More information on the state of the knees
Photo by Beth Wilson
I missed an article posted a few days ago on El Pais about Rafa’s knees. Thanks to Genny SS/SpanishRNFAN, we have a translation.
Nadal frena para llegar a los Juegos – by Juan Jose Mateo
Translation:
Nadal stops to get ready for the Games
Less than a month before the Games in London start, on the 27th, Rafael Nadal announced yesterday that he won’t play the exhibition organized with Novak Djokovic at the Bernabeu on July 14 because the pain in the patellar tendon in one of his knees is forcing him to stop his training sessions for 15 days. After being knocked out against Czech Lukas Rosol in the second round of Wimbledon, where both joints already ached, the Spaniard went to visit Dr. Angel Ruiz Cotorro, his personal physician and that of the Spanish Federation, and Mikel Sanchez, a specialist who treats him Vitoria. The break recommended by the doctors leaves the 11 times Grand Slam and defending Olympic gold champion with very little time to prepare the Games.
It all started at Wimbledon. The player underwent two scans in the facilities of the tournament, where he arrived dragging the pains from the spring which had forced him to withdraw from the semifinals of the Miami Masters 1000. On this occasion, the objective was not the quadriceps tendon of his knees, which have given him problems at other times, but the patella, especially on the left (knee). Having reviewed the images, and as the pain was bearable, the Spaniard was subjected to treatment with antiinflammatory drugs and a thermotherapy machine, treatments that he will have to repeat now. “In London we worked so that the injury did not get worse,” explained sources familiar with the medical condition of the number two, “but it did not get better, either.”
“Before,” explained the same sources, “it was thought that Nadal suffered tendinitis, that is, an inflammation of the tendons. Now we talk about tendinopathy: the tendon degenerates and the body must regenerate it. Someone, who punishes himself physically as much as him suffers more in this respect, and that is why he resorts to the injection of growth factors.” Nadal gets injections of these factors in the knees for which he travels to Vitoria an average of three times a year. Each painful session is followed by a subsequent period of rest, as now. There is, however, one difference: the Games are just around the corner. The tennis players will travel to London on July 22 and will begin his training on the grass on the 23th. Nadal’s medical condition, according to the tennis federation sources, has not altered in any way such plans. They count on him.
“The doctors have been checking my knee and tell me that I suffer from tendinitis in the patellar tendon and I have to rest for 15 days, which makes it impossible to play with Djokovic as we planned and announced,” the player himself explained in a statement. The Real Madrid Foundation and the Rafa Nadal Foundation hoped to beat the record of attendance at a tennis match and reach the 80,000 spectators. About 30,000 tickets, of between six and 25 euros, were already sold. “On Monday I was with the doctors and started the recovery treatment in order to also be able to play in London and represent Spain again,” he added. “Now I will combine my rehab with some short holidays and return to practice in 15 days.”
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Auww..i feel sad for Rafa,hvg to deal w recurring knee problems.
hope he is well enough for Olympics!Health comes firs
I was almost afraid to read the post, fearing what it might bring.
And I was sorta right. Get the rest you need Rafa and hope you are fine by the time of olympics. If not, we won’t ever ever hold it against you. Love you!
I feel terrible for Rafa, to have recurring problems of the knees. Hope his treatment went well and that he’s enjoying a good time off.
I miss Rafa and his tennis but how I wish he could play his tennis without these knee problems. Hope the tendons are regenerating well as we speak.
Poor Rafa, I wish him well.
Take your time Rafa. Your knees need to heal, that is the most important thing right now. Don’t feel down. You are the “GREATEST OF ALL”!
Judy from the U.S.
This is just so sad! Rafa, i wish u the speedy recovery. And we will not stop praying and hoping for the best that you deserve.
*speedy
Get well soon our Rafa. We miss you terribly and hope you will be fit enough to play at the Olympics.
Vamos our Rafa & God bless you.
This is the summary of Rafas career ı am afraid.İnjury problems are his biggest rival.When he is fit and confident,he is going to win.He is the most explosive player ever.I already missed him.I was tennis fan before Rafa but without him it is just a empty feeling watching major tournaments.I hope he gets well soon.
Thanks for the information, Miri and Genny.
Heath? Comments?
Sadly, this is no surprise and confirms what I thought, Melissa. Rafa has a chronic tendon problem, not an acute one and the treatments (Platelet Rich Plasma injections) are currently thought to be the most effective approach. Growth factors present in the platelets are injected directly into the fibrosed and scarred parts of the tendon under ultrasound guidance.
