Wrist Injuries in Tennis Players: A Narrative ReviewCLINICAL REVIEW

Max Stuelcken; Daniel Mellifint; Adam Gorman; Mark Sayers School of Health and Sport Sciences University of the Sunshine Coast QLD, Australia Sports Med (2017) 47:857-868

By Pip Sale

ABSTRACT

The wrist/hand complex forms the crucial final link in the kinetic chain between the body and the racquet. The internal and external loads that are created at the wrist during all tennis strokes have potential to contribute to pain and injury.

Epidemiological data suggests that wrist pain/injury accounts for a higher percentage of all injuries in more recent studies (2014-2015) than in earlier studies (1986-1995) and that the relative frequency of wrist pain/injury compared with other regions in tennis players is noticeably higher in recent studies, particularly in females. This collective data would suggest that wrist pain/injury has increased in the modern game and appears to be related specifically to the use of the semi-western or western forehand grip and the double handed backhand. Cumulative loading with inadequate time to complete normal processes of repair and adaptation would appear to also contribute to the cause of the increase. The complex interaction between load, repetition and training practices in tennis, particularly among young developing players who choose a path of early specialisation needs further investigation.

The wrist/hand complex has a number of important roles in the production of tennis strokes because it forms the crucial final link between the body and the racquet [1]. When players are performing tennis strokes the loads applied to the wrist, both internally (muscle force/torque) and externally (ball/racquet interaction at contact) have the potential to contribute to pain and injury [6]. Internal torques may be influenced by grip tightness [9-11], the type of grip adopted by the player [12], the alignment of the trunk when performing the stroke [6] , the type of spin imparted on the ball [13] and the relative size of the grip of the racquet [14]. External torques occur as a function of the racquet size and mass, string tension, and the relative location of the ball contact on the strings [5,9,10,15-19].

Although the relative magnitude of these torques is likely to be below levels at which permanent structural damage to tissues occurs, tennis players can hit in excess of 1100 ground strokes in a match [21] so the cumulative loads are considerable. Thus it would appear that wrist injuries in tennis players are primarily a result of overuse [22,23]. Overuse injuries will generally present when there is a combination of load and repetition that exceeds the tolerance level of bony and soft tissue structures when there is inadequate time allowed to complete normal processes or repair and adaptation.

CONTINUED ON NEXT PAGE >> Tennis injuries are described in all regions of the wrist. The literature describing the various injuries mirrors clinical practice by grouping conditions according to their location. Genuinely traumatic mechanisms of wrist injury are rarely noted in the tennis literature other than an occasional fall on an outstretched hand. Most wrist and upper limb injuries in tennis are associated with overuse and a chronic time course [23], with repeated loading during the tennis stroke [22, 40-42]. Even acute presentations may be the manifestation of chronic maladaptation of local tissue [43] and the kinetic chain [44]. Three quarters of tennis players [Tagliafico et al 12] most commonly report ulnar wrist pain [38] that is associated with stroke technique [22,35,41] and of those, two-thirds involved the extensor carpi ulnaris (ECU) tendon and furthermore 90% of the players

with ECU injuries used a western or semi-western grip. This relationship has been attributed to increased loading on the ulnar wrist structures, particularly through wrist extension, ulnar deviation and supination [12]. Evidence also supports an association between ulnar-sided wrist pain in the non -dominant wrist and the use of a double-handed backhand [22] as it loads the ECU tendon with excessive supination. The wrist experiences opposing torques that may result in relative supination of the hand and carpals on the pronating forearm [49]. Another group of ulnar wrist injuries has been directly attributed to grip error [39,51,52,53] and a small amount to ulnar variance [38]. Radial wrist injuries account for the majority of other (non-ulnar) injuries and appear to be significantly associated with an eastern forehand grip [Tagliafico et al. 12].

Other factors contributing to tennis injuries may be poor technique as this can effect the magnitude of loads transferred to the wrist [20,56] and early specialisation where and individual starts participating in one main sport at an early age and is exposed to early competition and engagement in high intensity training [60]. When a player is physically immature, the combination of load, repetition and inadequate recovery increases the susceptibility to injury [22,61,63,64]. The use of inappropriate or unnecessary repetitive blocked-type training drills involving the same stroke [68] may lead to physical maladaptations and overuse injury [22,65,66,69]. should ascertain the type of grips and stroke production used by their patients. For example, use of a double-handed backhand demands that the clinician should assess the non-dominant wrist and use of the western and semi-western forehand grip may be primarily associated with ulnar-sided wrist injuries.

Further literature should report data for the dominant and non-dominant wrist separately , the grip used for each stroke and explore the complex interaction between load, repetition and training practices in tennis, particularly among young developing players who have chosen early specialisation.

A full set of references is available on request

CONCLUSION

Clinicians treating tennis players should have a greater index of suspicion for a range of wrist injuries, including several diagnoses that should not be missed, that is those that are associated with a poor outcome if not identified and managed in a timely manner.

Wrist pain/injury is a relatively common problem for tennis players in the modern game, where the use of the western and semi-western forehand grip and double-handed backhand predominate. Clinicians