BOTH Andy Murray and Novak Djokovic have been in the news of late with elbow injuries. While Novak is back competing, Andy is still on the sidelines with a suspected "tear" around the elbow (no further details have been mentioned). Both missed the Miami Open this year and while they'll likely be back in form soon, I thought it was a good time to discuss why elbow injuries happen and some ideas on what we can do about them.

The most damaging injury to an overhead athlete is a tear in the Ulna Collateral Ligament (UCL), which typically requires reconstructive surgery, often labelled “Tommy John” surgery after the baseball player who was the first person to have the procedure done. This procedure isn’t as common in tennis players and I believe the reason is also “cure” for what ails Murray & the Djoker, but I’ll return to this later.

A quick bit of background info

  1. I am by no means a tennis coach, but I understand biomechanics and by watching a tennis serve can see that at its simplest, the movement starts central and uses the whole body to generate rotational force that is ultimately applied to the ball.
     
  2. By adding segment to segment to segment you can create a large sum of velocity from small individual forces; this is why taller players typically have bigger serves than shorter players - the long levers added together create more velocity into the ball.

As with many sports movements, the problem is in many ways, also the solution:

Deceleration is the key to injury management and/or prevention

The ability to add all these segments together, creates larger forces and this puts more stress on tissues, leading to injury. Many young players come through the ranks being able to hit huge serves or forehands or whatever, but they cant stop them, and thus get injured and therefore don’t have success. More on the deceleration phase of the serve in this article (including ballistic exercises to add to you training program). 

If the player can’t ideally decelerate the forces generated during the serve in this example, the forces will leak through the weakest point in the chain and without knowing exactly what injury Murray & Djokovic have suffered, it is safe to assume that the problem can be outlined as follows.

  • The muscles around the scapula should provide most the deceleration forces.

  • Followed by the rotator cuff and labrum in the shoulder

  • Followed by the elbow joint structures including the ulna collateral ligament

  • Followed by the muscles of the forearm around the wrist

Reduced ability to decelerate due to pain, fatigue or structural damage at any of these stages will put increased force through the next stage, setting it up for injury.

So, my hypothesis regarding Djokovic and Murray would be that reduced strength in the muscles around their scapula is putting more stress through the shoulder and elbow. In this case, both of their shoulders have survived (as far as we know) but the elbows have not and therefore they have been unable to continue playing.

What do we do?

Well if we assume they have minor damage to the elbow ligaments that don’t require surgery, then the solution is to reverse the problem:

  • Increase strength in the muscles around the scapula such as upper & lower trapezius, rhomboids and lats. The scapula is key to upper limb health; using big muscles to decelerate big forces and spare the small structures down the chain.

The video below shows some basic examples, starting with being able to isolate the movement of the scapula and then adding the complete movement such as a row or a chin up.

 

Isolated and combined scapula movements in horizontal and vertical planes.

 

**Note this is just a start point and you must progress towards more sport specific forces. This means increasing speed and making things more ballistic. Have a read of some of Matt’s other posts for examples on how to do this for the overhead athlete, like this one**

  • The rotator cuff is important, but I don’t believe training it should be the main emphasis for an overhead athlete, looking at it physiologically it just doesn’t have the ability or anatomy to tolerate/generate the forces being asked of it. Have you ever seen someone doing shoulder external rotation with more than about 5Kg? I haven't. Because it’s very hard and not really functional-5Kg is still a long way off the forces in a tennis serve.

  • Where this gets more complicated is when you consider the strength & endurance demands of tennis:

  • Rest would likely decrease pain for both athletes, but we need them to be able to do the aggravating movement at maximum effort, potentially (as we’ve seen from these two) for up to 5 or 6 hours over 5 sets.
  • This is where the rehab provider and the S&C coach need to get together and decide, how many serves does the player need to hit? How much rest do they need between? And therefore, how long is it going to take to develop sufficient strength to return to serving in practice to build up the necessary volume? *Note, an interval serve program is an absolute necessity.*

  • Much more complicated than saying 3 sets of 10 seated rows, 2x per week.