It is also interesting to note the use of the term tendinopathy as this is the term favoured by Sports medics and orthopaedic surgeons ain this piece as it more accurately describes a degenerative condition. The term tendonitis suggests an inflammatory problem which is not the case with Rafa. It is an indication of how much Rafa still wants to play that he is willing to undergo these very painful treatments as often as he is reported to have done here. As always, I wish him well.
Thanks, Heath. 8-( I appreciate your input, as always.
Vamos, Rafa.
This is what i think we kind of expected to hear, i think a lot of the awareness of that type of injury and how things have progressed for him were both touched upon by Heath and Melissa pretty accurately, so no real surprises. Thanks for your insight!
Very interested to see how he chooses to move forward, especially long term, from here forward.
God bless you Rafa, take your time and get well!
Hope Rafa recovers soon and starts practising for the Olympics..
VAMOS RAFA and GOOD LUCK !
Miri..Thanks for the updates and all. You are doing such a wonderful job .. BTW, isnt it time to get rid of “Wimby -Outplayed” title ? Just reminding ! :-)
i do not have a clue medically regarding the knee problems so excuse if i seem a bit on the thick side.
is patella tendonitis a different tendonitis , (i assume in a different area of the tendon) to the ongoing problems Rafa has had where he needs the treatments? And is it not as serious and do you recover quicker?
Novak pulled out of Queen’s in 2011 citing patella tendonitis but was ok for Wimbledon that year and i think Del Potro had the same problem at this years Wimbledon and quite often the players have this problem. Is it quite common in athletes?
can anyone enlighten me? thanks
I’ve said a little about this is a reply above – if that helps.
I think the knee tendonitis is pretty common (Del Potro and Novak are other examples). As for Rafa, the knee problem is something that he has had to manage since 2009 (if not even earlier), and he will have to continue to manage it for the rest of his career. He has managed the problem in the past with some success, so hopefully he can manage the problem well this time.
As much I love seeing Rafa play (could watch him every day), I hope that he will choose selectively if his health warrants it and that he can fully enjoy playing as long as he has the “illusion” to compete. I’d rather see a healthy rafa on a limited basis than an injured Rafa having to retire before he’s ready. Vamos Rafa…you are so loved by so many!!!!
I think Rafa should focus on the Slams, such as this year’s USO. If he wins this year’s USO, he should take a long break during the fall. Is that the kind of schedule you have in mind?
Good discussion about the tendanopathy. It shows how determined Rafa is to fight to keep his career despite the physical pain involved. He is not exaggerating when he complains about the stress of a long season. I hope he can manage the condition. I agree it would be better to see him less often but always fit and free of pain.
Keith, maybe you’ve addressed the following and I missed it. If so, please direct me to your post. Rafa’s movement was obviously hindered in the Rosol match. Given his condition, is it likely that he was experiencing severe pain at that point? If so, that would explain a lot, especially the number of missed shots he would normally make. Does the condition cause chronic pain during normal activity off court?
Oops, meant to send to Heath.
I think it’s entirely possible that he had pain during the Rosol match – as the French Open had been tough and he had little time inbetween to rest. As to your second question, the symptoms of tendinopathy/tendonitis vary considerably between individuals, but many suffer pain on simple movements like climbing stairs or walking on uneven ground. Obviously I can’t comment on Rafa in that respect but I would be surprised if he didn’t have some symptoms off court.
Thanks
Rafa should consider going to Germany and use kobe bryant and alex rodriguezs doctor. thus far this has proven to be the most advanced form of PRP used with one time success rate.
The doctor who treats Rafa’s knees with PRP injections, Mikel Sánchez (“Clinica La Esperanza” in Vitoria), is very good and one of the pioneers in the matter. He first treated Rafa with this technique in 2010 (test injection in one knee after Monte Carlo, full treatment in both knees after Wimbledon) and we all know Rafa’s achievements that year. All this to say that he is in good hands and that the treatment was really successful from the very 1st time it was applied.
However, as Dr. Mikel Sánchez noted in this interview from 2010 (*):
http://www.marca.com/2010/09/24/tenis/1285316815.html?a=PRO0de12b92732a812841aefcb33533d296&t=1341904720
(*) don’t know if this was translated at the time (I haven’t found it in the NN archive, but maybe I haven’t looked for it too hard), if it wasn’t and you’re interested, let me know and I’ll try to translate it as soon as I have a little free time
one injured tendon can heal with this treatment, but if it is subjected to the physical punishment Rafa subjects his body, the problem can reappear in that tendon or in another one. In fact, as stated in the article of this entry, Rafa is currently having problems in the patella tendon of the left knee, while in 2010 the main problem in this knee was the quadriceps tendon (see this: http://www.nadalnews.com/2010/08/10/no-longer-chronic/ ).
