A recently released study shows that the more matches a junior plays in a tournament, the more likely it is that he or she will have to pull out with an injury. How’s that for obvious? While it is intuitive, it’s the first time there’s been hard data on medical withdrawals for juniors. The study, which is based on findings from the four USTA national junior tournaments in 2005, found that after four matches, young players are twice as likely to withdraw for medical reasons.

The simple fact is that high-level tennis necessitates a high level of effort, and it can take a toll on the body. It’s the same in the pro game. After the grueling early part of the season, the pros always start to seem exhausted, like they’re collectively dragging themselves toward the off-season finish line. Most juniors don't play quite as much as professionals, but those who are very serious about tennis get close when you include the hours they spend training. Plus, at junior tournaments, breaks between matches can be much shorter, and many juniors play multiple matches in the same day.

So what does this mean for junior tennis? For the individual, it all comes down to taking care of yourself. Proper rest, nutrition and training are all key to making it through a tournament. In interviews with experts who train tennis players, there’s one thing they always seem to emphasize when it comes to preventing injury: “prehabbing.” It may be a made up word, but it’s important. As opposed to rehabilitation, where you do therapies and exercises to help heal an injury, prehabilitation is about preventing injuries. Prehab exercises usually involve working on flexibility or strengthening muscles surrounding and supporting a joint with very small weights or resistance bands. In a recent conversation with JohnMark Jenkins, who works with juniors as the strength and conditioning coach at Evert Academy in Boca Raton, Fla., he especially stressed prehabbing the rotator cuff (like in the exercise at right) to reduce risk of injury to your shoulder area. For a description of the exercise and a couple more anti-injury moves, click here.

Of course, there are things organizations like the USTA can do, too. The study’s lead author, Neeru A. Jayanthi, M.D., from Loyola University in Chicago, suggests that tournaments decrease the number of matches played each day for juniors. He also recommends an extended rest after a player’s fourth match. That would help juniors recover more fully and be ready to perform their best in the next round.

Did you know that April is stress awareness month? I didn’t either. But apparently it has been for the past 17 years. This year, though, I would say the 30-day recognition of emotional strain is more justified than most. These are uncertain times, and with job security to worry about, free-falling savings balances, and the fact that even our banks are currently undergoing stress tests, anxiety levels are soaring. It would almost be better if April had 31 days.

A recent New York Times article offers some insight into the collective mind-set of Americans right now. A couple of tidbits: In a September American Psychological Association poll, significant economy-related stress was up 14 percent from the previous April. And the National Sleep Foundation found that 27 percent of people polled in the fall of 2008 had trouble sleeping because of anxiety related to the economy.

Sponsored by the Health Resource Network, a health education nonprofit, stress awareness month is dedicated to disseminating educational information about the affliction. Stress can definitely take a toll on your health, causing things like headaches, stomach issues, insomnia and depression. It can also lead to weight gain or loss depending on how your appetite sways when you’re under pressure.

The Substance Abuse and Mental Health Services Administration has started a website to help people sort through stress related to the economy. Under “Managing Stress” it recommends “strengthening connections with family and friends” and “engaging in activities such as physical exercise, sports or hobbies.”

This is where your tennis comes in. When you’re worried about financials, hitting the court may be the last thing on your to-do list. But you should give it higher priority. Physical exertion can significantly reduce stress, making you better able to deal with your problems. And while doing something like going on a run can relax you, I think the release of whacking a tennis ball is an even better stress-reliever. 

The fact that tennis is a social sport is also great for your health. In times where it’s every man for himself when it comes to financial stability, socializing on a court can help you balance the bad with some good.

So take some time be aware of your stress this month, and to play some tennis.

In the May issue of TENNIS we have an article called “The Pro Treatment” about the different health professionals who help keep the pros in playing shape. But what about rec players? What can the health pros do for your game? While some of the services they provide may seem a bit indulgent, especially in this economy (a session with a sports psychologist, for example, starts at around $150 an hour), they do work wonders for the pros. Here’s a look at what they can do for you.

