Category Archives: Physio Perspective

Maria Sharapova Slides Into Second Round

Maria Sharapova opened the Australian Open on Rod Laver Arena with two double faults and had her serve easily broken by Tamarine Tanasugarn. The former champion responded by breaking back to love and holding he service game to love, sealing it with an ace. After being broken Sharapova ran away with six straight games to win the first set 6-1. Read more »

New Prince EXO3 Technology – Monfils, Zvonareva, Bartoli, Ferrer, Ferrero On Board

I received an interesting email about the ‘new and improved’ Prince now that Maria Sharapova has parted company with the firm. 2011 Starts with a huge marketing drive from Prince with their new EXO3 racquets. Read more »

Tommy Haas Continues PRP Treatment

As Tommy Haas and Sara Foster await the birth of their first child, Haas has updated fans via his website, saying he underwent the second of three PRP injections into his knee to treat chronic tendinitis on Thursday. Haas has been off the tour for some time after having hip surgery and has also been rehabilitating his knee injury at the same time. Haas hopes to return to training soon and his daughter is expected to make her arrival within the next two to three weeks. Read more »

More On Kinesio Tape

After people ask “What is that coloured tape?”, the next thing they want to know is how does it work and why is it different to other tapes. Read more »

>What Happened To Juan Monaco’s Wrist?

>Juan Monaco revealed in Madrid earlier this year that he was struggling with a wrist injury. Before long he was announcing he had decided to favour conservative management over surgery without anyone actually realizing how serious the injury was. He took a brief rest from competitive play but continued to practice and not surprisingly the injury didn’t improve. At the time his website revealed that he had “boney odemea” and “synovitis”. But what does this mean?

OMERACT defines boney oedema as  a “lesion within the trabecular bone, with ill-defined margins and signal characteristics consistent with increased water content.” Boney oedema is frequently seen in arthritic conditions. In Juan’s case it is most likely caused by low grade chronic wrist instability. The swelling and inflammatory infiltration into the bone affects tendon function which is vital in trying to control the instability.

While there are a few different types of synovitis, Juan not specifying if he had one of the more common types – tenosynovitis – it is generally a difficult injury to treat and is not uncommon in the presence of boney oedema secondary to chronic instability and overload.

The synovium, a fluid filled sheath (or a thin tissue layer that covers the tendon), becomes inflamed due to the repetitive stress a tennis player places on their wrist during play. If this remains untreated, or if players continue to play despite having pain, the synovium can become thickened and irritable making it difficult to settle. Surgery can be done to remove the inflamed synovium (synovectomy) or correct the underlying instability but is most frequently treated conservatively.

Both conditions will usually be treated with relative immobilization, Kinesio tape, rest, ice, anti-inflammatory medication, strength retraining, cortisone injections, and biomechanical assessment and correction.

What Treatment Has Nadal Had On His Knee?

The other day I mentioned that I suspected Rafa Nadal had undergone PRP treatment for chronic knee tendinitis. My reasons for being suspicious are that: Read more »

>Things Bleak For Blake

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Things aren’t looking too good for James Blake right now. Not only has he returned too soon after undergoing PRP therapy on knee tendinitis, berated Pam Shriver from commentating in the commentary box during his match but he’s now saying that he will be unable to beat most players in the top 100 when he’s at 100%. During his rehabilitation he has refused to take any anti-inflammatory medication – a huge issue when dealing with an injury characterized by chronic inflammation.
Blake was defeated 6-2, 6-4, 6-4 by Robin Haase.

