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Tennis is a sport with numerous health benefits for individuals of all ages. It is also a tremendously effective fitness activity. Regular participants experience a wide variety of health-related physical and mental benefits, from improved cardiovascular, metabolic, and bone health to improved agility, coordination, and even stress and anxiety management. Physicians and other health care professionals can play an important role in educating patients and the public about the health benefits of tennis as well as motivating them to take up this activity as part of an overall exercise prescription. Based on the scientific evidence available, it is difficult to find an activity that offers as wide a range of overall health benefits as tennis, and individuals who take up tennis reap tremendous rewards.
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40 © THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37
CLINICAL FEATURES
Introducon
Tennis is a lifetime sport with numerous health benets.1 Individuals of all ages can gain great physical
and mental rewards by taking up this activity, and physicians and other health care professionals can
play an important role in educating patients and the public about these benets and motivating them
to take up this activity. Sedentary behavior is dangerous, being as damaging to an individual’s health as
smoking a pack of cigarettes a day; yet increasing numbers of children and adults in the United States
remain inactive. When individuals are asked what factors might persuade them to avoid sedentary
behavior, become active, and take up tness activities, the number 1 reason cited by respondents was that
a recommendation from their physician would highly motivate them to make or consider this impor-
tant lifestyle change.2 us, physicians and other health providers have not only the ability but also the
responsibility to both promote and prescribe exercise and activity. On many levels, tennis oers a great
activity and sports option for those interested in becoming more active and, as a result, more healthy.2
e United States Professional Tennis Association (USPTA) has developed a nationwide initiative,
Tennis—For the Health of It!SM3 and has partnered with the American College of Sports Medicine
(ACSM) as part of their “exercise is medicine” endeavor. is health promotion eort will help spread
the word about the health benets of tennis, and it should also make it easier for physicians and health
care professionals to prescribe and promote tennis to their patients.
Tennis: General Health Benets
e benets of regular exercise are well documented. In this article, we provide explanations why tennis
is a great exercise activity and how it is one of the best choices for anyone who wants to be healthy and
t. Regular tennis provides individuals with general health benets, such as improved cardiovascular
and lung function, lower body fat, and decreased risks of diabetes and cardiovascular disease. It also
gives one stronger bones supported by stronger and more exible muscles, and improved balance,
coordination, and proprioception. Although the physical benets of exercise are widely publicized,
the mental and emotional benets have not been adequately promoted, yet they are just as important
to a person’s overall health.
Exercise has oen been scientically shown to relieve symptoms of stress, but it oers even greater
benets that have not been researched as extensively. Recently, it was discovered that a fast-paced
workout such as tennis improves the production and release of brain-boosting proteins and increases
the production of cells in the brain’s hippocampus, which is where learning and memory function
take place. For adults, an 8-year study found a relationship between physical inactivity and cognitive
Tennis: For the Health of It!
Jack Groppel, PhD; Nicholas DiNubile, MD
Abstract: Tennis is a sport with numerous health benets for individuals of all ages. It is also a tremendously eecve tness
acvity. Regular parcipants experience a wide variety of health-related physical and mental benets, from improved cardiovascular,
metabolic, and bone health to improved agility, coordinaon, and even stress and anxiety management. Physicians and other health
care professionals can play an important role in educang paents and the public about the health benets of tennis as well as
movang them to take up this acvity as part of an overall exercise prescripon. Based on the scienc evidence available, it is
dicult to nd an acvity that oers as wide a range of overall health benets as tennis, and individuals who take up tennis reap
tremendous rewards.
Keywords: tennis; health; exercise; exercise prescripon; tness; prevenon; bone density; osteoporosis; falls; psychology
Jack Groppel, PhD1
Nicholas DiNubile, MD2
1Human Performance Institute,
Inc., Orlando, FL; 2Premier
Orthopedics, Havertown, PA;
Correspondence:
Jack Groppel, PhD,
Human Performance Institute, Inc.,
9757 Lake Nona Road
Orlando, FL 32827.
Tel: 847-658-1077
E-mail: jgroppel@hpinstitute.com
See editorial for Dr. DiNubile’s
commentary on the benefits of tennis.
Tennis: For the Health of It!
