Injury Risk Factors of the Tennis Serve: A Systematic Review and Meta-Analysis

A key stroke in tennis is the serve. It is the most strenuous stroke in the game and has the greatest potential for injury. The serve has been broken down into a number of key stages to allow analysis of the movements involved.

The aim of this study was to conduct a systematic review of all injuries related to the stages of the tennis serve and to assess their relative impact on the risk of injury using a meta-analysis.

A systematic search was conducted across 8 electronic databases, supplemented with searches of grey literature. Eligible studies presented data from injured (injury group) and uninjured (control group) tennis players in a form that allowed further analysis of each risk factor for comparison. All results were presented as effect sizes (Cohen's d) to allow comparison of each risk factor and to identify the most important risk factors associated with injury. Overall study quality was assessed using an adapted Downs and Blacks checklist.

A total of 29 studies were included in the meta-analysis, identifying 130 risk factors. 36 risk factors had an effect size suggesting a large or significant association with injury in tennis players (d ⩾ 0.8 or ⩽-0.8). These were divided into general risk factors and those associated with the preparation, acceleration and follow-through phases of the tennis serve. Seven of the risk factors were from 3 or more studies allowing meta-analysis, 3 were from 2 studies and 26 were from a single study. Downs and Black checklist scores ranged from fair to good for the studies included in this review. There was no evidence of publication bias.

Meta-analysis identified dominant shoulder rotation strength, internal rotation range of movement, weekly tennis volume, age, body mass and height as risk factors for injury in the tennis serve.