kneecap to be pulled outwards; and too much, too long and too intensive training in too short a time. First Aid
Figure 6. Single leg on step

Figure 5. Double leg squats

Rest from offending activity and stretching and strengthening exercises will bring about the speediest recovery, though continued sports activity do not usually lead to irreversible problems or damage. Intermittent application of ice, particularly after exercise and at the end of the day, can help reduce pain and swelling. In the event of serious injury, have the injury examined by a (sports) physician, for example when there is swelling of the knee or when pain is also experienced when not playing tennis. In some cases the player will be referred to a (sport) therapist for further examination or treatment. How to Ensure the Best Recovery Once the worst pain has subsided you can gradually start increasing the load on your knee. In doing these exercises, pain is a sign that you need to rest. Warning: do not exceed the pain threshold, as this will only slow down the healing process! Rehabilitation progresses in three stages from easy to strenuous. Stage 1. Improvement of Normal Function Rehabilitation should be aimed at improving the maltracking. y Regular stretching of the muscles on the outer side of the leg (m. tensor fascia lata and tracts iliotibialis) will restrain the lateral tracking rotation of the kneecap and improve knee alignment. Stretching exercises should be performed as follows. Stand up straight and cross your right leg behind your left leg. Bend the upper body slowly left as far as you can (figure 3). Hold this position for 20 to 30 seconds, followed for 10 to 20 seconds of rest and repeat three times. y To ensure that the knee works properly, it is important that the muscles surrounding the kneecap i.e. the quadriceps (inner upper thigh) and hamstrings (rear upper thigh) are flexible enough.

Stretching exercise for the quadriceps. Stand up straight and find support for one hand. Bend one leg, take hold of the ankle and pull the ankle towards the buttocks until you can feel the strain in the upper leg. Bringing the upper leg further backwards can increase the stretch. Hold

this position for 20 to 30 seconds, followed by 10 to 20 seconds rest and repeat three times.

Stretching exercise for the hamstrings. Stand up straight. Place the heel of the leg that will be stretched in front of you and keep the heel on the ground. Keep your back straight and lean forward slowly from the hips until you feel a slight pull. Hold this position for 20 to 30 seconds, followed by 10 to 20 seconds rest and repeat three times.

y Static quadriceps strengthening (emphasis on medial oblique muscle). Sit down on the floor with your legs straight. Place a rolled-up towel under your knee. Try pushing the towel into the floor by contracting your quadriceps muscles. Hold for three seconds and relax. Start with three series of fifteen repetitions. y Straight leg raise (figure 4). Sit down on the floor with your legs straight. Bend the unaffected knee. Now tighten the muscles of the affected knee and point your toes towards the ceiling. Lift your leg ten to fifteen inches, keeping the leg straight. Hold for two seconds and return to the starting position. Perform two to three sets of fifteen repetitions. y Co-ordination training. Stand on the injured leg with arms spread, then close your eyes and try to keep your balance. y Cycling. The alignment of the kneecap can be improved by non-strenuous cycling every day for 15 to 30 minutes. When cycling be sure to use a bicycle with gears. Stay in the lowest gear which will allow high cadence. This produces the least strain on the knee. Try to avoid headwind and steep terrain. y Avoid long periods of sitting with bent knees or sitting in the same position. Stage 2. Build-up As soon as you are able to perform the exercises described above without discomfort, you can consider resuming your sport. Listed here below are a few exercises to improve your sport condition. y Double leg squats (figure 5). Stand up straight with your feet at shoulders width apart. Stretch your hand straight out in front of you. Bend your knees slowly and keep your back straight. Bend the knees to a maximum of 110 degrees. The knees must not protrude in front of the feet.. Start with two to three series of ten repetitions. y Single leg step (figure 6). Stand on the involved leg facing sideways on a step leaving the other leg hanging over the edge. Bend the involved leg and point the toes of the other foot towards the ceiling. Touch the step below you with the heel of the other leg and then straighten the involved leg. Start with one to two series of ten to fifteen repetitions. y Make small quick steps on the spot, shifting support between the left and right leg. y If this goes well, you can start jogging. Start off jogging and progress to short accelerations, followed by turning and pivoting exercises. Eventually you can include sprints in the exercise. y Following this you can do jumping exercises, such as hopping, lateral jumps (skating jumps) on alternating legs and skipping. Stage 3. Return to Play y In the event of a mild injury, there is no need to stop playing tennis altogether, as long as the player adapts his game to the restrictions imposed by the injury. With more serious injuries, training can usually be resumed after six weeks to three months. y Try to play on gravel courts as much as possible, and avoid hard court. The peak strain on the knee is less on a surface that allows some sliding than it is on surfaces where this is not possible. y Consult with your trainer and try to get him to adapt your training program, allowing you to start off hitting the ball from an area measuring two square meters( approx. two square yards). In this way you

