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.

MRI EVALUATION OF MRI EVALUATION OF TENNIS INJURIESTENNIS INJURIES

TENNIS ELBOW AND BEYONDTENNIS ELBOW AND BEYOND

Peter P. Chow, M.D., Peter P. Chow, M.D., M.P.H.M.P.H.

Pacific Medical Imaging & Oncology Pacific Medical Imaging & Oncology Center, Alhambra, CACenter, Alhambra, CA

Valley Imaging Partnership,Valley Imaging Partnership,West Covina, CAWest Covina, CA

Tennis Injuries OverviewTennis Injuries Overview

Extremely high demands on Extremely high demands on structural integrity of the body’s structural integrity of the body’s joints.joints.

Repetitive, asymmetrical and Repetitive, asymmetrical and technically challenging movements technically challenging movements at high speed in dynamic settings.at high speed in dynamic settings.

Testing the limits of players’ Testing the limits of players’ physical and mental endurancephysical and mental endurance

Top 5 Tennis InjuriesTop 5 Tennis Injuries

Tennis Injuries FactsTennis Injuries Facts-in ATP professional -in ATP professional

PlayersPlayers

35-50% to lower extremities35-50% to lower extremities 20% to upper limb20% to upper limb 20% to lower back20% to lower back Chronic overuse conditions more Chronic overuse conditions more

likely to occur in upper bodylikely to occur in upper body Acute injuries more likely to Acute injuries more likely to

occur in the lower limbs.occur in the lower limbs.

Sprain vs. Partial tearSprain vs. Partial tear

93 y/o F, lat. Ankle pain93 y/o F, lat. Ankle pain

Muscle Injuries in TennisMuscle Injuries in Tennis

Calf muscles

Hamstring muscles

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

the calfthe calf

Rupture of Plantaris Rupture of Plantaris TendonTendon

(Tennis Leg)(Tennis Leg) Middle-aged patientsMiddle-aged patients Forced dorsiflection of the ankle with Forced dorsiflection of the ankle with

the knee in extentionthe knee in extention Audible “pop” in the calf, with Audible “pop” in the calf, with

subsequent pain and swelling, and subsequent pain and swelling, and frequently with a palpable mass frequently with a palpable mass caused by hematomacaused by hematoma

Often associated with ACL tear and Often associated with ACL tear and posterolateral corner injuriesposterolateral corner injuries

Calf InjuryCalf Injury

Tommy Haas

Injuries to Med. Gastronemius Injuries to Med. Gastronemius muscle (Tennis Leg)muscle (Tennis Leg)

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

Medial Tibial Stress Medial Tibial Stress SyndromeSyndrome

Also known as shin splintsAlso known as shin splints Characterized by hyperintense signal Characterized by hyperintense signal

along the anterior tibial borderalong the anterior tibial border Related to periosteal avulsion and Related to periosteal avulsion and

periostitis at the medial soleus periostitis at the medial soleus insertional site insertional site

Grade I (periosteal edema)thru grade Grade I (periosteal edema)thru grade IV (stress fracture) IV (stress fracture)

Shin Splints -- periostitisShin Splints -- periostitis

Medial Tibial Stress Medial Tibial Stress SyndromeSyndrome

BONE BRUISE-26 y/o M MR BONE BRUISE-26 y/o M MR TechTech

4 wk 7wk 9 wk after injury

Jumper’s kneePatellar tendinosis

Patellar ChondromalaciaPatellar Chondromalacia

No. 1 USC player turned professional30 y/o male, anterior knee pain

Hamstring InjuryHamstring Injury

M. Sharapova at Pan Pacific Open, Feb. 2007

Partial Tear of Biceps Partial Tear of Biceps FemorisFemoris

Hamstring InjuriesHamstring Injuries MR depicts the location and extent of MR depicts the location and extent of

injuriesinjuries MR useful in grading of muscular injuries:MR useful in grading of muscular injuries:

Grade I – limited muscle fiber disruptionGrade I – limited muscle fiber disruption Grade II – partial tears at musculotendinous Grade II – partial tears at musculotendinous

junction without retraction of musclejunction without retraction of muscle Grade III – complete disruption of the Grade III – complete disruption of the

musculotendinous junction, often with musculotendinous junction, often with retractionretraction

Treatment options depend on the location Treatment options depend on the location and severity of the injuryand severity of the injury

Melbourne, Australia 01/06

Kim Clijsters

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

demands on the backdemands on the back

Pars Stress Fracture30% of adolescents involved in sports will have an episode of low back pain.Lumbar spondylolysis is one of the causes of LBPin this age group of athletes.Athletes involved in sports requiring repetitive bending and straightening of the spine are most commonly affectedMost patients have excellent clinical outcomes with conservative measures, and surgery is rarely necessary

