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Slide 2 Epidemiologic studies of tennis injuries Presented by: Rahman Sheikhhoseini PHD Candidates in Sport Injuries and corrective Exercises Tehran University Oct-2012 2 Slide 3 Introduction Truly a global sport, with tens of millions of yearly participants worldwide. Over 200 nations having an association with the International Tennis Federation. Reintroduced as a full medal sport beginning with the 1988 Summer Olympic Games in Seoul, South Korea (BJSM). The most common types of injury in tennis players of all ages are muscle and ligament strains or sprains secondary to overuse (MSK). In high-level players under 18 years of age, injury rates have been estimated to be anywhere from 2 to 20 injuries per 1000 h of tennis played Pluim et al, in a comprehensive meta-analysis across all player levels, reported tennis-injury incidence as ranging from 0.04 to 3.0 injuries per 1000 h played 3 Abrams 2012 Slide 4 INJURY LOCATION AND CHRONICITY Data show that most tennis injuries occur in the lower extremity (31%67%), followed by the upper extremity (20%49%) and lastly, the trunk (3% 21%). The most frequently injured parts of the lower extremity were the ankle and thigh, with ankle sprains being the most common specifi c injury. Upper extremity injuries most commonly involved the elbow and shoulder, with lateral epicondylitis being prevalent. 4 Abrams 2012 Slide 5 INJURY LOCATION AND CHRONICITY Acute injuries commonly occur in the lower extremity while chronic injuries most often manifest themselves in the upper extremity and trunk. In a 6-year injury-surveillance study, Boys National Championship, the prevalence of injury was 21.1%, with the back being the most common anatomic site of injury (3.4%), followed by the thigh, shoulder and ankle The rate of acute injures to the lower extremity, however, was nearly twice that of upper extremity and trunk, with acute ankle injuries demonstrating a prevalence of 2.4% Injuries in the younger players are usually not long-standing, and the overuse (chronic) problems seen in the older players, such as patellar tendinosis and tennis elbow, are less common in younger players 5 Abrams 2012 Slide 6 6 Slide 7 In conclusion: Age is a dominant factor the incidence rate was much higher for the over 35 age group. Gruchow suggests that it is a "degenerative disease". 7 Slide 8 In their study too: A questionnaire was constructed after discussion with players (interview) Men's teams in two tennis leagues (Division 1 and 2) in a large conurbation were surveyed. The total number of players surveyed was 74 of which 26 reported that they suffered or had suffered from tennis elbow. 8 Slide 9 In conclusion: The incidence rate is high, and the severity of the injury is a serious problem to local league tennis players. 9 Slide 10 Injury surveillance at the USTA Boys Tennis Championship: A 6-yr study Hutchinson MR, Laprade RF, Burnett QM, Moss R, Terpstra J Med & Sci in Spor & Exer, 1995,826-830 Subjects: USTA Boys Tennis Championship from 1986-1988, 1990-1992. Definition: All injuries that required physical or medical assistance Athletes were evaluated and injuries documented by an athletic trainer and referred to the tournament physician if needed. The court surface was Dynacourt Each injuries was classified as either recurrent or new. Prevalence was defined as the number of new and recurrent injuries that required medical evaluation or treatment. The injuries were classified to anatomic regions: upper & lower Exts and trunk. Injury subtypes (9): strain, sprain, contusion, abrasion, laceration, fracture, dislocation or subluxation, inflammation and miscellaneous. Specific injuries with eponyms associated with tennis were also recorded (tennis: shoulder, elbow, leg, toe). 10 Slide 11 Statistical analysis Bonferroni fix for simultaneous inference: to compare the incidence and prevalence of lower extremity injuries to that of upper extremity and central region. Contingency task analysis for independence (Chi square) Simple linear regressions: to assess trends in incidence and prevalence of injuries over the years as well as the actual number of athletes sustaining injuries. Year: independent variable Number of injuries or injured athletes: dependent variable 11 Slide 12 Results 12 Slide 13 13 Slide 14 The incidence and prevalence of lower extremity injuries was approximately twice that of upper extremity injuries and the difference was statistically significant but there were no significant difference between upper extremity and central injuries. Injury trends during the years studied (NS) 14 Slide 15 In Review: Injuries to the back, neck, and groin occur at a number roughly equal to that of upper extremity problems (shoulder, elbow and wrist). Overall, leg injuries (hamstring, knee and ankle) occur approximately twice as often as upper extremity injuries. The most common types of injury in young tennis players are overuse injuries. 