Injury Epidemiology and Athletic Training Services in Collegiate Tennis: A Longitudinal Perspective (2018–2023)

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Abstract

Introduction

In contemporary society, sports occupy a central role in the daily lives of individuals, whether through active participation or as spectators. For athletes to perform at their highest level, the development of key physical attributes, such as agility, balance, coordination, flexibility, strength, endurance, and power, is essential [1,2]. These attributes are cultivated through structured training and consistent practice. However, athletic performance is frequently challenged by the occurrence of injuries, which may necessitate periods of rest, rehabilitation, or withdrawal from competition [3,4].

To reduce recovery time and facilitate safe return-to-play protocols, the presence of on-site athletic trainers and sports medicine professionals during competitions is critical. These support services not only aid in immediate injury management but also contribute to long-term athlete health and performance [3-5]. While the availability and quality of such services may vary depending on the level of competition or institutional resources, their role remains integral to both injury prevention and recovery. Despite the recognized importance of athletic training services, there is a continued need for comprehensive data on their utilization and their relationship to injury trends and physical discomfort, particularly within specific sporting contexts such as collegiate tennis. Previous studies have collected and compared multi-year epidemiological data on sports-related injuries across various sports.

The International Tennis Federation (ITF) Global Tennis Report 2024 reports that tennis participation has risen from 84.4 million in 2019 to just under 106 million players globally, spanning 199 countries [6]. Recent data from the United States Tennis Association (USTA) indicate that 25.7 million people participated in tennis in the US in 2024, marking the sport’s 5th consecutive year of growth. This represents an increase of 1.9 million players from 2023, or an 8% rise, making tennis the 6th most popular sport in the US, following American football, basketball, baseball, soccer, and ice hockey [7]. As of 2024, at the collegiate level, the Intercollegiate Tennis Association (ITA) currently oversees more than 1,700 tennis programs, organized into 5 competitive levels: 3 National Collegiate Athletic Association (NCAA) divisions and 2 additional divisions based on institutional size. NCAA Division I includes over 300 women’s and 240 men’s programs, with each team typically consisting of 8 to 12 players. In 2023, more than 8,000 players competed in ITA tournaments [8].

A recent review titled “The Time Is Now”, published in the Women in Sport and Physical Activity Journal (2024), highlighted a significant surge in both elite and recreational female sports participation. Notably, it reported that the Paris 2024 Olympics achieved complete gender parity–50% women athletes– representing a 3,789% increase in female participation since the 1924 Summer Olympics, also held in Paris [9]. Similarly, college-level female athlete participation in the US has grown substantially since the passage of Title IX. The number of female NCAA athletes increased from 29,977 in the 1971-72 academic year to 215,486 in 2020-21, accounting for 44% of all college athletes [10].

According to epidemiological studies on injuries in collegiate tennis [11,12] have reported data on injuries occurring during competitions, practices, and overall activity. The top 3 injury sites during competition were: for women, the shoulder (16.2%), trunk (12.8%), and knee (11.1%); for men, the trunk (14.6%), ankle (12.4%), and hip/groin (11.2%).

This study analyzed AT services provided at ITA Division I women’s tennis tournaments over a 6-year period, using data collected from 5 tournaments held between 2018 and 2023 (excluding 2020). The primary aim was to evaluate the scope and nature of AT support during competition, while also examining the types and frequency of injuries and physical discomforts reported by participating athletes.

Methods

Results

Frequency of Player Retirements or Walkovers due to Injury or Illness from the First Round through the Final

As shown in <Table 1>, a total of 637 players participated in the singles first round across the five ITA tournaments analyzed, with 128 players per year, except for 2018, which had 125. A total of 617 singles matches were played from the first round through the finals. Of these, 7 matches resulted in walkovers, representing 1.13% of all matches. Four walkovers were due to injury (two in round 2 and two in round 3), and 3 were due to illness (all in round 1). Additionally, 8 matches ended in retirements, accounting for 1.30% of singles matches. Seven retirements were attributed to injury (one in round 1, five in round 2, and one in round 3), and one was due to illness (round 3).

Table 1.

Number of Participants and Retirements/Withdrawals Due to Injury/Illness in Singles Tournaments Leading Up to Final.

As shown in <Table 2>, 6 walkovers were recorded in doubles matches, accounting for 2.05% of the 293 total doubles matches. Of these, 4 were due to injury (two in round 1 and two in round 2), and 2 were due to illness (both in round 1). Notably, unlike in singles, no retirements were recorded in doubles; only walkovers were observed. Importantly, no walkovers or retirements occurred in the later stages of the tournaments beyond the quarterfinals in singles or the round of 16 in doubles.

