http://ajs.sagepub.com/ Medicine The American Journal of Sports http://ajs.sagepub.com/content/37/4/760 The online version of this article can be found at: DOI: 10.1177/0363546508328112 2009 37: 760 originally published online March 6, 2009Am J Sports Med Alberto Stefano Tagliafico, Pietro Ameri, Johan Michaud, Lorenzo E. Derchi, Maria Pia Sormani and Carlo Martinoli Wrist Injuries in Nonprofessional Tennis Players: Relationships With Different Grips Published by: http://www.sagepublications.com On behalf of: American Orthopaedic Society for Sports Medicine can be found at:The American Journal of Sports MedicineAdditional services and information for http://ajs.sagepub.com/cgi/alertsEmail Alerts: http://ajs.sagepub.com/subscriptionsSubscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: What is This? - Mar 6, 2009 OnlineFirst Version of Record - Mar 31, 2009Version of Record >> at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ http://ajs.sagepub.com/content/37/4/760 http://www.sagepublications.com http://www.sportsmed.org http://ajs.sagepub.com/cgi/alerts http://ajs.sagepub.com/subscriptions http://www.sagepub.com/journalsReprints.nav http://www.sagepub.com/journalsPermissions.nav http://ajs.sagepub.com/content/37/4/760.full.pdf http://ajs.sagepub.com/content/early/2009/03/04/0363546508328112.full.pdf http://online.sagepub.com/site/sphelp/vorhelp.xhtml http://ajs.sagepub.com/ http://ajs.sagepub.com/ 760 Article Title Article Subtitle Author Affiliation The abstract goes here and covers two columns. The abstract goes here and covers two columns. The abstract goes here and covers two columns. The abstract goes here and covers two columns. KEY WORDS list of key words goes here Presented at the interim meeting of the AOSSM, San Francisco, California, March 2001. Address correspondence to Author 1, Address 1, City, State, Zip, Affiliation. Any author’s notes could also go here. The American Journal of Sports Medicine, Vol. 33, No. X DOI: 10.1177/1073858403253460 © 2005 American Orthopaedic Society for Sports Medicine Tennis is practiced by a wide range of people throughout the world and is the most popular of all racket sports. For the last 10 years tennis practice has grown significantly for both recreational and competition purposes. Frequently tennis practice begins in childhood and may continue into late adulthood. In spite of the positive effects that tennis practice has shown on physical and mental fitness, the increased number of tournaments and competitions deter- mines an intense dedication to training by nonprofessional or young players. This intense practice exposes players to overtraining and excessive loads of specialized physical activity.17 Furthermore it is not rare that inexperienced or unqualified supervisors with lack of knowledge regarding the causal factors of overuse injuries and, in particular, the inappropriate increase in progression of the training pro- cess, propose adult training formulas to adolescents.12 The increased number of every level and age of players during recent years has been accompanied by deep technical modification involving almost all tennis strokes. This change has been attributed to new racket designs that are lighter, bigger, and stiffer than traditional wooden rackets. This new equipment allows players to hit the ball with Wrist Injuries in Nonprofessional Tennis Players: Relationships With Different Grips Alberto Stefano Tagliafico,*† MD, Pietro Ameri,‡ MD, Johan Michaud,§ MD, Lorenzo E. Derchi,† MD, Maria Pia Sormani,|| PhD, and Carlo Martinoli,† MD From the †Department of Radiology R, DICMI, University of Genova, Genoa, Italy, the ‡Department of Internal Medicine, University of Genoa, Genoa, Italy, the §Department of Physiatry, University of Montreal, Montreal, Quebec, Canada, and the ||Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy Background: Recent advances in tennis teaching techniques have been applied in nonprofessional tennis players to develop a more effective play. Hits with enormous amount of top-spin and lower technical and physical training are responsible for most wrist injuries in nonprofessional tennis players. Hypothesis: The use of different grips (Eastern, Western, semi-Western) determines the pattern of wrist injuries in nonprofes- sional tennis players. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Between January 2006 and August 2007, we evaluated 370 nonprofessional division III and IV tennis players. The screening consisted of a questionnaire appropriately prepared to investigate wrist injuries. Medical records of players who reported a wrist injury were reviewed. Body mass index, years of practice, weekly hours of training, racket weight, grip (Eastern, Western and semi-Western), kind of strings, injury type, time out of competition, and therapy (medical or surgical) were recorded. Statistical analysis was performed to assess the association of different wrist injuries with these variables. Results: A total of 320 players reported no injuries in their activity; 50 (13%) reported injuries to the wrist. Medical records of these players were reviewed, and 30 extensor carpi ulnaris