The Curious Case of Rafael Nadal

Regular followers of this blog will be familiar with much of the material in this post, which I am creating to use as a reference, documenting some the absurd drama of Rafael Nadal, as he battles dubious injuries and follows these up with amazing performances and a near Grand Slam. It is no secret that the opinion of this blog is that Nadal is benefiting from the use of performance enhancing drugs. This post will serve as a review of some the evidence, speculation and rumors over the past few years related to Nadal and doping. Please let me know of any omissions or errors. Sincerely, THASP

Many have suspected Nadal over the years for the simple reason that he came on the scene and quickly established himself as the biggest, strongest and fastest, but paradoxically, also a player with amazing stamina. His doctor describes him as "a very special athlete, with abnormal amounts of energy and explosiveness. He mixes the explosive pace of a 200-meter runner with the resistance of a marathon runner." Many find his doctor's assessment of this as natural, especially in an athlete who rarely lifts weights by his own admission, to be a little too fantastical. This includes some sportswriters, who began to take notice of Nadal’s suspiciously muscular frame and propensity to phantom injuries allowing him to miss lesser tournaments (often a sign of an athlete who is doping and cycles to prepare primarily for bigger competitions) at least as early as ’06, when Pete Bodo discussed the possibility in Jan ’06, effectively accusing him of exaggerating an injury and suggesting the possibility that he and other players might be skipping doping tests (something that was confirmed by this blog a few years later).
Later in 2006, the Spanish doping scandal known as Operacion Puerto uncovered widespread blood doping, spearheaded by a Spanish doctor, Eufemio Fuentes. Initially, this was assumed only to involve cyclists. However, a French newspaper stated that athletes in other sports were also on the list of athletes receiving Fuentes’ services, including some top Spanish soccer players and Rafael Nadal.
Nadal, of course, denied any involvement, and Spanish sports authorities denied any non-cyclists were involved (something proven to be a lie now that Operation Galgo [Greyhound] has opened up). To this day, the full list of atheletes' names connected to Operacion Puerto has been sealed by a Spanish judge, which is consistent with the Spanish attitude towards doping spanning back at least to the Barcelona Olympics in 1992 and continuing on to the present.
Rumors of Nadal using steroids heated up again with Nadal’s impressive 2008, culminating in his epic victory over Federer at Wimbledon. This victory raised at least a few eyebrows, not the least of which was ESPN sportscaster skip Bayless, who suggested that steroids might have played a role.
Nadal went on to a victory at the Olympics that year, before succumbing to Murray at the U.S. Open and his game went downhill from there, eventually ending with a “knee injury” described as “tendonitis” and withdrawing (to boos) after losing the first set to Nikolay Davydenko at the Paribas Masters, followed by a withdrawal from Davis Cup at year’s end.
In 2009, the ITF finally signed on with WADA and it was expected that players would now be subject to stricter testing, including more unannounced out-of-competition tests (by most accounts, testing had been quite lax up to that point, as this blog has documented). No one complained more loudly about this than Rafael Nadal. Nonetheless, Nadal performed well on the court and also seemed to have no particular difficulty with his knees on his way to an Australian Open victory over Federer that had many wondering again about doping, especially because the victory came on the heels of an exhausting five set, five hour semifinal match with Fernando Verdasco, that most observers felt would be too difficult to overcome so soon before the final.
His performance began to dip in the next few tournaments, with Nadal showing more of the usual sportsmanship, calling a trainer during a loss to Murray and again citing knee problems, once again without limping. This time the problem was diagnosed as a “strained ligament”. In other words, a completely separate knee problem from the “tendonitis” he cited at the end of 2008, as Nadal was quick to point out to the press. Nadal then skipped the Barclay tournament to “recover”.
In any case, whatever treatment he received was amazingly effective, as a few weeks later he was back on the court beating Janko Tipsarivic in a Davis Cup match, then winning Indian Wells. A loss in Miami to Juan Del Potro, was followed by Nadal waltzing through the clay court season leading up to the French Open by winning Monte Carlo, Barcelona and Rome, before being upset by Federer in Madrid and then being shocked by Soderling at the French Open. Shortly before the French Open, presumably while home in Mallorca on May 18th, Nadal was given an out of competition drug test according to ITF records (these records do not tell whether a player tested positive or negative). While he doesn’t refer to his own test, Nadal openly complains about drug testing in tennis while he is at the French Open ten days later (enough time for him to be made aware of the result). He boldly suggests that he might miss his next drug test and one might wonder whether something about that drug test distracted him during the French Open. As usual, though, Nadal cites knee problems (harking back to tendonitis) and thus effectively chalks up his French Open loss to bad knees, watering down any glory for Soderling. He then withdraws from the Queen’s Club event. It is also worth noting that in the same rant in which he complains about drug testing, he appears to invent an absurd defense for Richard Gasquet’s positive cocaine test, offering hypothetically that someone could get a positive test like that just from kissing a girl at a party who had used cocaine. Amazingly, Gasquet runs with it and goes on to successfully use this absurd defense to end his suspension.
Around this time, rumors were swirling that Nadal had failed a drug test and was not going to be able to participate in Wimbledon (these rumors continue to this day). During the same time period, as promised, Nadal missed his drug test scheduled for June 14th. Thus, despite all his complaining, Nadal only received one out of competition drug test in all of 2009 according to ITF statistics (It should be noted that the ITF accidentally released their drug testing document before erasing the incidents of players missing tests and this blog was able to make a copy before it was removed from their website that is available here . It should also be noted that several other players missed tests, including the Williams sisters right before their impressive performance at Wimbledon and Roger Federer). Apparently one out-of-competition drug test during an entire year, in exchange for tens of millions of dollars in prize and endorsement money was more than Nadal could endure.
Shortly after skipping the test, we were treated to the spectacle of Nadal entering an exhibition tournament (where there would be no drug testing and presumably no restrictions for a suspended player if he was indeed silently suspended). After the usual histrionic grunts and grimaces in a loss to Stanislaus Wawrinka, Nadal informed the world that his “tendonitis” would force him out of defending his Wimbledon title in 2009.
By this point, non-astute sportscasters, who had naively provided accolades throughout these so-called injuries, either holding him up for his courage in completing the match or for his graciousness in defeat after withdrawing, were now saying that Nadal’s “knee problems” were taking a toll on him and his career might be coming to a close. A month later, Nadal was “bravely” back on the court, competing reasonably well, although not spectacularly, but was thumped twice by Juan Del Potro, first at the Rogers Cup, then in the semifinals of the U.S. Open. This time, he courageously admitted that he was battling an “abdominal injury.”
He finished off the year with a drubbing in the World Tour Finals, in which he didn’t win a match, adding more naïve speculation that his career was coming to a close due to “injuries”.
It is difficult to fully evaluate Nadal’s 2009 without knowing whether the rumor of a positive drug test is true. It also is not clear whether he would have been able to receive PRP treatments with a Therapeutic Use Exemption, which might explain why he would be so clear in stating that his "injury" against Murray was a strained ligament, rather than tendonitis, which would allow a separate round of treatments. In any case, this brings us to the farcical year of 2010…

