https://orcid.org/0000-0002-7069-5798
Figures
Abstract
Tennis is one of the most practiced sports in the world and with high injury rates across professional players and effective strategies to return to sport after an injury are necessary. Thus, this systematic review aims to assess and identify the most effective and evidence-based protocols developed during the return to play process in tennis players. The search was conducted using Web of Science, PubMed, and Scopus electronic databases. Studies that report a structure training program after suffering an injury in tennis players published before October 12, 2023, were identified. A total of 1164 studies were identified, after removal of duplicates and assess full text for eligibility 5 studies were included in the systematic review. RTP (return-to-play process) should be divided in three phases. Firstly, training should be focused on restoring ROM through mobility exercises, the inclusion of technical training are also available. Following, prioritize reaching pre-injury strength levels, integrating more technical training increasing hitting velocity. Finally, include serve technique while gradually increasing velocity. Trainers and coaching staff professionals’ needs consider that the duration and progression of RTP should be tailored to the individual characteristics of each player.
Citation: Martín-Castellanos A, Barba-Ruiz M, Herrera-Peco I, Amor-Salamanca MS, Rodríguez-González EM, Hermosilla-Perona F (2025) A systematic review of the best-practice return to play programs in tennis players. PLoS ONE 20(3): e0317877. https://doi.org/10.1371/journal.pone.0317877
Editor: Emiliano Cè, Università degli Studi di Milano: Universita degli Studi di Milano, ITALY
Received: October 3, 2024; Accepted: January 7, 2025; Published: March 19, 2025
Copyright: © 2025 Martín-Castellanos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This publication was funded by the XVIII call for aid for the development of UAX-FUAX research projects (awarded to FHP). The funders had no involvement in the study design, data collection and analysis, decision to publish, or preparation of the study.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Tennis, recognized as one of the world’s most popular sports, owes its universal appeal with a mix of aerobic and anaerobic elements that cater to individuals of all ages and skill levels [1]. At the competitive level, tennis unveils a dynamic movements marked by the exchange of strokes and serves. Nevertheless, the sport’s demanding physical requirements could result in a risk of various musculoskeletal injuries for athletes [2]. While the specific occurrence of injuries varies based on factors like age, gender, and experience, studies encompassing the tennis community have shown that injury rates can range from 0.05 to 2.9 injuries per player annually [2]. Recent research on professional tennis competitions has revealed that injuries account for more than half of the withdrawals from both men’s and women’s events [3–5]. This prevalence of injuries has been analysed by numerous investigating the influence of tennis mechanics on the characteristics of different musculoskeletal injuries [6]. Descriptive epidemiological studies have indicated that injuries occur most frequently in the lower extremity, followed by the upper extremity, and lastly, the trunk [2,3,7]. However, lower extremity injuries in tennis are mostly acute and primarily result from trauma, while upper extremity injuries are predominantly chronic and stem from excessive and repetitive use [6].
To restore athletes to their preinjury performance levels coaches and physical trainers aid in attaining various physical function objectives. These include the restoration of complete range of motion, enhancement of strength, endurance, and power, as well as the reacquisition of dynamic stabilization, neuromuscular control, and sport-specific skills [2,8]. The selection of treatments and exercises is optional, with a focus on tailoring the rehabilitation plan to address an athlete’s specific needs, capabilities, and objectives play a pivotal role in the RTP (return-to-play process) [9].
The efficiency of the RTP often involves a combination of cardiovascular fitness, strength and flexibility exercises, as well as sport-specific drills to rebuild muscle coordination and enhance overall performance [10,11]. Efficient return to play training not only accelerates the recovery timeline but also reduces the risk of re-injury [12]. A well-structured program considers the individual player’s needs, injury history and the demands of the sport [10]. It is crucial to strike a balance between intensity and gradual progression to avoid overexertion and setbacks. A well-executed program not only facilitates a swift return to the court but also contributes to the long-term success and well-being of the athlete [13].
Nowadays, the scientific knowledge presents a substantial gap in our understanding of the dynamics and factors that influence an athlete’s safe and effective return to competitive tennis post-injury. The inadequacy of well-documented, evidence-based research restricts our ability to establish refined, effective, and tailored training programs for athletes and coaches, impede the refinement and standardization of RTP protocols and potentially prolonging recovery timelines and the susceptibility to reinjury. In this sense, a review of the training strategies developed to provide a safe recovery and effective return to competitive tennis post-injury has become an essential aspect that should be developed. Thus, the aim of this systematic review was to assess and identify the most effective and evidence-based protocols developed during the return to play process in tennis players.
