Tennis: Reduce Pain, Improve Performance

Tennis is one of the most popular sports in the world. In the U.S. alone, there are almost 18 million players, with another 14 million expressing interest (TIA 2018). Unfortunately, the dynamic, forceful twists and turns of the game pose ever-present injury risks to players (Roetert & Kovacs 2011).

If your fitness clientele includes people interested in playing this sport, you need to understand the causes of tennis-related injuries. This will help you develop strategies to improve movement function, reduce pain and keep clients on the court.

Causes of Common Tennis Injuries

Tennis players most often suffer joint and muscle strains to the knees, lower back and shoulders (Roetert & Kovacs 2011). The roots of these injuries start with basic tennis biomechanics.

Tennis groundstrokes—forehand and backhand—require the body to generate a lot of power to hit the ball. This force results primarily from taking the racket back and following through quickly while striking the ball. The legs pivot in the hip sockets, allowing the spine and shoulders to rotate and the arms to swing (Kovacs et al. 2016).

To generate even more power, advanced tennis players often jump during the swing and follow-through. These movements also sync with the leg/hip pivot to help generate upper-body rotation.

Thus, ample rotation of the hips is fundamental to many tennis moves that require rotation. Moreover, adequate hip rotation mitigates stress to the joints, tendons, muscles and other tissues most prone to tennis injuries (Kovacs et al. 2016). The knees are a hinge joint designed primarily to flex and extend. The lumbar spine can rotate but not as effectively as the hips. The shoulder blades protract and retract as the torso twists, but they lack the rotational capacity of the hips (Price & Bratcher 2010; McGill 2016; Cook et al. 2010).

Enhancing hip rotation therefore reduces the risks of tennis-induced overuse, potentially preventing pain and/or injury to the knees, lower back and shoulders.

You can improve clients’ hip rotation with a three-step process:

1. Assess their ability to internally and externally rotate the hips, looking for movement restrictions.
2. Identify muscles and other soft-tissue structures affected by the movement restrictions.
3. Select and design appropriate corrective exercise strategies to address muscle and movement dysfunctions (Price 2018).

Let’s explore these steps in greater detail.

Step 1: Assess Internal and External Hip Rotation

The hips must rotate internally and externally to allow a tennis player to make powerful, “pain-free” strokes. These tips will help you assess a client’s hip rotation:

Internal Hip Rotation

Have your client lie on the floor with legs spread about 18–24 inches apart. Coach him or her to try turning both legs inward so the feet move toward each other. Tell the client not to bend the knees or let the pelvis lift off the ground as the legs rotate inward.

Next, see how far your client can turn the legs toward the midline. Both legs should be able to turn in about 40 degrees. Assess if one leg cannot turn in as far as the other leg or if both sides lack internal rotation. In Figure 1, the client has an almost acceptable range of motion in one leg, while the other leg severely lacks the mobility to rotate inward.

External Hip Rotation

Instruct your client to try turning both legs outward so the feet move away from each other. See how far he or she can turn the legs away from the midline. Again, remind the client not to bend the knees or let the pelvis lift off the ground as the legs rotate outward. Both legs should be able to turn out about 45 degrees. Assess if one leg cannot turn out as far as the other leg or if both sides lack external rotation. In Figure 2, the client can externally rotate one leg well past 45 degrees, but the other leg has only limited external rotation.

Step 2: Identify Affected Soft-Tissue Structures

A client who cannot internally or externally rotate the hips may have problematic soft-tissue and muscle imbalances (Kovacs et al. 2016).

Muscles That Rotate The Hips

A thorough understanding of functional anatomy—including the muscles that affect hip function—is crucial to choosing the most appropriate corrective exercises. For example, inability to internally rotate the hip may result from muscle tightness and/or restriction in the gluteus maximus; in the posterior fibers of the gluteus minimus, tensor fasciae latae and gluteus medius; in the hip rotators, adductors and hip flexors; and in the obliques (indirectly). Conversely, an inability to externally rotate the hip may reflect soft-tissue restriction or dysfunction in the hip adductors and hip rotators; in the anterior fibers of the tensor fasciae latae, gluteus minimus and gluteus medius; in the medial hamstring muscles; and in the obliques (indirectly) (Price 2018; Gray 1995).

