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Wear, Tear And Repair

Photo By Susan Mullane By Steve Flink

In many ways, tennis is comparable to a contact sport. By and large, the players are faster and fitter than ever before, yet their susceptibility to injuries is alarmingly high. They train hard, but push their bodies beyond reason in a game that is extraordinarily punishing and demanding.
The powers that be — from the ATP to the WTA Tour to the USTA to a wide range of other ITF nations — are striving earnestly to keep players healthy and injury free at a time when the game is being played at a furious pace with even the most able-bodied competitors breaking down under the extreme duress. In a recent New York Times story examining the rising rate of injuries suffered by young athletes, reporter Bill Pennington wrote, "One factor was repeatedly cited as the prime cause for the outbreak in overuse injuries among young athletes: specialization in one sport at an early age and the year-round, almost manic, training for it that often follows."

Although the article focused on baseball, soccer and swimming, tennis could easily have been included — and, perhaps, should have been — when you consider the cavalcade of stars who have succeeded at young ages over the decades. Springing to mind are Chris Evert, Tracy Austin, Jennifer Capriati, Michael Chang, Pete Sampras, Andre Agassi, Maria Sharapova and the latest teen prodigy, Donald Young. Some of these players have been more fortunate than others in avoiding serious injuries, but almost all have been acutely aware of the potential pitfalls confronting every young player.

Asked for his opinion of the Times quote regarding overuse injuries, Gil Reyes, the renowned trainer for Andre Agassi since 1990, does not hesitate before responding, "I agree with every syllable in that quote. Every vowel and consonant in that quote is absolutely true. You can take this problem and try to make some sense of it, but it is not going to change. This is my 16th year with Andre, and the term ‘overuse syndrome’ is something we have referred to forever. You can deny it, but you can’t ignore it. Quite simply, we are talking about wear and tear." With Reyes playing a pivotal role, Agassi has stayed clear of too many serious injuries, but has had to battle some overuse injuries through the years. At the end of 1993, he had surgery on his right wrist, and early in 2002, a recurrence of that problem forced him to miss the Australian Open. Kim Clijsters was out for most of 2004 because of an overuse left wrist tendonitis and bone injury that required surgery. Serena Williams needed knee surgery in August 2003 after winning five of the previous six major events. Guillermo Coria’s left adductor curtailed his play last autumn. The list goes on and on. Agassi, however, is celebrating his 20th year in professional tennis, thanks largely to the depth of his commitment to training wisely. As Reyes says, "Andre will be 35 at the end of April and is still going strong physically and is still a major force and factor in every single tournament on every surface. That is because we have been able to mitigate the wear and tear of professional tennis by going from training harder to training smarter."

Such a concept — training smarter vs. training harder — is the essence of Altheus, a "health and human performance" center headquartered in Rye, N.Y., and co-founded by former U.S. Olympic Committee director of coaching Dr. Tom Crawford. Last August, Altheus established a tennis division, of which Rick Ferman, former executive director of the USTA, is president. "The trick is to prevent those (overuse) injuries through what we call pre-hab work by building strength where there is no strength to withstand the forces that are at play," Ferman says. Overuse injuries result from the constant strain placed upon different parts of the body, often during excessively long practice sessions in which players work on their strokes for much longer than is productive. Repetition produces aches and pains, and larger problems come with that pain. As Ferman asserts, "Overuse is simple to define. It is repetitive use where the machine can’t withstand the force. That is it in a nutshell."

For tennis players, the trunk (abdomen, back and hips) and shoulder are prime areas for overuse injuries. Kathleen Stroia, a longtime Sony Ericsson WTA Tour athletic trainer and vice president of Sports Sciences and Medicine/Professional Development, says, "The trunk area and the muscles around your shoulder are the two targeted areas that are a player’s power sources in the sport of tennis. That is why we are providing (players) with programs to strengthen their core stability."

Paul Roetert, managing director of the USTA’s USA Tennis High Performance program, attributes many of the overuse problems to technical changes in the game. As he points out, "We are seeing lower back injuries because so many baseline players hit with open stances, not just off the forehand but the two-handed backhand as well. And with the two-hander, you see wrist injuries because a lot of players are not just swinging from the arm as they did with the old wood racquets, but they are flexing their wrist with the top hand and the wrist drops down toward the pinky side. So there is extra motion now with the lighter racquets on that shot; so you are creating strain on that wrist, which is a fairly small joint."

