Injury Prevention in Tennis - Essay Example

Critically Review the Evidence for a Prevention Programme to Avoid Injury to the Lumbar Spine in Elite Tennis Player Introduction: Tennis is by far the most popular of all of the racquet sports. Tennis is an individual, non-contact sport played on a court 78 feet long with a net 3 feet in height dividing the court into two equal parts. Tennis is usually played outdoors, though it may be played indoors, usually on carpet. Tennis is a very versatile game that allows people of all ages and physical statures to play satisfactorily against their peers. Players of different ability can rally well, although minor skill differences can result in large score differences in a game. Conditioning is vital for singles play, whereas doubles is more forgiving. To play well in singles, one usually needs additional cardiovascular training such as interval running, whereas a doubles player does not need that additional work (Easterbrook and Cameron, 1985, 553-571). Most injuries in tennis are classified as overuse injuries. Some series report injury rates as high as 74% in men and 60% in women in world-class players. The most common injuries are to the back, shoulder, and elbow in that order. Overuse injuries of the central region are common in the racquet sports athlete. It has been reported that 38% of professional male tennis players reported missing at least one tournament because of low back pain and up to 50% of elite junior tennis players noted a history of low back pain (Easterbrook and Cameron, 1985, 553-571). There are several sources of low back pain in the tennis player. High demands placed on the lower back and trunk combined with low flexibility patterns result in frequent overuse-type injuries. The three areas most often involved are: (1) the posterior midline paraspinal musculature, used in the service motion, when charging the net or when dropping straight back for a volley; (2) the peripheral trunk musculature, the quadratus lumborum or oblique muscles used during the service motion or in ground strokes; and (3) the rectus abdominis, tears in this muscle may be associated with hitting overhead strokes or serves. Other potential causes of low back pain include intervertebral disk degeneration and herniation, facet impingement, sacroiliac joint dysfunction, and spondylolysis due to the repetitive hyperextension and rotation of the spine (Chandler, Ellenbecker, Roetert, 1998, 7-10). Overuse, over-reaching for the ball, hyperextension, and bending to hit the ball are motions that have been implicated in the high incidence of low back pain among elite players. These motions may produce flexion and rotation stresses to the spine, factors known to result in the commonly seen problem of intervertebral disc prolapse in tennis players. These injuries often may be traumatic in origin and were identified in the elite players. Some researchers have put forth the concept of clinical instability of the spines in the absence of mechanical instability. This leads to a form of instability that is not needed to be treated surgically and results from a lack of segmental control of the lumbar spine (Maffulli, Baxter-Jones, Grieve, 2005, 525-527). The stability in the lumbar spine and the surrounding areas is the result of an intricate interplay between the osseo-ligamentous system, the myofascial system, and the neural control system that work in synergy. As expected, disruption in any of these systems will lead to a lack of segmental control. It has been observed that the ability to maintain the spinal segment in a neutral zone is important in maintaining overall stability and preventing spinal pain. Therefore, a preventive approach should be directed to the factors, such as, osseo-ligamentous system, muscular system, and the neuromuscular system. The aim of prevention of injury in the lumbar spinal system should, therefore, be to allow functioning without undue stress in these systems by means of effective coordination (Lawrence, Greene, Grauer, 2006, 726-735). Depending on the sporting activity, age of the participants, and level of competition, rates of injury to the nervous system and the types of nervous system injury vary. One of the unique qualities regarding sporting-related neurologic injuries is the uniform nature of injuries identified within particular individual sports. Common athletic injuries to the spine include strains, muscle spasms, compression fractures, avulsion fractures, and disc herniations, with strains being the most common. Strains can be caused by any low-grade force to the spine, including the sudden extension-flexion mechanism associated with whiplash injuries. These athletes typically present with paravertebral muscle spasm, limited range of motion, and a normal neurologic examination (Dalichau and Scheele, 2002, 64-69). Back injuries are very commonly encountered in practice when the tennis players are concerned. The case of the elite players is that they usually play many hours a week, and they often sustain left versus right strength imbalances that might lead to stance and posture problems. Most of the elite players have a dominant side; therefore, they would have a dominant trunk rotation movement (Rivara, 2003, 20-23). Same is applicable for the lower extremities, and they feel comfortable on a particular leg to balance and to move on. Consequently, there would be a dominant hip movement. Even though there are differences among these two sides, each player would be having core stability, and if they lose that due to some reason, these imbalances become prominent enough to cause low-back problems (Pool-Goudzwaard et al, 1998, 12-10). As has been elucidated earlier, many tennis shots and movements in the court would involve back extension and flexion, leading to stress on the musculature of the back. The preventive approach, therefore, must include development of sufficient strength and flexibility in the spine and hips, without which, the elite tennis player may tend to overload his back (Safran, 2001, 617-656). Panjabi introduced a spinal stability system that includes passive, active, and control subsystems. The passive subsystems involve the osteoarticular and ligamentous components, which provide restraint primarily in the end range of motion. The active subsystems are of great interest in the research and clinical fields for looking at the role of muscle and fascia and their ability to control the mechanical components of the spine segments. The control subsystems introduce neurological function as well as its effect and timing on motor control. Panjabi has put forth the concept of clinical instability. This is not instability that an orthopedist would have to treat surgically but a lack of segmental control of the lumbar spine. The ability to maintain the spinal segment in a neutral zone is important for maintaining overall stability and preventing spinal pain. Stability of most joints in the body is maintained by a combination of the different tissues including the osseo-ligamentous system, muscular system, and the neuromuscular system. The ability of the patient to maintain an efficient coordination between these systems will allow him or her to function without undue stress on other systems. Playing tennis at the elite level places the player at the risk of injury. Many injuries are common in Tennis as in other elite sports, but the very nature of the professional Tennis as a sports activity dictates some unique profile of injuries. These differences arise from differences in equipment, biomechanics, and physical demands. These are common causes of disabilities, sometimes leading to absence from practice and sports, leading to enormous socioeconomic consequences, and for this reason, it is important to develop effective measures for the prevention of spinal injuries that might result from tennis (Panjabi, 2003, 371-379). As mentioned earlier, there are three subsystems for spinal stability. The intervertebral joints of the lumbar spine require a co-contraction for stability. In normal stance, the lumbar segments are in an open-packed position because of the lack of passive restraint at this point in space. This point in space where lumbar segments have no passive restraints acting on them has been termed the neutral zone. and requires muscle contraction to stabilize. The lumbar vertebrae and pelvic girdle can be stabilized effectively by co-contracting the transverse abdominis and multifidus muscles. This technique may be valuable for two reasons. One, it will increase intra-abdominal pressure, thereby stabilizing the lumbar segments and, two, it may compress the sacroiliac joints (Roetert, McCormick, Brown et al., 1996, 15-20). Practitioners have been inundated for some time now regarding the importance of the core. The core of the body has been identified as the structures about the lumbo-pelvic-hip complex. Active and passive structures in this area provide dynamic and static stability to this area of the body, which provides an essential base for appendicular movement. Core stability is instantaneous and relies heavily on muscular capacity such as endurance and neuromuscular control (Richardson and Jull, 1995, 2-10). An intricate relationship between these factors provides core stability and allows for appropriate control of movement and positioning of the trunk over the pelvis and legs during activity, which, in turn, provides a stable base for extremity movement and efficient absorption of forces transmitted through the extremities during complex multi-joint activities. Recent literature supports the theory that recurrent, nonspecific lumbar spinal injury during sports is the result of inefficient neuromuscular control of the transverse abdominis muscle. The integrity of the muscle tissue is not faulty, but the way people who have LBP plan movements is not effective. The transverse abdominis muscle should become more active before the prime mover of any limb (Kibler, Press, Sciascia, 2006, 189-198). Essentially, the way a tennis player prepares for movement is at fault. In the presence of inappropriate and/or aberrant muscle activity caused by poor core stability, potentially detrimental body positions and neuromuscular adaptations may prevail as the person who has problems (Knudson and Blackwell, 2000, 321-324). Evidence from literature is sparse, mainly due to the fact the prospective candidates for participation in research are not available. But research has indicated that the most important basic preventive strategy would be to avoid overuse. Overuse may result from too much game, too frequent games, and too quick games played in frequent successions. Poor techniques and lack of conditioning training are the most important reasons behind this. For the elite player, who is expected to be a full-time professional, the play schedule is hectic enough to play most of the days. The only way to intervene in this schedule is to include appropriate conditioning programme to prevent injuries. Although the conditioning programmes are not definitive, the main aims of these programmes are to include the knowledge about the anatomy and physiology of the muscles and their movements (Hodges, 2001, 261-266). Flexibility Training: With the goal to