CLINICAL FEATURES
© THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37 41
decline across all subgroups.4 e sedentary lives of corporate
workers result in insucient physical stress, and that energy
imbalance negatively impacts cognitive performance. e
results also found a “dose” relationship between exercise and
mental acuity—“a little exercise is good, but more is better”
so long as adequate recovery is provided, and overtraining
does not occur.
Tennis is the Ulmate Exercise Both
Mentally and Physically
A typical tennis match can last from 30 minutes to sev-
eral hours. Over the course of the match, a tennis player
can run 3 to 5 miles. The average tennis point lasts 3 to 7
seconds, requiring rapid change in direction with sudden
bursts of activity.5 In a typical tennis match, this involves
300 to 500 bursts of energy. Tennis both challenges and
builds an individual’s aerobic and anaerobic condition-
ing and also requires tremendous muscle strength and
endurance.
Tennis-specic research has uncovered the following points:
Because tennis easily meets the physiological requirements to
be considered a moderate and even vigorous physical activity,
individuals who participate in tennis 3 hours per week at the
moderately vigorous intensity level can cut their risk of death
from any cause in half.6 In the landmark study on physical
activity and longevity, Paenbarger et al6 specically cite ten-
nis as a moderately vigorous activity, along with swimming,
squash, racquetball, handball, and jogging or running. Tennis
match intensity has been documented using both heart rate
recordings and maximum oxygen uptake (VO2 max). Mean
heart rate during singles tennis range from 141 to 182 beats
per minute, which equates to 70% to 90% maximum heart
rate. Mean oxygen consumption ranges from 50% to 80% of
VO2 max.7 Also, when one measures the energy expenditures
involved in tennis using metabolic equivalent tests (METS),
doubles tennis has been shown to fall into the moderate exer-
cise category at 5 to 6 METS, depending on the activity code
used. Singles tennis falls into the vigorous exercise category
at 8 METS, which is similar in intensity to jogging at a pace
of 5 mph or swimming at a moderate to hard level.8
According to Finn et al,9 tennis players scored higher in vigor,
optimism, and self-esteem and scored lower in depression,
anger, confusion, anxiety, and tension compared with other
athletes and non-athletes.
Because tennis requires alertness and tactical thinking,
it may generate new connections between nerves in
the brain and promote a lifetime of continuing brain
development.10,11
As a racquet sport, tennis outperforms golf and most
other sports in developing positive personality charac-
teristics (Table 1).12
Competitive tennis burns more calories than many
other sports and tness activities, according to detailed
charts comparing energy expenditures for a wide
variety of activities.13 A detailed analysis compared
various activities and the calories burned. e article
showed that tennis ranks among the top 5 activities
that one can participate in to burn the most calories,
and it actually burns more calories than swimming,
rowing, weightliing, jazzercise, hiking, or golf.14 It is
not surprising that tennis players tend to be more lean
than the average person. Body fat levels are signicantly
lower in tennis players than in age-matched controls.15,16
ey are also metabolically more t, with improved lipid
metabolism and lower incidence of hyperlipidemia.1,15
Obesity is a health hazard, with its incidence continuing
to rise in children and adults. Tennis oers an excellent
option for anyone wanting to shed unnecessary pounds
and/or maintain a healthy body weight.
Physical Benets of Tennis
Aerobic Fitness
Playing tennis burns fat, improves cardiovascular tness,
and helps the body maintain higher energy levels. More
calories may be burned in high-intensity intervals of exercise
interspersed with low-to-moderate intensity levels (Figure 1).
Tennis, in its purest sense, is interval training because of the
nature of how points are played. Because the heart rate goes
into a so-called “fat-burning zone” and can easily go higher,
tennis has been recognized as one of the leading activities
to help burn fat. Also, because the intensity of tennis can get
fairly high (depending on how hard a player works while play-
ing), and because tennis is purely an interval sport, more fat is
burned aer working out than during the time on court. us,
overall physical capacity improves both on and o the court.
