The Musculoskeletal Health Benefits of Tennis

Abstract

Background:

The prevalence of musculoskeletal (MSK) conditions is increasing, and although current guidelines for physical activity attempt to combat this, many fail to achieve the recommended targets. The present study sought to investigate whether regular tennis participation is more effective at enhancing MSK function than meeting the current international physical activity guidelines.

Hypothesis:

Tennis players will display significantly enhanced MSK function when compared with age-matched healthy active nonplayers.

Study Design:

Cross-sectional study.

Level of Evidence:

Level 3.

Methods:

Ninety participants (age range, 18-65 years) took part in this study; there were 43 tennis players (18 men, 25 women) and 47 nonplayers (26 men, 21 women). MSK function was assessed by cluster analysis of 3 factors: (1) electromyographic fatigability of prime movers during handgrip, knee extension, and knee flexion; (2) isometric strength in the aforementioned movements; and (3) body composition measured by bioelectrical impedance analysis. Maximal oxygen uptake was also assessed to characterize cardiorespiratory fitness.

Results:

Tennis players displayed significantly greater upper body MSK function than nonplayers when cluster scores of body fat percentage, handgrip strength, and flexor carpi radialis fatigue were compared by analysis of covariance, using age as a covariate (tennis players, 0.33 ± 1.93 vs nonplayers, −0.26 ± 1.66; P < 0.05). Similarly, tennis players also demonstrated greater lower extremity function in a cluster of body fat percentage, knee extension strength, and rectus femoris fatigue (tennis players, 0.17 ± 1.76 vs nonplayers, −0.16 ± 1.70; P < 0.05).

Conclusion:

The present study offers support for improved MSK functionality in tennis players when compared with age-matched healthy active nonplayers. This may be due to the hybrid high-intensity interval training nature of tennis.

Clinical Relevance:

The findings suggest tennis is an excellent activity mode to promote MSK health and should therefore be more frequently recommended as a viable alternative to existing physical activity guidelines.

There is overwhelming evidence to suggest that leading an active lifestyle is associated with health benefits and the more time spent active, the lower the risk of all-cause mortality.²³ However, many fail to heed this advice and do not reach the minimum recommended 150 minutes of physical activity per week; in fact, globally, an estimated 31% of adults are categorized as physically inactive, with percentages seemingly greater in high-income countries and older adults in particular, irrespective of region.¹⁷ Additionally, with increases in sedentary behavior, the prevalence of conditions associated with poor musculoskeletal (MSK) health is also on the rise.³³ Sarcopenia is one such condition and is the term given to age-related loss of muscle mass, where functional capacity and thus quality of life is drastically reduced.¹⁰ It is not uncommon to see losses of between 30% and 50% muscle mass from the ages of 40 to 80 years.¹¹ Furthermore, osteoporosis is another such condition, characterized by low bone mineral density and increased risk of fractures, significantly associated with morbidity.²⁵ Having said this, it is clear that physically active individuals display healthier body mass, composition, and bone density; greater strength and muscular endurance; higher levels of cardiorespiratory fitness; and overall superior functionality, significantly reducing their risk of developing either sarcopenia or osteoporosis in later life.³⁸ Crucially, adopting an active lifestyle is integral to maintaining optimal MSK health across the life span.

To combat the ever-increasing rates of MSK conditions, exercise is invariably prescribed by practitioners but often with little underlying research, ambiguous recommendations, and hence, mixed results.²⁹ This highlights the need for more realistic and sustainable physical activity interventions that can readily promote MSK health outcomes across the life span.⁹ What is known is that optimal exercise prescription should integrate aerobic, muscle strengthening, and flexibility exercises.⁸ Previous literature has also commented on the particular effectiveness of group-based training interventions for adults, which result in higher levels of exercise adherence and program compliance.¹⁸

