1. 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

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

3. Top 5 Tennis Injuries

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

6. Sprain vs. Partial tear

9. 93 y/o F, lat. Ankle pain

10. Muscle Injuries in Tennis Calf muscles Hamstring muscles

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

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

13. Calf Injury Tommy Haas

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

15. 23 y/o F semi-pro athlete, training tennis >6h/day

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

18. Shin Splints -- periostitis

19. Medial Tibial Stress Syndrome

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

21. Jumper’s kneePatellar tendinosis

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

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

25. Partial Tear of Biceps Femoris

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

27. Melbourne, Australia 01/06 Kim Clijsters

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

30. 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

31. Spondylolysis

32. R. Nadal at Queens Club, June 2006

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

34. Subacromial Impingement

35. Shoulder Impingement Syndrome Adequate subacromial spaceNarrowed subacromial space

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

37. Ulnar Sided Wrist Pain

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

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

40. ECU Tendinitis – Tennis Wrist

41. Ganglion cyst + Carpal tunnel syndrome

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

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

44. LATERAL EPICONDILITIS

45. Lateral Epicondylitis

46. Lateral Epicondylitis - Mild

47. 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.

48. Single vs. double-handed backhand

49. Electromyographic and cinematographic analysis of elbow function in tennis players using single- and 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.

50. Vania King ( 金久慈 )

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

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

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