With Nick Kyrgios sensationally pulling out of the Australian Open, the Aussie joins a raft of tennis stars who will be absent from centre court this year. Kyrgios cited a knee injury – a paramensical cyst in his left meniscus – the 27 year old hopes to be back on court in time to play the Indian Wells tournament in California in March.
CSSM Physio Peter Stath explains this common injury as well as some other common tennis injuries that even the top athletes cannot avoid.
The meniscus is a piece of tissue that sits within the knee joint. There are 2 menisci in the knee, one circular shaped lateral (outer) meniscus and a crescent shaped medial (inner) meniscus. When healthy, the meniscus has functions of lubrication, joint nutrition & stability, shock absorption and force distribution during movement.
Injury to the meniscus is extremely common in all sports, especially those that involve rapid change of direction, twisting and/or lateral movements. In tennis, these are all very important movements to cover the court throughout a match. An acute meniscal tear can occur when the fibrocartilage structure of the meniscus gets caught/wedged between the two contact points of the bone through movement.
Meniscus tears can become a challenging injury due to their unique blood supply and limited ability to heal naturally. While the symptoms will settle over time, the nature of the tear does not always heal depending on the zone within the meniscus that it occurs. The blood supply to the meniscus occurs in zones. With only the outer 1/3 of the tissue receiving an adequate blood supply, while the inner 2/3 does not. Therefore, meniscal tears in the inner 2/3 have a reduced capacity for natural healing.
Making headlines in the first week of the Australian Open, is the news of both Alja Tomljanovic & Nick Kyrgios’ withdrawal from the tournament. While not much has been publicised about Alja’s ongoing and persistent knee pain, Nick Kyrgios’ and his physiotherapist have come out and confirmed the presence of a meniscal tear and a parameniscal cyst.
Within all our major moveable joints we have synovial fluid that acts to assist in the lubrication of our joints and facilitates the smooth gliding movements and assists in absorbing forces. The most accepted pathogenesis of a parameniscal cyst is related to our body’s synovial fluid passing through the region of a meniscal tear which can then accumulate within the joint space along the periphery of the meniscus. While meniscal tears are not always painful (due to the lack of nerve supply to the tissues) when a relatively small cyst (<2cm) begins to grow it can begin to impede function and contribute to more significant pain symptoms.
Meniscal tears have different methods of treatment depending on their type, location, and any presence of concomitant pathologies such as a cyst. As physiotherapists, if clinically appropriate, we will always opt for a more conservative option that focuses on a comprehensive rehabilitation program to develop and build strength, endurance and overall knee control and stability. However, these treatment methods do not always resolve the issue, or the type of meniscal tear indicates that a surgical pathway is more appropriate.
Meniscal repair is achieved by knee arthroscopy (keyhole) surgery. The aim of surgery is to preserve as much of the meniscal tissue as possible. If a parameniscal cyst is also present, this is generally excised with excess fluid normally drained.
Despite the treatment pathway, a key aspect of successful meniscal tear management is the rehabilitation program that occurs pre, post or instead of surgery. Important goals for conservative management include:
Meniscus rehabilitation at CSSM will commence with one of our physiotherapists, where an accurate diagnosis and management plan will be developed in alignment with your goals. From there, your rehabilitation program will be facilitated by one of our PIER programs in either Reformer or Gym, whichever best suits your goals and individual case.
Other common tennis injuries that can and frequently occur are:
A common type of shoulder injury seen in tennis athletes is a rotator cuff tendinopathy. Clinically this injury is also coined as an ‘impingement’ syndrome and reverse to the tendon of the rotator cuff (supraspinatus, infraspinatus, teres minor & subscapularis) becoming symptomatic and causing pain.
Given the extreme ranges of motion the shoulder moves through especially during an overhead smash and/or tennis serve, having a strong rotator cuff in extreme ranges of motion is a key way to minimise the risk of this injury developing.