Tennis is one such activity that can incorporate these different modes of aerobic and muscle strengthening exercise, because of the nature of play and the combination of skills required, all in a group-based environment. Nonetheless, at present there is a distinct lack of research analyzing the impact of tennis on MSK health in particular, despite its previously documented wide-ranging health benefits.¹⁶ In a review of the existing literature on the subject, Pluim et al³⁰ draw on several cross-sectional studies comparing tennis players with age-matched controls, and they found superior body composition and bone mineral density in tennis players. However, comparison groups in these studies did vary in their level of activity, from moderately active to completely sedentary. In line with these findings, Marks²⁴ also reported greater handgrip and knee extensor/flexor strength in a review of the health benefits for veteran tennis players, although not all studies came to the same conclusion, as once again lifestyle factors differed between reports. To add to this, Laforest et al²² demonstrated not only greater strength in their tennis players when compared with a sedentary population but also greater resistance to fatigue, ascertained by electromyographic (EMG) testing and isokinetic dynamometry. Finally, in a recent epidemiological study of over 80,000 UK residents, participation in racquet sports was strongly associated with the greatest risk reduction in all-cause mortality, more than any other sport listed.²⁷ However, with no distinction between racquet sports in this latter study and no attempt to elucidate the mechanisms behind their effectiveness, further research is warranted to examine tennis’s potential to enhance physical function, improve quality of life, and reduce risk of developing MSK dysfunction.

Thus, the aim of the present study was to investigate whether individuals who play regular tennis have superior overall MSK health than those currently attaining the international physical activity guidelines through other means. To this purpose, a variety of key markers of physical functioning were measured and compared between a group of tennis players and a group of age-matched healthy active nonplayers. It was hypothesized that the tennis players would display significantly improved MSK function compared with their nonplaying counterparts.

Methods

Participants

The study was designed in accordance with the recommended guidelines for ethical practice set out by the Declaration of Helsinki, and ethical approval was granted by the institutional review board. Sample size was determined using G*Power Software¹² and 80% power with α error probability of 0.05 (2-tailed), based on previous work by Swank et al,³⁵ detailing significantly lower body fat percentage in tennis players versus age-matched moderately active nonplayers. Henceforth, a sample size ≥42 participants per group was required to observe a significant difference. In order to ensure this was obtained, slightly more participants were recruited, and ultimately, 90 participants of both sexes (44 men, 46 women), aged between 18 and 65 years, took part in the study. Descriptive characteristics of the study population are presented in Table 1. All participants were recruited from the North West area of the United Kingdom. Tennis players (n = 43; 18 men, 25 women) were recruited primarily through the Liverpool and District Tennis Group and had an average of 19.96 ± 15.90 years of playing experience. When questioned, all but 3 players stated that they engaged in year-round tennis, most of which was doubles play and only occasional singles practice. Notably, all tennis players who volunteered to take part in this study were recreational players and despite playing competitively in local leagues, none were elite. For comparison, a group of age-matched healthy active nonplayers (n = 47; 26 men, 21 women) were recruited from within the same region. All nonplayers were healthy with no current health complaints or comorbidities, and although from a mixture of sporting backgrounds, all were physically active (at minimum, performing the globally recommended 150 minutes of moderate-intensity exercise each week³⁸), indicated by their responses to the International Physical Activity Questionnaire–Short Form (IPAQ-SF) (data presented in Table 2).

Table 1.

Descriptive characteristics of tennis players (TP) and nonplayers (NP) for the entire cohort and separated by sex ^a