Both Agassi and Clijsters faced career-ending situations with their respective wrist injuries, but came out of serious surgeries playing better than ever. Be that as it may, men and women have struggled equally to contain the number of overuse injuries that often occur from overtraining or poorly structured training. The ferocity of the rallies in matches among the leading players, the sudden changes in direction during a point and the bruising essence of the confrontations make it a tall task for the athletic trainers on the circuit. Per Bastholt, head trainer and director of Medical Services for the ATP, says, "We are investing a lot in the preventative part so future players will have better knowledge of their injuries and what causes them and then be able to prevent them a little better than we are today. We are collaborating with the WTA in doing physicals for the players and identifying issues so they can go into their off season with more information on injuries. With the ITF, we are working on recording information about junior players so when they become professional we will have knowledge of their injury problems.

"What is hurting the medical image of the sport is the high profile athletes we have getting injured. The men’s game overall has been pretty stable over the last four years with injuries. We cannot expect to have a totally healthy group of athletes, but we are trying to address the overuse injuries in a better way than we have been."

That philosophy is also in place at tennis academies, such as Nick Bollettieri’s and the Evert Academy, both located in Florida. Bollettieri has a wing of his multi-sports facility called the International Performance Institute and a unit called Bollettieri sports medicine that work hand-in-hand. He says, "What we are doing in tennis is a lot more stretching and looking at the injuries before they become serious. We have a whole staff that does nothing else but work with these kids on preventing injuries and getting to the injury before it gets out of hand. And we now make certain to have what we call a demand day of rest, where the players take a day off and do absolutely nothing or else they stretch or do yoga."

Chris Evert’s immensely consistent career was boosted by her staying relatively injury free. She is dedicated to having the kids at her academy avoid injury, too. Evert recollects, "When I got my injuries, I would feel it in my wrist or get twinges in my shoulder from over serving. I would try to recognize the signs. At an academy, that can happen if the balls are too used and they need to be re-supplied with newer balls. But what I see with some kids in different academies — and I have seen a lot of them — and even with pro players, is that when they feel a twinge, they keep playing because they think it might sound wimpy to say that their wrist hurts. They feel they have to tough it out, and soon it gets to be a chronic injury, when they should take care of it right away." Her brother John Evert, director of Player Development at the Evert Academy, adds, "We are pretty disciplined about having the kids with aches and pains ice them right away and that helps them heal quicker. Also, we have put more emphasis on our conditioning program and on making the kids and their parents more aware of potential injuries. Then, if they do get hurt, we take them off the court."

Again, at Altheus, every effort is made to be proactive in preventing injuries, as opposed to being reactive and treating them, though invariably there is a bit of both. From the beginning, Ferman and company make certain to gather as much data as possible on all of their athletes as a central part of their injury prevention program. As Ferman says, "We believe in an integrated approach — the physical development, the sports psychology aspect, nutrition, a sports-specific skills assessment — all wrapped together to give us as much information about a particular athlete as we can get. Then we customize a program that perhaps reduces the sports-specific practice, but increases the conditioning and training of the athlete and specifically addresses areas that tend to break down." Adds Crawford, the company president and executive director of programs, "We do a range of motion and flexibility analysis from head to toe to joint, with an orthopedic screen built into it that allows us to identify imbalances and range of motion injuries, as well as predict if there are some [injuries] coming down the road."

Perhaps no player in the Open Era has played a singularly more significant role in the transformation of the modern game and its training techniques than Martina Navratilova. In her prime years during the 1980s, Navratilova was the first champion to fully comprehend the value of supplementing on-court drills and practice with serious dedication to off-court work in the gym and elsewhere. It is her strong contention that the young pro female players today are not balancing the scales of their professional routines the way they should. Navratilova says, "They just play tennis and don’t do enough other things. Even when they are doing other training in the gym or whatever, the ratio of tennis to training is probably four-to-one — or maybe more — whereas mine was probably half-and-half. The ratio now is too much tennis. And they are doing just training off the court in the gym, just doing the safe stuff without playing other sports because they are afraid of getting hurt. So they don’t play soccer or basketball or anything because they don’t want to get injured. That is not using your body the way it ought to be used."