lesions, 3 lesions of the extensor tendons, 5 injuries to the flexor carpi radialis, 6 de Quervain diseases, 5 triangular fibrocartilage lesions, and 1 intersection syndrome were found. Ulnar-sided injuries were more frequently associated with Western or semi-Western grips while radial-sided injuries were associated with Eastern grip (χ2 = 20.7; P < .001). Average time out of competition was 69 days; 4 players underwent surgery; the others received medical and rehabilitative therapy. No differences were observed regarding body mass index, years of practice, weekly hours of training, racket weight, and strings. Conclusion: In nonprofessional tennis players with wrist injuries, different grips of the racket are related to the anatomical site of the lesion: Eastern grip with radial-side injuries and Western or semi-Western with ulnar-side injuries. Knowledge of this relationship may influence training, prevention, diagnosis, and therapy of wrist problems in nonprofessional tennis players. Keywords: tennis; grip; wrist; injuries; diagnosis 760 *Address correspondence to Alberto Tagliafico, MD, University of Genova, Radiology, Genova, Italy (e-mail:
[email protected]). No potential conflict of interest declared. The American Journal of Sports Medicine, Vol. 37, No. 4 DOI: 10.1177/0363546508328112 © 2009 American Orthopaedic Society for Sports Medicine at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ Vol. 37, No. 4, 2009 Wrist Injuries and Grips 761 more power and control. However, in nonprofessional play- ers, efforts spent to develop a more effective and aggressive play using tactics and techniques similar or equal to the professional players are not always supported by an ade- quate physical training and technical development.4 The imbalance between the power of the strokes and the level of physical conditioning, which includes coordination, power, strength, speed endurance, and flexibility, is respon- sible for negative adaptive changes that may determine the injury pattern.17 Musculoskeletal injuries related to tennis may be related to a single event, in which a macrotrauma is responsible for an acute injury, or to chronic overuse. Traumatic inju- ries occur more frequently in the lower extremities, while chronic injuries are equally distributed among upper and lower extremities.5,15 However, wrist lesions are considered relatively rare in comparison with other kinds of tennis- related injuries, and perfect wrist functionality is essential to an effective play. Such lesions are various and may involve different anatomical sites. Extensor or flexor tendi- nitis, ulnar carpal impingement, triangular fibrocartilage injuries, ligamentous tears, and fractures of the hook of hamate are the most frequently occurring injuries accord- ing to current literature.7,17 The variety of injuries reported may reflect different sequences of musculoskeletal activa- tion and loads on the wrist, which may be related to the different techniques of playing. Tennis coaches and instruc- tors have several ways to teach tennis strokes depending on the age, level of playing, and ambitions of the player; furthermore, players choose different grips and personal- ize the movement. Among popular media and tennis instructors it is generally believed that different grips and stroke movements determine different biomechanical loads on the wrist. However, to the best of our knowledge, there are no studies in the scientific literature that investigate the pattern of wrist injuries in relation to different grips. Therefore the aim of our study was to investigate if there is an association between the use of different grips (Eastern, Western, semi-Western) and the pattern of wrist injuries in nonprofessional tennis players. MATERIALS AND METHODS Between January 2006 and August 2007 we screened 400 nonprofessional division III and IV tennis players (323 men and 77 women; mean age ± standard deviation: 26.4 ± 14; range, 11-62 years) who participated in 7 division III official tournaments organized by the Italian Federation of Tennis. In Italy, the classification system is divided into 4 divisions: division I corresponds to the top level and includes the best 20 male players and the best 10 female players. Other divi- sions are II, III, and IV, indicating players of progressively lower levels. All the players are considered competitive, included in 1 of the 4 divisions, and authorized to participate in the tournaments if they achieve a specialist medical certi- fication. To obtain a national ranking, athletes must win a series of matches. More detailed information on the Italian tennis division system is available at www.federtennis.it. A questionnaire was prepared to investigate wrist injuries by modifying a previously employed tennis questionnaire used to assess the prevalence of injuries in elite junior players.5 The questionnaire was administered to all play- ers at tournament check-in. The questionnaire recorded age, body mass index (BMI) (by recording the weight and dividing it for the square of the height), years of tennis practice, weekly hours of training, racket weight, dominant arm, forehand grip (Eastern, Western and semi-Western), backhand type (double-handed or single-handed), kind of strings (synthetic, hybrid, or natural gut), injury type when a tennis-related injury had occurred and consequent time out of competition (self-reported by the player), and therapy (medical or surgical). The questionnaire consid- ered only injuries that occurred during the last 3 years of competition. All players who participated in this study gave written consent to the treatment of their data for scientific purposes. In regard to the racket, only weight was considered. (Racket stiffness was not considered because in competi- tive models it is often related to the manufacturer and the authors wanted to avoid any commercialization bias.) Furthermore, players often customize their rackets with additional weight (lead) on different parts of the racket, string vibration dampers, and silicone altering the original features of the racket. Grips The authors registered the 4 basic single-handed grips used to hit the forehand: continental, Eastern, semi-West- ern, and full Western. For each grip, the player places the base knuckle of the index finger and the heel pad of the palm on the grip bevel of the racquet. Different grips are defined on the base of the location of the base knuckle of the index finger on the 8 faces of the racket grip (Figure 1). Grip types were defined according to the International Tennis Federation and checked for accuracy by 2 tennis instructors in consensus who observed the players holding the racket at rest and during competition. Continental. In the continental grip, the base knuckle is placed on face number 2 and the heel pad between 1 and 2. This grip was once the universal grip used to hit almost all strokes: forehands, backhands, special shots, volleys, and the serve. It originated on the soft, low-bouncing clay courts of Europe. Today it is usually employed only for serves and volleys. Eastern. In the Eastern grip, the base knuckle is on face 3, and the heel pad between 2 and 3. This grip arose on the medium-bouncing courts in the eastern United States. It represents the classic forehand grip. The Eastern grip is appropriate for different styles of play, comfortable for beginners, and adaptable for all surfaces. The advantages of the Eastern grip are that it is easy for beginners to learn, is easy to generate power, is ideal for waist-high balls, and can be used to hit a variety of top-spin, under- spin, and flat drives. The disadvantage is that it is difficult to powerfully hit very high balls. Semi-Western. The semi-Western forehand grip has the base knuckle and the heel pad on face 4. Strength and control to the forehand are guaranteed by this grip; moreover, begin- ners feel comfortable because the palm of the hand supports at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ 762 Tagliafico et al The American Journal of Sports Medicine the racquet, providing additional stability at contact. Powerful top-spin forehands are the strokes facilitated by this grip. Advantage to this grip is that high balls are easy to hit, but low balls and back-spins are difficult, and grip changes are necessary to hit volleys and overheads. Western. In the Western grip, both base knuckle and heel pad are located on face 5. This grip originated on the high- bouncing cement courts of the western United States. The drawback of this grip is that it closes the racquet face too soon before contact. This is an excellent grip for high balls and top-spin but is awkward for low balls and under-spin. It is widely accepted in the popular media that this grip is the most dangerous for the wrist and that a strong wrist and perfect timing are essential to avoid wrist injuries. In our study we arbitrarily avoided to register the grip employed for every stroke as it would have been time- consuming for the player at the moment of writing the questionnaire, and this would have increased the refusal rate to participate in the study. Moreover, in modern tennis and among nonprofessional players, the forehand is the stroke that the player tries to hit in the majority of cases.3 Also, today nonprofessional players have a prevalent ground-stroke style of play. We believe, therefore, that recording of the forehand grip only is sufficient for a pre- liminary screening. Strings We recorded the 3 different possible string materials usu- ally employed. Natural gut strings are made of cow gut and have superb elasticity, tension stability, and “liveli- ness.” Synthetic strings are high-tech products that are now similar to natural gut strings but keep the advantage of synthetic materials’ higher durability. Hybrid strings are a combination of 2 different strings for mains and crosses; we recorded strings as “hybrid” when the main strings were of natural gut and the cross ones synthetic or vice versa. Injuries The players who reported a wrist injury in the question- naire were called by phone and asked to come to our department to review all medical records related to the injury. This procedure was performed to accurately define the type of injury. Records of clinical examinations and radiological data, including