Wrist Injuries

Q My daughter is a 17 year old competitive tennis player. She has a wrist injury that has been brothering her for over eight months. We believe that the injury originally occurred during a mixed doubles tournament in which the boys were very hard hitters. She went to an orthopedic doctor who diagnosed it as a TFCC injury. She went through physical therapy to rehab the wrist and everything appeared to be going fine. She took three months off and started to play again in and all was well for about two months. She now experiences swelling in the wrist after playing for a short period of time (1/2 hour), but has no pain. When her wrist swells, her hand feels weak and she has muscle spasms if she plays for an extended period of time. She has seen three doctors including a hand specialist and has had x-rays, an MRI and a bone scan. Everything turned up negative for tears, fractures, etc. Her form has been looked at and she has changed rackets and grip size. Nothing seems to help. Have you heard of any similar cases? Any help is appreciated.

A. The problem sounds pretty familiar and the injury may involve the Triangular Fibro-Cartilage Complex (TFCC) in the wrist – which functions much like the meniscus in the knee. However, this injury is impossible to diagnose over the Internet and the player would need to have the x-rays examined by a doctor who has experience with TFCC injuries, and has experience with tennis players, to get an accurate diagnosis. Unfortunately, I have found that not a lot of doctors really know what TFCC injuries in tennis players look like.

The classical treatments for a TFCC injury include change in grip - not necessarily a racquet change (e.g. use less of a Western grip on the forehand, less cocking on the two-handed backhand), taping the wrist, strengthening not only the wrist but the forearm and shoulder muscles, and making sure the player uses the entire kinetic chain, not just the arm when hitting.

Surgical treatment may be necessary if symptoms persist. The problem is often not in the actual TFCC, but in the attachments around the edges of the TFCC. When these attachments are damaged, the TFCC slides into the joint between the bones, and can give pain, swelling, and clicking.

Q. Follow-up question: The confusing thing about this is that the x-ray, MRI and bone scan don't show any tears or damage and that she doesn't have any real pain. She does have the "clicking" sound associated with the TFCC injury, but wouldn't something show-up? What would be causing the swelling and the muscle fatigue that's been bothering her? She's takes an anti-inflammatory and has had a cortisone shot, but they don't appear to help. Her doctors want to do surgery as a last resort, but it would be exploratory since they can't see anything wrong. This injury has been real frustrating for my daughter and everyone else involved. Please let us know what you find. Any information and help is appreciated. Thank you.

Q. I am sorry that the usual treatments have been of little effect. In response to your questions, here is some more information about TFCC injuries in tennis players:

TFCC injuries can show up, especially on MRIs, but most of the time they require injection of a dye into the joint to outline the tear. Sometimes, the injury can be hard to see if there has been a scar healing response, which even though it is not good tissue, can mask the injured area.

This injury does not seem to get much worse with play, but as you know it does not get much better with rest either.

The longer an injury of this nature lasts, the less likely it is to resolve on its own, due to the fact that this becomes a "failed healing response"- the body seems to give up trying to heal the injury and either puts down some scar or leaves the tear.

There are several theories about the weakness, but no hard facts. It is probably due to changes in the way the hand grips the racquet, or weakness due to swelling produced weakness.

Q. I recently started playing more tennis and now all of a sudden I have wrist soreness. It doesn't happen during the match or practice but later in the day it's sore and it doesn't totally go away. I'm left handed and it's my left wrist. It hurts even while typing or writing or other non-tennis wrist uses. I've never had prior wrist soreness. Is this over use or tennis technique and what can I do to correct it. I love playing tennis.

A. You likely have tendonitis of your wrist, and fortunately, you are in the beginning stages of it. You likely are experiencing low levels of inflammation which is why it doesn’t really hurt while you play tennis but only after.

The most important thing you can do is to have your technique checked by a certified tennis teaching professional. Often tendonitis in the wrist is caused by improper loading or technique, most specifically, using the wrist and elbow segments to produce the power behind your strokes rather than the entire kinetic chain (legs, hips and trunk).

Treatment usually consists of ice, rest, and sometimes in the more severe cases formal physical therapy to decrease the pain and inflammation with ultrasound and electrical stimulation. Also important is to increase your arm strength. Doing very light weights with multiple sets of 15 repetitions for wrist curls with the palm up and palm down are a good start. Additional exercises and specific guidance can be given by a sports physical therapist or athletic trainer.

