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Clinical Management of the Adult Recreational Tennis Player with Back Pain

Stephan Esser MD, USPTA

Back pain is ubiquitous. 80-90% of athletes and non-athletes alike will experience back pain in their lives and up to 30% of adults report daily back pain. In America, back pain is the 2nd leading reason to see a primary care provider, right after the common cold. So how do you approach the adult recreational tennis player who presents to your clinic or therapy/training room with complaints of back pain?

Safe or Dangerous

The scientific literature describes many and varied ways to approach back pain: by region (cervical, thoracic, lumbar, sacral), by distribution (axial vs radicular), by chronicity (acute vs chronic), by temporality (intermittent, chronic) by anatomic source (discogenic, facetogenic, stenotic) and many others. These approaches categorize the pain and guide management but sometimes overlook the basic question the patient really wants to know: "Is the pain "safe" or is it "dangerous." Let me explain. Spinal degeneration is a normal part of aging. Gravity, genetic inheritance and other environmental factors influence the process but like gray hairs and wrinkles the majority of humans are likely to demonstrate degenerative spinal changes on a quality MRI. By the age of 13, 30% of adolescents will have asymptomatic degenerative changes including disc bulges and facet arthropathy. By the age of 40 > 80% of adults will have degenerative changes of the spine seen on MRI. If 80% of adults over 40 have degenerative changes but fewer then 30% have daily pain, then most humans will "fall apart quietly.” For this reason the worst thing a health care provider can do is "over-pathologize" back pain or give too much value to imaging findings unless they correlate with clinical history and exam findings. So when the adult recreational tennis player presents with back pain, the first step is to ask about and look for "red flags." (Table 1). If the athlete has any of these then advanced imaging and further workup should be pursued. If none of these "red flags" exist then begin to "de-pathologize" their pain immediately. Validate their experience, empathize with and treat their pain aggressively but do not pathologize it. Plant seeds of optimism, develop a science-based pain reduction plan and follow closely.

Table 1: Red Flags of Back Pain

  • History of Malignancy

  • Numbness, Tingling, Weakness in the limbs or groin

  • Changes in Urinary or Bowel function (esp. Urin. Retention)

  • Fever, Chills, Night Sweats, Unexplained weight loss

  • Severe, unremitting Pain

  • Gait changes

  • Recurrent Symptoms after Spinal Surgery

The Conservative Approach

Once you have ruled out the "red flags" and after an excellent exam including (gait, lumbar and hip range of motion, a myotomal and dermatomal evaluation for deficits, palpatory and provocative exam, and general tennis technique evaluation etc) then it is time to develop a plan of care. Conservative care falls into three primary strategies: watchful waiting, exercise based modalities and medication management. (see Algorithm) If pain and functional limitations are minimal then trial a home exercise and stretching program to improve erector spinae firing as described by Renkawitz et al. If pain or functional limitations are moderate then encourage a program of outpatient manual and exercise based therapies to reduce pain more rapidly and correct biomechanical dysfunction about the lumbar spine, SI, Hips and Pelvis. Medications may be used including non steroidal anti-inflammatories for 7-10 days along with B vitamins as supported by Mibielli et al. If pain is more severe combination therapies including muscle relaxers for night time use or spasms and neuopathic agents for radicular symptoms may be used. In addition adjunctive modalities like acupuncture and home TENS should be considered.


Patients presenting with "red flags" or severe pain which fails to improve with 2-3 weeks of appropriate and aggressive conservative management will benefit from advanced imaging. For better image resolution a 1.5 Tesla or greater MRI with fine cuts through the area of concern should be ordered. If a patient has had previous back surgery then an MRI with and without contrast will help differentiate scar tissue and infection from new disc protrusion or progressive degenerative changes etc. In patients with suspected spondylolysis or those s/p recent lumbar fusion or with contraindication to MRI (eg: pace maker's/extreme claustrophobia etc), then a CT L Spine is indicated. Based on the patient's clinical history and exam the clinician should select imaging which will best evaluate the "pain generators" suggested by history and exam. CT for bone, MRI for soft tissues and so on.

Invasive Approach

If advanced imaging demonstrates changes consistent with the patient's symptoms and clinical exam, then spinal injections in conjunction with conservative care should be considered. Evaluate "tennis-specific" motions for pain including spinal hyper-extension and "stork/cobra" testing (mimicking service/overhead motion) and extremes of lumbar rotation during back swing and follow thru. Pain with extension/rotation and MRI findings of facet synovitis or progressive facet arthritis may benefit from facet injections. In comparison, pain worse with lumbar flexion and rotation +/- radicular symptoms and an MRI showing an acute disc deformation may benefit from a trans-foraminal or midline epidural injection. If patient's fail to improve with fluoroscopically-guided spinal

injections, PT and oral medications or if neurologic symptoms progress then surgery should be considered.

Tennis Specific Alterations and Technique

Tennis athletes develop biomechanical alterations from the repetitive, choreographed nature of the sport. Some habitual patterns may promote dysfunction. HIRD(Hip Internal Rotation Deficit) is present in many elite players, but the rates of the same have not been adequately identified in the recreational adult player. However alterations in hip range of motion, SI mobility and lumbar spine range of motion may contribute to low back pain and should be adequately addressed by the healthcare provider. Poor technique including toss location for the kick/topspin serve and excess lumbar hyperextension with inadequate hip and knee flexion during the serve may further exacerbate low back pain. Discuss these technical aspects with the tennis athlete and address them in the treatment plan.

Final Thoughts

Back pain is common and the majority of pain is “safe” and will improve with conservative care. Never forget the “red flags” and follow up closely to confirm resolution and return to full function. Use a tennis-specific approach and if indicated advance to interventions guided by imaging and an excellent clinical

history and exam.


  1. Mibielli et al. Diclofenac plus B vitamins versus diclofenac monotherapy in lumbago: the DOLOR study. Current Medical Research and Opinion 2009. 25:11: 2589-2599.

  2. Renkawitz, T, Boluki, D. Linhardt, O, Grifka J. Neuromucular imbalances of the low back in tennis players-the effects of a back exercise program. Sportverletz Sportschaden 2007 Mar;21(1): 23-8

  3. Vad et al. Hip and shoulder internal rotation range of motion deficits in professional tennis players Journal of Science and Medicine in Sport 6(1): 71-75.


Stephan Esser MD, USPTA is a Non-Operative Sports and Spine Physician at Southeast Orthopedic Specialists in Jacksonville, FL. He is also the founder and director of the Florida Institute of Tennis at

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