Wrist

ArticleInjuries
Title in Nonprofessional Tennis
Players: Relationships With Different Grips
Article Subtitle
Author Stefano Tagliafico,*† MD, Pietro Ameri,‡ MD, Johan Michaud,§ MD,
Alberto
AffiliationE. Derchi,† MD, Maria Pia Sormani,|| PhD, and Carlo Martinoli,† MD
Lorenzo
†
From the Department of Radiology R, DICMI, University of Genova, Genoa, Italy, the
‡
Department of Internal Medicine, University of Genoa, Genoa, Italy, the §Department of
||
Physiatry, University
The abstract goes here andof Montreal,
covers Montreal, Quebec, Canada, and the Biostatistics Unit,
two columns.
Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
The abstract goes here and covers two columns.
The abstract goes here and covers two columns.
The abstract goes here and covers two columns.
Background: Recent advances in tennis teaching techniques have been applied in nonprofessional tennis players to develop a
more effective play. Hits with enormous amount of top-spin and lower technical and physical training are responsible for most
KEY WORDS
wrist injuries inlist of key words goes
nonprofessional here
tennis players.
Hypothesis: The use of different grips (Eastern, Western, semi-Western) determines the pattern of wrist injuries in nonprofes-
sional tennis players.
Study Design: Cross-sectional study; Level of evidence, 3.
Methods: Between January 2006 and August 2007, we evaluated 370 nonprofessional division III and IV tennis players. The
screening consisted of a questionnaire appropriately prepared to investigate wrist injuries. Medical records of players who
reported a wrist injury were reviewed. Body mass index, years of practice, weekly hours of training, racket weight, grip (Eastern,
Western and semi-Western), kind of strings, injury type, time out of competition, and therapy (medical or surgical) were recorded.
Statistical analysis was performed to assess the association of different wrist injuries with these variables.
Results: A total of 320 players reported no injuries in their activity; 50 (13%) reported injuries to the wrist. Medical records of
these players were reviewed, and 30 extensor carpi ulnaris lesions, 3 lesions of the extensor tendons, 5 injuries to the flexor carpi
radialis, 6 de Quervain diseases, 5 triangular fibrocartilage lesions, and 1 intersection syndrome were found. Ulnar-sided injuries
were more frequently associated with Western or semi-Western grips while radial-sided injuries were associated with Eastern
grip (χ2 = 20.7; P < .001). Average time out of competition was 69 days; 4 players underwent surgery; the others received
medical and rehabilitative therapy. No differences were observed regarding body mass index, years of practice, weekly hours of
training, racket weight, and strings.
Conclusion: In nonprofessional tennis players with wrist injuries, different grips of the racket are related to the anatomical site
of the lesion: Eastern grip with radial-side injuries and Western or semi-Western with ulnar-side injuries. Knowledge of this
relationship may influence training, prevention, diagnosis, and therapy of wrist problems in nonprofessional tennis players.
Keywords: tennis; grip; wrist; injuries; diagnosis

Tennis is practiced by a wide range of people throughout increased number of tournaments and competitions deter-
the world and is the most popular of all racket sports. For mines an intense dedication to training by nonprofessional
the last 10 years tennis practice has grown significantly for or young players. This intense practice exposes players to
both recreational and competition purposes. Frequently overtraining and excessive loads of specialized physical
tennis practice begins in childhood and may continue into activity.17 Furthermore it is not rare that inexperienced or
late adulthood. In spite of the positive effects that tennis unqualified supervisors with lack of knowledge regarding
practice has shown on physical and mental fitness, the
Presented at the interim meeting of the AOSSM, San Francisco,
the causal factors of overuse injuries and, in particular, the
California, March 2001. inappropriate increase in progression of the training pro-
Address correspondence to Author 1, Address 1, City, State, Zip, cess, propose adult training formulas to adolescents.12 The
Affiliation.
*Address correspondence to Alberto Tagliafico, MD, University of increased number of every level and age of players during
Any author’s notesGenova,
could also go (e-mail:
here. atagliafico@sirm.org).
Genova, Radiology, Italy recent years has been accompanied by deep technical
No potential conflict of interest declared. modification involving almost all tennis strokes. This
The American Journal of Sports Medicine, Vol. 33, No. X
DOI:American
The 10.1177/1073858403253460
Journal of Sports Medicine, Vol. 37, No. 4
change has been attributed to new racket designs that are
© 2005
DOI: American Orthopaedic Society for Sports Medicine
10.1177/0363546508328112 lighter, bigger, and stiffer than traditional wooden rackets.
© 2009 American Orthopaedic Society for Sports Medicine This new equipment allows players to hit the ball with

