Nov 9, 2018
Net Impact
By Jodi Wotowey

At 6-feet tall, junior Idaho State University women’s tennis player Hristina Cvetkovic knows how to deliver a hard serve for an ace. But a recent shoulder injury — and the ensuing arduous recovery — almost jeopardized this skill, as well as her future in the sport.

Hristina Cvetkovic
Image by the 2017 Canada Summer Games.

Hristina’s freshman campaign went well. She finished .500 at the No. 1 singles position in conference play and 2-0 when playing at the No. 2 spot. The team made the Big Sky Conference Tournament for the first time since 2004.

However, things took a turn at the opening fall tournament of Hristina’s sophomore season. She began experiencing an aching in her shoulder. The symptoms quickly worsened and included pain, weakness, numbness, and tingling through the right shoulder, upper arm, forearm, and hand. When her fourth and fifth digits went cold and turned blue, then white, she was alarmed and came to see me.

[Hristina] told me the biggest aid that I provided during [her rehab] was a belief in her. I never thought she would be unable to return to play. Rather, I focused on ways to help her accept rest as a good thing.

My initial evaluation led to positive signs for Thoracic Outlet Syndrome (TOS), with what sounded like a secondary presentation of Raynaud’s phenomenon. TOS results from compression of the neural or vascular structures of the upper extremity at the thoracic outlet. Due to the multifaceted contribution of symptoms, Hristina was referred to an orthopedic physician who specialized in the hand.

He then sent her to a vascular clinic, where she underwent an angiogram to rule out vascular abnormality, including formation of a clot or other damage to her vessels. Thankfully, there was no clot, but Hristina did have some impaired vascularity of the common digital artery between the small and ring finger in the fourth web space. These findings brought about a new diagnosis of Hypothenar Hammer Syndrome (HHS).

HHS is a rare vascular overuse syndrome characterized by post-traumatic vascular insufficiency of the hand from repetitive compression over the hypothenar eminence. Patients who repetitively use the hypothenar eminence as a tool are at high risk for HHS — such as a tennis player who swings a racket over and over again.

With a diagnosis, our rehab plan was to pursue therapy for TOS. This included stopping all overhead activities and limiting Hristina’s bench press in the weightroom. She began occupational therapy several days per week. This was complemented on “off days” in the athletic training room, where we focused on reducing hypertonicity of the scalene and pectoralis minor muscles, as well as postural retraining to correct Hristina’s forward head, slightly kyphotic back, and shortened pectoralis major/minor.

To address the HHS, Hristina was told to stop playing tennis for two months and take an aspirin a day. She was devastated by the prospect of two months without tennis but knew failure to follow these recommendations could lead to a complete occlusion of her vessels and the loss of digits.

Hristina spent even more time in the athletic training room to hasten her recovery and received treatments of myofascial release. As her condition improved, we progressed with therapeutic exercises to address muscle balance and mobility, along with scapular control and dynamic stability.

The emotional strain of Hristina’s injury was just as bad — if not worse — than the physical toll. She told me the biggest aid that I provided during this time was a belief in her. I never thought she would be unable to return to play. Rather, I focused on ways to help her accept rest as a good thing, and I reserved Kinder chocolates for the really bad days.

Eventually, Hristina bounced back and could resume tennis. However, her racket grip had to be modified to prevent recurrence of symptoms. She adapted well to this and was able to start light hitting. By the start of the spring season, she was playing again.

During the season, I tried to coach her to play smart and within her range — to see the early season as a building block for the conference tournament. I reiterated how important it was for her to communicate as she got back in the swing of things. We kept her healthy in-season with continued therapeutic massage — especially myofascial release — therapeutic shoulder exercises, and kinesiotape.

Hristina ended up making a full comeback for the spring season. With some schedule and training modifications, she competed in nearly all of the team’s matches, as well as its return to the Big Sky Conference Championship.

Jodi Wotowey, MS, ATC/L, is Head Athletic Trainer at Idaho State University.

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