Serving Up Some Physical Therapy

By Keith Loria

When tennis superstar Pete Sampras won the 2000 Wimbledon championship, one of the people he made sure to thank was his physical therapist Robert Forster, PT. It was Forster who treated the tennis great's several injuries, helping him garner the strength to make it back on the courts when many in the sport thought he should simply retire.

"I was treating recreational tennis players when George Fareed, the Davis Cup doctor, referred Pete Sampras to me," said Foster, who has practiced sports physical therapy in Santa Monica, California, as owner of Forster Physical Therapy Clinic for more than 20 years. "I began working with Sampras on some minor injuries. He had hurt his disc in 1999 at the U.S. Open, and there was a long rehabilitation. People doubted he could ever come back, and I made my mark in tennis because he came back and won his 13th Grand Slam [event]. I continued treating him the last years of his career."

After his success with Sampras, Forster was asked to work as a physical therapist for the tennis tournament in Los Angeles (currently called the Countrywide Classic), and subsequently other tennis players came calling for his private services.

The next was Maria Sharapova, who came to see Forster for a chronic overuse injury to her right pectoral muscle. During one match in 2005, Sharapova complained that she felt pain in the muscle when she struck her shots, and the harder she hit the more painful it became. Eventually she was forced to withdraw from the match.

After an evaluation, Forster prescribed a rehab program for Sharapova's pectoral injury. The plan of care was to reassess the injury every couple of months to determine the best way to strengthen her muscle. When the pectoral muscle fibers are injured, the body attempts to heal by building up scar tissue, leading to a loss of function in the muscle. "Most important to her treatment [was] specific manual therapy techniques to break up the scar tissue, and then we implemented a strengthening and stretching program," he said. "When she got to the Open she was pain free in her right pectoral muscle."

The Russian superstar came back strong to win her first 4 matches, losing in the semifinals to eventual champion Kim Clijsters. "I was not going to play the U.S. Open if I was not 100% fit, and Bob helped me get there," Sharapova said.

While working at the tournament events each year, Forster's goal is to return players to full function immediately. During the 3 weeks, he sees a full range of injuries and performs many interventions, from recovery massage to compressing symptoms.

"At a tournament, someone comes in and says they have a chronic knee problem; well, I can't fix the meniscus, and a lot of the doctors will diagnose this," he said. "There's a lot of guarding and spasm in the gastroc in the calf and hamstring, and I work on that and get the knee to work better and that guy will get through a few more rounds."

As one of only seven physical therapists employed full-time by the Association of Tennis Professionals, Clay Sniteman, PT, MSPT, knows quite a bit about treating the tennis players on tournament day, since he spends most of his year traveling around the world to the different tournaments.

In 2008 Sniteman worked 20 tournaments (averaging about 2 weeks each) and has dealt with nearly every type of injury. He needs to be ready for anything and everything, since often he is the only PT on hand for the entire field.

"It's an all-encompassing job. We need to do all the treatments before they go out onto the court. Sometimes the players will stick around, and we will work with them before the next tournament," he said. "You're guaranteed to see a couple of shoulder problems, some lower back hip, maybe some elbow or wrist."

One might expect tennis stars would have their own PTs with them, but that is rare; Sniteman is just as likely to work on top-ranked Roger Federer as he is on 215th-ranked Benedikt Dorsch.

Maintaining "Tennis Shape"

On the women's side of tennis, Kathleen Stroia, PT, overseas the Sony Ericsson Women's Tennis Association Tour's Sport Sciences and Medicine program as well as PRO U, the tour's umbrella program for education and professional development.

"On the tour, the athletes we treat already are in 'tennis shape,'" Stroia said. "However, even these elite athletes—or especially these elite athletes—require preventive and maintenance management to allow them to avoid injury, recover more quickly from injury, and maintain their 'tennis shape' for optimal performance." The focus for these athletes is education and prevention; unfortunately, injuries may still occur.

"Tennis is an all-around sport that requires execution of speed, agility, power, strength, flexibility, and endurance, and as such we see a wide variety of illnesses and injuries, both acute and/or chronic," Stroia said. "Surface changes and modifications to the balls and racquet string tension are just a few of the factors to consider when assessing an injury and its cause in a tennis player."

"The tour's primary health-care providers offer an objective and measurable approach to prescribing individualized, sport-specific therapeutic exercise programs for each athlete. These exercise programs begin by focusing on the timing, stability, and strength of core muscles followed by functional and tennis-specific exercises that, when combined, are key to unleashing power and minimizing the risk of injury."

As director of sports medicine for the Association of Tennis Professionals' ATP Tour, Todd Ellenbecker, PT, DPT, MS, SCS, OCS, CSCS, has something of a dream job—he gets to combine his loves for tennis and physical therapy.

"I go to about 5 to 6 tournaments a year, and we perform physicals and musculoskeletal screenings," said Ellenbecker, who works by day in Arizona at Physiotherapy Associates. "I look at their flexibility and put together customized exercise programs ... to help their performance and hopefully ... prevent injury to the lower back, hip, and shoulder—areas we know are problematic in tennis."

"One of the most common things we see is shoulder injuries, primarily overuse injuries, just like in baseball. Most of the players have a very strong internal rotation from hitting forehands and serves," Ellenbecker said. "They break down with all the overuse. We evaluate shoulder range of motion and rotary cuff strength, and many times we find out that the rotary cuff is weaker than it should be."

One of the challenges that PTs have with the future Chris Everetts and Andre Agassis of the world is that many strength and conditioning areas don't really cater to tennis players.

"For the tennis player, the muscles in the front of the body, the pectorals, and a lot of these muscle accelerators are very strong and developed and imbalanced relative to the very weak decelerators of the scapula and back of the shoulder. They need to work on the scapula muscles and rotary cuff and ... normalize the balance of those muscles," Ellenbecker said. Another example is the core. Tennis players have strong abdominal muscles from serving, but it's not enough for a tennis player to do only abdominal strengthening for core training. Tennis players "need a lot of back extension work and rotational work to stabilize and normalize the muscle ratio in the core."

For those looking to follow in the tennis footsteps of these physical therapists, Ellenbecker offers this advice for the hard-to-come-by positions: "The best thing is to be very sound in orthopedic and sports physical therapy. Spending time in the athletic training room, understanding how acute injuries are managed from ankle sprains to soft-tissue injuries, blister tear…all the things you deal with as an athlete. A keen sense of exercise progression is also important because these athletes do need help with their exercises."

Forster maintains that the most important thing to do is to be around the sport as much as possible and dissect the players' methods. "I think the best thing for young therapists to do is observe the sport, and apply your basic knowledge," Forster said. "Evaluate and apply basics, and measure results. There's no one better than a physical therapist to design and build training programs, because we know how the body works—and breaks."

Perspectives for New Professionals of the American Physical Therapy Association, Supplement to Physical Therapy, January 2009, pages 27-28 

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