As a testimony to this, Bloomeld et al17 determined that
7- to 12-year-old tennis players had superior cardiovascular
endurance compared with casual sport participants. It has also
Jack Groppel and Nicholas DiNubile
CLINICAL FEATURES
42 © THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37
Table 1. Tennis Outperforms Many Other Sports in Development of Personality Characteristics
Tennis Golf Running Weight-lifting Inline Skating Downhill Skiing
Sociability Very high Very high Moderate Moderate Moderate High
Spontaneity Very high Moderate Low Very low Moderate Very high
Competitiveness Very high Very high High Moderate Low Moderate
Risk-seeking High Moderate Low Low Moderate Very high
Focused Very high Moderately high Very low Low Moderate High
Aggressiveness Very high Low Moderate Very high Low Moderate
Reproduced with permission from Gavin.12
been determined that singles tennis meets the intensity criteria
established by the ACSM and the American Heart Association
for developing and maintaining cardiorespiratory tness.18 In
another study of 141 tennis players 30 to 74 years old, Galanis
et al19 observed that even moderate physical activity improved
overall lung function.
It is well accepted that exercise-related oxygen use and
capacity diminishes with advancing age, meaning heart-lung
capacity also declines. However, erminarius et al20 found
that playing tennis regularly appears to decrease the rate of
age-related decline. Elderly players can also realize another
benet from tennis. When studying tennis players ( 55
years), Howley et al21 observed that older players had signi-
cantly improved their blood cholesterol proles with higher
high-density lipoprotein (HDL), which is good cholesterol,
and a higher HDL to total cholesterol ratio than a control
group. In reviewing 17 dierent studies, Pluim et al1 found that
singles play allowed a player to be in the 70% to 90% range
of maximum heart rate, which makes tennis an outstanding
activity for improving cardiorespiratory function.
Anaerobic Fitness
Playing tennis builds muscle power and improves physical
capacity. Because the average point in tennis is over rap-
idly, with sudden bursts of activity, tennis allows players
to fully engage their anaerobic (or power) system. During
the short duration of a tennis point, the body relies on the
energy provided by glycogen that is stored in the muscles.
e natural repetition provided by tennis allows the body to
adapt by building muscle and improving heart-lung func-
tion. Legros et al2 2 found that the rate of phosphocreatine
concentrations (a measure of anaerobic capacity/fitness)
recovery was much faster in tennis players or active subjects
than in sedentary subjects.
Improved Speed and Acceleraon
Tennis improves a person’s ability to accelerate. One of the
key measures of athletic success is the ability to accelerate
from a still position to maximum velocity. Regardless of the
sports activity, accelerating and positioning are foundational
to high achievement. In every point while playing tennis,
one must explode, sprint, and recover for the next shot. is
constant and repetitive “explosive movement” trains the body
for forceful movements that truly expand one’s capacity. As the
muscles adapt to the need for improved strength and power,
one becomes quicker and more agile.
In tennis, what matters is the rst step, which requires
anticipation, quick reaction time, and explosive action. Power
is work divided by time or, equally, power is force multiplied
by the distance moved and then divided by time. Because
of the natural demands of tennis, improved power is a basic
end result. Every move made toward the next shot is a very
short distance (4 m), so it should be questioned what kind of
speed is required to play tennis. Although it does not require
the speed for a 100-m dash, for instance, it does require a
powerful rst step, which enhances quickness in all activities.
Because tennis players continually practice “ready, read, react,
and explode” for each point, a powerful rst step becomes a
natural end product. is is why tennis is viewed as a terric
cross-training option for athletes in any sport. Athletes in
a number of sports, including basketball, football, baseball,
soccer, and volleyball use tennis as part of their o-season
training regimen to help improve their fundamental skills.
Dr. DiNubile has worked extensively with professional
basketball players and knows several who feel that playing
competitive tennis in high school and college signicantly
enhanced their basketball skills.
Speed is the distance one travels divided by time. Tennis is
a sport that, through its very design, improves peoples speed.
Tennis: For the Health of It!
CLINICAL FEATURES
© THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37 43
Figure 1. Heart rate of professional tennis players in a variety of tennis hitting workouts.
Reprinted with permission from the Tennis – For the Health of it!SM Web site © 2009, United States Professional Tennis Association, Inc.
Jack Groppel and Nicholas DiNubile
CLINICAL FEATURES
44 © THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37
During a point, players must respond to an opponent’s shot,
move forward and backward from the length of a 39- court
(the distance from the baseline to the net) and side to side
along the width of 27  (the distance in singles tennis from
sideline to sideline), and sometimes even farther if they move
diagonally. Based on the time per point and the distance a
player must move during that time, tennis is one of the world’s
best activities for developing multidirectional speed.