	Both Sexes		Males		Females
	TP (n = 43)	NP (n = 47)	TP (n = 18)	NP (n = 26)	TP (n = 25)	NP (n = 21)
Age, y	44.35 ± 16.83	39.02 ± 16.95	47.50 ± 16.25	37.04 ± 17.49	42.08 ± 17.20	41.48 ± 16.35
Height, m	1.69 ± 0.08	1.69 ± 0.09	1.74 ± 0.07	1.74 ± 0.08	1.66 ± 0.06	1.63 ± 0.07
Weight, kg	68.23 ± 8.01	72.36 ± 11.39	70.22 ± 8.11	76.08 ± 9.68	66.80 ± 7.78	67.76 ± 11.89
Body mass index, kg/m2	23.83 ± 2.80	25.19 ± 3.50 b	23.08 ± 2.35	25.08 ± 3.14 c	24.37 ± 3.02	25.34 ± 3.97
Waist:hip ratio	0.82 ± 0.07	0.84 ± 0.07	0.86 ± 0.06	0.87 ± 0.06	0.79 ± 0.06	0.78 ± 0.05
Fat mass, %	23.43 ± 7.63	23.16 ± 8.20	16.87 ± 5.22	18.32 ± 7.04	28.17 ± 5.17	29.16 ± 4.93
Fat mass, kg	15.89 ± 5.49	16.81 ± 6.67	11.95 ± 4.09	14.24 ± 6.56	18.73 ± 4.56	19.98 ± 5.42
Fat-free mass, kg	51.90 ± 8.11	55.56 ± 10.28	58.27 ± 6.72	61.84 ± 7.32	47.31 ± 5.56	47.78 ± 7.82
Muscle mass, kg	26.24 ± 3.57	28.10 ± 5.19 b	28.58 ± 3.46	31.44 ± 4.03 c	24.56 ± 2.60	23.97 ± 3.06
Handgrip strength, kg	33.51 ± 9.60	33.49 ± 9.67	41.39 ± 9.10	39.40 ± 8.13	27.84 ± 4.73	26.19 ± 5.58
Knee extension strength, N	314.42 ± 113.36	363.23 ± 123.96	379.10 ± 130.51	439.72 ± 105.93	267.85 ± 70.90	268.53 ± 65.50
Knee flexion strength, N	159.71 ± 55.14	188.3 ± 65.83 b	196.77 ± 57.36	228.37 ± 58.01	133.02 ± 34.91	138.69 ± 33.04
VO2MAX, mL/min/kg	39.20 ± 10.35	41.54 ± 10.22	44.60 ± 10.18	46.67 ± 9.85	35.15 ± 8.64	35.39 ± 6.76

^aData are presented as mean ± SD.

^bIndicates significant difference (P < 0.05) between tennis players and nonplayers when compared by independent t test.

^cIndicates significant difference (P < 0.05) between tennis players and nonplayers when compared by independent t test within respective sex.

Table 2.

International Physical Activity Questionnaire–Short Form responses for tennis players (TP) and nonplayers (NP) ^a

	TP (n = 25)	NP (n = 27)
Vigorous intensity, MET-min/wk	1217.60 ± 1571.16	1408.89 ± 945.49
Moderate intensity, MET-min/wk	1118.40 ± 851.15	494.81 ± 494.51 b
Walking, MET-min/wk	861.96 ± 783.61	927.06 ± 656.05
Total, MET-min/wk	3197.96 ± 1975.69	2830.76 ± 1339.66
Sitting, min/d	351.60 ± 156.25	447.78 ± 190.63

MET, metabolic equivalent.

^aData are presented as mean ± SD. Data are shown from 52 participants, although 72 completed the questionnaire, 20 were excluded following data processing and cleaning guidelines available at www.ipaq.ki.se.

^bIndicates significant difference (P < 0.05) between groups when compared by independent t test.

Study Design

All participants were provided with an information sheet stating all procedures, and once satisfied, all provided their written informed consent. Participants were then required to complete a physical activity readiness questionnaire confirming no contraindications to exercise. All procedures were completed in 1 visit to the School of Health Sciences laboratories at Liverpool Hope University over the course of approximately 2.5 hours, and all experiments were performed by a single examiner. Finally, participants were instructed to arrive nonfasted but abstaining from food consumption in the 2 hours prior and having not performed any strenuous physical exertion or consumed any alcohol or caffeine in the 24-hour period before testing.

Anthropometry

Participant height and weight were measured using stadiometer and mechanical measuring scales, followed by waist and hip measurements using ergonomic circumference measuring tape (Seca). Body mass index (BMI) and waist:hip ratio were calculated using these measurements. Bioelectrical impedance analysis (Bioscan 920-II; Maltron International Ltd) was then used to further assess body composition. According to the manufacturer’s guidelines, after 5 minutes of rest in a supine position, electrodes were placed down the right side of the body: on the dorsal aspect of the hand, over the third metatarsal, and between the styloid process of the radius and ulnar as well as on the dorsal aspect of the foot, over the third metatarsal, and between the medial and lateral malleoli. Body composition values were computed by accompanying software BioScan 920 v 1.1 (Maltron International Ltd).