760
Vol. 37, No. 4, 2009 Wrist Injuries and Grips   761
more power and control. However, in nonprofessional play-
ers, efforts spent to develop a more effective and aggressive
play using tactics and techniques similar or equal to the
professional players are not always supported by an ade-
quate physical training and technical development.4 The
imbalance between the power of the strokes and the level
of physical conditioning, which includes coordination,
power, strength, speed endurance, and flexibility, is respon-
sible for negative adaptive changes that may determine
the injury pattern.17
Musculoskeletal injuries related to tennis may be related
to a single event, in which a macrotrauma is responsible
for an acute injury, or to chronic overuse. Traumatic inju-
ries occur more frequently in the lower extremities, while
chronic injuries are equally distributed among upper and
lower extremities.5,15 However, wrist lesions are considered
relatively rare in comparison with other kinds of tennis-
related injuries, and perfect wrist functionality is essential
to an effective play. Such lesions are various and may
involve different anatomical sites. Extensor or flexor tendi-
nitis, ulnar carpal impingement, triangular fibrocartilage
injuries, ligamentous tears, and fractures of the hook of
hamate are the most frequently occurring injuries accord-
ing to current literature.7,17 The variety of injuries reported
may reflect different sequences of musculoskeletal activa-
tion and loads on the wrist, which may be related to the
different techniques of playing. Tennis coaches and instruc-
tors have several ways to teach tennis strokes depending
on the age, level of playing, and ambitions of the player;
furthermore, players choose different grips and personal-
ize the movement. Among popular media and tennis
instructors it is generally believed that different grips and
stroke movements determine different biomechanical loads
on the wrist. However, to the best of our knowledge, there
are no studies in the scientific literature that investigate
the pattern of wrist injuries in relation to different grips.
Therefore the aim of our study was to investigate if there
is an association between the use of different grips
(Eastern, Western, semi-Western) and the pattern of wrist
injuries in nonprofessional tennis players.
MATERIALS AND METHODS
Between January 2006 and August 2007 we screened 400
nonprofessional division III and IV tennis players (323 men
and 77 women; mean age ± standard deviation: 26.4 ± 14;
range, 11-62 years) who participated in 7 division III official
tournaments organized by the Italian Federation of Tennis.
In Italy, the classification system is divided into 4 divisions:
division I corresponds to the top level and includes the best
20 male players and the best 10 female players. Other divi-
sions are II, III, and IV, indicating players of progressively
lower levels. All the players are considered competitive,
included in 1 of the 4 divisions, and authorized to participate
in the tournaments if they achieve a specialist medical certi-
fication. To obtain a national ranking, athletes must win a
series of matches. More detailed information on the Italian
tennis division system is available at www.federtennis.it.
A questionnaire was prepared to investigate wrist injuries
by modifying a previously employed tennis questionnaire
used to assess the prevalence of injuries in elite junior
players.5 The questionnaire was administered to all play-
ers at tournament check-in. The questionnaire recorded
age, body mass index (BMI) (by recording the weight and
dividing it for the square of the height), years of tennis
practice, weekly hours of training, racket weight, dominant
arm, forehand grip (Eastern, Western and semi-Western),
backhand type (double-handed or single-handed), kind of
strings (synthetic, hybrid, or natural gut), injury type
when a tennis-related injury had occurred and consequent
time out of competition (self-reported by the player), and
therapy (medical or surgical). The questionnaire consid-
ered only injuries that occurred during the last 3 years of
competition. All players who participated in this study
gave written consent to the treatment of their data for
scientific purposes.
In regard to the racket, only weight was considered.
(Racket stiffness was not considered because in competi-
tive models it is often related to the manufacturer and the
authors wanted to avoid any commercialization bias.)
Furthermore, players often customize their rackets with
additional weight (lead) on different parts of the racket,
string vibration dampers, and silicone altering the original
features of the racket.
Grips
The authors registered the 4 basic single-handed grips
used to hit the forehand: continental, Eastern, semi-West-
ern, and full Western. For each grip, the player places the
base knuckle of the index finger and the heel pad of the
palm on the grip bevel of the racquet. Different grips are
