FROM THE EDITORS MESSAGE FROM THE PRESIDENT

ISSN: 1567-2352 The Journal of Medicine and Science in Tennis (JMST) is produced by the Society for Tennis Medicine (STMS) in As the COVID-19 pandemic surges on, there have been no traditional co-operation with the ITF, the ATP, and the WTA, and is issued professional or collegiate tennis events to enjoy. Even local tennis has been three times a year. JMST is listed in Altis, Free Medical Journals, MedNets, NewJour, Sponet and SIRC Sports Discus. off-limits in many parts of the United States, with neighborhood courts often The International Board of the STMS closed-up and locked. Only recently have certain venues figured out how to President Walt Taylor, MD stage some exhibition-style tennis events for television viewers, with limited Vice-President Kathleen Stroia Outgoing President Neeru Jayanthi, MD or no local attendees, and strict adherence to “social distancing” protocols. Treasurer Paul Caldwell, MD Secretary & Chair/Editor Stephan Esser, MD Chief Journal Editor Michael J. Griesser, MD Entertaining and educational reading has become more important than ever Associate Journal Editor Natalie L. Myers PhD, ATC as many people are limiting their social outreach as much as possible, and Education Committee Co-Chair Karen Jordan Education Committee Co-Chair Richard Gayle, MD keeping tight to their homes in an effort to limit infection risk and spread Scientific/Research Committee Chair Caroline Martin, PhD of disease. Once again, we have attempted to provide some intriguing and Sports both recreationally and professionally are starting to resume slowly and with caution. Planning for resumption Website Committee Chair Paul Caldwell, MD of the WTA and ATP Tour, as well as, ITF Tournaments are underway. Several professional exhibition tournaments Social Media Committee Chair Melissa Baudo, DPT stimulating tennis-science articles for your enjoyment during this curious Tennis Committee Chair Mark Kovacs, Phd period in human history. have been conducted. A women’s exhibition tournament was successfully hosted in Charleston, South Carolina. International Tennis Federation Miguel Crespo, MD Kudos to the tournament director, Bob Moran as he worked extremely hard with tournament staff and local medical ATP Representative Gary Windler, MD WTA Representative Kathleen Stroia Please enjoy a discussion of “backhand wrist” by Epperson et al, a professionals to keep the players and staff as safe as possible by following strict COVID-19 prevention guidelines. This Membership Committee Co-Chair Todd Ellenbecker, DPT Membership Committee Co-Chair Elaine Brady, PT comparison of general health outcomes in recreational tennis players by tournament has set the standard for future professional tournaments as competition resumes. World Team Tennis in Tishelman et al, and a technique of tactical tennis learning presented by JMST Peer Review Staff the United States has also had a successful restart. We all look forward to witnessing incredible tournament play from Deb Skinstad, Aylin Seyalioglu, Jonathan Fraser, Alaoui et al. Hopefully these unique articles provide some distraction from amazing professional tennis athletes again in 2020. However, we are living in a different world and players and those Deena Casiero, Jason Vescovi, Caroline Martin our current collective health crisis, and provide a basis for some stimulating running tournaments must make sure they attempt to minimize the risk to all involved of COVID-19. Subscriptions and Membership discussion amongst tennis and science professionals. Todd S. Ellenbecker, DPT E-mail: [email protected] Recreational tennis is felt to be a low risk sport, but those playing must still be careful and follow guidelines such as The Journal of Medicine and Science in Tennis (JMST) is a those recommended by the USTA. Many recreational players are back to play which will hopefully improve their membership benefit of the Society for Tennis Medicine and health and overall wellbeing. Science (STMS). Annual Subscription fees due 1st January Physicians and STMS Fellows $195 US With respect to future STMS meetings, we may need to look to having virtual educational meetings over the next Physiotherapists, Athletic Trainers $95 US year or two, depending on the progression of COVID-19 and a potential vaccine for this illness. I hope all of you are Coaches, Tennis Enthusiasts $30 (online access only) healthy and staying safe. Design Rebeca Anaya www.rebecaanaya.com Respectfully, Photography Walter Taylor, MD. Jeff and Manuela Davies, Orlando, FL, USA www.doubleXposure.com Circulation 1,000 Website www.tennismedicine.org Michael J. Griesser Natalie Myers, PhD, ATC Disclaimer Editor-in-Chief, JMST Associate Editor This journal is published by the Society of Tennis Medicine and The Journal of Medicine and Science The Journal of Medicine and Science Science for general information only. Publication of information in the journal does not constitute a representation or warranty in Tennis in Tennis that the information has been approved or tested by the STMS [email protected] [email protected] or that it is suitable for general or particular use. Readers should not relay on any information in the journal and competent advice should be obtained about its suitability for any particular application. © 2020 Society of Tennis Medicine and Science. All rights reserved. No part of this publication may be reproduced in any form without prior written permission of the copyright holder. Opinions and research expressed in this journal are not necessarily those of the STMS.

2 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 3 TABLE OF CONTENTS

JULY 2020, VOLUME 26, NUMBER 2

Backhand Wrist: 6 A New Tennis-Specific Diagnosis By Kayla Fujimoto Epperson, Neeru Jayanthi, Gary Lourie, Michael Gottschalk

Improved General Health Outcomes in US Recreational 20 Tennis Players By Jared Tishelman, Daniel Bu, James Gladstone, Alexis Colvin,

Outcome of the Teaching Games for Understanding (TGFU) approach when applied to tactical understanding of 32 strategy and tactics in the game of tennis for young people.

By Mustapha Alaoui, Georges Kpazaï, Michel Portmann, Alain Steve Comtois,

4 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 5 TENNIS SPORT SCIENCE REVIEW KEY RESULTS

Backhand Wrist is caused by repetitive, high-energy axial loading with rapid forearm rotation causing degenerative changes and/or poor force transmission throughout the ulnar quadrant. Excessive wrist extension, ulnar deviation, and supination during a two-handed backhand can Backhand Wrist: lead to the development of extensor carpi ulnaris pathology, triangular fibrocartilage complex pathology, distal radioulnar joint instability, and/or A New Tennis-Specific ulnocarpal impaction syndrome. Players with inefficient stroke mechanics may be at increased risk for developing Backhand Wrist. Diagnosis KEY WORDS:

Kayla Fujimoto Neeru Gary Michael Wrist, TFCC, injury, rehabilitation Epperson*,DPT,1 Jayanthi,MD,2 Lourie,MD,3 Gottschalk,MD,4 Former President STMS CATEGORY: Institution Affiliation Hand and Wrist 1. Physical Therapist The Athlete Connection 2. Director Emory Tennis Medicine, President Society for Tennis Medicine Science (STMS) 3. Head Team Physician Atlanta Braves, Head Orthopedic Physician Georgia Institute of Technology Baseball 4. Director of Clinical Research Emory Healthcare INTRODUCTION

* [email protected] Chronic overuse injuries are prevalent in tennis players due to the repetitive encountered stresses during strokes and on-court movement patterns.1 Epidemiological studies of injuries in professional tennis players note an increased prevalence of acute injuries occurring in the lower extremity and chronic overuse injuries occurring in the upper extremity.1,2 Injury incidence BACKGROUND data from the Australian Open revealed a 2.4 times increase in in-event treatment for upper extremity injuries in both male and female players.2 Moreover, the Ulnar-sided wrist pain is the most common complaint amongst athletic women’s side reported a 2.2 times increase in wrist injuries over the same time wrist injuries, especially in sports like tennis that involve high-impact, period.2 Similar results of increased incidence of wrist injuries are reported in repetitive forces and axial loading of the wrist. the US Open and Wimbledon in which the wrist accounts for a high percentage of all upper extremity injuries compared to other body areas.3,4 Injury incidence data collected from the US Open reported that wrist injuries accounted for CLINICAL QUESTION 13.6% of all injuries in female players followed by the shoulder/clavicle (11.8%), elbow (4.9%), and lumbar/pelvic/sacrum (4.9%).3 Epidemiological data from The primary purpose of this clinical commentary is to introduce Backhand Wimbledon reported that wrist injuries accounted for 12% of all injuries, which Wrist as a new condition related exclusively to non-dominant, ulnar wrist is only second to the knee (13%). Wrist injuries were the highest in the upper pain in elite level tennis players. By being able to clinically define Backhand extremity, followed by the shoulder (10%) and elbow (6%).4 Wrist in tennis players, will this improve diagnosis, clinical decision- making, treatment, and return to play outcomes in tennis athletes with ulnar wrist pain? In addition to reviewing and describing the relevant anatomy and risk factors, this narrative will provide practitioners with an outline on how to evaluate and treat Backhand Wrist as well as how to manage return to play.

