Wrist

Tennis Wrist Pain: Why Your Wrist Hurts and What to Do about It?

By June 20, 2019 September 16th, 2019 No Comments

For tennis players, wrist pain is no news. Wrist injuries have haunted even the most talented athletes, often limiting their career achievements. If addressed in time, however, most wrist injuries can be treated without surgery.

2009 was a big year for Juan Martín del Potro. At 20, the Argentinian tennis prodigy brute forced his way to the prestigious U.S. Open title, using his devastating serve and forehand to produce winners, scoring quick points—catching his opponents unprepared.

Del Potro was the first tennis player to beat both Rafael Nadal and Roger Federer—who, many agree, was at his top shape that season—in a Grand Slam event. He beat Rafa in an uneventful three-set match (6-2, 6-2, 6-2), only to endure a five-set drama against the number one seed at the time—Federer—which ended in a victory (3–6, 7–6, 4–6, 7–6, 6–2), bringing the Argentinian his first—and, sadly, the only—Grand Slam title.

It is safe to say that history was made on that day. Analysts, coaches and players were stunned by del Potro’s explosive stroke, and predicted a no-less explosive career for the young champion. By the end of 2009, Juan Martín was the youngest player in the ATP top-10.

At the beginning of 2010, the momentum seemed to stay strong for the Argentinian. After a win over Croatian world No. 24 Ivan Ljubičić at the AAMI Kooyong Classic in Melbourne, del Potro briefly moved to a career-high no. 4 position in the world ATP rankings.

It is difficult to imagine the disappointment for the entire tennis community—not to mention del Potro himself—when he withdrew from a match with Jo-Wilfried Tsonga on day 2 of the Kooyong Classic exhibition tournament. The reason: wrist injury.

At the time, nor Juan Martín nor his medical staff were ready to give in, and the Argentinian’s team decided not to back out of the imminent Australian Open. Del Potro fell to Marin Čilić in the 4th round in a painful four-and-a-half hour, four-set drama.

The rest of the Argentinian’s career can be summarized as a series of medical retreats and comebacks. After the Australian Open disappointment, the player had to take 9 months off the tour, at one point falling out of the top-250 in the ATP rankings.

Del Potro made an impressive comeback in 2011, leading Team Argentina to Davis Cup finals. In 2012, Juan Martín claimed bronze at the Olympic Games. In 2013, he reached the semifinals of Wimbledon. In 2014, however, he suffered a left-wrist injury, which forced him out of the game for two years.

After returning to the court, the Argentinian made many memorable appearances. In 2016, he won the Davis Cup for his country. The same year, he claimed silver at the 2016 Olympic Games.

More Wrist Problems

However, wrist problems never went away fully. Injuries have haunted Juan Martín to this very day, never allowing the former U.S. Open champion to fulfill his potential.

It is difficult not to sympathize with Juan Martín del Potro’s cautionary tale, but the reader should never assume that such stories are rare.

In October of 2016, Rafael Nadal had to take the rest of the season off due to a wrist injury. His uncle and coach, Toni Nadal, has openly spoken at the Congreso Murcia Sport & Business conference in Spain that Rafael has been ‘living with pain and painkillers since 2005.’

It is known that Venus Williams, while avoiding serious wrist injuries, has been suffering from tendinitis in both wrists—an inflammation of the tendon, a thick cord that attaches bone to muscle.

Statistically, wrist injuries in tennis—whether caused by a traumatic experience or simply wrist overuse—are a part of players’ everyday life.

According to a 2012 study of injuries in Wimbledon, almost 21 wrist injury occurs per 1000 sets played. Assuming the average of 4 sets per match, a player is statistically likely to encounter an injury every 12 matches. The study concludes that while men are more likely to encounter an injury in the lower part of the body (hip, groin, ankle), female players suffer from upper-body problems (such as wrist injuries) more often.

A more recent review studied injuries in the U.S. Open from 1994 to 2009. While the overall numbers were found to be lower among players (roughly 24 injuries per 1000 matches played per player), wrist injuries turned out to be the 2nd most common injury type.

All data points to the fact that tennis is particularly stressful for the wrists. Why is that?

Why Does Tennis Cause Wrist Damage?

Back in the era of wooden rackets, hitting a tennis ball was hardly more stressful on the wrist than striking a badminton shuttlecock. Tennis players would often hit the ball with the racket in vertical position, which alone indicates the level of force put into the motion.

In comparison, consider that 120 mph was considered a record-worthy serve speed back in 1932. Today, the fastest serve record belongs to Sam Groth, who landed a hardly-human 163.7 mph ace back in 2012.

The weight of the rackets used by professionals and amateurs has increased significantly, too. Most wooden rackets fall into the range of 90-200 grams. Even junior-oriented composite rackets used today weigh at least 250 grams, with equipment designed for professionals often exceeding the 300 g mark.