defined on the base of the location of the base knuckle of
the index finger on the 8 faces of the racket grip (Figure 1).
Grip types were defined according to the International
Tennis Federation and checked for accuracy by 2 tennis
instructors in consensus who observed the players holding
the racket at rest and during competition.
Continental. In the continental grip, the base knuckle is
placed on face number 2 and the heel pad between 1 and 2.
This grip was once the universal grip used to hit almost all
strokes: forehands, backhands, special shots, volleys, and
the serve. It originated on the soft, low-bouncing clay
courts of Europe. Today it is usually employed only for
serves and volleys.
Eastern. In the Eastern grip, the base knuckle is on face
3, and the heel pad between 2 and 3. This grip arose on the
medium-bouncing courts in the eastern United States. It
represents the classic forehand grip. The Eastern grip is
appropriate for different styles of play, comfortable for
beginners, and adaptable for all surfaces. The advantages
of the Eastern grip are that it is easy for beginners to
learn, is easy to generate power, is ideal for waist-high
balls, and can be used to hit a variety of top-spin, under-
spin, and flat drives. The disadvantage is that it is difficult
to powerfully hit very high balls.
Semi-Western. The semi-Western forehand grip has the
base knuckle and the heel pad on face 4. Strength and control
to the forehand are guaranteed by this grip; moreover, begin-
ners feel comfortable because the palm of the hand supports
762   Tagliafico et al The American Journal of Sports Medicine
Figure 1.  A, on the left side the 8 facets of the butt cap and
the reference points (base knuckle of the index finger and
heel pad) on the hand to identify the different grips are repre-
sented. On the right side the Eastern and Western grips are
illustrated; note that the hand of the players is in the same
position while the inclination of the racket changes. B, the
continental and the semi-Western grips are illustrated.
the racquet, providing additional stability at contact.
Powerful top-spin forehands are the strokes facilitated by
this grip. Advantage to this grip is that high balls are easy to
hit, but low balls and back-spins are difficult, and grip
changes are necessary to hit volleys and overheads.
Western. In the Western grip, both base knuckle and heel
pad are located on face 5. This grip originated on the high-
bouncing cement courts of the western United States. The
drawback of this grip is that it closes the racquet face too
soon before contact. This is an excellent grip for high balls
and top-spin but is awkward for low balls and under-spin.
It is widely accepted in the popular media that this grip is
the most dangerous for the wrist and that a strong wrist
and perfect timing are essential to avoid wrist injuries.
In our study we arbitrarily avoided to register the grip
employed for every stroke as it would have been time-
consuming for the player at the moment of writing the
questionnaire, and this would have increased the refusal
rate to participate in the study. Moreover, in modern tennis
and among nonprofessional players, the forehand is the
stroke that the player tries to hit in the majority of cases.3
Also, today nonprofessional players have a prevalent
ground-stroke style of play. We believe, therefore, that
recording of the forehand grip only is sufficient for a pre-
liminary screening.
Strings
We recorded the 3 different possible string materials usu-
ally employed. Natural gut strings are made of cow gut
and have superb elasticity, tension stability, and “liveli-
ness.” Synthetic strings are high-tech products that are
now similar to natural gut strings but keep the advantage
of synthetic materials’ higher durability. Hybrid strings
are a combination of 2 different strings for mains and
crosses; we recorded strings as “hybrid” when the main
strings were of natural gut and the cross ones synthetic or
vice versa.
Injuries
The players who reported a wrist injury in the question-
naire were called by phone and asked to come to our
department to review all medical records related to the
injury. This procedure was performed to accurately define
the type of injury. Records of clinical examinations and
radiological data, including conventional radiographs, as
well as ultrasonography (US), magnetic resonance (MR),
and computed tomography (CT) examinations, were
reviewed by 2 experienced musculoskeletal radiologists
and a physician experienced in physiatry to confirm or
exclude the injury reported on the questionnaire. When
medical records were not available or incomplete, the case
was not considered for analysis.
Extensor carpi ulnaris injuries. Extensor carpi ulnaris
(ECU) injuries are common causes of ulnar-side wrist pain
in tennis players and athletes.12,16 These injuries may be
related to luxation or subluxation of the tendon, tenosyno-
vitis, or complete rupture. This condition is easily diag-
