Hip and groin pain can be multifactorial in nature. Femoroacetabular impingement is a painful condition in the groin due to underlying morphological abnormalities of the hip joint. However, underlying abnormalities may be present on radiological examination (CAM and Pincer) but without pain and it is common in the majority of population. A non-symptomatic femoroacetabular impingement is more likely to become symptomatic with athletes or due to changes in activities or training that involve high hip flexion or rotation. Tennis causes the athlete to change direction and land on twisted leg. This type of training may lead to changes in the bone morphology. The grading of the pathology depends upon your clinical presentation and not on radiological imaging.
Symptoms include intermittent catching pain in the groin region with specific positions of the hip, such as flexion when the knee approximates the chest or rotation, as so in skiing. This condition rarely affects sleeping and it is normally pain-free soon after cessation of aggravating activity or position. If the pathology has been present for a while, inflammation will result in more generalised pain that can become a constant ache and can affect other structures. It can also lead to morning stiffness or stiffness after a period of rest, which will ease off with a few minutes of walking. Pain medication and especially anti-inflammatories can temporarily relieve the symptoms but it is important to understand that it will not cure the underlying condition. Signs of bruising or inflammation are rarely seen with a naked eye but examination will reproduce the symptoms. If there is a need for confirmation, further imaging may accompany the clinical examination.
The management of the abovementioned includes a combination of activity modification to protect the affected area from further irritation. Evaluation of running and changing direction will allow the clinician to advise you on changes that can be made according to your pain. Followed by exercise rehabilitation beginning with simple exercises which are the basis for then progressing and loading the joint to allow for necessary adaptations in posture and structures in order for you to return to playing tennis. In addition, in the initial stages, ice or pain medication may be advised to allow for progression with exercise rehabilitation. Manual techniques may be used with to decrease your pain and improving function. Other treatment modalities may be considered depending on your symptoms and rehabilitation is tailored towards each individual.
In severe cases where the labrum is affected, surgery may be considered. Following your operation, the rehabilitation will begin with a combination of ice and pain medication as well as using crutches in the initial days. This will be combined with simple lying down or standing exercises to re-activate muscles that are now malfunctioning due to the operation. As you progress the pain from the operation will decrease and you will be able to tolerate walking and more exercises. Static cycling without resistance starts after you are able to normally walk unsupported. Then progressive exercise rehabilitation and manual techniques may be used as in the non-operative approach.
Dynamic Shoulder Impingement
Shoulder impingement refers to the pinching of soft tissue structures between the shoulder during movement. Pressure along some structures with shoulder movement is common, however chronic irritation will lead to swelling of poor biomechanics and lead to pain. The bursitis in the shoulder refers to a pathologic inflammation of the sub-acromial bursa which has been inflamed due to an injury or due to chronic compression. A chronic shoulder impingement may lead to bursitis which is an extremely painful pathology. Pain will be present with movements as well as lying on the side. If a shoulder impingement has only affected the tendons, painful positions while playing tennis or in daily life will be present.
Examination will reveal pain and may have difficulty elevating the arm due to pain. There may be any underlying shoulder weakness due to irritation of the tendons. Functional daily tasks may become difficult because of the inability to use the shoulder as previously. Specific assessment manoeuvres will help guide the clinical towards its diagnosis, however specific radiology with ultrasound may be used further investigate and exclude other tissue damage. Contributing factors to a shoulder impingement are the spine and shoulder blade mobility as well as muscle balance. Poor mechanics in the latter may lead to impingement.
The management of the shoulder impingement is commonly conservative with great outcomes. This is achieved with ice, anti-inflammatory medication, and activity modification, followed by correction of structural abnormalities and strength imbalances. However, in cases of severe bursitis a corticosteroid injection may be used directly into the bursa. This has great outcomes and will be used in a shoulder that has failed conservative management.
Surgical management may be used to create more space between the impingement sites. Rehabilitation following surgery includes ice and mobility exercises, followed by strengthening and return to sport training.
Wrist pain in tennis players is common due to the significant forces transmitted from the racket to the arm. Pathologies in the wrist may include the tendons due to overload or structural pathologies due to altered mechanics in the wrist or mobility issues. Among all tendon pathologies the most common are De Quervain’s pathology and Intersection syndrome. The latter involve the tendons along the forearm to the side of the thumb or along the middle of the forearm. Pain will be increased whilst training or may present after the game. The overloading of the tendons is due to increased force in wrist extension.
Examination will reveal pain and may have difficulty in positions of resisted wrist or thumb extension. There may be any underlying shoulder or elbow weakness leading to more overload of the wrist tendons. Functional daily tasks may become difficult because of the inability to use the wrist as previously. Specific assessment manoeuvres will help guide the clinical towards its diagnosis. Contributing factors to the overload may be shoulder or elbow lack of mobility and or muscle imbalances.
The early management of these pathologies includes rest, ice and pain medication with or without a wrist support. Following successful pain reduction, gradual loading of the tendons will create tissue tolerance and prevent recurrence. In addition, correcting issues in the elbow and wrist will also assist in preventing recurrence.
The use of a corticosteroid injection may be used in persistent cases or in cases of early return to sport. Following an injection a short complete rest period is advised and should be followed with rehabilitation to prevent recurrence. The outcomes after the injection are very good, however it should be noted that rehabilitation should still be used to address the latter.
Rib Stress fracture
Rib pain in Tennis can be present due to injury from repeated loading of muscles. The muscle attachment on the rib can lead to a gradual bone reaction that can gradually worsen and progress into a fracture.
Examination will reveal pain with palpation over the affected area. There may be any underlying shoulder weakness due to irritation of the tendons. Functional daily tasks may not be affected but activity will lead to increase of the symptoms. Assessment including palpation as well as other tests and breathing techniques will help guide the clinical towards its diagnosis. Confirmed pathology will be under specific radiology with MRI that will reveal inflammation over the affect rib.
The management of the rib stress fracture includes initial rest from sporting activities with gradual strengthening affected areas. Return to sport depends on the symptoms. In the interim, your physiotherapist would help correct muscular and structural issues that have potentially contributed to the pathology development.