Introduction
Wrist injuries are a prevalent issue among tennis players, often resulting from repetitive stress and improper grip techniques. Understanding the common wrist injuries, such as ECU tendinitis, subsheath injuries, hook of hamate fractures, TFCC injuries, and De Quervain tenosynovitis, is crucial for prevention and effective treatment.
Extensor Carpi Ulnaris (ECU) Tendinitis
Tennis players most commonly report ulnar wrist pain (2). Wrist injuries are frequently experienced as ulnar pathologies related to the extensor carpi ulnaris (ECU) tendon, particularly during forehand groundstrokes (1). ECU injuries most often result from repeated transmission of high forces to the wrist in these strokes.
The ECU tendon inserts at the base of the 5th metacarpal (Figure 1) and is fixed to the ulna by a fibro-osseous subsheath (Figure 2), further stabilized by an overlying thick retinacular sheath (3). Dynamic repetition of forehand strokes largely depends on the integrity of the ECU and its ability to contribute to wrist flexion and extension (1).
A major component of the forehand stroke associated with wrist extensor and flexor overload is the generation of topspin, which can be achieved through specific racquet grip techniques (1). To generate more topspin and power, athletes typically use the Western and semi-Western grips, which place the wrist in excessive ulnar deviation (3). Utilisation of these grip types is associated with ulnar-sided wrist injuries, almost exclusively related to ECU tendinopathy.
Over time, this leads to stripping of the retinaculum and subsequent ECU tendinosis. This same mechanism of injury occurs in the non-dominant wrist during the two-handed backhand groundstroke, specifically in the wrist closest to the racquet head (3).
Figure 1. Extensor Carpi Ulnaris Muscle |
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Extensor Carpi Ulnaris (ECU) Subsheath Injuries
ECU tendon instability occurs when there is a rupture of its subsheath (Figure 2). In low forehand strokes requiring sudden supination of the forearm with the wrist in flexion and ulnar deviation, the ECU tendon can subluxate over the ulnar border, resulting in significant pain with a snapping sensation upon tendon subluxation (3).
Tennis players can also experience acute ECU injuries due to traumatic subsheath rupture or attenuation. Disruption of the ECU subsheath leads to a loss of tendon stabilization, resulting in painful subluxation or snapping of the ECU tendon over the ulnar groove (1).
Figure 2. Extensor Carpi Ulnaris Subseath |
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Hook of Hamate Injury
Repeated abutment of the end of the racquet grip against the hypothenar eminence is consistently cited as the cause of hook of hamate injury (Figure 3) and neurovascular compromise of the ulnar wrist/hand, seen in tennis players, with rare cases of hypothenar hammer syndrome (2)..
Figure 3. Hook of Hamate |
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Triangular Fibrocartilage Complex Injuries (TFCC)
The Triangular Fibrocartilage Complex (TFCC) consists of the ligamentous and cartilaginous structures that suspend the lunate, triquetrum, ulnar head, and radius (4) (Figure 4). The TFCC provides stability to the distal radio-ulnar joint and facilitates load transmission from the carpus to the ulna (3).
The mechanism of acute traumatic injury to the TFCC is predominantly due to a sudden reversal of momentum of the radius as the racquet connects with the ball, while the fixed ulna continues to travel in the direction of the swing (3). Physical examination reveals point tenderness just distal to the ulnar styloid in the area of the TFCC, and pain may be elicited by passively pronating and supinating the wrist with the examiner's fingers at the wrist level (5).
Clinically, positive ulnar variance (Figure 5) has been associated with ulnar impaction syndrome and TFCC lesions, while negative ulnar variance has been implicated in cases of lunate stress injury, particularly with the use of a western forehand grip (2). It should be noted that the thickness of the triangular fibrocartilage varies inversely with positive ulnar variance (5).
Figure 4. Palmer classification for TFCC abnormalities (4)  |
Figure 5. Ulnar Variance |
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De Quervain Tenosynovitis
De Quervain tenosynovitis (Figure 6) involves the first dorsal compartment of the wrist and is a common source of pain in tennis players who utilise the Eastern grip. The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are tightly secured against the radial styloid by the overlying extensor retinaculum. Repetitive wrist flexion leads to thickening of this retinaculum, which prevents normal tendon gliding and causes inflammation (3).
