Epidemiology of Injuries in National Collegiate Athletic Association Men's Tennis: 2014–2015 Through 2018–2019

Men's tennis exposure and injury data collected in the NCAA ISP during the 2014–2015 through 2018–2019 athletic seasons were analyzed in this study. The methods of the NCAA ISP have been reviewed and approved as an exempt study by the NCAA Research Review Board. Briefly, athletic trainers (ATs) at participating institutions contributed exposure and injury data using their clinical electronic medical record systems. A reportable injury was one that occurred due to participation in an organized intercollegiate practice or competition and required medical attention by a team certified AT or physician (regardless of TL). Exposures were defined as a school sanctioned event (scheduled team practices and competitions) and were reported by an AT, often because of coverage. Data from 6 (0.8%) participating programs in 2014–2015, 6 in 2015–2016 (0.8% of membership), 13 in 2016–2017 (1.7% of membership), 11 in 2017–2018 (1.5% of membership), and 33 in 2018–2019 (4.4% of membership) qualified for inclusion in analyses. Qualification criteria are detailed further in the methods.⁸ 

Injury counts and rates per 1000 AEs (in which 1 AE was defined as 1 athlete participating in 1 exposure event) were assessed across levels of event type (practice, competition), competition level (Division I, Division II, Division III), season segment (preseason, regular season, postseason), and TL or NTL. Weighted and unweighted rates were estimated, and results are presented in terms of unweighted rates due to low frequencies of injury observations across levels of certain covariates unless otherwise specified. Temporal trends in injury rates across the study period were evaluated using rate profile plots stratified on the aforementioned variables. Injury counts and proportions were examined by TL, body part injured, injury diagnosis, and activity at the time of injury. Injury rate ratios (IRRs) were used to evaluate differential injury rates across event types, competition levels, and season segments. IRRs with associated 95% confidence intervals (CIs) excluding 1.00 were considered statistically significant; all analyses were conducted using SAS (version 9.4; SAS Institute).

A total of 251 men's tennis injuries from 56 895 AEs were reported to the NCAA ISP during the 2014–2015 through 2018–2019 athletic seasons (rate = 4.41 per 1000 AEs). This equated to a national estimate of 15 583 injuries overall (Table 1). Overall, the competition injury rate was higher than the practice injury rate (IRR = 1.80; 95% CI = 1.39, 2.33). Competition injury rates varied throughout the study period with a dramatic decrease between years 2014–2015 and 2016–2017 followed by a sharp increase in 2017–2018 that leveled in 2018–2019 (Figure A). In contrast, practice injury rates have remained relatively stable across the study period (Figure A). The overall Division I injury rate (rate = 4.96 per 1000 AEs) was higher than Division II (rate = 4.20 per 1000 AEs) and Division III (rate = 3.57 per 1000 AEs) injury rates (Table 1); statistically significant differences were observed when comparing Division I with Division III rates (IRR = 1.39; 95% CI = 1.01, 1.91). Interestingly, practice injury rates across divisions were similar (Table 1); however, the Division I competition injury rate was significantly higher than Division II and Division III (IRR = 1.74; 95% CI = 1.02, 3.00; IRR = 1.92; 95% CI = 1.07, 3.44, respectively).

A total of 54 preseason injuries (national estimate: 3372), 190 regular season injuries (national estimate: 11 920), and 7 postseason injuries (national estimate: 291) were reported between 2014–2015 and 2018–2019 (Table 2). Preseason and regular season injury rates were similar (IRR = 1.30; 95% CI = 0.96, 1.76). Preseason and regular season injury rates differed between the 2014–2015 and 2016–2017 athletic seasons but became more similar during the 2017–2018 and 2018–2019 athletic seasons (Figure B). Postseason rates were not calculated due to the low frequency of reported postseason injuries.

Approximately one-third (34.3%) of all reported injuries resulted in TL of greater than or equal to 1 day (TL was not reported in ∼26% of all reported injuries). TL injuries accounted for comparable proportions of reported competition (33.7%) and practice (34.6%) injuries. Rates of competition-related TL injuries sharply decreased between 2014–2015 and 2016–2017 (most sharply during the first year), followed by a threefold increase during the following year, and a subsequent decrease thereafter. (Figure C). Practice-related TL injuries trended downward across the 5-year study period (Figure C). TL injuries were found to account for 34% of Division I injuries (NTL: 49%), 23% of Division II injuries (NTL: 25%), and 48% of Division III injuries (NTL: 35%). Across season segment, TL injuries accounted for 33% of injuries in the preseason (NTL: 33%) and 33% in the regular season (NTL: 43%).