More information on this type of injury can be found in another #teamCSSM blog.
As we have already seen so far in the first round of the Australian Open, some tennis matches can last for hours. The constant demand on the forearm musculature can cause some pain at their insertion point at the elbow. Tennis elbow, is the lay-term for the more complex lateral elbow tendinopathy, lateral epincondylitis, lateral epincondalgia.
Similarly to the rotator cuff tendinopathy of the shoulder, physiotherapy treatment and exercise rehabilitation is an effective strategy to help settle this painful condition that typically impacts your ability to grip, rotate your wrist and hold items with weight in your hands – all important facets of effective tennis skill and general activities of daily life.
An abdominal strain refers to the muscle group of our trunk. This particularly painful and rare injury is often seen in sports where over extension of the trunk is necessary for force production, typically seen in the unique action of a tennis serve/overhead smash. Frequent and repetitive high speed rotational and twisting movements can also leave these muscles at risk of injury, especially as fatigue increases in the latter stages of tournaments and in matches of a longer duration.
Just like any other muscle strain, this occurs when force output/generation exceeds muscular capacity for the given task. While there are many other factors that contribute to muscle strains, they can be incredibly painful and debilitating while they recover.
The more recent and notable abdominal strain can be dated back to last year’s Wimbledon and US Open competitions, where Rafael Nadal had to withdraw from the competition. Given the demand of the abdominal and oblique muscle groups in tennis, these injuries can take longer to heal than more common muscular injuries such as the quadriceps and hamstrings.
Contrary to what one might think, the abdominal muscle group is of paramount importance in tennis strokes due to the power that is needed to be generated from this region. The majority of hitting power would be generated from the hips and trunk rather than the shoulder. Therefore, larger strains of the abdominals >5mm can typically take months to heal as opposed to smaller strains requiring weeks.
Due to the high demand on change of direction, agility and in some players, sliding across the court, lateral ankle sprains are a very common injury sustained in any sport not only in tennis. As we can see in many tennis players not limited to this Aus open, ankle guards/braces can often be donned by players in a competitive setting to provide them with external support and stability.
A lateral ankle sprain can occur when we roll onto the outside of our foot (known as an inversion mechanism) that is followed by immediate pain around the outer ankle. A significant ankle sprain will make it difficult to continue sport due to the pain on weightbearing that immediately follows, and typically takes weeks to recover and return to sport.
More information on lateral ankle sprains and their rehab process can be found in another CSSM Blog post that covers lateral ankle sprains and their management.
While many of these injuries aren’t tennis specific, chat to one of our CSSM physios to find out how a rehabilitation program might work for you.
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Verdonk R, Madry H, Shabshin N, Dirisamer F, Peretti GM, Pujol N, et al. The role of meniscal tissue in joint protection in early osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2016;24(6):1763–74. https://doi.org/10.1007/s00167-016-4069-2.
José Leonardo Rocha de Faria, Douglas Mello Pavão, Marcos de Castro Moreirão, Hugo Alexandre de Barros Cobra, Rodrigo Pires e Albuquerque, Eduardo Branco de Sousa, Alan de Paula Mozella. How to Perform a Giant Parameniscal Cyst Exeresis: Step by Step Technique, Arthroscopy Techniques 2020; 9(5): 669-674, https://doi.org/10.1016/j.eats.2020.01.021.
CSSM’s Peter Stath relishes the opportunity to help his clients return to the things that mean the most to them, whether that’s sport, work or family. Peter is a strength and conditioning enthusiast with a unique understanding of the demands of high level competition and performance. Having previously worked within the National Premier League Victoria (soccer) as well as part of the medical team for Futsal Victoria at their National Championships, he has a passion for treating all aspects of musculoskeletal or sporting pain with a particular interest in shoulders, hips, knees and ankles. Peter has valuable experience in pre- and post-operative care and has developed expertise in using Clinical Pilates to facilitate optimal recovery and performance.
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