– Written by Joani Essenmacher and Brianna Rosa, USA

INTRODUCTION

Tennis is a major global sport; 10.1 million viewers tuned in to watch the Australian Open in 2023¹ In the 2023 season, the Women’s Tennis Association (WTA) reached a new global audience record of more than 1 billion².  The ATP Tour (ATP is the global governing body of men’s professional tennis) has 71 events in 2024 on 5 different continents. The Hologic WTA Tour has over 70 WTA tournaments in 30 nations and regions, in addition to the four Grand Slam events.  Every year, many ATP and WTA professionals will also play in the Olympics, the Billie Jean King Cup and Davis Cup. Events are played on different court surfaces, including clay-, grass- and hard courts. Each court surface contributes to different stresses on the musculoskeletal system, and hence distinct types of injuries, which can be debilitating for a professional athlete. The aim of this article is to review the influence of different playing surfaces on injuries in professional tennis, with objectives to: (i) provide an overview of injury data (and trends); (ii) compare acute versus chronic injuries; (iii) describe common body parts and pathologies for each of the three playing surfaces. Many injuries in professional tennis are non-time loss complaints which the players continue to manage while competing. We also describe the main injuries on each playing surface, and recommendations on how to mitigate these injuries during preparation for each surface, as well as during competition. Lastly, we present a sample of a player’s daily schedule to illustrate a typical day in the competing WTA athlete with an injury.

COURT SURFACES

Depending on the tournament, tennis professionals play on different surfaces. The most common surfaces in tennis are hard, clay and grass courts. The change in court surfaces can affect the style of play, speed of play, ball response, and player biomechanics which in turn, contribute to different types of injuries or complaints for each surface.

The four Grand Slams are played on three different surfaces; the French Open on clay, the Wimbledon Championships on grass, while the US Open and Australian Open are both played on hard court. The most common surface on the ATP and WTA Tours is hard court, which is composed of acrylic surfaces over concrete or asphalt, and varies based on the paint (ratio of sand). It is rigid with reduced shock absorption, increased frictional resistance, and higher mean maximal force and peak pressure on the rearfoot. Clay court is made of crushed stone, gravel and bricks, and is considered the slowest of the three surfaces (using Court Pace Rating (CPR) ITF classification). Because pieces of the clay stick to the ball, the ball absorbs weight and moisture, becomes heavier, and looses speed. Effective (match) play time is 20-30% longer on clay courts than hard courts and requires a higher physiologic demand³. Clay courts have decreased frictional resistance and mean force in the foot is significantly lower on clay than hard courts⁴. Grass courts are natural grass on a sand-filled layer. It is considered the fastest surface with lower ball bounce and a shorter point duration. Players need to reach the ball more quickly on grass surfaces and the court may be slippery.

During the season, professional players switch between all three court surfaces within short time frames, which challenges their ability to adapt to the surface and perform without sustaining an injury.

INJURIES RELATED TO COURT SURFACE

Clay:

Upper limb repetitive overuse injuries due to longer rallies and heavier balls

Shoulder, wrist and elbow injuries develop from lack of endurance and strength/power of the scapular stabilizers

For the same reasons, players may complain of mid- and low back tightness or pain

Groin/adductor injuries are common due to overstretching with sliding, sudden stopping and change of direction

Grass:

Gluteal, quadriceps and hamstring tightness or muscle strains are common from overstretching from slipping on the grass

Athletes may experience low back injuries and tightness present due to reaching for the ball versus using hip and knee flexion

Anterior knee pain (patellofemoral pain syndrome and patellar tendinopathy) related to sudden stopping and low bounce

Achilles tendinopathy and posterior ankle injuries due to sliding and sudden stopping on the baseline

Wrist injuries/pain because of the increased volume of volleying

Hard:

Due to the compression and lack of shock absorption low back tightness and facet/muscle injuries

Knee injuries/anterior knee pain

Shin soreness (tibialis anterior, posterior tibialis)

Hot-spots and blisters are common in the foot, as well as arch pain/tightness, plantar fasciopathy