15 Slide 16 16 Slide 17 Injuries with tennis eponyms such as tennis elbow, tennis leg, tennis shoulder and tennis toe are less commonly seen in the young tennis player. 17 Slide 18 Summary The shoulder is the most commonly affected part of the upper extremity. In contrast to older player with rotator cuff impingement and degenerative changes (even possibly a tear), the young players symptoms are more commonly secondary to instability of the glenohumeral joint. Traction apophysitis of the shoulder is similar to Osgood- Schlatters disease of the knee, at the insertion of the supraspinatus muscle into the greater tuberosity. Slipped capital humeral epiphysis occurs secondary to shear and distraction caused by rotational forces about the shoulder Tennis shoulder refers to a drooping internally rotated shoulder caused by long term overhead arm use contributing to generalised laxity of the shoulder capsule and musculature. Elbow: Both lateral epicondylitis (tennis elbow) and medial epicondylitis have been described in young tennis players. Tendinitis of the wrist: Wrist extensors are most frequently involved but flexor tendons may be involved as well. 18 Slide 19 Participants: In 2001, all the official junior tournaments of the Brazilian Tennis Confederation were catalogued to take part in this study In total, 13 tournaments, 2,307 games, 4,602 sets and 40,576 games were played, in male and female categories, with ages ranging from 10 to 18 years. A total of 258 athletes participated in this circuit 19 Slide 20 Methods The medical staff consisted of one doctor and two physiotherapists 151 (58.1% of all athletes) sought medical assistance: 105 males (69.5%) males and 46 females (30.5%) The medical questionnaire included: tournament, date, club, city, state, age, name, lesion, assistance on court or out-clinic and whether or not the player retired. tournament, date, club, city, state, age, name, injury, assistance on-court or out-clinic, and whether or not the player retired. medical assistance any consultation and/or treatment given to an athlete during a tournament on-site. No hospital care was required for athletes after medical consultation. The tournament medical department was the only place for medical consultations. 20 Slide 21 Statistical analysis Descriptive analyses: absolute and relative frequency (%) for qualitative. The incidence of assistance per match was calculated for each age category by dividing the number of injuries by the number of matches during the season. The same evaluation was applied for incidence of assistance per set and game. 21 Slide 22 Results 185 medical evaluations were performed on 151 tennis players. Medical assistance was provided on court 83 times (29.6%), at the medical department 185 times (66.1%), and in both locations (due to the same clinical complaint) on 12 occasions (4.3%). The 151 athletes received 1 to 6 medical evaluations during tournaments, the mean being 1.8 evaluations per athlete. 22 Slide 23 23 Slide 24 24 Slide 25 Conclusion We believe that older athletes have been exposed to a greater load of training and games since, at this age, many athletes take part in national tournaments, aiming for a professional career (or are currently participating in professional tournaments). 25 Slide 26 26 Slide 27 A systematic search of published reports Articles published since 1966. The following electronic databases were explored: Pubmed (from 1966 to October 2005), Embase (from 1989 to October 2005), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1982 to October 2005). search terms: injury, injuries, prevalence, incidence, incidence density, proportion, distribution, population, aetiology, etiology, mechanism, risk factor, risk factors, prevention and intervention. These terms were combined with tennis. 27 Slide 28 Methodology Inclusion criteria: they must contain data on tennis injuries; they must investigate the frequency of tennis injuries, the aetiology (for example, risk factors) of tennis injuries, the efficacy of prevention strategies, or a combination of these purposes; and they must have been published in English, German, or Dutch. Exclusion criteria: studies focusing on treatment and literature reviews. Studies classification: case reports, laboratory studies, descriptive epidemiological studies, analytic epidemiological studies, or intervention/prevention trials. In the Pubmed, Embase, and Cinahl databases resulted in, respectively, 1368, 1617, and 2460 potentially relevant hits The titles and abstracts were read and, if considered relevant, selected by two persons (BMP and JBS). 39 case reports, 49 laboratory studies, 28 descriptive epidemiological studies, three analytic epidemiological studies, and no intervention study 28 Slide 29 29 Slide 30 30 Slide 31 31 Slide 32 Results Injury incidence Injury incidence varied from 0.05 to 2.9 injuries per player per year. Per hour of play, the reported incidence varied from 0.04 injuries/1000 hours to 3.0 injuries/1000 hours. Incidence and prevalence rates for tennis elbow were quite high, with reported incidence varying from 9% to 35% and prevalence varying from 14% to 41%. Injury type Four of six studies reported more acute than chronic injuries. Most acute injuries occurred in the lower extremities Most chronic injuries were located in the upper extremities. Injuries to the trunk comprised 5% to 25% of all injuries. 