Sean Fyfe offers guidance through the maze of possibilities facing the therapist regarding wrist injuries in tennis
An examination of the complicated world of wrist injuries in tennis players is a means by which we can gain a comprehensive understanding of the wrist. This includes knowing exactly what part the individual wrist structures play in terms of flexibility and stability, and how these structures become overloaded, acutely and chronically.
The first part of this article concerns diagnostics. Even if you are not a diagnostician, it is still valuable information: knowledge of functional anatomy and injury loading patterns will direct your rehabilitation plan and help you to communicate with professional colleagues.
It can be very difficult to form a good diagnosis of a wrist injury. Start as always with the basics:
* Is the injury acute or chronic?
* Which region of the wrist is sore?
As with other joints, it is useful to divide the wrist into regions for the purpose of analysis, and there are four to be considered: volar, dorsal, ulnar, and radial.
Table 1 on page 2 shows the relevant structures of each region and the main tennisrelated injury considerations. The radial side of the wrist is the important weight-bearing surface. When the wrist is loaded in extension, the radial side absorbs the force, thus it consists of the larger articulations of the scaphoid and lunate carpal bones with the radius. These articulations become tightly packed in extension because of the ligamentous support of the radioscaphocapitate and radiolunotriquetrum ligaments.
Although the ulnar side also requires stability, its role has more to do with movement. Stability on this side is supplied mostly by all the components of the triangular fibrocartilage complex (TFCC). The TFCC is the primary passive stabiliser of the distal radioulnar joint (DRUJ). The DRUJ allows pronation and supination to occur around the wrist, which is crucial for controlling the position of the hand.
Aside from being the structures through which the forearm muscles affect movement of the wrist, the flexor and extensor tendons provide active stability for the wrist. Simultaneous tension through the flexor and extensor tendons, via co-contraction of the forearm muscles, helps to keep the carpal bones tightly packed while under load, thereby increasing stability. This last point is particularly important to remember when prescribing rehabilitation exercises.
Like any injury, the initial diagnosis is critical in order to establish the correct management plan. There are five key factors:
* Establish the mechanism of injury. * Accurately palpate wrist structures for tenderness. * Perform relevant special tests. * Use imaging techniques where necessary. * Know the injuries.
Establish mechanism of injury
In tennis the mechanism of injury will relate to a fall or a mistimed shot for acute injuries; or gradual pain building on a particular shot for chronic injuries. You should remember to assess training loads. A common training error that leads to injury is to repeatedly practise a single shot that needs improvement, day after day, usually to entrench a change in technique. This means the body is being loaded heavily and repetitively in an unfamiliar fashion.
I came across this training error recently with two young female juniors intensely practising the forehand volley. They had changed their grips and were practising laying the wrist back more while contacting the ball further out in front of the body. Both players ended up with an injury to the TFCC.
By establishing the exact pattern of injury it will be much easier to draw up a plan for future management, including an appropriate return-to-play schedule. For the two girls, their forehand volleys would need to be reintroduced eventually, but in the meantime they could continue to practise other shots.
Wrist mechanics in tennis
As always, the therapist needs a sound understanding of the biomechanics of the relevant sport. In effect, this means understanding the loading pattern on joint structures during execution of the sporting technique, in order to pinpoint the precise mechanism of injury. Any significant loading of the wrist joint during shotmaking will occur in the acceleration phase, at contact and at the initial stages of the follow-through. Table 2 (right) explains what happens to the wrist during these stages of the tennis strokes.
The sports therapist must also understand how strokes vary from player to player. The type of grip the player uses is particularly important. For example, the double-handed backhand can often inflict injuries on the nondominant wrist, depending on the precise placing of the grip. Communication with the coach is essential to gain this valuable information.
For palpation to be successful, the therapist must have an excellent knowledge of surface anatomy. This is particularly important for the wrist because the structures are very small and closely packed. During palpation the therapist also needs to manipulate the wrist so that certain structures become more accessible. For example, when palpating the lunate dorsally, the wrist should be taken into flexion.
As part of palpation, the therapist should mobilise the radiocarpal, ulnocarpal and midcarpal joints to gain information on the amount of joint play. Often players exhibit excessive movement, especially if they’ve previously had an acute injury which has led to instability or if they are generally hypermobile. Generalised hypermobility is a common underlying cause and is, I believe, one reason why the reported incidence of wrist injuries is higher among females (15.7% of all tennis injuries) than male players (11.2%).
To describe all the special tests is beyond the scope of this article; please refer to Clinical Sports Medicine by Brukner and Kahn(1). Of particular interest are:
* Watson’s test for scapholunate instability
* the loading test for the TFCC, reproducing positions of impingement with sufficient overpressure to elicit symptoms
* extensor carpi ulnaris (ECU) testing.
These are considered further below.
This can be quite complicated and sports therapists should consult an upper limb specialist or sports doctor when considering any imaging techniques. Here are some examples of imaging techniques when dealing with the wrist:
* Lateral X-ray to check for dorsal displacement of the ulnar styloid process during pronation, which indicates distal radio-ulnar joint instability resulting from a tear to the volar radio-ulnar ligament.
* Posterior-anterior stress X-ray (clenched fist), looking for a gap between the scaphoid and lunate of more then 3mm, indicating scapholunate dissociation.
Know the injuries
After an acute injury resulting from a fall on to an outstretched hand on a tennis court, the therapist should consider and test for:
* fractured scaphoid
* injury to the distal radius epiphysis in the younger player
* Colles’ fracture (distal fracture of the radius and ulna) in the elderly player
* carpal dislocation
* scapholunate dissociation
* tear to the radioscaphocapitate (RSC) or radiolunotriquetral (RLT) ligaments.