conventional radiographs, as well as ultrasonography (US), magnetic resonance (MR), and computed tomography (CT) examinations, were reviewed by 2 experienced musculoskeletal radiologists and a physician experienced in physiatry to confirm or exclude the injury reported on the questionnaire. When medical records were not available or incomplete, the case was not considered for analysis. Extensor carpi ulnaris injuries. Extensor carpi ulnaris (ECU) injuries are common causes of ulnar-side wrist pain in tennis players and athletes.12,16 These injuries may be related to luxation or subluxation of the tendon, tenosyno- vitis, or complete rupture. This condition is easily diag- nosed with US and sometimes with stress test or MR.7 Intersection syndrome. This syndrome is usually reported in rowers11 but can occur in racket sports. It derives from the attrition between the 2 radial extensors of the wrist and the first dorsal compartment muscles (abductor polli- cis longus and extensor pollicis brevis), 4 cm to 6 cm proxi- mal to the radial carpal joint. Clinical examination is usually sufficient to make an accurate diagnosis, but US and MR are helpful in doubtful cases.5,11 Extensor tendon injuries (IV and V compartment only). The fourth and fifth compartments of the wrist enclose the ten- dons of the extensor digitorum communis (for the second through the fifth fingers), the extensor indicis, and the exten- sor digiti quinti proprius. Ultrasonography is sufficient to differentiate these injuries from an ECU tenosynovitis. Triangular fibrocartilage lesion. The triangular fibrocar- tilage (TFCC) acts as a stabilizer of the distal radio-ulnar joint and absorbs loads between the distal ulna and the ulnar carpus. Injuries to the TFCC must be differentiated from other causes of ulnar side wrist pain. The diagnosis has to be achieved with MR with intra-articular injection of gadolinium or with arthro-CT.7,14,18 De Quervain syndrome. De Quervain disease is a stenos- ing tenosynovitis of the first dorsal compartment of the extensor tendons of the wrist. Tenderness and pain over the radial styloid with a positive Finkelstein’s test are usually Figure 1. A, on the left side the 8 facets of the butt cap and the reference points (base knuckle of the index finger and heel pad) on the hand to identify the different grips are repre- sented. On the right side the Eastern and Western grips are illustrated; note that the hand of the players is in the same position while the inclination of the racket changes. B, the continental and the semi-Western grips are illustrated. at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ Vol. 37, No. 4, 2009 Wrist Injuries and Grips 763 diagnostic. However, US may be helpful in doubtful cases (differential diagnosis with intersection syndrome). Flexor carpi radialis tenosynovitis. This condition is rarely observed in athletes; usually it is reported in middle-aged women. Pain over the radial aspect of the volar wrist and a local lump are the typical clinical signs. Ultrasonography is sufficient for appropriate diagnosis. Statistical analysis was performed to assess the associa- tion of different wrist injuries with the different variables using SPSS software (SPSS for Windows, release 10.1.3; SPSS, Chicago, Illinois), and a P value < .05 was considered statistically significant. Multivariate analysis and χ2 test were performed. RESULTS The total number of questionnaires administered was 400, and 370 (92.5%) of them were appropriately completed by the players. The main reason for an incomplete question- naire was the lack of identification of the grip. We noted that the majority of questionnaires excluded from the analysis belonged to very young players. Of the 370 selected questionnaire, 87% were negative for wrist injury, while 13% (corresponding to 50 players) were positive. Detailed results are illustrated in Figure 2. Concerning the grip, none of the players reported the use of a continental grip. The majority used a semi-Western or a full Western grip (75% of players among those never injured; male/female [M/F]: 77%/23% and 77% among those injured; M/F: 64%/36%); only 25% of male players (injured/noninjured: 35%/65%) and 23% of female players used an Eastern grip (injured/noninjured: 25%/75%). In most instances strings employed were synthetic: among the noninjured players 88% used synthetic strings, 4.2% natural gut, and 7.8% hybrid. Notably all the injured play- ers used synthetic gut. In our series there were no players who changed the grip in the past. For a subsequent statistical analysis we subdivided the wrist lesions according to their side (ulnar vs radial). The first group included ECU injuries and TFCC lesions, while the second group included de Quervain syndrome, inter- section syndrome, and flexor carpi radialis (FCR) teno- synovitis (Figure 2). Extensor tendon injuries related to the IV and V compartment were excluded from the analy- sis as these tendons are neither radial or ulnar-sided. Players’ characteristics and detailed results of the ques- tionnaire are illustrated in Table 1. A positive association was present between radial-side lesions