While these changes may not seem dramatic, they do compound. After hitting tens of thousands of ball strokes, even the slightest changes in the racket weight and hitting force translate into a radical increase in wrist wear-and-tear.

Naturally, new composite rackets are designed to absorb the shock that occurs upon contact. From string tension to the materials the frame is made of, modern rackets are built in a way to offset the largely increased hitting power.

However, shock is best absorbed when the ball is hit with the racket’s sweet spot—usually the point in the middle of the racket head. When the stoke misses the sweet spot, the shock is considerably larger—which translates into stress onto the wrist.

Not hitting the ball with the center of the racket also causes the racket to spin. This introduces additional stress in the arm.

For amateur players, consistently finding the racket’s sweet spot is often a challenging task, which means that wrist problems manifest after fewer matches, compared to professional players.

There are a number of factors that determine how much stress is produced onto the wrist during a tennis match.

In terms of technique, the double-handed backhand grip has proven to be extremely stressful on the non-dominant arm, causing many injuries for professionals and amateurs alike. Most players do not realize how much they supinate their non-dominant hand while performing a double-handed backhand. Only with the help of slow-motion filmed material it is possible to appreciate how severely the non-dominant hand is turned outwards during the backhand.

Counter-intuitively, a one-handed backhand is a safer option for players in terms of wrist damage. However, if switching the technique is not an option, it is necessary to train both sides of your body equally to prepare your non-dominant side to absorb the shocks repeatedly.

Not only the non-dominant hand is pressured to the extreme during the traditional double-handed backhand, but it is also, arguably, the most vulnerable body part in tennis players. Due to the forehand-focused game of today, it is not uncommon for players to have an underdeveloped left (or right) part of the upper body.

Two particular dimensions in which the non-dominant half of a tennis player must be trained to avoid injury are strength and flexibility, one no less important than the other. Exercises are usually performed either after practice, or during off-days, and frequently involve low-weight wrist curls, radial (thumb-side) and ulnar deviation of the wrist with use of elastic bands for resistance, and endurance drills such as ball dribble.

In a similar fashion, popular western and semi-western forehand grips require players to dramatically extend the dominant hand, which causes maximum stretch in the muscles and ligaments in the arm. When a ball is hit with significant force under that kind of tension, injury is more likely.

Variations of the eastern grip that favor a flatter groundstroke enable players to restrict wrist supination and overextension during the stroke. For that reason, eastern grip is less likely to cause an injury in tennis players.

Grip size is another frequent culprit in tennis-related wrist injuries, mostly due to overuse. If the grip is too large for a player’s hand, the racket handle is held more firmly, which, once again, causes unnecessary strain onto the arm’s ligaments. It is important to test different grip sizes and find the fit that requires the least effort when holding the racket.

Wrist Injuries That Haunt Tennis Players

While tennis-related wrist injuries can occur due to very specific reasons—such as subtle in-game technique or equipment choices—the injuries themselves are not rare and are well studied both in academia and practice.

Extensor Carpi Ulnaris Tendon Injuries

Tendons are the flexible, inelastic cords attaching our muscles to the bones. The Extensor carpi ulnaris (ECU) tendon, in particular, is a weak spot for tennis players.

Due to its position—lying across the edge of the wrist—and the way it attaches to the carpal bones, this particular tendon is put under immense stress whenever a forearm is rotated. Needless to say, there’s quite a bit of forearm rotation during a tennis match.

There are two common types of injuries in tennis players that involve the ECU tendon.

The first is tendonitis—an inflammation of the tendon, caused by excessive rotation and extension of the forearm. This is primarily observed in the non-dominant arms of players who use the double-handed backhand—a technique we’ve discussed previously.

Tendonitis can be successfully treated by resting, applying ice to the inflamed tendon, partially fixating the arm with a splint, taking anti-inflammatory medications. A combination of stem cells and PRP can also be used to relieve ECU tendon inflammation quicker.

The second type of injury—partial dislocation of the tendon—is a much more serious issue and may require more immediate measures. If the tendon is indeed dislocated, it will slide in and out of its sheath upon movement, causing snapping. Immediate fixation is necessary, and surgical treatment may be required as well.

Scaphoid Fracture and Stress Fracture

Scaphoid is a carpal bone articulating with the radius below the thumb. It is a relatively large bone that connects the arm to the rest of the hand. Due to its extended, curved shape, the bone resembles a boat—hence the name scaphoid, which means “boat” in Greek.

Due to its “middleman” position, the scaphoid often absorbs most of the shock wave induced by the impact when hitting a tennis ball.

There are no specific risk factors for scaphoid fractures, but it is a common injury for tennis players. Usually, fractures in the scaphoid occur due to a heavy ball strike, when the wrist is unusually supinated or otherwise extended. For example, a scaphoid fracture might occur after returning a powerful, well-placed serve with equal force, while failing to find the racket sweet spot.

Do You Have a Scaphoid/Stress Fracture? (Symptoms)

A scaphoid fracture can be either displaced or non-displaced.