Trainer

If you have a hard time motivating to work out off the court, a personal trainer can help. While it may be hard find a trainer who’s an expert in tennis, sessions with any strength and conditioning specialist should improve your overall fitness. And the more fit you are, the better you’ll feel and perform on court. “A trainer who’s played tennis would be very helpful, so they know what type of muscles they should work on,” says Jeff Michaud, owner of Fitness by Jeff in Atlanta, where he coaches tennis and does personal training. If you can’t find someone who plays tennis, tell a regular trainer that you need total-body strengthening, with specific attention paid to your core, shoulders, upper back and legs. “For weights I’d recommend anywhere from 20 and about 35 reps,” Michaud says. “You want to do more reps, less weight. You’re not playing football. You want to build endurance and lean muscle mass.”

Physical Therapist

A lot of us have gone to a physical therapist to get treatment for injuries, but many don’t realize the other purpose of P.T.: injury prevention. “Before you’re injured, a physical therapist can provide a preventative evaluation and do things to screen flexibility, strength and balance,” says Todd Ellenbecker, M.S., D.P.T., the ATP tour’s director of sports medicine and the chairman of the USTA Sport Science Committee. If they find a problem, like a muscle imbalance or a weak rotator cuff, they can design a “prehab” program to prevent an injury. So if you’re getting back in the game after time off or if you let yourself get out of shape over the winter, a P.T. evaluation could keep you from getting injured and spending more time away from the court. If you are injured, a physical therapist can perform in-clinic treatments for rehabilitation and prescribe exercises to help you heal and strengthen the injured area.

Nutritionist

Let’s face it: Many of us pack a few extra pounds. But moving around court is much easier if you’re not overweight, and that’s where a nutritionist comes in. The most obvious role of a nutritionist for someone who’s not an elite athlete is to design you an eating plan to help you reach and maintain the proper weight. Dietitians can also counsel you on the proper fueling and hydration for the best performance on court and detect and help you correct any deficiencies in your diet.

Sports Psychologist

Say a certain opponent has you spooked or you just can’t get your forehand to land in. It may not be that your opponent is better than you or that your forehand needs to be reworked; it might be mental. And sometimes mental blocks are the most difficult to break down. You may need help from an expert. “I think it’s an illusion that sports psychology is only for elite athletes,” says Dr. Alan Goldberg, Ph.D. “Pro and rec athletes have the same kinds of issues.” The Massachusetts-based Goldberg does his work primarily over the phone with athletes all over the country, hearing the history of their performance troubles and helping them work through them. “If I’m doing my job well, I’m going to be able to teach them to self-correct,” he says. “I teach them to identify when they’re beginning to make those mistakes on the court and teach them some skills to deal with it.”

Massage Therapist

Anyone who’s ever had sports massage knows it’s not a relaxing experience. The deep pressure can be downright painful. But from tight muscles and bands to scar-tissue buildup, massage therapists can push all the right buttons on your body to prevent injury and help you recover faster. For a full report on how sports massage can help you, check out this TENNIS article. This doesn’t mean that regular spa massages don’t have benefits for your tennis. Like yoga, massage can relax both your muscles and your mind and be almost meditative, which can lead to better concentration on court.

Tennis elbow: It’s a nagging injury that makes even the most casual play painful. It can linger so long that many sufferers resort to surgery. But there’s a new treatment for tendinitis of the elbow that’s less invasive than surgery and more long-term than the anti-inflammatory cortisone. It’s called platelet-rich plasma therapy, and, according to Dr. Allan Mishra, an assistant professor of orthopedic medicine at Stanford and one of the method’s pioneers, it’s one of the only truly biological treatments in use today. It works by enhancing the healing powers of your body, and more specifically, your blood.

That may sound like science fiction, but the process is pretty simple. It goes like this: Doctors take about 30 cubic centimeters of your blood (roughly 1/16 of what you would give when donating blood) and put it in a centrifuge to separate the red blood cells from the white blood cells and platelets. After it’s done processing, about 20 to 30 minutes later, they numb the injured area and inject the plasma containing the platelets and white blood cells into the frayed and degenerated tendon. Then your natural healers—growth factors or proteins within platelets—get to work.