can continue practicing your footwork (taking small steps, positioning yourself correctly to hit the ball) without putting excess strain on the knee. y Initially, you should limit activities that will put excess strain on the knee, such as sprints, jumping exercises, low volleys, intensive left-right exercises and serve and volley training. y If the adapted training goes well you can gradually start doing more exercises, and increasing the distance you have to run to reach the ball (tennis drills from corner to corner) y After this, low volleys and smash hits can be added to the training program and the player can resume playing (practice) matches. y If practice matches can be played without problems, then the player is ready to get back to playing competitions. Preventing Re-injury y Be sure to do a thorough warming-up. Do, in any case, some stretching exercises for the thigh muscles. In this way your muscles and the rest of your body are prepared for the work to come. y Increase the intensity and the extent of the exercise gradually in order to avoid straining. This is especially relevant in the change from summer season to winter season when gravel courts are exchanged for the harder indoor courts. y Do muscle strengthening exercises for the thighs to avoid (new) knee injuries. y Wear properly fitting tennis shoes when playing tennis, and properly fitting trainers when working out. It is essential for the shoes to be adapted to the players weight and to the surface he will be playing on. y In the case of (moderate) foot deformities, such as bunion deformity (hallux valgus) or hollow foot, it is advisable to buy special, individual reinforcements for the shoe to help correct the form of the foot and to give arches additional support. y Fatigue will cause your condition to deteriorate and lessen the strength of the muscles. This increases the chances of stumbling and straining a muscle. So, make sure to stay in shape! y Regular bicycling (low resistance and on flat surfaces) helps the knee cap alignment which in turn helps the knee to work efficiently. y You can try taping or knee braces to see if they help.

Lower Back Pain

Figure 1. The combined rotation and extension of the back during serving places high demands on the back

Figure 2. Stretching the lower back muscles

Figure 3. Spinal extensions

Figure 4. Bridging

Description Low back pain is very common among tennis players. Low back pain may have various causes, such as postural abnormalities, muscle dysfunction (imbalances, shortening or weakening of muscle), overuse, instability, and articular dysfunction in the lower back. In tennis, the combined rotation, flexion, and extension of the back during the serve may cause problems (Figure 1). In 95% of the cases of low back pain no specific physical abnormalities are found by additional diagnostic investigations that may explain the low back pain; this is why it is called non-specific. This includes muscle strains and back sprains. Specific low back pain is low back pain caused by structural abnormalities such as a herniated disc, a fracture, or a tumour.

Figure 5. Gym ball excerises

Symptoms Common symptoms are a sudden, sharp, persistent or dull pain in the lower back, sometimes on one side only, that worsens with movement. Prolonged standing, sitting, or running may also provoke pain. The pain may radiate to the hips, buttocks, or back of the thigh. Often, muscle spasms in the back may develop. First Aid Rest, medications and ice are recommended to relieve pain and muscle spasm. Bed rest beyond two days is not recommended, as this can have detrimental effects on bone, connective tissue, muscle, and the cardiovascular system. In the event of serious complaints, or if the pain is accompanied by other symptoms, such as shooting pain in the leg extending as far as the foot, a tingling sensation, numbness or loss of strength, consult a (sport) physician. He or she can give you personal advice and in some cases refer you to a (sport) physiotherapist for treatment. How to Ensure the Best Recovery As pain and spasm subside, exercises to improve strength and flexibility (core stability exercises) are started. This build-up proceeds in three steps, from light to strenuous. Step 1. Improvement of Normal Function. As soon as the pain allows, you can start moving your back again. The mobility and stability of the lower back can be improved by doing the following exercises. y Lie on your back with bent knees and keep your feet flat on the ground. Slowly move your knees from left to right, while your feet keep touching the ground. y Take up a position on your hands and knees. Round your back, like a cat, arching your back as far as you can. Then make your back as hollow as you can, letting it sag towards the floor. Lateral mobility can be improved by moving your hips from left to right. y Stretch the lower back. Especially in the morning, or after a longer period of over-use, the back will often feel stiff and painful. Stretching the lower back muscles can offer some relief from the pain. The simplest stretching method is to assume a relaxed, squatting position and hang over a table or chair. Hold this position for 20 to 30 seconds and repeat this two or three times, taking short breaks in between (Figure 2). y Spinal extensions (Figure 3). Support yourself on hands and knees and stretch the right arm and the left knee. Repeat this on the other side. You can make this exercise more difficult by stretching the arm and leg of the same side. Step 2. Build-up Strong abdominal and back muscles (a good abdominal corset) will protect the back and can help prevent excessive strain to the intervertebral disks. The following exercises can be done to prepare for normal training. It is, however, essential that the exercises are carried out correctly. Abdominal exercises