Trunk (15.1%) and shoulder (13.2%) injuries accounted for the largest proportions of all injuries reported during the study period. Shoulder injuries accounted for larger proportions of practice injuries (14.8%) than competition injuries (10.1%). In contrast, injury to the head or face and hip or groin accounted for larger proportions of competition injuries (5.6% and 11.2%, respectively) than practice injuries (3.1% and 7.4%, respectively). Other injuries sustained during the study period were distributed comparably in practices and competitions across the hand or wrist, trunk, thigh, knee, lower leg, and ankle (Table 3). Across both event types, 69.4% of injuries were attributed to either noncontact (35.1%) or overuse (34.3%); and noncontact and overuse injuries accounted for comparable proportions of practice- and competition-related injuries (Table 3). Contact injuries (player, surface, ball, racket, fencing, and net contact) accounted for 15.5% of all injuries. Surface contact injuries accounted for 10.4% of injuries overall and were more prevalently reported among practice injuries (11.1%) than competition injuries (9%).

Overall, most men's tennis injuries reported between 2014–2015 and 2018–2019 were strains (27.9%), inflammatory conditions (22.7%), and sprains (11.6%). Sprains and inflammatory conditions accounted for comparable proportions of practice- and competition-related injuries. Strains accounted for slightly higher proportions of competition injuries (30.3%) than practice injuries (26.5%). The most reported injuries during the study period were partial or complete lateral ligament complex tears of the ankle (8.4%), followed by partial or complete adductor (groin) tears (4.0%), and partial or complete hamstring tears (3.6%).

Most injuries in men's tennis between 2014–2015 and 2018–2019 occurred during general play (45%). Serving (12%) and forehand shots (6.4%) also accounted for notable proportions of all reported injuries. General play during competition resulted in greater proportions of injury (56.2%) than general play activities during practice (38.9%). Serving and forehand shots accounted for similar proportions of practice and competition injuries (Table 4).

We aimed to describe the epidemiology of tennis-related injuries among NCAA men's tennis players during the 2014–2015 through 2018–2019 academic years. Examining event type differences, we observed a higher rate of competition injuries than practice injuries. Division I competition injury rates were significantly higher than Division II or III competition injury rates. The results of our study contrast with existing literature in this population. Although the overall (inclusive of both TL and NTL injuries) practice injury rate observed in our study was comparable with previous reports (TL and NTL injuries from 2009–2010 to 2014–2015), the overall (inclusive of both TL and NTL injuries) competition injury rate was markedly higher than previously observed.⁷  It is difficult to contextualize the differences in injury rates observed across NCAA divisions given the dearth of existing empirical evidence related to this topic in previous reports.⁷  Authors of future studies should consider investigating differential injury incidence in NCAA men's tennis across divisions. In both previous and present studies, injury counts remained low across a 5-year period, which may be resultant of a small number of participating programs, which is limited in its representativeness of all NCAA men's tennis programs. It should be noted that estimates from the latter years of the study may be more indicative of injury burden in this population given the higher number of schools participating in the ISP during the latter years (2017–2018 to 2018–2019) of the study. NCAA ISP recruitment strategies have evolved over time, and the improvements in participation reflect the success of recently employed recruitment strategies (for instance, support and communication from the NCAA Sport Science Institute). Despite this increase in the latter years of the present study, low participation and its associated implications with regard to generalizability of findings are important limitations to note while interpreting the results of the present study. Yearly practice injury rates were stable throughout the study period, whereas competition injury rates varied considerably. Tennis competitions are unique, as a player can participate in multiple events (singles, doubles, or both) for varying amounts of time. Competition injury rates presented here may not be sufficiently sensitive to these nuances of NCAA tennis as a given exposure event (used in the estimate of an AE) may consolidate these exposures, does not capture variations in match duration, and is also based on AT discretion. While the benefits of having standardized measurements of exposures within the NCAA ISP allows for greater interpretation across and between sports, additional variables may need to be collected to capture competition exposures most accurately in tennis. Further consideration of this limitation as well as improvements in definitional clarity of tennis competition exposures is warranted to better describe at-risk exposure time within the sport and more precisely estimate injury incidence. When examining injury rates by season segment, although more injuries were reported during the regular season, the regular and preseason injury rates were similar. This observation differed from previous NCAA men's tennis injury surveillence.⁷  Tennis participation (in particular, formal training), unlike other NCAA sports, is not regimented by season. Players can and often use a vast network of privately owned facilities and publicly owned courts.¹  Therefore, exposure classification by season segment, albeit a corollary of NCAA schedule structures, may be limited in this context.³  Overall, TL injuries accounted for approximately one-third of all reported injuries, a decrease from previous study of this population.⁷  This trend was consistent across both practice and competition. Interestingly, NTL injuries were found to account for close to 50% of Division I injuries in contrast to 25% of Division II and 35% of Division III injuries. These differences across divisions may be multifactorial in nature and resultant of variations in AT staffing and off-season training patterns.^1,9  However, it is important to note that approximately 26% of all injuries reported did not include TL information. As such, the prevalence of TL injuries may be higher than what is estimated here. More robust collection of tennis injuries with special attention to NTL injury characteristics will be critical in improving the health care provided for NCAA men's tennis participants and therefore should be a focus of future studies. Interestingly, overuse and noncontact injuries accounted for approximately 70% of all reported injuries. Juxtaposed with a low TL prevalence, this should be further examined to better explain both the nature of TL and management of injuries within men's tennis.