In your assessment, ask where the client feels the most tightness or restriction. This information will help you identify the muscles and soft-tissue structures that need the most help from corrective exercises.

Step 3: Choose Appropriate Corrective Exercises

Next up: Start integrating corrective exercises that can help the client improve hip function, enhance movement performance, and decrease the incidence of pain and/or injury from playing tennis.

Begin with self-myofascial release (or self-massage) techniques to rejuvenate and regenerate dysfunctional soft-tissue structures and muscles, and then move on to stretching and strengthening exercises (Price & Bratcher 2010; Rolf 1989; Myers 2008). Repeat all exercises on both sides of the body.

Improving Internal Rotation

Self-myofascial release. Use a foam roller (or similar equipment) to address larger areas and entire muscle groups, such as the gluteus maximus and adductors, that might affect a client’s ability to internally rotate the hips. Use smaller massagers, like tennis balls, to address specific muscle-dysfunction areas, such as the posterior fibers of the hip abductors and tensor fasciae latae, the origin of the hip flexor group, the hip rotators, and so on (Figure 3) (Price 2018; Price 2013). During self-myofascial release exercises, ask the client for feedback on tender areas to help you identify which specific structures need to be addressed to improve movement.

Stretching and flexibility. Once you’ve restored the health and suppleness of a client’s muscles, begin introducing stretching exercises to increase the flexibility of the muscles needed to facilitate better internal hip rotation. Start with isolated stretches of the gluteus maximus, hip abductors, flexors and adductors, tensor fasciae latae, and hip rotators (Figure 4).

As the flexibility of individual soft-tissue structures increases, incorporate more dynamic forms of stretching that introduce multiple parts of the body and mimic tennis-specific movements (Figure 5).

Corrective strengthening exercises. When your client has achieved the desired range of internal hip rotation, start integrating strengthening exercises that will eccentrically load (lengthen under tension) the appropriate structures with the client’s feet on the floor. You’re looking for closed-kinetic-chain exercises.

Select movements that internally rotate the leg by pivoting the torso around the weight-bearing side. Choose moves like lunge with knee pull (Figure 6) and single-leg straight-leg deadlift (Figure 7), where the hip is flexed (and target leg/hip in front of the body), or a pivot exercise (Figure 8), where the hip is extended (target leg/hip straight and/or behind the body).

As your client’s movement capabilities improve, progress the strengthening phase of the program by adding external loads to the exercises. Possible options include holding a medicine ball or light weight and/or using resistance bands.

Improving External Rotation

Self-myofascial release. If your assessment reveals that the client lacks external rotation, use self-myofascial release techniques for the adductors, the hamstring muscles toward the medial side of the leg (semitendinosus), the anterior fibers of the abductors (gluteus medius, gluteus minimus and tensor fasciae latae), and the hip rotators.

Stretching and flexibility. Progress to isolated, and then integrated, stretching techniques that improve these muscles’ ROM in preparation for the strengthening phase of the program (Figure 9).

Corrective strengthening exercise. As your clients gain confidence and competence with increased ROM, incorporate eccentric strengthening exercises to increase external hip rotation. Pivot the upper body around the leg/hip, using exercises where the foot of the weight-bearing leg is in contact with the ground (Figure 10).

Like all strengthening exercises, these moves can be progressed by adding external loads and/or uncontrollable variables. For example, you could coach your client to catch and throw a ball while performing the desired movement.

The Right Moves for Tennis and Other Twisting Sports

Effective internal and external rotation of the hips can improve tennis performance and decrease pain and injury to the lower back, knees and/or shoulders. Hip rotation is also essential for producing power and minimizing musculoskeletal stress during other sports movements that require forceful rotation of the trunk (e.g., executing a golf swing, throwing a baseball, throwing a discus or Frisbee^® disc, etc.).

Therefore, identifying and correcting flaws in hip rotation will make a client not only more athletic on the tennis court but also less likely to suffer pain and injury in a wide range of other sports and activities.