Strength, Coordinaon, and Agility
Leg muscular strength can be improved through the hundreds
of starts and stops that tennis requires. is includes both
concentric and eccentric strength. e constant lunging,
pushing o, or leaping to hit an overhead develops leg mus-
cular development unlike many other activities. Laforest
et al16 found that the muscles of tennis players demonstrated
a greater resistance to fatigue than those of sedentary indi-
viduals across 2 sets of age groups (27–30 and 64–66 years).
Tenn is deve lop s i ncr e dib le coor dina tio n and
proprioception. It requires a nely tuned integration of the
mind-body network. Not only must the tennis player be on
the move constantly to get into position to return the oppo-
nent’s shot, he or she must also be forward thinking to get
back into position for the opponent’s next shot. e player’s
ability to read the opponent’s movements, predict the ball
placement, position himself or herself at an optimal distance
from the anticipated ball landing, prepare and execute his
or her own return shot, then get back into position for the
next shot is testimony to the mental and physical complex-
ity of tennis.
In one investigation, timing was studied regarding how
well a person tracks an object and positions himself relative to
the arrival of the object. In a study examining tennis players
and novices at ages 7, 10, 13, and 23 years, it was found that
tennis practice accelerates the development of timing accu-
racy.23 In a study specically using tennis to examine aging
and coordination, Lobjois et al2 4 observed tennis players
and non-tennis players of various ages (20–30; 60–70; and
70–80 years). A timing task had an object accelerating (at
constant velocity or decelerating), and the subjects were asked
to time their response to the object’s movement. Even though
all participants were aected by the velocity manipulation,
this response bias was increasingly pronounced with advanc-
ing age in non-players, and no dierence was found among
player groups of dierent ages.
Tennis also enhances both gross and ne motor control.
In tennis, movement and ball striking skills require control
of large and small muscle groups. e large muscle groups
get a great workout, not only from the force production but
also from the coordination required to get into position.
Andersson et al25 observed tennis players reach higher exion
torques (rotational force production) than other athletes and
non-athletes. Tennis players also demonstrated more strength
in lateral movements. In tennis, the ball must oen be slowed
down and hit with a gentle, so return. ese shots are called
drop shots or drop volleys. Hitting successful touch shots
requires the development of ne motor control in the arms
and hands to decelerate the racquet and hit a highly controlled
shot that will barely clear the net with a very low bounce. In
a study examining the ability to be rhythmically accurate and
maintain a steady rhythm in movement execution (considered
to be one of the best basic abilities of an athlete), Zachopoulou
et al26 found that a tennis group (compared with basketball,
swimming, and a control group) was the most rhythmically
accurate.
Tennis improves agility because it forces a change in
direction as many as 5 times in 10 seconds during a typical
point. The overall agility gained from playing tennis is
tremendous. Also, coaches in other sports are constantly
looking for ways in which to vary their practices and workouts.
Cross-training has become a huge part of athletes activites, both
for the improvement and/or maintenance of all forms of tness
and the improvement of general skills that will benet them in
their specic activity. Tennis provides excellent cross-training
for other sports that require rapid changes in direction, includ-
ing football, basketball, soccer, baseball, and volleyball.
Dynamic balance (balance while moving) is as important
in everyday life as it is in sports. Tennis requires total control
of ones body even while running at top speed. is skill easily
translates to everyday life. Tennis provides great dynamic
balance training because it requires one to develop total body
control to prepare for shot execution. Joint position sense and
proprioception are also developed on the tennis court. Children
benet from learning tennis because it makes them more agile
as they develop. Dynamic balance training is benecial for
older adults because it allows them to function at very high
levels in normal life, even into their 90s. According to the
American Academy of Orthopaedic Surgeons,27 11 million
senior citizens fall each year in the United States—that is
1 of every 3 people 65 years, making it the leading cause
Tennis: For the Health of It!
