Given the increasing popularity of tennis, more and more players will present with injuries to the heel, Achilles, and ankle. These authors offer expertise on the mechanics of injury as well as exercises you can recommend to players for their rehabilitation to get back on the court.

Tennis has been one of the fastest-growing traditional sports in the United States during the past decade. With an estimated 46 percent increase in the number of participants, tennis has outpaced the growth of other popular sports, including baseball, ice hockey, gymnastics and football.1,2

The sport of tennis has changed significantly in the past 25 years. New equipment, including racquets and polymer strings, has increased the speed of the game even for the recreational player. The physicality of the sport is demanding with rapid changes in direction and frequent stopping and sprinting. Differences in skill level, court surface type, player age and physical conditioning can further influence or complicate injury manifestation.3,4

As a result of these changes, we are seeing an increase in the number of foot, ankle and leg injuries. The treatment and prevention of these injuries continue to change as well. With this in mind, we would like to share our experience with the management of these injuries.

In a prior study on 376 participants, Feit and Berenter determined that common foot and ankle injuries in tennis players included Achilles tendon injuries, plantar fasciitis, ankle sprains, subungual hematomas, muscle cramps and blisters of the feet.5 In recent years, we have seen an increased incidence of hip, hamstring, groin and thigh muscle injuries. We believe the increased speed of the game has contributed to this.

A Closer Look At The Mechanisms Of Tennis Injuries

Understanding the most common strokes in tennis will help the coach and practitioner in the prevention and treatment of these injuries.

When hitting a forehand (see above left photo) or a backhand (see below right photo), most players use an open stance, which places a majority of the stress on the rear hip, thigh and calf during the backswing, and the weight transfers to the opposite foot after contact with the ball. The player is more prone to a muscle injury of the hip, thigh or groin. After one hits a wide forehand or backhand shot, the groin and ankle are prone to injury as the player tries to plant the outside foot and recover back into the court.

When hitting a serve, the calf muscle and Achilles tendon are most prone to injury, which is a result of stress on the legs and hips during the ball toss. Then there is a rapid jump to make contact with the ball and a forceful landing on the the back leg during the follow through as the back leg moves forward into the court (see photos below). The gastrocnemius muscle is susceptible to injury when a rapid eccentric contraction occurs as the foot experiences rapid dorsiflexion in the presence of knee extension. Although this is common when serving, it may also occur after an overhead smash or when chasing after a short ball.5

When Tennis Players Develop Muscle Strains

The most common muscle strains in tennis players are to muscles like groin and calf muscles that cross two joints. Injury most often occurs when the efforts of the adductors and hip flexors are opposed by lateral momentum, and contraction results in muscle tearing rather than the anticipated deceleration.6

Predisposing factors to muscle strains include muscle weakness, muscle imbalance and a lack of flexibility of muscles and the associated ligaments.7,8 The hamstrings, another common site for injury, should be at least 60 percent as strong as the quadriceps or injury to these muscles is likely.9,10 In recent years, players have been hitting forehand shots with the majority of the weight on the leg farthest from the net in an open stance position (see above left photo) As a result, players often develop one leg that is stronger than the other, which potentiates injury.

Many young tennis players often have weak lower extremity muscles and therefore do not have sufficient strength to hit the ball the way older players do. They must instead rely on biomechanical efficiency and looser string tension to hit the ball with more pace. If there are deficits anywhere in the kinetic chain, there will be an increased load of other joints and muscles, which leads to increased injury risk.8

Patients with hamstring and groin injuries commonly receive physical therapy including phonophoresis, electrical stimulation, taping and ice. These injuries will often keep a player off the court for two to six weeks, depending on the severity of the strain or tear. Continuing to play on the injury will only make it worse.

The calf muscle is a very common site of injury. The medial head of the gastrocnemius muscle is the site of predilection for calf muscle tears.11,12 The mechanism of injury is the result of a sudden step or jump producing an acutely painful situation that players describe as having been struck hard with a club on the back of the calf.

When it comes to calf muscle strains, patients typically receive physical therapy modalities including phonophoresis, electric stimulation and passive motion exercises. Immobilization is not recommended unless it is a severe tear or there is Achilles tendon involvement. Patients should apply topical anti-inflammatory gel in the form of diclofenac gel three times a day and seek treatment with a physical therapist.