And based on Mishra’s research, they really do work. In 2006, he published a study in the American Journal of Sports Medicine on PRP’s efficacy in treating tennis elbow. He took 20 patients with tendinitis so bad that they were considering surgery (“these were the worst of the worst cases,” Mishra says), and gave 15 of them PRP therapy and the other five an anesthetic. After two months, there was 60 percent improvement in the PRP group and only 16 percent in the control group. Two years later, Mishra says, after that single procedure, over 90 percent of the PRP group were better.

After his patients have the procedure, Mishra advises that they start a gentle stretching program within a few days and then gradually work back to their activities. “The significant majority of patients are going to get better when properly selected,” Mishra says. He advises that patients get checked out before getting the treatment to make sure their elbow soreness isn’t referred pain from a pinched nerve in their neck or a rotator cuff injury. In those cases, a shot of PRP to their elbow won’t solve the problem.

The therapy isn’t just for tennis elbow, though. It was created about eight years ago, and is becoming more common for use with a variety of injuries. Professional athletes have tried it, too. Pittsburgh Steelers receiver Hines Ward had the therapy on his injured knee so he could be in playing shape in time for his team to win the Super Bowl. His teammate Troy Polamalu had it, too.

But is this akin to that backroom, mad-scientist procedure known as blood doping where you give blood, store it, then inject it back in before the big match so you feel like Superman? There are similarities, but also definite differences. The World Anti-Doping Agency’s website says they classify as blood doping techniques that increase your red blood cell count, allowing your body to get more oxygen to your muscles. If anything, Mishra says, PRP decreases your red count because the red cells that are separated out in the centrifuge are discarded. A New York Times story discussing platelet-rich plasma and blood doping brought up the fact that WADA bans a certain growth factor contained in platelet-rich plasma, but the agency declined to comment on whether PRP was a violation of their code.

Mishra makes the case that PRP is a treatment for injury, not for enhancing performance. “All we’re doing is concentrating what you already have in your blood and putting it in a tendon where the blood supply is poor,” he says. “We’re not storing it and reintroducing it at a different time. And probably most importantly, I haven’t heard of anybody who is some phenomenally better person for it.”

But recreational athletes typically don’t have to worry about doping code violations. And for those who have suffered with tennis elbow and tried everything from time off to cortisone, and even considered surgery, platelet-rich plasma might be something else to consider.

Todd Ellenbecker, D.P.T., chairman of the USTA Sport Science Committee and co-author of Complete Conditioning for Tennis, answers your tennis health questions.

I have often experienced painful cramps in my legs, mostly the calf area, while playing. This normally happens during a tournament after three or so matches in the heat. I know that it could be caused by heat and excess sweating, but I drink plenty of Gatorade and water. Is there anything you know about this as far as supplements, stretches and training?—Hassan Rashid

Cramping as you describe it is likely due to an electrolyte imbalance and improper hydration practices. Even though you are drinking Gatorade and water, you may be starting matches dehydrated and not able to keep up with the fluid loss while you’re playing despite your efforts. Some players sweat excessively and really lose a lot of fluid and electrolytes while playing (especially sodium). A physiologist can evaluate you for this to determine if you need to take extra steps to combat this problem.

Some things I would recommend include weighing yourself before and after play in the heat. This will allow you to know how much fluid loss you have encountered while playing and also ensure that you drink enough to regain your pre-match weight ensuring that you replace the fluid you lost before you play the next day. Also, research has shown that many players are dehydrated before they even step out on the court. Monitoring the color of your urine can help as well. If it is yellow or dark colored, you are still dehydrated and need to keep drinking fluids (though if you take supplements, it may never be clear). Gatorade allows you to get extra electrolytes by adding the contents of electrolyte packages to your drink. Stretching is always a good idea but likely will not help if you are cramping due to a fluid imbalance.

What is the best way to build stamina for tennis?—Nicole Ross

By studying physiology in tennis, scientists have shown us that fitness in tennis requires bursts of activity known as anaerobic fitness, as well as aerobic fitness due to the long matches and the repetitive nature of the game. Given that, players need both explosive power and aerobic endurance to be successful. So, for the stamina aspect, you should try to supplement your training with some aerobic training. Research has shown that players with higher levels of aerobic fitness recover better between points. To build your aerobic fitness level, the American College of Sports Medicine recommends you perform steady exercise for periods of 20–30 minutes at least three to four times per week at an intensity of 60–80 percent of your maximum heart rate. To do this you could use a stationary bike, elliptical trainer or Stairmaster and use your heart rate as a guide to get optimal benefit out of our workout. Go here to learn to calculate your target heart rate.