CLINICAL FEATURES
© THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37 45
of injuries in the elderly population. Falls are also a leading
cause of hospitalizations among persons of all ages; in 2000,
falls accounted for 46% of all hospitalizations from injuries.27
Prevention strategies to prevent falls are essential, particularly
in those who have or are at risk for osteoporosis. e earlier that
an individual incorporates preventive balance-type training,
the more successful they will be in lowering their fall risk
associated with aging.
Tennis players develop tremendous hand-eye coordination
because they must constantly judge the timing between the
oncoming ball and the proper contact point. is ability
is developed both when stationary, and more oen when
moving at high speeds. Not only must the player position his
or her body correctly to prepare for the shot, coordination is
required to execute the swing. e trunk, arms, and legs must
all work in sync with appropriate racquet placement coupled
with impeccable timing to hit the oncoming tennis ball. If
any of these are o,” the player’s shot will suer. In a study
comparing 53 university athletes (including tennis players)
and 46 non-athlete university students, Ishigaki and Miyao28
determined that dynamic visual acuity of the athletes was
superior to that of the non-athletes.
Flexibility
Because tennis players continually stretch and maneuver to
return the ball to their opponent, they become more exible.
is includes both static and dynamic exibility of major
muscle groups of the upper and lower extremity and the core
area. Tennis requires a player to get in position and “reach
to return the opponent’s shot. In one investigation, exibility
improved in children (average age 11.4 years) aer a 12-week
session of playing sports such as tennis. e average gain was
3.76 cm.29
Cross-training
It is well accepted that athletes can improve their tness and
performance by embracing sports or activities outside their
main sport. e eyes of the sporting world were opened to
the cross-training benets of tennis when it was revealed in
popular literature during the mid-1980s that many world-class
Alpine skiers played tennis in the o season. Tennis provides
athletes of other sports with a wide variety of physical skills
that translate back to their primary sport or activity. In a 1999
study, Japanese junior tennis players were compared with
non–tennis-playing children, and it was determined that the
tennis players were superior in aerobic capacity, agility, and
muscle power.30 Tennis provides cross-training benets on a
variety of physical and mental parameters, perhaps more so
than any other sport.
Addional Health Benets
Bone Health
For years, scientists and physicians have recommended impact
or weightbearing exercises for people who want to increase
bone strength and density and prevent osteoporosis. According
to Wol ’s law, bones remodel in response to mechanical
demands placed on them. When used and “loaded,” more bone
is laid down, and the “stressed” bone gets stronger.31 Tennis
places bone-building dynamic stresses on the body, with a
positive impact on skeletal health and overall durability. In
general, the body adapts to bouts of mechanical overload by
getting stronger. is adaptation is not only true of bones but is
also seen in muscles, tendons, and ligaments.31 Optimal skeletal
health necessitates movement and loading, and “if you don’t
use it, you lose it.” As exercise physiologist omas Cureton
once said, “the human body is the only machine that breaks
down when not used.
Experts usually recommend weight training, running,
jogging, or even walking to build bones; however, when it
comes to an activity that creates repetitive impact with the
ground and impact when striking the ball, nothing beats
tennis. Bone development for children is critical, and bone
growth and maintenance for seniors is equally important.
Pluim et al1 analyzed 22 independent studies documenting
the positive impact of tennis on bone health and bone density.
Tennis players consistently had greater bone density in their
dominant arm and better bone density in the hip and lumbar
spine compared with age-matched controls. Interestingly, bone
mineral content and bone density were greater in those who
took up tennis at earlier ages. is underscores the impor-
tance of bone-building activities like tennis in children and
teenagers, especially young females, who reach peak bone
mass in their late 20s. e more bone that is “banked” early,
the less vulnerable an individual will be, as expected skeletal
losses occur in middle age and older. e key to a healthy adult
skeleton begins in youth with proper exercise and nutrition.
ese are the critical bone-building years. Researchers also
agree that tennis, 3 times per week, supports the exercise
recommendations of the ACSM regarding physical activity
and bone health, both for the development of bone minerals
Jack Groppel and Nicholas DiNubile
CLINICAL FEATURES
46 © THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37
in children and adolescents and the preservation of bone
health during adulthood.32 In the ACSM position statement
on physical activity and bone health, the authors specically
cite tennis as a bone-building option.