INJURY EPIDEMIOLOGY RESEARCH IN TENNIS

Incidence & Definitions

Injury incidence reported in tennis ranges from 0.04 to 3.0 injuries per 1000 playing hours in players of all ages⁵. Several studies examined injuries in tennis and reported different incidence, nature and severity of the various injuries. Variations are mainly related to research methodologies and definitions of injury⁶. In a 2009 consensus statement Consensus on epidemiological studies of medical conditions in tennis, it was suggested that match exposure should be defined as actual match play and recorded as incidence (number of injuries/1000 player hours)⁶. The number of days lost is considered the overall severity of a condition and is grouped according to the duration of time loss (slight = 0), minimal (1-3days), mild (4-7 days), moderate (8-28 days) and severe (>28 days-6 months) and long-term (>6 months)⁶. New guidelines in 2021 provided updates to the 2009 Consensus statement, including recommendations to define risk as either number of injuries per 1000 hours or 1000 games played.⁷ If this was not feasible, the authors recommended using injuries per 1000 sets or matches⁷. Acute-medical conditions are defined as resulting from a specific identifiable event (or a sudden onset of severe pain or disability). (e.g. ankle sprain, muscle tear) versus gradual-onset (non-acute) injuries, which are a medical condition that manifests with a gradual increase in the intensity of pain or disability, without a specific identifiable event (e.g. tendinopathy)⁶.

Recreational

In recreational players, acute injuries, such as ankle sprains, are more common in the lower extremity, while chronic overuse injuries, such as lateral epicondylosis, are more frequent in the upper extremity⁸. In contrast, high-level players had a greater incidence of shoulder pain⁸. Notedly, professional players generally sustain medial epicondylosis, as lateral epicondylosis is usually related to poor technique.

According to a study of 3656 recreational members of the Royal Netherlands Lawn Tennis Association, there is no link between injury rates and court surfaces among players who typically play on one particular court surface⁹. However, players who switch between multiple surfaces have a higher risk of overuse injuries than those who play mainly on one surface. Switching between playing surfaces may also increase the risk of injury among elite players. For example, the French Open and the Wimbledon Championships are held only about a month apart; interestingly 61% of injuries during the Wimbledon Championships were initially sustained prior to the tournament¹⁰.

Pro-circuits/juniors

In pro circuit events, women were more likely to experience an injury when playing on clay court surfaces, and they also experienced more injuries during the first half of the season. Injury rates for men often peaked during the qualifying months for Grand Slam competitions. Compared to women, men had a higher injury rate¹¹.

Professional (ATP, WTA)

There is a paucity of injury data in professional tennis. Using different models for exposure, injury data was compiled from the Australian Open, US Open, and Wimbledon. To date, there is no published data for the French Open (clay). Injury data was collected from the US Open from 1994 to 2009 and injury rate, classified by location and type of injury¹². Injury rates (determined based on the exposure of an athlete to a match event) were calculated as the ratio of injuries per 1000 match exposures (MEs). During the study period, acute injuries occurred more frequently than gradual-onset injuries, as medical assistance was sought for 76.2±19.6 total injuries and 43.8±11.8 acute injuries per year¹². The most common type of acute injury was muscle or tendon injuries. The rate of lower limb injuries was significantly higher than upper limb and trunk injuries (p<0.01). The most common sites of injury were the ankle, followed by the wrist, knee, foot/toe and shoulder/clavicle¹².

During the Australian Open from 2011-2016, epidemiological data was collected for sex, injury region, and type (and reported as frequencies per 10,000 game exposures)¹³. Muscle injuries were most frequent. High treatment frequencies were noted in both sexes for spine (including the cervical, thoracic and lumbar), trunk/abdominal, hip/groin and pelvis/gluteal areas. Female players experienced more injuries than male players (201.7 vs. 148.6)¹³. Shoulder, wrist, knee, and foot were the most prevalent injured areas among females, while in males thigh, knee, and ankle injuries were the most common. Notedly, over the 5-year period, stress fractures and treatment frequency for upper arm injuries increased more than twofold in both women and men.; as well as treatment frequency for upper arm injuries¹³.