6 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 7 Dominant ulnar-sided wrist pain is one of the most well as how to manage return to tennis activity with tennis- carpal bones.5,8 The TFCC is comprised of the triangular In a 10 year retrospective study of 50 elite tennis players, common complaints among athletic wrist injuries, specific stroke modifications for optimal outcomes. fibrocartilage disc, ulnar collateral ligament, dorsal and 28 players presented with ECU related injuries: 12 cases of especially in sports such as golf, baseball, hockey, and tennis volar radioulnar ligaments, ulnolunate and ulnotriquetral traumatic ECU instability, 14 cases of ECU tendinopathy, that involve high-impact, repetitive forces into forearm ligaments, and the deep sheath of the ECU.5,12 The three and 2 cases of ECU tendon rupture.11 Of the 12 reported pronation/supination, ulnar/radial deviation, and axial CLINICALLY RELEVANT primary functions of the TFCC are to reinforce the stability cases of traumatic ECU instability, 10 presented on the loading of the wrist.5-8 These injuries are also difficult to ANATOMY of the DRUJ, to absorb shock at the ulnar side of the wrist, non-dominant wrist during a two-handed backhand.11 In diagnose due to the numerous complex structures within the and to stabilize and facilitate load transmission between the ECU instability, three different types of damage can occur ulnar quadrant of the wrist.8 Due to the lack of heterogeneity In order to understand the pathophysiological components ulnocarpal joint.5,12,13 The remaining stability is supplied by to the retinaculum: 1) ulnar rupture of the fibro-osseous and consistency in defining ulnar wrist pain in the literature, to Backhand Wrist, one must understand the anatomy and the curvature of the sigmoid notch of the radius and the sheath; 2) radial disruption of the fibro-osseous sheath; or 3) it has been difficult to identify the true incidence of wrist complexity of the structures within the ulnar quadrant and various dynamic stabilizers of the wrist such as the pronator periosteum detachment from the ulnar side of the ulna.11 pain in tennis players, particularly incidence of dominant sixth dorsal compartment of the wrist. quadratus.5 In pronation, the dorsal superficial and volar deep The players who presented with ECU instability reported versus non-dominant wrist pain or wrist pain during the radioulnar ligaments become taut to stabilize the DRUJ.5 In intense, sudden pain that limited their play for a few forehand or two-handed backhand.9 supination, the deep dorsal and superficial volar radioulnar minutes, while others attempted to hit a flatter groundstroke EXTENSOR CARPI ULNARIS ligaments become taut to create stability across the DRUJ.5 to reduce the amount of ulnar deviation typically used to Additionally, the TFCC is responsible for absorbing 18-20% produce more top spin.11 CLINICAL QUESTION The extensor carpi ulnaris (ECU) tendon originates at the of all axial load transmission across the wrist.5 The most ulnar lateral epicondyle and travels along the posterior aspect of portion of the TFCC is supplied by branches of the ulnar Tennis players may also develop ECU tendinopathy, which In tennis, the two-handed backhand has become a more the ulna until it inserts on the base of the fifth metacarpal. artery while the central and radial portions of the TFCC, is a more chronic overuse injury that presents gradually popular stroke which was initially introduced with the The sixth compartment of the wrist is unique in that the including the triangular fibrocartilaginous disc, are relatively over time. The repetitive nature of hitting backhand intention that using both hands could assist with increasing ECU tendon is enclosed within its own fibro-osseous avascular which limits their healing potential.5 groundstrokes may place stress to the ECU tendon during force production and power. Similar to the forehand, the sheath beneath the extensor retinaculum.5-8 Through forearm rotation, especially in cases of inefficient stroke repetitive loading and ball impact during a two-handed anatomical dissections, it has been shown that the floor mechanics or poor technique.9 backhand subjects the structures in the ulnar quadrant to of the sub-sheath provides support to stabilize the distal MECHANISM OF INJURY degenerative changes and possible overuse injury.9 This risk radioulnar joint (DRUJ), making the ECU tendon a Finally, tennis players may experience acute ECU tendon of overuse injury is increased in the presence of inefficient dynamic stabilizer.5,7 The subsheath is stabilized to the In tennis players, Backhand Wrist is caused by repetitive, rupture possibly related to repeated stress and microtrauma stroke mechanics that play a role in load transmission dorsal medial aspect of the ulna by the linea jugata, which high-energy axial or torsional loading with rapid forearm to the ulnar side of the wrist. In the study by Montalvan through the wrist and forearm.10 The extreme amounts deepens the sulcus and extensor retinaculum. Its primary rotation causing degenerative changes and/or poor force and colleagues,11 2 of the 28 players presenting with ECU of ulnar deviation and supination combined with rapid action is to extend and ulnarly deviate the wrist and hand. transmission throughout the ulnar quadrant. Excessive pathology experienced tendon rupture in the non-dominant forearm rotation during a two-handed backhand may Because the ECU tendon moves from dorsal to palmar wrist flexion/extension, ulnar deviation, and supination wrist during a two-handed backhand. Both players had a place certain players at increased risk for developing non- with varying degrees of forearm rotation, the ECU tendon during a two-handed backhand can lead to the development history of recurrent pain and weakness during a two-handed dominant ulnar wrist pain. exits the subsheath at varying points of angulation during of ECU pathology, TFCC pathology, DRUJ instability, and/ backhand as well as history of multiple local corticosteroid pronation and supination.5,7,11 In full supination, the ECU or ulnocarpal impaction syndrome.5,7.10,11,13 It is important injections.11 High profile, professional tennis players have also suffered tendon exits the subsheath dorsally at approximately 30 to note that pathology can occur independently in each time-loss injuries and surgical intervention due to non- degrees, contributing more to extension of the wrist while individual structure, but multiple pathologies can coexist, dominant ulnar wrist pain. With the increased prevalence of also increasing tension on the ECU tendon and ECU especially in the case of TFCC pathology with concomitant TFCC PATHOLOGY wrist injuries among junior and professional tennis players, retinaculum.5,7,11 This concept is important to understand ulnocarpal impaction syndrome. one must question if changes in training load or how stroke when reviewing backhand stroke mechanics as the greatest The TFCC is subject to injury during repeated stress to mechanics are being taught are contributing to the rise of stress on the ECU tendon and fibro-osseous tunnel the ulnocarpal joint during a two-handed backhand as non-dominant wrist injuries in tennis players. occurs when the wrist is positioned in supination with ECU PATHOLOGY it attempts to stabilize and absorb shock at the DRUJ. In combined ulnar deviation and/or wrist flexion.7 In forearm addition to combined supination and extreme ranges of Therefore, the primary purpose of this clinical commentary pronation, the ECU tendon lies on the palmar surface and Repetitive loading can lead to overuse injury and the ulnar deviation during the preparation phase of a two- is to introduce Backhand Wrist as a new tennis-specific exits the subsheath in a more linear fashion, increasing its development of ECU tendonitis or tenosynovitis. ECU handed backhand, gripping and forceful pronation may diagnosis related exclusively to non-dominant ulnar wrist contribution to ulnar deviation.5,7,11 pathology is one of the most common etiologies of contribute to increased force across the ulnocarpal joint and pain in high level junior and elite level tennis players. Backhand Wrist. The wrist is most vulnerable to instability stress to the TFCC.5,13 Defining this condition in sports medicine will not only when the ECU tendon contracts eccentrically to attempt help to better track incidence, treatment and return to play TRIANGULAR FIBROCARTILAGE to stabilize the ulnar side of the wrist, while moving from outcomes, but also aid in recognition and identification COMPLEX supination to pronation with the wrist fixed in flexion and ULNOCARPAL IMPACTION of tennis-specific risk factors and treatment interventions ulnar deviation.7 This movement pattern is apparent during for successful conservative management. In addition to The floor of the fibro-osseous tunnel encompassing the a traditional two-handed backhand and can lead to injury The backhand wrist travels from a hypersupinated to reviewing and describing the relevant anatomy and risk ECU tendon blends to form the triangular fibrocartilage in cases of extreme ulnar deviation to achieve more topspin hyperpronated position from pre to post impact imparting factors, this narrative review will provide practitioners with complex (TFCC), which suspends from the distal radius and or possibly due to high loads of eccentric contraction at ball force and thus possible injury to the ECU and the TFCC an outline of how to evaluate and treat Backhand Wrist as inserts on the base of the ulnar styloid and proximal row of impact.6,10 respectively. In the case of limited space in the ulnocarpal

8 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 9 joint, a player may experience ulnocarpal impaction or examined until Jayanthi and colleagues10 developed a stroke triquetrohamate impaction syndrome in the case of carpal abutment of the distal ulna against the proximal carpus. efficiency rating (SER) to assess injury risk and mechanics pain or involvement.20 Special Tests Players who utilize excessive ulnar deviation to drop the with the serve, forehand, and backhand. racket head below the ball in an attempt to create more In Backhand Wrist, players may complain of diffuse, dorsal ECU Synergy Test21 (Figure 1): topspin may further exacerbate this stress in combination When considering backhand stroke mechanics, injury risk ulnar wrist pain of insidious onset and pain with ulnar The player sits with the elbow flexed at 90 degrees and with the rapid forearm pronation through ball impact.9 associations (IRA) are related to non-dominant wrist and deviation and/or on impact during a two-handed backhand. the forearm resting in full supination, wrist neutral, and elbow positioning during a two handed backhand.10 Expert Typically, symptoms are described as chronic and related to fingers extended. The examiner provides resistance against opinion suggests ulnar deviation be limited to less than 30 overuse and repetitive motions. Players may note clicking abduction of the thumb and middle finger with one hand RISK FACTORS degrees during the preparation phase to limit stress to the or swelling along the ulnar side of the wrist or pain with while palpating the ECU tendon with the other hand. A DRUJ and ulnar quadrant.10 At the point of contact, ulnar combined wrist flexion, ulnar deviation, and supination. In positive test is described as reproduction of pain along the deviation should be closer to 0 degrees with the wrist in a addition, there may also be pain with gripping or lifting an dorsum of the wrist. neutral position and the elbow extending throughout the object with an extended arm or during resisted supination. Intrinsic Risk Factors acceleration phase to absorb ball impact forces and reduce injury risk to the wrist and elbow.10 Anatomical variations seen on radiographic imaging can CLINICAL EXAMINATION contribute to risk for developing Backhand Wrist. Ulnar Grip type is also associated with injury risk. In a study of FOR ECU PATHOLOGY variance is a measure of the length of the ulna relative to the 370 non-professional tennis players, 50 players reported length of the radius.14 Neutral ulnar variance is defined by wrist injuries.18 Western and semi-Western grip types were a difference between ulna and radius length that is less than consistently associated with ulnar-sided wrist injuries, 1mm.14 Positive ulnar variance is associated with an ulnar while the Eastern grip was associated with radial-sided ECU Tendonitis or Tenosynovitis articular surface that extends more distal than the radial injuries.18 An extreme Western or semi-western grip with articular surface. Positive ulnar variance may predispose the non-dominant wrist during a two-handed backhand On physical examination, the player may report tenderness tennis players to develop ulnocarpal impaction or TFCC places the wrist in a more supinated and ulnarly deviated to palpation of the ECU tendon. Symptoms are reproduced pathology possibly related to repetitive loading at the position which places increased load to the ulnocarpal with combined resisted wrist flexion, ulnar deviation, and ulnocarpal joint, causing stress and strain on the TFCC.5,9 joint and TFCC. This also creates increased tension on the supination. Some players may report that their pain lessens Ulnocarpal impaction occurs from direct impact of the distal ECU tendon and ECU retinaculum as the tendon exits the once they are warmed up.11 Diagnosis of ECU tendonitis or ulna on the proximal carpus.13 Ulnar positive morphology is subsheath at an angled position during forearm supination tenosynovitis is supported by a positive ECU synergy test, also associated with increased force transmission across the with combined ulnar deviation. but a negative FUSS maneuver (flexion, ulnar deviation DRUJ and decreased thickness of the TFCC contributing to supination stress), which would indicate instability due to instability.5,9 A two-fold increase in axial loading has been In addition to stroke mechanics, junior tennis players injury of the fibro-osseous sub sheath and require more described in the literature for ulnar positive variance of may be at increased risk for developing overuse injuries, extensive surgical treatment.8 2.5mm.13 Conversely, negative ulnar variance describes an specifically Backhand Wrist, due to their training patterns Figure 1. ECU Synergy Test ulna that projects more proximally compared to the radius.14 or whether or not they have specialized in tennis at an early Negative ulnar variance is associated with ECU pathology or age.9,19 Highly specialized athletes, those who train in a instability.5 Additionally, the depth of the ulnar groove may single sport to the exclusion of other sports and train more ECU Instability FUSS (flexion, ulnar deviation, supination stress) play a role in ECU pathology. On imaging, patients with a than eight months out of the year, are at increased risk for Maneuver8: more shallow ulnar groove presented with ECU pathology.5,15 developing overuse injuries.19 Furthermore, junior tennis ECU tendon instability occurs when the subsheath ruptures The examiner passively moves the wrist into supination In the case of ECU tendinopathy, individuals with a large players are at an increased risk for overuse injury if they or detaches from the ulna or the tendon leaves the subsheath while maintaining wrist flexion and ulnar deviation to assess ulnar styloid process may be at increased risk for developing train more hours per week than their age or more than 16 during supination and then returns during pronation.11 Upon for laxity compared to the unaffected side. ECU pathology due to the direct mechanical involvement and hours per week with a history of prior injury.19 clinical exam, the clinician may note the ECU tendon is able proximity of the tendon to the bone.5 to sublux over the ulnar border during forearm pronation and “Ice cream scoop” Test8,13: supination. Athletes may also note localized swelling or pain The athlete places their wrist in pronation, ulnar deviation CLINICAL EXAMINATION at the distal ulna immediately following play.11,13 Players may and extension and then performs an ice cream scooping also report intense pain with passive supination and pain with motion against resistance into supination while maintaining Extrinsic Risk Factors While Backhand wrist can involve injury to the ECU, TFCC, palpation of the ECU tendon at the ulnar groove.11 A positive extension and ulnar deviation. A positive test is indicated by or DRUJ and ulnocarpal joint in isolation, it is common FUSS maneuver and “ice cream scoop” test are suggestive of reproduction of pain at the ECU tendon or snapping of the Stroke mechanics can play a large role in injury risk amongst for these pathologies to occur concomitantly requiring a ECU instability. 8,13 ECU tendon over the distal ulna. tennis players, although current evidence in causation is thorough clinical exam and subjective history report. Because limited, especially in junior tennis players. Kovacs et al16 and there are a number of different structures within the ulnar Myers et al17 have described models for analyzing the serve quadrant, a specific and comprehensive examination is critical in elite level tennis players, but systematic and standardized to differentiate the etiology involved in ulnar-sided wrist pain. assessments for groundstroke mechanics had not been Differential diagnosis should also include consideration for

10 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 11 CLINICAL EXAMINATION FOR TFCC (22/52) wrists presented with ECU instability during dynamic PATHOLOGY AND DRUJ STABILITY ultrasound imaging with 91% (20/22) demonstrating tendon subluxation.15 Overall, the prevalence of ECU tendon In Backhand Wrist, TFCC injuries are typically due abnormalities including tendinosis, tearing, instability, to degenerative overuse injuries and inefficient stroke and subluxation was similar between dominant and non- mechanics. Players will complain of ulnar-sided wrist pain dominant wrists.15 that is exacerbated with resistance and ulnar deviation combined with forearm pronation and supination. Players MRI may be used to evaluate the ulnocarpal joint with either will also present with tenderness at the fovea or a positive arthrogram or a 3T scanner to fully evaluate the TFCC and ulnar foveal sign.8,9 for any ulnocarpal abutment.5,13

CONSERVATIVE MANAGEMENT Special Tests Most cases of backhand wrist can be treated conservatively Ulnar Fovea Sign21 (Figure 2): and non-operatively. Treatment should include medical With the athlete’s forearm placed in neutral, the examiner treatments, tennis progressions (including appropriate uses their thumb to apply force at the fovea between the volume adjustments) and tennis stroke accommodations. ulnar styloid and flexor carpi ulnaris tendon. A positive test Figure 3. Ulnocarpal Stress Test Figure 5. DRUJ Ballottement Test is indicated by reproduction of pain and suggestive of foveal disruption of the TFCC or ulnotriquetral ligament. BRACING AND TAPING DRUJ Ballottement Test21 (Figure 5) With the athlete seated and the arm relaxed on the table, In cases of traumatic ECU instability, a period of the examiner grasps the triquetrum with the thumb and immobilization may be warranted to avoid forearm index finger and the lunate using the opposite thumb and supination while allowing the subsheath to heal.11 For in- index finger. The clinician moves the lunate in a palmar season injuries or playable injuries, players may consider and dorsal direction. A positive test is indicated by laxity or playing with a wrist brace or supportive taping. The primary reproduction of pain throughout the movement suggestive goal of bracing or taping is to create stability across the of lunotriquetral ligament instability. DRUJ while taking stress away from soft tissue structures or the TFCC by limiting excessive ulnar deviation, extension, and supination during a two-handed backhand. Stroia and IMAGING colleagues22 from the WTA have proposed a McConnell unloading taping method in place of traditional compression X-ray can be helpful in determining degree of ulnar variance taping that may cause symptom irritability or restrict full as well as presence of dynamic positive ulnar variance in the range of motion. The proposed McConnell unloading taping ulnocarpal joint.5 method for TFCC and ECU pathology unloads the ulnar side of the wrist while blocking supination, ulnar deviation Ultrasound may be helpful to dynamically evaluate the ECU and extension to allow for comfort and ability to hit a tennis Figure 4. Piano Key Test tendon during forearm pronation and supination.11,13 While stroke without fully restricting all ranges of motion.22 attempting to reproduce the ECU instability, the examiner can force the forearm into supination to visualize the ECU tendon Bracing may also be considered during a period of rest to Figure 2. Ulnar Fovea Sign Piano Key Test21 (Figure 4): subluxing over the distal ulna as it leaves and re-enters its manage acute or subacute symptoms. If playing with a With the athlete seated and the arm relaxed on the table, the sheath.11 In cases of ECU tendinopathy, the retinaculum will brace, players may experience discomfort due to the size examiner places their thumb dorsally over the ulna and their appear intact with possible swelling or thickening about the and bulkiness of the material may affect tennis stroke form. Ulnocarpal Stress Test21 (Figure 3): index finger over the pisotriquetral complex. The clinician tendon.11,15 Anecdotal evidence supports the use of gymnastics-type Player sits with the elbow fully flexed, forearm supinated, produces a dorsal glide of the pisotriquetral complex by wrist braces as they allow for comfort, but also stability when and wrist in full ulnar deviation. While maintaining ulnar squeezing their thumb and index finger together. A positive Sole and colleagues15 performed a sonographic imaging study playing tennis. deviation, the examiner supports the elbow, grasps the test is indicated by reproduction of pain or laxity suggestive on 26 asymptomatic recreational tennis players to assess for patient’s hand, and moves the wrist into supination and of TFCC pathology or triquetral instability. ECU tendon abnormalities. Both static and dynamic tendon pronation. A positive test is indicated by clicking or pain in assessments were performed bilaterally using ultrasound the ulnocarpal region and suggestive of DRUJ instability. imaging. ECU abnormalities including tendinosis or tearing were identified in 75% (39/52) wrists.15 Forty-two percent

12 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 13 PHYSICAL THERAPY does not affect a player’s swing speed. String tension is often SURGICAL INTERVENTIONS lowered to reduce the load to the wrist, but the weight of the It is recommended that clinical examination findings be strings are typically about 1/10th the weight of the racket This article has documented the dorsoulnar quadrant used to direct specific physical therapy intervention and and may not actually play as large a role in force generation. as a specific site of both acute and chronic injury in the treatment. In the case of instability, rehabilitation should non-dominant wrist of high level tennis players, aptly focus on restoring DRUJ stability and neuromuscular re- The initiation of on court progressions should begin with a named Backhand Wrist. The anatomy, mechanism of education for neutral wrist alignment and motor control low compression ball from the service line keeping in mind injury, diagnosis, ancillary studies, and initial conservative to minimize significant ulnar deviation or end range load management strategies and progressions to regulation treatment have been discussed with a strong emphasis extension during tennis-specific activities. Rehabilitative sized tennis balls and full court hitting.23 (Appendix A) on stroke and technique modification to affect a positive exercise should emphasize neutral wrist positioning and result. Fortunately, this treatment is usually successful in stability especially during closed chain activities, plyometric There are three general areas to evaluate to reduce load to allowing full return to play with minimal risk. However, in activities, or when receiving repeated impact through the the ulnar wrist on the backhand24: a small percentage of players, surgical intervention may be arm or upper extremity to mimic ball impact forces. To necessary when conservative measures fail. Currently there is address ECU tendinitis or tendinopathy, forearm and ECU limited evidence on surgical interventions and return to play eccentric loading exercises are recommended to improve outcomes in a tennis specific population. tensile strength of the tendon while also decreasing symptom irritability and improving overall forearm and grip strength. 1 Ulnar deviation of the non-dominant wrist is Figure 6. ECU Tendon Instability/Subluxation Clinicians should also incorporate scapular and glenohumeral recommended to be 30 degrees or less to limit EXTENSOR CARPI joint stability exercises and rotator cuff strengthening if ulnocarpal stress and to also reduce extreme ULNARIS (ECU) significant side to side differences exist in order to improve supination. proximal strength and control through the entire kinetic Surgical treatment of ECU tenosynovitis is determined by the chain. Players may also benefit from pronation and supination extent of inflammation encountered at time of exploration. exercises that focus on neuromuscular control and stability at 2 Hand dominance where the dominant hand Most commonly seen is a proliferative noninvasive end ranges of motion utilizing proprioceptive neuromuscular initially may do at least 50% or more of the inflammatory response. When the tenosynovitis has not facilitation or rhythmic stabilization techniques. force generation of the backhand. This may invaded the tendon, simple debridement of this tissue is be adjusted progressively, but ideally to be satisfactory in achieving a good result. It is necessary to It is important to address the entire kinetic chain when a more symmetric between non-dominant and avoid compromising the subsheath and causing iatrogenic player presents with Backhand Wrist. Addressing lower dominant wrists. instability of the tendon. body mechanics and rotational power production as well as scapular and proximal stability may influence energy transfer Often at exploration the inflammatory reaction has and load transmission that may decrease ulnar wrist pain 3 Lower body force and power generation is invaded the tendon. This is usually seen in a more chronic during the two-handed backhand. A detailed tennis stroke recommended to decrease stress at the wrist presentation. When this occurs, often the surgeon may analysis may aid in clinical decision making when deciding upon acceleration and to avoid positions of encounter longitudinal slit tears in the tendon. In addition, whether or not to immobilize the athlete or allow return to excess ulnar deviation. Players should aim for a the tendon may become adherent to the floor of the sheath Figure 7. ECU Stabilization Procedure utilizing extensor play with stroke modifications and a targeted rehabilitation ball contact position that is waist high, utilizing found on the dorsum of the ulna. In this situation the retinaculum flap program.10 lower body loading to adjust for optimal strike procedure requires more specific attention. Slit tears are best zone and neutral wrist positioning. treated with excision of the found injury and suture repair. Adhesions of the tendon to the bare dorsum of the ulna TENNIS SPECIFIC MODIFICATIONS must be lysed and often interposition of soft tissue or other commercially available substances (amnion, extracellular After appropriate medical treatment for backhand wrist, matrix) are used to prevent scarring. an on-court progression may be initiated. The rate of BIOLOGICS progression may be dictated by pathology, treatment, With further injury to the ECU, the subsheath can be and the treating provider. Prior to initiating the on-court In some situations, conservative rehabilitation, bracing, compromised resulting in post traumatic subluxation of the progression, a player must have pain-free resisted ulnar taping and/or cessation of tennis may not be adequate to tendon (Figure 6). Treatment now requires stabilization of deviation and extension, greater than 85% grip strength reduce pain and may not allow a full return to competitive the tendon, effectively recreating the subsheath. Use of an compared to the uninvolved side, and tolerance to terminal tennis. There is limited data to support biologic treatments autograft such as a palmaris longus tendon can be used, but range of motion in all planes. such as PRP (platelet rich plasma). However in certain non- most advocate a flap of the extensor retinaculum wrapped responsive situations, such options anecdotally have been and anchored around the tendon to recreate a stable tunnel Additionally, equipment should be evaluated for appropriate performed to avoid surgery and improve symptoms with (Figures 7,8). racket weight, string type and tension. Typically, some success. recommendations include choosing the heaviest racket that Figure 8. ECU Stabilization Procedure utilizing extensor retinaculum flap