Nadal played well in the warm-ups leading up to the 2010 Australian Open, but begins to fade there. – He gets down 2 sets and is losing the third in the quarterfinals with Andy Murray, before showing more courage and sportsmanship and withdrawing from the match. The diagnosis again being knee problems, with his doctors prescribing a whopping 2 weeks rest. Nadal also adds some drama and sportsmanship in March in a loss to Andy Roddick at the Sony Ericsson in Miami, at one point slapping at his knees and reportedly saying in Spanish, "I can't! The knee... The knee!", only later to fist pump on one leg in no apparent discomfort. At some point shortly after this, Nadal begins receiving “PRP” treatments (Platelet Rich Plasma therapy) for his knee “tendonitis.” PRP treatment involves removing blood and “enriching” it so that it is in a highly-concentrated platelet form. Platelets are a part of the blood that contains numerous growth factors and are involved in healing, so the theory behind it is more rapid healing. Whether such a procedure has any real effect is the subject of much debate. More importantly, though, it is controversial for use with athletes due to the potential doping effects of the growth factors, which include IGF-1, a high potency muscle building growth factor. In 2010, PRP was allowed by declaration (no TUE was needed) for joints, so the treatments could be delivered only for joints and tendons, but not intramuscularly without a TUE. One of the leading proponents of PRP therapy, who pushed strongly for removing any ban of its use with professional athletes, was a Dr. Mikel Sanchez, who just happens to be the doctor who performed the procedure on Nadal.
Dr. Sanchez has written numerous articles, studies and case reports related to the benefits of PRP. These studies have received some criticism for the “lack of details concerning methodology, outcomes, and follow-up.”
In fact, other independent researchers find PRP little more effective than an injection of saltwater (It might also be worth noting that Dr. Sanchez has a strong financial interest in this "technology," as he admits here: "As you probable are aware, we have been working with plasma rich in growth factors (PRGF®), the pioneer in autologous technologies, for more than a decade. Our first publication dates back to 2003 and PRGF® is one of the products, if not the product, that has been characterized more extensively in the literature, both clinically and biologically." It might also be noted that Dr. Sanchez was personally involved in getting this special treatment approved for Rafael Nadal, as he discusses in the same blog posting: "PRPs cannot be used in muscle injuries, but its use in tendinopathies is allowed after completing a TUE (Therapeutic Use Exemption) document. In fact, some representatives of the spanish anti-doping agency and the spanish olympic committee visited Dr. Eduardo Anitua´s research center in Vitoria, and granted us permission to use this treatment in this particular athlete [Nada]").
Over the past year, it has come out that this procedure is often used to mask doping. For example, recent revelations from the ongoing Spanish doping investigation known as Operation Galgo (Greyhound), show that the doctors involved were instructing athletes to fake joint injuries so that steroids could be injected intra-articularly.
Hopefully, more details will come out as Operation Galgo (Greyhound) continues. In the United States, PRP and doping were also linked when a Canadian doctor, Tony Galea, who performed the procedure on Tiger Woods, Dara Torres and many unnamed NBA players, was caught smuggling growth hormone into the country, presumably to “augment” the treatment in at least some of the athletes in question. Dr. Galea is also still under investigation.
From what can be gathered in press reports, it appears Nadal received PRP treatment at least 3 times in 2010. One of the treatments was during the clay court season, right after Monte Carlo. Nadal claimed he only received a treatment at that time in his left knee, but “didn’t have time” to get one in his right knee. This, of course, is puzzling, since one might wonder why it would take longer to treat two knees at the same time and why he would simply leave one knee untreated. One possible explanation is that Nadal needed an excuse to get multiple PRP treatments, assuming the treatments were directly or indirectly providing some performance enhancement. That way, he can get double the treatments by alternating each knee (Dr. Sanchez insists that, "In our opinion a chronic tendinopathy must be treated with two or three consecutive infiltrations.")
.

