Anterior cruciate ligament (ACL) injuries are among the most common knee injuries, with over 80,000 occurring in the United States each year alone. ACL injuries have been shown to lead to temporary as well as permanent disability in a young and active population. The majority of ACL injuries occur in noncontact, cutting and pivoting sports. Although tennis is undoubtedly classified as a noncontact, cutting and pivoting sport, the incidence of ACL injuries is significantly lower than sports such as soccer and basketball. The literature specifically related to ACL injuries in tennis players is limited, but the incidence has been reported as low as 1.8%. Majewski et al. reviewed the epidemiology of 7769 athletic knee injuries over a ten-year period and found that 295 were directly related to tennis. Of these 295 knee injuries related to tennis, 129 patients underwent arthroscopic evaluation, and 33 (11.2%) were found to have an ACL injury. This was compared to other sports: 18.3% in judo, 19.3% in gymnastics, 20.2% in squash, 21.4% in soccer, 23.7% in volleyball, 24.8% in handball, 25.4% in badminton, 26.0% in basketball and 26.4% in skiing. Powell et al. looked specifically at intra-articular knee injuries in racket sports (tennis, racquetball, badminton and squash). Over a five year period, 404 patients presented with an injury associated with a racquet sport, and 222 (55%) sustained knee injuries. Although they did not divide specific pathologies by sport, these investigators found 31% of their 222 knee injuries occurred while playing tennis. Of the 222 patients, 121 underwent arthroscopic examination, and 28 (13%) were found to have an injury to the ACL. All of the patients with ACL injuries described twisting with a fixed leg and their pelvis and upper body twisting due to either an improper landing or fast turn. Maquirriain et al. evaluated 16 recreational tennis players with chronic ACL deficient knees and found that they subjectively evaluated their tennis performance as 67% of their pre-injury levels. They were particularly affected in landing after a smash, stopping abruptly and changing direction, playing a three set singles match, and playing on hard courts. Results from this study advocate the need for surgical reconstruction of the ACL in competitive tennis players. They also point out that further studies are needed to determine the true incidence of ACL injuries in tennis, and to establish the degree of improvement in tennis ability after ACL reconstruction. Although non-contact ACL injuries are very common in cutting and pivoting sports, the incidence remains low in tennis as compared to that of soccer and basketball. The basis for the lower rate of ACL injury in tennis players appears to stem from the essential nature of the sport itself. First and foremost, tennis is a true non-contact sport in which the majority of movement is anticipated with little perturbation. The fundamentals of tennis movement promote neuromuscular training which provides a protective intervention program at the basic level. As beginners, players are taught to stay on their toes, keep a wide base, and flex their knees and hips to maintain the "ready position." At a more advanced level, players are taught to maintain their balance and agility with the essential "split step." This early positional instruction as well as the ability to anticipate movements potentially promotes neuromuscular adaptations that stabilize the knee and provide ACL protection from increased loads.
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