Let’s not forget something important that has been discussed at length, especially after Rafa’s bio book went out: many of the problems Rafa has in his knees, particularly on the left knee, come from the sole he has to use in his shoes to somehow correct the congenital problem he has in the left foot… Unfortunately, there is no magical solution for this.
It is complicated, I lost my toes 4 years ago due to a chronic infection I picked up, my left foot is particularly bad so I have to where orthotics, unfortunately I don’t have Rafas money to get the expert treatment I need and the ones on the NHs are useless so its an on going problem trying to fix my gait… for Rafa this will also be extremely bad due to his choice of career and his explosive way of playing, (which is why I love to watch him btw), pushes everything to its limits, he is a marvel he really is, but there will come a time that his body might make the decision for him, hope its not anytime soon.
Rafa says in his autobiography that he has 100% confidence in his doctors, particularly Dr.Cotorro. I hope that Dr. Cotorro has at least consulted with the doctors in Germany.
I think Rafa’s knee problems started well before 2009. For years he wore tape below each knee and it wasn’t until he started the therapy with Dr. Cotorro that he was able to take the tape off.
Heath makes an excellent point. Teninopathy implies a chronic, degenerative condition. I wonder if its something that could be fixed with surgery?
Heath? comments?
I’m not Heath but I do have a comment here. I think Rafa’s best hope is stem cell therapy. This is beyond PRP and actually something even newer and part of why athletes are going to Germany. If Kobe Bryant can have his best year after having this treatment, one could only imagine what it could do for Rafa. I think it remains to be seen but if Bryant plays another 3-4 years at this level, which I expect, I could easily see Rafa have a good 5-6 more years on the tour at the highest level. I hope Rafa’s getting the most advanced treatment possible. PRP injections alone aren’t going to solve his problems but stem cell therapy just might.
FWIW,here is evidence of a company curing tendons on horses, who put extreme amounts of stress on their tendons. Looks like they went into trials last year on humans and are hoping to achieve similar results.
http://singularityhub.com/2011/03/10/uk-stem-cell-company-cures-race-horse-tendons-humans-next/
This is the kind of stuff Rafa needs to be on the leading edge on:
VetCell states that in the “athletic horse” tendon stem cell therapy leads to about 80% recover rates, compared to about 40% using conventional surgery, as well as having very low re-injury rates after treatment.
Uh-oh, i can see it now, Rafa goes to this new type of therapy, where he is getting injected with the bone marrow of a horse, then the French Paparazzi gets hold of it, and then we get a whole new spin and chapter on blood doping courtesy of our friends in the French press! ;)
Actually, that is an interesting read, I’m assuming A-Rod and Kobe have given testimony to its effectiveness? Would anyone know if there comes an issue with Rafa’s PRP injections to where there becomes a tolerance to that type of treatment, which reduces the effectivenss? That may be a silly question, i’m not sure. I suppose i’m taking that line of thought from how the body can begin to adapt and no longer respond to certain drugs in the body if over-exposed. I’m sure he is in good hands, great hands with his doctor and his team, and will get world class advice and treatment, but this stem-cell treatment does sound pretty intriguing.
Maybe we could come up with a way to have Rafa get a horse tendon transplant type of surgery, where he actually has horse tendons! I’m positive the French would love that! ;)
If you read the story, you know it said that the patient’s own tendon is used to regenerate. And if you know anything about stem cell therapy, you know that there are no drugs involved and it is actually the patient’s own DNA that is used to heal them. Stem cell therapy is already extending the life of some athletes here in the US. There’s nothing illegal about using your own body to fix repetitive stress injuries.
Casual Observer, did you really read my post very clearly? I’m assuming not.
My apologies, however, since written words on blogs and what-not may be misconstrued. I don’t question whatsoever the efficacy of the procedure you are putting forth. Further, i asked a legitimate question in regard to the limits of how effective certain treatment protocols (in this case, the PRP injections)can be over time, as the body begins to develop tolerance to drugs over time. None of what i put forth in my post has anything to do whatsoever with drugs being a part of the procedure. None of what i put forth indicates anything whatsoever about Rafa and/or his team doing anything illegal.
