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Background:   Few studies have examined the association between the acute:chronic workload ratio (ACWR) and complaints/injuries in young tennis players. Primary aims of this study were to investigate if accumulated external workload “spikes” in ACWR of tennis training, match play, and fitness training, and to see if high or low workload/age ratio were associated with the rate of shoulder complaints/injuries in competitive adolescent tennis players. Additional aims were to report the incidence of complaints/injuries stratified by sex and level of play and to describe shoulder injury characteristics.Hypothesis:   Rapid increases in external workload are associated with the incidence of shoulder complaints and injuries.Study Design:   A cohort study.Level of Evidence:   Level 3.Methods:   At baseline, 301 adolescent competitive tennis players, 13 to 19 years, were screened and followed weekly for 52 weeks with questionnaires, in the years 2018 to 2019. Information about time-varying accumulated external workload spikes (uncoupled ACWR &gt;1.3), and workload/age ratio, in 252 uninjured players were used in Cox regression analyses with the outcomes shoulder complaints (≥20) and injuries (≥40) (Oslo Sports Trauma Research Center Overuse Injury Questionnaire).Results:   For each additional workload spike in tennis training/match play, the hazard rate ratio (HRR) was 1.26 (95% CI, 1.13-1.40) for a shoulder complaint and 1.26 (95% CI, 1.15-1.39) for a shoulder injury. The HRR for fitness training was 1.11 (95% CI, 1.02-1.20) for a shoulder complaint and 1.18 (95% CI, 1.09-1.27) for a shoulder injury. Workload/age ratio was not associated with the rate of shoulder complaints or injuries.Conclusion:   Accumulated external workload spikes of tennis training, match play, and/or fitness training are associated with a higher rate of shoulder complaints and shoulder injuries in competitive adolescent tennis players.Clinical Relevance:   Consistency in training load on a weekly basis is most likely more beneficial for adolescent tennis players regarding shoulder complaints/injuries than a training schedule comprising rapid increases (ie, spikes) in workload.

Association Between Spikes in External Training Load and Shoulder Injuries in Competitive Adolescent Tennis Players: The SMASH Cohort Study