Displaced fractures are usually fairly obvious to notice, even to the untrained eye. Besides the pain, the wrist should appear physically deformed. The bones in your wrist will either have gaps between them, or overlap—in either case, it is difficult to miss the injury while visually examining the hand.

Early, non-displaced fractures—also called stress fractures—can be more difficult to diagnose. Since the fracture occurs internally in the scaphoid, there is no significant displacement, making the wrist appear normal on the outside. Non-displaced fractures are usually diagnosed after the pain in the thumb side of the hand and wrist doesn’t go away for a few days or longer. If it is indeed a fracture, swelling on the thumb side of the hand and wrist is to be expected.

It is important to treat a scaphoid fracture right away, as an idle approach may lead to serious complications. One of the more common complications to bone fractures in general is called nonunion—a condition where the bone fails to heal properly, restricting blood flow to the area. Since oxygen and nutrient intake is vital to successful bone healing, surgery may be required to fix the issue.

How to Treat a Scaphoid Fracture?

The optimal treatment plan for a scaphoid fracture depends on several factors:

  • Whether the bones are displaced or not
  • How long ago had the injury occurred
  • The exact location of the fracture

Fractures that occur near the thumb are usually the easiest to treat. Due to a good supply of blood into this area of the bone, the treatment usually doesn’t involve surgery and takes about 2-3 weeks. The activity will be restricted during the healing period, and your arm may be fixated in a cast or a splint.

Fractures that occur closer to the forearm are more difficult to treat, since the blood supply to this area is weaker. A cast may be used to treat these types of fractures.

To avoid surgical intervention, a combination of stem cells and PRP (Platelet Rich Plasma) can be used to accelerate the healing process. During the treatment, stem cells are harvested from a patient’s bone marrow or adipose tissue (fat), concentrated in a centrifuge, enabled with PRP and transplanted into the fracture site. It is a quick procedure that fosters natural regeneration capabilities.

In extreme cases—for example, if your scaphoid is broken at the waist or proximal pole or if pieces of bone are displaced—surgical treatment may be necessary:

  • Reduction. An incision is made, and the bones are surgically manipulated into their proper positions.
  • Internal fixation. A metal implant is placed inside the bone to assist safe and correct healing.
  • Bone graft. A small part of the bone is taken from your arm or hip and placed into the fracture site.

Dorsal Carpal Ganglion Cyst

While common in a wider population, the formation of ganglion cysts is particularly frequent among tennis players.

Essentially, a ganglion cyst is a hernia (a “leak”) of fluids into the soft tissues in the hand. Ganglion cysts usually form just above the Scapholunate joint—the structure of bones and ligaments connecting the arm to the rest of the hand. In the absolute majority of cases, ganglion cysts form idiopathically—which means that there can be a number of possible causes to the condition. However, once they do form, they tend to put pressure on the surrounding nerves, causing pain and restricting movement.

Larger ganglion cysts often surface on the back of the hand as small, visible lumps.

As many as 50% of the cysts will resolve spontaneously. For that reason, the recommended treatment plan is often simply waiting until the cyst goes away eventually.

In severe cases—where the cyst is causing significant pain and discomfort—more immediate measures may be required. Ganglion cysts can be removed via aspiration/injection—however, this type of treatment usually results in recurrence of the cyst. Cysts can also be removed surgically.

Tips to Avoid Wrist Injuries for Tennis Players

As always, the best treatment is prevention. Here are a few crucial steps any tennis player can take to avoid wrist overuse and injury:

  • Use wrist guards. Even the most basic wrist guards can help stabilize the wrist and absorb shock.
  • Always, always warm up. Performing warm-up exercises for wrists in particular can go a long way in preventing injury.
  • Invest into finding the right gear. Everything about your racket—the string tension, the head size, the weight, the grip size—can have an impact on your wrists’ longevity. Make sure to consult a specialist before committing to a specific piece of equipment.
  • Use a one-handed backhand. As we’ve discussed extensively in this article, many of tennis-related injuries come from using a double-handed backhand. Consider switching to a one-handed alternative.
  • Exercise your non-dominant side. While a piece of general advice, this is particularly important for players who use the double-handed backhand. Flexibility and strength exercises for the non-dominant hand are especially important in preventing injury.

Final Verdict: Tennis Causes Wrist Wear-and-tear, but Injury Can Be Prevented

Tennis can be an unforgiving sport in terms of wrist damage. Wrist injuries have haunted even the best players—even to the extent of ending careers.

If symptoms of an injury do occur, do not ignore them. Many injuries can become worse over time, which may limit treatment options. Always consult your physician if you feel like there may be signs of damage to your wrists.

Dr. Matthew HC Otten

Dr. Matthew HC Otten

Director of Orthopedic & Orthobiologics
Fellowship-trained & Board Certified in Sports medicine
Director Angiography at Harvard Clinical Research Institute
Michigan Stage University Alumni