nosed with US and sometimes with stress test or MR.7
Intersection syndrome. This syndrome is usually reported
in rowers11 but can occur in racket sports. It derives from
the attrition between the 2 radial extensors of the wrist
and the first dorsal compartment muscles (abductor polli-
cis longus and extensor pollicis brevis), 4 cm to 6 cm proxi-
mal to the radial carpal joint. Clinical examination is
usually sufficient to make an accurate diagnosis, but US
and MR are helpful in doubtful cases.5,11
Extensor tendon injuries (IV and V compartment only). The
fourth and fifth compartments of the wrist enclose the ten-
dons of the extensor digitorum communis (for the second
through the fifth fingers), the extensor indicis, and the exten-
sor digiti quinti proprius. Ultrasonography is sufficient to
differentiate these injuries from an ECU tenosynovitis.
Triangular fibrocartilage lesion. The triangular fibrocar-
tilage (TFCC) acts as a stabilizer of the distal radio-ulnar
joint and absorbs loads between the distal ulna and the
ulnar carpus. Injuries to the TFCC must be differentiated
from other causes of ulnar side wrist pain. The diagnosis
has to be achieved with MR with intra-articular injection
of gadolinium or with arthro-CT.7,14,18
De Quervain syndrome. De Quervain disease is a stenos-
ing tenosynovitis of the first dorsal compartment of the
extensor tendons of the wrist. Tenderness and pain over
the radial styloid with a positive Finkelstein’s test are usually
Vol. 37, No. 4, 2009 Wrist Injuries and Grips   763
Figure 2. Flowchart of injury selection. ECU indicates extensor carpi ulnaris; TFCC, triangular fibrocartilage; FCR, flexor carpi
radialis.
diagnostic. However, US may be helpful in doubtful cases
(differential diagnosis with intersection syndrome).
Flexor carpi radialis tenosynovitis. This condition is
rarely observed in athletes; usually it is reported in
middle-aged women. Pain over the radial aspect of the
volar wrist and a local lump are the typical clinical signs.
Ultrasonography is sufficient for appropriate diagnosis.
Statistical analysis was performed to assess the associa-
tion of different wrist injuries with the different variables
using SPSS software (SPSS for Windows, release 10.1.3;
SPSS, Chicago, Illinois), and a P value < .05 was considered
statistically significant. Multivariate analysis and χ2 test
were performed.
RESULTS
The total number of questionnaires administered was 400,
and 370 (92.5%) of them were appropriately completed by
the players. The main reason for an incomplete question-
naire was the lack of identification of the grip. We noted
that the majority of questionnaires excluded from the
analysis belonged to very young players.
Of the 370 selected questionnaire, 87% were negative for
wrist injury, while 13% (corresponding to 50 players) were
positive. Detailed results are illustrated in Figure 2.
Concerning the grip, none of the players reported the use
of a continental grip. The majority used a semi-Western or
a full Western grip (75% of players among those never
injured; male/female [M/F]: 77%/23% and 77% among
those injured; M/F: 64%/36%); only 25% of male players
(injured/noninjured: 35%/65%) and 23% of female players
used an Eastern grip (injured/noninjured: 25%/75%). In
most instances strings employed were synthetic: among
the noninjured players 88% used synthetic strings, 4.2%
natural gut, and 7.8% hybrid. Notably all the injured play-
ers used synthetic gut. In our series there were no players
who changed the grip in the past.
For a subsequent statistical analysis we subdivided the
wrist lesions according to their side (ulnar vs radial). The
first group included ECU injuries and TFCC lesions, while
the second group included de Quervain syndrome, inter-
section syndrome, and flexor carpi radialis (FCR) teno-
synovitis (Figure 2). Extensor tendon injuries related to
the IV and V compartment were excluded from the analy-
sis as these tendons are neither radial or ulnar-sided.
Players’ characteristics and detailed results of the ques-
tionnaire are illustrated in Table 1.
A positive association was present between radial-side
lesions and the Eastern grip while ulnar-sided injuries
were more frequently associated with Western or semi-
Western grips (χ2 = 20.74; P < .001). A multivariate analy-
sis was performed to assess the different contribution of
the age and grips to the injuries. The results show that
only the grip was associated with the injury (Table 2). The
association between the different injuries related to the
3 grips considered is summarized in Table 3. Eastern grip
players had a significant higher age (42 years) in compari-
son with semi-Western and Western grip players (22
years). Moreover, the Eastern group had a significantly
longer duration of activity in comparison to the semi-
Western and Western one (20 years of activity vs 8 years;
P < .01) as shown in Table 1.
764   Tagliafico et al The American Journal of Sports Medicine