carried out incorrectly can in fact aggravate the back injury! y Straight crunch. Lie on your back on a firm surface with your knees bent and your feet flat on the ground. Place the tips of your fingers behind your head and, let your elbows stick out sideways. Look straight ahead and make sure your head and neck are relaxed. Tense the abdominal muscles and raise yourself to a point where your shoulders are just off the ground. Hold this position for 3 seconds. Repeat as often as possible. y Oblique crunch. Lie on your back on a firm surface, with your right knee bent place it across your left knee. Place your fingertips behind your head, so that the elbows are pointing outwards. Look straight ahead and make sure your neck and head are relaxed. Tense the abdominal muscles and curl your body up with a twisting motion, bringing your right elbow towards your left knee, to a point just above the ground. Hold this position for 3 seconds and repeat as often as possible and then repeat the exercise on the other side. y Bridge. In doing this exercise you train your back and abdominal muscles simultaneously. Lie on your back on a firm surface, keeping one leg bent. Push your pelvis upwards and stretch the other leg so that the leg, the pelvis and the torso form one straight line. You can make this exercise more difficult by taking your weight on your elbows (Figure 4). y Balance exercises on a gym ball. Sit up straight on a gym ball. Raise your right leg five centimeters from the ground and hold this for a few seconds. Repeat this with the other leg. Do it at least 15 times. You can make this exercise more difficult by stretching your leg, closing your eyes or by passing a weight (1-2 kg) in circular movements from one hand to the other behind your back or over your head (Figure 5). You can also lie on your back on the gym ball and try to keep your balance. Step 3. Return to Play y Try to play on clay as much as possible, avoid hard courts. Longer braking distance on a clay court causes lower peak strain on the back than is the case on a hard court. y If possible, start off by hitting the ball from an area measuring two square meters. In doing this you can practice your footwork (taking small steps, always getting into the right position to hit the ball) so that your back will not be strained by having to stretch too much. y The following exercises put more strain on the back and must therefore be built up gradually: the service (particularly the kick service and the topspin service); powerful topspin open stance forehands; long series of low or wide volleys; difficult left-right exercises; and high topspin backhands. In addition to these there are combinations of volley-overhead drills that involve alternating volleys and overheads, which are very taxing for the back. It is better to train these strokes in separate sessions. Preventing Re-injury y Do a thorough warming-up before and cooling down after the training or match- take at least 10 minutes for each. Concentrate on performing these exercises correctly. y Make sure you have an adequate abdominal corset by doing abdominal and back exercises at least twice a week. y Make sure you build up training step by step, so that your body can get used to the extra exertion gradually. y Make sure you have the right tennis shoe and pay attention to shock absorption, lateral stability, feeling for the surface (good traction) and optimal comfort.

Osgood Schlatter Knee Injury

Figure 1. Osgood Schlatter knee injury

Figure 1a.

Figure 2. Stretching the quadricep muscles

Diagnosis Osgood Schlatters disease is an overuse injury of the knee that occurs in junior players. The affliction is most commonly observed in adolescence, particularly in 10 to 15-year-old boys and 8 to 13-year-old girls. It is seen more often in boys than in girls. The powerful quadriceps group of muscles converge to a single patellar tendon attached to a vulnerable area of the lower leg (tibial tubercle, Figure 1 and 1a). Continuous pulling of the patellar tendon on the developing tibial tubercle leads to pain, tenderness and swelling at the point of repeated stress. Sometimes, both knees can be affected. The symptoms are a warm, swollen and painful bump below the knee. Cycling, stair climbing, starts, stops, sprints, deep knee bends and kneeling Figure 3. Stetching the hamstring muscles are usually painful. In tennis, low volleys, court drills involving sudden changes in direction and serving may provoke pain. The symptoms may appear suddenly or develop gradually, and may be intermittent. The injury takes six months to heal on average, with a range from two months to more than two years. Occasionally, a player will have symptoms during adulthood. This is caused by bone fragments, which must be removed surgically. First Aid y Cool the painful area with ice cubes or with a cold pack for 10 to 15 minutes, repeating this process several times a day. Do not place ice directly on the skin, but wrap it in a towel. y If the knee hurts, stop play or reduce the intensity of the training. The injury usually heals well if the load on the knee is reduced.