Coming back to why don’t tennis players have as many “Tommy John” surgeries as baseballers?

This is something the baseball world is consistently trying to figure out. One hypothesis which makes sense to me is the racquet. Weighted ball training is en vogue at the moment in baseball; pitchers go through their motion with a heavier than normal ball, but don’t let go of it. The logic has come from tennis, where players generate huge overhead forces-just like baseball. But unlike baseball, they don’t let go of the racquet, suggesting that tennis players have to better decelerate the service force in order to stay in the rally (obviously if they lost the grip on their racquet, they wouldn’t be able to hit the return and would lose the point).

This makes sense to me, because as I said earlier deceleration is the key to sports injuries. The vast majority of injuries occur from not being able to stop the forces being generated. One of the most remarkable things about Federer, Djokovic & Murray is the huge amount of time they have spent on court. These three have rarely missed matches throughout their careers, meaning they can win more. Nadal on the other hand……And my personal opinion is that he doesn’t stop well and that’s why he’s had so many knee tendon issues, but that’s a discussion for another day.

An important side note:

  • Pain is irrelevant. Decreasing pain is easy; stop doing the thing that hurts, but it should not be the deciding factor on when these players return to play.

  • In non-contact injuries, pain is a result of the tissue not being able to cope with the demands of the sport. If you reduce the stress on the tissue by resting and then go back to competition PAIN WILL COME BACK! This is because the demands of the sport haven't changed, i.e. all you’ve done is reduce the need for the body to send pain signals to the brain, as soon as you add that stimulus back in, the body will start sending the same signals.

  • Rehab must be directed at ensuring the tissue can cope with the demands of the sport and to understand this, you must understand the following:

 

  1. Understand the movement to know how things should be done vs. how they are being done which may preclude injury. Working with the sport coach is very important here.
     
  2. In order to perform the movement properly, the athlete must have sufficient mobility to hold the ideal posture (the human body is designed to do things a certain way).
     
  3. Output is related to how much force the movement requires e.g. the radar gun says the serve is 200 Km/H, but what is the force that puts on the shoulder, elbow etc?
     
  4. Finally the capacity, as I eluded to earlier, how many times does the injured tissue have to withstand the force in question? If we go back to pain, “resting” from the painful stimulus and then being able to do it once, DOES NOT mean they are ready to return. In the current example, if I were rehabbing Murray or Djokovic I wouldn’t send them back unless they were capable of lasting the extreme-playing 5 sets every match to win a Grand Slam.
     
  5. Also, once pain is gone don’t stop doing the things you’ve been doing to get rid of pain; Don’t just train to enhance performance, train to prevent pain!

In summary

Sport at the elite level is a high force, high velocity environment - in order to be successful, you need to be able to generate elite forces. BUT, the blessing of ability, can also be a curse. “What goes up, must come down” so whatever you generate, you must be able to stop, otherwise something will break. If you understand how the athlete generates force, you can understand how they should stop it, and if they haven’t been able to, you can figure out how to rehab them, not to remove pain, but to ensure it doesn’t return.

If you enjoyed my thoughts, feel free to give me a follow or contact me with any questions:

Instagram & Twitter: @lukewilson21

Luke Wilson

BExSci. GDip Rehab, MPT, MS&C, MSPT.

Currently I am the rehabilitation physiotherapist for the New Zealand Warriors Rugby League Team, previously NRL Physio with the Canberra Raiders for 2014 & 2015 seasons. Before that I was practicing at Balmain Sports Medicine & Head of Performance at the Sydney Blue Sox Baseball Club in the Australian Baseball League. I gained my initial sporting experience at FITS Toronto where for 4 years I was involved in the treatment and training of athletes from the Canadian Beach Volleyball, Basketball, Wrestling & Alipine Ski Teams in the lead up to the London 2012 and Sochi 2014 Olympic Games.

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