Keys To Addressing And Preventing Achilles Tendonitis

Achilles tendon injuries may be acute or chronic. A sudden significant increase in activity or the effect of long-term repetitive stress on the tendon may lead to the development of microtears with or without calcium deposits, or degenerative changes. The area located 2 to 6 cm above the insertion of the Achilles tendon in the posterior aspect of the heel is the most common site of injury. This region of the tendon has poor vascularity and is more prone to injury. Calcaneal eversion, a plantarflexed first ray, flexible forefoot valgus and abnormal pronation may contribute to this injury as well.13,14Rapid, abnormal pronation in gait results in a whipping action of the Achilles tendon, producing an increase in friction between the tendon and peritenon.

Initial treatment for Achilles tendonitis should include a heel lift, ice, topical diclofenac gel, a night splint and rest. If the patient is limping, controlled ankle motion (CAM) walker immobilization may be needed for two to four weeks prior to physical therapy and rehab exercises.

Once the inflammation resolves, we recommend custom orthotics that would include a semi-rigid material (i.e., polypropylene). This material will have some flex when the patient is playing but still provide adequate support. We do not recommend rigid materials for tennis players. A rearfoot post is needed with Achilles tendon injuries to help prevent overstretching of the tendon and further injury. Top covers with nylene and Poron will provide more shock absorption and minimize stress on the lower extremity.

Pertinent Insights On Ankle Sprains

An ankle sprain is a common injury that will prevent the player from competing for two to six weeks, depending on the severity of the sprain. The most common mechanism involved is a plantar flexion inversion type injury. Etiologic factors that predispose the athlete to ankle sprains include a rigid forefoot valgus or plantarflexed first ray, rigid or high degrees of rearfoot varus, limited ankle joint dorsiflexion, intoeing conditions, limb length discrepancy, muscle imbalance or weakness, fatigue, ligamentous laxity, shoes and playing surface.15

Treat grade 1 ankle sprains with ice, compression and proprioceptive exercises. Grade 2 ankle sprains require CAM walker immobilization for two to four weeks followed by the use of an ankle brace. Physical therapy is very helpful after three weeks to help reduce the pain and inflammation. A popular ankle brace for college and professional players is the ASO ankle brace, which patients wear over a sock and has laces with Velcro straps for support. Taping is not as popular anymore as we have found it often loosens up 50 percent after one hour of use. Patients can tighten ankle braces periodically as needed if they are wearing them while playing.

Grade 3 ankle sprains will require more time off the court as they often require six weeks of immobilization in a CAM walker and ankle brace, and then at least four weeks of physical therapy prior to the patient returning to the court. Even after the ankle heals from a sprain, we recommend using an ASO ankle brace for at least one year after the injury for grade 2 or grade 3 sprains to help prevent recurrence. Despite proprioceptive exercises, the ankle is vulnerable to recurrence with the physical demands of playing tennis.

How Can Tennis Players Recover From Plantar Fasciitis?

Pain in the heel and arch is a common injury in tennis players. This injury is a result of chronic overuse caused by microtearing of the fascia fibers secondary to longitudinal midtarsal joint supination with subtalar joint pronation. The microtearing that occurs initiates an inflammatory response in an attempt to repair the damaged fibers. The pain produced is most often localized to the attachment site of the plantar fascia at the medial tubercle of the os calcis. Pain may be most severe when taking the first few steps out of bed in the morning or when warming up to play tennis. The pain may gradually lessen with exercise only to return after a period of rest.

Treatment for plantar fasciitis should initially include ice, calf stretching, over-the-counter orthotics, oral anti-inflammatories and using more supportive shoes. If the pain persists, treatment often includes a night splint and a corticosteroid injection. For long-term pain relief and prevention of recurrence, we often recommend custom orthotics. We recommend a semi-rigid polypropylene device with a soft top cover. Research has shown that custom orthotics help reduce peak pressures on the feet at specific plantar regions, which will help prevent recurrence of the injury.16

Preventing Injuries Before Athletes Take The Court

Fitness training has evolved in recent years to help prevent injuries and enhance play. Prior to playing, patients often perform dynamic exercises to help warm up the hamstring, groin and hip muscles. This may include straight leg swings, skipping, light jogging and side to side shuffling. After playing, static stretching and yoga exercises are the most important factors in muscle recovery and maintaining elasticity of the muscles. Professional players such as Roger Federer and Novak Djokovic will often spend 30 to 60 minutes stretching and doing yoga-type exercises after a match or long practice.

The top five most important stretches or yoga positions after practice include hamstring stretching with a strap or elastic band. The safest way to do this stretch is while the patient is lying on his or her back, and keeping both legs straight. Then the patient should slowly elevate one leg with the use of the strap until he or she feels resistance. Have the patient hold the stretch for at least 30 seconds. It is vital to also stretch the iliotibial band at the same time. The iliotibial band often contributes to knee and thigh injuries. The patient can also stretch the iliotibial band easily while lying on his or her back by simply moving the leg medially with the strap.