Using tennis players as the experimental group and
comparing them with sedentary people of the same age, Pirnay
et al33 clearly demonstrated that there was a positive correlation
between the tennis players and bone mineralization. In another
study on this topic, the bone mineral content of athletes (tennis
players) was signicantly greater than that of non-athletes, but
did not dier among the sports. erefore, tennis contributes
to bone mineral density.34 When one considers the bone-
building potential of tennis with its ability to improve balance,
coordination, and agility, tennis becomes an attractive preven-
tive strategy for the commons falls and/or fracture problems
encountered in adult and elderly populations. Again, starting
early, before higher level of fall risk becomes a contraindication
to tennis, is the key.
Improved Overall Health, Immune Funcon,
and Body Composion
Tennis promotes overall health, fitness, and resistance
to disease through its conditioning effects. Studies have
demonstrated that the more active an individual is, the stronger
and healthier his or her immune system will be. e intensity
of exercise helps to strengthen the immune system further.
erefore, it makes sense that tennis, with its inherent demands
for heart rate, interval training, impact and agility is one of the
most benecial activities in which one can participate. Sch-
neider and Greenburg35 cited tennis specically as an activity
in which participants were less likely to be obese, smoke, or
be involved in other forms of threatening activities compared
with those who participate in team sports and an aggregate
of other sports. ese positive lifestyle choices allow for opti-
mal immune activity and function. We also know that systemic
inammation can have serious negative health implications,
and inammation can be related to excessive body fat. Laforest
et al16 discovered that recreational tennis players who par-
ticipate twice a week had a lower body fat percentage than
age-matched control groups.
Finally, adding to the study conducted by Paenbarger
et al,6 Houston et al36 published a longitudinal investigation of
1000 male students examined aer an average of 22 and 40
years. Sustained playing of activities such as tennis was associ-
ated with a lower risk of cardiovascular disease. ey inferred
that a primary factor for this benecial health prole may be
that tennis was the sport played most oen through middle age.
Psychological Reasons to Play Tennis:
The Mind-Body Tennis Connecon
Tennis offer s tr emendous ment al and psychological
benefits for individuals of all ages, from building con-
fidence and self-esteem in children to reducing stress
and maintaining cognitive abilities in adults and seniors.
Studies have demonstrated that people w ho play tennis
develop a perception of control in what they do. In one
study of football players, tennis players, and non-athletes,
the ten nis players and footba ll players had a greater
perception of control than the non-athletes. Addition-
ally, tennis players were found to be highest in personal
efficacy, meaning that they felt they could achieve the
desired results more effectively.37
Tennis can help improve the habit s surrou nding
self-discipline and decision-making abilities. In tennis
singles, the player is alone on the court, making his or
her own decisions, planning strategies, and developing
innate skills of self-discipline. In 1996, Yoo38 examined
self-confidence and competition anxiety among play -
ers in various sports activities. Tennis was among the
sports examined in which several psychological factors
of players were studied. Yoo38 found that the higher the
sport orientation, the less competition anxiety and more
self-confidence was reported. In another investigation
of wheelchair tennis participants, Greenwood and Dze-
waltowski 39 compared wheelchair tennis players with
wheelchair non-tennis participants. It was determined
that wheelchair-mobile people participating in tennis
appear to be more confident about general wheelchair
mobility tasks than wheelchair mobile nonparticipants.
Tennis builds responsibility and discipline. It requires
the player to practice and show up for competition on
time with all the necessary equipment. In a study examin-
ing p erformance attributions and how self-centered an
individual was, Van Raalte40 observed that people tend
to take credit for success and blame external factors for
failure. This investigation observed that in a laboratory
setting, these self-serving biases were confirmed. How-
ever, when observing tennis players and their perfor-
mances, the incidence of self-serving attributions was
signif icantly lower.
Tennis: For the Health of It!
CLINICAL FEATURES
© THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37 47
Stress Management
e physical, mental, and emotional stress of tennis forces
the player to increase his or her overall capacity for stress
management. Stress is a normal part of living, and when
managed eectively can actually be benecial to the overall
growth of an individual. However, when it is unchecked,
particularly in long-term situations, it can take its toll on
one’s health.