Repetitive ulnar deviation is most commonly implicated as the cause of this syndrome (5). A positive Finkelstein’s test will suggest this condition (5)..
Figure 6. De Quervain tenosynovitis |
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The Role of Acupuncture and Osteopathy in Treating Tennis Injuries
Acupuncture
Acupuncture, an ancient Chinese practice, has gained popularity in sports medicine for its ability to manage pain and promote healing (6-10). For tennis-related wrist injuries, acupuncture can be particularly effective by:
Reducing Inflammation and Pain: Acupuncture stimulates the body's natural painkillers and reduces inflammation in the affected area, providing relief from chronic wrist pain.
Improving Blood Flow: Enhanced circulation to the injured wrist area accelerates the healing process and aids in the recovery of tendons and ligaments.
Balancing Muscle Activity: Acupuncture helps balance the activity of muscles around the wrist, reducing strain and preventing further injury.
Osteopathy
Osteopathy, a form of manual therapy, focuses on the body's musculoskeletal system. It plays a vital role in treating and preventing tennis wrist injuries through:
Manual Adjustments and Manipulations: Osteopathic practitioners use hands-on techniques to adjust and manipulate the wrist and surrounding joints, improving alignment and function.
Soft Tissue Techniques: These techniques alleviate muscle tension and enhance the flexibility of the wrist, reducing the risk of repetitive strain injuries.
Holistic Approach: Osteopathy considers the entire kinetic chain, ensuring that issues in the trunk and lower body, which contribute to wrist strain, are addressed. This holistic approach helps prevent recurrence and promotes overall well-being.
Conclusion
Preventative measures, proper technique, and holistic care are key to maintaining wrist health and ensuring a long, injury-free tennis career. Remember, addressing wrist pain early and adopting the right strategies can make all the difference in your performance and overall well-being on the court. Incorporating practices like acupuncture and osteopathy, athletes can manage pain, reduce inflammation, and enhance recovery.
References
1. Chung KC, Lark ME. Upper Extremity Injuries in Tennis Players. Hand Clinics. 2017 Feb;33(1):175–86.
2. Stuelcken M, Mellifont D, Gorman A, Sayers M. Wrist Injuries in Tennis Players: A Narrative Review. Sports Med. 2017 May;47(5):857–68.
3. Patel H, Lala S, Helfner B, Wong TT. Tennis overuse injuries in the upper extremity. Skeletal Radiol. 2021 Apr;50(4):629–44.
4. Rekant M. Injuries to the Triangular Fibrocartilage Complex. In: Hayton M, Ng CY, Funk L, Watts A, Walton M, editors. Sports Injuries of the Hand and Wrist [Internet]. Cham: Springer International Publishing; 2019 [cited 2024 Jun 3]. p. 235–53. (In Clinical Practice). Available from: http://link.springer.com/10.1007/978-3-030-02134-4_12
5. Rettig AC. Wrist problems in the tennis player. Med Sci Sports Exerc. 1994 Oct;26(10):1207–12.
6. Pujalte GGA, Malone M, Mandavalli A, Phrathep DD, Shah NP, Perlman AI. Acupuncture in Sports Medicine. J Acupunct Meridian Stud. 2023 Dec 31;16(6):239–47.
7. Bell AE, Falconi A. Acupuncture for the Treatment of Sports Injuries in an Austere Environment. Current Sports Medicine Reports. 2016 Mar;15(2):111–5.
8. Kang L, Liu P, Peng A, Sun B, He Y, Huang Z, et al. Application of traditional Chinese therapy in sports medicine. Sports Medicine and Health Science. 2021 Mar;3(1):11–20.
9. Sfara M. The Use of Acupuncture in Sports Medicine. Utah State University [Internet]. 2013; Available from: http://digitalcommons.usu.edu/gradreports/252
10. Lee JW, Lee JH, Kim SY. Use of Acupuncture for the Treatment of Sports-Related Injuries in Athletes: A Systematic Review of Case Reports. IJERPH. 2020 Nov 6;17(21):8226.
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