Maria Sharapova’s victory over Sara Errani 6-3, 6-2 last Saturday was remarkable for many reasons. She won the 2012 French Open in her first final on the red clay of Roland Garros. In the process, she became only the tenth female player to complete a career Grand Slam. But the most remarkable feat might have been that she was competing at all.

Rotator cuff tear
This arthroscopic image shows how one of the rotator cuff tendons (orange arrow) has pulled off of the bone, leaving a full-thickness rotator cuff tear (green arrow)
Sharapova’s battles with shoulder problems have been well chronicled. In 2008, not long after winning her third Grand Slam tournament in Australia, she developed shoulder pain. She underwent an MRI, and doctors diagnosed her with inflammation. By July her pain became so severe that she pulled out of a tournament in Montreal. She flew to New York, where she was met at the airport by renowned surgeon Dr. David Altchek. There he reviewed a new MRI and saw two tears in her rotator cuff.

After initially trying to treat her shoulder injury with rehab, she decided to have surgery in October. Sharapova told reporters in Paris that feared she might never return to tennis. “I had my doubts. I would always ask around who had such problems with their shoulder and who recovered from it, and who had surgery, and who got back to the top. And I didn’t get many answers back, which was a little frightening, because you always want to look toward the positives.”

After a long recovery that included a painful bone bruise, she finally returned to singles after a 10-month absence in May 2009. She struggled for most of the next two years as well. “It took a lot of time, it took a lot of bad losses, it took a lot of bad days. It certainly didn’t come easy for me,” she described. “I went through so many tough days to get here. I never put my head down. I was grumpy and I had my tough days and I would yell at people and say, ‘You’re promising one thing, and it’s not happening.’ I certainly had my doubts, but I kept going, and I didn’t let anybody tell me otherwise.”

Inserting anchor in rotator cuff repair
Two limbs of suture are passed through the rotator cuff tendon and are pulled down to the bone with an anchor being placed.
If Sharapova had surgery to repair a rotator cuff tear and not simply to smooth out a partial tear, then her return to the top of the sport is remarkable. Rotator cuff tears are largely problems of older individuals that develop over time and with overuse. In overhead athletes, the rotator cuff tendons help stabilize the ball in the socket while the larger muscles of the shoulder, chest, back, and arm generate tremendous force with motion. The tendons are usually inflamed or frayed, which can usually be treated without surgery. Full-thickness tears are often career-ending injuries.

A repair of a full-thickness tear involves the surgeon reattaching the tendon to bone with stitches and anchors. The overall rehab process, including weeks of immobilization, months of work to regain motion and strength, and then functional overhead training, can take many months.

Rotator cuff repair
Arthroscopic view of the same tear from a different angle showing the sutures and anchors reattaching the rotator cuff tendon to the bone.
In elite overhead athletes, there is no guarantee that they ever return. In 2006, Dr. James Andrews published the results of a study that showed that only one of the twelve professional baseball pitchers on whom he had performed a repair of a full-thickness rotator cuff tear actually returned to play at a high level. Tennis is not exactly baseball pitching, but the forces generated by the shoulder are very similar. An elite player requires a shoulder strong enough to generate crushing serves and groundstrokes thousands of times a day against the world’s top players. If Sharapova did, in fact, require such a surgery, the odds of returning to the world number one ranking, or even returning to play at all, would have been stacked against her.

It would have been understandable if Maria Sharapova had retired after surgery. She is currently the highest paid female athlete in the world, and her career as a celebrity and model likely could have gone on for years to come. But she chose to fight to get back to the court. “I love competing. There’s nothing in the world that gives you that adrenaline feel of just being in the moment of a match. There’s nothing that I’ve done in my life that’s given me that experience. This sport, it’s all in your own hands, and that’s what I love about it — that I control my own wins and losses.” Tennis fans should admire her determination to return to the top of the sport she loves.

Note: A modified version of this post appears as my latest sports medicine column in the June 21, 2012 issue of The Post and Courier.