Dynamometry

Handgrip strength, as a primary measure of upper body strength, was measured on the dominant side using a wireless Jamar dynamometer (E-LINK; Biometrics Ltd) in a seated upright position with the elbow flexed at 90° and the wrist in a neutral position. After familiarization, participants were instructed to perform 3 maximal efforts for 5 seconds, with verbal encouragement and a 30-second rest period between measurements. The mean of the 3 trials was recorded as the maximal voluntary contraction (MVC).

To assess lower body strength, maximal isometric knee extension and flexion forces were measured using a portable fixed dynamometer (Myometer; Mecmesin Ltd). The dynamometer was secured to a fixed stanchion and a strap was looped around the ankle, just above the lateral malleolus; participants remained seated upright while grasping the underside of the chair with the knee flexed at 90°. Although the position of the chair was adjusted 180° between knee extension and flexion, body position remained the same. After familiarization, 3 MVCs were performed on the dominant side, each for 5 seconds, with verbal encouragement and 30 seconds of rest between trials. As with handgrip, the mean across the 3 trials was recorded as MVC for both knee extension and knee flexion.

Electromyography

Electromyography data were recorded to measure the fatigability of key muscles during the upper and lower body isometric exercises outlined above, following methods previously published by Hawkes et al.¹⁹ Participants were asked to maintain submaximal voluntary contractions at 25% of the previously measured respective MVCs in handgrip, knee extension, and knee flexion for 1 minute and 10 seconds (the first and last 5 seconds were excluded from analysis). As with MVC measurements, participants were instructed to maintain the same positions in each type of contraction. In order to ensure that 25% of MVC was held constant, visual feedback was provided to participants by respective software of the handgrip dynamometer (E-LINK Version 14.02; Biometrics Ltd) and myometer (Emperor Lite Version 1.18-408; Mecmesin Ltd). EMG activity was recorded from the main agonists during each movement: flexor carpi radialis during handgrip, rectus femoris during knee extension, and biceps femoris during knee flexion. After skin preparation, disposable, self-adhesive Ag/AgCl bipolar surface electrodes with 10-mm conducting area and 20-mm interelectrode distance (Noraxon Inc) were used to record EMG data. Electrodes were placed parallel to muscle fibers on the belly of the muscles previously identified, and following accepted anatomical criteria,³ signals were confirmed by manual muscle testing. A Telemyo DTS system (Noraxon Inc) and MyoResearch software (Version 3.8, Noraxon Inc) were used for signal acquisition and data analysis, respectively. Signals were differentially amplified (common-mode rejection ratio [CMRR] >100 dB; input impedance >100 Mohm; gain, 500 dB), digitized at a sampling rate of 1500 Hz, and band-pass filtered at 10 to 500 Hz.

Fatigability of each muscle was quantified by calculating median frequency (MDF) in 1-second intervals across the 60 seconds of sustained submaximal isometric contraction at 25% MVC. A fast Fourier transformation was performed to allow analysis of the power spectrum. MDF was then normalized relative to starting value, and the mean rate of change, assessed by linear regression, was used as a fatigue index.

Maximal Oxygen Uptake

Maximal oxygen uptake (VO_2MAX) was assessed by an incremental test to exhaustion using a treadmill (h/p/cosmos) and a standard Bruce protocol.⁶ Indirect calorimetry was performed using a breath-by-breath analyzer (Ergostik; Geratherm Respiratory GmbH), calibrated prior to testing. Participants’ heart rates were also monitored during the entire protocol (FR70; Garmin International Inc). VO_2MAX was considered at the observation of a plateau in VO₂ or the point of volitional exhaustion. If a plateau was not reached, VO_2MAX was considered where either respiratory exchange ratio was >1.15, heart rate was within 10 beats of age-predicted maximum (220 – age), or rating of perceived exertion was >19.⁵

Statistical Analyses

Data are presented as means ± standard deviation or standard error of the mean as appropriate. All variables were first analyzed between tennis players and nonplayers using independent-samples t tests, following tests for normal distribution and transformations where data were nonnormal. Additionally, in limited cases where a normal distribution was not achievable, a nonparametric Mann-Whitney U test was employed in lieu of a t test. To analyze any potential sex-based differences, the above analysis was repeated in male and female participants separately.

