How common it is, and who gets itEmerging evidence
Most tennis injuries are in the legs, then the arms, then the trunk, and most wrist problems in tennis come from overuse rather than one injury. In 370 Italian club players, 50 (13%) had had a wrist injury over about 18 months: 30 were ECU tendon problems, 6 de Quervain's, 5 flexor tendon injuries, 5 TFCC injuries, 3 other extensor tendon problems and 1 intersection syndrome. In 600 German league players, tendon problems were the commonest overuse diagnosis, with the shoulder first, then the elbow, then the wrist.
In professionals, the wrist was the second commonest injury site at 16 US Opens, one of the four commonest regions in women at 6 Australian Opens, and commoner in women than men at Wimbledon; over a full season of professional women's tennis it wasn't among the top four sites, and in 101 elite juniors the lower back and shoulder came first. A review concludes that wrist pain seems to have become more common in the modern game. How often young players get overuse wrist injuries is largely unknown; the data come mostly from gymnasts.
Sources 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11
What the strokes ask of the wristEmerging evidence
The modern forehand is hit with the palm turned up and the wrist bent back and towards the little finger, where the ECU tendon and its sheath are most exposed; hand surgeons say most tennis wrist injuries are ECU problems from forehand groundstrokes, and a review of elite players lists ECU tendinopathy and a slipping ECU tendon among the common arm injuries. In 14 competitive players, topspin came from more shoulder and forearm turning rather than from the wrist. In 12 skilled players, hitting the forehand fast rather than slow bent the wrist back 16% further and snapped it forward 118% faster, and faster hitting sent more vibration to the wrist in 9 players.
In a two-handed backhand the front (non-dominant) wrist does real work. In 28 professional players with ECU problems, 12 had a tendon that suddenly slipped out of place, and in the 10 of those hurt in a two-handed backhand it was the hand nearer the racket head, the front wrist. Two papers from one group of elite players found little-finger-side pain in that wrist common. The ITF says wrist tendon injury often affects the non-dominant wrist in players with a two-handed backhand. The only lab work measured wrist angles, not strain: in 16 players, a Continental grip on the top hand bent the front wrist further back and sideways than an Eastern grip.
Sources 12, 13, 14, 15, 16, 17, 18, 19, 20, 21
Grips, rackets and strings: one survey and expert opinionMixed evidence
In the Italian club study, little-finger-side injuries went with Western and semi-Western forehand grips and thumb-side injuries with the Eastern grip. That rests on one cross-sectional study of the 50 injured club players, so it shows an association, not proof that the grip caused the injury. The same study found no link with racket weight or strings, the German league players' racket properties weren't linked to their arm problems, and string dampers didn't reduce vibration at the wrist in a lab study of 20 people. The French tennis federation's doctors blame wrist-driven topspin, the two-handed backhand and high string tension for little-finger-side pain in professionals; the string tension part is expert opinion, not a measured link.
Grip size has been studied only for the elbow: a quarter-inch change made no difference to forearm muscle activity in 16 college players, while in a lab and modelling study a handle that fitted lowered grip force. The ITF's check is to grip the racket lightly, as if shaking hands: the little finger should fit between the base of the thumb and the fingertips.
Sources 4, 5, 22, 17, 23, 24, 21
Telling the causes apartEmerging evidence
Clinicians press on the exact spot and compare movement, swelling and grip strength with the other side. ECU problems come in three patterns: a sudden painful snap as the tendon slips out of its groove, often with one low forehand; a tendinopathy that comes on gradually; and, rarely, a rupture. An NHS hand clinic says the commonest symptoms of a TFCC injury are pain and swelling on the little-finger side and difficulty turning the forearm. ECU and TFCC problems often come together, and their signs overlap. A case review calls TFCC injury the commonest cause of little-finger-side wrist pain in general, but in club tennis players the ECU came first (30 against 5 of 50 wrist injuries).
A hook of hamate fracture hurts on the little-finger side of the palm or the back of the wrist; it was missed by most doctors in one old series, so mention a jarring shot. Falls are different: in 449 recreational players treated at an Austrian hospital, 47 of 86 wrist and hand injuries came from falls, including 11 broken wrists and 7 scaphoid fractures, often on the free arm players put out to break the fall.
Sources 2, 17, 12, 25, 26, 4, 27, 28, 29
When a scan helps, and what it doesn't meanStrong evidence
After a fall, an X-ray comes first, and a broken scaphoid can hide on the first one, which is why the warning signs ask for follow-up. For overuse pain, scans often find things that don't hurt: in 26 long-time club players without wrist pain, 92% had ECU tendon changes on ultrasound and 73% an ECU tendon that slipped in at least one wrist. In elite two-handed players, wrists with pain showed only about one more change on MRI than pain-free wrists, and the authors say MRI findings should be read alongside the examination. An NHS hand clinic says wear changes in the TFCC are very common and often cause no symptoms.
A scan matters when it changes the plan: a suspected fracture, a tendon that snaps out of place and may need surgery, an unstable joint between the forearm bones, or pain that hasn't settled with good care.
Sources 30, 31, 18, 19, 25, 32
How it usually goesEmerging evidence
In the club study, players were out of competition for 69 days on average, and 46 of the 50 were treated without surgery. In the professional series, players with an ECU tendinopathy often kept playing because the pain eased after the warm-up, and in most cases the pain went within 2 to 24 weeks; 5 with a slipping tendon treated in a cast for 2 to 3 months were back in competition 5 to 6 months after the injury without symptoms. A review says most ECU tendinopathy settles with about 3 weeks in a splint, anti-inflammatory medicine and retraining the muscle.
An NHS hand clinic says the vast majority of TFCC tears heal with time, healing takes about 3 months, and normal function often takes longer. In 20 racket players with a TFCC injury, 11 of the 15 treated without surgery got back to their usual activity, and age over 50 and a previous TFCC problem went with not getting back. In 5 hard-hitting players with a lunate stress injury, all recovered without surgery by 14 weeks. The ITF says tendon injuries are slow to heal and may take six weeks or more. No one can promise a date.
Sources 4, 17, 33, 25, 34, 35, 21
