P-45 Conservative treatment of traumatic extensor carpi ulnaris instability in a tennis player: case report

Abstract

Tennis is the most popular of racket sports, and is practiced by people of all ages with recognised health benefits. As the number of practitioners is growing, more attention should be given to injury patterns, prevention and treatment in professional and non-professional players. According to the few published studies, lower limb injuries are the most common overall, and acute injuries are more common in the lower limbs whereas chronic overuse injuries occur more frequently in the upper limbs and trunk. Wrist lesions are considered relatively rare in tennis. Ulnar pain in this context is caused by injuries of extensor carpi ulnaris (ECU), triangular fibrocartilage, triquetrum-lunate ligament or bone fractures (lunatum, triquetrum and hook of the hamate). ECU tendon disease includes tenosynovitis, tendinopathy, rupture and instability, and these conditions can occur alone or concomitantly. We present a case of sudden onset of ulnar pain during practice, and its diagnostic investigation, treatment plan and process of returning to play. 15 year-old right-handed male, who is an elite junior tennis player (2-3 hours of daily practice), felt sudden ulnar side pain in his right hand after hitting a backhand on practice. There was a moderate amount of swelling and he stopped playing. After 3 days of rest and analgesia (ice, topical and oral NSAIDs), he tried to return to play but he couldn’t, because he was unable to hit backhands. He was referred to us and, on physical examination, pain was elicited on resisted extension combined with ulnar deviation. Ultrasound examination was performed, and on dynamic evaluation (at rest and during supination) ECU tendon instability was identified. The goal of the rehabilitation program was to have him ready to play 12 weeks from the observation, since there was an important tournament then. Cast immobilisation in pronation and extension was recommended, but after 10 weeks (when the cast was removed) pain was still present on hitting the backhand stroke, and so return to play had to be delayed. After 14 weeks the second cast was removed and he started a rehabilitation program including manual therapy, stretching and progressive strengthening of the wrist (from isometric to eccentric exercises), and a program to maintain aerobic conditioning. Return to practice was achieved after 4.5 months and competitive return on 5.5 months after beginning of rehabilitation. Ulnar pain associated with professional or non-professional tennis practice has been described elsewhere, and ECU tendon abnormalities are the most common causes. ECU instability results from disruption or dysfunction of its subsheath, and there is particular risk of injury when the wrist moves from pronation to supination (fixed in flexion and ulnar deviation). In tennis, a two-handed backhand stroke is the shot that is most associated with its injury. Other risk factor identified for ECU injuries was the Western or semi-Western grip, because of the larger amount of top spin used in the backhand shot. In the present case, we believe conservative treatment was successful, enabling return to play in 5.5 months, which is in accordance with the literature. References 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. Campbell D, Campbell R, O’Connor P, Hawkes R. Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. Br J Sports Med 2013;47:1105–1111. Tagliafico AS, Ameri P, Michaud J, Derchi LE, Sormani MP, Martinoli C. Wrist injuries in nonprofessional tennis players: relationships with different grips. The American Journal of Sports Medicine, 2009, Vol. 37, No.4. Graham TJ. Pathologies of the extensor carpi ulnaris (ECU) tendon and its investments in the athlete. Hand Clin 2012;28:345–356.