Tennis Medicine: Wrist Overuse and Today’s Tennis Player ... Taking Preventative Action

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Tennis is a fantastic sport that tests an athletes’ accuracy, endurance and skill. It is becoming increasingly popular as a great way to exercise and have fun. However, like anything that involves repetitive use of a couple of body parts, those parts can wear down and cause pain. The entire upper extremity is placed under significant stress while swinging a tennis racquet. Although tennis elbow maybe the most popular tennis injury, wrist injuries are extremely common … just ask Rafael Nadal!

Wrist injuries can occur with tennis players at any level. During a forehand backstroke, the wrist is typically in hyperextension and progresses to hyper flexion at the follow-through. Depending on the type of shot the player hits—slice or topspin—the wrist is also deviated toward the pinkie side, ulnar deviation (slice), or forced in a palm down position, supination (topspin). Either severe ulnar deviation or forced supination of the wrist can cause significant stress on the ligaments and tendons on the pinkie side of the wrist. This is the same with the players non-dominant hand while hitting a two-handed backhand. The complex anatomy in this area provides the hand and wrist with stability and strength- however when over used, it can start to wear down, get inflamed, and even tear.

The pinkie (ulnar) side of the wrist is comprised of a tendon (extensor carpi ulnaris, ECU), numerous ligaments, and cartilage disc which all work together to stabilize the wrist with rotation and gripping. This unit of stabilization is called the TFCC (Triangular Fibrocartilage Complex). And because of its intricate and multifaceted anatomy, it can be difficult to treat.

As with most problems in medicine, it is best to prevent the injury from occurring than to treat it afterwards. Equipment choice is extremely important in injury prevention. Grip size, string types, and string tension can all lead to wrist injuries in players if not tailored appropriately to the individual. Grip size can determine the amount of force the player needs to hold the racquet through the stroke. Too much strength can restrict motion in the wrist and lead to injury. Also extreme grips, like the Western Grip, can cause more strain on the wrist.

String technology is always evolving. Natural gut strings are popular with professionals because of their elasticity, tension stability and liveliness—however, they are expensive and not durable. Synthetic strings are much more durable and less costly. However, they are typically not as gentle on the arm as gut or multifilament strings. Multifilaments are typically advantageous due to their combination of gentleness to the arm and tension hold, power, and control. Most important is to understand your ability, strength and technique and tailor strings accordingly.

String tension can also cause wrist pain. Lower string tensions increase ball on string time and thus increase power and increase risk of injury. This is especially common in novice players who hit with off-center ball strike which increases rotational forces, thus increasing strain on the wrist. Although most high-level players like high-tension strings due to increased control, it can be advantageous to have a combination of low tension with stiffer-acting strings (such as polyester) which decreases stress on the wrist.

Physical preparation in tennis is more important than most sports because of overusing muscles on one side, while under-utilizing the other side. The non-dominant side will have less strength and endurance which increases susceptibility to injury. In addition to maintaining equal strength, it is just as important to maintain flexibility. It is essential that pre- and post-play stretching and strengthening sessions are instructed to the player early in their tennis career so they can maintain balance in their upper extremities while limiting risk of injury. Strengthening is best performed after practice/play or on off days. Examples of different exercises include low-weight wrist curls, radial (thumb-side) and ulnar deviation of the wrist with use of elastic bands for resistance, and endurance drills such as ball dribble.

Tennis players with persistent wrist pain can be difficult to treat because they are typically playing three or four days a week and do not want to stop. Initial treatment for wrist pain is rest, anti-inflammatory medication, ice and bracing. Hand therapy is very helpful after the initial two to three week resting period to increase flexibility and strength with professional guidance. High resolution MRIs are extremely useful in diagnosing inflammation, sprains or tears within the wrist. And if pain persists with conservative management, an MRI can guide your physician to further treatment options including injections (eg. cortisone, platelet-rich plasma, and/or stem cells) and surgery.

For the player with significant inflammation, a cortisone injection can be extremely beneficial and potentially long lasting. Cortisone is an anti-inflammatory and when injected to the specific area of inflammation can cure the problem. Platelet-rich plasma (PRP) is blood plasma that is enriched with platelets and other healing factors that can stimulate tendon, ligament and cartilage healing. Stem cells have the ability to re-grow damaged tissue. Both PRP and stem cells are relatively new treatment options for wrist injuries and have the potential to heal tears and treat more severe problems while avoiding surgery.

Surgery is the last option, and can be avoided most of the time. However, when conservative management and injection(s) do not help, surgery can be beneficial. The vast majority of patients who require surgery are treated with minimally invasive arthroscopic surgery. This allows for a quicker return to sport than an open procedure. Each injury is different and the treatment and surgery would be tailored to the specific patient and problem.

Wrist pain is extremely common with tennis players and can be difficult to treat. Understanding the basic anatomy of the wrist and the position and force generated in the wrist while stroking the ball, along with prevention techniques can significantly decrease a player’s risk for injury.