Serena Williams Wins Australian Open Despite Rib Dislocation!

Time Out --

I watch tennis for a lot of reasons. Recently, my rationale for this pastime has expanded as I am learning all about unusual and infrequently encountered medical problems that affect young superstar athletes in the peak of their athletic prime.

Like rib dysfunction.

If you are not a tennis spectator, then let me explain. During a match, a professional tennis player is allowed to call one injury time out, at which point a trainer trots out onto the court and addresses the "injury."

Here is the USTA rule on medical time outs (italics mine):

No extra time shall be given to allow a player to recover condition. However, a player suffering from a treatable medical condition may be allowed one medical time-out of three minutes for the treatment of that medical condition.

What is treatable and what is treatment? I'm sure they don't know, so why put that word in the rule?

And three minutes to treat? Are they kidding? What's the sense? The truth is, medical time outs almost always take longer than three minutes; for example, Serena Williams took a medical time out in the women's final at the Australian Open this weekend and actually took eight minutes, on and off court!

It is really remarkable how frequently these top superstar athletes are injured during important matches.  Of course, the injuries almost always come at a time when the injured player is losing (I guess that makes sense, right?).

Description of a New Medical Phenomenon

Even more remarkable is the way I have anecdotally observed that an injury time out represents a turning point in a match. I suppose, logically, that if the trainer is able to successfully "fix" or ameliorate the injury, then the superstar player returns to superstar status and is able to better compete.

Trouble is, I don't believe that. I have to laugh every time I see this little piece of gamesmanship in action. This weekend, in the Australian Open finals, I watched the "time out turnaround event" (TOTE) phenomenon occur twice.

Ribs? I Like Mine Barbecued

In the women's final, Serena Williams (a regular TOTE user) was playing against Lindsay Davenport, and losing badly during the first set. Unforced errors, two breaks of serve, and general malaise plagued Serena's game.

Suddenly, Serena began wincing and stretching on every point, reaching for her chest wall and scowling. Then she called an injury time out. The trainer attended to Serena's rib cage as Davenport cooled her heels, and her game.

When Serena came back out to play, the TOTE reared its magical head. Serena -- showing absolutely no further discomfiture -- steamrolled Davenport for the next two sets and walked away with the title. It was a classic TOTE phenomenon.

Serena would later say that she was suffering from "rib dysfunction" and that the trainer "popped it back in," thus the miraculous recovery. She said:

"I reached for a backhand and I think it tweaked my back out, one of my ribs out"

"I finally decided, ‘OK, why don’t you call for the trainer and see if she can put it back in place?’ She did, and everything worked out" 

Problem is that there is no such thing as rib dysfunction and ribs can neither pop out nor in. Evolutionarily, the ribs developed as a solid, unmoving apparatus designed to be a source of order, design, and stability, guarding the delicate Samba dance that goes on beneath their bony framework. If ribs were poppable, there would be dead tennis players littering the grand slam courts -- and no one would ever watch!

Sure, you can find the topic of rib dysfunction on the web, but predictably, it is an undocumented, unproven, unstudied diagnosis used by non medical personnel who make money by snowing patients with exaggerated physiological descriptions of human anatomy and teleological speculations designed to baffle uninformed consumers. Here's a good example.

By the way, FSU is looking to open a graduate school teaching rib dysfunction treatment along with dozens of other unproven therapies -- so maybe Serena is on to something?

Not a Sex Gene Related Phenomenon

TOTE is not exclusive to the women's circuit. Marat Safin showed that he CAN learn something as he slumped to the sideline at a critical point in the third set when he seemed to be orchestrating a typical big match Safin breakdown.

Tied at one set each, Safin and Lleyton Hewitt were at a critical juncture in the match. Playing brilliantly in the third set, saving break points and breaking Safin's serve for a 3-0 lead, Hewitt clearly had the match momentum moving his way. After the third game of the set, Safin slammed his racquet to the court and trudged to the sideline where he promptly...called a medical time out!

It was quite humorous to watch the trainer attend to Safin. The "treatment" consisted of rubbing Ben Gay into Safin's dorsal thighs over a drawn out, unctuous several minutes (more than three, seemed to me). It was even more humorous to hear Saffin explain that there may have been trouble with the blood circulating in his thighs...egad!

It is certain, to me, that the trainers understands exactly what is happening when these superstar athletes, in the prime of their athletic lives, calls these time outs. I'm sure that if the trainers were to poke around and quickly assure the players -- within the three minutes of time allowed -- that there was nothing serious amiss, said trainers would be quickly out of work and applying for adsmission at the FSU chiropractic college.

The TOTE worked again as Safin returned to the court and proceeded to mow down Lleyton Hewitt from then on -- to convincingly win the slam.

It seems a worthwhile sports science topic -- the TOTE. A study of the process might go a long way in understanding sports physiology and psychology, and may also help, eventually to refine the rule so that it isn't so commonly abused. If I were Davenport or Hewitt, I would be even more interested in elucidation of this phenomenon.

Comments

[Joe P.]

I like eveything "popped", especially my neck. It's so safe and effective. But perhaps aroma therapy would be a useful adjunct, methane gas mandated for on-court rib pops, in and out. I've witnessed neck manipulation for enlarged lymph nodes, and heard of skull suture manipulations for seizures in a 3 year old, whose minerally aware parents had managed to produce virtually a continuous seizure disorder in their child by giving him what were in effect ground up rocks. National Health Care certainly will have to include these vital therapies.

[nick]

>Evolutionarily, the ribs developed as a solid, unmoving
>apparatus designed to be a source of order, design, and >stability, guarding the delicate Samba dance that goes on >beneath their bony framework.

apparently chiropractors don't have a monopoly on nonsense. all ribs have flexible attachment at the spine, and most have a flexible connection to the sternum as well. motion at these joints is necessary for healthy breathing. if you hold your abdominal wall in place and inhale you should be able to notice this in yourself.

and while they serve some protective function, the vital function of the ribs is to allow the lungs to reach partial vacuum so that air will flow in from the outside.

i agree that a rib literally "popping out" would be completely incapacitating, but there are certainly lots of flexible connections there, and "popping out" could be bad nomenclature for some real condition - probably a muscle cramp.

[mike]

This isn't limited to professional sports. I wrestled in high school and there was always a problem with people taking injury time outs either because they were about to lose a move or were just tired. (Injured. Oh yeah, his lungs hurt, ref!) Its easy enough to see when a whole team takes injury time one after the other, but I don't know how you could practically determine it on an individual basis.

[CodeBlueBlogMD]

Non-sense is in the mind of the beholder, I guess.

I certainly never meant to imply that the thorax was one solid bone,like the humerus, but the idea that a rib can be casually dislocated or relocated, outside of the scene of a head-on car collision is SO ludicrous that it seemed a safe subject to adumbrate. I guess I was wrong.

Insofar as your analysis:

Flexible means capable of being bent. Ribs are solid, hard bone and cannot be flexed without shattering. Neither do any of the articulations of the ribs flex. They glide-- very slightly. And they are not in any way physiologically primary in breathing, and you can hold your abdomen all day long for all I care.

Anyone who has ever done a dissection can tell you how tightly the ribs are bound to the vertebral bodies and the transverse processes. Very little movement is possible. According to Gray's (a famous Atlas of Anatomy):

"The heads of the ribs are so closely connected to the bodies of the vertebræ by the radiate and interarticular ligaments that only slight gliding movements of the articular surfaces on one another can take place. Similarly, the strong ligaments binding the necks and tubercles of the ribs to the transverse processes limit the movements of the costotransverse joints to slight gliding, the nature of which is determined by the shape and direction of the articular surfaces"

The sternocostal joints are similarly immobile.

The costovertebral joints are so tightly fixed because they are stabilizers, with no real range of motion, and have been shown by elegant biomechanical experiments to be, primarily, inhibitors of lateral bending and axial rotation of the thoracic spine.

As such, they help form a constant and fixed cage beneath which the most vital and always moving heart and lungs are protected. Evolution is as multifaceted as the ribs, and neither did I intend to imply that protection of viscera was the only function of the thoracic cage.

If you do not think the protective function of these relatively fixed structures is important, however, it is only because you lack the clinical knowledge and experience to see just how vulnerable these organs are in those who have damage to this form of armor. I am reminded of a 25 year old Carribean man I saw as a patient in a major cancer institution, who had a virulent form of multiple myeloma and had lost his central sternum to the disease. Every single day he was in danger of dying from direct cardiac contusion and the night he died we did CPR on his unprotected heart (which was palpitating visibly under his skin) with our fingertips.

To say that the ribs "allow" the lungs to reach "partial vacuum" is a weird and untamed asseveration that sounds like something written for a basic primer of respiratory physiology meant for...?? Where did you get that?

Ribs are passive and secondary in the process of respiration, basically reacting to the major muscles (diaphragm and intercostals, et al) and to gravity.

Vital function? I argue those semantics. You can breathe without your ribs, but you certainly wouldn't live long out there is the world without them. And neither would your species survive long enough to create something like, say, the blogosphere.

Bad nomenclature aside, was it not evident to all that the entire purpose of my post was to call into question the illegitimate use of the injury time out in professional tennis matches?

I must be losing my touch...or my audience...

CODEBLUEBLOGMD

[CodeBlueBlogMD]

The above comment was for Nick.

As for Dave, thank you for getting my point. Maybe someone IS listening out there.

I had similar experiences as a (bad) wrestler -- in fact, maybe it was ME calling the time out!

The difference is that in professional tennis we are talking about matches upon which millions of dollars in prize money and endorsements rest. Not to mention the grand slams which bestow on the winner a form of eternal tennis greatness -- which is priceless.

If using performance enhancing drugs is unfair, then claiming injury to cool off your opponent is also unfair, especially when the rule specifically designates that there must be a treatable problem and gives a time frame in which to perform the treatment.

[SarahW]

I can't speak for Serena's major malfunction, but I take exception to the characterization of ribs as a "solid, unmoving apparatus." Maybe in someone with ankylosing spondylitis....

[Ian]

The use of tactical delays are part of the psychological aspect of almost any game, especially amongst professional sports. Much of baseball is the constant duel between the batter in/out of the batter's box and the pitcher on/off the rubber in baseball between the split seconds of delivery. Add in the occasional visit to the mound (scaling up from catcher to pitching coach to manager), and there are real delays in the action of the game, somewhat questionable but all legal. And all add wonderfully to the tension on the field during the game.

In timed sports (football, basketball, wrestling, lacrosse, etc.), using up the clock is a drill that all players go through at almost any level. They are part and parcel of each game and its rules.

The events of the Australian Open reflect less the rules themselves and more the judges' interpretations (i.e. just how long is three minutes?How many times is one visit from the trainer?) and the players' use/abuses of those interpretations. Players should be allowed to use the rules to their advantage, whether physically or mentally. I think that Safin's use of the trainer was a great psychological ploy that worked to his favor, even if it tested the limits of the rules. I doubt that banning all trainer access would be advisable, but certainly enforcing the rules would be an effective start.

As for the bizarre justification of a "dysfunctional rib" provided by the trainer (and scoffed at by Mary Carillo during the broadcast), I am at a loss. If it is just a delay tactic, then describing the complaints a a "cramp" seems almost acceptable, if still deceptive. Why, then, come up with an absurd claim of a "dysfunctional rib?" Enough with the lies (or at least deception), let them play the game.

[CodeBlueBlogMD]

Sarah:

Why won't you read more carefully? Did I not, in the comments section right before you, explain my characterization of the ribs as a solid apparatus?

I mean, do you WANT to be roasted?

And ankylosing spodylitis? Do you even know what it is?

I could really unload on you, but...I'm tired. Just back up and reread.

[CodeBlueBlogMD]

Ian,

I dispute your characterization of lying and cheating as tactics. In chess, when I position my Knight in a key space in order to control the center of the board --that is a tactic. When I castle despite having moved a covering pawn and I hope the other player doesn't pick it up -- that's cheating.

I mean, I agree with everything you say regarding tactics and the psychological aspects of competition, but I do not believe that this particular tennis situation is included under that rubric.

That's why it bothers me.

I cannot find anywhere in the tennis guidebook where there are instructions for the judges to INTERPRET the rules. It is my belief that interpretations are needed for what falls in between the rules.

I believe that we must assume that when the rules were written, the rule writers had something specific in mind when they used the terms "treatable" and "treat" and "three minutes." I mean, three minutes are three minutes -- even by Jacques Derrida's interpretation!

Why is professional tennis considering using computers to calculate the trajectory of the ball in order to more accurately call the lines (in or out)? Because everyone understands that nowadays the stakes are SO high (money and fame) that allowing gross errors of the enforcement of the rules is unfair.

So why on earth would everyone stand by while a player, abetted by atrainer, lies about an injury and then proceeds to take three times the allowed break?

I mean they called Lleyton Hewitt for a microscopic FOOTFAULT (a persnickety and almost unreasonable enforcement of a hardly noticeable infraction) at an absolutely critical point in the match -- completely unnerving him -- and yet they allowed Marat Safin to sit on the sidelines and have his thighs massaged while completely flauting the same set of rules from the same book.

This, in my mind, is not really gamesmanship. It's cheating, and everyone is looking the other way.

[Peggikaye]

Ok ... I read what you said. It makes sense. Which is why I'm getting confused. Bear with me and be nice... I don't want to be roasted, I like the education.

I had repeated problems with severe isolated pain. I was told by a physical therapist that he thought it was a rib 'subluxation' he said they don't dislocate like ball joints, but the rib & cartilege can become 'misaligned' and cause this pain. He did some traction stuff to get it back in.
NOW ... that being said ... I also have ... Elhers Danlos type 3 (aka hypermobile joint syndrome) AND myasthenia gravis AND lupus.
So my joints don't like to stay in place anyway. (going in for knee surgery for a knee cap that won't behave itself and stay in place after a fall in december)

I do NOT have normal joints, muscles or tissues of any kind.

So, your explination makes sense to me. The PT kept saying the words with using his fingers to make quotation signs when using the word subluxation too. So ..even then I wondered if that was just the best way he could explain it to me.

I cannot imagine what kind of force it would take to cause someone with healthy muscles and joints to have this happen ... even with my problems ..it didn't JUST happen, didn't happen in the coarse of every day life, it usually happened in a fall ...

I went to a rheumatologist (a few years before the lupus diagnosis) and she took one look at me and said "with your joints, why have you not had a breast reduction?"( I was a 36 ii and medicare didn't hesitate to pay for it)
I got one ...my shoulders have not dislocated since, my rib has only 'malfunctioned' once ..and that was when I fell down some stairs when I should have been taking these MG legs down an elevator not stairs.

[Peggikaye]

Ok ...not only do I find it hard to understand the force for someone who is typically american version of healthy ..but I really find it baffling that an athlete would do it in an activity that they do all the time.

[CodeBlueBlogMD]

PK:

Please read my disclaimer on the main page. I do not offer medical advice or propose treatment.

There is no body of literature anywhere to support the notion of "subluxed" or dislocated ribs as a source of thoracic wall pain.

My specialty is interpreting images of muscles and bones. I went to medical school for 4 years, did 2 years of in-hospital medical training afterward, and followed that with a four year in-hospital training program in radiology. That's 10 years of intense study and learning. I followed this up now with 15 years of daily work in the field.

I have no interest in dissuading people from treatment they need for legitimate problems.

Some peripheral professionals and workers in the medical and rehab fields like to exaggerate what they know with unsubstantiated guesswork about physiological and pathological mechanisms they neither were copmpletely trained in nor completely understand. It's a way to legitimize what they are doing.

Most aches and pains get better by themselves in a short time period; there is also a substantial placebo effect (up to 60% of people respond to treatment for certain aches and pains with ANYTHING you give to them).

So, certain "providers" either are blind/ignorant believers in the validity and efficacy of the bogus explainations they are telling you in justifying their care; or, they are outright conning you in order to collect a fee.