“I’m a little bit scared about the knee,’ Nadal said, and this time, he meant the right one.“

To hammer his point home, Nadal presented another theatrical display of good sportsmanship and drama in a match against Philipp Petzschner (no stranger to dodging drug tests himself ). Nadal won, 6-4, 4-6, 6-7 (5), 6-2, 6-3, but, much to the dismay of Petzschner (who later said that he thought Nadal looked like he could have run for 3 more sets), Nadal called for the trainer on numerous occasions and received quite a bit of illegal coaching from his coach/uncle, making sure that everyone knew that he had another knee problem.
Apparently, his fears were unfounded, as he went on to win Wimbledon, and was now fully set up to receive his next “treatment” before The U.S. Open, skipping Davis Cup to make sure that he was in “good health”.
Nadal then received another PRP treatment prior to the hard courts and went on to win the U.S. Open. Nadal’s performance was quite impressive, particularly his serve, which suddenly had gained 10 mph from what it was just weeks before. This was quite surprising to the broadcasters, who brought a sheepish Nadal on the air to explain this amazing transformation in his serve. Nadal chalked it up to a simple change in his grip. This obviously seemed dubious to John McEnroe, who later surmised that Nadal must have been secretly working on this new serve “for years” before unveiling it at the U.S. Open. One might wonder whether McEnroe considered another possible explanation in line with a similar improvement seen in the home run hitting of Barry Bonds, but, if so, he never went there.
As one might predict, his performance drifted for most of the rest of the year, treating us to a bonus “shoulder tendonitis” claim in dodging the Paris Masters in November (just before ironically winning the Stefan Edberg Sportsmanship award), before another speedy healing in time for the World Tour Finals where he lost in the finals to Federer. To cap off 2010, Nadal wins the Laureus "Sportsman of the Year".