Medical staff performed a retrospective observational cohort injury study at the Wimbledon Championships over 10 years (2003-2012)¹⁴. Although less scientifically robust, it is arguably better for reporting injury rates in professional tennis. Data were collected per 1000 sets. The overall injury rate for all players over the 10-year period was 20.7  per 1000 sets played and 700 injuries were sustained. The spine and trunk accounted for (approximately) 25% of injuries, upper limb 28%, and lower limb 50%. Similar to the Australian Open study, injury rates were higher for females (23.4 per 1000) than males (17.7 per 1000). Lumbar spine, shoulder, and knee injuries were the most common in both genders. Men appeared to sustain more groin, hip, ankle and heel injuries, while women sustained more wrist and foot injuries. Most injuries over the time period were muscle tear or strain or tendinitis/bursitis/enthesopathy/apophysitis. Over 6-year period, 48% injuries were traumatic and 52% overuse. During this time, 39% injuries were acute new occurrences while 61% were sustained prior to arrival¹⁴.

Using the official Association of Tennis Professionals (ATP) and Women’s Tennis Association (WTA) web pages, Okholm Kryger¹⁵ examined the reasons for retirements and withdrawals (excluding the 4 Grand Slams) from 2001-2012 on the ATP and WTA Tour. The main reasons for retirement(s) and withdrawal(s) were injuries. Women left primarily because of thigh injuries and were injured significantly more than men. Men left mainly because of back injuries. Women’s injury withdrawals were affected by the round of tournament. Playing surface only had an influence on the risk of lower back injury.

In comparison with recording data at only a single event, Dakic et al¹⁶ examined injury incidence rates in singles and doubles players during the 2015 WTA season. Thigh injuries were most common.  While mild thigh injuries were frequent, when injury type and location data were combined, both abdominal and thigh muscle strains commonly resulted in loss of time from competition¹⁶. Okholm Kryger et al¹⁵ also reported thigh injuries as the most frequently reported injury location for time loss from competition.

SUMMARY

Previous reviews on injury location have suggested that lower limb injuries are more prevalent (31–67%) than upper limb (20–49%) and trunk (3–21%) injuries across all levels of tennis^5,8. Injuries sustained by the WTA Tour players are consistent with other studies that lower limb injuries are most common. Top injuries in the last year were thigh muscle strains, ankle sprains, trunk/abdominal strains, groin/hip strains, shoulder tendinopathy, wrist/ankle/knee tendinopathy, and foot blisters and lacerations.  Although research has been conducted on injury incidence and prevalence in tennis, we do not have enough data to clearly correlate injury to surface type. A trend towards increased incidence of achilles tendonopathy, enthesopathy and plantar fasciitis has been observed on hard courts due to the decreased shock absorption, increased frictional resistance, and higher mean maximal force and peak pressure on the rearfoot as previously mentioned.

A wide range of injuries is evident from studies investigating injuries among professional athletes., likely as tennis players use most of their kinetic chain, characterised by intense movements with quick and repeated start/stops, lateral movements and directional changes during a match. Overall data suggest that male players in all studies had a lower injury rate; however, playing style and match duration are risk factors too. Indicative of the long season on different surfaces, many injuries occur prior to a tournament. For example, as mentioned earlier, at Wimbledon Championships, 61% of injuries were sustained prior to the event¹⁴. Interestingly,  many injuries are non-time loss complaints, which the players continue to manage while they continue to compete¹⁴. This is consistent with our findings in the WTA training room; players may be managing injuries sustained at another event or managing overuse and chronic injuries (e.g. patellar tendinopathy). Analysing time-loss injuries alone in literature (which some studies have done) does not give a true representation of injuries on the tour. Like Dakic¹⁶, we also find that abdominal and thigh muscle strains are common time-loss (from competition injuries).

Recent standardisation and consistency of injury and exposure data in tennis make future comparisons between studies more accurate. Some injuries are managed by the player’s own team, which is a limitation of some studies in elite athletes. Overall, this review suggests that further research in this elite-level population is warranted for researchers and clinicians to identify risk factors and develop evidence-based injury prevention strategies.