Since you love tennis, you could also try enrolling in a cardio tennis program—any type of sustained exercise as mentioned above would be a great choice. If you have had any types of knee or leg issues, running would be my last choice since the pounding of tennis along with the pounding of running may be an overload in your training.

I partially tore my ACL in February 2008. I’ve seen a couple of ortho docs and some physical therapists and I’m really confused. My knee feels OK now, but it starts to hurt after an hour or so, especially when I serve. But I can still play and move. If I elect to have surgery, which is better for a tennis player? One doctor wants to do a hamstring autograft and the other doctor wants to do a cadaver/allograft. One P.T. I saw said I shouldn't get the surgery because it gives you arthritis in 10 years! He said just play with a brace. So, I’m really confused. Help!—Joe Polito

Injury to the ACL in a tennis player is a significant functional problem. With the weight-bearing, loading and twisting that occurs when you play tennis, not having the surgery in a knee that is unstable can lead to arthritis due to increased translation between the femur bone and tibia. You have done the right thing in consulting with numerous orthopedic surgeons and physical therapists as they can give you the specifics of the surgery and rehabilitation following the procedure.

Recent research following patients for as long as 10 years after surgery has not shown a superior graft choice. Patients using their own tissue (autograft) as well as a cadaver graft (allograft) both can return to function following reconstruction. Failure to have the ACL reconstructed can lead to continued meniscal (cartilage) tears which can lead to accelerated rates of arthritis in the knee.

Regardless of the graft and procedure chosen, a steady course of rehabilitation is required following surgery to retrain the muscles in the lower extremity and core to allow for an optimal result. Unfortunately, there is no best surgery, but by consulting the top sports-medicine physicians in your area and asking them the key questions you have outlined will likely guide you to the best procedure for your specific knee injury. Either way, making sure you regain the strength in your quads and hamstrings will help to stabilize the knee, no matter what you decide.

How can I avoid a bruise on the heel of my hand where the racquet rests? I use a [K] Three Wilson raquet.—Sharon Ortega

This problem is most likely not due to the racquet but rather how you grip it. Each racquet has an enlarged end (butt cap) to keep the hand from sliding downward on the racquet when playing. Having your grip and hand position checked by certified teaching professional is likely the best line of defense for this issue, as your hand might be too far down on the racquet. Additionally, if you have your hand positioned in a grip so increased loads are transmitted to certain parts of the hand, like the bones in your wrist, this may cause more discomfort. Sometimes an overgrip can give additional cushioning to your hand, but I would first consult the teaching professional to be sure your grip is proper and best suited for your game.

I am 53 years old and starting to develop knee pain after playing for 30 minutes, is there a certain type of knee support that would offset the discomfort. I really don’t want to give up tennis, I use it as an encouragement to keep getting in better shape.—Jim Cielma

Without examining your knee is difficult to determine what is best for you as there are many options. Knee supports can consist of simple sleeves with a cut-out around the knee cap to support the kneecap when you play. These can be particularly effective if you don’t have really good quadriceps strength and need that support. If your knee pain is caused by an alignment issue (such as if you are bow-legged), then there are specific braces that can be used to unload your knee and relieve compressive type pain in the knee from early arthritis. The best advice for making sure you have the correct support and exercise program for you ailing knee is to see an orthopaedist to examine the knee and determine the source of the discomfort, then perhaps a physical therapist to get the right exercises. The combination of the right brace and exercise regimen will hopefully keep you out on the courts for a long time to come.

I’m trying to train my sister and get her as fit as possible. I want to do some stuff but I’m not sure if they’re a little bit too extreme for her since she’s only 9. Can you please give me some advice on what things she could do?—Erik Angamarca

At that age, working on basic athletic skills is very helpful. Lifting weights and other typical training methods are not as effective and could be dangerous without the supervision of a trained professional. However, doing general calisthenics and body-weight exercises like squat and lunges, sit-ups and push-ups can be used to tone the muscles and gain coordination. Often, exercises that promote body awareness and balance, such as agility drills and kicking (soccer) can be very helpful for general coordination. Many tennis drills can be used or altered for young players to keep it fun and promote overall athletic fitness at that early age, which can go a long way in a player’s development.

