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Will Knee Pain Cost Rafael Nadal $1 Million?

Posted Jun 13 2009 10:10pm

He failed to win the 2009 French Open, the first time in four years, because of knee pain and knee pain may keep him from defending his Wimbledon title later this month.

It could cost him $1,200,000.

Rafael Nadal is considered as one of the most athletic and fit tennis players in the world. Yet, he his doctors say he has tendonitis in both knees that has plagued him for many, many months.

How does such a fit person end up with tendonitis and why does he still have it?

I doubt Rafael has tendonitis (and that may not be what his doctors actually said but what the media chose to report). Tendonitis is an acute inflammation of the tendon. Considering that Rafael has had knee pain since at least the end of 2008, he more likely has tendonosis. Now, you may think I'm just being picky or hyper about word choice but the two conditions are treated very differently.

Tendonosis does not respond to the usual anti-inflammatory procedures used for tendonitis like ice, non-steroidal anti-inflammatory drugs or other modalities aimed at reducing inflammation. Tendonosis is a focal weakness in the tendon from very small tears that have not fully healed. Why you hurt is still not completely understood but some research suggests that the pain comes from the stress applied to this weakened area as well as certain chemicals that ooze out of the injured tendon into surrounding tissue activating pain receptors.

Tendonosis of the knee usually involves the patellar tendon. This tendon is exceptionally strong so to tear it, even at the microscopic level, you have to use a lot of force. How this happens is most often from a combination of biomechanical abnormalities and high force levels with a large volume of activity and inadequate rest.

Tennis, certainly played at Rafael's level, is a game that creates a lot of force on the knees from sliding, lunging, sprinting, stopping, turning for hours at a time. And Rafael has been very active over the past year. Consider what he has accomplished:

  • his fourth French Open title.
  • his first Wimbledon title in a match considered the greatest ever.
  • an Olympic gold medal.
  • a Davis Cup.
  • a first Australian Open title.
  • several Masters titles.
  • a 33-match unbeaten run on clay. 
  • became the number one player in the world.
  • played 14 matches in three weeks to win clay titles in Monte Carlo, Barcelona and Rome.

And, for at least some of this work, he was already injured. So, he has two ingredients for chronic tendonosis: high force levels with large volume of activity and inadequate rest (in fact, Rafael complained about the tournament calendar being too busy back in May 2009).

As for the other factor, biomechanical abnormlaties, only Rafael, his doctors, trainers, and therapists know anything about that. Typically, the biomechanical abnormalities are usually two things: weakness of the external rotators of the hip and a tendency for the arch of the foot to collapse to the floor. These two events lead to an increase in load on the patellar tendon from a twisting effect on the leg.

So, how does he heal his injured tendon? A treatment that shows a lot of promise for tendonosis is Platelet Rich Plasma injection (and in Austin, here ) or PRP. Your blood contains growth factors, chemical agents that encourage tissue to heal. PRP is a process that extracts these growth factors from your blood and then injects them back into the injured tissue at a super concentrated level. But, from the people I've spoken to who have had this procedure done, it's not exactly a smooth ride. It still takes several months for the tissue to heal and in that time, you often experience spikes in your symptoms. So, just about the time you think all is well, your symptoms return sometimes with a little more bite. The end result can be very good though when combined with the appropriate forms of exercise.

If Rafael has tendonosis and he's just now starting his rehab, I think his chances of being 100% at Wimbledon are slim (and he's said that if he's not 100%, he won't play). In his case, tendonosis may come at a very high price.


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