Preventative Strategies/Mitigation

Providing integrated care, the WTA Performance Health team uses a holistic injury management approach, that includes WTA Primary Health Care Providers (PHCPs), Mental Health Care Providers (MHCPs) and Massage Therapists. Medical advisors serve as consultants to athlete care and include the fields of cardiology, internal medicine, nutrition, orthopedics, podiatry, dermatology and psychology. Our sport sciences & medicine team blend “science and art”⁵ to provide comprehensive quality care to all WTA Tour athletes, including manual therapy, individual exercise programs, biomechanical services (orthotics, OTSA, bra fitting), massage therapy, mental health care, women’s health, health education, nutritional support and follow-up after or between events.

Skilled WTA Primary Health Care Providers (PHCPs) (with tennis-specific sports medicine and science knowledge and experience) provide day-to-day health care, on-court emergency care, and sport science services (e.g. biomechanical evaluations), while applying their knowledge of expectations and demands of an elite professional tennis player⁵. For example, if a WTA athlete has a shoulder injury, the complete kinetic chain is evaluated; besides the shoulder, the lumbopelvic region, lower extremity and foot/ankle complex will be examined. A key component of prevention and mitigation of injuries on different court surfaces is specificity of training and appropriate transition to a different surface. Given the athletes’ demanding travel schedule, this can be difficult! To educate players, the WTA provides a Physically Speaking topic posted in training rooms and on the Player Zone “Preparation for Court Surfaces Changes.” Table 1 summarizes strategies and education employed by the WTA Performance Health team.

Key Complaints: Hard, Clay, Grass

The WTA has developed several taping techniques to help prevent and manage injuries. Among these techniques is the unload tape, as shown in Figure 1. The unload tape is applied over the injured muscle by lifting and shortening the soft tissues towards the painful area, which helps minimize painful stretching during activity. Another common tape used is for hot spots or high friction areas. The WTA uses a combination of foam, gauze, and cover roll to reduce friction on these areas and prevent blisters from occurring.

Match Day Injury Management

Professional tennis players should find a balance between the demands of competition and the need to perform at their best while also staying healthy. To achieve this balance, it is important to manage any injury with a combination of physiotherapy, nutrition, hydration, massage therapy, and mental health and performance practices (as shown in Table 2). These different disciplines work together on-site to optimise physical readiness, mental resilience, and recovery strategies on match, practice, travel, and rest days. Table 2 demonstrates a sample match day schedule of a professional tennis player dealing with an injury during competition.

CONCLUSION

In this paper, we reviewed how the three different playing surfaces in tennis—grass, clay and hard court—influence injuries in professional tennis players. We emphasised comprehensive and integrated in-competition management strategies for the professional tennis player. More research is needed to allow researchers and clinicians to identify injury risk factors and develop better evidence-based injury prevention strategies.

Joani Essenmacher D.P.T., P.T., M.S., A.T.C.

Director, Sports Science and Medicine Education

WTA Tour

Brianna Rosa M.S., L.A.T., A.T.C.

