Christopher R. Sforzo, MD, FAAOS, SCSH; Yutaka Nakamura, BS, NSCA, CSCS; Lee Nakamura, USPTA, USPTR
Wrist injuries in tennis players, even elite/professional players, are common. Due to the anatomic location of the wrist and its major role in the kinetic chain needed in stroke production, it is unfortunately a common site of pain and disability. Often, the pain presents on the pinkie-side, or ulnar side, of the wrist. Many players experience this ulnar pain in the non-dominant hand during two-handed backhand strokes. In this stroke, the top hand is placed in extreme ulnar deviation and extension, while dynamically moving from supination to pronation. This same motion-type occurs in many tennis strokes, and as such can lead to acute and chronic ulnar wrist injuries.
The ulnar portion of the wrist is composed of complicated yet sophisticated anatomy that gives tremendous stability to the wrist while at the same time allowing for incredible degrees of movement. The main structures on the ulnar side of the wrist anatomically are the distal radioulnar joint (DRUJ); the intrinsic and extrinsic ulnocarpal ligaments; the triangular fibrocartilage complex (TFCC), the extensor carpi ulnaris (ECU) tendon; the pisiform and pisotriquetral joint; as well as the hook of the hamate. All of these structures can be the source of ulnar wrist pain; however, they can present in similar manners, thus clouding the clinical picture, causing potential delays in correct diagnosis and treatment. Henceforth, the ulnar wrist has garnered the pseudonym “the black box of the wrist.”
Tennis players can present with an acute event of sudden onset – either after a violent fall with the wrist in extension and pronation/supination, or after hitting the tennis ball and having an immediate feeling of ulnar wrist pain. When the presentation of pain is chronic and insidious, the ulnar wrist pain arises over the course of days or weeks, and the athlete usually cannot recall a single inciting injury.
In either case, the player typically experiences pain with stroke production, which gradually worsens during play, which decreases performance and then forces the player to curtail practice or match play. Sometimes the player describes the pain associated with an audible or palpable click on forearm rotation.
Examination focuses on the athlete’s anatomy and the use of certain provocative tests in order to illicit abnormal responses. The examiner must have knowledge of the anatomy, the structures at risk, the important exam tests to perform, and a high index of suspicion. Palpation of the lunotriquetral (LT) joint, the fovea or ulnar snuffbox, ECU, FCU (flexor carpi ulnaris), ulnar styloid, pisotriquetral joint, and hamate hook, all must be performed. Provocative tests include the ECU subluxation test, ulnocarpal stress test, LT ballottement test, and piano key test also need to be completed and will further help to ascertain the location of injury.
Sometimes imaging needs to be performed to further elucidate the pathology. This can be done beginning with standard but well-positioned x-rays, focusing in on ulnar variance (ulnar length compared to the radius), the ulnocarpal joint, and the DRUJ. Bilateral clenched fist views can further uncover dynamic ulnar positive variance. Advanced imaging can include static or dynamic ultrasound or MRI arthrogram of the wrist, which can be quite sensitive in detecting tears or bony changes. In the end, the history and clinical exam, and potentially selective lidocaine and/or cortisone injections will be the gateway to uncovering the correct pain-generating diagnosis.
Common problems include injuries to the TFCC, the ECU, and the lunotriquetral (LT) ligaments, or dynamic problems such as ulnocarpal abutment and ECU subluxation/ dislocation.
Treatment is tailored to the specific diagnosis. Strain or tears of the TFCC can be initially treated non-operatively, with a combination of rest, wraps, NSAIDs, strengthening, and potentially cortisone injections. If the players’ schedule allows, surgery can be done to either debride or repair the torn TFCC at the appropriate time in her or his schedule. If need be, surgery can be postponed and the player can be allowed to play per pain tolerance. Arthroscopic TFCC debridement typically requires 2-4 weeks of splinting with another 4 weeks of therapy to regain strength, motion, and stamina, with a gradual return to hitting after 8 weeks. Full recovery can take 10-12 weeks. TFCC repair is a protracted recovery, with typically 6 weeks of significant immobilization/splinting, followed by a progressive ROM program, strengthening, modalities, and then gradual return to hitting and full play by 4-6 months.
ECU tendonitis can typically be managed with splinting techniques, rest, NSAIDs, therapy modalities, and injections, with a return to play timeline between 2-4 weeks. ECU subluxation/dislocation can be initially treated via non- operative means to include rest, splinting, wraps, or aggressive immobilization for 3-6 weeks, and then a gradual return to play program centered on regaining strength, dexterity, range of motion, proprioception, and then stamina. If symptoms persist, ECU stabilization via open surgical means may be needed, with a return to play after 3 months. ECU tears require surgical repair and a period of protection, with a prolonged return to match play ranging from 4-6 months.
Lunotriquetral (LT) ligament tears are also (and usually) treated by non-operative means, including rest, modalities, splinting, and injections. Arthroscopic debridement and/or repair versus reconstruction are typically re- served for extreme cases where there is chronic pain and/or significant lunotriquetral joint instability.