Figure 4. Patellar tendon strap

y Do not treat the painful area with ultrasound, since this may affect the growth plate. Fast and adequate first aid is of major importance for a rapid recovery. Serious injuries should be evaluated by a physician. Occasionally, patients will be referred for further evaluation (ultrasound scan or X-rays of the knee). How to Ensure the Best Recovery Pain is a signal to rest the knee. Do not to cross the pain threshold, as this will slow the healing process. The increase of the training load occurs in two stages. This program is described below, including several tips. Stage 1. Improvement of Normal Function y Regular stretching of the muscles at the front and back of the thigh (quadriceps and hamstrings) decreases the tension of the muscles and the pulling forces on the patellar tendon. Stretching should not hurt, so do not stretch too much in the acute phase of the injury. y Quadriceps. Stand up straight, with support for one hand. Bend one leg, hold the ankle of the other leg and pull the heel towards the buttocks until you feel the stretch in the thigh. The stretch can be increased by extending the thigh backwards (Figure 2). Stretch for 10 to 15 seconds, followed by a break of 10 to 20 seconds. Repeat three times. y Hamstrings. Place one leg horizontally on a bench or step. Bend forwards while keeping the back straight and extend the toes towards your body. Keep both legs straight. Hold for 10 to 15 seconds, followed by 10 to 20 seconds rest. Repeat three times (Figure 3). y Co-ordination exercises. Stand on the injured leg, with the arms spread for balance. Close your eyes and try to keep your balance. Count to 20. Now try to perform 10 to 20 small knee bends. y Use a patellar tendon strap (Figure 4) or brace during play. This ensures that the load on the insertion

point of the patellar tendon at the tibial tubercle is spread out over a larger area, decreasing the point pressure. y Use a bike with gears. Use the lightest gear, which results in a high pedal frequency. This is easiest on the knees. Try to avoid cycling uphill or against the wind. y Avoid prolonged sitting in the same position or with the knees pulled up. Stage 2. Return to Play It is not necessary to stop playing tennis completely if the complaints are minor. However, training programmes should be adapted. Even with serious complaints, most players can resume play after three to six months. y Try to play on clay or sandy surfaces that allow gliding and avoid playing on hard courts as much as possible. Because of the longer braking phase, the peak load on the knee is lower on a clay court than on a hard court. y Ask your coach to adapt your training load so that you do not have to run so much, but can hit the ball from an area of 2 square meters. This will still enable you to do the footwork well (take small steps, position yourself well for the ball) without putting excessive load on the knee. y If the adapted training sessions go well, you can introduce exercises with longer distances to reach the ball (tennis drills from corner to corner). Preventing Re-injury It is not always possible to prevent an Osgood Schlatter knee injury, but paying attention to the following can reduce the risk: y Perform a complete warm-up each practice or match, and a cool-down afterwards, of 10-15 minutes each practice. Pay attention to correct performance of stretching exercises. y Ensure a gradual build-up of the training load, so your body can adapt to the extra load. y Sprinting and jumping exercises should be introduced gradually. The day after intense sprint training, the training load should be reduced. y Do not do too many jumping exercises during the growth spurt. y Make sure to wear well-fitting tennis shoes, e.g. shoes with adequate shock absorption, sideways stability, feeling with the surface (grip) and optimal comfort. y When there are leg length discrepancies (valgus or bow knees, flat or cavus feet), inlays should be worn in firm shoes with sturdy soles.

