The world’s top players have to slog through some epic matches. Little wonder they occasionally need medical care. How do slams keep these pit stops fast and fair?
Injury can threaten to derail triumph for the world’s best tennis players during a grand slam. That’s why the ability to have occasional medical treatment is part of the game. First seed Rafael Nadal, Austrian Dominic Thiem and American Danielle Collins, for example, are among players to call for medical timeouts at the Australian Open this year.
The Open has more than 90 medical professionals – physios, massage therapists, doctors – to tend to athletes before and after matches. But the pressure on them really dials up when players are injured on court – where medical time-outs don’t last long.
“You need to be confident that whatever you’ve decided to use to treat that player, you can complete within three minutes,” says physiotherapist Melanie Omizzolo, the Australian Open’s manager of health and wellness. “It really is a pit stop.”
Adding to the pressure is the potential for a pause in play to spark controversy. Eyebrows can be raised when a timeout called by one player breaks their opponent’s momentum. Yet experts say the current rules are the best way to keep the game fair.
So, how does the medical timeout rule work? What injuries are they allowed for? And what else can you have a break for during a grand slam match?
Felix Auger-Aliassime was granted time out for ankle strapping during a marathon quarter-final at the Open in 2022.Credit:Getty Images/Kathleen Adele
First, what kind of injuries do players get at the Open?
“Show me any professional athlete who doesn’t have something going on,” says former Australian Open head physiotherapist Anne-Marie Cavanagh, of players’ recent niggles or old injuries. “You would be hard-pressed.”
It’s not so much tennis elbow that’s likely to afflict the world’s best – that’s more typical in social players – but more injuries to their lower back and shoulders, Omizzolo says. A player will serve more than 100 times in a singles match – some hitting the ball faster than 200 kilometres an hour – each time using the same muscles, ligaments and tendons. “That repeated nature of the serve on the back and on the shoulders tends to take the toll on them the most,” she says.
Because it’s played on hard courts, the Open exerts more force through the body than clay courts (think, the French Open) or grass (Wimbledon). “The loads going through our joints, our body and our soft tissues are a lot higher,” says Cavanagh, who since 2015 has worked privately with players including Serena and Venus Williams. The harder surface can cause problems for tendons in some players’ lower limbs, she says. And, unlike the hard-court US Open (in late August) the Melbourne tournament is the first grand slam of the year. “After an off-season, you can imagine for some players that there’s a huge spike in activity, so tendons do respond unfavourably.”
‘Most of them will have trouble with blisters on their feet, some will have blisters on their hands.’
Melanie Omizzolo, physiotherapist
Not all aches and pains are musculoskeletal. High temperatures and hard surfaces produce painful blisters for players, requiring dressing and taping before matches. “Most of them will have trouble with blisters on their feet, some will have blisters on their hands,” Omizzolo says.
Temperature is a risk to players’ health in other ways, too. The tournament uses a heat stress scale – that accounts for air temperature, radiant heat, humidity and wind speed – to inform its chief medical officer and referee whether to call a 10-minute break during play.
“[Players] can come off the court to have a cold shower, change their clothes, freshen up, and the idea is to prevent heat illness,” Omizzolo says. “We also have ice towels on every court that players can use throughout the match to put around the neck as they change over to try to keep their core temperature down.”
Rafael Nadal receives attention after requesting a medical timeout on January 18 at the Open.Credit:Getty Images
When can a player ask for medical timeout, and what for?
Unlike in many sports, elite tennis players with their own medical team cannot access these practitioners once on court. “It’s not designed to be like a basketball timeout, for example, where you can stop and collect your breath and have a bit of a break and speak to your coach,” Omizzolo says. “So to try and keep that fair, so that it’s only being called for medical attention, to have impartial therapists is the only way to do it.”
The rules, part of the Grand Slam Rule Book first formed in 1990, allow players to ask the referee for a medical assessment for a treatable injury. This can happen during play (say, if the player sprains their ankle in the middle of a point and cannot continue) or during the 90-second change of ends, if an injury such as a blister has developed.
A therapist then has a “reasonable length of time”, generally about two minutes, to make a call about their condition. (This can take longer for some ailments.) If they decide the player needs treatment, the treatment can last no longer than 180 seconds – and the pressure is on. “You need to have a lot of training to be able to do this, even if you’re an excellent sports physio in private practice,” Omizzolo says. “There’s 15,000 people watching you, there’s a camera right behind you … it’s full on.”
