by Steven H. Goldberg, MD

Tennis is the most popular racket sport. It provides great exercise and develops hand-eye coordination, strength, and endurance. However, is tennis risky? Many people might think of football or rugby are dangerous contact sports. However, surprisingly tennis has twice the injury rate as rugby.1 

Why does tennis have a high injury rate?

Tennis is a repetitive sport. Repetition can lead to stress reactions over time in tendons, ligaments, and bones. Tennis strokes are often forceful repetitive motions with sudden, rapid changes in wrist movement. Playing tennis can require high intensity. Intensity may be measured by hours, strokes, or games to name a few. When tennis is the dominant sport for an athlete or is played year-round, it increases injury risk. The concept of limiting repetitive sports motions has been popularized in little league baseball. Pitchers have strict throw counts per game and have a corresponding number of required days of rest before they can throw again. These limits change with age. 

What causes wrist injuries in tennis?

Although wrist injuries can occur with a single event, most tennis wrist injuries happen from stress over time. In a typical high-level competitive match, a player could hit the ball more than a thousand times. In tennis, wrist injuries are less common than leg injuries, but wrist injury rates are increasing. They are the most common upper limb injury in men and women. Women are more likely to have a wrist injury than men. It is important to determine whether the wrist injury is in the dominant or non-dominant side, as the cause of injury is often different. For example, the non-dominant wrist is often injured in two-handed backhand strokes, whereas the dominant wrist is often injured in forehand strokes. 

Types of wrist injuries

Soft tissue tendon injuries are the most common wrist injury. Tendons are rope-like structures that attach the muscle to bone. Tendon injuries are called strains. The extensor carpi ulnaris (ECU) is by far the most injured tendon in tennis players. ECU injuries may cause up to 75% of wrist pain. The ECU can be affected by tendinitis, tenosynovitis, instability, or a tear. Other ulnar-sided injuries include: TFCC tear, ulnar collateral ligament tear, lunotriquetral ligament tear, hook of hamate fracture, ulnar nerve compression in Guyon’s canal, ulnar artery thrombosis (hypothenar hammer syndrome), and chondral/bone stress injury to the lunate, triquetrum, or hamate.

Radial sided wrist injuries are less common in tennis than the ulnar-sided injuries mentioned above. The radius is the forearm bone closer to the thumb side. The most common radial-sided injuries include flexor carpi radialis (FCR) tendinitis and de Quervain’s tenosynovitis. 

How to avoid wrist injuries in tennis

In tennis, the above wrist injuries may be increased by many factors. Lack of physical conditioning, flexibility, or rest can all lead to injury. Proper leg support, stance, and ball contact with the racket center are important in minimizing injury. When the ball hits the racket off-center, it causes more extensor muscle strain and torque and more vibration, often causing a higher degree of wrist motion.  Improper leg position and or inadequate knee flexion can increase loads on the upper extremity.

Style of play has also increased wrist injury. With open stance forehand, the wrist is critical to produce angular momentum for a hard stroke. Most current forehand strokes use a lot of top spin which requires rapid and forceful wrist and forearm rotation and acceleration. During serving, the wrist has powerful, rapid flexion at ball contact to increase ball velocity. The wrist is critical in positioning the racket face in all strokes to control ball direction and generate top or backspin.  Other factors that impact wrist load and stress include how tight the athlete grips the racket, the specific grip style, and racket features. 

It is important for the athlete to select an appropriate racket. Modern rackets designs are lighter but also have bigger frames, with increased stiffness compared to wooden rackets. Racket features that may affect injury include size, weight, stiffness, grip diameter, type of strings (synthetic, hybrid, or natural gut), string tension, and customization. 

Grip style has a large part in determining risk of wrist injury.2 The main grips styles are Continental, Eastern, Semi-Western, and Western.  Each grip has advantages for certain strokes and ball height. Radial-side injury, for example, is more common with the Eastern grip. This may be because power is generated through more wrist flexion. Eastern grip users are often older and have more years of total experience. Ulnar-side injuries are more frequently seen with Western or Semi-Western grips. Since most younger and new tennis players today use a semi-Western or Western grip, ulnar wrist pain is much more common today. This grip uses more ulnar deviation to generate power and topspin, placing more stress on the ECU tendon.

What wrist injury do I have?

Your specific wrist injury can be diagnosed based on history, physical exam, and imaging. X-ray, ultrasound, and MRI imaging are the most useful to assess tennis injuries. Many wrist injuries can be treated with a change in training technique, adequate rest, external support with splints or casts, oral medications, steroid injections, and therapy. It may take many weeks or months before the wrist pain resolves, so patience is key. Occasionally an injury requires surgery. If you suffer from wrist pain, you can find a hand surgeon near you on from the American Society for Surgery of the Hand (ASSH). Your hand surgeon can also treat injuries of the hand, elbow and shoulder that may have arisen from tennis, such as tennis elbow.

Steven H. Goldberg, MD is a board-certified hand surgeon with Bellin Health Titletown Sports Medicine and Orthopedics in Green Bay, WI. He is a member of ASSH, as well as the American Academy of Orthopaedic Surgery.  He serves as the Co-Chair of the ASSH Public Education Committee.


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