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Ask the Lab: Wrist Injuries

May 25, 2008 12:25 PM

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    Author's Note:
    The topic of wrist injuries in tennis is one that comes up quite regularly. We have posted an “Ask the Expert" column on this topic in the past, but want to highlight a Q&A that went back and forth between a parent of an injured player and an orthopedist familiar with TFCC injuries (Triangular Fibro-Cartilage Complex) in the wrist. We thought this exchange contains some useful information and may provide a reader with some questions to ask his or her orthopedist if experiencing wrist pain.

    Related: Dr. Todd Ellenbecker answers questions on wrist soreness.

    My daughter is a 17-year-old competitive tennis player. She has a wrist injury that has been brothering her for over eight months (since July 2005).

    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 recently and all was well for about a month.

    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. Any help is appreciated. Thanks.

    Orthopedist response: The problem you describe sounds pretty familiar. I have found that TFCC injuries in tennis players can be difficult to diagnose.

    The symptoms you describe makes it sound like a TFCC injury, but I would need to review the patient and the x-rays to be sure.

    The classical treatments include change in grip, not racquet (less Western on the forehand, less cocking on the 2 handed backhand), taping the wrist, strengthening not only the wrist but the forearm and shoulder muscles, and making sure the nodes are being used in the entire kinetic chain, not just how the arm moves.

    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.

    Follow-up Question: Thank you the response. 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?

    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.

    We believe that we are doing everything possible to treat this injury including wearing a wrist brace and strengthening the wrist, forearm and shoulders as suggested. She uses an eastern grip on her forehand so hopefully the grip isn't an issue. However, this injury has been lingering for sometime and it may be time for surgery.

    We just want to resolve this injury. If I may, I have some questions:

    1. Would this type of injury show up in the x-rays, MRI or bone scan that were performed?

    2. Is there the possibility of further damage if she continues to play with her injury?

    After 8 months, is there a chance that this injury will go away on its own?

    She has swelling but not any real pain. What causes the muscle fatigue or the tiredness in the hand (including fingers) that she feels after playing tennis for a short period of time?

    Thank you for your continued assistance. It's comforting to know that there are knowledgeable people who can help.

    Doctor response:
    I am sorry that the usual treatments seem to have been of little effect. In response to your questions:
    • A TFCC injury can show up, especially on MRIs, but most of the time it requires injection of 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.

    Additional comments:

    This was a good question, because it allows a lot of room for answering.

    • Technique-wise, no stance "creates" an injury. Some positions and motions create biomechanically and physiologically less desirable situations, that when coupled with frequency, duration, or repetition of play, can be associated with injury. The site of injury is likewise variable. The letter writer did not specify what type of injury the stance created.

    • The open stance forehand in young players may be an example of this. There is very little literature (Duane may have access to more than I do) that demonstrates higher loads on any body part in the open stance compared to the closed stance. However, the method by which the stance affects the execution of the shots is important. Several factors may play into it.

    • The young player often hits with an extreme Western grip. A lot of times it is to develop topspin to get the ball deep and over the net, and they learned it when they were shorter and had a harder time getting it back and deep.

    • A majority of the young players have weakness in their legs and trunk, so they hit their shots with more "catch up" in the distal segments, in trying to hit the deep topspin.

    • The combination of these two factors means that often the player:

      A. Cocks the wrist and racquet in more extreme positions of ulnar deviation and extension, producing extra compression load on the TFCC and bone.

      B. Uses the wrist and forearm muscles more to power the racquet through the hitting zone, putting more pressure on the muscles, increasing the risk of tendinitis/tendinopathy.

      C. Leads with the elbow trying to get through the hitting zone, increasing the load on the medial elbow structures, increasing the risk of medial elbow pain and MCL injury.

      A lot of this was touched on in the USTA’s white paper on Technique, Technology and Injury in Tennis.

      Additional information on Tennis Injuries can be found in a recent edition of the High Performance Coaching Newsletter, 8(2).



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