achieve good range of motion in all principal joints, everyday stretching exercises of the relevant muscle groups must be performed. These would include the muscles of the calf, hamstrings, quadriceps, hip flexors, groin muscles, gluteal muscles, low back flexors, upper back extensor muscles, rotators of the trunk. The program must also involve general strength training. Since the elite players are already strong due to condition training, workout may be scheduled once a week year round with the goal of maintaining consistent general strength (Comerford and Mottram, 2001, 3-14). As mentioned earlier, core stability training is perhaps the most important step to prevent lumbar spinal problems. The players would thus be able to isolate the transverses abdominis muscle in order to perform the correct abdominal hollowing exercise. The goal of the core stability training is to maintain a neutral lumbar spinal position during various movements during the game. This may involve recruitment of transverses effectively along with the muscles that maintain stability of the trunk and the hips (Dekker et al. 2000, 651-666). Few examples of exercises that have been mentioned in the literature are based on recruitment of the transversus effectively along with the other trunk muscles. The player may be trained to lift one leg while lying on the back, lift one leg while standing, lean forward at the hips while standing, extending the leg behind while kneeling on all fours. The stabilizing exercises for the pelvis with the target to use and strengthen the gluteal muscles are also important. This can be accomplished by bridging exercises and hip extension movements. These exercises are directed towards gluteal recruitment over the back and training involving hamstring muscles. In this way, a graduated exercise programme can be implemented, and the elite players master the basic skills, dynamic exercise programmes may be instituted. These may comprise one-leg squat keeping the lumbar spine in the neutral with stable pelvis. As envisaged, this would help the player to maintain stability during game movements (Dekker et al., 2003, 1153-1157). The core stability skills must be transferred onto the court at the time of the event. For this to be achieved, some programmes contain cable rotation exercises using a pulley machine. In this machine, the player would mimic the forehand and the backhand movements while maintaining good posture as well as core stability through the rotation movement. Development of good core strength has other benefits too. During each contact phase, the preventive posture would be to maintain the pelvis at level and lifted up position. This would allow greater power from the legs to be converted into horizontal speed with the lowest risk of low back injuries. The next step in injury prevention in to develop core stabilization skills that can develop better functional strength. Core stabilization exercises involving recruitment of transversus, gluteus, and low back muscles would follow more advanced core-strength exercise programmes involving gluteal leg raises, back extensions on a Swiss ball, straight-legged dead lifts using a barbell, and the crunch type abdominal exercises (Kibler, 1990, 759-769). In summary, the posterior chain muscles of the lumbar spine comprise of the back and hip extensors. Since these are the muscles responsible for force production in the lumbar spinal area, these along with the deep multifidus, would stabilize the core during the movements of an elite tennis player in the court. The close proximity of the multifidus to the vertebral axis responsible for the lumbar extension cannot effectively produce the very necessary torque. Despite this fact, they are critical in preventing inadvertent injuries to the lumbar spine during high-power professional tennis since they impart the very necessary segmental vertebral stability to the spines in the lumbar region. They are also known to prevent shear forces by action across the disc and the segment of the vertebral column concerned. The torque producers of the hip are the gluteus maximus, adductor magnus, and the hamstrings. In this mechanism, the latissimus dorsi is also involved in that through its attachment to thoraco-lumbar fascia, its gets a corresponding attachment to the contralateral gluteus maximus. This acts functionally as a posterior oblique myofascial sling that attaches itself to the long dorsal sacroiliac joint ligament. During movements, these structures support the elite players with the explosive powerful locomotion. Moreover, the these structures along with the abdominal muscles provides universal stability to the lumbosacral spine. Elite tennis demands fast ballistic movements, and these exert extensive forces across the lumbar spine. Muscular protection is necessary to prevent shearing forces across the lumbar spine that could lead to injury and breakdown. These would, otherwise, lead to disc prolapse, degenerative disc disease of the lumbar spine, sprain in the facet joints, and all may result into nerve damage. Emphasized programmed exercises to strengthen posterior chain core strength, as evidenced in the literature would address the muscle imbalances encountered in these players. One such example may be a programme comprising of Romanian stiff-legged deadlifts, single-leg Romanian deadlifts, Powerlifting deadlifts, and back extension exercises. References Chandler T, Ellenbecker T, Roetert E., (1998). Sport-specific muscle strength imbalances in tennis. Strength Condition;20:7-10. Comerford MJ, Mottram SL. (2001). 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