mri evaluation of tennis injuries tennis elbow and beyond peter p. chow, m.d., m.p.h. pacific...
TRANSCRIPT
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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
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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
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Top 5 Tennis InjuriesTop 5 Tennis Injuries
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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.
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Sprain vs. Partial tearSprain vs. Partial tear
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93 y/o F, lat. Ankle pain93 y/o F, lat. Ankle pain
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Muscle Injuries in TennisMuscle Injuries in Tennis
Calf muscles
Hamstring muscles
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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
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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
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Calf InjuryCalf Injury
Tommy Haas
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Injuries to Med. Gastronemius Injuries to Med. Gastronemius muscle (Tennis Leg)muscle (Tennis Leg)
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23 y/o F semi-pro athlete, training 23 y/o F semi-pro athlete, training tennis >6h/daytennis >6h/day
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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)
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Shin Splints -- periostitisShin Splints -- periostitis
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Medial Tibial Stress Medial Tibial Stress SyndromeSyndrome
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BONE BRUISE-26 y/o M MR BONE BRUISE-26 y/o M MR TechTech
4 wk 7wk 9 wk after injury
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Jumper’s kneePatellar tendinosis
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Patellar ChondromalaciaPatellar Chondromalacia
No. 1 USC player turned professional30 y/o male, anterior knee pain
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Hamstring InjuryHamstring Injury
M. Sharapova at Pan Pacific Open, Feb. 2007
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Partial Tear of Biceps Partial Tear of Biceps FemorisFemoris
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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
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Melbourne, Australia 01/06
Kim Clijsters
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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
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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
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Spondylolysis
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R. Nadal at Queens Club, June 2006
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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
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Subacromial Subacromial ImpingementImpingement
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Shoulder Impingement Shoulder Impingement SyndromeSyndrome
Adequate subacromial spaceNarrowed subacromial space
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Articular sided partial tear
High school varsity baseball pitcher-shoulder pain before end of the season games
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Ulnar Sided Wrist PainUlnar Sided Wrist Pain
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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
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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
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ECU Tendinitis – Tennis ECU Tendinitis – Tennis WristWrist
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Ganglion cyst + Carpal tunnel Ganglion cyst + Carpal tunnel syndromesyndrome
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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
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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
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LATERAL LATERAL EPICONDILITISEPICONDILITIS
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Lateral EpicondylitisLateral Epicondylitis
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Lateral Epicondylitis - Lateral Epicondylitis - MildMild
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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.
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Single vs. double-handed Single vs. double-handed backhandbackhand
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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. .
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Vania King (Vania King ( 金久慈金久慈 ) )
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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
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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.
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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.