Spondylolysis

R. Nadal at Queens Club, June 2006

Shoulder Pain in AthletesShoulder Pain in Athletes

AC joint sprainAC joint sprain Calcific rotator cuff tendinopathyCalcific rotator cuff tendinopathy Clavicle fractureClavicle fracture Dislocated shoulderDislocated shoulder Adhesive capsulitisAdhesive capsulitis Rotator cuff tearRotator cuff tear Subacromial bursitisSubacromial bursitis

Subacromial Subacromial ImpingementImpingement

Shoulder Impingement Shoulder Impingement SyndromeSyndrome

Adequate subacromial spaceNarrowed subacromial space

Articular sided partial tear

High school varsity baseball pitcher-shoulder pain before end of the season games

Ulnar Sided Wrist PainUlnar Sided Wrist Pain

Extensor Carpi Ulnaris(ECU) Extensor Carpi Ulnaris(ECU) TendinitisTendinitis

Related to racquet sports with repetitive Related to racquet sports with repetitive wrist motionwrist motion SquashSquash BadmintonBadminton RaquetballRaquetball TennisTennis RowingRowing

Tennis player with two-handed backhandTennis player with two-handed backhand using excessive ulnar deviation inusing excessive ulnar deviation in nondominant wristnondominant wrist

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

tendon injurytendon injury

ECU Tendinitis – Tennis ECU Tendinitis – Tennis WristWrist

Ganglion cyst + Carpal tunnel Ganglion cyst + Carpal tunnel syndromesyndrome

Tennis ElbowTennis Elbow

Middle-aged female with a single-Middle-aged female with a single-handed backhand who leads with elbow handed backhand who leads with elbow

Straightens elbow and extends wrist on Straightens elbow and extends wrist on contactcontact

Placing the wrist extensors under Placing the wrist extensors under excessive tensionexcessive tension

Correct form – swinging from the Correct form – swinging from the shoulder with a straight arm and using shoulder with a straight arm and using the entire body to execute the strokethe entire body to execute the stroke

TENNIS ELBOWTENNIS ELBOW A painful condition caused A painful condition caused

by inflammation or small by inflammation or small tears of the wrist extensors tears of the wrist extensors and tendons, esp. extensor and tendons, esp. extensor carpi radialis brevis rubbing carpi radialis brevis rubbing over the lateral epicondyle over the lateral epicondyle and the radial headand the radial head

Most experts believe that Most experts believe that tennis elbow is caused by tennis elbow is caused by overloading of the forearm overloading of the forearm muscles due to faulty muscles due to faulty backhand technique backhand technique

LATERAL LATERAL EPICONDILITISEPICONDILITIS

Lateral EpicondylitisLateral Epicondylitis

Lateral Epicondylitis - Lateral Epicondylitis - MildMild

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 Single vs. double-handed backhandbackhand

Electromyographic and cinematographic Electromyographic and cinematographic analysis analysis of elbow function in tennis players using of elbow function in tennis players using single- single- and double-handed backhand strokesand double-handed backhand strokes

It is generally believed that tennis players It is generally believed that tennis players using a using a double-handed backhanddouble-handed backhand rarely rarely develop develop lateral epicondylitislateral epicondylitis since the since the helping arm appears to absorb more helping arm appears to absorb more energy and changes the mechanics of the energy and changes the mechanics of the swing.swing.

Giangarra CE, et al, American Journal of Giangarra CE, et al, American Journal of Sports Medicine, Vol 21, Issue 3 394-399Sports Medicine, Vol 21, Issue 3 394-399. .

Vania King (Vania King ( 金久慈金久慈 ) )

Racquet Selection to AvoidRacquet Selection to Avoid Tennis Elbow Tennis Elbow

Use a more flexible racquet made of Use a more flexible racquet made of graphite, fiberglass, etc.graphite, fiberglass, etc.

Use an oversized racquet with bigger Use an oversized racquet with bigger “sweet spot”“sweet spot”

Use a heavier but comfortable racquetUse a heavier but comfortable racquet Lower string tension by 10%Lower string tension by 10% Correct grip size. Add a cushioned over Correct grip size. Add a cushioned over

grip.grip. Do not use extra-long racquetDo not use extra-long racquet

If you followed all those tips that I If you followed all those tips that I gave you:gave you:

There is no guarantee There is no guarantee that you will become a that you will become a better tennis player.better tennis player.

There is a good chance There is a good chance that you will have a that you will have a pain-free elbow.pain-free elbow.

You will enjoy tennis You will enjoy tennis better and live your better and live your life happily after.life happily after.

CONCLUSIONCONCLUSION Because of its superior soft tissue Because of its superior soft tissue

discrimination, multiplanar capability, discrimination, multiplanar capability, non-invasive, and non-radioactive nature, non-invasive, and non-radioactive nature, MR is well-suited for imaging in sport MR is well-suited for imaging in sport medicine.medicine.

Understanding of mechanism of injuries Understanding of mechanism of injuries would enable better diagnosis and would enable better diagnosis and facilitate management of sport injuries.facilitate management of sport injuries.

Patient education can be better achieved Patient education can be better achieved by providing visual evidence of disease by providing visual evidence of disease processes.processes.