2011 is shaping up to be even more farcical for Nadal. His performance in the lead up to the Australian Open was hampered by what he described as a “flu”, although without any of the usual symptoms (cough, congestion, fever, sore throat muscle aches, etc.) other than fatigue during matches which might make one wonder whether he was actually lacking some stamina enhancing supplements.
Although he won his early matches in the Australian Open, his performance seemed a bit flat, which he attributed to the lingering “flu.” In his quarterfinal match with countryman David Ferrer, we got to see another example of his courageous, Stefan-Edberg-like sportsmanship as he struggled with an apparent hamstring injury, grimacing in pain as he extended his leg and taking trips to the locker room to wrap his left hamstring, while losing in straight sets.
Inexplicably, we are later informed that an exceptionally precise MRI performed by his personal physician indicated an adductor longus “rupture” of his right leg. This, of course, is perplexing, since it was his left hamstring that was apparently injured and this is a right groin muscle. We are also told that they expected this “rupture,” supposedly visible on an MRI, will be fully healed in an astonishing 10 days. What makes this more interesting is the fact that intramuscular injections for muscle tears have just this year no longer required a TUE. Anyone that doubted Nadal's incredible capacity for healing from injuries, take note that Nadal was cured in only 8 days from his "rupture," although it again became a hamstring injury, and he resumed training.

While some might question the diagnoses and treatments of Nadal by his personal physician, Dr. Angel Cortorro, and Dr. Sanchez, who performed the PRP, it should be noted that aiding players in doping has now been made against the law in Spain, so they would be risking a lot if they are not on the up. Whatever the truth, it seems likely that another round of PRP, this time intramuscularly, will be given to Nadal as the year unfolds, with more “injuries” between amazing performances.
To be continued…

Ah yes, let's fast forward to Wimbledon, 2011, in which Nadal feigns back to back injuries. The first fake injury occurred in his match with Gilles Muller:

After the match, he said: "I felt the leg was a little bit more tired than usual. I called the trainer for that. Today I'm still feeling it a little bit, but this is not limiting my game. I can play without problems."
He was keen to explain that, despite him touching his knee at times, the problem was a muscular one rather than related to that potentially troublesome joint.

Despite Nadal's inexplicable improvement in his serve over the past year (inexplicable by natural means, that is), he has still not learned the art of faking an injury. It is interesting that he makes sure to tell us again that this fake injury was to his muscle rather than his knee, probably because he wants to get his performance enhancing PRP intramuscularly. If there was any doubt about that, Nadal clarified it for us quickly, claiming that he was going to take some time off in his doping-friendly nation of Spain, on the doping-friendly island of Mallorca, where he planned to take a month off.
That would be enough BS for most dishonest athletes for one tournament, but Nadal decided to double-down and fake yet another injury in his next match with Juan Del Potro. In this case, the hard grass surface led to an apparent heel injury. He can be seen faking a grimace here. In an unusual turn of events, several journalists seemed openly skeptical about this conveniently timed fake injury (which apparently prompted Del Potro to try his hand at faking an injury later in the match). Nadal took the unusual step of getting an MRI for his fake injury, apparently in response to these critics. Lo and behold, the MRI showed no injury (he might have had better luck if he had an MRI done back in Mallorca and read by his own doctor). This marks the first time in the history of sports that an athlete was unable to determine that he was not really injured and needed an MRI to prove to himself that hewas not actually injured. If there was still any doubt that Nadal would be back getting himself another PRP treatment, he made sure to let us know:

Rafael Nadal pulled from the Spain at U.S. Davis Cup match in Austin, Tex., following Wimbledon on Monday, slamming event organizers and the Davis Cup scheduling: “I won’t be there. The priority is to be healthy and I have to stop. I can’t be everywhere. After finishing the first part of the season I need to rest. I need 15 to 20 days to be in good shape for the second half of the season. I should have a check-up on my knees, and see how everything is going with the treatment we did, which is what has allowed me to carry on. The idea is to do what I did in 2010 to arrive the same or even better prepared for the US Open.

Once again, this post will be continued after the U.S. Open and whatever shenanigans Nadal pulls between now and then.