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ISSN: 2638-6003

Orthopedics and Sports Medicine: Open Access Journal

Research Article(ISSN: 2638-6003)

Epidemiology of Musculoskeletal Injuries in Real Tennis Volume 2 - Issue 3

JA Humphrey1*, PPA Humphrey2, A Greenwood3, J Anderson4, HS Markus5 and A Ajuied6

  • 1Orthopedic Consultant Surgeon, London, UK
  • 2 Fellow of the School of Pharmacy, London, UK
  • 3Fellow of the School of Pharmacy, London, UK
  • 4Principle Lecturer, London, UK
  • 5Professor of Neurology, Department of clinical neurosciences, UK
  • 6Orthopaedic Consultant Surgeon, Guys’ and St Thomas’ NHS Trust, Orthopedic Department, London, UK

Received: December 13, 2018   Published: December 18, 2018

Corresponding author: Joel A Humphrey, Orthopedic Consultant Surgeon, London, UK

DOI: 10.32474/OSMOAJ.2018.02.000138

 

Abstract PDF

Abstract

Introduction: Real Tennis is a growing, unique and well-established sport. To date there has been no epidemiological data on Real Tennis injuries. The primary aim of this retrospective study is to record the incidence and document any trends in Real Tennis musculoskeletal injuries, so as to improve injury awareness of common and possibly preventable injuries.

Methods:A surveillance questionnaire e-mailed to 2,036 Tennis & Rackets Association members to retrospectively capture injuries sustained by amateur and professional Real Tennis players over their playing careers.

Result: 485 (438 males and 47 females) questionnaires were fully completed over 4 weeks. A total of 662 musculoskeletal injuries were recorded with a mean of 1.4 injuries per player (range 0-7). The incidence of sustaining an acute Real Tennis musculoskeletal injury is 0.4 / 1000 hours. The three main anatomical locations reported injured were elbow 15.6% (103/662), knee 11.6% (77/662) and face 10.0% (66/662)). The most common structures reported injured were muscle 24% (161/661), tendon 23.4% (155/661), ligament 7.0% (46/661), soft tissue bruising 6.5% (43/661) and eye 6.2% (41/661). The majority of the upper limb injuries were gradual onset (64.7%, 143/221) and the lower limb injuries were sudden onset (72.0%, 188/261).

Conclusion: This study uniquely provides valuable preliminary data on the incidence and patterns of musculoskeletal injuries in Real Tennis players. In addition, it highlights a number of reported eye injuries. The study is also a benchmark for future prospective studies on academy and professional Real Tennis players.

What are the New Findings?

a) Real Tennis players sustain similar injury patterns to other racket sports like lawn tennis, with chronic upper limb injuries and acute lower limb injuries

b) Real tennis players’ injury risk increases the more hours they play per week

c) Real Tennis players need to be aware they are susceptible to eye injuries

How Might it Impact on Clinical Practice in the Near Future?

a) The inaugural study on the epidemiology of musculoskeletal injuries in real tennis provides preliminary data for future research

b) The next step would be to perform prospective seasonal studies, focused on academy and professional players.

c) More accurate information on these specific player groups are invaluable to formulate injury prevention strategies.

Introduction

“To see Good Tennis! What divine joy Can fill our leisure, or minds employ? Let other people play at other things: The King of Games is still the Game of Kings” Parker’s Piece by JK Stephen [1].

Real Tennis is an indoor racquets game, which involves high skill levels and strategy. It originated from a form of handball played by medieval Tuscany villagers against monastery and castle walls. By the 16th century the game had fully developed into tennis; rackets were employed, courts were enclosed and the rules more formal. In 1874 the term Real Tennis was used to distinguish it from its derived counterpart lawn tennis. The sport of Real Tennis though has essentially remained unchanged over the last five centuries.

Real Tennis was the first sport to be described as ‘the beautiful game’ in 1800 [2]. It has had a remarkable revival in the last 3 decades and is now played worldwide by over 10,000 officially registered players. The main governing bodies in the UK are the Tennis & Rackets Association (T&RA) and the Ladies Real Tennis Association (LRTA). The International Real Tennis Professional Association (IRTPA) supports Real Tennis professionals and drives the development of the sport worldwide. The professional circuit focuses on the four annual International Opens (British, United States, Australian and French). The World Championship is played every two years.

The Lancet published a case report in 1883 on a lawn tennis leg injury and subsequently there have been several studies describing lawn tennis injuries [3,4]. Other racket sports including squash, badminton and even padel tennis have followed suit [5,6,7]. However, there is currently no data on the epidemiology of injuries in this unique and well-established sport. The primary aim of this retrospective study is to record the incidence of Real Tennis musculoskeletal injuries and determine factors associated with injuries, so as to improve both injury awareness and strategies for prevention among amateur and professional players.

Methods

This retrospectively cross-sectional study captured data from active Real Tennis players over their playing careers to date. An email was sent to Real Tennis players >18 years old identified through the T&RA members’ database requesting participation in the study and to complete an injury surveillance questionnaire through the anonymous Bristol On-Line Survey online and a hard copy is attached in the supplementary material. E-mail reminders were sent at one and two weeks and the on-line link was active for a month from the original participation request.

Terminology, definitions and methods were adapted from the published consensus statement describing the methodology for epidemiological assessment of medical conditions in lawn tennis [8]. An injury was defined as any ‘musculoskeletal complaint directly related to playing Real Tennis irrespective of the severity.’ The International Tennis Federation (ITF) differentiate between the incidence of acute musculoskeletal injuries (number of injuries / 1000 playing hours) and the al prevalence of gradual onset injuries (number of injured players in the season x 100 / number players in the study) [8]. A retrospective study design means only the incidence of acute musculoskeletal injuries can be calculated.

Players’ demographics, baseline playing information and details of injuries sustained (if any) were recorded. Each specific musculoskeletal injury was classified into anatomical location, structure / system injured, injury presentation (acute / gradual onset) and nature of injury (new / recurrent). Musculoskeletal injury severity was determined by days required off playing before return to sport, and by participants rating their injury from 0 (insignificant) to 10 (life threatening). Details on the management on each musculoskeletal injury was also captured. Ethical approval for the study was granted by Brighton and Sussex Medical School Research & Governance Ethical Committee.

Statistical Analysis

Factors associated with injuries were explored. The following factors were investigated: Demographic characteristics (age, gender, height, weight), dominant hand, number of years played, hours played per week, whether they usually stretched pre-game, warmed up and warmed down, and Real Tennis handicap. Each player has a handicap, which determines their individual level of play. Associations with total number of injuries were initially examined by univariate analysis using Chi square for categorical data, or Pearson’s or Spearman’s correlation according to whether data was normally distributed or not for continuous data. Variables which met a P<=0.1 were entered into multivariate analysis using logistic regression to determine which associations were independently associated with the number of injuries. All statistical analysis was performed in Statistical Package for the Social Sciences (SPSS) version 25 for Mac.

Results

Player Characteristics

In total 2,036 real tennis players were e-mailed and invited to participate in the study, with 485 (438 males and 47 females) fully completed questionnaires being returned (response rate 23.8%). Baseline demographics and play metrics. The players participating in the study represented 30 Real Tennis clubs worldwide, including all the 24 Real Tennis clubs in England, but also clubs from the United States (four) and Australia (two). The most represented club was the Royal Tennis Court, Hampton Court Palace with 45 participants.

The mean number of years played per respondent was 18.8 (range <1-56), with a mean of two hours (range <1-12) playing time per week. The cohort had a player handicap mean of -44.9 and median of -46 (range +8 to -91). Hand dominance was right for 419 players (86.4%) and left for 66 players (13.6%). All players (485) used single handed forehand strokes. The majority of players (469, 96.7%) used single handed backhand strokes, and the remaining players (16, 3.3%) used double handed backhand strokes.

