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Original Issue

The doc who tells you what's up

If you play the game until it hurts, specialist Robert Nirschl will help to ease those throbbing joints

Suddenly last summer, I developed tendinitis in my right wrist. It hurt when I played tennis. It hurt when I played squash. It hurt when I shook hands. It hurt when I paid off bets.

Now, the ordinary cure for tendinitis goes something like this: heat it, wrap it, give it plenty of rest and take Geritol twice a day. The main thing is rest. Which is fine, except that I need my right hand to write, type, shake hands and eat. In other words, to live. And I wasn't willing to give up tennis. So I went on suffering.

Then I heard about an Arlington, Va. doctor named Robert P. Nirschl. He was recommended to me as the "compleat" tennis doctor, a man who takes your measurements by examining your grip size and your weight by putting your racket on a scale.

His credentials were indeed impressive: assistant professor of orthopedic surgery at Georgetown University School of Medicine, chairman of the committee on medical aspects of sports for the Medical Society of Virginia, author of more than a dozen papers on sports injuries and physician to numerous tennis pros. Robert P. Nirschl should be able to keep me on the courts.

His presence was reassuring: younger looking than his 42 years, trim, handsome, athletic, with a fine sweep of brown hair and a freckled face that reddens a bit when he smiles. He began the examination by observing, "Looks like you've got the old politician's malady. They get it from arm-twisting, hand-shaking and back-slapping."

I was given some wrist tests and X rays. Then Nirschl started to do his number. "Touch your toes with your knees straight," he said. "That's all right—Tom Okker couldn't either. Now try to scratch your back with your right hand."

With a final flourish, Nirschl pulled out a tape and measured my right hand from the second crease of the palm to the tip of the ring finger. It measured 4‚Öù". "I discovered that this correlates to grip size," he said. Among tennis people this may be Nirschl's most noted innovation, of which he can claim many.

His treatments for tennis injuries break down into four categories: relief from inflammation by means of elevation, heat, ice, pills, shots and braces; changes in equipment and strokes; exercises; and, should all else fail, surgery. The first and fourth measures—minor therapy and surgery—are familiar to most doctors, although Nirschl generally shuns the scalpel. It is his uses of seemingly nonmedical ideas that make him a bona fide tennis doctor, as opposed to a doctor who treats tennis injuries.

One of Nirschl's firmest beliefs is that injured parts must be rebuilt as well as rehabilitated or they will atrophy from disuse. "There's a lot of mythology about getting musclebound," he said as he showed me to a room in which he keeps Nautilus weight-lifting machines. "When I was growing up in the '40s and '50s, anyone who lifted weights was ostracized. But if properly administered, weight lifting can improve both strength and flexibility."

Nirschl insists on weights for most of his patients, whether they are young men or 80-year-old women recovering from broken hips. And lest one assume that the exercises deal with injured parts alone, he said, "We make the mistake of zeroing in on one part of the body when others also are involved. If you hurt your knee, your arms and shoulders will have to work much harder to compensate." Nirschl had me try touching my toes and scratching my back to determine if ligaments and joints elsewhere had affected my wrist. He found my overall coordination average, which was a relief to me. I never earned enough letters to spell the word "jock."

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 4‚Öû" 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."

Nirschl handed me the phone. "Is this guy a quack?" I asked Smith.

"Not at all," Smith said. "A lot of guys have seen him and he's been very helpful. Very few doctors have done the amount of research he has. And I definitely agree with him on positioning. It's very critical."

By now swelling at the thought of the tournaments I would win after seeing this guru, I obtusely suggested to Smith that he must owe his comeback entirely to Nirschl. "Well," he reminded me, "I think I've been playing better, too."

Nirschl brought me further down to earth that afternoon in his parking lot when I took out my racket and began pantomiming strokes for him. His comments ought to be protected under the most sacred canons of doctor-patient confidentiality but won't be. "Your weight's back," he said. "You're not transferring it forward and you're probably rolling your wrist. Your stroke is tentative and the racket's too close to your body." It's a miracle, I thought, that I don't have elbow trouble, too.

I was convinced that poor positioning contributed to my ailment. I'm always late getting to the ball (in high school I was called Snowshoes). Nirschl gave me prescriptions for Butazolidin and a painkiller called Empirin. I was to wear a wristband, take aspirin before playing and do some mild weight lifting. Before leaving Arlington, I was also fed to the Stan Smith heat machines. In a whirlpool, I was given ultrasound, a common practice in which sound waves are sent into the injured muscles to increase circulation. The galvanic stimulator, which pumps direct current into the patient, is not as well known. A couple of wet pads were attached to my wrists, the machine was turned on and my arms began to twitch and shake as 80-100 volts juiced me up. The feeling was more eerie than painful; it was as if a tiny mouse were charging up and down my veins.

As the treatment ended and Nirschl and I prepared to part, I noticed a picture of another doctor, Julius Erving of the New York Nets basketball team, on the wall. Dr. J, who has had knee trouble for years, is attached to a galvanic stimulator before every game.

By now I wasn't sure which doctor was treating me. What would happen next? Would I get a triple-pump cortisone shot? A slam-dunk into the whirlpool? Nirschl stuck out his hand. "Squeeze it," he said. "Harder." There was no pain. The Doctor was doin' it.