Avoiding Backhand Wrist in Junior Players

Summary

Kayla Fujimoto Epperson, a doctor of physical therapy and former collegiate tennis player at Illinois, discusses the newly named clinical diagnosis of “backhand wrist” — ulnar-sided wrist pain on the non-dominant hand caused by the biomechanics of a two-handed backhand. Epperson co-authored a clinical commentary on the diagnosis, published in the Journal of Tennis Medicine and Science in July 2020, alongside Dr. Manu Janthi (Emory University), Dr. Michael Goshak (Emory), and Dr. Gary Lorry (Atlanta Braves). Her personal story drives the episode: she suffered this injury in college, underwent unnecessary surgery (and then hardware removal years later), and became a physical therapist partly motivated to prevent other players from the same ordeal. The episode covers symptom identification, three key injury risk patterns (excessive ulnar deviation, low contact zone, extreme Western grip), conservative management steps, surgical thresholds based on ulnar variance, and both prehabilitation and recovery exercises.

Guest Background

Kayla Fujimoto Epperson holds a Doctor of Physical Therapy (DPT) and runs The Athlete Connection PT practice in Illinois. She was a collegiate tennis player who developed backhand wrist injury during her sophomore year, underwent surgery during her junior year, and subsequently had the hardware removed years later due to ongoing complications. Her co-author, Dr. Manu Janthi, leads the Emory Tennis Medicine Program in Atlanta — one of the few dedicated tennis medicine clinics in the country — and was seeing increasing numbers of junior players presenting with similar ulnar wrist complaints, which catalyzed the clinical commentary. CeCe Bellis is cited by name as a public example of a player who disclosed having this injury and surgery.

Key Findings

1. Backhand Wrist: A Newly Named Tennis-Specific Diagnosis

Prior to this paper, ulnar-sided wrist pain in tennis players had no tennis-specific diagnostic label. The authors named it “backhand wrist” to parallel “tennis elbow” — giving coaches, parents, players, and non-tennis-specialist clinicians a shared vocabulary to recognize and address it. The anatomy involves three structures: the ECU (extensor carpi ulnaris) tendon, which stabilizes the wrist during topspin rotation and can develop tendinitis or subluxation; the TFCC (triangular fibrocartilage complex), the primary shock absorber and stabilizer at ball impact; and the ulnar-carpal space, which varies by anatomy and can be congenitally narrow.

2. Three High-Risk Stroke Mechanics

Emory’s Dr. Janthi identified three injury risk patterns from video stroke analysis: (1) excessive ulnar deviation — dropping the non-dominant wrist more than 30 degrees toward the pinky side during backswing or contact; (2) contact below waist height — forcing the wrist into a compromised position to generate topspin; (3) extreme Western or semi-Western grip on the non-dominant hand — supinating excessively under the racket, increasing stress on the ECU and compressing the ulnar-carpal space. Players with all three risk factors and a Western grip are at high cumulative risk.

3. Conservative Management Is the Correct First-Line Approach

Epperson’s treatment hierarchy begins with stroke modification (grip change, adjusted contact zone, revised take-back mechanics), progresses to bracing/taping (she used a Tiger Paw gymnastics brace throughout her sophomore season), and adds forearm/rotator cuff/scapular strengthening to improve stability up the kinetic chain. She is explicitly conservative about pain medications and cortisone injections, noting she received a cortisone injection in college to mask symptoms, which she would not now recommend as a first-line approach. Ice/heat can manage symptoms post-activity but do not address root causes.

4. Surgical Thresholds Based on Ulnar Variance

The TFCC has poor blood supply and does not heal independently — continued play without addressing mechanics can create permanent degenerative damage. Surgical guidance from Dr. Gary Lorry (Atlanta Braves hand surgeon): ulnar variance under 2mm = conservative management only; 2-4mm = minimally invasive ulnar shortening (arthroscopic shaving); over 4mm = ulnar shortening osteotomy (cutting the bone, inserting a plate and screws). Epperson’s own variance was just 1mm — meaning her surgery was likely unnecessary. CeCe Bellis reportedly had variance of 4mm or more.