14 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 15 TRIANGULAR FIBROCARTILAGE The author’s algorithm for treatment of ulnocarpal cannot emphasize enough attention to mechanics and core IMPLICATIONS: COMPLEX (TFCC) impaction starts with documentation of the degree of strength maintenance before return to play. positive variance of the ulna (Figure 10). For symptomatic This commentary highlights conservative management of Injury to the TFCC requires astute diagnosis and players with 0-2 mm, no treatment of the ulna is necessary non-dominant ulnar sided wrist pain in the tennis athlete recognition of its presentation, along with clinical acumen and priority is directed to the ECU and TFCC is necessary. SUMMARY and the unique surgical indications and options. Special in ruling out other causes of ulnar sided wrist pain. It For variance found between 2-4 mm the author usually opts consideration should be made to tennis stroke mechanics also requires a sound knowledge of the TFCC’s function to perform a distal “wafer” procedure in which the end of Understanding the mechanisms and underlying anatomy of and specific stroke modifications that may aid in the and its anatomy. Therefore injury to this structure can the ulna is shaved down or removed with a saw, a procedure Backhand Wrist can aid in clinical decision making when treatment of Backhand Wrist. involve a spectrum of symptoms. Further acute versus that may be done arthroscopically or through a mini open working with tennis players with ulnar-sided wrist pain chronic presentation exists, but for purposes of clinical procedure. Again, concomitant treatment of the ECU and in the non-dominant wrist. It is important to differentiate comprehension, the most common types of injury will be TFCC is important. When the ulnar positive variance is between the various structures that play a role in ulnar- presented. It does need to be emphasized that asymptomatic greater than 4 mm, successful treatment necessitates a sided wrist pain in order to perform an accurate clinical TFCC tears do exist and it is important that the clinician is formal ulna shaft shortening osteotomy. This is usually examination and create an individualized treatment plan. APPENDIX A: ON-COURT confident the athlete’s diagnosis is due to this injury. accomplished through a removal of bone and placement of a With respect to rehabilitation, clinicians may consider PROGRESSION plate to stabilize the shaft while healing occurs. More recent working directly with the player’s coach to assess stroke The most common form of injury to the TFCC involves mini invasive procedures in which the head and not the mechanics and inefficient stroke mechanics that may 1. Dynamic lower body warm up (light jog, side a stable slit tear in the articular disc found ulnar to the shaft is shortened and secured with a single screw may have contribute to injury risk over time. Tennis and strength and shuffle, lunges, etc.) origin of this structure off the distal radius. The tear can reduced morbidity. conditioning coaches may consider adding prehabilitation 2. Upper extremity arm circles, shadow swings, and result in a flap of tissue that creates pain and often locking exercises into their player’s current routine to address for wrist circles in the athlete. Often this symptom will be exacerbated Currently there are no standards for surgical clinical ECU injuries and wrist instability. 3. Low compression ball: Service line warm up with rotation of the forearm. The surgical treatment for decision making when managing positive ulnar variance and with <25% use of Non-dominant wrist, limited this particular tear involves arthroscopic debridement of ulnocarpal impaction in the tennis player. Future research It is important to address the entire kinetic chain when a the flap with care to avoid too overzealous of a removal is necessary to better track surgical outcomes as well as player presents with Backhand Wrist. Addressing lower supination/ulnar deviation (10-15 min) of the articular disc to prevent iatrogenic instability of the return to play for each procedure type as well as validated body mechanics and rotational power production as well 4. Low compression ball: Service line warm up radioulnar joint. clinical decision making for conservative versus surgical as scapular and proximal stability may influence energy with <50% use of Non-dominant wrist, limited management of Backhand Wrist in the elite tennis player. transfer and load transmission which may decrease ulnar supination/ulnar deviation (10-15 min) The second most common tear involves injury to the wrist pain during the two-handed backhand. A detailed 5. Low compression ball: Baseline warm up with peripheral rim of the triangular disc. These tears can be In a general, non-athletic population, the arthroscopic tennis stroke analysis may aid in clinical decision making <25% use of Non-dominant wrist, limited problematic as they can be associated with radioulnar joint wafer procedure is associated with improved postoperative when deciding whether or not to immobilize the athlete or instability if total disruption occurs. Fortunately, many of outcomes and lower rates of complications compared to the allow return to play with stroke modifications and a targeted supination/ulnar deviation (10-15 min) these injuries are partial and can heal with conservative ulnar shortening osteotomy in ulnar positive individuals.25 rehabilitation program. 6. Low compression ball: Baseline warm up with treatment. The blood supply to the disc is directed Similar outcomes were reported when comparing TFCC <50% use of Non-dominant wrist, limited peripheral to central which adds to the accelerated healing debridement and arthroscopic wafer distal ulnar resection Future research should consider utilizing the term Backhand supination/ulnar deviation (10-15 min) seen in these injuries due to the rich vascularity. When versus TFCC debridement and ulnar shortening osteotomy Wrist to define, non-dominant ulnar wrist pain in elite and 7. Yellow ball: Service line warm up with <25% use conservative treatment does not give relief, surgery is an for ulnocarpal impaction syndrome.26 Ulnar shortening professional tennis players to better track injury incidence, of Non-dominant wrist, limited supination/ulnar acceptable choice. In our experience peripheral stable tears, osteotomy procedures were associated with prolonged but also treatment and return to play outcomes specific to as determined at arthroscopy, are usually managed with recovery times, development of DRUJ arthritis, hardware tennis athletes. More research is also needed to assist with deviation (10-15 min) debridement to a stable rim. More rare unstable injuries may complications, and secondary procedures to address clinical decision making in the case of surgical intervention 8. Yellow ball: Service line warm up with <50% use necessitate repair of the peripheral rim, a procedure that can hardware irritation.26 Conversely, the arthroscopic wafer after failed conservative management to prevent future of Non-dominant wrist, limited supination/ulnar be done open or arthroscopically. procedure was associated with improved grip strength and complications and to avoid additional time loss or inability deviation (10-15 min) subjective patient reported outcomes compared to the ulnar to return to tennis due to complications or secondary 9. Yellow ball: Baseline warm up with <25% use of As stated previously, the three most common injuries seen shortening osteotomy procedure.25 procedures. Non-dominant wrist, limited supination/ulnar in the backhand wrist are ECU injury, TFCC injury, and ulnocarpal impaction and they commonly coexist. This is Post-operative physical therapy varies according to the Players, parents, coaches, and healthcare professionals deviation (10-15 min) crucial for the clinician to understand, especially with TFCC complexity of the procedure and is out of the scope of should educate on tennis-specific stroke modifications 10. Yellow ball: Baseline warm up with <50% use of injury and concomitant ulnocarpal impaction. this discussion, but most players do not return to full to reduce Backhand Wrist injury risk, but also to better Non-dominant wrist, limited supination/ulnar unrestricted activity for 4-6 months. Most of the previous manage athletes who are suffering from non-dominant, deviation (10-15 min) described procedures require immobilization for up to ulnar wrist pain. Tennis-specific conservative management 11. Progress load to normal training volumes gradually ULNOCARPAL IMPACTION 4-6 weeks (longer for an osteotomy) followed by active may serve to speed up recovery and return to play while 12. Progress load to normal competition volumes and then passive range of motion. When pain free avoiding costly and invasive surgical interventions that may Once the diagnosis of ulnocarpal impaction is established motion is achieved, strengthening commences with a prolong return to sport or contribute to future complications gradually and conservative measures have failed to decrease goal of documented grip and pinch strength to 85% of the postoperatively. symptoms, then surgery becomes necessary for the athlete. contralateral side before full activity is allowed. The author

16 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 17 REFERENCES ABOUT THE AUTHORS

1. Fu MC, Ellenbecker TS, Renstrom PA, Windler GS, Dines DM. Epidemiology of injuries in tennis players. Curr Rev Musculoskelet Med. 2018;11(1):1-5. doi:10.1007/s12178-018-9452-9 Kayla Fujimoto Epperson, PT, DPT 2. Gescheit DT, Cormack SJ, Duffield R, et al. Injury epidemiology of tennis players at the 2011-2016 Australian Open Grand Slam. Br J Sports Med. 2017;51:1289- 1294. doi:10.1136/bjsports-2016-097283 Kayla is a sports physical therapist in the Chicago western suburbs. 3. Sell K, Hainline B, Yorio M, Kovacs M. Injury Trend Analysis from the US Open Tennis Championships Between 1994 and 2009. Br J Sports Med. She currently works with local travel sports teams and overhead 2014;48(7):546-51. doi:10.1136/bjsports-2012-091175 athletes. In addition to pursuing specialty board certification in 4. McCurdie I, Smith S, Bell P, et al. Tennis injury data from the championships, Wimbledon, from 2003 to 2012. Br J Sports Med. 2016;51(7):607-611. doi:10.1136/ Sports Physical Therapy, she is a Certified Strength and Conditioning bjsports-2015-095552 Specialist through the NSCA. Kayla was a former Division 1 tennis 5. Pang EQ, Yao J. Ulnar-sided wrist pain in the athlete (TFCC/DRUJ/ECU). Curr Rev Musculoskelet Med. 2017;10:53-61. doi:10.1007/s12178-017-9384-9 player at Indiana University. Her experiences as a competitive athlete 6. Lourie GM. Tendinopathy and Tendon Instability in the Athlete’s Wrist: The ECU and ECRB. In: Carlson M, Goldfarb C, eds. The Athlete’s Hand and Wrist. have made her passionate about empowering youth and teen Chicago, IL: American Society for Surgery of the Hand; 2014. athletes with sports specific rehabilitation and education to help 7. Campbell D, Campbell R, O’Connor P, Hawkes R. Sports related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and them stay healthy and performing at their highest potential. management. Br J Sports Med. 2013;47(17):1005-1011. doi:10.1136/bjsports-2013-092835 8. Gaston RG, Robinson EP, Lourie GM. Hand and Wrist Diagnosis and Decision Making. In: Miller MD, Thompson SR, eds. Orthopaedic Sports Medicine Principles and Practice. 4th ed. Atlanta, GA: ELSEVIER; 2014:815-825. Gary M Lourie, MD 9. Stuelken M, Mellifont D, Gorman A, Sayers M. Wrist Injuries in Tennis Players: A Narrative Review. Sports Med. 2017;47:857-868. doi:10.1007/s40279-016- 0630-x Dr. Gary M. Lourie is a hand and upper extremity surgeon affiliated 10. Jayanthi N, Seyalioglu A, Soelling S, et al. A Novel Stroke Efficiency Rating (SER) with an Injury Risk Assessment (IRA) for On-Court Stroke Evaluation in with Emory University and also serves as Chief of the Hand Surgery Junior and Elite Competitive Tennis Players. J Med Sci Tennis. 2017;22(3):27-41. Service at WellStar Atlanta Medical Center. He is the head team 11. Montalvan B, Parier J, Brasseur JL, Le Viet D, Drape JL. Extensor carpi ulnaris injuries in tennis players: a study of 28 cases. Br J Sports Med. 2006;40(5):424-9. physician for the Atlanta Braves and Consultant to the Georgia Tech doi:10.1136/bjsm.2005.023275 Athletic Association. He serves as the Orthopedic Physician for the 12. Casadei K, Kiel J. Triangular Fibrocartilage Complex (TFCC) Injuries. Treasure Island, FL: StatPearls; 2020. GT baseball team and Assistant Team Physician for the GT football 13. Gil JA, Kakar S. Hand and Wrist Injuries in Tennis Players. Curr Rev Musculoskelet Med. 2019;12(2):87-97. doi: 10.1007/s12178-019-09550-w team. 14. Kox LS, Jens S, Lauf K, Smithuis FF, van Rijn RR, Maas M. Well-founded practice or personal preference: a comparison of established techniques for measuring ulnar variance in healthy children and adolescents. Eur Radiol. 2020;30(1):151-162. doi: 10.1007/s00330-019-06354-x 15. Sole JA, Wisniewski SJ, Newcomer KL, Maida E, Smith J. Sonographic Evaluation of the Extensor Carpi Ulnaris in Asymptomatic Tennis Players. PM R. Michael Gottschalk, MD 2015;7(3):255-63. dio:10.1016/j.pmrj.2014.08.951 16. Kovacs M, Ellenbecker T. An 8-stage model for evaluating the tennis serve: implications for performance enhancement and injury prevention. Sports Health. Dr. Gottschalk is a hand and upper extremity surgeon at Emory 2011;3(6):504-513. doi:10.1177/1941738111414175 University and is the director of clinical research for the department 17. Myers N, Kibler B, Lamborn L, et al. Reliability and Validity of a Biomechanically Based Analysis Method for the Tennis Serve. Int J Sports Phys Ther. of orthopaedics. In addition to being the hand consultant for the 2017;12(3):437-449. Atlanta Falcons, Hawks, and Dream, he is an avid tennis player and a 18. Tagliafico AS, Ameri P, Michaud J, Derchi LE, Sormani MP, Martinoli C. Wrist injuries in nonprofessional tennis players: relationships with different grips. Am former qualified USTA tennis player (USTA Championship Qualified J Sports Med. 2009;37(4):760-7. doi: 10.1177/0363546508328112 16 and under). 19. Jayanthi NA, LaBella CR, Fisher D, Pasulka J, Dugas LR. Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes. Am J Sports Med. 2015;43(4):794-801. doi: 10.1177/0363546514567298 20. Lourie GM, Booth C, Nathan R. Triquetrohamate Impaction Syndrome: An Unrecognized Cause of Ulnar-Sided Wrist Pain; Its Presentation Further Defined. Hand. 2017;12(4):383-88. doi: 10.1177/1558944716670138 Neeru Jayanthi, MD 21. Reiman MP. Orthopedic Clinical Examination.1st ed. Champaign, IL: Human Kinetics; 2016. 22. Stroia K, Baudo M, Martin K. Taping Techniques for TFCC and ECU Injuries on the Sony Ericsson WTA Tour. JMST. 2009;14(1):15-19. Dr. Jayanthi is a sports and tennis medicine physician who 23. Myers NL, Sciascia AD, Kibler WB, Uhl TL. Volume-based Interval Training Program for Elite Tennis Players. Sports Health. 2016;8(6):536-40. leads Emory’s Tennis Medicine program. He is the immediate doi:10.1177/1941738116657074 Past-President of the International Society for Tennis Medicine 24. Jayanthi N, Tzakis, E. Return to Play Tennis On-Court Stroke Modifications Following Injury in Junior Competitive Tennis Players. J Med Sci Tennis. and Science (STMS) and a certified USPTA and PTR teaching 2016;21(1):28-34. professional. He has also been a volunteer ATP (Association of 25. Oh WT, Kang HJ, Chun YM, Koh IH, An HM, Choi YR. Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment for Tennis Professionals) physician for nearly 20 years, serves as a Idiopathic Ulnar Impaction Syndrome. Arthroscopy. 2018;34(2):421-430. medical advisor for the WTA (Women’s Tennis Association) Player 26. Bernstein MA, Nagle DJ, Martinez A, Stogin JM Jr, Wiedrich TA. A comparison of combined arthroscopic triangular fibrocartilage complex debridement and Development Panel, USTA Sport Science Committee, and is on the arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal commission for the (ITPA). He is currently a team physician for the abutment syndrome. Arthroscopy. 2004;20(4):392-401 Atlanta Braves, Georgia Tech University tennis teams, and Johns Creek High School. Dr. Jayanthi has been a course director over 30 times and has been an invited speaker over 150 times to local, regional conferences as well as at national academy conferences, international STMS, Sports Medicine, Tennis Medicine, USTA, USPTA, and PTR conferences.