Methods
Search strategy
The current systematic review was conducted following the guidelines provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [14]. A comprehensive search of three online databases (PubMed, Scopus, Web of Science) was undertaken by two independent reviewers. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database.
Title, abstract and keyword fields were searched using the following search strategy: tennis AND injury OR injuries AND “return to play” AND “training program” OR “conditioning program”.
Eligibility criteria
Studies were selected according to the inclusion and exclusion criteria established. Firstly, the inclusion criteria follow during the screening of the articles were: (i) articles published in English language, (ii) experimental research and case studies. Secondly, articles were retracted from the first search according to the following exclusions criteria: (i) publications that do not qualify as original articles, case studies, or reviews, (ii) articles focused on other sports, (iii) articles focused on other racquet sports, (iv) participants older than 45 years old and younger than 13 years old, (v) articles not focusing on structured training programs for return-to-play in injured tennis players.
Study selection
Searches were limited to articles written in English language. Two researchers performed independently October 12, 2023, the identification, screening, eligibility, and inclusion of studies, with disagreement settled by a third researcher. Where abstracts suggested that papers were potentially suitable, the full-text versions were obtained and included in the review if they were found to fulfil the selection criteria. Reference lists of included papers and known published systematic reviews were hand searched to ensure the inclusion of all the available published evidence.
Identification of studies
Our initial search identified a total of 1164 studies (see Fig 1 Flow diagram). The reference list of selected manuscripts was also examined for other potentially eligible manuscripts. After removal of duplicates and elimination of papers based on title and abstract screening, 348 manuscripts remained, 48 was assess full text for eligibility. Finally, 5 studies were included in the systematic review. The studies that did not match the eligibility criteria based on full-text screening were discarded for one or more of the following reasons: (i) articles not oriented in return to play process, (ii) articles focused on other sports, (iii) articles which do not provide details of the training program and (iv) articles written in non-English language.
Data extraction
Two of the authors independently extracted characteristics of training protocols and results using a standardized form. Data extracted from all the eligible studies were injury type, main exercise classification, complementary exercise, recommended drills, exercise program. Based on the analysis of the contents of the reviewed publications and considering the RTP processes carried out in other sporting environments, the data were organised in 3 different phases: (i) Return to participation, (ii) Return to sport and (iii) Return to performance [15]. These phases were designed as a general guideline for applying rehabilitation and training across different sports. Typically, a continuum is followed that includes: (i) a gradual onset of rehabilitation and training, (ii) progression towards return to sport, and (iii) a goal of achieving performance levels comparable to pre-injury levels.
Assessment of methodological quality and risk of bias
Two independent reviewers analysed the quality of included studies using the modified Newcastle-Ottawa Quality Assessment Scale (NOS) and Oxford Levels of Evidence (Table 1) [16]. The Newcastle Ottawa scale [17] for cohort and case–control studies have been adapted to case report studies by removing items that relate to comparability and adjustment (which are not relevant to non-comparative studies) and retained items that focused on selection, representativeness of cases and ascertainment of outcomes and exposure. This tool was applied in several published systematic reviews with good inter-rater agreement [18,19]. Newcastle Ottawa scale modifications converge into eight items that can be categorised into four domains: selection, ascertainment, causality and reporting [20]. Oxford Level of Evidence scores range from 1a to 5, with 1a a systematic review of high-quality randomized controlled trials, and 5 an expert opinion [16].
Results
Participants
The included studies presented athletes with a mean age of 19.66 years and a standard deviation of 4.19 years. Only the level of two subjects was reported, indicating that they competed at a semi-professional level. The studies primarily focused on return-to-play protocols for shoulder injuries, with interventions targeting rotator cuff, acromioclavicular, and glenohumeral joint issues emerging as the most frequent. The times from operation to RTP process were equally disparate, ranging from 10 weeks postoperatively to 6 months.
Stages of intervention
Return to participation.