The singles player is out there alone. Stress can be a
powerful stimulus for personal growth. e key is to learn
and develop eective coping and management skills. e key
to successful living is learning techniques to build recovery
naturally so that stressful situations are better managed and
diused.41 Tennis helps to build recovery in a natural way
by the very essence of how it is played. e player gets to
regularly practice thinking and acting under stress, which is
huge preparation for life skills. It is a continual battle with an
opponent and oneself. Every point has the capacity to become
an emotional slap in the face. Yet the more one plays, the more
eectively one learns to manage the stresses that life and tennis
competition create.
Recovery—Not Just Physical
Because of the nature of tennis, a player must learn to recover
quickly, adapting to the stress that each point presents. Fitness,
both physical and mental, has always been measured by how
quickly one can recover from a bout of stress. Everything about
the human system oscillates. Brain activity, heart rhythms, and
sleep cycles are just a few of the body’s systems that constantly
go up and down. ere are also predictable biochemical and
hormonal changes. By the very nature of how it is played, tennis
virtually duplicates this natural oscillation. Stress or heart rate
goes up during a point, and then recovery occurs for very short
periods between points. e ability to recover from bouts of
stress is a skill that can be modied and trained. Loehr42 has
demonstrated how to use the between-point time in tennis to
recover from the stress of the previous point and then prepare
for the upcoming point.
Tennis professionals work with coaches to learn muscle
relaxation, breathing control, focus, and improved concentra-
tion. ey also learn to project condence, even under duress,
and not allow negative emotions to intrude into their recovery
time. e certied tennis teaching professionals can teach the
same skills to recreational players and even beginners.43 An
eective tennis coach or instructor can provide additional
benets. In his doctoral dissertation research, Ryska44 found
that highly supported tennis players reported lower anxiety
compared with less supported athletes. As predicted, a sig-
nicant coach support state was seen in people who were able
to reduce higher levels of inherent anxiety. Tennis coaching
can and will help one with all of life’s battles. e mind-body
connection, as it relates to tennis, was also referenced in an
article in which the question was asked: “how good are you
at playing tennis?” e reason this was asked was because
good coordination appears to be an important marker of how
intelligent we are.45
Life Lessons
Tennis particularly lends itself to the physical and emotional
development of children and young adults. ere are countless
life lessons between the lines of a tennis court, and in the time
before practice and/or competition. A tennis player quickly
learns about victory and defeat. e legendary Chris Evert
said it best: “if you can react the same way to winning and
losing, that’s a big accomplishment. at quality is important
because it stays with you the rest of your life, and there’s going
to be a life aer tennis that’s a lot longer than your tennis life.
In a study examining adolescent tennis players and a group of
adolescents who did not participate in sports, Daino46 found
that tennis players scored higher in extraversion and a will to
win, while exhibiting less neuroticism, anxiety, apprehension,
obsession, and depression than non-sport participants.
Tennis builds self-esteem. In a study on achievement and
self-esteem in female athletes in which tennis was one of
the sports examined, Brown47 determined that participating
in a sport such as tennis is an avenue in which females can
experience achievement and enhanced self-esteem. Tennis
also teaches teamwork, fairness, honesty, respect, and overall
sportsmanship. Great tennis players have learned to ght a
one-on-one battle on the court, but they are also incredibly
sportsmanlike when their opponent hits a great shot. All of
the great players have been seen clapping their racquet face
at a great shot or they have been heard saying, “great shot” or
“well done.Any athlete, at any level and in any sport, can learn
about the essence of sports and competition and how it should
be by watching one of the many tremendous matches between
Roger Federer and Rafael Nadal. e combination of talent and
professionalism seen in these top players, and not uncommon
in the world of tennis, would be a welcome addition to many
other sports arenas and venues in our modern world.
Jack Groppel and Nicholas DiNubile
CLINICAL FEATURES
48 © THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37
Tennis helps develop problem-solving skills. It is a game of
rhythm and preparation. In between points, players prepare
themselves physically, emotionally, and mentally for the next
point. Performance rituals are oen used before each serve
or return to control rhythm and deal with pressure. ese
same preparatory skills can transfer to taking examinations,
conducting a meeting, or making an important presentation.