18 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 19 TENNIS SPORT SCIENCE REVIEW

Results: Conclusions:

10,380 USTA league members were included for In reference to the general population, USTA League analysis. For all SF-36 domains, tennis players scored athletes have higher general, physical, social and higher than the general population mean (general mental health scores. The present study indicates health Improved General Health population mean=50). Athletes who reported playing benefits of tennis in athletes of all ages, ability and tennis more times a week had higher SF-36 outcomes frequency. Outcomes in US Recreational (all domains p<0.01). Elite tennis players (NTRP>4) scored higher on the SF-36 physical functioning domain than those with less advanced tennis skills. Key Words: Tennis Players Athletes who reported playing more than 3 days per week scored higher in all categories than those who SF-36, Patient Reported Outcomes, Tennis, Athletes competed less frequently. Jared Tishelman*, Daniel Bu, James Gladstone, Alexis Colvin, BA,1 BA,1 MD,1 MD,1

Institution Affiliation * Corresponding Author: Jared C. Tishelman 1. Department of Orthopedics, Icahn 5 East 98th Street, 9th floor School of Medicine at Mount Sinai New York, NY 10029, USA Tel: 212-241-1815 Email: [email protected]

Disclaimer: The authors report no conflicts of interest. Funding: None.

ABSTRACT Methods:

The present study is a cross-sectional study employing Purpose: a modified SF-36 version 1.0, administered to USTA League members. The following patient variables The United States Tennis Association (USTA) is the were collected: age group, days of tennis per week, largest competitive adult tennis league in the United self-reported ability, National Tennis Rating Program States. Although there have been extensive studies (NTRP) score, smoking status, body mass index, and employing the Short Form-36 (SF-36) outcomes survey assigned gender at birth. Population norm-based SF-36 on disease specific populations, there is a paucity of domains were calculated. Sub-analyses were performed data available concerning athletes. This investigation for patients competing more than 4 days/week, elite aims to determine if tennis players score better than tennis ability (NTRP > 4), and patients over 70 years general population norms on the Short Form-36 old. outcomes survey.

image: Freepik.com

20 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 21 INTRODUCTION week (0, 1 2-3, 4-5, 6+), self-reported ability via National groups. Multivariate analysis was conducted using ANOVA. responded and completed the modified SF-36 questionnaire. Tennis Rating Program (NTRP) score (2.5, 3.0, 3.5, 4.0, All statistical tests were conducted using Statistical Package The majority of respondents were between the ages of 40 Tennis is one of the most popular recreational sports 4.5, 5.0, 5.5), smoking status, body mass index (BMI) and for the Social Sciences (SPSS), Version 22.0. Statisticla and 69 years (Table 1). Females comprised 63% of the worldwide with international organizations in more than assigned gender at birth. NTRP scores are based on a rubric significance was set at p<0.05. All results were compiled athletes, the average BMI of the cohort was 24.8 4.1 kg.m- 200 countries and with more than 75 million participants that breaks down player skills into forehand, backhand, securely and confidentially with no risk to human or animal 2, and 1.4% of the cohort were smokers (Table 1). 97.7% worldwide. (1) In the United States, the US Tennis serve/return of serve, volley, special shots and playing style. subjects. Appropriate IRB approval was obtained for this of athletes reported that playing tennis helps manage their Association Leagues is the largest adult competitive tennis investigation. health. When tennis players were asked how often they organization in the country. Tennis athletes make up a The SF-36 outcomes survey generates standardized domains played tennis, 1,048 (10.1%) reported one day/week, 6,329 diverse population, varying in experience, skill and physical that characterize eight health concepts. The included (61%) responded with two to three days/week, 2,648 (25.5%) fitness. domains in this investigation were physical functioning (PF), RESULTS responded with four to five days/week, and 255 (2.5%) bodily pain (BP), role limitations due to physical health responded with six to seven days/week. 8,823 (85%) athletes The physical health benefits of exercise are well-established, problems (role physical: RP), role limitations due to personal competing at the 3.0-4.0 NTRP level. including decreasing the risk of cardiovascular disease or emotional problems (role emotional: RE), general Demographics and USTA Characteristics and diabetes, improving lipid profiles, and increasing bone mental health (MH), social functioning (SF), energy/fatigue density and strength.(1-6) Furthermore, the mental benefits or vitality (VT), and general health perceptions (GH). Surveys were sent via email to 312,447 USTA Leagues of exercise, including improved cognitive performance Individual items that contribute to a scale are scored in such members. There were 10,380 USTA League members who and memory have also been noted.(2-7) There is strong a way that higher scores correspond to a better health state evidence to support the health-related quality of life benefits and all items for a domain are averaged together. In order conferred to athletes in comparison to non-athletes. (8-11) to normalize to the general population, Norm-Based Scores A positive relationship of the beneficial effects of exercise (NBS) were computed for these domains using an algorithm (specifically running) has been seen with increasing provided by Optum (General population mean = 50, SD = duration and frequency. (25) However, the majority of athletes 10). Two summary scores were generated using the SF-36 Table 1. Demographics distribution and USTA rankings of respondents. in these studies have focused primarily on elite groups in data: the Physical Component Summary (PCS) score and comparison to the general population. (8-11) Moreover, the the Mental Component Summary (MCS) score. These are influence of specific sports on health, however, has not been both aggregate of the eight scale scores and confer several No. of Respondents % well studied. analytical and statistical advantages, including smaller confidence intervals and smaller ceiling/floor effects. (4) The The SF-36 is a validated and commonly used metric for methodology of calculating the PCS and MCS scores has Total Number 10,380 100% evaluating various aspects of health that contribute to an been previously published and validated by Taft et al. (14) individual’s quality of life and overall health state. Although Norm-based scores were computed for all SF-36 domains Age Group there has been extensive research characterizing the SF-36 which are population adjusted based on age and gender in various medical conditions, there is a lack of information sub-stratifications of the original sample of the United States 18-29 308 3.0% with regards to the general, physical, social and mental population that was used to create and validate the SF-36 30-39 683 6.6% health of competitive adult athletes. Previous studies version 1.0. 40-49 2073 20.0% examining SF-36 scores in athletes have focused on the elite 50-59 3399 32.7% (collegiate) level across a variety of sports. (1,8,9,19,15) There is Sub-analyses were performed to evaluate the effect of more 60-69 2768 26.7% little known about the benefits on general health of playing a frequent play, higher self-reported skill level, older age, and 70-79 990 9.5% specific sport, as measured by the SF-36. higher BMI. USTA Leagues members who were competing 80-89 72 0.7% more than 4 days/week were categorized to be more frequent The present study hypothesizes that even at a players. The NTRP rating system defines an NTRP score Sex (F) 6575 63% Female nonprofessional level, tennis players would have improved of 4 as any player who demonstrates very consistent shots, health-related quality of life scores than the general using speed and spin effectively, with a high level of control BMI 10096 24.88 ± 4.173 population with improvements related to increased for all different strokes, and adjusts strategy to opponents’ frequency of play, higher skill level and lower BMI. style of play. The authors considered any plater with an Smoking Status (Y) 143 1.4% NTRP score greater than or equal to 4 as an elite player. Players over 70 years old were considered to be elderly METHODS athletes. BMI was categorized based on the World Health Organization’s Definition of obesity: Normal weight (BMI: A modified SF-36 version 1.0 was administered to USTA 15-25), Overweight (BMI: 25-30), and Obese (BMI: 30+). Leagues players via online survey form. Additionally, the following patient variables were included: age group (18-29, Independent-samples t-tests were employed to compare 30-39, 40-49, 50-59, 60-69, 70-79, 80+), days of tennis per continuous variables with normal distribution between

22 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 23 No. of Respondents % General Health Number of USTA Respondents General Population Outcomes Respondents Mean (SD) Mean (SD) Days of Tennis Playing Per Week

0 98 0.9% Social Functioning 10308 54.25 (5.99) 50.00 (10.0) 1 1050 10.1% 2-3 6329 61.0% Role Emotional 10293 53.31 (6.47) 50.00 (10.0) 4-5 2648 25.5% 6-7 255 2.5% Mental Health 10289 53.36 (7.09) 50.00 (10.0)

NRTP Score Summary: Physical 10285 54.00 (5.85) 50.00 (10.0) Component 2.5 560 5.4% 3.0 2269 22.0% Summary: Mental 10287 54.34 (7.11) 50.00(10.0) 3.5 3707 36.0% Component 4.0 2777 27.0% 4.5 855 8.32% 5.0 118 1.11% 5.5 5 0.49% Table 3. Whole cohort multivariate ANOVA comparisons for Norm Based Scores (NBS) SF-36 Domains based on the number of days played week (top), and NTRP Rating (bottom). PF: physical functioning, RP: role physical, BP: bodily pain, GH: general health, VT: vitality, SF: social functioning, RE: role emotional, MH: mental health.

