January 2014

inside the stms

Happy New Year and welcome to 2014! The beginning of the year is al- ways exciting in the tennis world, as all eyes point to Australia for the first Grand Slam of the year. The tennis world has had its share of excitement in 2013, and only time will tell what will happen in 2014. In our “Inside the world of tennis”, there is a preview of what may be in store for 2014 from si.com. All the tennis organiza- tions will be very active again to keep the performance of the players high, and our job in the tennis medicine world will be to keep them healthy. One particular injury that has sidelined a number of top players such as Kim Clijsters and Juan Martin Del Potro, among others, is wrist pain. As many of us know, ulnar wrist pain can be limiting to tennis players of all levels, and particularly devastating to the elite level players. Dr. Chris Sforzo, who is an upper extremity orthopaedic surgery specialist (special consultant to the Bolliteiri Tennis Academy) and tennis performance specialists and teaching professionals, Yutaka Nakamura, BS, NSCA, CSCS and Lee Nakamura, USPTA, USPTR have prepared a comprehensive evaluation of ulnar wrist pain in tennis players. You will get a detailed background of evaluation and treatment options, but also specific tennis-related adjustments in equipment and tennis strokes.

The WTA continues to produce some excellent information in their “Physically Speaking” section. The topic “Liquefy your assets” included in this edition of “Inside the STMS” is relevant with the heat of the Australian Open looming. Practical tips on hydration, choosing sports drinks, performance, and then recovery techniques are discussed. Specific advice such as this will help us properly educate our tennis players, rather then just saying “drink more!”.

A start of a new year, is also a good reminder to renew your membership to the most reliable source in STMS BOARD tennis medicine medical information, the STMS. Please visit stms-web.org right away to maintain all of your membership benefits and receive your journal. Please also mark your calendars for STMS President Javier Maquirriain conferences that will be upcoming. Work is under way for a possible North American regional Buenos Aires, Argentina th conference towards the end of the year, and the 14 STMS World Congress in Rome May 8-9, 2015. Vice President Please contact me directly with any submissions for the “Inside the STMS” newsletter at Neeru Jayanthi Chicago, IL, USA [email protected]. Secretary/Treasurer Have a great 2014!! Mark Kovacs Chicago, IL, USA Neeru Jayanthi, MD Membership Officer Todd Ellenbecker Scottsdale, AZ, USA

Clinical Pearls

Ulnar Wrist Pain in Tennis – History, Diagnosis, Treatment, & Prevention

Christopher R. Sforzo, MD, FAAOS, SCSH; Yutaka Nakamura, BS, NSCA, CSCS; Lee Nakamura, USPTA, USPTR