The most common injury diagnoses reported in NCAA men's tennis during 2014–2015 through 2018–2019 were strains, inflammatory conditions, and sprains. These observations closely resemble previous studies of this population.⁷  While strains were more common in competition, inflammatory conditions and sprains accounted for comparable proportions of practice and competition injuries in the present study. Lower extremity injuries (48%) were more prevalent among all reported injuries than upper extremity injuries (29%). Trunk injuries alone accounted for 15% of all injuries and appear to be prevalent across tennis groups, accounting for 3% to 22% of all tennis injuries.^10–12  Injury to the shoulder was the next most common site, followed by the ankle. The prevalence of injury to the shoulder and trunk, as well as the prevalence of serving and forehand activities associated with injury, is of clinical relevance. Authors of previous studies of athlete mechanics during tennis serving and forehand motions have shown a close relationship between the shoulder and trunk.^13,14  Given that approximately one-third of tennis injury mechanisms were associated with overuse pathologies, when coupled with the prevalence of trunk injuries in this population, it may be reasonable to suggest that injury to the trunk may cause disruptions in the kinetic chain, predisposing tennis athletes to other injuries in the upper and lower extremity.¹⁵  Targeted, small-scale investigation of the relationship between overuse mechanisms and the kinetic chain may be an important avenue for further investigation given the pattern of injury observed to be associated with NCAA men's tennis athletes.

The most common specific injuries reported were partial or complete lateral ligament complex tears of the ankle, partial or complete adductor (groin) tears, and partial or complete hamstring tears. Lateral ligament complex tear of the ankle has been previously reported as the most prevalent injury in this population, though it was followed by rotator cuff strains and wrists sprains.⁷  This difference in specific injury reporting may be partially attributable to participation levels in the NCAA ISP among men's tennis programs, both throughout the present study and in previous studies. Low and inconsistent participation in the surveillance program has resulted in unstable injury trends. Therefore, examinations of commonly observed injuries among NCAA men's tennis athletes are important avenues for further research. Most injuries occurred during general play and were attributable to noncontact and overuse mechanisms. Given that the ankle, groin, and hamstring were the most prevalently injured body parts, it could be surmised that these injuries may also be occurring during general play and do not involve contact. Intervention strategies that offer a protective effect against noncontact injuries, such as eccentric training, neuromuscular control, and prophylactic bracing, may be indicated, given the success of these interventions in other sports that report a high prevalence of lower extremity injuries.^16–18  Notably, the NCAA ISP does not capture preventative interventions, and therefore, this may also serve as an important avenue for future research.

Continued monitoring of NCAA men's tennis injuries is critical to maintain the health of these athletes as well as the larger population of tennis players throughout the global community. Increased and stable participation in injury surveillance will be necessary to produce consistent observations of specific injuries. The findings of the present study and continued observations will allow for more targeted studies to be developed and implemented to better understand and address the etiology of injuries sustained in NCAA men's tennis.

The NCAA Injury Surveillance Program was funded by the NCAA. The Datalys Center is an independent nonprofit organization that manages the operations of the NCAA ISP. The content of this report is solely the responsibility of the authors and does not necessarily represent the official views of the funding organization. We thank the many ATs who have volunteered their time and efforts to submit data to the NCAA-ISP. Their efforts are greatly appreciated and have had a tremendously positive effect on the safety of collegiate student-athletes.