SF-36 Outcomes for USTA Leagues Members age groupings revealed higher SF-36 outcomes scores for Days PF RP BP GH VT SF RE MH younger athletes (all SF-36 domains, p<0.01). Athletes who played Mean Mean Mean Mean Mean Mean Mean Mean For all norm-based SF-36 domains, USTA Leagues players reported playing tennis more times a week had higher SF-36 per week (SD) (SD) (SD) (SD) (SD) (SD) (SD) (SD) scored higher than the general population mean (mean = outcomes (all domains, p<0.01) (Table 3). 50, SD = 10) (Table 2). Multivariate comparisons between

1 day 54.1 53.2 52.1 53.5 53.0 53.2 52.0 52.2 (5.8) (7.4) (8.1) (7.2) (8.7) (6.9) (8.3) (8.0)

Table 2. Descriptive Statistics for Norm-Based SF-36 scores. Mean for the general population is equivalent to a score of 50. 2-3 days 54.6 53.6 51.8 55.5 56.1 54.2 53.2 54.3 SD=Standard Deviation (4.6) (6.9) (7.2) (6.6) (7.5) (6.0) (6.4) (7.0)

4-5 days 55.1 54.5 52.8 57.5 58.2 55.1 54.0 55.9 (4.4) (5.7) (7.0) (6.0) (6.7) (4.6) (5.1) (6.0) General Health Number of USTA Respondents General Population Outcomes Respondents Mean (SD) Mean (SD) 6-7 days 55.0 54.5 54.5 57.9 59.2 53.8 54.1 55.6 (3.1) (5.1) (6.2) (5.2) (6.8) (8.1) 4.1) (7.4)

Physical Functioning 10311 54.74 (4.76) 50.00 (10.0) p value <0.001 <0.001 0.014 <0.001 <0.001 <0.001 <0.001 <0.001

Role Physical 10301 53.94 (6.62) 50.00 (10.0) NTRP Rating Bodily Pain 10302 52.01 (7.36) 50.00 (10.0)

General Health 10324 55.62 (6.70) 50.00 (10.0) 2.5 55.1 54.4 52.5 55.7 55.5 54.1 53.2 53.5 (4.4) (6.0) (7.0) (7.0) (8.1) (6.1) (6.4) (7.5) Vitality 10290 56.39 (7.48) 50.00 (10.0)

24 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 25 NTRP Table 4. Among elite-level tennis players (NRTP 4+), SF-36 domains compared between different groups by days played per Rating week. Statistical significance is set at p<0.01.

2.5 54.5 53.9 52.2 55.5 56.2 54.3 53.3 54.3 (5.1) (6.6) (7.4) (6.9) (7.4) (5.8) (6.4) (6.9) Days PF RP BP GH VT SF RE MH played Mean Mean Mean Mean Mean Mean Mean Mean per week (SD) (SD) (SD) (SD) (SD) (SD) (SD) (SD) 3.5 54.6 53.9 51.9 55.6 56.5 54.3 53.3 54.5 (4.6) (6.7) (7.4) (6.7) (7.5) (6.0) (6.5) (7.2)

4.0 54.9 54.0 51.9 55.8 56.7 54.3 53.5 54.5 1 day 54.0 53.9 51.7 53.4 52.5 52.8 51.7 50.8 (4.6) (6.5) (7.3) (6.6) (7.4) (6.0) (6.2) (7.1) (6.7) (6.6) (8.9) (6.5) (8.4) (7.5) (9.0) (8.8)

4.5 54.9 53.7 51.8 55.4 56.1 54.1 53.1 54.3 2-3 days 54.8 53.4 51.9 55.3 56.4 53.8 52.9 54.4 (5.2) (7.1) (7.6) (6.5) (7.6) (6.3) (7.2) (7.0) (4.9) (7.2) (7.4) (6.5) (7.4) (6.3) (7.0) (6.9)

5.0 55.8 54.9 52.7 56.9 56.2 54.3 52.2 53.7 4-5 days 54.9 54.5 52.5 57.1 58.1 55.0 54.0 55.9 (4.1) (5.1) (7.2) (5.9) (6.9) (6.4) (8.1) (6.4) (5.0) (5.5) (6.8) (5.7) (6.2) (4.8) (4.8) (5.3)

5.5 52.1 53.4 45.4 54.4 56.6 49.5 53.2 54.5 6-7 days 55.0 53.1 53.0 58.4 57.9 53.2 53.7 56.6 (10.1) (6.3) (13.8) (10.3) (8.6) (17.0) (4.7) (12.9) (3.1) (6.8) (7.4) (5.2) (6.7) (7.3) (3.9) (5.3)

p value 0.001 0.274 0.085 0.290 0.240 0.624 0.299 0.108 p value 0.009 0.001 0.150 <0.001 <0.001 0.002 0.008 <0.001

The whole cohort was filtered for elite tennis athletes, as scores (PCS), and lower BMI (BP: 51.49 vs 52.26, p<0.01; defined by a NTRP rating greater than 4 (N=3755) (Table GH: 54.54 vs 56.63, p<0.01; PCS: 53.54 vs. 54.48, p<0.01; 4). Even among elite tennis players, those who played more BMI: 26.11 vs 23.36 kg.m-2, p<0.01). days per week had higher domain scores in 7 of 8 categories, with only bodily pain scores unimproved when more days Elderly tennis players (age > 70 years) scored worse than Table 5. SF-36 health domains from the present study and previously published population norms. Non-weighted SF-36 were more played. These players scored higher for the younger competitors for physical function, role physical, scores refer to un-adjusted, non-weighted scores. Norm-Based SF-36 scores are adjusted such that the general population SF-36 physical functioning domain than those with less general health, vitality, social functioning, role emotional, mean is 50 (SD=10).8,15,19,13 advanced tennis skills (54.64±4.78 vs 54.93±4.71, p=0.003). and mental health domains for the SF-36 (PF: 95.36 vs 92.47, Elite tennis players were also found to have lower mean p<0.01; RP: 92.63 vs 90.54, p<0.01; GH: 81.58 vs 82.97, McAllister Huffman et Snyder et al Maglinte BMI than less skilled tennis athletes. Additionally, USTA p<0.01; VT: 68.17 vs. 74.41, p<0.01; SF: 92.52 vs 94.75, et al (2001)1 al (2008)8 (2010)15 et al (2011)4 league members who reported playing more than 3 days p<0.01; RE: 92.20 vs. 95.85, p<0.01; MH: 81.34 vs 85.49, per week scored higher in all SF-36 categories (PF: 54.56 p<0.01). vs 55.19, p<0.01, RP: 53.70, vs 54.55, p<0.01; BP: 51.88 vs 52.35, p<0.01, GH: 55.08 vs 57.01, p<0.01, VT: 55.80 vs Table 5 illustrates the present study’s data alongside Population USTA NCAA Division NCAA USTA High School US General 57.90, p<0.01; SF: 54.06 vs 54.74, p<0.01, RE: 53.13 vs 53.74, previously published studies employing the SF-36 outcomes Leagues I Athletes Division I and Leagues Athletes Population p<0.01; MH: 54.01 vs 55.27, p<0.01). domains in both elite athletes and normative populations. Players II Athletes Players Un-adjusted scores from the present study are listed The SF-36 domains were compared between male and alongside previously published data for elite, collegiate Scoring Un- Unweighted Unweighted Norm- Norm-Based Norm-Based female athletes. This analysis revealed that female athletes athletes.(1,8) Norm-adjusted SF-36 scores are listed alongside System weighted SF-36 SF-36 Based SF-36 SF-36 had worse pain scores (higher SF-36 BP), accompanied by previously published, normative data for the general SF-36 SF-36 higher general health and physical component summary population and for adolescent athletes. (4,15) N 10,380 562 696 10,380 219 3,844

26 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 27 Non-Weighted SF-36 Scores Norm Based SF-36 Scores DISCUSSION: The present study has several limitations. Despite using a The present study is the largest cross-sectional study to validated outcomes metric and distributing the survey in Mean Mean Mean Mean Mean Mean date to use Norm-Based SF-36 scores to characterize the a user-friendly online submission form, the collection of (SD) (SE) (SD) (SD) (SD) (SD) health state of a sport specific population. There were data via survey inherently allows for nonresponse error, 10,380 USTA League players encompassing a range of due to some recipients not completing and returning ages and abilities who were determined to have general, the survey. Moreover, there was some non-compliance Physical 54.00 52 -- 54.00 53.2 49.22 physical, social and mental health scores comparable to in completing all items on the survey or withholding Component (4.85) (0.4) (5.85) (5.4) (15.13) previous literature with elite collegiate athletes, and higher certain answers for reasons unknown to the investigators. Summary scores than studies characterizing the general population Finally, the introduction of demographic items in the (Table 5). Furthermore, athletes who played more and were questionnaire may have also had an effect on the accurate of a higher self-reported skill level were found to have even completion of the SF-36 portion, despite the authors’ Mental 54.34 52 -- 54.34 49.6 53.78 better outcomes. ensuring confidentiality and anonymity. Nevertheless, our Component (7.11) (0.5) (7.11) (9.5) (13.14) study is the largest of its kind to date to support the health Summary One of the primary motivations for the present study was benefits of tennis. to determine the extent to which players associated their tennis activity with improvements in their health. When Future directions for research include the comparison Physical Function 94.27 95 97.7 54.74 55.1 50.68 asked whether playing tennis helped them in managing of the health benefits of tennis to other sports as well as (11.4) (0.9) (8.0) (4.76) (4.5) (14.48) their health, 97.7% of respondents replied affirmatively. further investigation into the effects of different skill levels, This overwhelming majority confirms the positive impact frequency of play and demographic factors. In addition, that playing a sport at any level can have on a player’s the health benefits of tennis in managing chronic disease in Role Physical 91.86 87 94.5 53.94 52.2 49.47 well-being, even in such a large, heterogenous sample an aging population should be further investigated. (23.4) (1.9) (17.8) (6.62) (7.0) (14.71) of athletes. Additionally, only 1.3% of athletes reported smoking tobacco, which is lower than previously published evidence of smoking prevalence in the United States. (16- Role Emotional 93.56 91 96.8 53.31 49.6 51.44 17) The low rate of tobacco smoking in this population CONCLUSION (20.5) (1.6) (14.2) (6.47) (9.4) (13.12) may highlight an unanticipated positive externality of participating in recreational sports—that athletes more often avoid deleterious habits. USTA Leagues players have higher general, physical, Bodily Pain 74. 93 75 83.9 52.01 52.1 50.66 social and mental health scores than the general (17.2) (1.5) (17.9) (7.36) (8.3) (16.28) Another strength of our study was the ability to stratify population median as measured on the SF-36. athletes based on frequency of play and skill level. Tennis Patients with a higher level of skill have higher athletes who played more frequently (>3days/week) had physical functioning. Younger tennis players and Mental Health 82.90 78 82.6 53.36 51.2 54.27 higher SF-36 scores for all eight subscales. Additionally, athletes who competed more than three times per (12.5) (0.9) (10.7) (7.09) (9.4) (13.28) players with higher skill levels had higher physical week scored higher in all SF-36 domains than those functioning scores and lower BMI than other tennis players who were older and played less, respectively. The of a lesser ability. Previously, McAllister et al demonstrated present study demonstrates the health benefits of Vitality 70.50 67 69.1 56.39 51.8 53.71 that higher frequency of play for collegiate athletes was tennis to players of all ages, skill levels and frequency (15.8) (0.9) (13.7) (7.48) (9.7) (15.35) correlated with higher SF-36 MCS and GH. (1) Additionally, in the largest cross-sectional study of its kind to date. the present study reports that 10% of respondents compete past the age of 70. An investigation performed by Pluim et Social Function 93.34 85 94.5 54.25 51.5 51.37 al suggested that tennis-injury incidence ranged from 0.04 (13.8) (1.4) (11.9) (5.99) (8.1) (13.93) to 3.0 injuries per 1000 hours played. (10) In this way, tennis has appeal as a lifelong sport and form of exercise that may confer a lower risk of injury complemented by more General Health 82.10 77 84.5 55.62 48.8 50.10 experience. (14.3) (1.1) (13.4) (6.70 (5.4) (16.87)

28 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 29 REFERENCES Dr. James Gladstone