I’m 21 years old, and I haven’t played tennis for six or seven years. I started playing again, but now when I play I feel some pain in my wrist. What kinds of exercises can I do to prevent the pain and to strengthen my wrist?—José Dias

Great question. Since you have taken some time off from tennis, you may not have as much strength in your forearms and wrist as you once had when you were playing more regularly. I would recommend doing some wrist exercises to increase your strength to get you back in playing shape. These would involve using 3–5 pounds (I don’t know how large you are, how strong you are etc, so starting out with just a few pounds would likely be the best choice) and doing wrist curls both with your palm facing upward (flexion curls) as well as palm facing downward (extension curls).

In addition to the curls, you can squeeze a ball, holding for five seconds and repeating 10–15 times per session. The curls can be done moving the weight slowly in an upward and downward direction for 3 sets of 15–20 repetitions. These exercises should not be done right before playing or practicing as it will tire out your muscles before you play. Do these several times a week and in 4–6 weeks your wrists will be stronger.

I am 55 years old and play mostly men’s doubles at a 4.5 level. I have a ruptured disc in the lower lumbar spine area. The pain dictates when I can play and for how long. Should I stop doing what I love, consider surgery or try and live with the pain? I have had decent results with Z-pak steroids (a small dose for 6 days straight). Would this be OK to help me keep playing?—Ron Eddy

Injuries to the spine are common in tennis players of all ages and ability levels. Typically the best treatment for tennis players with back problems is to improve their core stability. The core consists of the muscles of the lower back, abdomen and hips. All players need to have a strong core to perform the rotational movements required in tennis. There are many ways to strengthen the core, and for tennis players, exercises with rotation are most specific to the movements you do in tennis. Using a physio ball adds a lot to the exercise by providing an unstable base, which works muscles of the core even more. Doing sit-ups with rotation, as well as exercises for the lower back such as the superman and pointer exercise can be especially helpful as research has shown that elite tennis players actually have fairly strong abdominal muscles, but have relatively weak low back muscles. Injections and surgery should be resorted to after physical therapy and exercise have not remedied the problem. Go here for a core workout from TENNIS. Adopting a comprehensive core training program would be a great step to playing with greater core strength.

Fitness and nutrition advice is everywhere, and with good reason. We all want to be healthy. To help you pick through the maelstrom of health info online, here are three regular Web features that I’ve found helpful.

1. Men’s Health lists
The Men’s Health motto, “Tons of Useful Stuff,” comes through in its lists, which boil down health and lifestyle issues into easy-to-decipher tidbits. Men’s Health has made them a linchpin of its operation. Aside from the entertaining “10 Ways to be Her Best Lover Ever” staples, the lists provide advice nutrition, strength and conditioning, and health in general. And many of them apply to both men and women, like “10 Ways to Stick to Your Workout” and “The 10 Best Things You Aren’t Eating.”

2. New York Times “Recipes for Health”
Sweet potatoes, beets, swiss chard: You know they’re good for you, but do you know multiple ways to prepare them so they taste good? If not, check out “Recipes for Health” from the New York Times. Each week, the Times spotlights a healthy food and supplies readers with five fairly easy recipes, from old basics to interesting new ideas, so you’ll never get bored. The photographs of the dishes add to their appeal. It’s a great reminder that eating healthy isn't hard if you plan ahead, and that cooking can be simple and fun.

3. LA Times "Good Form"
Proper form is essential to get the most out of any exercise and to avoid injury. So check out “Good Form” from the LA Times, which has clear, concise descriptions of exercises along with photos to illustrate them. It shows you the right form for common exercises and gives you ideas for new moves you may not have tried, from strength training to stretching to yoga. It’s a great way to ward off workout fatigue.