SLAP Lesion

Figure 1. SLAP lesion (grade II), SLAP lesion, Biceps tendon, Shoulder socket, Labrum

Figure 2. Stretching the structures down the back of the shoulder

Figure 3. Protraction and retraction of the shoulder

Figure 4: Sawing

Diagnosis The shoulder socket is very shallow. There is a rim around this socket, called the labrum. The labrum enlarges the socket and ensures that the ball of the shoulder joint fits neatly into it. The labrum is also vital for the stability of the shoulder joint and acts as an insertion point for the shoulder capsule, the ligaments and the long biceps tendon. This biceps tendon attaches to the upper part of the labrum. A tear in this area is called a SLAP lesion (Superior Labrum Anterior - Posterior). SLAP lesions are generally graded I IV. Figure 1 shows a grade II SLAP lesion. A SLAP lesion can occur when the biceps tendon and the upper part of the labrum are put under tension during a serve or overhead smash. Other causes may be falling on an outstretched arm or a strong pull of the shoulder. There is virtually no pain when in the rest position. Pain to the shoulder usually occurs during overhead activities such as a serve. Another symptom is a clicking or locked shoulder joint. During overhead activities there may be a loss of muscle strength, reducing the power and speed of the serve.

Figure 5: Extension with resistance

Figure 6: External rotation with resistance

Physical examination is usually not sufficient to obtain an accurate diagnosis. An MRI scan using contrast dye will normally confirm the diagnosis. An arthroscopy may be required. Depending on the symptoms and the severity of the injury, treatment will consist of rest and muscle strengthening exercises (grade I and II). If the symptoms persevere or if the injury is more serious, arthroscopy (keyhole surgery) may be required (grade III and IV, sometimes for grade II). First aid Here are a number of exercises along with some tips. Note: these exercises cannot replace a rehabilitation programme devised by a (sports) physiotherapist. If you have had shoulder surgery, strictly adhere to the instructions given by the surgeon and/or physiotherapist. Step 1: Restoration of normal function y Stretching the structures at the back of the shoulder. Bring your injured arm up to shoulder height in front of your body and take hold of your elbow with your other hand. Pull your elbow towards you until you feel a stretch down the back of your shoulder (figure 2). Hold it for 20 to 30 seconds. Rest for 10 to 20 seconds and then repeat the stretch three times.. Also do exercises to strengthen the muscles which stabilise the shoulder blade. Gradually build up the exercises. They should not be painful. Start with a set of 10 to 15 repetitions per exercise. If your shoulder feels heavy the next day, take a day off. Gradually build up to three sets of 10 to 15 repetitions per day, with a 60 second rest between each set. An exercise band or small free weight can be purchased in a sports shop. y Protraction and retraction of the shoulder (figure 3). Attach an exercise band to a fixed sturdy object, such as the leg of a table. Stretch out your injured arm. Next, pull the exercise band back, whilst keeping your arm straight. This is done by moving your shoulder forwards (rounding your shoulders) and then back again (straightening your shoulders). Step 1: Restoration of normal function

y Sawing (figure 4). Attach an exercise band to a fixed sturdy object, such as the leg of a table. Using a sawing motion, pull the exercise band to your middle and back again.

y Extension (figure 5). Attach the middle of the exercise band to a fixed sturdy object in front of your body. Hold on to the ends and stretch both arms along the side of your body. Keeping your arms straight, stretch them against the resistance of the band, and then back again. Stage 2: Build-up of the rotator cuff As soon as you are able to perform the exercises described above confidently and you can stabilise the shoulder blade, you can start performing muscle strengthening exercises for the rotator cuff itself. These exercises are quite tough, so do not perform them every day and incorporate a day off. This will enable the muscles and tendons to heal and adapt. y Exercising the front of the shoulder: attach an exercise band to a fixed sturdy object to the right hand side of your body. Place your right elbow on your side so that your forearm is pointing forward. Remaining in this position, rotate your arm towards your stomach. Do three sets of 15 to 20 repetitions. Repeat on the left side. y Exercising the back of the shoulder: attach the end of an exercise band to a fixed sturdy object to the left hand side of your body. Place your right elbow on your side so that your forearm rests on your stomach. Remaining in this position, rotate your arm outwards by 70 degrees and back again. Do three sets of 15 to 20 repetitions. Repeat on the left side (see figure 6). y Wall push-ups: lean your hands against a wall, standing at a distance of approximately two feet. Now do wall push-ups, changing the position of your hands (hands closer together, hands further apart, one hand above the other, using only one hand etc.). The closer you stand to the wall, the easier the exercise is. You can increase the difficulty by standing further away from the wall. y Rowing: attach the middle of an exercise band to a fixed study object in front of you. Stand in front of it, grasp each end of the exercise band and pull your elbows back. Hold for a few seconds and then slowly release. Maintain a constant and even tension, and tuck in the abdominals. Do three sets of 15 to 20 repetitions. Stage 3: Return to play When you can do all of the exercises confidently and without pain, you are ready to play tennis again. y At first avoid any overhead smashes. Start off by playing against a practise wall or by playing minitennis, gradually taking small steps back. Use an underhand serve, delivering the ball below shoulder level as much as possible. y Subsequently step up baseline speed, only hitting the ball flat. Only play low volleys when using a net. y You may gradually start including topspins and higher volleys. y The next step is to throw a ball over the net. Standing at the service line, throw the ball overhead to the other side of the net. Once this is going well, gradually increase distance and speed. y You can now start incorporating serves. The first time you do so, serve without using a ball. Then serve standing at the service line. Gradually increase distance and speed. You may also perform a gentle smash. Pay close attention to technique and timing. y The next step is to play points, and then a game, a practice set and a practice match. Once practice matches have been completed for two to four weeks pain free, you can sign up to play a match. Preventing Injury y Regularly stretch the structures at the back of the shoulder. y Be sure to perform a thorough warm-up before playing and a cooling down after the training or match, for a minimum of ten minutes each. Ensure that shoulder stretching exercises are performed correctly.

