Polo

Polo and the Elbow and Wrist

Participation in polo is increasing and the HPA estimates that approximately 3000 people play in the UK.  It is a physically demanding mounted contact sport.  As such, players of all levels are at risk of sustaining sports injuries, and these injuries may force players to moderate their play or abstain altogether.  Of course, collisions and falls can also cause acute trauma, such as fractures and dislocations.  While no player wishes to dwell on injuries, most will nevertheless be interested to know more about the common injuries and, how they might be avoided and, if you have an injury, how it might be treated.

There is scant data on sports injuries from polo in the published medical literature, so in 2016 Mr Granville-Chapman surveyed over 200 members of the Hurlingham Polo Association in order to gain a better understanding of the incidence and nature of both sports injuries and acute traumatic injuries from polo. This data forms one of the largest representative samples in polo. 

• 75% of players reported at least one sports injury from polo
• The upper limb dominated the breakdown of injuries:
  • Over a third reported a shoulder injury
  • Almost 40% suffered an elbow problem 
  • A third had a wrist injury
• 60% of players required physiotherapy or chiropractor input 
• 22% required referral to a sports physician or orthopaedic surgeon
• 30% of those injured could not play chukkas for more than two weeks
• 7% were impacted for the rest of the season

The commonest problems in the elbow were tennis elbow and golfer’s elbow. These were reported in 33% of players who reported a sports injury.  The elbow and wrist are prone to overload in polo: 

Gripping the mallet

• Although the polo mallet feels relatively light and easy to grip when balanced, the forces are hugely amplified through your wrist and elbow on their way to your trunk as the mallet is taken off vertical and passes through a swing or other manoeuvre
• Many amateur players have inefficient swings that require more grip to control the mallet and generate power
• While an off-side swing may be relatively easy, backhands, nearside shots and neck shots require stronger grip to control the mallet and often involve extremes of wrist rotation and flexion/extension, risking strain to your tendons

Hooking 

• A player may attempt to hook the mallet of an opposing player as they attempt to strike the ball.  This is often performed at full stretch with the and sometimes on the near side: the grip required to control the mallet during these actions is large and both elbow and wrist are therefore vulnerable to overload injury of tendons
  As with most sports, repeated technical imperfections can produce issues such as tendinopathies
• Most players reported undertaking between 4-8 hours of polo (including between 3 and 10 chukkas) per week in the season.  22% play for ten hours or more a week - this represents many repetitions of a high-load activity for the elbow and wrist
• 75% of players held handicaps of -2 or -1.  These relatively inexperienced players are likely to have more rudimentary and inefficient swings than the high goal players, so although they may play fewer hours of polo, they may well be exposing their arms to extra risk of injury
• 42% of players in the survey were aged between 35 and 55.  This age bracket is typical for the onset of most tendinopathies, so it is unsurprising that tennis elbow and De Quervain’s (wrist tendonitis) were commonly reported
• Sport-specific training is employed in many sports to reduce injury rates
  • Only 12% of polo players reported undertaking any polo-specific pre-season training
  • The majority reported generally keeping fit and conditioned, but almost 30% stated that they simply turned up to play with no preparation
  • A focussed polo-specific programme may reduce the incidence of polo sports injuries

What are tennis and golfer’s elbow?  

Please see the elbow conditions section for more information on these conditions.  In short tennis elbow is a common condition of painful abortive healing in the tendinous origin of a muscle that extends (bends up) your wrist. Pain is felt right on the outer knuckle of your elbow and made worse with gripping and forcefully bending back your wrist.  It normally recovers (80% of patients are better by one year) but some patients suffer ongoing problems.

Golfer’s elbow is less common, but essentially the same problem in a different tendon. Isn golfer’s elbow, it is the tendons that flex your wrist that are affected and these originate on the inner knuckle of your elbow.

What to do if you have tennis/golfer’s elbow from polo?

• Initially avoid or reduce quantity of polo for a few weeks
• Consider wearing a wrist brace or a tennis elbow forearm strap when playing
• Check your mallet to ensure you have the correct length, shaft flex, grip size
• Check your swing technique with your coach to optimize your biomechanics and reduce overload to your elbow
• Optimize your core stability and shoulder girdle control as weakness here places more demand on your elbow
• If it hasn’t settled after a few weeks, see your physiotherapist
  • They should teach you an eccentric strengthening and stretching programme for your extensor muscles
• If it still hasn’t settled after 8 weeks of diligent physio exercises, consider a referral to an Orthopaedic surgeon
• Your surgeon may recommend platelet-rich-plasma (PRP) injection
  • This has a success rate of approximately 70-80% and is done with you awake
  • If you still don’t recover then surgery (either open or keyhole) may be required
  • Avoid cortisone injections for tennis and golfer’s elbow – these have been shown to damaging to tendons and they prolong the problem compared to no treatment.  You are better off having physio and PRP

What is De Quervain’s / wrist tendinopathy

In polo the right wrist, as well as gripping the mallet, has to control the balance and rotation of the mallet’s face through impact.  Large forces are required to maintain correct wrist position as the mallet produces a very long lever arm.  

Alongside the forearm muscles that stabilize your wrist, two relatively small tendons pass through a narrow sheath on the thumb side (radial side) of your wrist.  These tendons control the position of your thumb (abductor pollicis longus and extensor pollicis brevis).  De Quervain’s is a condition where the tendons suffer degeneration and the inner lining of the tendon sheath gets inflamed.  Patients see swelling over the thumb side of their wrist and have pain in that region.  Tucking your thumb into a closed fist and stretching the tendons causes acute pain.

Not all pain and swelling around the wrist is De Quervain’s however. Ganglions (jelly-filled lumps), arthritis, nerve entrapment (carpal tunnel syndrome) and wrist ligament damage can all cause pain in the same area so it’s worth getting an opinion relatively early to avoid confusion.

What to do if you have De Quervain’s?

• Initially avoid or reduce your quantity of polo for a few weeks to rest it
• Consider wearing a wrist Futuro splint when playing if that allows you to grip the mallet
• As for tennis elbow above - check your mallet, swing technique and optimize your core and shoulder girdle control
• If it hasn’t settled after a few weeks, see your physiotherapist
  • A stretching programme may help 
• If it still doesn’t settle, consider a referral to an Orthopaedic surgeon 
  • First it is important to be clear on the diagnosis or your pain
  • If it is De Quervain’s, your surgeon may suggest an injection (in this case cortisone is an effective and low-risk procedure as the injection is not directly into the tendon). The injection often helps for some months and may cure the problem altogether
  • If this fails, or your symptoms recur, then you may require surgical release of the tendons, which can be done with you wide awake under local anaesthetic

Elbow and Forearm acute trauma in polo 

• The majority of these injuries will occur after a fall or a collision
• Landing on an outstretched arm, or directly onto the shoulder is common when falling in polo
• Over half of the players in the survey recorded at least one acute injury (fracture or dislocation) in the previous five years
• Again the upper limb dominated the injury breakdown:
  • 19% broke their arm or forearm
  • 14% sustained a break in the hand
• As you would expect, these injuries had a significant impact on work, driving, time off play and return to pre-injury level