Medical Timeout with Bill Tyner: Wrist Injuries

Medical Timeout

Certified Athletic Trainer (ATC) Bill Tyner has provided sport medicine services for USTA Regional Training Center camps and tournaments at the College Park Tennis Club (CPTC) for the past three and a half years.  Bill has experience helping professional tennis players with their fitness programs and has provided sport medicine services for local and national junior tennis events.  An avid tennis player, fan and student of the game, Bill believes that proper injury care/maintenance, fitness and nutrition programs allows the tennis athlete to get the best out of their abilities.  

The latest buzz with tennis injuries are ones that occur in the wrist.  Juan Martin del Potro has missed considerable time on and off since 2009 with surgeries to both wrists, his latest being to the non-dominant.  Rafa Nadal missed the 2014 US Open with an injury to his non-dominant wrist. NCAA champion Danielle Rose Collins (University of Virginia) has had numerous wrist surgeries to her dominant wrist.  At the ITF tournament in College Park last month I saw first hand numerous wrist and forearm injuries with one player retiring from a semifinal match because of wrist pain.

The most common wrist injury is tendinopathy (tendinitis).  This is the result of repeated over-stretching of the tendons, caused by deceleration forces when the racket strikes the ball.  The extensor tendons on the back of the wrist are affected when hitting backhands while the flexor tendons on the front of the wrist are affected hitting forehands.  Increased frequency of play and faulty stroke mechanics lead to increased chances of getting tendinitis.  Women appear to get these injuries more often than men.  Typically pain and tenderness is experienced over the involved tendon.  When the flexor or extensor carpi ulnaris tendons are injured, pain will be on the ulnar side of wrist.  Pain over the flexor carpi radialis tendon causes pain of the radial side of the wrist.  Extensor carpi ulnaris tendon injury is seen more frequently in the non-dominant hand of two handed backhand players.  Pain can be elicited when the wrist is extended against resistance or with ulnar flexion.  Serving and hitting forehands affects the flexor tendons and can be elicited by wrist flexion and pronation against resistance.  The injury should be treated with ice, rest and anti-inflammatory medication.  Strengthening exercises can begin once the pain has subsided.  Splinting of the wrist is occasionally done to reduce motion and symptoms.

Wrist sprains involve over-stretching or tearing of one or more ligaments. These are bands of fibrous tissue that connect the bones to one another. Usually these injuries happen when a player falls on the court. Symptoms include tenderness and swelling initially over the area of injury.  Pain and swelling may progress with time and eventually involve the whole wrist and hand.  Some bruising may develop and the ability to use the hand and wrist may be impaired.  Treatments for sprains include ice, rest and anti-inflammatory  medication.  This is followed by strengthening exercises after pain has subsided.  Splinting or bracing is done to reduce motion and symptoms. One of the more complicated wrist injuries is the snapping wrist.  This involves the extensor carpi ulnaris tendon snapping on the backside and small finger side of the wrist.  When the roof (retinaculum) tears or stretches players will experience a snapping sensation when the tendon slides back and forth from its normal position.  This injury can result from a single sudden movement or repetitive movements.  Flexing the wrist toward the little finger side of the wrist (as when hitting slice forehands, low volleys and topspin serves) will cause this occurrence.  Symptoms include snapping and pain on the little finger and backside of wrist when rotating the forearm and wrist.  The tendon can be observed moving from its normal position with supination (palm up) and relocates to the normal position with pronation (turning palm down).  Acute injuries of this type should be immobilized for six weeks.  Surgery is necessary when treatments fail and symptoms persist over long periods.

Clicking and painful  wrist involves the triangular fibrocartilage complex (TFCC).  This small disc-like structure serves as ligament connector, stabilizer and shock absorber between the bones of the wrist and forearm.  The TFCC may tear as a result of traumatic injury or degenerate with time and age.  This cartilage may develop a tear with continuous repetitive motions.  Players with an ulna that is longer than the radius are at higher risk for this injury.  This anomaly causes a pinching of the TFCC between the ulna and the bones of the wrist and also leads to degenerative situations.  Symptoms include pain and uncomfortable clicking on the little finger side of wrist.  Sometimes clicking may be painless and not as concerning as clicking with pain.  Flexing the wrist towards little finger side or extending wrist such as doing push ups or gripping a racket may cause pain. The wrist will generally hurt during play and may or may not persist after play.  Rest and immobilization may allow for torn cartilage to gradually heal.  Splinting is recommended for several weeks followed by improving grip strength after healing.  When symptoms persist you may require surgery.  Surgical options for this injury include arthroscopy to repair torn fibrocartilage, or an open procedure depending on the location of the tear.  In cases where the ulna is particularity long it can be shortened with an open procedure.  This requires a three to six month recovery period.  Wrist pain in adolescent players involves inflammation of the growth plates (wrist epiphysitis).  This usually occurs on the thumb side (radius).  The wrist growth plates become inflamed when repetitive  stress is applied such as repeated hyper-extension and rotations. Repeated stress or injury to growth plates interferes with bone development, causing inflammation and developing into premature closure of the growth plate and bone shortening.  This injury is seen most in adolescents under the age of sixteen who over train and attempt  to hit lots of topspin while they are experiencing growth spurt.  Symptoms include tenderness over the distal end of radius.  Inflammation and swelling could appear along with a tender bump in this area.  Activity increases pain especially serving, bending or bearing weight on the wrist.  Decreasing activity helps mild cases of this injury while moderate to severe cases require significant reduction of activity and immobilization.

Peritendinitis crepitans, intersection syndrome (also known as squeaker’s wrist) is inflamed tendon sheaths of the two radial wrist extensors.  The two muscles that move the thumb are affected with pain and swelling.  In addition four to eight centimeter proximal to the thumb side of wrist are affected by pain, crepitus and swelling.  When there is a sudden increase in activity, repetitive wrist flexion and extentsion there are chances that this injury will develop. Symptoms include swelling on back of forearm thumb side near wrist. Moving wrist or thumb against resistance increases pain. ROM of wrist and thumb is limited and movements produce cracking sound that is sometimes audible and can be palpated.  Treatments include activity modification, ice, splinting and in some cases cortisone injections are used.  When nonoperative methods of treatment fail surgery is required to release or remove the inflamed tendon.

As you can see lots of things can go wrong with a wrist.  I believe this is overlooked by players and coaches and you can get misled by some of the information passed on.  It is very important for tennis players to implement a comprehensive shoulder/elbow/forearm and wrist conditioning program in their training.  Taking a proactive approach and finding a balance between training to prevent specific injuries and court time will allow players to spend less time being injured.

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