Overall MSK function was analyzed via a cluster-based approach following the techniques set out by Andersen et al.² Variables were selected to represent 3 contributing factors toward overall MSK function, as identified by Cawthon et al⁷: factor 1, adiposity component; factor 2, relative strength component; and factor 3, physical performance component. Furthermore, it was decided to calculate a separate score for upper and lower body function, and in both cases, body fat percentage was chosen to signify the adiposity component (factor 1). Handgrip strength and knee extensor/flexor strength were selected to represent factor 2 in the upper and lower extremity, respectively. Finally, factor 3 was characterized by muscle fatigue index for the primary muscles during either handgrip, knee extension, or knee flexion to match factor 2.

All selected variables were then converted to sex-specific z-scores, and to ensure each factor had the same directional weighting, body fat percentage was multiplied by −1 to convert scores to a positive weighting. Cluster scores for both upper and lower body MSK function were then calculated by the summation of their respective factors, where the greater the cluster score, the greater the assumed MSK health or physical function. Last, to analyze the differences between tennis players and nonplayers, groups were compared using analysis of covariance (ANCOVA), with age as a covariate. Statistical significance was set at P < 0.05. All analyses were performed in SPSS (Version 24; IBM).

Results

No significant differences (P > 0.05) were observed for the majority of variables (for descriptive characteristics, see Table 1); however, tennis players did display a significantly lower BMI, muscle mass, and knee flexion strength than nonplayers (P < 0.05). When t tests were performed separately for males and females (see Table 1), as nonplayers had slightly more male participants, no differences were reported among female participants. On the contrary, males in the tennis playing group still displayed significantly lower BMI and muscle mass but no difference in knee flexion.

Table 2 displays the physical activity data collected from the IPAQ-SF of both groups. Although crucially no significant difference was reported in total physical activity, vigorous-intensity exercise, sitting time, or walking time, tennis players did report a significantly greater (P < 0.05) amount of time taking part in moderate intensity exercise than nonplayers.

Table 3 illustrates MDF slope (%·min⁻¹) of each agonistic muscle during handgrip, knee extension, and knee flexion fatiguing protocols. All participants completed fatigue measurements; however, some data were excluded from the final analysis due to poor signal or equipment error. For clarity, a more negative MDF slope indicates a greater level of fatigue in that muscle. When group means were compared using independent t tests, no significant differences in fatigue were detected for any of the muscles studied (P > 0.05).

Table 3.

Fatigue index of tennis players (TP) and nonplayers (NP) indicated by median frequency (MDF) slope of the studied agonistic muscles during handgrip, knee extension, and knee flexion ^a

	MDF Slope (%·min−1)
Muscles	TP	NP
Handgrip
Flexor carpi radialis	−1.79 ± 1.34 (n = 42)	−2.48 ± 0.88 (n = 47)
Knee extension
Rectus femoris	−4.91 ± 1.49 (n = 40)	−7.76 ± 0.97 (n = 46)
Knee flexion
Biceps femoris	−5.52 ± 2.02 (n = 41)	−2.75 ± 1.83 (n = 46)

^aData are presented as mean ± SEM.