Ulnocarpal abutment is a dynamic process whereby the ulna impacts the carpus repeatedly with power grip. This can present as chronic ulnar wrist pain with abnormal or normal x-rays. However, sometimes patients will have a longer length ulna in relation to the radius (i.e. positive ulnar variance), which causes dynamic ulnar wrist overload with tennis play. This can sometimes be managed with the above-mentioned non-operative means as well as cortisone injections. If the problem is protracted and imaging reveals a thinned or torn TFCC with ulnocarpal reactive changes due to chronic impingement, a surgical procedure to shorten the ulna can be performed, via either an arthroscopic wafer procedure or an open ulnar shortening osteotomy. Some, by its minimally invasive technique and early return to sport, prefer the wafer procedure. This may allow early return to stroke production at 4 weeks postoperatively. However, it can be technically demanding and lacks the extrinsic tensioning of the ulnocarpal ligaments that occurs in the ulnar shortening osteotomy procedure, which remains the gold standard for this problem. It carries the risk of delayed union or bone healing, or
even nonunion or no bone healing. It also requires a longer recovery and retained hardware, which may become symptomatic in the future. With the use of newer, low profile osteotomy systems, hardware complication has diminished significantly.
Wrist injuries in tennis players often result from overuse, improper technique, and even using the wrong equipment. Also, excessive wrist motion during the stroke will predispose a player to injury.
Some things to consider when facing a player with ulnar wrist pain:
Equipment: using the wrong grip size, wrong strings, and improper string tension can all lead to wrist pain. The grip size can determine the amount of force needed to hold the racket through the stroke, leading to increased firmness of grip and potential injury. Too firm a grip can restrict free movement of the arm. The grip should be only as firm as necessary to ensure proper stroke technique.
Strings types include natural gut, synthetic gut, or a hybrid/combination of the two. Gut strings are very popular among professional players because of their elasticity, tension stability and liveliness, but are expensive. and not very durable. Gut is also very sensitive to moisture. Synthetic strings were produced to give the user different characteristics such as higher durability at a better price. Synthetic gut strings are classified as nylon, polyester and Kevlar, and multifilament. Nylons are the most popular, are durable, have good feel, and hold tension well. They are not as gentle on the arm as gut or multifilament. Polyester/Kevlar are extremely durable, hold tension well, and excellent control; however, these (Kevlar especially) may be too strong for most players and are better used as a hybrid. Multifilaments have the advantage of a great combination of gentleness on the arm, tension hold, power, and control. Thus, when choosing strings, it’s important to understand the players’ ability, strength, and technique. Its best to start with the basics and then tailor strings moving forward based upon needs and physical ability/limits.
String tension can be a component in wrist pain as well. Lower tensions increase power due to increased ball on string time, but impart less ball control and can predispose to injury: the lower the tension, the longer the ball is on the strings – which can be problematic on repetitive eccentric (off-center) ball strike. This leads to increased rotational forces that transfer to the racket, which are in turn transferred to the wrist causing strain. This is especially common in recreational or novice/youth players. Most elite players generate topspin by imparting fast swings without swinging long, thus brushing the ball from low to high while still propelling it forward. A fast swing produces both spin and power, and the higher string tension gives them better control with this technique. It gets complicated when you add the fact that some strings produce more or less spin at different tensions. Thus, an ideal combination for some competitive players is to have stiffer-acting strings (e.g. polyester) strung at lower tensions, which may improve control while decreasing the force or strain on the arm or wrist.
Technical: Extreme grips such as an Western will compromise the position of the wrist, forearm, and elbow which places additional stress on the adjacent muscles and tendons. For the two-handed backhand player, we prefer the use of the continental grip on the bottom hand and the Eastern forehand grip on the top hand. Players using extreme grips (Western) place their wrist and forearm in positions that place additional stress on the muscles, tendons, and ligaments and can predispose them to injury. Additionally, another breakdown in technique is when the player uses the wrist and hand as primary force generators during ball strike. The wrist and hand must be viewed as links in the kinetic chain whereby large forces generated from the ground, lower extremity, and trunk are transferred.
Position of wrist at ball strike: In the two handed backhand, the tendency for some players is to place the top hand in extreme extension and ulnar deviation prior to ball strike. The thought is to power the ball into creating topspin at contact. By using the Eastern Forehand grip in the top hand (left hand in right handed players) and by incorporating the players’ core and lower body/legs into the stroke properly, the lower body/core can load the energy and transfer load and energy up the kinetic chain into the arm and wrist to abate some of the torsional stress on the wrist. A common mistake we see, especially in the junior player, is that the wrist is hyperextended. Problems are further exacerbated when hitting the ball late, especially on a repetitive basis. This position is weaker and less stable, and after repetitively hitting balls improperly in this loaded position, ulnar wrist pain can result. When proper technique at ball strike in employed, wrist problems can be diminished significantly.
Physical: Due to the physical demands of tennis and all of the repetition that is involved, tennis play causes the dominant playing side to over-develop which leads to overall body muscle imbalance. The non-dominant side does not see the loads that the dominant one does, thus has less strength and stamina, and is less able to absorb the loads placed across it. It is imperative to not only maintain equal sided strength in the upper extremities but also maintain flexibility, especially as the player ages. Post-practice strength and stretching protocols should be engendered at an early age so as to combat this imbalance and predisposition to non-dominant wrist injury. Exercises that strengthen the wrist, forearm and elbow include wrist curls, radial and ulnar deviation resistance maneuvers, and ball dribble off the floor then wall to improve both strength and endurance.
Prevention Pearls:
Choose your equipment carefully, take into account level of play and age.
Be sure to impart proper grip and technical skills, and be open to reviewing these periodically, even using video, taking care to notice changes in swing mechanics pre and post ball strike.
Have a daily routine to include strength and flexibility exercises that increase stamina and maintain range of motion; this should include the hands, wrists, forearms, elbows, and shoulders.
Have elastic bands in the player’s bag to allow he or she to perform these exercises anytime and have them easily accessible; also, the player should be able to perform this routine away from the supervision of coaches, trainers, and parents.
It is best to perform strengthening exercises after practice or match play or on “off” days where not hitting is done so as to not impart muscle fatigue during play.
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