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Recovering From & Preventing Injury

Q. As we saw before Wimbledon with Rafael Nadal and many other players, a lot of pros are struggling with injuries and some even have to retire pretty young due to that. I also see here a lot of recreational players in the clubs struggle with ankle, wrist, back and elbow problems. Tennis is not a contact sport yet it seems to involve a lot of injury. Is this due to bad technique (which would not seem the case for pros) or does it come from the type of movements involved in this game? What can we do (besides a good warm-up) to prevent these injuries?

A. Injuries are attributable to multiple factors. Sometimes there is a trauma, like a sprained ankle. Other times it is based on over-use, and the repetitive action of a specific movement(s) can break your body down. Sometimes there is a weakness in one area of your body and it forces you to compromise your swing or movement ever so slightly and this causes a separate injury.

As you wrote, improper technique (even with the professional player) can be the root of an injury. In other words, there is no telling for sure.

Q. I have both Tennis and Golfer's elbow on my right arm and these injuries limit me to playing tennis once a week in order to make time for the healing process. At one time, I played tennis 3 days a week, and the following week I was in great pain and was not able to play at all. I'm under prescribed medication for muscle and joint inflammation and physical therapy as well. I want to play tennis as often as I can; do you have any tips on how I can play more? Whether it's equipment related or pre- and post-game exercises.

A. I have been afflicted with these injuries myself, and it is damn frustrating. As for equipment, you might demo the HEAD Protector model, which was made exclusively for players suffering from elbow troubles. You could also experiment with lower string tensions, “softer” strings, and a different handle size (to alter the “pressure points” slightly).

Be sure to warm-up slowly. A jarring hit (or mis-hit) can really hurt if you are not ready. When you are finished, ice the area where you feel (or felt) pain for fifteen minutes. Get into the gym for strength work so that other areas of your body can “absorb” some of the impact that hurts your elbow. Hang in there…

Q. I enjoy playing tennis 4-5 times a week, but I have recently developed tendonitis in my wrist. I'm unable to put the same amount of topspin on my forehand or serve with the same amount of speed. What would you recommend for me to remain competitive in my league?

A. First of all, see a Doctor. If it is “only” tendonitis (which can be painful) take extra precaution to warm up slowly. Make sure that you ice the wrist after you are done playing for fifteen minutes. If you have time, ice for another fifteen minutes that night. Experiment with a “softer” string (ask an expert in your local Pro Shop about this) and reduce the tension by a few pounds.

You might also book a lesson with a local teaching professional and ask him/her if you are doing anything, in terms of your stroking technique, that is aggravating your wrist. As tennis players, we all go through these little ailments. Hang in there and go to extra lengths to assure that it does not become chronic.

Q. I have been playing tennis all winter and had no injuries now when I went outside to play I feel pain in my forearm, shoulders and my back, I would like to know what could have caused it and how to recover from it?

A. The transition to outdoor tennis, for those accustomed to playing on indoor courts during the winter months, is not easy. Players must contend with the wind, temperature extremes, low sun angles (and the glare), and the background is not always as ideal as on an indoor court. Injuries can occur because you have to work a little harder to hit with the same pace (especially against the wind), and you need to move your feet more because the path of the ball is affected by wind (even a small breeze).

Make sure that you warm up properly and dress in layers. When you are finished playing, do some static stretching and change into dry clothes immediately. Ice any tender areas of your body for fifteen minutes to reduce swelling or inflammation. Over time, the discomforts you feel will dissipate. And… summer will arrive before you know it.

Q. I was just wondering do you think dynamic stretching is a large part in not getting injuries, and in the long run helping your tennis.

A. I am not sure. I know that the experts say that this is the case and I know that it has helped me considerably. Every player, everyone’s body, is different though. I know that Andre Agassi basically never stretches, but he is unique. Most every top player that I have observed goes through a full range of dynamic stretches before they begin a practice session or match play.

