This is Part 1 of a 3-part series on wrist pain in tennis due to ECU tendinosis. Part 1 looks at the role of the ECU, symptoms of ECU injury, and differentiating between tendinosis and tendinitis.
I’ve been struggling with ulnar (pinky-sided) wrist pain throughout my entire tennis career. It has come and gone, lessened and worsened, always seeming to be one overly long, improperly warmed-up hitting session away. I’ve spent countless hours consulting with Dr. Google about symptoms and treatments, have visited athletic therapists, physiotherapists, chiropractors, and even an orthopaedic surgeon (who, thankfully, confirmed that surgery was not the best option), and am finally on the path to recovery.
All of my research and appointments led to suspicions of injury to my extensor carpi ulnaris (ECU) tendon, but wrist pain is complicated so I was getting many different opinions. After finally getting an MRI on my wrist last year when the pain had increased to the point that it was very difficult to play tennis, I learned I had ECU tendinosis. A quick google search told me this would take 3 months to a year to heal.
To say I was devastated was putting it mildly! But after discovering ways to self-manage this injury, I’ve learned that I don’t need to be sidelined. I went from being in nearly constant pain last spring to being able to play tennis pain-free 5-6 times a week all season long.
I thought it might be worth sharing my experience and what I’ve learned from this in case others are struggling with the same or similar conditions. While my injury is in my wrist, I think that at least some of this discussion could probably be applied to other overuse-induced tendon pain.
I’m breaking this information up into a 3 part series. This post is Part 1.
Part 1: ECU function and symptoms of ECU tendinopathy, tendon injury diagnosis, and considerations for treatment
I want to preface this by saying that I’m in no way qualified to give medical advice, I’m just sharing my personal experience and research. Please talk to your doctor if you’re experiencing pain.
What is the ECU?
The ECU tendon crosses the wrist joint and attaches the ECU muscle to the bones of the hand. As the name would imply, the extensor carpi ulnaris primarily acts to extend the hand, and tilt it towards the pinky (ulnar) side.
The ECU doesn’t act in isolation but is part of a complex system in the forearm. The flexor and extensor muscles work together to allow precise movements in the fingers. We use them almost constantly in movement and stillness. Hold your arm straight out in front of you with your fingers pointing away from you and your palm facing the floor. While it might not seem like your extensor muscles are working hard, they do need to overcome the force of gravity so if you relax them completely your fingers will drop towards the floor and your palm will face you.
Symptoms of ECU Injury
Pain levels in injured tendons can vary widely. My pain was mostly quite mild, achy, and intermittent (it would come and go with various activities) although I would at times get a quick, sharp pain if I made a sudden movement involving my ECU. It would improve with rest and worsen with use. If I took a few weeks off from tennis it would seem to be completely cleared up, only to return shortly after I resumed play.
The following activities hurt my wrist during day-to-day life:
- tilting my hand towards the pinky side (ulnar deviation, like in the picture)
- Supinating my hand as far as it would go
- Lifting anything with my hand in a supinated position (think waiter tray)
- Putting weight on my hands with my wrist extended, so for instance in a push-up position.
We use our wrists a ton in tennis, so our ECUs are involved in every shot. But I did find that some shots hurt my wrist while others didn’t at all. For me, I found it painful whenever my hand would become extended and ulnar deviated at the wrist and in particular if I contacted the ball while in this position. It was also painful when my ECU was stretched as in the two-handed backhand (see the image of Serena below).
Shots that hurt:
- forehand (high forehands in particular)
- two-handed backhand
- forehand slice
- forehand volleys
Shots that didn’t hurt:
- one-handed backhand
- backhand slice
- backhand volleys
Tendinitis vs Tendinosis vs Tendinopathy
Tendons are made of tough connective tissue (mostly collagen) and connect muscles to bones. When muscles contract, tendons transmit the force from the muscles to the bones, causing the bones to move. Healthy tendons are up to twice as strong as muscle (making them unlikely to tear before the muscle tears).
Researching tendon pain can be confusing because there is some misinformation and controversy in regards to the role of inflammation in tendon injuries. Also, the presence of pain in degenerative tendon injuries isn’t well understood. Tendonpain.org is a site with great information on tendon injuries that gives a good summary of the history and links to other sources as well.
- TENDINITIS describes a tendon injury where classic inflammation markers are present (and externally visible symptoms like swelling, heat and redness). This typically occurs in acute tendon injuries where a single force stronger than what the tendon can bear is applied and causes micro tears in the tendon. This is actually much more rare than tendinosis in overuse injuries.
- TENDINOSIS describes a tendon injury where evidence of degradation is present without inflammation (or at least without the classic inflammation markers). As tendons are stressed they adapt and repair (collagen breaks down and new collagen is formed). However if the stress applied overcomes the ability to repair, which happens in chronic overuse scenarios, then the repair mechanism can’t keep up and the cells produce new, abnormal (structure and composition) collagen.
- TENDINOPATHY describes a tendon injury with no indication if it is tendinitis or tendinosis (i.e. it’s just saying there’s a problem with the tendon).
In the article titled “Overuse Tendinosis, Not Tendinitis” the authors summarize the differences between tendinosis and tendinitis. Key information from this article is:
- The prevalence of tendinitis is rare and resolves quickly (several days – 2 weeks) while the prevalence of tendinosis is common and takes longer to resolve (6-10 weeks for early presentation and 3-6 months for chronic presentation)
- For tendinitis, the focus of conservative (non-surgical) focus should be anti-inflammatory modalities and drugs (such as rest, ice, compression, elevation, and ibuprofen)
- For tendinosis, the focus of conservative (non-surgical) focus should be the encouragement of collagen synthesis, maturation and strength
The takeaway from this is if you’re been experiencing wrist pain for longer than a few weeks, it’s likely tendinosis -not tendinitis – and your focus should be on repairing the tendon rather than fighting inflammation.
Ok, I hope Part 1 of this series has been helpful in helping you determine if you might have ECU tendinosis.
Up Next: Managing the Pain of ECU Tendinosis
My wrist is now about 95% pain free. Without getting another MRI I can’t say for sure if my tendon has substantially healed, or if I just no longer feel pain. My suspicion is that my tendon is still compromised since I will occasionally feel some wrist pain, particularly when playing in cold weather (I’ll discuss this more later in the series).
I was initially concerned that by playing tennis before my tendon was fully healed then I was risking further damage which would eventually start hurting again, or worse, would cause my tendon to rupture because it’s in a weakened state. I spoke with an orthopaedic surgeon about this, who told me that pain is our bodies’ way of telling us that there’s a problem, so if I’m not feeling pain then I shouldn’t worry about it.
So I’m taking his advice and letting pain guide me. I’ll discuss in Parts 2 and 3 how I think I’ve been able to reduce the stress I had on my ECU tendon, thus breaking the cycle of tendinosis and allowing it to start to heal even while I engage in the activities that used to hurt it.
But regardless of whether my tendon has healed, or maybe has started to heal, or hasn’t healed at all, I no longer feel the pain that I used to. In the next three parts of this series I’ll be discussing how I’ve eliminated my wrist pain as follows: