The demanding sport of Tennis requires a strong and supple upper limb to control the racket which functions as an extension of the athlete’s dominant arm. While lower limb injuries are also common, the diagnosis of these is usually much more apparent, as well as manageable, in this non-contact sport. Ankle sprains, knee injuries and back strains are all frequently seen entities that rarely end the tennis athlete’s career. However, a persistant wrist instability or shoulder cuff lesion can doom the competitor whose power and precision stroke requires a strong extremity that is wielding the instrument of attack.

Tennis related injuries of the upper limb are of two major types: The less common acute injury from a poorly executed stroke or fall on the court, or the much more common overuse injury, often an exacerbation of an underlying degenerative condition. The latter is frequently seen in older participants and mature tennis players often demonstrate the common pathologies seen in the general population. Ironically, many of these problems are seen much earlier due to the unnatural mechanism required of the upper limb during the different tennis strokes.

Acute injuries to the hand are uncommon in tennis while development of painful syndromes can be very common, particularly due to underlying arthritis or tendonitis conditions. Carpal tunnel syndrome is a common nerve compression disorder at the wrist that can be more symptomatic the night following multiple sets of play. Gripping the racket can worsen symptoms typically described as numbness and a cramping feeling in the hand. The tennis activity itself, however, does not cause this problem which is really multifacorial and is related to certain metabolic/hormonal conditions that cause changes of the tendon sheaths which pass within the carpal canal. This explains why this affliction is often seen in diabetics, hypothyroid patients, pregnancy and even middle aged women. Typing or repetitive motion occupations have never been found to be related in scientific or epidemiologic studies, and sporting activities are certainly not causative. Initial treatment is with a night splint, high doses of vitamin B6 or anti-inflammatories. A corticosteroid injection in the wrist is occasionally used but the usual treatment is surgical. This involves opening the carpal tunnel which takes pressure off the nerve. This can be done through a small incision in the palm or endoscopically. The endoscopic technique implies use of a small fiberoptic instrument and local anesthesia with almost no post-op discomfort. An added benefit is that the tennis player can get back on the courts within a three to four week period. Post-op patients will experience some palmar discomfort commonly termed “pillar pain” but should not interfere with the gradual resumption of tennis play. Some modification of the racket or string tension may be initially required.

Tendonitis of the fingers or wrist usually requires an injection or occasionally a minor surgical release. This can be a very painful condition and should be addressed promptly  to avoid developing weakness in the hand and loss of grip strength.

Osteoarthritis in the hand can be greatly exacerbated by vigorous squeezing as can be seen in gripping a tennis racket. Although the cause of arthritis is unknown, this will almost exclusively occur in older players and requires an x-ray and clinical examination. The most common locations are the base of the thumb and the last joint of the digits. Mild symptoms can be managed by oral anti-inflammatories, corticosteroid injections but severe pain and occasional deformity is successfully managed using surgical techniques. Arthroscopy is now possible within the smaller joints of the hand and can produce the same rapid recovery seen in larger joints such as the knee.

Deep wrist pain can be the most common complaint seen in competitive tennis players. This is often initially ignored by the player or inadequately diagnosed by the primary care doctor or athletic trainer. Evaluation by an orthopedic surgeon is often critical and will consist of a careful physical exam sometimes followed by x-rays and even an MRI. However, when a clear diagnosis and treatment plan are not formulated, the player should seek consultation with a hand and wrist specialist. This is because the complex interplay between bony, ligamentous and soft tissue disorders require evaluation by a dedicated specialist and can often save the time and expense of a lengthy diagnostic work-up that may not even be necessary. It should be noted that MRI does not have the diagnostic sensitivity found in larger joints such as the knee or shoulder. A careful exam by a dedicated wrist specialist is often more useful and the surgeon should be adept at small joint arthroscopy since that will often determine the true diagnosis.

Wrist pain can be separated into 3 major regions: The radial (thumb side), central and ulnar (small finger side). Simply assigning the disorder to one region can already begin to narrow down the possibility of causes and diagnoses.

Radial sided wrist pain is very commonly a severe tendonitis known as DeQuervain’s tendonitis, although other types are possible as well. DeQuervain’s can be very disabling but is easily diagnosed simply by careful physical examination. Eighty percent of sufferers can expect relief by a single corticosteroid injection when well placed.

A post-traumatic arthritis of the wrist known as SLAC wrist is also common and reflects a painful sequelae to an old ligamentous wrist injury. This is why timely treatment of ligamentous wrist injuries is so critical. This late reactive arthritis is usually painful on the radial side of the wrist and may require surgical intervention if progressive.

