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Sometimes equipment can be the cause of trouble. "Take tennis toe," said Nirschl. "It's one of the most common tennis injuries, especially on surfaces that prevent the shoe from sliding. The shoe stops but the foot continues to move, leaving you with bleeding in the longest toe or pain in the joint connecting the toe with the metatarsis. The medical cure is to inject cortisone. That's fine as far as it goes, but it won't prevent a recurrence. I may give an injection but I will also recommend a shoe that holds the foot in place and at the same time gives accommodation in front."
Measuring hands for grip size was a revelation. "Until recently," Nirschl said, "women usually had to play with man-sized rackets. It was ridiculous. It also seems silly for kids to play with adult-sized rackets. They should make grips smaller than size 4, which is rarely done, and build rackets at shorter lengths for both kids and beginners. I've talked with someone at Wilson about this. He was open-minded, but he may have trouble convincing the marketing department that these rackets will sell."
Inevitably the talk drifted to Nirschl's preference in rackets. Though he was understandably reluctant to name names, he did refer me to a colleague, Stanley Plagenhoef, director of the biomechanics lab at the University of Massachusetts. Since 1974 Plagenhoef has been filming tennis strokes at more than 1,000 frames per second. Recently he taped an electronic sensor to the hand of an instructor and had him hitting balls with 63 different rackets. The conclusion: tightly strung flexible, and more loosely strung stiff rackets transmit less force to the arm and shoulder.
"There are many variables involved in treating injuries," Nirschl said. "You have to know the patient's entire history." Nirschl's prescriptions may run to balls and court surfaces. One of the few invariables he has found is that good players rarely get tennis elbow. "Inferior players punch at the ball and fail to transfer their weight, putting great pressure on their arms," he said. "My own experience was empirical. I had tennis elbow until I began hitting a more fluid backhand. The backhand is what almost always causes tennis elbow. I fought the two-handed backhand when my daughter Suzanne started using it, because I think the stroke has weaknesses in range and volleying, but I must admit that I have never seen a player who uses it get tennis elbow." And he has seen more than 600 tennis elbows.
For a number of years Nirschl and Ed Eberth, a former patient, filmed world-class players. "We were able to develop expertise about injuries from watching good players, because their problems are so subtle," he said. "After a while you begin to dovetail injuries with strokes. I don't mean to ruffle any feathers, but I think injuries would decrease if tennis were taught differently.
"I think the volley should be taught first. It involves much body transfer and hardly any backswing. The major difficulty medically is that teachers exaggerate the backswing at the expense of the body turn. 'Get your racket back!' is misunderstood. It really means get your body in position so that the racket will have plenty of time to impact the ball. If a player doesn't turn his body correctly, he must accelerate the swing and do much more work with his hand. I've never seen anybody get in trouble with a short backswing.
"Second, mobility and positioning should be taught before stroking. The correct sequence is body position first, stroke pattern second. If the lower body can't get in position, the upper body will have to work extra hard."
As one might expect, such heretical talk raises hackles in teaching circles. "If tennis is taught badly, I can see his point about the volley," says Dennis Van der Meer, a well-regarded teaching pro, "but if it's taught well, you always start the player off with less than the full stroke. As for mobility, the people with the best movement are panthers. They can't play worth a damn. Mobility has to be combined with a moving ball."
Van der Meer will be glad to hear that Nirschl has given more medical therapy than chalk talks to the 600 tennis elbows he has treated. Therapy was complex for Stan Smith, who approached Nirschl after suffering perhaps the most humiliating loss of his career in the first round of the 1975 U.S. Open. Suffering from forearm and elbow problems as well as subpar play, Smith was particularly bothered by volleys that forced his long arm into awkward positions. Nirschl had him reduce his grip from 4⅞" to 4¾", his racket weight from 15 to 14¼ ounces and the tension of the strings from 60 to 56 pounds. Smith took Butazolidin, treatments with heat machines and buffered aspirin 10 minutes before playing. He worked with hip and back weights to increase his mobility and began wearing a special nylon elbow brace that prevents his muscles from inflaming. He has since made a modest comeback.
Smith phoned during my visit, and I could hear the doctor going over a checklist with him. "What's the tension? How-do you feel about the amount of pace you can put on the ball with it? How does the new grip feel? How is the balance with the new racket? After your afternoon practice, do your icing and add the ultrasound if you can. If you feel better it's O.K. to enter a tournament but I sure would avoid the doubles."