TABLE 1
Players Characteristics and Questionnaire Resultsa

Years of Hours of Racket Grip Strings Time Out of Therapy,

n = 370 Age, y BMI Practice Training, wk Weight, g (E/W/SW) (S/H/G) Competition, d M/Sg

Never injured 320 26 ± 14 22 ± 2 14 ± 8 6 ± 4 309 ± 30 80/38/202 281/25/14 – –

Injured with E 12 42 ± 5b 23 ± 3 22 ± 8b 6 ± 4 330 ± 31 12/0/0 12/0/0 69 ± 20 12/0
Injured with 38 22 ± 8b 21 ± 1 8 ± 3b 7 ± 3 304 ± 23 0/16/22 38/0/0 69 ± 11 33/5
   SW and W
a
Data are expressed in mean ± standard deviation and standard error for time out of competition. Dominant arm and backhand type are
not reported. BMI, body mass index; E, Eastern; SW, semi-Western; W, Western; S, synthetic; H, hybrid; G, natural gut; M, medical; Sg,
surgical.
b
P < .01.

TABLE 2
Multivariate Analysis Including Grip, Age, Years of Playa

95% CI for Exp(B)

B SE Wald df Sig Exp(B) Lower Upper

Step 1(a)
   Gripb –3.431 1.189 8.324 1 .004 .032 .003 .333
   Age .048 .050 .906 1 .341 1.049 .951 1.157
   Years of activity –.059 .071 .684 1 .408 .943 .821 1.083
   Constant .417 2.035 .042 1 .838 1.517
a
B, estimated coefficient; SE, standard error; Wald, Wald statistic (calculated by squaring the ratio of B to SE); df, degree of freedom; Sig,
significance; Exp(B), predicted change in odds for a unit increase in the predictor; CI, confidence interval.
b
Note that only the contribution of the grip is significant.

No statistically significant differences were observed
between the group of injured players and the noninjured one
regarding body mass index, years of practice, weekly hours
of training, racket weight, and kind of strings (Table 1).
DISCUSSION
The main result of our study is the demonstration of an
association between different grips and different patterns
of wrist injury in nonprofessional tennis players. Eastern
grip was associated with radial-side wrist injuries, while
Western and semi-Western grips were associated with
ulnar-side wrist injuries (Figure 3). To our knowledge, this
association has never been investigated in the scientific
literature, even if in popular media and among tennis
instructors it is well known that extreme grips such as the
Western grip require a strong wrist and good timing on the
ball to avoid injuries.18 Other results that emerged from
our study were that wrist injuries in nonprofessional ten-
nis players are not uncommon as 13% of the players
reported at least 1 injury to the wrist and this resulted in
a great loss of training and competition time. Moreover, a
significant difference between the age of the injured play-
ers using the different grips (Eastern vs semi-Western and
Western) was demonstrated, reflecting generational
changes in tennis technique.
Power and control are the main concerns of tennis
­players, and to achieve the best stroke possible, a proper
c­ ombination of angular and linear momentum has to be
reached.4 In modern tennis the forehand is the most pow-
erful and employed stroke, it is played with an open-stance
position, and the wrist plays a key role in developing angu-
lar momentum to increase the speed of the racket head.
The modern forehand is usually hit with a semi-Western or
Western grip with a lot of rotational motion. The ball is hit
very hard with a lot of top-spin.2 This violent movement is
greatly different from past years when ground-strokes
were hit gently with a long swing and a long follow-
through; the top-spin rotation was rarely used. This change
in ground-strokes technique has also been encouraged by
the new materials; lighter and comfortable rackets allowed
the new technique to develop.18
Given the central role of the wrist in ground-strokes, espe-
cially in the forehand, wrist injuries are relatively common
in tennis practice, and the majority of injuries described in
the literature are related to tendinitis or tenosynovitis. A
prevalence of wrist injuries of 19% in the nondominant wrist
and 6% in the dominant wrist of young players involved in
the 1998 United States Tennis Association (USTA) National
Championship was reported.5,8 These data are quite similar
to our findings for the dominant wrist, whereas we did not
notice any injury in the nondominant arm. A possible
explanation for this difference may be given by the differ-
ent level of playing in our sample in comparison to the
average level in the USTA Championship. The tourna-
ments that we considered represented a local selection of
players with a much lower level of play than the USTA
Vol. 37, No. 4, 2009 Wrist Injuries and Grips   765