and the Eastern grip while ulnar-sided injuries were more frequently associated with Western or semi- Western grips (χ2 = 20.74; P < .001). A multivariate analy- sis was performed to assess the different contribution of the age and grips to the injuries. The results show that only the grip was associated with the injury (Table 2). The association between the different injuries related to the 3 grips considered is summarized in Table 3. Eastern grip players had a significant higher age (42 years) in compari- son with semi-Western and Western grip players (22 years). Moreover, the Eastern group had a significantly longer duration of activity in comparison to the semi- Western and Western one (20 years of activity vs 8 years; P < .01) as shown in Table 1. Figure 2. Flowchart of injury selection. ECU indicates extensor carpi ulnaris; TFCC, triangular fibrocartilage; FCR, flexor carpi radialis. at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ 764 Tagliafico et al The American Journal of Sports Medicine No statistically significant differences were observed between the group of injured players and the noninjured one regarding body mass index, years of practice, weekly hours of training, racket weight, and kind of strings (Table 1). DISCUSSION The main result of our study is the demonstration of an association between different grips and different patterns of wrist injury in nonprofessional tennis players. Eastern grip was associated with radial-side wrist injuries, while Western and semi-Western grips were associated with ulnar-side wrist injuries (Figure 3). To our knowledge, this association has never been investigated in the scientific literature, even if in popular media and among tennis instructors it is well known that extreme grips such as the Western grip require a strong wrist and good timing on the ball to avoid injuries.18 Other results that emerged from our study were that wrist injuries in nonprofessional ten- nis players are not uncommon as 13% of the players reported at least 1 injury to the wrist and this resulted in a great loss of training and competition time. Moreover, a significant difference between the age of the injured play- ers using the different grips (Eastern vs semi-Western and Western) was demonstrated, reflecting generational changes in tennis technique. Power and control are the main concerns of tennis players, and to achieve the best stroke possible, a proper combination of angular and linear momentum has to be reached.4 In modern tennis the forehand is the most pow- erful and employed stroke, it is played with an open-stance position, and the wrist plays a key role in developing angu- lar momentum to increase the speed of the racket head. The modern forehand is usually hit with a semi-Western or Western grip with a lot of rotational motion. The ball is hit very hard with a lot of top-spin.2 This violent movement is greatly different from past years when ground-strokes were hit gently with a long swing and a long follow- through; the top-spin rotation was rarely used. This change in ground-strokes technique has also been encouraged by the new materials; lighter and comfortable rackets allowed the new technique to develop.18 Given the central role of the wrist in ground-strokes, espe- cially in the forehand, wrist injuries are relatively common in tennis practice, and the majority of injuries described in the literature are related to tendinitis or tenosynovitis. A prevalence of wrist injuries of 19% in the nondominant wrist and 6% in the dominant wrist of young players involved in the 1998 United States Tennis Association (USTA) National Championship was reported.5,8 These data are quite similar to our findings for the dominant wrist, whereas we did not notice any injury in the nondominant arm. A possible explanation for this difference may be given by the differ- ent level of playing in our sample in comparison to the average level in the USTA Championship. The tourna- ments that we considered represented a local selection of players with a much lower level of play than the USTA TABLE 1 Players Characteristics and Questionnaire Resultsa Years of Hours of Racket Grip Strings Time Out of Therapy, n = 370 Age, y BMI Practice Training, wk Weight, g (E/W/SW) (S/H/G) Competition, d M/Sg Never injured 320 26 ± 14 22 ± 2 14 ± 8 6 ± 4 309 ± 30 80/38/202 281/25/14 – – Injured with E 12 42 ± 5b 23 ± 3 22 ± 8b 6 ± 4 330 ± 31 12/0/0 12/0/0 69 ± 20 12/0 Injured with 38 22 ± 8b 21 ± 1 8 ± 3b 7 ± 3 304 ± 23 0/16/22 38/0/0 69 ± 11 33/5 SW and W aData are expressed in mean ± standard deviation and standard error for time out of competition. Dominant arm and backhand type are not reported. BMI, body mass index; E, Eastern; SW, semi-Western; W, Western; S, synthetic; H, hybrid; G, natural gut; M, medical; Sg, surgical. bP < .01. TABLE 2 Multivariate Analysis Including Grip, Age, Years of Playa 95% CI for Exp(B) B SE Wald df Sig Exp(B) Lower Upper Step 1(a) Gripb –3.431 1.189 8.324 1 .004 .032 .003 .333 Age .048 .050 .906 1 .341 1.049 .951 1.157 Years of activity –.059 .071 .684 1 .408 .943 .821 1.083 Constant .417 2.035 .042 1 .838 1.517 aB, estimated