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Arm Injuries

Q. I have a 14 year old daughter who plays junior tennis at a high level. Recently she had to default in a sectional tournament when she began to experience sever "stinging" in her right (dominant) arm, primarily above the elbow, especially when hitting forehand drives and serves.

Though initially thought to be an injury to her triceps tendon, a visit to an orthopedist revealed that the injury is actually to her radial nerve, which as I understand it, runs the length of the arm. The doctor put her on a medicine to alleviate the nerve irritation (a medicine given to adults suffering from shingles) and also prescribed an anti-inflammatory medication.

Apart from this, he stated that there is really nothing to do but lay off for awhile and to give it a try after 10 days or so. Are you familiar with this type of tennis injury and possible alternative treatments such as acupuncture?

A. Richard, peripheral nerve injury in the arm of an overhead athlete can occur from the repetitive stresses brought about by throwing, serving, or hitting forehands. Initially, you must let the inflammation in the nerve decrease as you have been told.

A complete evaluation of your daughter’s mechanics is important to determine if excess load or stress is imparted to the elbow or upper extremity to ensure a complete recovery. Additionally, evaluation of the entire arm for strength and flexibility deficits is also important.

While no direct evidence exists for acupuncture for this type of treatment alternative methods can be used in some cases, but typically after the more mainstream methods have been tried and deemed unsuccessful.

Q. A lot of times you see players playing up in age group (e.g. a 12 year old playing in 14s). Because of the way the power and speed of the game changes as players get older, does a player who does "play up" put him or herself at a greater risk for injury?

A. In general I would say "Yes." And the reason I say "yes" is because it is not the power you generate with your strokes but the power you have to accept coming from the other player. I think that is one of the major issues - the power, the load, coming at you. The reason for that is you get behind on your strokes. You get behind on your forehand and your backhand. You're cocking too much. You try to do too much with your arms and don't involve your legs. The other player gets some muscle behind the shot and all you are relying on is technique - because you don't have as much muscle. When you are dealing with players who are 16-18 that may not be as large an issue, but at 12 and 14 you really have to consider it. One of the things we might think about is having players start playing up once they reach puberty. There is a point at which the tradeoff of playing against more experienced players comes at an increased load a player has to face as well as an increased risk of injury.

A 12 year old will base the speed of his/her swing on the speed of the ball coming in from other 12 year olds. Moving up to 14s, if the ball is coming in faster, and that 12 year old still swings with the same speed on the racket there is going to be a problem. The 12 year old moving up should not try to hit the ball as hard as he or she did playing other 12 year olds. The 14 year old hits the ball harder. The power, the speed you get off the racket, depends not only on the racket head speed but also on the speed of the ball coming in from the player. So, if you're playing against someone who hits the ball hard, you do not have to match the other player's racket head speed to get good ball speed. And yet, there is a certain macho about trying to do this, and that macho can lead you into trouble. If you are going to play up, do not try to hit the ball as hard as they did against their own age group.

Q. What exercises do you recommend to ensure a player does not get tendonitis in the upper arm area?

A. Prevention of tendonitis in the upper arm/ shoulder can be best prevented through a combination of stretching and strengthening. With regards to stretching, tennis players are typically tight in internal rotation of the shoulder. Internal rotation can be improved by performing the two stretches illustrated below. As with all types of static stretching, it is best to do these exercises after play.

Some general guidelines when performing these stretches are:

You should feel a stretching sensation in the back of your shoulder – if during either of these stretches you feel a pinching sensation or pain in the front of your shoulder discontinue the stretching program until further evaluation is performed.

Hold each stretch for 15 to 20 seconds while breathing normally. Repeat 3 to 5 times. Do not bounce or stretch to the point of pain.

Sleeper Stretch: Lie on your side with your shoulder flexed out in front of you about 90 degrees (right angle). Bend your elbow 90 degrees as pictured.

Using your other hand, rotate your forearm and hand toward the ground until you feel a stretch in the back of your shoulder. Hold that position.

Posterior Shoulder Stretch: Stand with your arm in front of you at shoulder level. Using your other arm, bring your arm across your body as pictured. Don’t rotate your trunk and try to keep your upper back from rotating as you bring your arm across your chest. You can increase the intensity of this stretch by leaning against a wall with the edge of the wall against the outside border of your shoulder blade.

This will block your shoulder blade from moving when you do this stretch and make the stretch feel more like when your therapist or trainer is doing the stretch for you. Hold the end position and repeat.

Also perform a dynamic warm up before practice or competition that uses the shoulders and trunk (arm swings, windmills, trunk rotations) just before play. Also cool down by performing arm swings after play.

Strengthening exercises to prevent tendonitis should actually emphasize strengthening the rotator cuff (primarily external rotation), the core of the body (push ups, sit ups, trunk extensions), the front of the shoulder (rubber tubing punches in front of the body), and the upper back (rowing exercises).

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