TABLE 3
Pattern of Wrist Injuries and Time Out of Competition in Relation to Different Gripsa

Injuries ECU TFCC Intersection De Quervain Extensors

Grip (n = 50) (n = 30) (n = 5) (n = 1) FCR (n = 5) (n = 6) (n = 3)

Eastern 12 3 1 3 5
Western 16 11 3 1 1
Semi-Western 22 16 2 1 1 2
Time out, wk 2-42 2-42 12 4 6 4-42 2
a
ECU, extensor carpi ulnaris; TFCC, triangular fibrocartilage; FCR, flexor carpi radialis.

take periods of rest at the start of the pain without impair-

Figure 3.  Photographs representing the association between
Eastern grip and radial-side wrist injuries or Western and
semi-Western grips and ulnar-side wrist injuries.
players. Moreover, it is well known that all players, espe-
cially at low levels, tend to hit the majority of ground-
strokes with the forehand, therefore it is likely that the
limited use of the backhand, as well as the reduced speed
of play reached by lower-level players, avoid nondominant
hand injuries.
Our study considered only nonprofessional players; how-
ever, the mean time of weekly training was respectable.
Surprisingly, in our series we did not observe injuries that
are sometimes associated with tennis practice, such as
ulnar nerve compression in the Guyon canal, fractures of
the hook of the hamate, or ulnar artery thrombosis.8 These
kinds of lesions are usually associated with a constant
abutment of hypothenar eminence on the racquet handle.
It has been reported that in cases of fracture of the hook of
the hamate, the predominant pathomechanism is repre-
sented by a stress injury.16 In accordance with this hypoth-
esis we believe that nonprofessional tennis players are less
exposed to stress injuries than “pros” because they can
ing their career. On the contrary, professional players are
used to continuing their activity with mild inflammatory
disorders.
In our series we reported 5 cases of FCR tenosynovitis;
it is worth noting that this condition has never been associ-
ated with tennis practice. A possible explanation for this
observation is that the pathogenesis of this disorder is also
related to arthritis. Not surprisingly the mean age of the
players affected by this disorder was almost double that of
the whole group of players. It is likely that the association
of early osteoarthritis and tennis-related loads on the
wrist may have contributed to this condition.
To keep with this hypothesis, it is important to remem-
ber that degenerative changes in the musculoskeletal sys-
tem of tennis players, such as lumbar spine facet joint
arthritis, are already present in asymptomatic elite adoles-
cent players,1 therefore the degenerative theory may play
a role in FCR tenosynovitis of this “over 35” group of non-
professional tennis players. Moreover, professional tennis
players usually retire quite young, before developing evi-
dent osteoarthritis, and probably their subsequent medical
records thus no longer reference them as a “pro” tennis
player but a normal patient.
Concerning the different grips considered, our study is the
first to associate wrist injuries with different technical skills.
It is well known that ulnar-sided wrist injuries such as
TFCC and ECU are possible in professional tennis players
who develop powerful strokes with a marked top-spin.12
Recently a French group described 28 cases of ECU injuries
in professional tennis players.13 Although it is not clearly
specified by the authors, it is conceivable that these
Association of Tennis Professionals players used semi-West-
ern or Western grips given their extremely high ranking.
In our series ulnar-sided wrist injuries were associated
with these 2 grips, confirming the hypothesis that modern
top-spin strokes are associated with these kinds of lesions.
In our series we observed 5 lesions of the TFCC; 4 players
affected by this injury used to play at the highest level (divi-
sion III, first group). It is likely that the high performance
level of these players implies higher loads on the TFCC in
comparison with lower-level players. These injuries were
the worst that we recorded as all of them required surgical
intervention and approximately 3 months of recovery.
Extensor carpi ulnaris tenosynovitis derives from a tear
of the retinaculum of the sixth compartment of the extensor
766   Tagliafico et al The American Journal of Sports Medicine