My general disdain of the press, coupled with the evident sense of doom and gloom around here prompted me to take a little bit of a stab at the press, especially the French press, since so many people around here get so concered about what the press thinks. Thought i’d inject a little levity. A little laughter? A little laughter never hurt anyone, now did it?
But no one picked up on it, you seem offended by what i’ve posted, which is fairly mystifying to me, except when it is pretty clear you didn’t read what i posted.
With that said, i’ll refrain from any more tongue-in-cheek posts and encourage you to lighten up a bit.
That’s ok Joel, I thought your horse transplant bit was funny and could see you were just trying to lighten up the mood as we are all so concerned about Rafa. :D
Sorry for the misinterpretation on my part.
You do however mention the efficacy of “drugs” over time. Just for reference, PRP doesn’t involve drugs either as it is merely just a highly concentrated form of the patients own plasma. However there have been studies done indicating that efficacy over long periods of time with repeated same treatments eventually has a limit.
I’m with you regarding the press in certain parts of the world. Irrespective of what Rafa does, it will be misconstrued. Part of me wishes Rafa would just not reveal his injuries and get treatment for them the way Federer does, in silence.
Casual Observer, thanks for getting back, and i couldn’t agree more with how Rafa handles injuries and the press. I do think he’s become a little more judicious in not opening up as quickly, as i think he did in this instance, as compared to last year. There were times last year, esp. when he was so candid about how Nole was in his head, where i wished someone would just grab him by the shoulders and shake him and beat it in to his head that the press, man, these guys are not your friends!!! At the same time, his innate humility, innocence, his very apparent humanness is part of his draw as well, to many of his fans, including myself.
To clarify a little more, i do understand the nature of the injections are not in any way drug related, i mentioned that just for the sake of comparison of drug tolerance, and how that might compare in regard to his treatment protocols, which Heath clarified as well. Another example that i’m experiencing in my own right thru ALCAT testing, are issues in regard to food sensitivities, and how the body isn’t supposed to be exposed over and over and over again to the same types of food, to where eventually it starts to tax our immune system as certain foods start to create an allergic reaction (no matter if symptoms are present are not) within our system, triggering an immune response where the body attacks these agents as foreign invaders, and taxes our immune system as a result.
This too, kind of entered my thinking when considering the long term effectiveness of his treatment regimens, and how the PRP and stem cell therapies bear themselves out.
Again, thanks for your understanding, this is a very cool site with lots of passionate fans, many of whom have some angles on things that are very interesting to draw from.
Alright, on to the Olympics!
Well said JC !
I do a fair bit of reading on these newer therapies b/c I think it could eventually benefit my parents in their old age. Even healthy human beings wear down eventually but athletes wear down even quicker.
That’s a good point regarding immune system response. The promise of stem cell therapy is that genetically identical nature of what is used to heal. This is thought to make the immune system less prone to longer term consequences but in my opinion only time will tell on a lot of these therapies.
It is almost time to VAMOS for Olympic Tennis. I’m fairly certain Rafa will play. I’m a bit more concerned about the hardcourt season. I think he will likely skip the MS1000 in Canada and just play Cincy and the USO if he doesn’t have any lingering issues.
Casual Observer is right to mention Stem Cell Therapy as potentially the next step for Rafa after PRP injections. Many orthopaedic surgeons see this as a treatment reserved for more serious joint damage and therefore won’t consider it as an early option for tendinopathy. Specialists in different countries see it differently and I’m sure Rafa’s doctors will explore all the options on his behalf. However, I noticed that Rafa has tweeted today hoping ‘to come back early to the courts’ – so it looks like his latest PRP has given him reason to be optimistic.
Emir, your comment that injury has been Rafa’s biggest rival is very poignant, indeed.
Okay let me clarify the tendinopathy-tendonitis questions. Histopathologically speaking-meaning under the microscope, a tendon that is overused may look similar to a tendon that is inflamed due to a rheumatic disease. In fact, tendonitis, plantar fasciitis, heel spurs are all part of spondyloarthropathy, a disease which is called ankylosing spondylitis when it affects the spine.
So some people with chronic foot and tendon problems, lower back problems don’t know that that they actually have a rheumatic disease. However athletes can develop some of these problems without an underlying disease. So the doctor may call it tendinopathy or tendonitis or even tenosynovitis depending on what else is going on. Hard to know if Rafa’s problems are just overuse.
All this sounds rather depressing. Good to know stem cell therapy is available though. I suppose Rafa will consider it if he wants to remain at top level and extend his career. I hope he does even if it means he has to see another doctor.