In the mid-1980s, Loehr42 demonstrated how tennis players
use pre-performance rituals as they prepare to serve or return
serve. He taught that aer every point, great tennis players
have developed the skills for 4 very specic actions. ere
is a positive physical response aer the point, a relaxation
phase, mental preparation, and then rituals. When serving, for
example, a person decides where to serve the ball, how hard
to hit it, and with what kind of spin. is mental preparation
ritual plays a huge role in many other sports activities as well as
life. Research at the Human Performance Institute has shown
that “great leaders know how to manage their energy.” Tennis
can provide a perfect training ground in which one can learn
to prepare for a wide variety of situations. Tennis is a moving
chess match, working the brain and the body in a positive way.
Although competitive at its heart, tennis can also be great
fun for its participants. People who play tennis on a regular
basis experience healthy feelings of enjoyment, competitive-
ness, and physical challenge. It is a fun activity, and it is very
social. Whether you play at a club or the public parks, tennis
players always gather before and aer matches. e gatherings
that can be seen after league matches develop incredible
camaraderie. e connections made through tennis play can
and oen do last a lifetime.
Addional Consideraons
ere is a growing body of scientic literature to support
the promotion of tennis by physicians and health care
professionals; however, more in-depth tennis-specic stud-
ies are needed if we are to better understand the full array of
benets gained by regular participation in tennis, as well as the
limitations and potential risks. Marks48 provides a thoughtful
comprehensive review of this subject and excellent recom-
mendations for future investigation.
As noted, tennis is not without its risks. Although it is
considered a relatively safe sport, there will still be injuries.
ese include both acute injuries and the more common
overuse type. Both Perkins and Davis49 and Pluim et al50
provide detailed analysis of the tennis-related injuries and
strategies for prevention. Injury rates can be minimized with
attention to proper instruction, proper equipment, and overall
balanced conditioning. Modication of program design and
teaching are recommended for those with orthopedic and/or
medical conditions, and this can easily be accomplished when
necessary. In addition to traditional tennis instruction, there
are many innovative, creative programs that allow for more
rapid learning, fun, and tness on the tennis court without the
need to “play” traditional tennis. ese programs are invaluable
for children and inexperienced adults, or even adults who
need modications because of orthopedic or medical issues.
As we deal with an aging population, especially those with
musculoskeletal conditions, the need for exercise modication
becomes essential.31 is is true not only on the tennis courts,
but also any time adults take up activity and/or exercise. e
ACSM has excellent recommendations for prescribing and
promoting physical activity for older adults and these should
be taken into consideration when prescribing any exercise
program or sport for older individuals.51
Conclusion
Tennis is a lifetime sport with numerous health benets3 for
individuals of all ages. It is almost never too early or too late to
start. Physicians and other health care professionals can play an
important role in educating patients and the public about the tre-
mendous health benets of tennis, and motivating them to take up
this wonderful activity as part of an overall exercise prescription.
e USPTA has developed an initiative, Tennis—For the
Health of It!SM is nationwide eort helps spread the word
about the health benets of tennis, and it should also make it
easier for physicians and health care professionals to learn more
about tennis, and to prescribe and promote tennis to their patient
population. In the opinion of the authors, it would be hard to nd
a better exercise choice for individuals wanting to become more
active and to reap the numerous health benets that exercise
oers. In fact, we believe that tennis should be considered any
time exercise and activity are being discussed, recommended
and/or prescribed by physicians. ere are a variety of programs
oered by certied professionals for individuals of all ages and all
skill levels to get interested participants o to the right start for
lifetime of fun and improved health.
Acknowledgments
Portions of information presented in this review were repro-
duced with permission from USPTASM.
Tennis: For the Health of It!
CLINICAL FEATURES
© THE PHYSICIAN AND SPORTSMEDICINE ISSN – 0091-3847, June 2009, No. 2, Volume 37 49
Conict of Interest Statement
Jack Groppel, PhD discloses conicts of interest with Glaxo-
SmithKline and Procter & Gamble. Nicholas DiNubile, MD
discloses conicts of interest with Genzyme Biosurgery and
H-wave®.
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Chapter
In addition to the musculoskeletal injury emphasis described in other chapters of this book, there is a tremendous stress to the entire body during tennis play. This requires high-level medical care for the competitive tennis player against illness and overtraining syndromes. This chapter overviews these key medical issues.
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