Wrist injuries in tennis players, even elite/professional include the ECU subluxation test, ulnocarpal stress test, LT players, are common. Due to the anatomic location of the ballottement test, and piano key test also need to be com- wrist and its major role in the kinetic chain needed in pleted and will further help to ascertain the location of stroke production, it is unfortunately a common site of pain injury. and disability. Often, the pain presents on the pinkie-side, Sometimes imaging needs to be performed to further eluci- or ulnar side, of the wrist. Many players experience this date the pathology. This can be done beginning with stand- ulnar pain in the non-dominant hand during two-handed ard but well-positioned x-rays, focusing in on ulnar variance backhand strokes. In this stroke, the top hand is placed in (ulnar length compared to the radius), the ulnocarpal joint, extreme ulnar deviation and extension, while dynamically and the DRUJ. Bilateral clenched fist views can further moving from supination to pronation. This same motion- uncover dynamic ulnar positive variance. Advanced imag- type occurs in many tennis strokes, and as such can lead to ing can include static or dynamic ultrasound or MRI acute and chronic ulnar wrist injuries. arthrogram of the wrist, which can be quite sensitive in The ulnar portion of the wrist is composed of complicated detecting tears or bony changes. In the end, the history and yet sophisticated anatomy that gives tremendous stability clinical exam, and potentially selective lidocaine and/or to the wrist while at the same time allowing for incredible cortisone injections will be the gateway to uncovering the degrees of movement. The main structures on the ulnar correct pain-generating diagnosis. side of the wrist anatomically are the distal radioulnar joint Common problems include injuries to the TFCC, the ECU, (DRUJ); the intrinsic and extrinsic ulnocarpal ligaments; the and the lunotriquetral (LT) ligaments, or dynamic problems triangular fibrocartilage complex (TFCC), the extensor carpi such as ulnocarpal abutment and ECU subluxation/ ulnaris (ECU) tendon; the pisiform and pisotriquetral joint; dislocation. as well as the hook of the hamate. All of these structures can be the source of ulnar wrist pain; however, they can Treatment is tailored to the specific diagnosis. Strain or present in similar manners, thus clouding the clinical pic- tears of the TFCC can be initially treated non-operatively, ture, causing potential delays in correct diagnosis and with a combination of rest, wraps, NSAIDs, strengthening, treatment. Henceforth, the ulnar wrist has garnered the and potentially cortisone injections. If the players’ schedule pseudonym “the black box of the wrist.” allows, surgery can be done to either debride or repair the torn TFCC at the appropriate time in her or his schedule. If Tennis players can present with an acute event of sudden need be, surgery can be postponed and the player can be onset – either after a violent fall with the wrist in extension allowed to play per pain tolerance. Arthroscopic TFCC deb- and pronation/supination, or after hitting the tennis ball ridement typically requires 2-4 weeks of splinting with and having an immediate feeling of ulnar wrist pain. When another 4 weeks of therapy to regain strength, motion, and the presentation of pain is chronic and insidious, the ulnar stamina, with a gradual return to hitting after 8 weeks. Full wrist pain arises over the course of days or weeks, and the recovery can take 10-12 weeks. TFCC repair is a protracted athlete usually cannot recall a single inciting injury. recovery, with typically 6 weeks of significant immobiliza- In either case, the player typically experiences pain with tion/splinting, followed by a progressive ROM program, stroke production, which gradually worsens during play, strengthening, modalities, and then gradual return to which decreases performance and then forces the player hitting and full play by 4-6 months. to curtail practice or match play. Sometimes the player ECU tendonitis can typically be managed with splinting describes the pain associated with an audible or palpable techniques, rest, NSAIDs, therapy modalities, and injec- click on forearm rotation. tions, with a return to play timeline between 2-4 weeks. Examination focuses on the athlete’s anatomy and the use ECU subluxation/dislocation can be initially treated via non- of certain provocative tests in order to illicit abnormal operative means to include rest, splinting, wraps, or ag- responses. The examiner must have knowledge of the an gressive immobilization for 3-6 weeks, and then a gradual atomy, the structures at risk, the important exam tests to return to play program centered on regaining strength, perform, and a high index of suspicion. Palpation of the dexterity, range of motion, proprioception, and then stami- lunotriquetral (LT) joint, the fovea or ulnar snuffbox, ECU, na. If symptoms persist, ECU stabilization via open surgical FCU (flexor carpi ulnaris), ulnar styloid, pisotriquetral joint, means may be needed, with a return to play after 3 and hamate hook, all must be performed. Provocative tests months. ECU tears require surgical repair and a period of hybrid/combination of the two. Gut strings are very very are strings Gut two. ofthe hybrid/combination a or gut, synthetic gut, natural include Strings types stroke technique. proper ensure to necessary as asfirm only be should grip The arm. of the movement restrictfree can grip a firm Too injury. potential and of grip firmness increased to leading stroke, the through racket the hold ed to of forceneed- amount the determine can The size grip wristpain. to lead all can tension string improper and Equipment: wristpain: ulnar with player a facing when consider Some to things injury. to player a predispose stroke will the during motion wrist excessive Also, equipment. wrong the using even and technique, use, improper over- result often from players tennis in injuries Wrist significantly. diminished has tion hardware complica- osteotomy systems, er, lowprofile usenew- ofthe With the future. in symptomatic come be- may which hardware, retained and recovery longer a also requires healing. no It bone or nonunion even or healing, bone or union of delayed carries risk the It this problem. for standard gold the remains which procedure, osteotomy shortening ulnar the in occurs that ligaments ulnocarpal ofthe extrinsic tensioning lacksthe and demanding technically be can However, it postoperatively. 4weeks at production stroke to return early allow may This waferprocedure. prefer the sport, to return early and technique invasive its minimally by Some, shorteningosteotomy. ulnar open an or dure proce- wafer arthroscopic an either via be performed, can ulna the shorten to procedure surgical a pingement, im- chronic to due reactive changes ulnocarpal with TFCCtorn or thinned a reveals imaging and protracted is problem the If injections. as cortisone well means as above the with managed be This sometimes can play. tennis with wristoverload ulnar dynamic causes which variance), ulnar positive (i.e. radius the to relation in ulna length longer have a x normal malor abnor- with wristpain ulnar as chronic This present can grip. power with repeatedly carpus impacts the ulna the whereby process is dynamic a abutment Ulnocarpal instability. joint lunotriquetral significant and/or pain chronic thereis where extreme cases served for re- aretypically versus reconstruction repair and/or debridement Arthroscopic injections. and ties, splinting, non by treated usually) (and tears also are (LT) ligament Lunotriquetral from4 ing rang- play match to return prolonged a with protection, - 6 months. 6 months. using the wrong grip size, wrong strings, strings, size,wrong grip wrong the using - operative means, including rest, modali- including means, operative - rays. 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About the Authors