32 Slide 33 Results Gender differences Lanese RR 1990. 1.6 injuries per 1000 hours were recorded for male tennis players versus 1.0 injury per 1000 hours in female (p=0.37). Sallis et al 2001, 1822 year old tennis players, The incidence was 0.46 injuries per male player per year and 0.42 injuries per female player per year.(NS) Hutchinson et al 1995, no significant difference in the overall rate of injury Winge et al 1989, found a higher injury rate in men (2.7 injuries per 1000 hours) than in women (1.1 injuries per 1000 hours). (P Injury definition and classification The definition of an injury was when the injury made it impossible for the tennis player to participate fully in regular tennis training or matches during at least one occasion, which is referred to as a time-loss injury. Recurrence: an injury of the same type and at the same site that occurred within 12 months after the index injury. Injury severity: the number of days from the date of injury to the date of returning to full participation in training or match. (Minimal = 13 days, mild = 47 days, moderate = 828 days, and severe = >28 days, end of career) Location of injury, type of injury and the diagnosis were based on the Orchard Sports Injury Classification System (OSICS). 56 Slide 57 Statistical analysis Descriptive statistics To compare Boys and Girls, the MannWhitney U Test was used for continuous variables and the Chi square test was used for categorical variables. Injury incidence was calculated as the number of injuries per 1000 h exposure for tennis. A 95% CI for the incidence was calculated with the formula I 1.96*I/R (I = incidence rate, R = total time at risk). All data were tested at a statistical significance level of 5% (P\0.05). 57 Slide 58 Results Twelve players sustained three or more injuries during the 2-year study period. Seventy-six percent (n = 76) of the injuries occurred during practice and 24% during match. 30% of the players did not sustain any injury 45% did not sustain any lower extremity injury 65% did not sustain any upper extremity injury 75% did not sustain any trunk injury. There were no significant gender differences in terms of injury distribution. 58 Slide 59 Results 59 Slide 60 Results 60 Slide 61 Results 61 Slide 62 Results 62 Slide 63 63 Slide 64 64 Slide 65 Main Results Tennis elbow The overall incidence of lateral epicondylitis has been reported to be anywhere from 35% to 51% The rate of lateral epicondylitis is lower in those with two-handed backhands The development of lateral epicondylitis is likely more related to improper technique. Shoulder The percentage of tennis players at all levels with shoulder injuries in these studies ranged from 4% to 17%. 33% of the tennis players had radiographic signs of degenerative changes in the glenohumeral joint of their dominant arm versus only 11% of matched controls. 65 Slide 66 PLAYER-SPECIFIC RISK FACTORS Age and sex Age: There was no significant correlation for tennis players across a variety of skill levels. rate of injury between men and women: the literature is fairly clear that there are no significant differences. Volume of play Volume of play is positively correlated with an increased injury rate. Skill level This study did not fi nd any signifi cant differences in rate of injury for multiple comparisons across a variety of skill levels. Although professional tennis players have improved technique and therefore a theoretically decreased risk of injury, their increased volume of play as compared with the nonprofessional may account for the similarity in injury rates between the two groups. 66 Slide 67 PLAYER-SPECIFIC RISK FACTORS Racquet grip position Ulnar-sided injuries (extensor carpi ulnaris tendonitis and triangular fibrocartilage complex pathology) were significantly associated with western or semiwestern grips while radial-sided injuries (flexor carpi radialis tendonitis, DeQuervians tendinopathy and intersection syndrome) were more common in players with the eastern grip. Racquet properties Hennig et al showed that between different racket properties, increased racket head size as well as a higher resonance frequency of the racket was found to reduce arm vibration. There have been no studies, however, to determine the effect of arm vibration on injury rate or severity COURT SURFACE The RR of receiving treatment while playing on hard court as compared with grass was 0.8 (grass had a higher risk) while the RR between hard court and clay was 2.3 times (hard court had a higher risk). Risk of injury is lower on clay courts. 67 Slide 68 Thanks for your attention 68