While this seems like a lot of advice, it shows how all aspects of care are important – checking your technique, decreasing inflammation and finally increasing arm strength – good luck.

Q. Does stretching prevent injury? Particularly in the wrist - does flexibility in the forearm have anything to do with wrist injury?

A. Inflexibility by itself is not a predictor of injury. However, what it does, it creates abnormal mechanical motions or inefficient mechanical motions. Then if you do something wrong, or a lot, you can get into trouble. The wrist is a perfect example. Where is the wrist supposed to be in most of your strokes during tennis? Within 30 degrees either way from a neutral position. Therefore flexibility does not play a huge role - unless you are so tight you do not even have those 30 degrees of motion. However, if you get out to 60 degrees or more (of wrist flexion or extension), flexibility will play a role, putting added stress on the joint. Should you do stretching? Yes. Will stretching act as the primary mechanism for injury prevention? No. You have to make sure you are not behind on your strokes.

A. What we would like to see is a controlled study on this topic, as it pertains to the wrist. We would like to look at some players with flexible wrists and some with inflexible wrists and then track their injury patterns. Unfortunately we do not have that information and my response would be purely my anecdotal opinion. I do believe that if you get to the extremes of the ranges of motion in all your strokes (and you do not have adequate flexibility), and you keep doing it, you are begging for an overuse injury in that part of the body.

One of the sports we do have data on related to injuries and flexibility is running. The data shows that those runners who have the lowest injury rates are those that have "normal" flexibility, or they are in the middle of the range of motion. The runners who are very flexible or very inflexible have the highest injury rates. I tell my students that athletes should strive to maintain normal flexibility by stretching after your activity (tennis play). If a player is very flexible then they should only engage in minimal stretching. If they are super tight, they should stretch like crazy after they play to try to get to that "normal" range of motion.

Q. I am a physician/surgeon/competitive tennis player. I have been plagued with TFCC JT pain, not responding to nsaids rest and only temporized by steroid injections for nearly two years. One wrist specialist said I may have too long an luna bone which impinges on the triangular cartilage. Please High Performance experts, I have a lot at stake here!

A. One of the causes of TFCC (triangular fibrocartilage complex- a cartilage like shock absorber between the forearm and wrist) injury is that the ulna, or bone on the pinkie side of the wrist, may be too long. This puts pressure on the cartilage as the wrist rotates, and may cause a tear. X-rays are good at determining the length of the bone. Other problems on that side of the wrist need to be evaluated as well. These include tendon injury and cysts.

Poor technique, with extra cocking of the wrist before ball impact, or too much "wristiness" in the swing, make all the symptoms worse. Treatments for each of these conditions will usually allow return to play. Consultation with a sports medicine doctor who is familiar with tennis and wrist injuries should be done.

Q. Is there more stress on the wrist using the open stance forehand compared to the closed stance forehand, or is it equal?

A. The amount of wrist stress is more related to the type of grip and/or the type of forehand technique, a single unit or a multi-segment forehand. The research studies on the open stance tend to show non-significant advantages on ball or racket velocity over the traditional square stance.

In 2003 we conducted a study to investigate the upper extremity joint loading between the open and square stance tennis forehand and we found that the open stance did not generate greater loadings in the upper extremity joints than the square stance (Bahamonde & Knudson (2003), Kinetics of upper extremity in the open and square stance forehand. Journal of Science and Medicine in Sports, 6(1): 99-101. The wrist loadings were small for both stances but our subjects used a standard eastern forehand grip. It is very likely that type of grip will strongly affect wrist stresses.

Bruce Elliott and his co-workers from the University of Western Australia have shown the type of grip affects how much of the racket velocity is generated by the hand segment (Elliot et al, (1997)), The influence of grip position on upper limb contributions to racket head velocity in the tennis forehand, Journal of Applied Biomechanics, 3: 182-196. It is very possible that players who rely on excessive wrist motion during the forehand stroke will generate greater loadings or stresses at the wrist, which could lead to overuse injuries in the joint — this has not been documented in the biomechanics literature

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