It creeps up every time. The end of November brings two things: the Davis Cup final and Thanksgiving. Bring on the food, drink, and festivities of the holidays. With all the overeating, drinking and added stress of the season, it can be a dangerous time for your health. Articles and TV news shows often say holiday weight gain can be as much as 5–7 pounds. But a study from the National Institutes of Health is encouraging: It found that from before Thanksgiving until after New Year’s the average person gains only about a pound. Here’s the bad news: Study subjects who checked in later in the year had not lost that pound. Doing the math, that adds up to 5 pounds in five years, and 10 pounds in 10. Here are a few tips to help you prevent this year’s pound. For more ideas, check out WebMD's Healthy Holidays guide.

Satiated, Not Stuffed
The holidays are about mingling over munchies, sipping on drinks, sitting down to huge meals, and double the desserts. And that’s just on big days like Thanksgiving. There are also the holiday party calorie fests and goodies that make their way into the workplace. It’s all tough to resist, so here are a few guidelines for different situations.

Hors d’oeuvres: First you must survey the spread, then fill a small plate with just a little of the stuff you know is bad for you and a lot raw fruits and vegetables and whole grains. After your trip to the appetizer table, hang back or go to another room with your plate to avoid more munching (especially if you know you’re going to be sitting down to a big meal).

Mealtime: At the main event, take small portions of everything you like and only go back for seconds of the stuff you know you won’t get for another year. If there are three different types of pie for dessert, don’t have a full serving of any of them; just have a taste of each.

Surprise Sweets: There’s no way to avoid the tons of treats that pop up during the holidays. My best advice is to go into each day with a plan, having ideas for a healthy breakfast, lunch and dinner, and then only allow yourself one holiday snack per day.

Keep Moving
Sitting idle in overstuffed pain is part of many holiday traditions, but before you undo the top button and plop down this year, think of that pound compounded over years.

Celebrations: What better way to feel good after some gorging than hitting the courts? Schedule some time at an indoor facility and play a round robin or some doubles with the family. If the whole family isn’t into tennis, try going on a walk, doing some outdoor sports, or playing tennis on the kids’ Wii.

Everyday: Many people get so busy during the holidays that they skip working out altogether. Don’t let this be you. Time on the court and other exercise will help you relieve stress, keep your fitness maintained, and give you a little extra wiggle room when it comes to that second helping of mashed potatoes.

You Time
Take some time to take it easy this holiday season. It might mean you have to be diligent about scheduling to get everything done in time to relax. Start early and divide up the tasks of cooking, shopping and decorating. And if you’re one of the delinquents who lets someone else in the household do all of the prepping and stressing for the holidays, step up and help out. It’ll lead to a much more relaxing, enjoyable season. Happy holidays!

Stretching took top honors on the New York Times most e-mailed list earlier this week, and I may single-handedly be responsible. That’s not because I sent it to everyone I know; it seems like everyone I know sent the article, “Stretching: The Truth,” to me. I guess I know what I should write about. Thanks for the input, everyone!

According to the article, the USTA’s advice, which TENNIS follows in its articles, to do a dynamic warm-up before a workout and static stretching afterward, is the right advice. It is now believed that static stretching can decrease muscle strength (by as much as 30 percent according to one study), so it should only be done post-workout. Before a workout, you should do a dynamic warm-up to loosen up your muscles and tendons and increase range of motion. Check out the article for some new dynamic moves and a video with Mark Kovacs, Ph.D., the USTA manager of Sport Science. In August I blogged about another Times article about two new studies on stretching. Maybe those will bring us an even better understanding.

Another breakthrough I wanted to touch on is in the study of fatigue. With the days getting shorter and the stressful election season leading directly into the holiday season, feeling tired and sluggish may start to become a regular state for many of us. But for anyone who knows how energizing time on a tennis court can be, you know there’s often an answer in exercise. Physiologists have started to connect the dots between the biological processes of fatigue and exercise, and in September they convened to agree on a new understanding of the condition. Read about it here at the home of Bud Collins, the Boston Globe.

The new view links fatigue with sluggish mitochondria within cells, which make energy, and too many pro-inflammatory cytokines, which battle infection. The exciting part about this is that both mitochondrial and cytokine problems have been shown to improve with exercise (they actually get worse with too much rest). The takeaway? If you’re feeling tired, try working in some extra court time this fall.