MRI EVALUATION OF TENNIS INJURIES TENNIS ELBOW AND

MRI EVALUATION OF TENNIS INJURIES TENNIS ELBOW AND BEYOND Peter P. Chow, M. D. , M. P. H. Pacific Medical Imaging & Oncology Center, Alhambra, CA Valley Imaging Partnership, West Covina, CA

Tennis Injuries Overview Extremely high demands on structural integrity of the body’s joints. n Repetitive, asymmetrical and technically challenging movements at high speed in dynamic settings. n Testing the limits of players’ physical and mental endurance n

Top 5 Tennis Injuries

Tennis Injuries Facts -in ATP professional Players n 35 -50% to lower extremities n 20% to upper limb n 20% to lower back n Chronic overuse conditions more likely to occur in upper body n Acute injuries more likely to occur in the lower limbs.

Sprain vs. Partial tear

93 y/o F, lat. Ankle pain

Muscle Injuries in Tennis Hamstring muscles Calf muscles

Middle-aged male pushing a stalled car and felt a pop in the calf

Rupture of Plantaris Tendon (Tennis Leg) Middle-aged patients n Forced dorsiflection of the ankle with the knee in extention n Audible “pop” in the calf, with subsequent pain and swelling, and frequently with a palpable mass caused by hematoma n Often associated with ACL tear and posterolateral corner injuries n

Calf Injury Tommy Haas

Injuries to Med. Gastronemius muscle (Tennis Leg)

23 y/o F semi-pro athlete, training tennis >6 h/day

Medial Tibial Stress Syndrome Also known as shin splints n Characterized by hyperintense signal along the anterior tibial border n Related to periosteal avulsion and periostitis at the medial soleus insertional site n Grade I (periosteal edema)thru grade IV (stress fracture) n

Shin Splints -- periostitis

Medial Tibial Stress Syndrome

BONE BRUISE-26 y/o M MR Tech 4 wk 7 wk 9 wk after injury

Patellar tendinosis Jumper’s knee

Patellar Chondromalacia No. 1 USC player turned professional 30 y/o male, anterior knee pain

Hamstring Injury M. Sharapova at Pan Pacific Open, Feb. 2007

Partial Tear of Biceps Femoris

Hamstring Injuries MR depicts the location and extent of injuries n MR useful in grading of muscular injuries: n Grade I – limited muscle fiber disruption n Grade II – partial tears at musculotendinous junction without retraction of muscle n Grade III – complete disruption of the musculotendinous junction, often with retraction n n Treatment options depend on the location and severity of the injury

Melbourne, Australia 01/06 Kim Clijsters

The combined rotation and extension of the back during serving places high demands on the back

Pars Stress Fracture 30% of adolescents involved in sports will have an episode of low back pain. Lumbar spondylolysis is one of the causes of LBP in this age group of athletes. Athletes involved in sports requiring repetitive bending and straightening of the spine are most commonly affected Most patients have excellent clinical outcomes with conservative measures, and surgery is rarely necessary

Spondylolysis

R. Nadal at Queens Club, June 2006

Shoulder Pain in Athletes AC joint sprain n Calcific rotator cuff tendinopathy n Clavicle fracture n Dislocated shoulder n Adhesive capsulitis n Rotator cuff tear n Subacromial bursitis n

Subacromial Impingement

Shoulder Impingement Syndrome Adequate subacromial space Narrowed subacromial space

Articular sided partial tear High school varsity baseball pitcher-shoulder pain before end of the season games

Ulnar Sided Wrist Pain

Extensor Carpi Ulnaris(ECU) Tendinitis n n Related to racquet sports with repetitive wrist motion n Squash n Badminton n Raquetball n Tennis n Rowing Tennis player with two-handed backhand using excessive ulnar deviation in nondominant wrist

Players who hit with a lot of topspin are at increased risk for extensor carpi ulnaris tendon injury

ECU Tendinitis – Tennis Wrist

Ganglion cyst + Carpal tunnel syndrome

Tennis Elbow Middle-aged female with a single-handed backhand who leads with elbow n Straightens elbow and extends wrist on contact n Placing the wrist extensors under excessive tension n Correct form – swinging from the shoulder with a straight arm and using the entire body to execute the stroke n

TENNIS ELBOW n n A painful condition caused by inflammation or small tears of the wrist extensors and tendons, esp. extensor carpi radialis brevis rubbing over the lateral epicondyle and the radial head Most experts believe that tennis elbow is caused by overloading of the forearm muscles due to faulty backhand technique

LATERAL EPICONDILITIS

Lateral Epicondylitis

Lateral Epicondylitis - Mild

The backhand is generally found to be the prime cause of tennis elbow in non-professionals due to the complexity of this stroke. A bent elbow or "swinging" just at the elbow and not the entire arm, causes excess torques and forces in the elbow region. Other causes of tennis elbow are: Late backhand stroke with hyper-extended wrist. Too tight of grip. Excessive wrist "pop" on overhand serve. Forehand stroke with excessive wrist movement. Using too many “topspin” shots.

Single vs. double-handed backhand

Electromyographic and cinematographic analysis of elbow function in tennis players usingleand double-handed backhand strokes It is generally believed that tennis players using a double-handed backhand rarely develop lateral epicondylitis since the helping arm appears to absorb more energy and changes the mechanics of the swing. Giangarra CE, et al, American Journal of Sports Medicine, Vol 21, Issue 3 394 -399.

Vania King (金久慈)

Racquet Selection to Avoid Tennis Elbow Use a more flexible racquet made of graphite, fiberglass, etc. n Use an oversized racquet with bigger “sweet spot” n Use a heavier but comfortable racquet n Lower string tension by 10% n Correct grip size. Add a cushioned over grip. n Do not use extra-long racquet n

If you followed all those tips that I gave you: n n n There is no guarantee that you will become a better tennis player. There is a good chance that you will have a pain-free elbow. You will enjoy tennis better and live your life happily after.

CONCLUSION Because of its superior soft tissue discrimination, multiplanar capability, noninvasive, and non-radioactive nature, MR is well-suited for imaging in sport medicine. n Understanding of mechanism of injuries would enable better diagnosis and facilitate management of sport injuries. n Patient education can be better achieved by providing visual evidence of disease processes. n