Table 2.

Number of Participants and Retirements/Withdrawals Due to Injury/Illness in Doubles Tournaments Leading Up to Final.

A retirement occurs when a player is unable to continue a match after it has already started, typically due to injury, illness, or another unexpected circumstance. In contrast, a walkover refers to a situation in which a player, having completed a previous match in the event, is unable or chooses not to compete in their next scheduled match, either prior to the start or during the warm-up, due to injury, illness, personal emergency, or another legitimate reason.

In cases where no alternate is available, tournament regulations allow a player who is unable to participate in their first-round main draw match (for a legitimate reason such as injury or illness) to be placed into the consolation draw. When this happens, the unplayed main draw match is recorded as a walkover rather than a withdrawal.

Frequency and Reasons for Medical Timeouts During Tournaments

<Table 3> summarizes the occurrence of medical timeouts across 5 tournaments. A total of 31 medical timeouts were recorded, averaging 6.2 per tournament. Ankle injuries were the most frequently reported condition, accounting for 7 cases. Six types of conditions were observed on 2 or more occasions, while isolated cases involved the finger, shoulder, and head. One atypical case involved anxiety-induced dyspnea, which appeared to be associated with the athlete’s perceived underperformance during the match.

Table 3.

Medical Timeouts During Tournaments.

AT Service Provided and Injury/Physical Discomfort

A total of 978 cases of injury or physical discomfort were recorded by AT services across 5 tournaments <Table 4>. Of these, 419 cases (42.9%) involved the lower extremity, 358 (36.7%) the upper extremity/trunk, and 198 (20.3%) other body regions. The most frequently administered AT interventions were taping applications, including both athletic taping and kinesiology taping.

Table 4.

Athletic Training Services Provided During Tournaments.

For lower extremity treatment, the 5 most commonly provided AT services included taping for ankle inversion sprains (120 cases; 28.6%), toe blisters (61 cases; 14.6%), plantar foot blisters (48 cases; 11.5%), toe bruises (47 cases; 11.2%), and hip adductor strain wrapping (36 cases; 8.6%).

For upper extremity/trunk treatment, the 5 most frequently provided AT services included taping for the following condition: wrist compression (73 cases; 20.3%), abdominal strain (36 cases; 10.0%), finger blister (33 cases; 9.2%), elbow hyperextension (30 cases; 8.4%), and both wrist extensor strain and shoulder deltoid strain, each with 29 cases (8.1%). Additional commonly services included hot pack application and stretching of the lower back and hamstrings.

Injury distribution by body part indicated that, among lower extremity injuries, the most frequently affected areas were the ankle (120 cases; 28.6%), toe (108 cases; 25.8%), and foot (73 cases; 17.4%) <Figure 1>. For upper extremity/trunk injuries, the most commonly involved regions were the wrist (102 cases; 28.4%), shoulder (52 cases; 14.5%), and elbow (49 cases; 13.6%) <Figure 2>.

Figure 1.

Distribution of AT Services/Injuries by Body Part in the Lower Extremity.

Figure 2.

Distribution of AT Services/Injuries by Body Part in the Upper Extremity.

Discussion

Unlike many other sports, tennis matches have no fixed duration, and the extended length of play may increase the risk of injury due to prolonged physical exertion. Across the 5 tournaments analyzed, lower extremity injuries and physical discomfort accounted for the majority of cases (42.9%), a finding consistent with prior research emphasizing the high physical demands placed on the lower body during tennis play. Ankle inversion sprains were the most frequently treated condition, comprising 28.6% of all lower extremity cases, aligning with the findings of Lynall et al. [11], who identified ankle sprains as one of the most common injuries in collegiate men’s tennis.

In contrast to previous reports, injuries and physical discomforts involving the upper extremity and trunk accounted for a substantial proportion (36.8%) of all cases in our study. The wrist (28.4%), shoulder (14.5%), and elbow (13.6%) were the most frequently affected regions in this category. These findings partially diverge from those of Robinson et al. [12], who reported a different injury distribution during competition in women’s collegiate tennis, with higher prevalence observed in the shoulder (16.2%), trunk (12.8%), knee (12.0%), foot (11.1%), and thigh (10.3%). Notably, their study did not distinguish between upper and lower body regions, which may account for differences in categorization and interpretation. Similarly, Robinson et al. [13] identified a distinct injury pattern during competition in men’s collegiate tennis, reporting the trunk (14.6%), ankle (12.4%), hip/groin (11.2%), and shoulder (10.1%) as the most affected injury sites, with the thigh, knee, and foot each at 7.9%.