Q. What can one do to prevent getting a sore elbow from playing tennis?

A. I wish I knew… I had a chronically injured elbow for about two years, and it was a frustrating experience. A few things that I learned through trial and error are as follows:

1. Warm up slowly.

2. Commit to some resistance training to assure that your body (including your legs, core muscles, and shoulder region) is strong enough to absorb the impact of hitting hundreds of tennis balls.

3. Dynamic stretching before you begin and static stretching after you have finished.

4. Ice after you finish playing.

5. Use a heavier racquet to absorb more of the ball’s impact and experiment with looser string tensions.

Q. I have been playing tennis for a couple years now but recently I have been getting blisters (5 to be exact) and always in the exact same spots. Is there a way I can still play but not get these blisters?

A. Some players are more prone to blister problems than others. Marat Safin, for one, has had some real problems with getting severe blisters at inopportune times. Generally, if you play frequently, calluses will form in the areas where your hand touches the grip.

When players attend our Weekend Adult Tennis Camps at the USTA NTC, I advise them to put a fresh over-grip on their racquet(s) to, hopefully, avoid blisters on their hands. Camp attendees might play once or twice a week, but when they get on the court for twelve hours over the course of a weekend camp, they are more susceptible to getting blisters. Having a soft, dry over-grip tends to mitigate the possibility of these dreaded blisters.

Q. Recently I pulled something playing tennis. I think I now have a rotator cuff injury. Do you have any recommendations regarding how to heal quickly from this type of injury? Also, besides a lot of dynamic stretching, do you have any recommendations regarding how to avoid this type of injury in the future?

A. First of all, if you believe that you have suffered an injury to your rotator cuff, please see a specialist. Immediately.

To avoid future problems with your shoulder, and specifically the rotator cuff, you should begin doing some strengthening exercises. Try to work on making all of your surrounding muscle groups, especially your core area, stronger so that less stress is put on your shoulder. As for shoulder exercises, you can do some general military presses, some frontal raises, lateral raises and reverse butterflys- all with dumbbells and at a weight that you can manage for at least eight repetitions per set. For more specific rotator cuff “pre-hab” exercises, please visit our High Performance website.

Q. I am about to return from rotator cuff surgery, which must rank high on the list of tennis injury comeback problems. Do you have any specific thoughts on rehab on the court for my shoulder?

A. I would strongly urge you to use caution as you come back. Make sure that you have stretched properly before you begin (see the first Q & A from this week), warm up slowly (beginning with some short-court shots to avoid any jarring hits early in the sessions), and be sure to care for this sensitive area after you are done (perhaps with ice).

Avoid the temptation of trying too much too soon. The idea is to get back to full strength eventually… not immediately.

Q. Pro players suffer from many injuries, but I never heard of pros suffering from tennis elbow. Why is that? What is it they do, or don't do, that keeps these athletes from getting tennis elbow? Any suggestions on how to prevent this type of injury? I appreciate your help.

A. First of all, I have heard of professional players who have gotten tennis elbow although, as you pointed out, this is rare. It seems that tennis elbow afflicts those who have faulty technique, lack balanced strength, or are using the wrong equipment. Naturally none of that would apply to professional players. It also can be a chronic over-use injury, and this would affect professional players. Bear in mind that when a professional athlete feels any twinge or discomfort, he/she immediately gets treatment from a trainer than plenty of expert medical guidance.

Q. My daughter broke her foot and is in a walking cast. What can she do with 'one foot' to keep her tennis up... drills, etc.? She is in the cast for 6 weeks.

A. Thomas Muster, the Austrian who reached #1 in the world, had a terrible knee injury early in his career. He famously constructed a bench where he could hit tennis balls throughout his recovery without moving or placing stress on the knee. I am not sure that this helped his strokes too much but it might have fueled his desire.

Taking a few weeks off and getting proper rest makes the most sense. This time will allow your daughter’s entire body to heal properly. Be careful about rushing back too soon. That is where and when injuries to other areas of the body begin to occur.

Q. I have a serious question. One month ago I hurt my knee because, when serving, I hit my knee with my racquet several times. My question is what can I do to let my knee feel better?