The other type of acute injury occurs when making contact with the ball, often because of a mistimed shot. In these cases you should consider:
* ECU tendon rupture or subluxation
* acute bony impingement of the scaphoid or lunate with the radius
* ligament tear
* TFCC tear or dislocation of the ulnar head
* fracture to the hook of hamate as a result of impact with the racquet handle.
Tennis players are much more likely to incur chronic rather than acute injuries. The following four are common:
Extensor carpi ulnaris (ECU) dysfunction
Montalvan et al (2006)(2) reported finding ECU dysfunction in 76% (male) and 45% (female) of players who sought medical advice for wrist injury. The ECU tendon passes behind the lower end of the ulna and runs through a bony groove between the head of the ulna and its articular groove. The tendon inserts on the internal process of the fifth metacarpal. Its anatomy means that the ECU tendon comes under significant stress during pronation and supination, being tightly bound to the ulnar head. As the forearm moves from pronation to supination, the ECU tendon is pulled at 30 degrees from its position in the bony groove to still reach the base of the fifth metacarpal. It is this tensioning and angulation that causes injury to ECU in tennis players.
There are three types of injury to the ECU tendon. Acutely, the supporting sheath can be torn, resulting in subluxation from the groove, which is relatively common; or the tendon can rupture. Chronically, a tendinopathy can develop from repeated micro-trauma.
The pain is associated with the topspin forehand stroke or in the non-dominant wrist on the double-handed backhand, both strokes involving an alternation between pronation and supination under load (see Table 2).
Special tests for ECU tendon problems are:
* acute subluxation – pain will be present on passive supination
* rupture – pain will be present on active extension in ulnar deviation
* tendinopathy – pain will be present on forced isometric supination.
Triangular fibrocartilage complex (TFCC)
The TFCC sits between the distal end of the ulna and the triquetrum and part of the lunate. It consists of the triangular fibrocartilage, the ulnar meniscus homolog, the ulnar collateral ligament, carpal ligaments and the extensor carpi ulnaris tendon sheath. The special test for the TFCC is to place the wrist in extension and ulnar deviation and then rotate. This movement, as in the forehand volley, relates to overloading of the complex.
The integrity of the TFCC is closely bound up with the stability of the distal radio-ulnar joint (DRUJ). In a study by Adlercreutz et al(3), it was shown that a complete tear of the TFCC is almost always associated with instability of the DRUJ. Instability of the DRUJ is also associated with generalised capsuloligamentous laxity. Often pain on the ulnar side of the wrist is multifactorial and stability-related. Another underlying cause of compression injuries to the TFCC is ulnar variance.
Impingement symptoms are the result of a forced compression of two bones. Such injuries include:
* impaction between the scaphoid or, less commonly, the lunate and radius with forced extension
* triquetrohamate impingement with forced extension and ulnar deviation
* radial styloid impaction with forced radial deviation
* intercarpal impingements.
Refer to Tables 1 and 2 on page 2 for guidance as to which structures are at risk during which strokes. Impingements also relate to instabilities, the more accessory joint gliding there is during physiological movements, the greater the chance of impingement.
The radiocarpal, ulnacarpal and distal radioulnar joints often become inflamed. I have found this is usually the result of excessive joint translation related to slight instability. Especially at first, the irritation tends to be mild. Increased training time, which ups the degree of forearm muscular fatigue, is usually the mechanism of injury.
Finally, don’t be fooled if there are multiple areas of tenderness or conflicting signs. It is not uncommon for tennis players, especially those who have continued to play on an injured wrist, to present with multiple injuries. One of the young female players mentioned above is a perfect example. The MRI of her wrist showed a small tear to the TFCC, but also inflammation in the distal radio-ulnar joint and the lunotriquetrum articulation.
To recap: if the therapist gathers relevant information in the five key diagnostic areas outlined above, and matches this up with good sport-specific knowledge, they should be able to reach an accurate diagnosis.
To review possible rehabilitation strategies, I will use an irritated TFCC as an example. Rehab starts with a recovery timeframe for the injured structure. In this case we are looking at approximately six weeks before the player should start to hit tennis balls again and another four weeks before full training volume is achieved. As always, this timescale should be monitored and extended if required.
For the first two weeks the player should be splinted at all times, as well as using regular anti-inflammatories and ice. The next four weeks will involve a gradual increase in stretching. Regular massage to the wrist flexor and extensor muscles is also necessary to decrease tone, which can affect joint function, and to ensure full range of wrist flexion and extension.
However, probably the most important aspect of rehab is to restore and improve muscle function. Generalised laxity is, in my experience, definitely an underlying cause of ulnar side wrist pain, particularly in young elite female players. Muscle function is critical to being able to maintain wrist stability through contact for prolonged periods during practice and matches. Table 3 on page 3 gives an example of a strengthening programme.
The next step is to return to play. I believe it is essential to tape the wrist in the initial stages, particularly if instability or hypermobility is part or all of the problem. Duration and pace of play should be gradually increased. Ice and self-tests should be applied initially to monitor symptoms. In all but extreme cases, the player can be gradually weaned off the taping.
It is very important to educate the client that, should symptoms return at any time, they must stop playing, ice immediately and seek assistance.
1. Brukner P, Kahn K (2001) Clinical Sports Medicine 2nd Edition, McGraw Hill
2. Montalvan B, Parier J, Brasseur JL, Viet DL, Drape JL, ‘Extensor Carpi Ulnaris Injuries in Tennis Players; a study of 28 cases’ British Journal of Sports Medicine 2006; 40:424-429
3. Adlercreutz C, Aspenberg P, Lindau T, ‘Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures’ Journal of Hand Surgery 2000 May; 25(3):464-8