tendons of the wrist as a result of the mechanical friction
between this tendon and the ulna. In tennis and racquet
sports in general, ECU injuries are quite common in the
nondominant wrist of players with a 2-handed backhand.12
Biomechanical studies have shown that the wrist in tennis
is in ulnar deviation for most shots and that the nondomi-
nant wrist is in extensive ulnar deviation during the
2-handed stroke.16 Moreover, the use of top-spin rotation
with repeated sudden pronation movements from a supi-
nated position causes stress forces over the ECU and may
lead to stripping of the retinaculum.18 This condition is
easily diagnosed with US and sometimes stress test or
MR.7 In our series, none of the players with an injury to
the ECU tendon reported a complete rupture and no one
had undergone surgical repair.
The association between Eastern grip and radial-side
lesions has never been described in the literature, although
it is known that flexor tendons also may be involved in
tennis-related wrist injury.7,8 It is interesting to note that
the players affected by radial-side lesions and using an
Eastern grip were those with the oldest age: all of them
were older than 35 years. The differences between pattern
of wrist injuries and age of the groups using Eastern and
semi-Western or Western grip reflect the different loads
that the wrist has to bear in relation to the style of play.
We also noted that the 6 players with de Quervain syn-
drome were all tennis instructors. It is possible that the
daily activity on the tennis court represents a risk factor
for this disorder. Movements requiring forceful grasping
with the wrist in ulnar deviation or repetitive use of the
thumb are known to predispose to de Quervain syndrome,
and these movements are typical of a tennis instructor.
Similarly, intersection syndrome and extensor tendon
injuries are likely to be related to repeated flexion and
extension movements of the racket while performing
drills during tennis lessons more than during tournament
activity.
It is important to remember that during the last 10 years
the tennis forehand stroke has changed dramatically. The
traditional description of the forehand as a 3-phase move-
ment (racket preparation, acceleration, and follow-through)
is not sufficient today to explain the complex biomechani-
cal improvements of modern ground-strokes.2,3 Also non-
professional players use the modern top-spin forehand.
The technical changes have influenced the type of grip in
conjunction with racket backswing and forward swing.
The preferred grip used today is the semi-Western or
the Western because it is easier to generate top-spin and
maintain racket orientation at impact. The disadvantage
of the Western grip is that it is difficult for tennis players
to hit low-bouncing balls.2,9 The effects of using Eastern
and Western forehand grips on the rotational contribu-
tion of the upper-limb segments to racket head velocity
have been investigated.6 Players using the Western grip
were able to produce greater forward (toward the court)
and sideways (along the baseline) velocities through hori-
zontal flexion, abduction, and internal rotation at the
shoulder, and through ulnar deviation. In contrast, play-
ers using the Eastern forehand grip used more horizontal
flexion and abduction at the shoulder and more wrist
flexion. The increased wrist flexion of Eastern grips
described by Elliott et al6 could explain the FCR teno-
synovitis and the de Quervain syndrome, which typically
occur in repeated flexion and extension movements. The
increased rotational velocity of the head of the racket and
consequently to the wrist obtained with Western and
semi-Western grips explains the ulnar-side injuries asso-
ciated with these grips. The dissimilar injury pattern
associated with the different grips reflects the diverse
biomechanical loads on the wrist joint developed by the
traditional and modern strokes: traditional strokes are
performed on a closed position and low-bouncing balls,
while modern strokes require an open-stance position to
hit high-bouncing balls. This observation has great impli-
cation for tennis wrist injury prevention and training.
Our data support the study by Bahamonde and Knudson2
in which it has been suggested that people with injuries