y Make sure your shoulder muscles are strong and that you have adequate shoulder muscle balance by performing strengthening exercises at least twice a week. y Build up training gradually, so that muscles and tendons can adapt to the increased load. Allow for a sufficient recovery period between training sessions and matches

Tennis Elbow

Figure 1. Tennis elbow

Figure 1a.

Figure 2. Stretching of the forearm extensor muscles

Diagnosis Tennis elbow is the best-known and also the most painful elbow injury in tennis players. An estimated 50% of all tennis players will suffer from tennis elbow in the course of their career. Players aged over 35 are particularly at risk. Tennis elbow is an overuse injury of the extensor muscles of the wrist, in which pain and tenderness are felt at the attachment of these muscles at the outer side of the elbow (Figure 1 and 1a). The pain may radiate into the arm, wrist and fingers. The injury usually develops gradually, as a result of multiple micro ruptures and scar tissue at the muscle attachment. The injury may also occur suddenly, for instance as a result of miss-hitting the ball, so that a larger tear develops. Lifting, gripping, twisting the wrist, shaking hands, washing dishes or opening a door may all be very painful. During tennis, hitting backhands usually provokes the pain. First Aid Tennis elbow is a common complaint, but as yet, there is no consensus on the optimal treatment strategy. There are various therapies, all based on rest, cooling with ice and stretching techniques. In some cases, rest will mean complete withdrawal from play. In others, the complaints can be controlled by training modification and discontinuation of match play. Physiotherapy (friction massage, ultrasound, and a standardised exercise programme aimed at the mobility of the elbow and wrist, stretching exercises and strengthening of the muscles of the forearm, upper arm and hand) and manual therapy often have good effects, if necessary in combination with a brace. A corticosteroid injection may have a positive effect in the short Figure 4. Strengthening the forearm term, but the long-term results are less positive than those of extensor muscles physiotherapy or rest. One negative side effect of corticosteroids is that they weaken the tendon tissue. A more conservative approach is therefore taken with this therapy today than in the past, especially with competitive tennis players. Surgery is generally advised if the complaints persist, despite long-term intense therapy for more than a year. How to Ensure the Best Recovery Stage 1. Improvement of Normal Function In this phase, attention focuses on improving flexibility and strengthening the forearm muscles. y Daily stretching of the forearm extensor muscles. Extend the arm forward from the shoulders with the palm down and the elbow straight. The fingers point to the floor. Grasp the wrist and fingers with the other hand and bend the wrist down, until tension is felt at the outside of the forearm (Figure 2). y Increase grip strength. This is a general exercise, which can be performed by squeezing a stress ball or low-pressure tennis ball. y Strengthening the forearm flexor muscles. Sit on a chair and lean forward. Rest the forearm with the elbow slightly bent on the knees. Turn the hand so the palm is facing up. Holding a weight, curl the hand towards the ceiling. Return to the starting position and repeat 10-15 times (Figure 3). y Strengthening the forearm extensor muscles. Turn the palm of the hand towards the floor and rest the forearm with the elbow slightly bent on the knees. Holding a weight, curl the hand towards the ceiling and return to the starting position. Gradually build up to three series of 10 to 20 repetitions (Figure 4). y To maintain general fitness, running (20-30 minutes) or cycling (30-60 minutes) three times per week is recommended. Swimming is also acceptable, but should be restricted to kick-board work to limit stress on the arm/wrist. Stage 2. Return to Play