5. Junior Players Should Not Play Through Pain

Epperson is more conservative about youth athletes than college athletes. Pre-pubescent and early adolescent players have open growth plates, less muscular maturity, and less biomechanical resilience. Her recommendation for under-16 players: shut down, address stroke mechanics, and make changes now before the injury becomes entrenched. In a college athlete mid-season the calculus is different — but even there, she would not recommend pushing through significant pain without a clear understanding of whether tissue is being permanently damaged.

6. Grip Type Is the Most Modifiable Risk Factor

An extreme Western or semi-Western grip on the non-dominant hand — the grip most associated with heavy topspin production — is the primary mechanical driver of backhand wrist. The fix: move toward an Eastern forehand grip on the non-dominant wrist. This changes the wrist position at contact, reduces ulnar deviation stress, and decreases compression in the ulnar-carpal space. Grip changes take 2-4 weeks to groove and should be initiated by coaches early in a player’s development, before the pattern is deeply ingrained.

7. The Medical System Often Misses Tennis-Specific Diagnosis

A recurring theme: physical therapists and physicians who don’t know tennis struggle to connect wrist pain to stroke mechanics. A clinician might successfully rehabilitate the structural symptoms while the player returns to court doing the exact same mechanics that caused the injury. Epperson’s recommendation for parents: bring the racket to PT appointments, demonstrate the stroke, and explicitly discuss grip type and contact zone. The coach-PT communication loop is often missing but essential.

Actionable Advice for Families

• If your child develops pain on the pinky side of the non-dominant wrist, especially at ball impact on the backhand, seek evaluation from a sports medicine professional or physical therapist before it becomes a chronic issue — do not simply play through it
• Ask your child’s coach to evaluate their non-dominant wrist grip type during the two-handed backhand — extreme Western grips on the non-dominant side are the most modifiable risk factor for backhand wrist
• If your child needs physical therapy, bring their racket and ask the therapist to observe the actual stroke mechanics, not just the isolated wrist anatomy — treatment divorced from on-court mechanics is frequently insufficient

INTENNSE Relevance

• Player health and longevity: INTENNSE’s format (rally scoring, unlimited substitutions) requires consistent high-volume stroke production — backhand wrist is a direct risk for professional players in this format, making this research relevant for INTENNSE’s sports medicine protocols and player health infrastructure
• Coach education: Mic’d coaches in INTENNSE broadcasts can communicate with players about real-time stroke mechanics adjustments — a coaching awareness of injury risk patterns like those Epperson identifies should be part of coach education at the INTENNSE level
• Player development pipeline: Junior players who suffer backhand wrist without proper diagnosis and treatment may drop out of the sport before reaching college or professional levels — addressing this gap is part of building a viable player pipeline for INTENNSE
• Medical partnerships: INTENNSE is Atlanta-based; Dr. Manu Janthi’s Emory Tennis Medicine Program is also in Atlanta — a natural institutional partnership for player health, research collaboration, and broadcast content around sports medicine
• College-to-pro bridge: College players (like Epperson herself) are especially vulnerable to this injury due to the high match volume of collegiate seasons — INTENNSE players transitioning from college need proper evaluation and mechanical assessment before their professional careers begin
• Broadcast content: The science and visibility of player injuries — handled sensitively — is compelling broadcast content; INTENNSE could partner with sports medicine experts to provide in-broadcast insights into player health, physical demands, and recovery

Notable Quotes

“I really wish I might have spent more time on the conservative management or just trying to understand this injury a little bit more.”

“In our youth athletes or more of our junior tennis players, if they can choose to make that decision at that time, in the developing players definitely be a stronger consideration.”

“I think a player can come in with wrist pain on their pinky side of the wrist and we could rehab it all day and do strength training, but then if they’re going back on the court and maybe using some of the stroke mechanics that are putting more stress on the wrist then you know the injury may or may not change from that point going forward.”

“For backhand wrist, it’s ulnar wrist pain… tennis players will complain of pain right where the end of that long bone in the forearm, but just before the hand area.”

“The more we can start using this diagnosis the more coaches can recognize it, players can start to recognize it and then hopefully health care professionals can start to recognize it.”