During the match Blake complained that he could hear Pam Shriver’s commentary and then when she responded saying her must have “rabbit ears” to be able to hear her, he retaliated by saying it wasn’t his fault he could hear her (and a minor obscenity). Shriver later said she shouldn’t have contributed once she knew he could hear her. “I should never have said a word to him once I realized he could hear me. He was already down a set and a break and once I realized I could be heard, I’ve got to step back, talk quieter. That’s the only thing I regret. And I helped make what happened into an exchange. I shouldn’t have.”
Blake was not impressed with his performance. “You know, it’s almost embarrassing to go out and play a Grand Slam match like that. The knee is not great. I just took 10 weeks off. I thought that was going to do it and be the answer. The reason I wanted to take time off is I didn’t want to continue playing in pain.”
Worryingly, Blake doesn’t sound like he’s in a mental state that is likely to improve soon, if anything it sounds like he has started thinking about retirement. “I can’t beat these guys at 80%. I can’t beat a lot them at 100% on a given day. So to think that I’m gonna compete with the top level of the game at 80% is just silly” It’s a huge sentiment for a player who fought his way back after a fractured cervical spine (neck) and after the zoster virus left half of his face paralyzed. It’s a bleak time for Blake.
On PRP treatment, I have a patient with chronic tendinitis who underwent PRP on one side but not on the other and the non treated side is better, although both continue to progress slowly. Simply put, if you refuse to manage tendinitis properly right from the beginning then you will struggle to keep it at bay when you abuse your body the way tennis players do… James 10 weeks break is not enough.

>Juan Monaco To Miss Wimbledon

>I was a little confused a week or so ago when I saw new images of Juan Monaco practicing, despite just deciding not to have wrist surgery. Unsurprisingly it turns out his wrist still hurts and the practice hasn’t gone according to plan. The tennis star released a statement in Spanish on his website juanmonaco.com.

Given that it’s Friday and I’m about to go away for the weekend in about 5 minutes, I don’t have time to use my dodgy Spanish to translate it. Basically he says that its been a difficult decision to come to with his team, but the pain has been too intense to ignore and he has had to make the difficult decision to withdraw from Wimbledon. He says that he has boney oedema and synovitis (I will expand later) and that his wrist has been sore for the better part of 6 months. He then goes on to say his doctors have finally refused to allow him to continue, fearing further damage and that he will be completely immobilized in a splint (think JM del Potro) as of today for 12 days to then be followed by some kinesiology treatment before he resumes training for 3 weeks and returns at Montreal.

Given the long duration of his issues, the fact that he’s just made it worse by training when he should have been resting, and the fact that he requires immobilization, I think its fair to say his plan has him coming back to training, and to the professional circuit, too soon… but that’s just my opinion. Synovitis can take a long time to settle and is easily flared up.

>Safina Blogs About Spinal Fractures

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Dinara Safina has finally spoken about the back injury that has kept her off court since the Australian Open. It turns out Safina had stress fractures in her L5S1 (i.e. at the very base of her spine). In therapy terms these are often known as ‘Spondylolysis’ or a ‘Pars defect’ and they are common in fast bowlers in cricket who repetitively extend their spine to generate pace and power. It occurs in 3-6% of the population

“My injury from Australia was pretty bad and takes so long to heal. The problem is that I had it since Cincinnati last year, and since then had been playing all the time while on pain killers. My back was really bad there but I didn’t feel anything the rest of the season until my last match at the Australian Open. After that match, I had an MRI and I had two stress fractures on L5S1 and a rupture on the muscle. That was the worst news I could ever hear from a doctor, but now finally I’m recovering, though not as fast as I would prefer. My physio is really taking care of me and I’m slowly starting to practice.”

This type of injury occurs in the L5 area in 80% of cases and often occurs due to excessive loading in adolesence or the shape of your vertebrae. It is not known if Dinara has progressed to a Spondylolisthesis where the vertebrae slips forward (which is associated with significant back pain). Some spinal stress fractures can initially be symptom free, but usually have at least low grade discomfort associated with them, particularly with continued loading.

What does this mean for Dinara’s game?

It means she will have to slowly return to play because a stress fracture is caused by repeititve excessive strain on a joint. If she returns to quickly and plays too much, and continues to overload her spine, she will find herself back in rehab again recovering from the same type of injury.

As she returns to normal play and training you will likely see some slight alterations to her game. For example she will likely use a slice serve sparingly as it requires more lumbar spine extension, she may even have to change her entire service motion depending on how much extension she normally gets.

It usually takes at least 3 months for orthopaedic surgeons to be happy with the healing of the bone and for muscular rehabilitation to be sufficient for a safe return to sport.

>What Happened To Rafa Nadal & Gilles Simon’s Knees?

>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.”