Figure 3. Strengthening the forearm extensor muscles

In this phase, attention focuses on building up the specific tennis load. The increase of the load could take place as follows: y Mini-tennis (within the service-lines), both forehands and backhands. y Baseline tennis, hitting only forehands and (double-handed) backhands. It is preferable to start on a slow court (clay), because on fast courts there is less time available to perform the strokes well. y Baseline tennis, hitting flat or double-handed backhands only and gradually introducing slice backhands (no topspin!). Volleys. y Baseline tennis with all types of backhands. y Smash and service. y Practice match. y Match play. During Stage 2, it is important to pay close attention to timing and technique. The sense of timing ensures that renewed mastery and improvement of the techniques occurs with minimal use of strength. This is important, because it allows the player to keep the wrist straight and to hit the stroke fluently. A few tips for the gradual build-up of the tennis-specific load, especially the backhand: y Try to hit the ball in front of the body, so it is easier to fully use the shoulder and trunk and to stabilise the wrist. y When the ball impacts the racket, the wrist should be straight. The forearm extensor muscles are better able to handle the shock when the wrist is straight than when it is flexed. y Try to use the forearm for control instead of strength. The application of strength should come mainly from the shoulder and trunk muscles, which are much stronger than the forearm muscles. y Try to use the other arm for balance when hitting a one-handed backhand. The function of the balance arm is to ensure a smooth stroke (supporting the racket in the starting position, enabling a change of grip, improving the shoulder turn etc). y If the player cannot develop sufficient strength or co-ordination during the one-handed backhand stroke, hitting a double-handed backhand may be considered. The advantages and disadvantages of double-handed backhands should be discussed with the coach. y In addition to the backhand, the service and overhead may also provoke pain in the elbow. Try to build up these strokes gradually too. Preventing Re-injury It is not always possible to prevent tennis elbow. However, risk can be reduced by measures such as a gradual build-up of the training programme, warm-up and stretching exercises, suitable equipment (see below) and the correct technique (hit the ball in front of the body with a straight, firm wrist). Tips for Choosing Correct Equipment: y The racket. To prevent tennis elbow, it is best to choose a flexible racket with a large sweet spot, such as a mid-size or oversize racket. Even though a stiff racket gives the player more power and control, a flexible racket is gentler on the arm with off-centre hits, because the flexion will absorb some of the shock and spread it over a longer period. y Strings. Relatively low string tension is better for the arm, because it increases the dwell time of the ball on the strings. The longer contact time means that the shock of the ball impact is spread over a longer period of time. Thinner strings are more elastic and have better shock-absorbing capacities, and are therefore better for the arm than thicker strings.

y The ball. Choose new, pressurised tennis balls. Avoid, old, wet, and pressure-less tennis balls. y The grip. A grip that is too small or too large may cause problems. In both cases, the player may have to grip the racket too tightly to prevent it from twisting, and high grip force may increase the risk of elbow injury. An easy way to determine the correct grip is by measuring the distance from the long crease in the palm (the second one down from the fingers) to the tip of the ring finger.