Ulnar Wrist Pain in Tennis – History, Diagnosis, Treatment, & Prevention

Christopher R. Sforzo, MD, FAAOS, SCSH; Yutaka Nakamura, BS, NSCA, CSCS; Lee Nakamura, USPTA, USPTR

Christopher R. Sforzo, MD, FAAOS, SCSH

Dr. Sforzo is a board certified orthopedic surgeon, fellowship trained in hand and upper extremity surgery with a Subspecialty Certificate in Surgery of the Hand. He has an extensive experience in the care of the professional, semi-professional, collegiate, youth, and recreational tennis player, and is a special consultant to the Nick Bollettieri Tennis Academy in Bradenton, Florida. He is in private practice located in Sarasota, FL.

Yutaka Nakamura, BS, NSCA, CSCS

Mr. Nakamura is a professional strength and conditioning coach with over 20 years of experi- ence in tennis; he has trained and coached many professional tennis players and athletes; he is a full time member of Team Maria Sharapova.

Lee Nakamura, USPTA, USPTR (not pictured)

Mrs. Nakamura is a tennis professional and tennis-specific conditioning coach with over 20 years of experience; she is also a former professional tennis player; she currently coaches youth and advanced recreational tennis in Lakewood Ranch, FL.

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PREDICTIONS FOR THE 2014 TENNIS SEASON By: Jon Wertheim, INSIDE TENNIS

Roger Federer hasn't won a Grand Slam since Wimbledon 2012, where he beat Andy Murray in the final.

Peering into the crystal ball, which, in keeping with tennis, is not standardized from event to event.  No player outside the Big Four will win a Grand Slam. The concentration of power would offend Paul Volcker. If any other global industry saw one of four institutions so thoroughly dominate the marketplace -- divvying every Major singles title, save one, since early 2005 -- there would be an investigation. But not only have Novak Djokovic, Rafael Nadal, Andy Murray and Roger Federer rendered every colleague a journeyman; there's no suggestion their oligopoly will end in 2014. We can debate whether they're that much better than the others; or whether the "others" are defi- cient. But there's little to suggest that the other guys (Milos Raonic and Grigor Dimitrov, neither of whom have been beyond the fourth round of a Slam? David Ferrer, who's 10-46 against Federer, Nadal and Djokovic?) are ready for the Big Boys.

 A year from now, Roger Federer will be ranked higher than he is today. Yes, we know the case against. Federer is older than Gardnar Malloy. As a committed father, he is shopping for Go-Gurt and Applesauce Crushers while his rivals are running wind sprints. His back is sore. His racket is small. He lacks a guru from the 1980s. He has won one Grand Slam in the last 47 months. The vec- tors tend to go in one direction: once athletes move beyond their primes, the downward slope is constant.

Here's what Federer has going for him: he is still Roger Federer, blessed by the tennis gods. He still moves gracefully. He still can tinker with his schedule. He can regain self-belief. He can still discharge his duties better than all but three men on the planet. Write him off at your peril.

 Serena Williams will continue to ride high. The notion that "30 is the new 20" has already hard- ened into conventional tennis wisdom. And while Williams' chronological age is 32, that doesn't quite paint an accurate picture. All those years that she played sparingly, drawing criticism from the WTA and the hidebounds? She's getting that time back now. All those matches she waltzed 6- 0, 6-1 in 53 minutes? Again, it pays dividends. Serena doesn't just play better tennis than the rest of the field; she competes better. And until that changes, it's hard to see her losing her edge. In The World of Tennis

cont.

 Maria Sharapova will regain some of her mojo (but not all). Last year was thoroughly forgettable for Sharapova. Losses and injuries were compounded by some uncharacteristic unforced p.r. errors, not least her bizarre shotgun coaching marriage with Jimmy Connors. Sharpova missed the U.S. Open and the fall season on account of a shoulder injury and won just one matched since the French Open. Yet she enters the new season healthy, rejuvenated, and in the company of a new coach (Sven Groeneveld). Her competitive instincts have never been in question and -- as we saw last year with Nadal -- these mini-sabbaticals have a way of helping the player. She still needs to solve the Serena Riddle that has vexed her for a decade now. But Sharapova will re-enter the conversation.

