During last week's Australian Open semifinal match against Sloane Stephens, world number one tennis player Victoria Azarenka took a 10-minute medical break that has caused a ruckus in the tennis world. Most of the controversy has been about whether she took the break to regain her momentum after falling behind. But as an emergency room doctor, I can't help but wonder: was there any real medical justification for her break? And if not, how did she move on to the finals?
First, the background. Many have been skeptical about her break -- which violated both custom and tennis regulations -- for a number of reasons. First, she called the timeout at a strategic point in the match. Up 5-3 in the second set, she had just failed to convert five match points on her serve and lost the game, giving Stephens a glimmer of hope. That was significant: in the previous round against heavily favored Serena Williams, Stephens had pulled out a similarly tough second set after losing the first and went on to win the match. In much the same way, Stephens was halting Azarenka's momentum in the semifinal when Azarenka took the medical break for almost ten minutes. The official explanation was that Azarenka had actually taken two, back-to-back medical timeouts -- each of which is permitted to be three minutes -- for separate injuries, initially rib and then knee pain. Even so, Azarenka exceeded her allotted time by more than three minutes. After that break, she returned to the match, cured of her ailments, and won.
All observers agree that the timing of her break certainly suggested "gamesmanship," questionable (but not outright illegal) delay tactics that tennis players sometimes use to gain an advantage. Tennis commentators have heavily criticized Azarenka for this, while acknowledging that she is hardly the first, and won't be the last, to use this strategy.
But what about the medical indication for her timeouts? Was the medical staff justified in ruling this to be a "medical" timeout -- and then permitting her to return? I can think of only one syndrome that causes acute rib pain in an elite athlete at such a strategic point in the match, resolves completely within 10 minutes of treatment, and allows her to vanquish a troublesome giant-killer in a professional tennis match in near 100-degree weather: acute anxiety. This can come on suddenly, cause physical symptoms such as rib pain and shortness of breath, be debilitating, and resolve very quickly, often without medication. Now comes the sticky (at least for Australian Open officials) part: what is the difference between the medical entity that is an acute anxiety attack and what's popularly known as "choking?"
When the setting is a professional tennis match, I would argue that there is no difference. We demand a certain mental toughness from top professional athletes, especially in individual sports like tennis. Dealing with anxiety during a match is a major part of what distinguishes a Grand Slam champion from ordinary players. In tennis, mental toughness is probably even more important than the quality of strokes. Truly great players raise their game when the pressure is highest. So when the world's top-ranked player seems to use a medical timeout to avoid choking, we are justifiably disappointed. Losing with honor to a tough opponent is better than gamesmanship.
Azarenka's post-match comments belied a greater fear of being perceived as a choker than as a cheater. When asked about the timeout she took in the post-match interview, she stated she was "overwhelmed" and was afraid to commit "the choke of the century." She later stated she hadn't known the question was about her medical timeout rather than the match as a whole.
If the anxiety attack were truly severe enough to require medical attention, the medical staff should not have allowed Azarenka to return to the court. Match officials should have forced her to forfeit and undergo thorough medical evaluation by the medical staff (which takes longer than ten minutes for such severe symptoms). Azarenka is lucky that she wasn't disqualified simply for the fact that her breaks went beyond the time allowed. She should apologize to Stephens for the obvious gamesmanship and thank the teenager for showing maturity beyond her years in dismissing the issue during the post-match press conference.
Perhaps officials will use this incident to change the rules for professional tennis. Under the new system, players would be allowed to take a general timeout to calm themselves and manage the stress of, for example, losing five match points -- and won't have to make up phantom injuries to call this timeout. Instead of calling this "gamesmanship," we'll consider it simply sound strategy. This potential rule might help reduce choking -- Jana Novotna could have sorely used such a timeout in the throes of her famous choke at Wimbledon in 1993 and prevented defeat at the hands of Steffi Graf.
As a fan of tennis in general (and Stephens in particular as a young, American up-and-comer), I propose that we call this timeout the Azarenka Rule. Which is probably more appropriate than fruitlessly seeking that elusive medical diagnosis known as Azarenka Syndrome.
Amer Aldeen, MD, FACEP, a Public Voices Fellow with The OpEdProject, is assistant professor of Emergency Medicine at Northwestern University Feinberg School of Medicine.