Cluster Analysis

For analysis of overall MSK function, clusters were created from markers of adiposity, strength, and physical performance data. More specifically, standardized z-scores of these 3 key categories were summed to provide measures of both upper and lower body function. First, to assess the upper extremity, body fat percentage was combined with handgrip strength and flexor carpi radialis fatigue to create cluster 1 (C1). When compared by ANCOVA (using age as a covariate), tennis players revealed a significantly greater score in C1 than nonplayers (tennis players, 0.33 ± 1.93 [n = 42] vs nonplayers, −0.26 ± 1.66 [n = 47]; P < 0.05). Second, to compare lower body function and to create cluster 2 (C2), z-scores of body fat percentage, knee extensor strength, and rectus femoris fatigue were combined. Once again, tennis players demonstrated significantly greater function than nonplayers in this cluster (tennis players, 0.17 ± 1.76 [n = 40] vs nonplayers, −0.16 ± 1.70 [n = 46]; P < 0.05). Last, to assess the lower body further and formulate cluster 3, standardized scores of body fat, knee flexion, and biceps femoris fatigue were summed and compared by ANCOVA, although no differences were observed between groups in this final cluster (tennis players, −0.29 ± 1.69 vs nonplayers, 0.24 ± 1.88; P > 0.05). Figure 1 highlights the significantly greater overall MSK function of both upper and lower body clusters (C1 and C2) in tennis players versus nonplayers.

Figure 1.

Upper and lower body musculoskeletal function cluster scores of tennis players (TP) and nonplayers (NP). Cluster 1 (C1) represents the upper body and is the sum of z-scores for body fat percentage, handgrip strength, and flexor carpi radialis fatigue index. Cluster 2 (C2) represents the lower body and is the sum of z-scores for body fat percentage, knee extension strength, and rectus femoris fatigue index. Data are presented as mean ± SEM. *Indicates a significant difference between TP and NP when analyzed by analysis of covariance (age as covariate).

Discussion

Although the health benefits of tennis have previously been documented,^24,30 this is the first study to employ cluster analysis in an attempt to elucidate its potential to enhance MSK health. Moreover, with the presence of a healthy active control group, these benefits can be attributed to tennis specifically, independent from those normally associated with increased physical activity. Past literature has also clearly identified tennis as a sport that promotes longevity; epidemiological studies in particular have highlighted a much lower mortality rate in those who regularly partake in the game.^27,28 Smaller studies have suggested tennis players possess more favorable body composition components than nonplayers.^22,35 Additionally, several researchers have demonstrated that tennis players have an enhanced grip strength in the dominant arm. However, only Laforest et al²² were able to demonstrate a significant difference in knee extensor strength. It is plausible that conflicting results of past studies are due, at least in part, to the previous studies not fully accounting for the impact of varying activity levels. In the current study, having taken into account sex-based effects, no significant differences in strength were reported, and only a slightly more favorable BMI was seen in male tennis players. Nevertheless, after cluster analysis, a significant difference was reported, likely owing to marginal differences in each measure contributing to a greater collective effect on overall MSK function. Importantly, this finding not only expands on the work of other authors in demonstrating the superior physical condition of tennis players but more specifically highlights its potential in a previously understudied area, where newer, more practical alternatives to existing physical activity recommendations are much needed.

As discussed, there is some convincing evidence in favor of the ability of playing tennis to enhance and maintain MSK health. Presently, there is a distinct lack of research investigating fatigability in tennis and how it compares with other sports/activities. To date, some support has been found, documenting a greater resistance to fatigue in tennis players during sustained isometric knee extension when compared with active nonplayers.^22,37 Indeed, in the current study, when measures of muscular fatigue during both handgrip and knee extension were combined with markers of adiposity and upper and lower body strength, respectively, tennis players displayed enhanced overall condition. To put the findings into context, decreases in both isometric strength and EMG activity have been shown to be more pronounced in older adults.¹ Consequently, when tennis players’ greater resistance to fatigue is coupled with greater isometric strength and reduced body fat percentage, their functional capacity is enhanced and the normally associated decline with age is much reduced. Moreover, this is the first time that EMG fatigability has been employed as a measure of physical performance in a cluster of overall MSK health. Although based on existing guidelines in the field established by Cawthon et al⁷ that specify walking speed and chair stand tests, this variation offers a more sensitive measure of physical performance. Although not always practical, this does highlight the need for more accurate and reliable alternatives for populations where traditional markers may not be sensitive enough to detect differences in MSK function, such as younger or middle-aged adults.