 Marion Bartoli will return. It's become as predictable as time, tide and gripes over the lack of a roof at the U.S. Open: players -- especially female -- who retire, reconsider their decision. Bartoli, of course, won Wimbledon last summer, one of the more inspiring stories of 2013. A few weeks later, sacre bleu! (Or Sock-re bleu?) She announced her retirement.

Bartoli always seems to regard conventional wisdom as a personal affront. And part us applauds her for staying true to her instincts and calling it quits when others would be renegotiating racket deals, booking exhibitions and otherwise cashing in on their new found status. But, Bartoli has too much good tennis left to stay on the sidelines. And it's hard not to notice: she's still ranked No. 13.

 Novak Djokovic and Boris Becker will bid each other auf wiedersehen by the French Open. It makes for a pretty good reality show conceit: tennis stars of the 80s try and dispense their magic on players today. The Surreal Life meets the Ultimate Fighter. For all the recently announced pairings, none was stranger than Boris Becker and Novak Djokovic. While both are thoroughly unobjectionable -- pleasant, sporting, genial-- on their own, their Venn diagram would seem to have little overlap. Culturally, tem- peramentally, philosophically. Maybe this is a case of opposites attract. Maybe this is one of those ro- mantic couples who confound the outsiders-- "What do they see in each other?" -- but make it work. Says here, Becker and Djokovic cordially part ways, by, say the end of the clay-court swing.

 Tennis will fall prey to more anti-doping contretemps. This is based more on common sense than a suggestion the sport is a cesspool. But consider the circumstances: you have an individual enterprise with incentives to cheat, especially when it comes to accelerating recovery. You have more injuries than ever (see below). You have players seeking incremental advantages, reading instructions that are often not in their native tongues. And a banned substance list that includes everything from recreation- al drugs to anti-hair loss medication. The meeting will provide an excellent opportunity to expand our scientific knowledge through the workshops, with direct, close interaction with the most renowned International Specialists. The majority of tennis injuries are overuse injuries involving both upper and lower extremities as well as the back and abdominals. Many of these injuries can be prevented with a proper under- standing of the etiology of the injuries and appropriate evaluation and intervention. The high-level scientific program provided during interactive sessions by the organizing committee will cover both tennis-related pathology and the health benefits of regular physical and psychological activity throughout life. Practical workshops will also enable participants to discover new techniques and innovative equip- ment. There will be lectures on the latest notions by International leaders in tennis medicine, sym- posiums, and hands-on workshops Click here for details: stms-web.org/conferences

See you in Rome!!! Organizing Secretariat Concordia Hospital for “Special Surgery”

STMS 2014 MEMBERSHIP RENEWAL

Hello STMS Members:

You can now renew your membership on the STMS website The website has now been updated to allow easy renewal of your mem- bership so you can continue to receive the member benefits and Todd Ellenbecker continue your membership with STMS.

Simply click on this link http://stms-web.org/membership.html to renew your STMS membership using a credit card and paypal. Please contact us if you have any questions or help. Thank you for your continued support and membership in STMS.

Best Regards Todd Ellenbecker

Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS Senior Director of Medical Services ATP World Tour Clinic Director, Physiotherapy Associates Scottsdale Sports Clinic National Director of Clinical Research, Physiotherapy Associates

STMS MEMBERSHIP

Go to www.stms-web.org and to renew!!!

Joining STMS entitles you to receive educational information from leading Sports Medicine and Sport Science professionals working with tennis players around the world, as well as access to unique mem- bership benefits (below). Most of the scientific rationale for caring tennis players (i.e. clinical manage- ment, rehabilitation, training and prevention) in the last decade have been provided by STMS members!

We invite you to tour our website at www.stms-web.org to view public access information.

JOIN US BY CLICKING HERE!!!!!

What you get with STMS membership

 Subscription to three issues per year of the Journal Medicine and Science in Tennis

 Free online access to all editions of the Journal (with your STMS member password)

 Subscription to four issues per year of the STMS E-mail Newsletter

 Discounts to STMS meetings

 Access to the dedicated Members Area (with your STMS password) STMS voting rights

Subscription Rates:

 Physician & STMS Fellow (1 year) US $195

 Physician & STMS Fellow (3 years) US $500

 PhD/PT/ATC/Chiropractor (1 year) US $75

 Tennis Coach & Player/Enthusiast (1year)** US $30 ** includes three online journals per year. subscription of four online STMS email newsletters, discount to all STMS conferences and free online access to all published STMS journals.