The athlete’s first approach during the first two weeks could be placed in this phase. Exercise recommendations were geared towards mobility and technical drills [21–25]. Mobility work generally involved the shoulder joint [21,24], and technical development focused on simple technical tasks throughout the week, mainly forehand and backhand groundstrokes [22,23,25]. The number of repetitions per set starts at around 10 [22,25], increasing throughout the week to as many as thirty for some strokes. Supplementary strength-based exercise guidelines are found,[21,24] although this is not the main objective, they are performed at low intensity (<6/10 RPE (Rate of perceived execution). Some considerations on hitting can be found depending on the location of the injury [21], as shown in the notes to Table 2.
Return to sport.
In this phase, which covers the period from the 3rd week to the 6th week, the orientations towards exercise are eminently technical, supported by contents related to mobility and strength, being complementary aspects (Table 3).
Regarding the recommended technical exercises, the number of repetitions per exercise should be increased in the previously included strokes (forehand and backhand) [22,23,25]. The serve also could be included in this stage [22,23,25], however, some indicators should be considered, as: at the beginning, serve must be executed with ranges of less than 50% of the athlete’s strength or at less than 25% of the athlete’s pre-injury speed, to increase the power week by week [22,23].
Similarly, from the third week onwards, volleys can be started [22], but at reduced speeds, increasing the pace progressively. Overhead strokes would be included during the fifth week, progressing in the sixth week. Some of the recommendations from the fifth week [22] onwards are based on hitting in a semi-closed and open stance, emphasising the continuation of strokes, and initiating high and low shots, high balls, all shots hitting crosscourt, and down centre line strokes. This phase would be orientated to the recovery of the athlete and the beginning of the search for their pre-injury levels.
Considering the mobility side, a higher number of drills are included, focussing on range of motion and stability work for the shoulder and upper extremity [21,24]. The proposals should follow a progression, facilitating the exercise at the beginning (positions from the wall or facilitating the demands of the position of the athlete who performs it) to progress according to his evolution [21].
Strength exercises aimed primarily at improving the upper body include an increasing perceived exertion rate (8-10 RPE) [24], although that in the early stages adaptations are recommended, for example, scapula push-ups offer the consideration of performing the exercise on a bench to ease the difficulty [21]. These recommendations are repeated throughout this phase, although some authors include core work and discourage service strokes. However, this may depend on the degree and type of injury.
Thus, in this phase, the aim is to progressively increase the load with aspects related to the athlete’s performance context; therefore, the volume of training sessions or series/repetitions increases in this section [23]. The inclusion of modified games is also considered, controlling the number of games and breaks. This progressive adaptation is proposed by some authors from week 4 onwards [22,23].
Return to performance.
In this last section, the athlete is approached towards his or her performance in the field. Factors related to strength and technical training come into play. The athlete performs serves at intensities close to 100%, which will increase until the eighth week, including the practice of conditioned simulated matches with breaks for rest (Table 4). These recommendations could also be modified according to the level of competition of the trained athletes, with more complex strokes not recommended for amateur athletes [22]. All these phases are resumed on the Fig 2.
The first line represents the main training, while the second line denotes the supplementary training. W represents each week.
Discussion
The main objective of this research article was to examine the return to play training programs carried out by tennis players after suffering a musculoskeletal injury. However, one of the principal limitations to develop this research has been the limited number of articles in the field. Only five studies had developed different training programs focused and organised over the return to play in tennis players [21–25]. Despite this limitation, the research included in this review offers valuable insights for structuring training loads and exercises following a musculoskeletal injury. The research recommendations and findings presented here concentrate on post-shoulder injury rehabilitation, as the articles included are exclusively focused on this topic.
RTP is multifactorial and is dependent of several intrinsic and extrinsic factors, there are so many aspects that could be consider during the RTP as reestablishment of muscle strength and joint ROM (range of motion), regaining of proper motor control and proprioception, psychological readiness and recovery of functional ability [10]. Previous studies have analysed the return to play process in other sports as baseball [26,27]. Rebelo-Marques, Andrade (10) established different phases (return to participation, return to sport and return to performance) according to the training characteristics which can be applied also to tennis.
Firstly, the recommendations based on the studies analysed suggest that during the first two weeks after the rehabilitation process, the main exercises are developed with the aim of recovering full ROM with mobility exercises and initiating specific technical training. The focus should be on mobility as the main component of practice [21,22], and gradually include technical training, performing some specific drills such as forehand and backhand strokes [23–25], In this sense, traditional non-operative and post-operative rehabilitation programs for these athletes involve a gradual restoration of range of motion (ROM), strength, muscular endurance, dynamic stabilization and neuromuscular control [8,28].