The percentage of players that engaged in pre-game stretching was 55.8% (271/484), players that warmed-up before commencing play was 75% (364/485) and players that warmed-down after completing play was only 21% (102/485).

Musculoskeletal Injury Details

Out of the 485 players, 368 (75.9%) sustained at least one Real Tennis musculoskeletal injury during their playing career to date. A total of 662 musculoskeletal injuries were recorded with a mean of 1.4 injury per player (range 0-12). The incidence of sustaining an acute Real Tennis musculoskeletal injury was 0.4 / 1000 playing hours. The 55-64 age category had the highest percentage of injuries sustained 29.7% (144/485).

The five most frequently injured anatomical locations were: elbow 15.6% (103/662), knee 11.6% (77/662), face 10.0% (66/662), lower leg (calf) 8.8% (57/662) and shoulder 8.2% (54/662). Injury location was further stratified as lower limb 39.4% (261/662), upper limb 33.3% (221/662), head and face 15.7% (104/662), trunk and spine 8.5% (51/662), and other 3.8% (25/662). The most commonly injured tissue structures were: muscle 24% (161/661), tendon 23.4% (155/661), ligament 7.0% (46/661), soft tissue bruising 6.5% (43/661) and eye 6.2% (41/661).

More new musculoskeletal injuries (76%, 504/660) were recorded than recurrent musculoskeletal conditions (24%, 156/660). Sudden onset (acute) musculoskeletal conditions (64%, 418/656) were more common than gradual onset (overuse) musculoskeletal conditions (36%, 238/656). The majority of the upper limb injuries were gradual onset (64.7%, 143/221) and the lower limb injuries were sudden onset (72.0%, 188/261).

Severity of musculoskeletal conditions determined through time off playing Real Tennis was categorized as follows: 7.3% no days off (48/655), 7.7% 1-3 days off (51/655), 11.0% 4-7 days off (72/655), 31% 8-28 days off (203/655), 32.7% 1-6 months off (214/655) and 10.2% >6 months off (67/655). The mean subjective musculoskeletal condition severity rating was 3.8 (range 1-10).

The healthcare systems that players were treated in included- State funded health care (e.g. The UK’s National Health Service) 21.5% (142/662), privately funded healthcare 33.5%, both State and private healthcare 11.8% (78/662) and was not applicable in 33.2% (220/662) of injuries. Only 29.2% (193/662) of the reported injuries were not assessed by a healthcare or medical practitioner. The remaining 70.8% (469/662) of reported injuries were assessed by one or more of the following healthcare or medical practitioners -physiotherapist 35.8% (240/670), medical doctor 35.2% (236/670), orthopedic surgeon 18.7% (125/670), other 7.0% (47/670) and chiropractor 3.3% (22/670).

In total 65.7% (435/662) of the reported injuries did not require any medical imaging. The remaining 34.3% (227/662) of reported injuries required one or more of the following medical imaging- X-ray 39.1% (115/294), CT scan 7.5% (22/294), MRI scan 29.6% (87/294), ultrasound scan 18.0 (53/294) and another modality 5.8 (17/294).

Treatment was self-administered in 36.3% (240/662) of the reported injuries. The remaining 63.7% (422/662) of injuries required formal treatment with one or more of the followingrest / ice / compression / elevation (RICE) 39.7% (292/736), physiotherapy 32.2% (237/736), surgery 12.0% (88/736), other 12.0% (87/736), hydrotherapy 0.3% (2/736) and acupuncture 4.1% (30/736).

Factors Associated with Injuries

On univariate analysis the following variables were associated with the number of injuries with a p<=0.1 and were entered into multivariable analysis; namely height, number of years played, hours play per week, pre-match stretch, warm-up and warm down. The strongest independent predictor of the number of injuries was the hours of play per week. Number of years played and amount of pre-stretch were also positively associated with number of injuries. There was an inverse relationship between height and number of injuries. The amount of warm-up and warm-down exercises were not independently found to correlate with the number of injuries. Results table of multivariate analysis determining which factors were independently associated with the number of injuries in supplemental data.