Navratilova would like to see the WTA take better advantage of a strong training staff and put more funding into health care. She is very concerned about the past three years having been so disruptive for the women’s game, with so many leading players forced to endure long absences from the circuit due to prolonged injuries. "To me, the biggest problem in women’s tennis at the moment is we don’t have the top players playing at the same time," she says. "The health care people on the WTA Tour are addressing it, but we are not spending enough money on the whole on the players’ health care. That should be the No. 1 thing in our budget, but it is not. The people are there, but we are not paying for them as we should be. You get what you are paying for. We have very good people working for us, but you still need more experts, including a podiatrist, a chiropractor, an osteopath, an acupuncturist, people who can take care of chronic problems or even prevent them from happening in the first place."

Fortunately for most of the top men and women players, they can afford their own trainers. Doug Spreen, formerly an ATP athletic trainer, has been working exclusively with Andy Roddick since the start of 2004. Roddick did hurt his wrist and had to retire when down a set and 4-3 to Fernando Verdasco in the second round of the NASDAQ- 100 Open, but he was not expected to be out for long. For the most part, he has stood up ably to the rigors of the pro tour. "Andy’s big advantage and the reason he has not had a lot of injuries," says Spreen of the 22-year-old, "is that he is such a good physical specimen. He is way stronger than he was a year ago. There is so much stress on the body these days. If you look at the films of when John McEnroe was playing, these guys kind of glided across the court and only occasionally would they be on the dead run. If you go to a tennis match now, you see a physical pounding. They are going harder and farther; so they are jumping and lunging at balls and not hitting the ball biomechanically the way they would like all the time. The key thing for Andy and all young players is to look at the long term. You can’t be playing 30 events a year when you are 19. You have to give your body time to develop in the right way. I worry about a guy like [18-year-old] Gael Monfils and wonder if he is protecting himself. He is playing a lot already."

Another major problem is the tendency of some players to rush back too swiftly from injuries, before they have sufficiently recuperated. As ATP athletic trainer Bill Norris says, "The level of play steps up every year, and players aren’t giving themselves enough time between injuries to really heal properly. As much as you try to preach to these players to take a certain amount of time off or to train a little better or more completely, the problem persists. We just try to do our part as trainers with education."

Kathy Martin, manager of Professional Development for the WTA’s Sports Sciences and Medicine division, points to another challenge in making sure players avoid getting hurt. She believes — as do most authorities in the field — that coaches and parents need to be as informed as players about the dangers of bad training. The WTA hands out "education material" at the U.S. Open every year to give not only the players, but also the coaches and parents proper guidance. "I think that is helping," says Martin.

It also is helpful when trainers consult carefully with coaches to provide players with a training regimen that is efficient and productive. Pat Etcheberry has trained the likes of Jim Courier, Pete Sampras and Jennifer Capriati across the years. These days, he works with Justine Henin-Hardenne. Etcheberry firmly believes it is his duty to devise a program that is approved not only by Henin-Hardenne, but also by her coach, Carlos Rodriguez.

"We make sure we are always on the same page," says Etcheberry. "We look at the whole year and plan it out. Communication between the fitness coach and the tennis coach is critical. It was the same way in the past when I worked with Jim Courier and his coach Jose Higueras, and with Pete (Sampras) and Tim Gullikson and later Paul Annacone. If you don’t do this, you could end up overtraining the player, which would be a big mistake."

It bears mention that Henin-Hardenne played only nine events in 2004 because viruses made it impossible for her to compete on a regular basis. Then she stepped up her training with the hope of being ready for this year’s Australian Open, only to injure her knee and be forced out of action until the NASDAQ-100 Open in March. "When she was training for Australia," explains Etcheberry, "she felt something in her knee and the doctor told her to rest for a few days. We felt it was the best decision for Justine to back off. She had to look at the whole year and not rush back. It was the right thing to do."