Similarly, it has been observed that the intensity recommendations in the different studies should not be above 6 points over 10 in the Rating of Perceived Exertion (RPE) [24]. Besides, Amrani, Gallucci (23) indicate that the maximum volume during this two weeks should not be over 15% of the match volume. During the technical training Félix, Dines (22) noted that it could be include some technical movements (forehand and backhand), However, the overall recommendation from this study advises tennis players to avoid the hit with open stance for all groundstrokes for upper extremity during the first three weeks.
Upon successful completion of the early phases of the rehabilitation program, a gradual and controlled return to sport activities has been advocated by several authors [28–31]. In our results, this phase was developed during the following weeks until the 6 weeks. This phase in the research included in this review are characterised by the inclusion of strength training (core training can also be included) and technical training about the serve motion and volleys could be part of the training exercises [22,23]. The intensity raises until 8-10 RPE [24] and the training volume can achieve values around 70% of the match volume [23]. Strength training should achieve a balance between anterior and posterior shoulder musculature, special emphasis should be given to the posterior rotator cuff and scapular musculature for any strengthening program [8,28].
Beginning with the sixth week the players do the 100% of the volume training performed before the injury. Thus, it can be considered as the starting point of the return to performance phase that would finish when the athletes recover the preinjury specific performance. This phase could be characterised with the facts that executes serves with intensities nearing 100% could take part of the daily training and carrying out conditioned simulated match practices with intervals for rest [22,24].
Finally, it is crucial to underscore that the training program ought to be tailored to each individual’s specific needs and circumstances. The recommendations of the research articles include in this review needs to be adapted to each specific case, especially the temporal margins. Although models or decision-making guidelines are generated for the RTP process, this personalised approach ensures that the rehabilitation process effectively addresses the player’s strengths, weaknesses and recovery timeline, maximising their chances of a successful return to competition and reducing the re-injury probability [9,32].
Conclusion
The tennis player’s return-to-play process should adhere to three stages tailored to their training needs. Initially, the focus is on restoring full range of motion (ROM) through mobility exercises, potentially incorporating technical training. Subsequently, the emphasis shifts to reaching pre-injury levels of strength, incorporating more technical training to enhance hitting velocity. Lastly, serve technique is addressed, with a gradual increase in serve velocity. However, each of these aspects should be personalized to suit the individual player’s characteristics.
References
- 1. Over S, O’Donoughue P. Analysis of strategy and tactics in tennis. Coach Sport Sci Rev. 2010;18(50).
- 2. Pluim BM, Staal JB, Windler GE, Jayanthi N. Tennis injuries: occurrence, aetiology, and prevention. Br J Sports Med. 2006;40(5):415–23. pmid:16632572
- 3. Okholm Kryger K, Dor F, Guillaume M, Haida A, Noirez P, Montalvan B, et al. Medical reasons behind player departures from male and female professional tennis competitions. Am J Sports Med. 2015;43(1):34–40. pmid:25398243
- 4. Hartwell MJ, Fong SM, Colvin AC. Withdrawals and retirements in professional tennis players. Sports Health. 2017;9(2):154–61. pmid:27879298
- 5. Maquirriain J, Baglione R. Epidemiology of tennis injuries: An eight-year review of Davis Cup retirements. Eur J Sport Sci. 2016;16(2):266–70. pmid:25675134
- 6. Fu MC, Ellenbecker TS, Renstrom PA, Windler GS, Dines DM. Epidemiology of injuries in tennis players. Curr Rev Musculoskelet Med. 2018;11(1):1–5. pmid:29340975
- 7. Lynall RC, Kerr ZY, Djoko A, Pluim BM, Hainline B, Dompier TP. Epidemiology of National Collegiate Athletic Association men’s and women’s tennis injuries, 2009/2010-2014/2015. Br J Sports Med. 2016;50(19):1211–6. pmid:26719502
- 8. Wilk KE, Arrigo C. Current concepts in the rehabilitation of the athletic shoulder. J Orthop Sports Phys Ther. 1993;18(1):365–78. pmid:8348138
- 9. Ekizos A, Santuz A. “Biofeedback-based return to sport”: individualization through objective assessments. Front Physiol. 2023;14:1185556. pmid:37378078
- 10. Rebelo-Marques A, Andrade R, Pereira R, Espregueira-Mendes J. Return to Play (RTP). Sports Med Phys. 2019:149–698.