Discussion

Our inaugural epidemiology study on Real Tennis injuries documents the incidence and details of musculoskeletal injuries sustained among amateur and professional players. The International Tennis Federation recommended that their consensus statement for epidemiological studies in lawn tennis can be applied to other racquet sports [8] and here we have uniquely adapted it to Real Tennis. By using these consistent definitions and terminology any further Real Tennis data collected can be compared directly, and potentially allow for future meta-analysis.

We have captured well over 600 Real Tennis injuries sustained on court. The incidence of acute musculoskeletal injuries is 0.4 / 1000 playing hours, which is relatively low. This is not surprising given the retrospective design and the remarkably long recall period with a mean of 18.8 years. Less serious self-diagnosed injuries sustained may not have been particularly memorable and therefore may have been under-reported. Also, as recommended by the ITF gradual onset injuries are not included in the calculation for incidence of acute musculoskeletal injuries. Our results are comparable with lawn tennis as their reported incidence in the literature varies from 0.04 to 3.0 injuries / 1000 playing hours [4].

Our results highlighted a similar pattern of injury to lawn tennis with sudden onset lower limb injuries and upper limb gradual onset injuries [9]. Real Tennis is played with a hand-made ball composed of a cork core surrounded by felt and a rigid wood-based racquet with tight strings, which are both significantly heavier than their lawn tennis equivalents. Essentially this means the ball travels at high velocity and with a low bounce, so requires a bent elbow and a cocked wrist to play repetitive strokes. Some serves, most notably ‘the railroad’ and volleying require overhead movements. All these factors contribute to players sustaining upper limb gradual onset, repetitive strain type, injuries of the elbow, shoulder and wrist.

The forces on the lower limbs draw similarities to a combination of lawn tennis with running side-to-side across court and squash with bending the knees close to the playing surface whilst retrieving low bouncing balls. These active movements correlate with findings that players are sustaining sudden onset lower limb injuries mainly affecting the knee and lower leg (calf). Lower limb and upper limb injuries were relatively evenly distributed highlighting the overall physical demands of playing Real Tennis. In isolation sudden onset injuries were found to be more common than overuse injuries, consistent with the sport’s dynamics.

The playing surfaces on Real Tennis courts are all hard but can vary depending on when the courts were constructed, ranging from 17th century slate tiles to more modern materials. In theory hard surfaces increase the injury risk due to higher ground reaction forces putting more stress on joints, tendons and muscles. A recent study in lawn tennis highlighted there was a higher prevalence of lower limb overuse injuries when playing on a hard surface as compared to clay or artificial grass [10]. Appropriate footwear aims to reduce the shock during any impact whilst playing.

All indoor racquet sports have an intrinsic risk of eye injuries, which have already been well documented in badminton and squash [11,12]. Interestingly, the only Real Tennis injury described in the academic literature to-date is an eye injury, mentioned within a broader study on eye injuries in sport [13]. Our results flaggedup a relatively high percentage of facial injuries sustained (10%, 66/662), with 41 of those 66 facial injuries specifically involving the eye. These were probably accurately reported due to the significance of the event. The unique combination of balls hit hard with heavy spin within an asymmetrical court with sloping roofs (penthouses), posted openings (galleries) and an angulated wall (tambour), means the ball rebounds at unexpected/unpredictable angles and deflections into the player’s face can occur off the small racquet head. However, courts are well-lit, the balls are colored ‘optic yellow’ to improve visual recognition and some players routinely wear eye protection in order to minimize risk of facial injuries. The T&RA is currently further exploring eye injury prevention strategies.

The most common structures injured were muscles and tendons, which is similar to the findings of previous epidemiological studies on lawn tennis injuries [14,15]. These observations are compatible with the sport’s technical requirements. New musculoskeletal injuries were more commonly reported than recurrent musculoskeletal conditions. This correlates with our other findings that players were appropriately seeking medical attention and formally managing their injuries prior to returning to play.