A. Ahhh, Daniel… my best advice would be to adjust the follow through on your serve so that you do not keep hitting yourself. I have seen this happen before, so take heart in realizing that this uncommon injury HAS occurred with others.

A good way to assure that you do not keep doing this is to turn, or rotate, your hips. If you are facing the net when you finish hitting the serve, there is a greater chance of hitting your opposite knee on the follow through. Instead, try to really rotate through your finish.

Q. I got tennis elbow a year ago. Stopped playing. I have seen different doctors, specialist etc. But, the pain just doesn’t go away. What do I do?

A. I can relate to your troubles. I’ve played a lot of tennis through the years and had never had elbow pain. Two summers ago, I developed acute pain in my elbow (on the inside, so it hurt on forehands and serves). It took about eighteen months for this pain to go away entirely.

I would suggest that you be diligent about a few things.

1. Warm up slowly. A jarring hit early in a playing session can make the pain miserable.

2. Ice the area when you are done playing. Admittedly, this is a hassle but it will help to keep the inflammation down.

3. Get in the gym and do some strength training. As you strengthen other areas of your body (shoulders, back, legs, etc.), then your elbow will be less vulnerable because these stronger muscles will absorb more of the impact.

By the way, there is a new product that might appeal to you. HEAD Racquet Sports has just released a new racquet called the “Protector.” This racquet was designed specifically for players suffering from tennis elbow, which unfortunately includes up to 60% of the playing population. The racquet has an electronic dampening system and independent test studies showed that 91% of acute sufferers reported significant or full recovery from pain when they used this racquet. I only wish that they had this racquet ready for mass production two years ago.

Good luck getting over this ailment so that you can get back to playing pain-free tennis.

Q. I’m 12 and have not been able to play tennis for the past 7 months due to knee problems. I just had surgery to correct the problem in April. Physical Therapy has helped my knee get back in shape.

Now that I’ve been cleared to play tennis again, where do I start? Why am I so frustrated that I cannot play like I used to play? (I was a nationally ranked junior and top 20 in the MWTA). Half of me still loves tennis, but the other half of me wants to quit. My mom told me this was normal psychologically, but I’m confused why I wanted to play so badly when I couldn’t, but now I’m unsure.

A. Hang in there! Recovering from a serious injury is usually a long, difficult process. It is frustrating when you struggle with inevitable setbacks. You need to demonstrate patience and have faith that eventually your physical ability will return in full.

I can imagine that it would drive you crazy to lose to some players who you were beating before the injury occurred. Avoid being comparative in these cases and instead focus on the specific areas that you need to improve. As you are able to play “pain free” tennis, your game will come back- and even get better.

Q. Right now, i am making a comeback from a broken finger. I had two surgeries on it, and twelve weeks worth of physical therapy. It has healed well, and it works great. All of my shots are progressing great, except for my forehand. I seem always have difficulty with it now, more than ever. I feel like from practice match to practice match, something with it changes, such as my grip, follow through, where or how i hit the ball, etc. What are some basic forehand tips that could keep my forehand in a natural rythem, and an effective shot.

A. This is a tricky question due to the medical aspects. There may have been some neurological damage that is challenging your proprioceptive abilities (sense of feel). I would suggest asking your physician about this, and taking it from there.

There is an inexpensive teaching aid called "Perfekgrip" that you can put on your racquet to help maintain correct grip formatting while practicing forehands. www.perfekgrip.com

Q. I have played recreational tennis for many years (about 30) starting way back when in Queens, NY, against a handball wall! I took to the game and as an adult have played at my local tennis club as well as USTA leagues. A few years ago- I was playing at a club in a USTA League, I had what was my first back incident/injury. I bent over to make my bed one morning and could not get up...I thought it was a fluke.

My tests showed 2 herniated disks. I have gone to physical therapy, acupuncture, medical doctors and although I am not in pain on a day to day basis, whenever I try to start playing tennis again (even hitting casually with my 14 year old son) my back starts to hurt.