- 11. Morrison S, Ward P, duManoir GR. Energy system development and load management through the rehabilitation and return to play process. Int J Sports Phys Ther. 2017;12(4):697–710. pmid:28900575
- 12. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football-the UEFA injury study. Br J Sports Med. 2009.
- 13. Blanch P, Gabbett T. Has the athlete trained enough? A missing part in the return to play decision. Br J Sports Med. 2016;50:471–5.
- 14. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. pmid:19622551
- 15. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, et al. 2016 Consensus statement on return to sport from the first world congress in sports physical therapy, Bern. Br J Sports Med. 2016;50(14):853–64. pmid:27226389
- 16.
Phillips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes B, et al. Levels of Evidence: Oxford Centre for Evidence-based Medicine. Centre for Evidence Based Medicine, Department of Primary Care: Old Road Centre, Oxford. 2009.
- 17.
Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Oxford; 2000.
- 18. Bazerbachi F, Sawas T, Vargas EJ, Prokop LJ, Chari ST, Gleeson FC, et al. Metal stents versus plastic stents for the management of pancreatic walled-off necrosis: a systematic review and meta-analysis. Gastrointestinal Endoscopy. 2018;87(1):30-–42.e15.
- 19. Haffar S, Bazerbachi F, Prokop L, Watt KD, Murad MH, Chari ST. Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: a systematic review. Pancreatology. 2017;17(2):166–75. pmid:28236520
- 20. Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med. 2018;23(2):60–3. pmid:29420178
- 21. Bennett S, Macfarlane C, Vaughan B. The Use of osteopathic manual therapy and rehabilitation for subacromial impingement syndrome: a case report. Explore (NY). 2017;13(5):339–43. pmid:28780211
- 22. Félix I, Dines D, Dines J. Interval Return to Play Programs for the Tennis Athlete. Curr Rev Musculoskelet Med. 2021;14(2):185–91. pmid:33532974
- 23. Amrani K, Gallucci A, Magnusen M. Data-based interval hitting program for a collegiate tennis player: a case report. Int J Athletic Ther Training. 2019;24(1):15–8.
- 24. Wang Y, Yi N, Ericksen HM, Zhang W. Case report: Self-performed orthopedic exams in telehealth treatment of a youth athlete with acute rotator cuff strain. Front Sports Act Living. 2023;5:1150850. pmid:37325800
- 25. Reinold MM, Wilk KE, Reed J, Crenshaw K, Andrews JR. Interval sport programs: guidelines for baseball, tennis, and golf. J Orthop Sports Phys Ther. 2002;32(6):293–8. pmid:12061709
- 26. Smith R, Lombardo DJ, Petersen-Fitts GR, Frank C, Tenbrunsel T, Curtis G, et al. Return to play and prior performance in major league baseball pitchers after repair of superior labral anterior-posterior tears. Orthop J Sports Med. 2016;4(12):2325967116675822. pmid:28203588
- 27. Giberson-Chen CC, Shaw BL, Rudisill SS, Carrier RE, Farina EM, Pearson B, et al. Return to play after shoulder surgery in professional baseball players: a systematic review and meta-analysis. Orthop J Sports Med. 2023;11(1):23259671221140853. pmid:36655019
- 28. Wilk KE, Reinold MM, Andrews JR. Postoperative Treatment Principles in the Throwing Athlete. Sports Med Arthros Rev. 2001;9(1):69–95.
- 29. Axe MJ, Snyder-Mackler L, Konin JG, Strube MJ. Development of a distance-based interval throwing program for Little League-aged athletes. Am J Sports Med. 1996;24(5):594–602. pmid:8883678
- 30. Axe MJ, Wickham R, Snyder-Mackler L. Data-based interval throwing programs for little league, high school, college, and professional baseball pitchers. Sports Med Arthros Rev. 2001;9(1):24–34.
- 31. Wilk KE, Reinold MM, Dugas JR, Andrews JR. Rehabilitation following thermal-assisted capsular shrinkage of the glenohumeral joint: current concepts. J Orthop Sports Phys Ther. 2002;32(6):268–92. pmid:12061708
- 32. Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20(5):379–85. pmid:20818198