A recent study by Llanes et al. (2023) reported injury patterns among U.S. high school tennis players, noting that the most commonly affected regions for female athletes were the ankle (25.9%), knee (13.0%), wrist (11.1%), shoulder (9.3%), and lower leg (8.3%). Our findings are consistent with theirs regarding the high incidence of ankle, wrist, and shoulder injuries. However, we observed a notably lower frequency of knee injuries, aside from 12 cases involving preventive patellar tendon taping.

This discrepancy may be attributed to several factors, including differences in age, physical maturity, competitive level, and training exposure between high school and collegiate athletes. Collegiate players may benefit from more advanced strength and conditioning programs, enhanced movement mechanics, and targeted injury prevention strategies, all of which could contribute to a reduced risk of knee injuries. Additionally, variations in match intensity, training volume, and playing surface may also influence the injury patterns observed across different athletic populations.

Musa et al. [14] further highlighted the impact of skill level on injury patterns, noting that amateur players were more likely to sustain elbow and knee injuries. In contrast, our cohort comprising high-performing collegiate athletes demonstrated fewer knee-related injuries, potentially reflecting the influence of systematic conditioning programs and greater access to professional athletic training services.

AT services in this study were used predominantly for preventive care, with a high frequency of ankle and wrist taping, particularly before matches. This pattern suggests a proactive approach by athletes and AT staff to address regions under high mechanical stress and prevent injury onset. The frequent treatment of blisters, especially on the toes and plantar surfaces, highlights a potential relationship between footwear, playing surfaces, and injury risk, factors that merit further investigation.

Another notable finding was the timing of injury reports and treatments, which were most frequent during the early rounds of competition. This may reflect the higher match density during these rounds, with some players competing in multiple matches per day. The absence of retirements beyond the quarterfinals may suggest that only the fittest and best-prepared athletes progress to the later stages, possibly due to superior physical conditioning or effective injury management strategies that mitigate the cumulative effects of fatigue.

While our findings confirm several well-documented injury trends in tennis, they also reveal patterns unique to women’s collegiate competition. These include a relatively high incidence of toe and finger injuries and frequent use of soft tissue recovery treatments, such as stretching and hot packs. These insights emphasize the need for tailored AT services that address both the sport-specific demands of tennis and the physiological needs of female collegiate athletes.

Limitations

Some participating schools traveled with their own athletic trainers, and the services provided by these personnel were not captured in the present study. Additionally, some athletes arrived pre-taped or applied their own taping prior to matches, which was also excluded from the recorded data. These factors may have resulted in an underestimation of the total volume of athletic training services provided during the tournaments and should be considered when interpreting the findings.

Conclusions

This study presents a multi-year overview of AT services and injury patterns observed during Division I women’s collegiate tennis tournaments. The majority of AT interventions occurred prior to matches and were largely preventive in nature, most commonly involving taping, stretching, and hot/cold therapy. The findings highlight the predominance of lower extremity injuries, particularly ankle sprains and toe-related conditions, underscoring the physical demands placed on players during competition. Upper extremity injuries, especially those affecting the wrist and shoulder, were also frequently treated, reinforcing the need for comprehensive injury prevention strategies targeting both upper and lower body regions.

Medical timeouts, retirements, and walkovers were relatively infrequent but tended to occur more often during the early rounds of play. This pattern suggests that cumulative fatigue and high match density may contribute to increased injury risk. The low rate of retirements observed in later rounds may reflect the superior physical conditioning, coordination, and endurance of higher-performing athletes, which likely contribute to both enhanced performance and reduced injury susceptibility.

These findings underscore the critical role of structured on-site AT support, evidence-based recovery protocols, and individualized injury prevention strategies in safeguarding athlete health. Implementing such measures, particularly during the early stages of tournament play, may help mitigate injury incidence [16]. Future research should examine the long-term outcomes of common tennis injuries, evaluate the effectiveness of specific preventive interventions, and investigate genderspecific risk factors to better tailor care for female collegiate athletes. Additionally, larger, multi-institutional studies are warranted to validate and expand upon these findings and to inform best practices for injury management across competitive levels.

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