Vivian Grisogono

Wrist injury

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Wrist injury from tennis
Q. One of the girls I'm working with as a tennis coach has injured her wrist. She has been told it is a strained ligament on the ulnar side, but the pain eases when the wrist is warmed up, which I thought was more typical of a tendon injury. How would the feeling be for a ligament, is it similar?

She has also been told that when it doesn't hurt, she can play 10 mins with a  sponge ball. When that doesn't hurt at all, she can play longer, then move to one of those pressureless balls. The pressureless balls come in different colours and pressures. She has been told to move through the different pressures until finally using the normal yellow tennis ball. Are those balls really useful as part of rehabilitation? I know they are not good for timing or feel for tennis, but are there physiological problems with hitting a pressureless ball, especially when there is an injury to be concerned about?
Male tennis coach, 24, UK

A: Generally speaking, I don't recommend playing with the soft sponge balls at all, because they completely disrupt the normal dynamics of tennis, and in fact in a way put more stress on the racket arm to keep control of the ball.

Usually, wrist problems in tennis players are related to the racket and/or the way the racket is gripped and manipulated. The cause of the problem has to be identified with care, in order to correct it as part of recovery and prevention of future problems. Firstly, one needs to know exactly how the pain started: was it during or after tennis, was it linked to playing too much, practising in repetitive patterns, or changing rackets or style of play? Then one has to identify when the wrist hurts. It might be on certain strokes, certain parts of a stroke, or in situations such as lunging for the ball or being caught off-balance and hitting the ball late. There may or may not be pain during normal activities, such as turning door handles or stirring liquids. Is there pain only on movement, or also when the wrist is at rest? Is there pain in bed at night? Is there tenderness on pressure? Is there any swelling? Does the skin look abnormally red, dark or pale?

It'll be good for you to see if you can identify any possible problems with racket or technique as you watch the girl playing. You could make a list of possible risk factors and see how many you can tick in her case. The things to take into account are: is the racket grip the right size and shape? is she gripping correctly on the racket handle? does the racket head drop down as she strikes the ball? how is her backswing? is she hitting the ball late or early, therefore too far behind or in front of her body? how is her footwork? how much body rotation does she use during the strokes?

All of this information is vital for everyone dealing with the girl, you as her coach, and also her physiotherapist or any specialist she might see. She should be encouraged to write down her symptoms day by day, to build up a clear picture of the problem.

Problems on the ulnar side also tend to happen when the player grips the racket too low on the handle, so that the ulnar side of the palm is not on the handle. This allows the player to use more wrist action to create spin and power. However, dropping the wrist in this way weakens the grip considerably, and puts a lot of stress on the tendons and muscles on the thumb side of the hand and forearm, which have to work harder to keep the racket stable. If this is happening, one has to look at the balance of the hand: most often the inner side of the palm is weak relative to the thumb side. A good exercise for correcting this is to squeeze a squash ball or similar sized object with the 4th-5th fingers, trying to avoid engaging the other fingers. This can be done with the elbow bent, then with the elbow straight, palm up and palm down. Repeating this frequently a few times during each day can strengthen up the inner (ulnar) side of the hand relatively quickly. 

With problems affecting the small joints of the wrist, any of the structures can be involved - ie bone, ligament, joint capsule, tendon, tendon sheaths, to name the main ones. As you say, the fact that the wrist gets better when warm might suggest a tendon problem, but in fact this can be the case with ligaments or joint capsule too, as all it means is that as the circulation gets going and the area warms up the pain sensation is lessened. In this situation, the pain is usually evident again very quickly after playing, or during play as the player gets tired.

I personally don’t believe in continuing playing when there is any pain at all. Most often these wrist problems require a good spell of rest from tennis, and very accurate rehabilitation exercises. It can be helpful for the player to use a removable wrist splint to protect the injured area, while still allowing use of the fingers and thumb. If the player can play with the other, non-dominant hand, then she can continue to practise, partly to keep her eye in, but also because playing with the non-dominant hand is excellent for maintaining body balance and helping to prevent injury, especially in the back. During the recovery period, every injured player should do the rehabilitation exercises appropriate to the injury and the stage it’s reached. Overall fitness training (avoiding stressing the injured area) is a must. Very often, an injury is an opportunity which allows a tennis player to work on areas of fitness which have been neglected in favour of excessive intensive playing.

For any physical injury, functional tests will show what actions cause pain. Once all the tests can be done without pain, and good general activity has been established round the injured area through training exercises involving not only the wrist but the arm, shoulder and rest of the body, then play can be re-started. One cannot predict how long healing takes in wrist injuries associated with tennis, but it’s likely to be at least three months, and can be much longer. As the girl’s physiotherapist has said, it’s important to work within pain limits, and not try to play if pain returns. An important part of building up tolerance is allowing rest days in between playing. Ideally, after an extended lay-off the player should start by playing just once a week for the first 3-4 weeks, then twice a week, up to four times a week.

I don’t recommend practising every day, even in normal circumstances, especially for young players. Partly because there is such a big risk of overuse injuries, and partly because the player can easily get stale. It’s much more efficient for a young player to have a rounded programme, preferably including different sports and general body conditioning. Playing matches is very different from practising. Practising for hours does not necessarily make a player fit for playing several matches in quick succession, as might happen at a tournament. If the player is tired from over-practising, and mentally stale from repetitive drills, winning matches is much harder, and injury and illness are much more likely.