Wrist Tendinopathy

Figure 1. Wrist tendinopathy

Figure 2. Strengthening the wrist flexor muscles

Figure 3. Strengthening the wrist extensor muscles

Diagnosis A wrist tendinopathy is an overuse injury of one of the tendons around the wrist. Usually it involves the extensor tendon, which is located at the ulnar side of the wrist (Figure 1). Often, the injury occurs in the non-dominant wrist in players who use a doublehanded backhand. The flexor tendon is also located lower down on the ulnar side of the wrist. This injury leads to complaints during serving and when hitting forehands and forehand volleys. The cause of the injury is the high loads that the tendons around the wrist have to deal with when the ball impacts with the racket. This results in overstretching and micro-tearing of these tendons. Women are more commonly affected than men, because they have looser and weaker wrists. The injury is characterised by Figure 4. Push-ups using handle bars pain, swelling, heat and redness at the insertion point of the tendon in the wrist. Usually, extension and flexion of the wrist against resistance is painful. Tendon injuries are slow to heal and may take six weeks or more. First Aid y Activity modification (if you do not stop playing completely while the injury heals, hit mainly shots that do not hurt, such as double-handed backhands or only forehands and serves depending on the location of the injury). y Cool the wrist with ice. y Stabilise the wrist with a wristband or tape, so the ligaments and tendons can heal. Fast and adequate first aid is very important to ensure good recovery. In severe cases, or when in doubt, the player should have the injury evaluated by a physician, who may make a referral for more detailed diagnosis and prescribe physiotherapy. How to Ensure the Best Recovery The recovery process takes place in three stages, using exercises to enhance strength. These are described below, with several tips. Stage 1. Improvement of Normal Function At this stage, special attention is paid to enhancing the strength of the muscles that are responsible for stabilising the wrist. Players with a double-handed forehand or a double-handed backhand need to make sure they strengthen both wrists. y Wrist flexor muscles (Figure 2). Start with a light weight (max. 1 kg) or elastic tubing. Support the forearm with a slightly flexed elbow on the knee, palm of the hand facing up. Move the wrist up and down, from a neutral position (2-3 sets of 10-20 repetitions). y Wrist extensor muscles (Figure 3). This exercise is the opposite of the exercise for the wrist flexor muscles. Support the forearm with a slightly bent elbow on the knee, but now with the palm of the hand facing down. Move the wrist up and down from a neutral position. This can be built up to 2-3 sets of 1020 repetitions. When starting these exercises, it is sufficient to simply hold the weight, without moving the wrist. y Once the wrist flexion/extension exercise is tolerated, progress to ulnar/radial deviation and pro/supination to further build strength in the wrist region. Ulnar/radial deviation. Support the elbow on the knee, palm facing down and light weight in the hand. Move the hand to the left and right. Pro/supination. From the same starting position, rotate the hand clockwise and counter clockwise. y Improve grip strength. This is a general exercise that strengthens al the muscles of the forearm and hand. Use an older, softer ball (3 sets of 10-20 repetitions). Stage 2. Return to Play

In this phase it is important to build up the tennis-specific load. The increase of the load could take place in the following way. y Mini tennis (i.e. half court within the service lines), both forehands and backhands. y Baseline tennis, with only forehands, slice backhands, or a single-handed backhand. Be careful of your technique if you use a double-handed backhand. y A slow court (clay court) is preferable at first, since fast courts afford less time for a good stroke performance. y Gradually introduce volleys. Do not practice these for too long. Stabilise the wrist well at the point of impact. y Baseline tennis with all types of backhands. Limit the use of the short cross-court backhand, because this puts a high strain on the wrist. y Service and overhead. y Practice match. y Match play. During stage 2 it is important to pay attention to timing and technique. The feel for the timing ensures that improvements in technique occur with a minimum use of strength. This is very important for the maintenance of a correct position of the wrist and a fluent stroke. Some Tips for the Backhand y Try to hit the ball in front of the body, so it is easier to fully use the shoulder and trunk and to stabilise the wrist. y Try to use the forearm for racket control only, and not for strength. Strength should be exerted mainly via the shoulder and trunk muscles instead of the forearm muscles. y When hitting a backhand, try to use the other arm for balance. The function of the balancing arm is very important for a fluent stroke. It supports the racket in the starting position and enables an easy grip change when preparing for the backhand. y If the injury is the non-dominant hand and persists during the double-handed backhand, the player could consider switching to a one-handed backhand. Since there are both advantages and disadvantages to the use of a single-handed backhand, the player should discuss this with his/her coach first before making the change. y Since volleys may also provoke the pain, these should be gradually introduced into the training programme. Preventing Re-injury y Perform a complete warm-up before play and a cool-down afterwards, for approximately 15 minutes each. This should be followed by mini-tennis. y Make sure the build-up of the tennis training is gradual, so your body can adapt to the increased load. y Alternate volley exercises with other strokes, so your wrists have enough time to recover. y Avoid push-ups with a bent wrist, because this may worsen a wrist injury. If you do want to perform push-ups, use handlebars or support yourself on your knuckles (this straightens the wrists) (Figure 4). y Make sure to use the correct grip. If the grip is either too thick or too thin, you have to squeeze the racket to prevent it from twisting in the hand. The correct grip can be determined as follows: grip the

racket lightly, as if you were shaking hands. The little finger should fit between the base of the thumb and the fingertips. Consult your coach for further details regarding the correct grip size. y Continue to work on wrist strength to stabilise the wrist using the exercises and a low-resistance, highrepetition format.