The medical community is seeking always to make the right moves as well. There is a lot more knowledge out there about the nature of injuries than there was a decade or two ago. Consider the case of Tracy Austin, who left the game at 21. Repeated visits to alleged authorities in the field turned up conflicting judgments on what was wrong with her. As she recalls, "Mine was a sciatic nerve problem. My back was much stronger than my stomach and my right side was much stronger than my left as a tennis player. I wasn’t doing exercises to balance that out. I went to four different doctors around the country and they couldn’t figure out what I had. Now, of course, people know that if you have a pain in your rear end that goes down your leg that it is called a sciatic nerve problem. One doctor thought mine was a hamstring problem, and I got cortisone shot in my rear end from another. So sports medicine has come so far. And now if I was playing the game, I would have someone as a trainer like Maria Sharapova does to get her ready for a match and take care of her afterward. After Sharapova won the WTA Tour Championships in Los Angeles last year, you would think, like most people, she would go celebrate. But she went in with her trainer and stretched for 20 minutes. That is the kind of dedication you need in today’s game."

But even the most devoted performers in the professional game, even those who take every precaution against injuries and don’t overdo their training, are well aware that their careers could be curtailed in an instant by misfortune in the heat of competition. Bollettieri contends, "These injuries are not going to stop. They haven’t stopped in football or basketball. The only way you can have some way of preventing this is a shorter season. But we have to remember: This is a business. You can’t stop a multimillion-dollar business. I don’t care what anybody says; it ain’t gonna stop. Money is the root of evil, and this is the only way they can make a living. We will keep losing great players or potential great players to injury. But there will always be other great ones to replace them. Let’s be realistic."

Dr. Brian Hainline, chairman of the ITF Sports Science and Medicine Commission and the chief of medicine for the U.S. Open, sees similar warning signals for the sport. He does not see any of it playing out very well over the next five to 10 years. "This is societal," he says, "and I don’t see our society changing. I can’t see this really changing in the next five to 10 years. I see medicine trying to keep up with it, and maybe we will do a better job. Maybe we will get the message out that if you are going to compete globally you have to be in good health and train off the court properly, but I don’t know. This might be the pendulum swing of society, and sometimes there is nothing you can do about it.

"But I don’t feel pessimistic. From a medical care perspective, the WTA is phenomenal and the ATP has had a recent reorganization and they are catching up. Both have some very good people in that area. There is a willingness with the ITF, ATP, WTA and the national governing bodies to work together to promote a healthy sport. Long term, I am cautiously optimistic."

Tennis Week Senior correspondent Steve Flink has remained injury free throughout his career, although he did sustain a paper cut at the 1983 U.S. Open.

This story appears in the latest issue of Tennis Week Magazine. To subscribe with a special reduced web rate, please visit this Subscription link.

Plainclothes Division
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It's an interesting read, and there is much merit in what some of the experts are saying. The birth of sports science led to the development of sport-specific training programs. If you were playing sport X, you were told how to develop parts Y and Z.

Now, of course, they are realizing their mistakes. While this narrow focus has made athletes better at their spot at younger ages, it has also caused the imbalance refered to in the article. One sign of this is when your "throwing" arm is significantly bigger than the other. It's a sign of the body being out of balance.

The players need a more diverse training schedule. If, as Martina says, the players are reluctant to play other sports for fear of injury, then perhaps they should at least do some of the training exercises associated with those sports, to work other muscle groups which would support the ones they normally use.

This injury epidemic isn't just occuring in tennis. Most of the other sports leagues, at least in the U.S., have seen a lot of injuries in recent years. This, I would blame on this overtraining for one sport syndrome. (And not, as some old-time athletes derisively suggest, the "softness" or "wimpiness" of modern athletes.) In the "old days", there wasn't sport-specific training, at least not to the degree there is today. Athletes got more of a general workout. And in those days before the big $, many athletes had to work in the offseason, often at physically demanding jobs. This was a de facto form of cross-training.

As today's athletes are pushed to get bigger stronger faster better sooner, they are just plain wearing down sooner. A course correction in the science of sports training is long overdue.

It's funny how, with every new generation, some long-accepted notion of sports is turned on its head. I remember when I was young, we were told to do our situps with our knees straight, and not those "wimpy" bent-knee situps. It was later learned that keeping the knees straight damaged them. Yet that was the type of antiquated thinking that prevailed back then. (And you don't want to even know what the prevailing "wisdom" was on women athletes.) Here's hoping that the recent adjustments in sports science are able to help eliminate the injury problem. By putting more time, money, and effort into prevention, you can save even more T, M, & E later. (Something our health services would be wise to heed.)
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