Category Archives: Physio Perspective

>Gilles Simon hasn’t played many professional matches since Novemeber 2009. At the end of last season in Paris, Simon was basically playing on one leg. He was clearly in pain throughout all of his matches, struggling to get down low for balls, and unable to push off and generate power on his serve despite having his patella tendons heavily strapped. In January, in the lead up to the Australian Open, he lost to Bernard Tomic where it was obvious to all watching that something was still very wrong with Gilles’ knee. Months later he’s still struggling, most recently being knocked out of the first round of Dubai by Marco Baghdatis. Why?

The original injury occurred in his third round US Open match against Juan Carlos Ferrero in 2009 where he damaged the patella tendon (the tendon from the quadriceps that surrounds the knee cap and inserts onto the shin bone) in addition to some pre-exisiting tendinitis, otherwise known as ‘Jumpers Knee’.

Essentially in patella tendinitis the collagen fibers in the tendon, which are normally parallel, are disturbed and replaced by scar tissue, which frequently doesn’t line up with the parallel tendon fibres, creating an underlying weakness. This then progresses to a tendinitis (the presence of inflammatory changes in the tendon) because of the continual abuse that tennis players knees receive from the stop-start play style and the varying court surfaces, particularly unforgiving hard courts.

Treatments for tendinitis often includes cortisone injections or anti-inflammatory medications, but as Rafael Nadal found out at last years French Open, these methods may improve the pain symptoms but they do nothing for the underlying damage that’s in the tendon.

Under these stressed and weakened conditions micro-tears can form in the tendon further damaging the tendon and leading to increased scar tissue being laid down. This is a huge problem for tennis players because they use their legs to develop their power and drive for all shots and the quadriceps are a vital part of this.

What has happened to Gilles Simon is very similar to what has happened to Rafa Nadal. Both players, particularly Nadal, like to grind from the baseline in extended rallies which only further abuse their over-worked knees. As Rafa has discovered over the last 18 months, tendinitis is hard to shake off if the cause, his brutal, fight-to-the-death style play, is not removed. Without the cause being removed the tendon can not heal and the knee will always be vunerable.

How can they recover? It’s difficult and in the case of both Nadal and Simon its a chronic problem. Acute flare ups require rest to let the inflammation and any oedema (swelling) to settle. The tendon then needs to be retrained and strengthened under a load that doesn’t cause further damage, but includes eccentric strengthening of the tendon, which is essentially strengthening the tendon while it lengthens. They then need to strengthen all muscles that specifically support the knee joint so that they don’t continue to overload the knee joint, while also addressing any other strength deficits or biomechanical abnormalities with, for example, orthotics. Avoiding overload may also include some weight loss to reduce the stress on the knee.

In Simon’s case his inflammation has resolved but he has been left with weaker muscles, reduced physical fitness, reduced confidence and a weakened damaged tendon that will be prone to flare ups and inflammation. “It’s difficult because it’s the tendon. It’s not regenerating itself. It’s very hard. So I know I have to get used to it. I just work a lot to be stronger all the muscles around. I did what I had to do and from here on my leg I have no  inflammation anymore. So inflammation can come back any time, but at the moment, I have to play.”

In an ideal world our professional tennis players wouldn’t be asked to play 11 months a year in order to maintain a good ranking, but it doesn’t look like there will be any significant change to the schedule in the near future. For players such as Nadal, if they don’t take a stand and refuse to play some tournaments, and control the volume of work they do better, then it will certainly see them retiring before their time.

As Rafa’s personal doctor, Angel Ruiz-Cotorro, says the development of technology in tennis has meant “more speed, bigger problems.” He has also said when discussing Rafa specifically that “tendinitis is hard to treat. The first thing you have to do is decrease the inflammation and rest. But for an athlete like this, the word ‘rest’ does not exist.”