1. Mcallister DR, Motamedi AR, Hame SL, Shapiro MS, Dorey FJ. Quality of Life Assessment in Elite Collegiate Athletes. Am J Sports Med. 2001;29(6):806-10. is Chief of the Sports Medicine Service and Associate Professor of 2. Hu FB, Stampfer MJ, Solomon C, Liu S, Colditz GA, Speizer FE, Willett WC, Manson JE. Physical activity and risk for cardiovascular events in diabetic women. Orthopedic Surgery at the Icahn School of Medicine at Mount Sinai. Ann Intern Med 2001;134:96–105. Dr. James Gladstone is the Medical Advisor to the US Men’s Davis 3. Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women: is ‘no pain, no gain’; passé? JAMA Cup tennis team and orthopedic consultant for the US Open tennis 2001;285:1447–54. tournament and NFL Officials. He is currently involved in several 4. Maglinte GA, Hays RD, Kaplan RM. US general population norms for telephone administration of the SF-36v2” J. Clin. Epidem. 2012;65(5):497-502. clinical studies, one of which was an FDA Phase II study, where he 5. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473–83. was the principal investigator on a novel method of transplanting 6. Wei M, Gibbons LW, Mitchell TL, Kampert JB, Lee CD, Blair SN. The association between cardiorespiratory fitness and impaired fasting glucose and type 2 cartilage cells for chondral injuries in the knee joint. diabetes mellitus in men. Ann Intern Med 1999;130:89–96. 7. Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS Jr. Physical Activity and Reduced Occurrence of Non-Insulin-Dependent Diabetes Mellitus. N Engl J Med 1991;325:147–52. Jared Tishelman 8. Huffman GR, Park J, Roser-Jones C, Sennett BJ, Yagnik G, Webner D. Normative SF-36 values in competing NCAA intercollegiate athletes differ from values in the general population. J Bone Jt Surg - Ser A 2008;90:471–6. is a current third-year M.D. candidate at the Icahn School of Medicine 9. Marks BL. Health benefits for veteran (senior) tennis players. Br J Sports Med 2006;40:469–76. at Mount Sinai pursuing a career in Orthopedic Surgery. He earned 10. Pluim BM, Staal JB, Windler GE, Jayanthi, N. Tennis injuries: occurrence, etiology, and prevention. Br J Sports Med 2006;40:415–23. a B.A. in Biochemistry from New York University in 2016 and 11. Simon JE, Docherty CL. Current Health-Related Quality of Life in Former National Collegiate Athletic Association Division I Collision Athletes Compared With subsequently completed a one year clinical research fellowship at Contact and Limited-Contact Athletes. J Athl Train 2016;51:205–12. the NYU Langone Orthopedic Center’s Spine Research Institute. His 12. Williams PT. Relationships of heart disease risk factors to exercise quantity and intensity. Arch Intern Med 1998;158:237–45. current research interests include sports medicine, spine deformity 13. Laucis NC, Hays RD, Bhattacharyya T. Scoring the SF-36 in orthopaedics: A brief guide. J Bone Jt Surg - Am Vol 2014;97:1628–34. and total knee and hip arthroplasty. 14. Taft C, Karlsson J, Sullivan M., Do SF-36 Summary Component Scores Accurately Summarize Subscale Scores? Qual Life Res 2001;10(5):395-404 15. Snyder AR, Martinez JC, Bay RC, Parsons JT, Sauers EL, Valovich McLeod TC. Health-related quality of life differs between adolescent athletes and adolescent nonathletes. J Sport Rehabil 2010;19:237–48. Daniel Bu 16. 2014 Surgeon General’s Report: The Health Consequences of Smoking—50 Years of Progress. U.S. Department of Health and Human Services. 2014. 17. Jamal A, Phillips E, Gentzke AS, Homa DM, Babb SD, King BA, Neff LJ. Current Cigarette Smoking Among Adults — United States, 2016. MMWR Morb Mortal is third-year M.D. candidate at the Icahn School of Medicine at Wkly Rep 2018;67:53–59. Mount Sinai, and an Oxford Pershing Square Scholar, who will be completing the MBA+MPP at the University of Oxford between 2020-2022. His research has been focused on global surgery, health policy simulation modeling, and systems science.

ABOUT THE AUTHORS

Dr. Alexis Colvin

is a board certified orthopedic surgeon and Associate Professor in the Department of Orthopaedic Surgery at Mount Sinai Hospital. The previous Chief Medical Officer of the USTA, she is the current CMO of the U.S. Open and the team physician for the U.S. Fed Cup team. She has also served as a physician at the United States Olympic Training Center in Colorado Springs, CO. She is also the co- editor of The Young Tennis Player.

30 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 31 TENNIS SPORT SCIENCE REVIEW

Outcome of the Teaching Games for Understanding (TGFU) approach when applied to tactical understanding of strategy and tactics in the game of tennis for young people.

Mustapha Georges Michel Alain Steve Alaoui*, Kpazaï, Portmann, Comtois, PhD,1 PhD,3 PhD,2 PhD,2

Institution Affiliation * Corresponding Author: Mustapha Alaoui, PhD 1. Department of Physical Physical Education Department education, College of Education, College of Education Qatar University; Qatar University 2. Department of physical activity Doha, Qatar sciences, Faculty of Science, Mobile : +974 31118907 University of Quebec in E-mail: [email protected] Montreal, Quebec; LinkedIn: www.linkedin.com/in/drmustapha-alaoui 3. School of Human Kinetics. Laurentian University, Ontario.

32 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 33 ABSTRACT Tennis instruction using methods that focus on technics, EXPERIMENTAL PROCEDURE i.e., a technical approach, is sometimes labelled as a classical The goal of the present study was to determine if the “ Teaching Games for Understanding “ (TGFU) approach would approach and appears to show some limits in developing The primary outcome variables were based on two sets help young tennis players (9-12) improve their strategic and tactical decisions as compared to tennis instruction using a young tennis players. In fact, it has been shown by Butler of circumstances: (i) service and return; and (ii) volley traditional or strictly technical approach. (2006) that young tennis players who have learned using exchange during the game. The service and return outcome traditional methods tend to abandon the sport prematurely was based on analysis of 20 successful service and return (Butler, 2006; Mandigo et al, 2007; Bunker and Thorpe, sequences. A total of twenty balls were randomly served in METHODS: 1982; Mitchell and Oslin, 1999; Turner and Martine,. 1992). order to attain an equal opportunity of ten balls for each side However, new approaches—including TGFU—have since (left and right). The coach for each group (experimental and Instruction was carried out using the TGFU approach in the experimental group at a frequency of two sessions of 45 minutes been developed. These approaches place primary emphasis control) conducted the service for each group and for all per week over an eight-week period while the control group applied the so-called traditional technical approach. Two on strategy and tactics, and on a sense of enjoyment, to players. situations were taken into account during the study: 1) “service and return”; and 2) “volley exchange.” increase efficiency and trainee retention. So, in answer to the following research question: "What are the effects of The volley exchange situation was similar to the service TGFU approach on performance, and consequently, on and return situation explained above. Briefly, twenty the tactical understanding of the game in tennis among exchange sequences, ten on each side, where the first RESULTS: young people aged 9 to 12?” we hypothesized that young tabulated return began after the player returned the ball people would benefit from the TGFU approach by showing delivered by the coach who conducted the volley exchange Results indicate that service return showed an improvement of 52%, on average, of attack balls between experimental and improved performance, and consequently, better tactical with all the players for both groups. All twenty balls were control groups. A reduction of approximately 19% in the percentage of defensive bullets was observed for the experimental understanding of tennis when compared with those who randomly served in order to eventually attain an average group as compared to the control group. Taken together, they point to a significant improvement in performance and better train using the traditional technical approach. of ten balls for each side (left and right) with an exchange tactical understanding when a TGFU-like approach is used. With respect to volley exchanges during a game, an increase of speed substantially similar for all players. During the volley won balls by more than 34% in the TGFU group was noted. exchanges, the coach was positioned at mid-court for the METHODOLOGY first ball exchange. The duration of ball exchanges in each sequence was taken into consideration. A total of 28 participants were recruited for the study and CONCLUSION: their physical characteristics are presented in Table 1. Pre- and post intervention analysis was performed as Participants were separated into two groups. The groups thoroughly as possible on with both groups by comparing In conclusion, it can be observed that the TGFU group demonstrated a net superiority as compared to the traditional were randomly assigned as either experimental or control. the score (ball in or out) measured on the field and with technology-oriented pedagogical approach to training. The experimental group (n=14) followed a training program a posteriori video analysis. When discrepancies between using the TGFU approach, while the control group (n=14) the on-field scoring and video analysis arose, the on-field received “classical” tennis instruction based on the technical scoring was retained. This allowed us to verify apparent KEYWORDS: approach. Both groups trained for a total of eight weeks (16 aberrant variables collected during the study; these, if truly sessions of 45 minutes each). The duration of the experiment aberrant, were then corrected. Training session protocol Tennis, learning and understanding the game; decision-making; educational intervention; cognitive sport; tactical was comparable to that found in the literature: Giménez, A. details are indicated in Table 1. understanding. M., Valenzuela, A. V., & Casey, A. (2010).

Table 1. Description and homogeneity groups (mean ± standard deviation) INTRODUCTION

Hopper (2007) has shown that the Teaching Games for regularly leave the court; students must wait their turn to be Groups Understanding (TGFU) approach has been less frequently able to hit the ball, etc. Frustrations among younger players applied to tennis than to other sports disciplines. Apart are stronger still, since they, as a rule, have not mastered Variable Experimental (N = 14) Control (N = 14) Value p from McPherson and French (1991), who examined the the mechanics of the game as thoroughly as adults. Since TGFU approach, very few studies have focused on tennis. the benefits and limitations of the TGFU approach have McPherson and French explain their positive results (in not yet been studied in children’s tennis, the present study Age (years) 11,53 ± 0,61 11,66 ± 0,68 0,606 terms of technical improvement) by the use of direct focuses on this age group. Thus, the aim was to ascertain technique-related instruction. Nonetheless, tennis remains a whether the TGFU approach can have a beneficial effect on Weight (Kg) 36,72 ± 7,50 34,71 ± 8,28 0,508 very promising area for the application of TGFU because of performance, and consequently, on tactical understanding in the challenges peculiar to this sport. Hopper (2007) asserts youth (age 9 - 12) tennis as compared with those who train Height (m) 1,48 ± 0,10 1,44 ± 0,06 0,316 that playing tennis, by nature, can be frustrating: balls using the technical approach.