While this study contributes to the growing body of evidence detailing the many positive benefits of regular tennis participation, it is not yet clear why tennis is so uniquely effective at enhancing MSK health. Repeated bouts of high-intensity aerobic exercise have been shown previously to be particularly successful at promoting neuromuscular function.⁴ Additionally, resistance training has also been associated with improvements in resistance to muscular fatigue.³⁴ Evidently, this would suggest that concurrent training, as outlined by the current American College of Sports Medicine (ACSM) guidelines,¹⁵ combining both modalities would lead to the optimal conditions for enhanced MSK health. Nevertheless, in this study, many of the nonplayers were routinely following these guidelines but still had markedly lower MSK functionality than the tennis players, evidenced by lower cluster scores in both the upper and the lower extremity (Figure 1). A possible explanation is that tennis not only replicates the benefits of both aerobic and resistance exercise through its natural game play, but it also tends to be played for much longer periods than many other sports.²¹ Notably, despite no difference in overall physical activity and vigorous-intensity exercise in the present study, tennis players tended to spend more time exercising at moderate intensities than nonplayers, likely leading to a greater relative workload and, consequently, a greater physiological response. Most tennis matches will last in excess of 1 hour, with short bouts of high-intensity exercise (4-10 seconds) and minimal rest periods (10-20 seconds), typically completing 300 to 500 intensity efforts a match.¹⁴ These numerous bursts of high-intensity exercise bring about moderate physiological responses, equating to approximate intensities of 60% to 80% maximal heart rate, 60% to 70% maximal oxygen consumption, and blood lactate values in the region of 2 to 4 mmol·L⁻¹.^31,36 In combination with minimal rest periods, this work-to-rest ratio means tennis players continuously exhaust the phosphocreatine system and rely heavily on glycogenolysis and glycolysis to sustain efforts, resulting in increased lactate levels, reduced pH, and a considerable metabolic challenge to the exercising muscle.²⁰

Moreover, it is also possible that shifts in muscle activation patterns caused by a speed-accuracy trade-off during strenuous tennis play may contribute to greater neuromuscular adaptations.³² Subsequently, the aforementioned stimuli promote alterations in both type 1 and type 2 muscle fibers, leading to a phenotype with characteristics comparable with both shorter and longer duration sports,²⁶ and thus, an all-round athleticism that translates to enhanced physical functioning across broad domains. Furthermore, players do not need to be of a certain caliber to reap these benefits, as demonstrated by Fernandez-Fernandez et al¹³ who reported no significant differences in any physiological responses or activity profiles of advanced and recreational veteran players. Ultimately, if played regularly, the ACSM’s target of recommended physical activity is readily achieved and likely surpassed, resulting in an improved MSK profile.

Nonetheless, this study is not without limitations. As a cross-sectional design has been employed, it is only possible to assume that the differences between groups are caused by participants’ chosen physical activity and not another underlying factor. In order to account for this, an effort was made to control for potential extraneous variables, such as age, sex, and physical activity level. However, socioeconomic data were not collected and may therefore still have a confounding effect. A more longitudinal design, such as a prospective cohort study or clinical trial, may be able to better account for these extraneous variables and is therefore required. Finally, although the nonplayers in this study were all considered active and, at minimum, meeting the government guidelines for physical activity, no information was collected regarding their chosen mode of physical activity. Future studies should provide more information in this regard to provide further insight into how tennis may compare with other more specific modes of exercise.

Conclusion

The present study offers support for improved MSK functionality and adds to the existing literature base on the benefits of tennis. Cluster analysis of body composition, muscular strength, and muscular fatigue data revealed significantly greater function in both the upper and lower extremities of tennis players compared with nonplayers. This may be due to the hybrid high-intensity interval training nature of tennis. Tennis is not only an excellent activity mode to promote MSK health and aerobic fitness, it also provides a fun game-sport atmosphere. As such, tennis should be recommended more frequently as a viable physical activity for health and fitness.