coefficient; SE, standard error; Wald, Wald statistic (calculated by squaring the ratio of B to SE); df, degree of freedom; Sig, significance; Exp(B), predicted change in odds for a unit increase in the predictor; CI, confidence interval. bNote that only the contribution of the grip is significant. at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ Vol. 37, No. 4, 2009 Wrist Injuries and Grips 765 players. Moreover, it is well known that all players, espe- cially at low levels, tend to hit the majority of ground- strokes with the forehand, therefore it is likely that the limited use of the backhand, as well as the reduced speed of play reached by lower-level players, avoid nondominant hand injuries. Our study considered only nonprofessional players; how- ever, the mean time of weekly training was respectable. Surprisingly, in our series we did not observe injuries that are sometimes associated with tennis practice, such as ulnar nerve compression in the Guyon canal, fractures of the hook of the hamate, or ulnar artery thrombosis.8 These kinds of lesions are usually associated with a constant abutment of hypothenar eminence on the racquet handle. It has been reported that in cases of fracture of the hook of the hamate, the predominant pathomechanism is repre- sented by a stress injury.16 In accordance with this hypoth- esis we believe that nonprofessional tennis players are less exposed to stress injuries than “pros” because they can take periods of rest at the start of the pain without impair- ing their career. On the contrary, professional players are used to continuing their activity with mild inflammatory disorders. In our series we reported 5 cases of FCR tenosynovitis; it is worth noting that this condition has never been associ- ated with tennis practice. A possible explanation for this observation is that the pathogenesis of this disorder is also related to arthritis. Not surprisingly the mean age of the players affected by this disorder was almost double that of the whole group of players. It is likely that the association of early osteoarthritis and tennis-related loads on the wrist may have contributed to this condition. To keep with this hypothesis, it is important to remem- ber that degenerative changes in the musculoskeletal sys- tem of tennis players, such as lumbar spine facet joint arthritis, are already present in asymptomatic elite adoles- cent players,1 therefore the degenerative theory may play a role in FCR tenosynovitis of this “over 35” group of non- professional tennis players. Moreover, professional tennis players usually retire quite young, before developing evi- dent osteoarthritis, and probably their subsequent medical records thus no longer reference them as a “pro” tennis player but a normal patient. Concerning the different grips considered, our study is the first to associate wrist injuries with different technical skills. It is well known that ulnar-sided wrist injuries such as TFCC and ECU are possible in professional tennis players who develop powerful strokes with a marked top-spin.12 Recently a French group described 28 cases of ECU injuries in professional tennis players.13 Although it is not clearly specified by the authors, it is conceivable that these Association of Tennis Professionals players used semi-West- ern or Western grips given their extremely high ranking. In our series ulnar-sided wrist injuries were associated with these 2 grips, confirming the hypothesis that modern top-spin strokes are associated with these kinds of lesions. In our series we observed 5 lesions of the TFCC; 4 players affected by this injury used to play at the highest level (divi- sion III, first group). It is likely that the high performance level of these players implies higher loads on the TFCC in comparison with lower-level players. These injuries were the worst that we recorded as all of them required surgical intervention and approximately 3 months of recovery. Extensor carpi ulnaris tenosynovitis derives from a tear of the retinaculum of the sixth compartment of the extensor Figure 3. Photographs representing the association between Eastern grip and radial-side wrist injuries or Western and semi-Western grips and ulnar-side wrist injuries. TABLE 3 Pattern of Wrist Injuries and Time Out of Competition in Relation to Different Gripsa Injuries ECU TFCC Intersection De Quervain Extensors Grip (n = 50) (n = 30) (n = 5) (n = 1) FCR (n = 5) (n = 6) (n = 3) Eastern 12 3 1 3 5 Western 16 11 3 1 1 Semi-Western 22 16 2 1 1 2 Time out, wk 2-42 2-42 12 4 6 4-42 2 aECU, extensor carpi ulnaris; TFCC, triangular fibrocartilage; FCR, flexor carpi radialis. at TULANE UNIV on September 30, 2014ajs.sagepub.comDownloaded from http://ajs.sagepub.com/ 766 Tagliafico et al The American Journal of Sports Medicine tendons of the wrist as a result of the mechanical friction between this tendon and the ulna. In tennis and racquet sports in general, ECU injuries are quite common in the nondominant wrist of players with a 2-handed backhand.12 Biomechanical studies have shown that the wrist in tennis is in ulnar deviation for most shots and that the nondomi- nant wrist is in extensive