My doctor thinks I should consider another sport...I DO NOT want to do that, I love tennis.

Can you suggest any exercises/drills or methods that I may try to improve the possibility to play again? I am now 48 years old but otherwise thin, healthy and in good shape. He thinks it is the torqueing motion which is causing my discomfort. Any suggestions would be welcome and I of course understand that you are not a doctor and would run any advice by mine first.

A. Sorry to be slow getting back to you but I reached out to some friends for help in answering your question.

Lumbar injuries in pro tennis are very common due to impact loading, and also common regardless of tennis play. 80% of general populations suffer back problems at one time or another and this is an enormous medical and job absentee issue. As you have already discovered treatments and outcomes have very mixed and often confusing results. Finding a physiotherapist that understands the biomechanics of tennis is a good resource.

Recommended reading:

Back Pain Understood: A Cutting-Edge Approach to Healing Your Back by Dr. Brian Hainline.

Dr. Hainline has served as Chief Medical Officer for the US Open since 1992. He has given lectures around the world on tennis and spine injuries, and is probably the foremost authority on back injuries in tennis. He is currently Chief of Neurology and Integrative Pain Medicine at ProHEALTH Care Associates in Lake Success, New York, and is Clinical Associate Professor of Neurology at New York University Scholl of Medicine.

One aspect that is notoriously stressful to the lumbar spine is the combination of lumbar flexion (bending at waist) and axial rotation (twisting of spine) particularly while under load (hitting/running/lifting). You need to be very careful, even when you are pain free.

Disk pathologies are a completely different beast than other common tennis injuries. The pain-free condition might only indicate the disk protrusion is simply not impinging the descending nerve, but is close and one wrong move (as you discovered making your bed) could increase the protrusion, significantly exacerbating the symptoms and possibly put you in need of surgical intervention.

Making the bed did not cause the herniation; it was only the proverbial “straw that broke the camel’s back”. If you are able to keep tennis in your life, you may need a long rehab period before carefully and gradually returning to play. As I mentioned above, this is a different breed of injury beast. It takes 6-24 months for the basic healing process to occur, where the disk protrusion resorbs and scars over. Furthermore, the disk will never (naturally) regain its shock absorbing properties since the nucleolus pulpous (fluid inside of disk) is gone (desiccated), and the facet space (distance between vertebrae) is narrowed. This condition can induce level degeneration (likely cause of second herniation) in compensation for dysfunction.

I know this sounds bleak so far, but many players have recovered and continued to play, perhaps at diminished levels. Also, medicine continues to advance and disk prostheses are making headway.

After checking and getting clearance from BOTH your physician and physiotherapist, I would generalize your plan into five segments:

1. Lumbar stabilization exercises – ability to functionally maintain a neutral pelvis. You have been doing these, but you must fully comply and progress with the exercise prescriptions. Poor compliance is one of the most well known problems relative to quality of outcome in all rehab programs.

2. Symmetrical strength and flexibility throughout the trunk/legs – ability to get down to balls with less spinal flexion (less challenge to maintain neutral pelvis). Again, your exercise prescription, with care to not aggravate.

3. Biomechanics – altering and adapting techniques. Tennis and “modern” techniques have increased torque from angular momentum (rotational power). Flexing the hip and knees to push-off the ground will reduce stress-binding friction between your shoes and court surface. The toss on your serve is another area to look at, as poor/erratic placements can exacerbate stress, as well as other serving biomechanics. Can you identify which strokes or situations seem to irritate your back the most? (Don’t take any risks experimenting to find out!)

4. Do you have access to clay courts? If not, try looking for shoes with less traction (court bite). If you stand still on a clay court; you can swivel your feet over the surface…now try that on a hard court and you will see and feel the difference. Now flex the hips/knees and push-off the court to rotate and you understand how this reduces friction-binding stress.

5. Prehab arm exercises: you will naturally compensate for your diminished lumbar function by using more “arm”; so it is prudent to try to prevent these compensatory stresses from adding tennis elbow or a rotator cuff injury to your list of impairments.

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