I have nothing against massage therapy. It has benefits. But it should not be sold to a consumer as anything but massage. NO ONE is moving ribs around and fixing ANY biomechanical thoracic cage problem. PERIOD. As I stated above, if ribs were mobile, our lives would constantly be in danger because the HEART and LUNGS are dynamically in action just inches deep to the ribs. That's why ribs are attached so sturdily to the vertebrae and sternum.

What IS common are subtle inflammations/irritations of the ribs as well as degenerative disease at the rib attachments.

People with inflammatory arthrits or connective tissue disease (like Elhers Danlos and certain forms of lupus)have special problems including laxity of joint capsules and recurrent inflammation of joints.

THESE PROBLEMS IN THESE SPECIAL PATIENTS MUST BE PRIMARILY EVALUATED BY A RHEUMATOLOGIST.

It is in PRECISELY this kind of situation (with ED or lupus) where perpipheral practitioners can do real and severe DAMAGE to the joints and muscles they are working with, because these conditions could possibly be made worse with the wrong type of manipulation.

NO amount of "manipulation" is going to significantly decrease joint inflammation AND whenever one's joints are "inflamed" one runs the risk of damaging them with overuse -- so the inflammation must be gauged and assessed by a specially trained physician -- the rheumatologist. Only then, with that physician's blessing, should one pursue other avenues of treatment for unexplained pain/swelling/inflammation.

[David]

Shocking! Professional athletes push the limits of the rules during major competitions for their OWN ADVANTAGE!

Alert the news media!

[peggikaye]

And you have made more sense in your explination to me than any chiropractor ever has! That makes total sense. It also makes sense with the PT's using the subluxation in quotation's ... as if it was the best way to describe it to me but wasn't the exact medical cause of what was happening.

I love learning this stuff, and feel the more I learn about it, the better patient I will be & the more informed I will be about treatments and also the less likely to fall victim of things that will cause further harm.

Then there is the added natural interest in that I wanted to be a doctor ... always ... and had I not been such a stubborn brat of a teenager, I probably WOULD have become a doctor. (Except that I got sick at 24 and probably would not have been able to finish). So I find all of this information fascinating in general. The first several years of my illness, my neurologist would parade every female medical student in her 30's past me, showing me that it wasn't too late, I noticed, as I didn't go into remission, that happened fewer and fewer times. Now he introduces me to medical students so they can meet a myasthenic, rather than me seeing that 30 isn't too late to start medical school ..besides ... now I've hit 40.

Just as a side note, the FSU Chiro Proposal was shot down by the Board of Governors (finally).

[Jeanne]

My child had Lupus.They let her starve to death much like Terry Schiavo--only worse. Fed her 100 mg Cortisone, THEN removed "generous portions of her heart" against family wishes. NO organ was problematic without 7 years of UNWISE use of high levels of Prednisone, which eventually affected hip bones requiring replacement. Why do so many people want OTHER people to die prematurely? lying on gurney for 8 hours without food/water is CRAZY "medical treatment."that lead to her demise.

[joshua]

If two your ribs squeze together between one notch in the spinal column I'm not sure what to term that but rib dislocation. It certainly hurts and it visualizes on an x-ray. You are clearly not an orthepedic physician.

[Nicole]

I have to make a comment concerning your statement that there is no such thing as rib dysfunction or ribs dislocating. You are incorrect. I have five ribs, which have been dislocating regularly for the last four weeks. The doctors and physical therapists are able to put them back where they are supposed to go with gentle manipulation, but they continue to dislocate. My case is a more severe case than it seems you listed above, as mine do not respond to the manipulation.

The ribs are bones, but the problem occurs in the ligaments and cartilage, which holds them in place. This is an actual diagnosis, and if you review it on the web you will find doctors sites listing this as a problem. I encourage you to ask your own doctor about it, if you still believe that it is not an actual diagnosis, or talk to someone who has it, and perhaps you can see the rib poking out of their back near the spine (which mine does).

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[Andrew]

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To say a 'rib dislocation' was causing her discomfort was probably an exaggeration. But aggravation to the rib capsule/ligaments and surrounding musculature as a result to the rib aggravation, is definatly an existing condition.

[gandi]

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