ulnar deviation during the 2-handed stroke.16 Moreover, the use of top-spin rotation with repeated sudden pronation movements from a supi- nated position causes stress forces over the ECU and may lead to stripping of the retinaculum.18 This condition is easily diagnosed with US and sometimes stress test or MR.7 In our series, none of the players with an injury to the ECU tendon reported a complete rupture and no one had undergone surgical repair. The association between Eastern grip and radial-side lesions has never been described in the literature, although it is known that flexor tendons also may be involved in tennis-related wrist injury.7,8 It is interesting to note that the players affected by radial-side lesions and using an Eastern grip were those with the oldest age: all of them were older than 35 years. The differences between pattern of wrist injuries and age of the groups using Eastern and semi-Western or Western grip reflect the different loads that the wrist has to bear in relation to the style of play. We also noted that the 6 players with de Quervain syn- drome were all tennis instructors. It is possible that the daily activity on the tennis court represents a risk factor for this disorder. Movements requiring forceful grasping with the wrist in ulnar deviation or repetitive use of the thumb are known to predispose to de Quervain syndrome, and these movements are typical of a tennis instructor. Similarly, intersection syndrome and extensor tendon injuries are likely to be related to repeated flexion and extension movements of the racket while performing drills during tennis lessons more than during tournament activity. It is important to remember that during the last 10 years the tennis forehand stroke has changed dramatically. The traditional description of the forehand as a 3-phase move- ment (racket preparation, acceleration, and follow-through) is not sufficient today to explain the complex biomechani- cal improvements of modern ground-strokes.2,3 Also non- professional players use the modern top-spin forehand. The technical changes have influenced the type of grip in conjunction with racket backswing and forward swing. The preferred grip used today is the semi-Western or the Western because it is easier to generate top-spin and maintain racket orientation at impact. The disadvantage of the Western grip is that it is difficult for tennis players to hit low-bouncing balls.2,9 The effects of using Eastern and Western forehand grips on the rotational contribu- tion of the upper-limb segments to racket head velocity have been investigated.6 Players using the Western grip were able to produce greater forward (toward the court) and sideways (along the baseline) velocities through hori- zontal flexion, abduction, and internal rotation at the shoulder, and through ulnar deviation. In contrast, play- ers using the Eastern forehand grip used more horizontal flexion and abduction at the shoulder and more wrist flexion. The increased wrist flexion of Eastern grips described by Elliott et al6 could explain the FCR teno- synovitis and the de Quervain syndrome, which typically occur in repeated flexion and extension movements. The increased rotational velocity of the head of the racket and consequently to the wrist obtained with Western and semi-Western grips explains the ulnar-side injuries asso- ciated with these grips. The dissimilar injury pattern associated with the different grips reflects the diverse biomechanical loads on the wrist joint developed by the traditional and modern strokes: traditional strokes are performed on a closed position and low-bouncing balls, while modern strokes require an open-stance position to hit high-bouncing balls. This observation has great impli- cation for tennis wrist injury prevention and training. Our data support the study by Bahamonde and Knudson2 in which it has been suggested that people with injuries to the wrist should consider using the traditional fore- hand stroke instead of any of the variations of the modern strokes because the traditional forehand stroke does not imply the use of the wrist and elbow joints to accelerate the racket. A possible limitation of our study is it was a cross- sectional study and not a prospective study. Another limi- tation concerns the voluntary participation to the tournaments: at least theoretically the prevalence of the injuries could be underestimated. Moreover, time out of competition was self-reported by the players and so it may not be accurate. Because professional players are obliged to play tournaments, time out of competition corresponds to the absence from official tournaments over a certain time span and thus can be accurately defined. On the con- trary, nonprofessional players participate in tournaments on a voluntary basis, so that the time out of competition was only estimated according to the information given in the questionnaire. Our study has not only an impact in terms of injury pre- vention and training modules but also has a practical use for all physicians who have to diagnose a wrist injury in a tennis player. 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