For a pre-existing injury, a player can’t call for assistance unless the injury gets worse during the match. “Say, for example, you’ve had an Achilles injury for the last 12 months,” Omizzolo says, “you can’t then decide to have treatment in the middle of the match. You could if you aggravated that Achilles injury.” On-court physios travel with tennis’ governing bodies – the Association of Tennis Professionals and Women’s Tennis Association – and build up encyclopaedic knowledge of players’ injury histories.
A player can ask for a timeout for “distinct” medical conditions that crop up but not for each related one. For example, injuries that are part of a “kinetic chain continuum” – where movement in one part of the body affects another – are considered to be one distinct condition, as are all clinical manifestations of heat illness.
Muscle cramps come in for particular regulation. They can be treated if they are part of heat illness but otherwise they’re a no-go for a medical timeout – they have to be dealt with during a change of ends or set break and even then, cramp treatments are capped at two per match. (A player who calls for a medical timeout but is found to have just muscle cramping not connected to heat illness will be asked to resume play and, if they can’t, may forfeit the points needed to get to a change of ends.)
There are, of course, some injuries that can’t be treated right there, for example when French player Julien Benneteau fell and suffered ankle and wrist injuries in the 2012 Monte Carlo Masters, forcing him to retire from the match. But Omizzolo says it is surprising what physios can achieve in three minutes. “You can really tape someone up, and they can complete a match and they can win.”
Venus Williams takes a timeout at the Open in 2021. Credit:Getty Images
What don’t you have to ask for a timeout for?
More extreme situations are dealt with by specific rules. All bets are off if an athlete is bleeding or vomiting, for example, which causes play to be paused. For a serious emergency, the medical professionals recommend the player is ruled unable to compete. Tournament officials are expected to “use great discretion before taking this action”, taking the players’ professional interests, medical advice and available information into account.
Why can the timeouts be controversial?
Pauses in play – for toilet breaks, changes of attire and medical timeouts – can be controversial if a player is perceived to be using the time to interrupt their opponent’s momentum. “We try to avoid players taking medical timeout for tactical reasons by assessing each injury on its merits,” Omizzolo says. “A physio will assess that player, and if they think it’s a non-treatable condition, then they won’t take a medical timeout.” However, this does not stop medical timeouts from becoming a source of debate among players, commentators and fans.
Australian Ajla Tomljanovic accused her opponent Jelena Ostapenko of feigning an abdominal injury in the fourth round of Wimbledon in 2021, telling the court supervisor: “You know she’s lying, right? We all know.” At the end of the match, Ostapenko retorted, “If you think I’m faking, you can talk to the physio … you have zero respect.”
Andy Murray said Novak Djokovic appearing shaky on his legs during the Australian Open final in 2015 had distracted him during the game. The then world No.1 appeared to be in pain at several points in the match, taking a medical timeout for treatment on his thumb during the first set. Djokovic later said he “felt very exhausted” during the match.
Victoria Azarenka was accused of bending the rule by taking a timeout immediately after dropping serve to Sloane Stephens in an Australian Open semi-final in 2013. She later explained she had a locked rib affecting her breathing.
In 2021, Ash Barty said Karolina Muchova was within her rights to have a medical timeout for dizziness during their Australian Open quarter-final, but Barty was just disappointed she had let that become a turning point in the match.
Toilet breaks, also for three minutes, can be a source of controversy for similar reasons. Men are allowed to take two during a five-set match – one during the first three sets, the second only after the end of the third set. Women get one toilet break during their three-set matches. Players can also take a change of attire break, extending the toilet break to five minutes.
Under the rules, if senior officials find that “gamesmanship” was involved in a break, they can issue a code violation for unsportsmanlike conduct.
Czech star Barbora Krejcikova received a code violation in her Australian Open match against Ostapenko last year for taking an eight-minute toilet break. She told the chair umpire she needed the break because she had broken her necklace.
Murray also feuded with Stefanos Tsitsipas after the Greek star took a long toilet break in the first round of the US Open in 2020. Tsitsipas said he did nothing wrong.
Under the rules, if senior officials find that “gamesmanship” was involved in a break, they can issue a code violation for unsportsmanlike conduct.
Cavanagh says there has been speculation the rules have been misused in the past. “There are a lot of people around who believe that the medical timeout rules should be abolished because they can be used for those purposes,” she says.
However, while she says policing the rules can be problematic, abolishing medical timeouts would be unfair on players.
“That’s just a very difficult topic,” she says. “I think it just has to be limited to a certain amount of time. If you can make a quick difference – and you certainly can in three minutes – it can get a player through a match.”
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