34 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 35 STATISTICAL ANALYSIS (pre- and post-test) and a non-repeated factor at two levels It follows that a decrease in gap for defensive balls was in the control group, it was not statistically significant (15% (experimental and control). A significant intervention effect observed on the order of roughly 19 % points for the ± 8% to 20% ± 8%; an increase of 5%; p = 0.089). This Analysis of the results was done first through a test was observed when the interaction term time * group was experimental group compared with the control group, as difference according to time (pre- vs post-) was statistically of homogeneity of the two groups using the t test for significant. If the group * time interaction was significant, shown in Fig. 1B. For the experimental group, there was significant (p <0.001) and corresponded to a 3.3 effect size continuous variables (age, weight, height) and a chi-square subsequent analyses were conducted to study the effect time a significant (p = 0.021) 10 % decrease in defensive balls (Cohen’s d). test for the gender-based variable. The performance of both separately for each group as well as to compare the groups (31% ± 17% to 21% ± 8%). In contrast, there was a non- Before the procedure, as indicated in Table 2, a significant groups was measured by using the elements of service and at each time. Analysis was performed using SPSS Version 21 statistically significant increase of 8 % in the control group correlation was observed between exchange time and return, and volley exchange. Analysis of the service and software with an alpha significance level of 5%. (19% ± 8% to 28% ± 14%; p = 0.100). The difference in the the percentage of won balls (r = 0.591; p = 0.001). This return situation considered: i. the average of attack balls evolution of time between the experimental and control significant linear association indicates that the percentage of percentage; average defensive balls percentage; the average group was statistically significant (p = 0.007) with an won balls is directly proportional to the duration of volleys percentage of won balls; the average of unforced errors and RESULTS ES of 1.2 (Cohen’s d). Initially, i.e., pre-intervention, the (see Fig. 2A, dashed line). A similar result was observed for stray bullets percentage. Analysis of the volley exchange average defensive ball percentage was statistically higher lost balls, but was inversely proportional to volley exchange situation considered the average percentage of earned Figure 1 illustrates the pre and post-test differences obtained in the experimental group versus the control group (31% time (Fig. 2C, dashed line), suggesting that longer volley bullets; the average unforced error percentage; the average on the percentage of attack, defensive, won and lost balls ± 17% versus 19% ± 8%, respectively; p = 0.030). After the exchange durations resulted in a decrease of lost balls (r percentage of stray bullets; the average volley exchange by each group (experimental vs control). The coaches intervention (post), the 7% difference observed between = 0.589; p = 0.001). time; the correlation between volley exchange time and attempted to control to the maximum possible extent service the two groups was not statistically significant (21% ± 8% percentage of balls won and lost observed before and after speed to all players. The results that in the experimental compared to 28% ± 14%; p = 0.145), but nonetheless, the After the intervention, as shown in Table 2, similar but the intervention. group (Fig. 1A), there was a significant (p <0.001) 43 % experimental group appears to show a reduction in the stronger correlations (r = 0.875, p = 0.0001) were observed points increase in average attack balls (26% ± 8% to 69% ± number of defensive balls. between the exchange time and the percentage of won The performance comparison was made with ANOVA 9%) that contrasted with a significant (p = 0.002) 9 % points balls (Fig. 2B, dashed line) and for lost balls (r = 0.871, p = for repeated measures of two factors: time at two levels decrease in the control group (42% ± 10% to 33% ± 5%). The average percentage of balls won, as shown in Fig. 1C, 0.0001; Fig. 2D, dashed line). before the intervention (pre) was not statistically different Individual group analysis shows that correlations are between groups (21% ± 14% versus 15% ± 8%; p = 0.172). different between the two groups (see Table 2 and Fig. 2, After the intervention (post), however, a statistically black circles and white circles). Before the intervention, the Figure 1. Percentage of balls successfully treated following the return service situation and volley situation by the significant difference of 39 % points was observed between correlation between the exchange time and the percentage of experimental and control groups. A) Percentage of attack balls; B) Percentage of defensive balls; C) Percentage of won the two groups (59% ± 12% versus 20% ± 8%, p <0.001). won balls is significant in the experimental group (r = 0.817; balls; D) Percentage of lost balls. Dark vertical bars represent before treatment (pre) and light vertical bars represent after As well, there was a significant (p <0.001) increase in the p <0.001) but not in the control group (r = 0.090; p = 0.758). treatment (post). Significance at p<..05; * within group differences; † between group differences. proportion of balls won in the experimental group (21% ± A similar result is observed for lost balls (r = -0.825; p = 14% to 59% ± 12%, representing a 38 % increase), whereas 0.003 and r = -0.126; p = 0.668, respectively). A) Pre B) Pre Post Post 100 100 80 80 Table 2. Pearson correlations between exchange time and percentage of games won and lost balls 60 60 40 40 Relationship of variable with exchange time Variable 20 20

Percent Success Percent Success Percent Pre Post 0 0

All subjects (N = 28) Experimental Control Experimental Control % Won balls 0,591 (0,001) 0,875 (0,0001) % Lost balls -0,589 (0,001) -0,871 (0,0001) C) Pre D) Pre Post Post Experimental Group (N = 14) 100 100 % Won balls 0,817 (<0,001) 0,443 (0,112) 80 80 % Lost balls -0,825 (<0,001) -0,417 (0,138)

60 60 Control Group (N = 14) 40 40 % Won balls 0,090 (0,758) -0,09 (0,751) 20 20

Percent Success Percent Success Percent % Lost balls -0,126 (0,668) 0,18 (0,537) 0 0 Numbers represent r values (p values) Experimental Control Experimental Control

36 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 37 Figure 2. Relationship between volley exchange time and the percentage of won and lost balls before (pre) and after (post) In situations of service return, this indicates a significant the intervention for all participants (dashed line), the experimental group (dark circle symbols) and the control group (white improvement in performance and a better tactical CONCLUSION circle symbols). understanding for the group that used the TGFU approach. This situation approximates the vision of authors French and McPherson (1992) and McPherson and Thomas (1989) who In conclusion, it is quite clear that the experimental A) 35 B) 35 argue, for example, that tennis players who are instructed in group evidenced a net difference as related to the Experimental Experimental Control Control the tactical approach tend to develop a game plan involving control group that was trained with technical oriented 30 30 many tactical responses when compared with those training approach. Similarly, it would appear that involved in a real-game volley exchange situation, where the training with the TGFU approach promotes improved 25 25 experimental group enjoyed more than a 34% superiority performance with better understanding of the tactics in terms of balls won (Figure 1). Consequently, it can be of the game. Our data indicate that the use of the 20 20 argued that the latter group was able to enjoy the benefits TGFU approach could help improve performance 15 15 of the TGFU approach as documented by Hopper (2007). and, consequently, tactical understanding of the game Likewise a 35% greater reduction in stray bullets (Figure 1) of tennis. We conclude that such research tends to 10 10 was identified in the experimental group as compared to improve the state of knowledge of the educational aims

Volley exchange time Post (s) time Post exchange Volley the control group. This may well indicate a better tactical of the TGFU approach to performance and tactical Volley exchange time Pre (s) time Pre exchange Volley 5 5 understanding of the game as McPherson and French understanding of the game of tennis for young players 0 20 40 60 80 100 0 20 40 60 80 100 underscore (1991) as well as McPherson and Thomas (1989) aged 9 to 12. as compared to the technical approach. Point won Pre (%) Point won Post (%)

C) 35 D) 35 Experimental Experimental Control Control Table 3. Protocol session determinants 30 30

25 25 Tactical Problem Lesson Focus Objective

20 20 Setting up attack by creating Awareness of court Understanding the concept of 15 15 space on opponent’s court creating space

10 10 Volley exchange time Pre (s) time Pre exchange Volley

Volley exchange time Post (s) time Post exchange Volley Setting up attack by creating Understanding the value Creating space using ground 5 5 space on opponent’s court of forcing opponent to the strokes baseline 0 20 40 60 80 100 0 20 40 60 80 100

Point lost Pre (%) Point lost Post (%) Defending space on your own Getting to the net to attack Ability to push opponent back court with strong ground strokes

Winning the point. Getting to the net to attack. Approach shot to net. After the intervention, there are no longer significant in their tennis performance through improved tactical correlations between volley exchange time and the understanding and better game playing. In the current Winning the point. Winning the point using the Using a volley to win a point percentage won and lost balls, regardless of group. However, study, a change in the mastery of the game pre- and volley it is clear from Fig. 2B and D that the experimental and post-intervention was noted, a point also mentioned by control groups (black circles and white circles) show McPherson and French (1991). Defending space on your own Recovery to center baseline. Recovering to center baseline substantial differences. court. between shots. It was likewise observed that young people in the experimental group started to adopt better field position Defending as a pair. Two-back formation. Using a two-back formation in DISCUSSION and became faster during the course of the experiment. This doubles. may have occurred because of a better understanding of the It emerges that two months of TGFU intervention with tactical aspects of the game that as has also been reported by Adapted from Griffin, L. L., Mitchell, S. A., & Oslin, J. L. (1997). young tennis players (age 9-12) leads to an improvement Crespo and Machar (2002).

38 · JULY 2020 · JOURNAL OF MEDICINE AND SCIENCE IN TENNIS JOURNAL OF MEDICINE AND SCIENCE IN TENNIS · JULY 2020 · 39 ABOUT THE AUTHORS

Dr. Mustapha Alaoui, ChPC, ACD,DEFC, MSc, PhD

is a university lecturer in Physical Education department, College of Education at Qatar University in numerous courses, principles of training , didactics, theories and practices (Tennis, Soccer, Athletics, swimming etc..). In exercise physiology and performance training courses for several years in the department of kinanthropology at UQAM. Professional coach approved with the highest certificate level (5) NCCP, Coach formatter and Master Coach Developer in NCCP. National fitness coach for the Moroccan tennis team at the Olympic Athens games and Davis Cup World Group. Consultant and formatter at the Moroccan tennis federation. Coach of the national Canadian athletics team at Pan-American Games.

Dr. Alain Steve Comtois

Professor, Department of Physical Activity Sciences, University of Quebec in Montreal (UQAM). Research interests target respiratory and skeletal muscle cell physiology to modalities of physical fitness evaluation and coaching. Active in the National Hockey League since 1999 and numerous other professional sport associations. Have been involved with Tennis Canada on numerous occasions. Published over 100 articles in peer reviewed journal and more than 200 abstracts presented by graduate students at various international, national, and provincial/local

REFERENCES Dr. Michel Portmann, PhD 1. Bunker, D. & Thorpe, R. (1982). A model for the teaching of games in secondary schools. Bulletin of Physical Education, 18(1), 5-8. 2. Butler, Joy I. (2006). Curriculum constructions of ability: enhancing learning through teaching games for understanding (TGfU) as a curriculum model Sport. Retired Professor, researcher, Department of kinanthropology at Education and Society, 243-258. University of Quebec in Montreal (UQAM). Olympic coach of gold 3. Crespo, M. and Reid, M. (2002). Modern Tactics: An Introduction. ITF Coaching and Sport Science Review, (27), 2. medalist sprinter Bruny Surin. Master Learning facilitator NCCP. 4. Griffin, L. L., Mitchell, S. A., & Oslin, J. L. (1997). Teaching sport concepts and skills: A tactical games approach. Champaign, IL: Human Kinetics 5. Hopper, T. (2007). Teaching Tennis with Assessment for/as Learning. Physical and Health Education Journal, (73), 3-22. 6. Mandigo, J., Butler, J., & Hopper, T. (2007). What is teaching games for understanding? A Canadian perspective. The Physical Educator, 73(2), 14-20. 7. McPherson, S. L. (1992, June). Instructional Influences on Longitudinal Development of Beginner Tennis: A Longitudinal Study. [Report presented to the Annual Meeting of the North American Society for the Psychology of Sport and Physical Activity]. Asilomar. 8. McPherson, S. L. and French, K. E. (1991). Changes in Cognitive Strategies and Motor Skill in Tennis. Journal of Sport and Exercise Psychology, (13), 26-41. 9. McPherson, S., and Thomas, J. (1989). Relation of Knowledge and Performance in Boys Tennis: Age and Expertise. Journal of Experimental Child Psychology, Dr. Georges Kpazaï Ph.D (48), 190-211. 10. Méndez Giménez, A., Valero Valenzuela, A. & Casey, A. (2010). What Are We Being Told about How to Teach Games? A Three-Dimensional Analysis of Dr Georges Kpazaï is a full professor at the School of Kinesiology Comparative Research into Different Instructional Studies in Physical Education and School Sports. Revista Internacional de Ciencias del Deporte. Accessed and Health Sciences of Laurentian University (Sudbury, Ontario, May 21 2011 at: http://www.cafyd.com/REVISTA/ojs/index.php/ricyde/article/view/260 Canada). He is interested in the manifestations of Critical Thinking 11. Mitchell, S. & Griffin, L. (1994). Tactical awareness as a developmentally appropriate focus for the teaching of games in elementary. Physical Educator, 51(1), during the quest for knowledge and Competencies development in 8-29. Sport, Health and Physical Education settings. 12. Mitchell, S. & Oslin, J. (1999). An investigation of tactical transfer in net games. European Journal of Physical Education, 4, 162-172. 13. Turner, A. & Martinek, T. (1992). A comparative analysis of two models for teaching games (technique approach and game centered [tactical focus] approach). International Journal of Physical Education, 24, 131-152.

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