Our results highlight the main factor associated with Real Tennis injuries is hours played per week. Unusually pre-game stretch was associated with an increased injury risk and warmup or warm-down exercises did not reduce the risk of injury. These findings may be a result of subject recall error, with players potentially changing their pre- and post-match routines over the years, and no information was requested on exact exercises and stretches e.g. static v dynamic stretching. Or indeed, pre-stretching may genuinely predispose to injury by some yet unrecognized mechanism. More robust evidence is required prior to proposing formal pre-stretch, warm-up and warm down recommendations.

Strengths

A large proportion of global Real Tennis players were captured as all 2036 T&RA members were requested to participate in the study. The number of officially registered Real Tennis players in the UK is 6,392, not all of whom are T&RA members, and worldwide the total number of players is 10,831. Real Tennis is a niche sport and the players are quite engaged, so as envisaged we achieved a good response rate of 23.8%. By comparison, a similar study investigating musculoskeletal injuries in lawn tennis-teaching professionals only achieved a response rate of 8.7% [14]. The T&RA database captured not all the sent emails were opened, so it is likely that not everyone read the participation request. Emails not being opened can be attributed to inactive addresses, spam diversion or non-engagement.

The participants are a representative sample of the Real Tennis population. The worldwide male to female ratio was similar to the study cohort, 7:1 and 10:1 respectively. The majority of players are over 25 years old (84.1% worldwide and 97.1% study cohort). The low numbers of females and younger players are most likely related to lack of Real Tennis exposure, limited courts, cost and other competing racquet sports. The T&RA endeavor to make sure the sport is well publicized and accessible to everyone.

A nuance of Real Tennis is the global handicap system, which determines a player’s level. Scoring for matches can be adjusted accordingly to allow players of all levels to compete against each other. The worldwide official player handicap mean is -48 and median is -60, ranging from +16 (elite) to -108 (novice). Our cohort had slightly better player handicaps with a mean of -44.9 and median of -46, but with a similar range from +8 to -91. This could be attributed to T&RA members playing more regularly than nonmembers with subsequent improving handicaps.

Currently only 15 players currently have a positive handicap (12 professional and 3 amateur). Given the vast majority of Real Tennis players have a negative handicap the negative prefix is generally discarded, so better players are referred to as having a lower handicap. Although players were not asked whether they were amateur or professional, it can be deduced that professional players participated given some of the elite handicaps recorded.

Limitations

Our study had limitations secondary to the retrospective design being susceptible to recall bias. This can lead to inaccurate injury details and potential underreporting. Also, the self-reporting questionnaire did not require injuries to have a formal diagnosis from a medical practitioner.

In addition, the study cohort incorporated a broad spectrum of ages and abilities. So, the next step would be to perform prospective seasonal studies, focused on academy and professional players. This will provide more accurate information on specific player groups to focus on injury prevention. The seasonal prevalence of gradual onset injuries can then be ascertained and compared to other racket sports.

We had realistic expectations that Real Tennis careers played over many years could not be summarized into a tick box quantitative questionnaire. Another interesting avenue in the future would be to further explore players’ qualitative injury experiences throughout their extensive careers.

Conclusion

This study uniquely provides valuable preliminary data on the incidence and patterns of musculoskeletal injuries in Real Tennis players. The majority of the upper limb injuries were gradual onset and the lower limb injuries were sudden onset. In addition, it highlights a high number of reported eye injuries. The study is also a benchmark for future prospective studies on academy and professional Real Tennis players.

Acknowledgements

We would like to thank Nick Wood (Head Real Tennis Professional, Royal Tennis Court) and Chris Davies (Chief Executive, Tennis & Rackets Association) for their support and input throughout the project.

Funding

To improve study participation, the players who completed the questionnaire could choose to be placed into a confidential randomly allocated drawer for a bottle of Champagne, which was supplied and sent directly to the winner by Pol Roger. No other financial assistance with the project.

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