On occasion, radial sided wrist pain can actually emanate from arthritis at the base of the thumb (basal joint) and therefore requires thorough radiographic examination of the entire hand. As mentioned, there are now arthroscopic techniques that can relieve this pain and allow the mature tennis player to continue playing. More aggressive surgical techniques that are more traditional for this region may severely limit the player’s return to future play. Arthroscopy now provides a good alternative for treatment of this common ailment which is more commonly seen in female tennis players. This can occasionally be seen in younger players who demonstrate ligamentous laxity.

Central wrist pain can have many more causes. Striking the ball while holding the wrist in an inadequate posture during an intense swing can lead to a severe ligamentous injury known as a scapholunate ligament tear. This can also occur during a fall on the outstretched hand while diving to return a volley. This subtle ligamentous injury can often be missed on MRI, hence, it is important that an experienced wrist surgeon evaluate the patient. Many times arthroscopy will be required to not only diagnose the injury but also allow definitive treatment. This is a painless ambulatory procedure where the surgeon inserts a tiny fiberoptic instrument into the joint allowing clear visualization while small instruments perform the surgery inserted via other portals (small incisions). This technique can also be used to remove painful ganglion cysts. These are occasionally painful benign masses that can limit wrist range of motion and also cause weakness. For a tennis player, the main advantage is that one could be working on their tennis stroke as soon as three to four weeks after surgery, depending on what is done. A complete ligament tear requires temporary pin fixation and casting for nearly eight weeks to allow healing. A more intense rehabilitation program will then be needed. I have had the experience of treating several top-100 ranked players with this carpal instability (wrist ligament tear) lesion  and all have gone back to the tour.A dedicated athlete and physical therapist, as well as patience, is required. A high level tennis player can expect to get back to hitting against the wall at about 4 months post-op from this type of severe wrist injury. A missed diagnosis here will be career ending.

Ulnar sided wrist pain is the most common affliction seen in high level tennis players, but fortunately, consistently demonstrates the most successful response to treatment, if appropriate. The triangular fibrocartilage (TFCC) is a thick cartilaginous structure deep in the wrist that can tear either centrally or on its peripheral attachment site. The central tear is generally degenerative in nature and is commonly seen in older players who gradually develop increasing wrist pain. This is akin to meniscal tears that are seen in the knee and are also treated with arthroscopic debridement.  Peripheral tears are detachments of this cartilaginous disc that require suture repair and a period of post-op immobilization. Current technology allows the repair to be done with all arthroscopic means as well. This injury is often seen in younger players and many times comes from one poorly executed swing. The high level tennis athlete can often recall the exact moment of injury. Injuries of the TFCC cartilage are perhaps the most commonly underdiagnosed injury in tennis players. Younger players usually require a direct suture repair of the TFCC in order to restore the integrity of this critical cartilage. I have pioneered an arthroscopic technique where the suture, once passed, is welded rather than tied into bulky knots. This allows for a stronger repair and one where the patient will not have the occasional discomfort that comes from suture knots under the skin.

Fortunately, the majority of ulnar sided wrist pain is due to tendonitis of the extensor carpi ulnaris. The tendon is responsible for ulnar deviation and dorsiflexion of the wrist. This is critical during backhand stroke and seems to be more susceptible in players with a one handed swing. Treatment is usually conservative including cryotherapy, ultrasound modalities, and  steroid iontophoresis followed by a strengthening program. If necessary, judicious use of a low dose corticosteroid can be injected within the 6^th extensor compartment, but one must be cognizant of the low incidence of late tendon rupture after steroid administration. Activity modification may also be necessary as in changing racket handle diameter, tension of strings as well as swing mechanics. In rare cases, the basic grip must be altered and even evolution to a more balanced back handed swing. In rare cases, the subsheath can be too constrictive for the tendon or conversely a subluxing ECU tendon may be present due to laxity or subsheath rupture. Both scenarios may require a minor procedure that is performed under local anesthesia. Therapy is again critical for a good outcome.

Unfortunately, some players do have a predisposition to this ulnar sided pain due to their underlying bony anatomy. When the ulna bone is longer than the radius, deemed ulnar plus variance, patients do have an increased tendency to lesions of the triangular fibrocartilage complex. Some even have direct impaction injury to the carpus, usually the lunate bone. In these less common scenarios, surgical alteration of the anatomy is successful to resolve this developmental problem.

A final, but common , cause of wrist pain is the ganglion cyst. This is a fluid filled mass which leads to secondary swelling or irritation of the wrist capsule and can truly interfere with certain motions in the wrist, such as dorsiflexion. The smaller lesions are surprisingly often the most painful, and MRI imaging can miss these more subtle cysts. Arthroscopic excision not only allows removal of the most occult lesions, but also speeds the recovery.