to the wrist should consider using the traditional fore-
hand stroke instead of any of the variations of the modern
strokes because the traditional forehand stroke does not
imply the use of the wrist and elbow joints to accelerate
the racket.
A possible limitation of our study is it was a cross-
sectional study and not a prospective study. Another limi-
tation concerns the voluntary participation to the
tournaments: at least theoretically the prevalence of the
injuries could be underestimated. Moreover, time out of
competition was self-reported by the players and so it may
not be accurate. Because professional players are obliged
to play tournaments, time out of competition corresponds
to the absence from official tournaments over a certain
time span and thus can be accurately defined. On the con-
trary, nonprofessional players participate in tournaments
on a voluntary basis, so that the time out of competition
was only estimated according to the information given in
the questionnaire.
Our study has not only an impact in terms of injury pre-
vention and training modules but also has a practical use
for all physicians who have to diagnose a wrist injury in a
tennis player. According to the player grip, the physician
can focus his or her attention either on the radial side of
the wrist if the grip is Eastern or on the ulnar-side if the
grip is a semi-Western or Western. We believe that all phy-
sicians should consider this association to achieve a more
precise and accurate diagnosis, also considering that ten-
nis players often travel and therefore do not constantly
refer to the same physician or medical center.
ACKNOWLEDGMENT
The authors thank all the clubs involved in this study, all
the players, and the officer of the Italian Federation of
Tennis, Mrs Roberta Righetto. The photographs are by Dr
Ing Giulio Tagliafico (division III).
REFERENCES
1. Alyas F, Turner M, Connell D. MRI findings in the lumbar spines of
asymptomatic, adolescent, elite tennis players. Br J Sports Med.
2007;41:836-841.
Vol. 37, No. 4, 2009 Wrist Injuries and Grips   767
2. Bahamonde R, Knudson D. Kinematics analysis of the open and
square stance in tennis forehand. J Sci Med Sport. 2003;6(1):88-101.
3. Bollettieri N. Tennis tips. Tennis tip #3: grips. Part II. http://www
.nickbollettieri.com/tips/tipDetail.cfm?tipID=5. Accessed November
6, 2008.
4. Browne J, Helms CA. Intersection syndrome of the forearm. Arthritis
Rheum. 2006;54:2038.
5. Bylak J, Hutchinson MR. Common sports injuries in young tennis
players. Sports Med. 1998;26:119-132.
6. Elliott B, Marsh T. A biomechanical comparison of the top-spin and
back-spin forehand approach shots in tennis. J Sports Sci.
1989;7:215-227.
7. Jacobson JA, Miller BS, Morag Y. Golf and racquet sports injuries.
Semin Musculoskelet Radiol. 2005;9:346-359.
8. Kibler WB, Safran MR. Tennis injuries. Med Sport Sci. 2005;48:120-137.
9. Knudson D, Blackwell J. Trunk muscle activation in open stance and
square stance tennis forehands. Int J Sports Med. 2000;21:321-324.
10. Le Viet D, Kerboull L, Lantieri LA, Collins DE. Stabilized resection
arthroplasty by an anterior approach in trapeziometacarpal arthritis:
results and surgical technique. J Hand Surg Am. 1996;21:194-201.
11. McNally E, Wilson D, Seiler S. Rowing injuries. Semin Musculoskelet
Radiol. 2005;9:379-396.
12. Micheli LJ, Klein JD. Sports injuries in children and adolescents. Br J
Sports Med. 1991;25:6-9.
13. 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;40:424-429.
14. Pfirrmann CW, Theumann NH, Chung CB, Botte MJ, Trudell DJ,
Resnick D. What happens to the triangular fibrocartilage complex
during pronation and supination of the forearm? Analysis of its mor-
phology and diagnostic assessment with MR arthrography. Skeletal
Radiol. 2001;30:677-685.
15. Pluim BM, Staal JB, Windler GE, Jayanthi N. Tennis injuries: occur-
rence, aetiology, and prevention. Br J Sports Med. 2006;40:415-423.
16. Rettig AC. Wrist problems in the tennis player. Med Sci Sports Exerc.
1994;26:1207-1212.
17. Tagliafico A, Rubino M, Autuori A, Bianchi S, Martinoli C. Wrist and
hand ultrasound. Semin Musculoskelet Radiol. 2007;11:95-104.
18. Zlatkin MB, Rosner J. MR imaging of ligaments and triangular fibrocar-
tilage complex of the wrist. Radiol Clin North Am. 2006;44:595-623.