The incidence and distribution of stress fractures in elite tennis players

Background: Modern professional tennis involves powerful movements repeatedly subjecting the musculoskeletal system to heavy mechanical load. Thus tennis players are exposed to high risk of overuse injuries including stress fractures. Objective: To determine the incidence and distribution of stress fractures in elite tennis players. Study design: Retrospective cohort study. Methods: The cohort study population consisted of 139 elite players (mean (SD) age, 20.0 (5.0) years; 48 female, 91 male). Stress fractures were identified and confirmed radiologically from medical records during a two year period. Injuries were analysed according to age, sex, site, severity, delay in diagnosis, and time needed to return to sports. Results: 15 players sustained 18 stress fractures, corresponding to an overall case incidence of 12.9% (95% confidence interval (CI), 8.1 to 20.0). The tarsal navicular was most affected (n = 5; 27%), followed by the pars interarticularis (n = 3; 16%), the metatarsals ( n = 3; 16%), the tibia (n = 2; 11%) and the lunate (n = 2; 11%). Magnetic resonance imaging showed a greater incidence of "high grade" lesions (94.4%). Stress fracture incidence was significantly higher in juniors (20.3% ( 95% CI, 11.4 to 33.2)) than in professional players (7.5% ( 2.8 to 15.6)) (p = 0.045). Conclusions: There was a high absolute risk (12.9%) of stress fractures in elite tennis players over a two year period. Junior players were at highest risk. The lesions are a major cause of disruption both of training and of competition. Risk factors should therefore be identified and prevention emphasised.