Regardless of the problem, it is crucial to make a clear and unambiguous diagnosis when wrist pain is present in the tennis athlete. Continued play can aggravate the condition and prolong the recovery period once the definitive diagnosis is established and appropriate treatment instituted

Elbow injuries are seen less commonly than wrist problems but can be much more resistant to treatment. While inappropriately named, tennis elbow  (lateral epicondylitis) is common in the general population However, when present in the tennis enthusiast, this condition can be extremely debilitating and recalcitrant. The affliction  tends to be persistent and leads to pain when the athlete tries to fully extend the elbow. This can lead to particular limitations in backhand shots where power and good follow-through are necessary. Treatment is also centered on intermittent injections but it is preferable to avoid more than three injections as tendon weakening can be a side effect. Resistant cases may require surgical treatment that has traditionally been done with an open incision and potentially long recovery time. Arthroscopic techniques are now also possible in the elbow and allow for very rapid recovery. Newer technology using radiofrequency waves to dissolve away the painful inflammatory tissue are also possible.

The entity known as golfer’s elbow is a tendonitis of the flexor origin at the medial (inside) aspect of the elbow. While the name associates the condition with golfing, it is actually relatively uncommon. This painful tendonitis can greatly impede a forehand stroke and treatment usually centers on an injection of corticosteroid followed by a course of therapy for stretching and strengthening of the flexor muscles. In rare cases, open surgical debridement is necessary for the most resistant pathology

Bicep, or even tricep, tendonitis is much less common and is amenable to conservative measures. Fractures about the elbow, as in the wrist, can occasionally be seen after a fall on the court. One should be particularly careful when jumping over the net to congratulate an opponent….

Deep persistent pain in the shoulder can affect both young and old tennis players alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution.

Young, active patients often feel that there is an overuse syndrome. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If this is a chronic problem, with no history of a single traumatic event, the patient will usually respond to a strengthening therapy protocol that requires diligence on the part of the patient and therapist.

An acute injury, such as fall or impact on the raised arm, may lead to a discrete anatomic injury that may require repair.  This mechanism is less likely in the tennis athlete but the unnatural swing required to return certain shots can occasionally causes a discrete lesion. Poor service mechanics can also lead to discrete shoulder injuries. Because of this, it is critical to make a diagnosis and this is often suggested by the patient’s history of the problem. When acute injury leads to persistant pain, we often order an MRI which is a diagnostic study that best looks at the soft tissue structures deep in the shoulder. A plain xray only looks at the bony structures and is usually normal in people with painful shoulder syndromes. The MRI can usually indicate the severity of the soft tissue injury and can dictate whether continued conservative treatment (anti-inflammatories, cortisone injection, and therapy) or surgical intervention is warranted. A true anatomic disruption, such as a torn cartilage rim (glenoid labrum) or tendon rupture, will usually not get better on its own; hence, a mechanical solution may be necessary. Even more than in the previous joints discussed, arthroscopy is used to both diagnose and treat these acute injuries. In fact, open surgery about the shoulder is becoming quite rare.  This minimizes scarring, improves the surgeon’s visualization of the problem, and speeds the recovery. In certain cases, an open incision may be required depending on the severity and location of the problem.. Older tennis players often attribute their shoulder pain to “arthritis”. In fact, arthritis in the shoulder joint (particularly the ball and cup joint) is rather rare. Arthritis is when there is loss of cartilage in a joint and can lead to bone grinding against bone. This osteoarthritis condition is more commonly seen in the knee, hip or basal joint of the thumb as previously mentioned, but much less so in the shoulder.

The most common cause of shoulder pain in older athletes is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis”. Impingement refers to the mechanical process where the overlying bony arch of the shoulder (acromion of scapula and clavicle) is pressing on or irritating the underlying rotator cuff tendons and bursa. With age, the blood supply to the rotator cuff is diminished, and small microtears in the tendon leads to tendonitis and bursitis and even larger tears. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis, and shoulder therapy to improve the strength of the intact rotator cuff.

A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and therefore, cannot stabilize the head of the humerus against its cup joint (glenoid). The patient will either be unable to physically raise the arm or they can do this only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, discomfort that is markedly worse at night, and inability to lie on the side of the affected shoulder. This will severely limit a tennis player’s game and may permit the athlete  to only utilize certain shots and even prevent the overhead serve motion.

Once the pain is severe enough and does not respond to therapy and other conservative measures, then surgery is indicated. Some smaller tears can be repaired through arthroscopic means, but larger tears are usually repaired through a traditional incision. Most repairs require a one month period of immobilization in a sling and several months of post-operative therapy closely directed by the surgeon.

The shoulder is a demanding joint and requires patience on the part of both patient and treating surgeon. The recovery is usually not rapid, but diligent adherence to the therapy protocol will in most cases yield a good result and a functional shoulder with minimal or no pain.

Unlike other sports where the lower extremity joints are injured much more commonly, tennis players highly depend on a smooth harmony of shoulder, elbow and wrist motion to exert precise control of the tennis ball. For this reason, painful conditions should be promptly addressed by an upper limb orthopedic specialist in order to allow the athlete to return to their sport at the best possible level, and in rapid fashion.