Manager, Performance Health and PHCP

WTA Tour

Contact: JEssenmacher@wtatennis.com

References

1. https://www.statista.com/statistics/1454089/australian-open-viewership/#:~:text=During%20the%202024%20Australian%20Open,reach%20of%203.26%20million%20viewers.Accessed April 18, 2024.
2. https://www.wtatennis.com/news/3839503/wta-sets-unprecedented-record-with-1-billion-viewers. Accessed April 18, 2024.
3. Martin C, Prioux J. Tennis playing surfaces: effects on performance and injuries. J Med Sci Tennis. 2016;21(1):6-14.
4. Girard O, Eicher F, Fourchet F, Micallef JP, Millet GP. Effects of the playing surface on plantar pressures and potential injuries in tennis. Br J Sports Med. 2007 Nov;41(11):733-8. doi: 10.1136/bjsm.2007.036707. Epub 2007 Jun 12. PMID: 17566048; PMCID: PMC2465293.
5. Pluim BM, Miller S, Dines D, Renström PA, Windler G, Norris B, Stroia KA, Donaldson A, Martin K. Sport science and medicine in tennis. Br J Sports Med. 2007 Nov;41(11):703-4. doi: 10.1136/bjsm.2007.040865. PMID: 17957002; PMCID: PMC2465261. Accessed April 13, 2024    
6. Pluim BM, Fuller CW, Batt ME, Chase L, Hainline B, Miller S, Montalvan B, Renström P, Stroia KA, Weber K, Wood TO; Tennis Consensus Group. Consensus statement on epidemiological studies of medical conditions in tennis, April 2009. Clin J Sport Med. 2009 Nov;19(6):445-50. doi: 10.1097/JSM.0b013e3181be35e5. PMID: 19898070.
7. Verhagen E, Clarsen B, Capel-Davies J, Collins C, Derman W, de Winder D. Tennis-specific extension of the IOC consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020. Br J Sports Med. 2021. Jan;55(1):9-13.
8. Abrams GD, Renstrom PA, Safran MR. Epidemiology of musculoskeletal injury in the tennis player. Br J Sports Med. 2012 Jun;46(7):492-8. doi: 10.1136/bjsports-2012-091164. Epub 2012 May 25. PMID: 22554841.
9. Pluim BM, Clarsen B, Verhagen E. Injury rates in recreational tennis players do not differ between different playing surfaces. Br J Sports Med. 2018 May;52(9).
10. Fu MC, Ellenbecker TS, Renstrom PA, Windler GS, Dines DM. Epidemiology of injuries in tennis players. Curr Rev Musculoskelet Med. 2018 Mar;11(1):1-5. doi: 10.1007/s12178-018-9452-9. PMID: 29340975; PMCID: PMC5825333.
11. Hartwell MJ, Fong SM, Colvin AC. Withdrawals and retirements in professional tennis players. Sports Health. 2017 Mar/Apr;9(2):154-161. doi: 10.1177/1941738116680335. Epub 2016 Nov 23. PMID: 27879298; PMCID: PMC5349393.
12. Sell K, Hainline B, Yorio M, Kovacs M. Injury trend analysis from the US Open Tennis Championships between 1994 and 2009. Br J Sports Med. 2014 Apr;48(7):546-51. doi: 10.1136/bjsports-2012-091175. Epub 2012 Aug 25. PMID: 22923462.
13. Gescheit DT, Cormack SJ, Duffield R, Kovalchik S, Wood TO, Omizzolo M, Reid M. Injury epidemiology of tennis players at the 2011-2016 Australian Open Grand Slam. Br J Sports Med. 2017 Sep;51(17):1289-1294. doi: 10.1136/bjsports-2016-097283. Epub 2017 Jul 7. PMID: 28687543.
14. McCurdie I, Smith S, Bell PH, Batt ME. Tennis injury data from the Championships, Wimbledon, from 2003 to 2012. Br J Sports Med. 2017 Apr;51(7):607-611.   10.1136/bjsports-2015-095552. Epub 2016 Jan 11. PMID: 26755678; PMCID: PMC5384430.
15. Okholm Kryger K, Dor F, Guillaume M, et al. Medical reasons behind player departures from male and female professional tennis competitions. AJSM. 2015;43(1):34-40. doi:10.1177/0363546514552996
16. Dakic JG, Smith B, Gosling CM, Perraton LG. Musculoskeletal injury profiles in professional Women's Tennis Association players. Br J Sports Med. 2018 Jun;52(11):723-729. doi: 10.1136/bjsports-2017-097865. Epub 2017 Oct 26. PMID: 29074474.
17. Pogson C, Essenmacher J. Tennis injuries: the effects of court surface. Mt. St Mary’s University Capstone Project. 1995.
18. Kim, S. The intrinsic and extrinsic risk factors for injury in professional tennis players on clay and grass court: a systematic review. King’s College London, April 21, 2022. https://lbsm.co.uk/wp-content/uploads/2022/05/tennis-risk-factors.pdf. Accessed April 20, 2024.

Header image by cottonbro studio (Cropped)