Other vital stretches include the crescent lunge, which will stretch the plantar heel and arch, hip, calf and thigh muscles. The groin and quadriceps stretches are also essential after playing.

Another important yoga stretch after playing is the pigeon pose, which creates a deep hip opening while also stretching the quadriceps and hip flexors for the side of the upper leg (see left photo).

Strength training is a vital part of a tennis player’s training not only to help improve his or her game but help prevent injury as well. Some exercises that are very helpful are lunges, rotational exercises with a medicine ball and balance exercises with the feet flat or the heels raised in a semi-seated position known as a chair pose (see below photos). When performing this exercise with a medicine ball, patients will strengthen core muscles as well as the peroneals, calf and quadriceps.

What You Should Know About Knee Injuries On The Tennis Court

The sharp side-to-side movements in tennis predispose the athlete to significant valgus and rotary stresses on the knee. The most common injuries include patellar tendonitis, patellofemoral pain, meniscus injuries and cruciate ligament damage. These side-to-side movements require pushing off with the knee in a flexed, valgus and externally rotated position. This places abnormal lateral forces on the knee extensor mechanism, contributing to injury. Some predisposing factors to knee injuries in tennis players include playing surface, shoe gear, increased femoral anteversion, increased external tibial torsion, increased genu valgum and excessive foot pronation.17,18

Patellar tendonitis is a common knee injury in tennis. This may be caused by the constant bending, jumping and pushing off during the recovery of wide shots. This repetitive action leads to fatigue and tissue microtearing at predisposed areas near the insertion of the patellar tendon. Microtearing often occurs at the lower pole of the patella. A hypermobile patella or tight iliotibial band are often etiologic factors in patellar tendonitis.19,20 Treatment often includes ice, physical therapy and use of a patellar tendon strap/brace.

Dr. Feit is in private practice in Torrance and San Pedro, Calif. He is the President of Precision Foot and Ankle Centers.

Dr. Kashanian is in private practice in Torrance and San Pedro, Calif.

Mr. Feit is a research assistant at Precision Foot and Ankle Centers.

References

1.     United States Tennis Association. Tennis fastest growing sport in America. Available at www.usta.com .
2.     Gaw C, Smith G. Tennis related injuries treated in United States emergency departments, 1990-2011. Clin J Sport Med. 2014; 24(3):226-232.
3.     Perkins RH, Davis D. Musculoskeletal injuries in tennis. Phys Med Rehabil Clin N Am. 2006; 17(3):609-631.
4.     Bylak J, Hutchinson MR. Common sports injuries in young tennis players. Sports Med. 1998; 26(2):119-132.
5.     Feit EM, Berenter R. Lower extremity tennis injuries: prevalence, etiology, and mechanism. J Am Pod Med Assoc. 1993; 83(9):509-514.
6.     Balduini FC. Abdominal and groin injuries in tennis. Clin Sports Med. 1988; 7(2):349–57.
7.     Liemohn W. Factors related to hamstring strains. J Sports Med. 1978; 18(1):71–6.
8.     Hjelm N, Werner S, Renstrom P. Injury risk factors in junior tennis players: a prospective 2-year study. Scand J Med Sci Sports. 2012; 22(1):40-48.
9.     Burkett LN. Causative factors in hamstring strains. Med Sci Sports. 1970; 2(1):39–42.
10.     Casperson PC. Groin and hamstring injuries. Athlete Train. 1982; 17(1):43.
11.     Miller WA. Rupture of the musculotendinous juncture of the medial head of the gastrocnemius muscle. Am J Sports Med. 1977; 5(5):191–3.
12.     Millar AP. Strains of the posterior calf musculature. Am J Sports Med. 1979; 7(3):172–4.
13.     Leach RE. Achilles tendinitis. Am J Sports Med. 1981; 9(2):93–8.
14.     Nelen G. Martens M. Surgical treatment of chronic Achilles tendonitis. Am J Sports Med. 1989; 17(6):754–6.
15.     Petrov O, Blocher K. Footwear and ankle stability in the basketball player. Clin Pod Med Surg. 1988; 5(2):275–90.
16.     Hodge MC, Bach TM. Orthotic management of plantar pressures and pain in rheumatoid arthritis. Clin Biomech. 1999; 14(8):567-575.
17.     Gecha SR, Torg E. Knee injuries in tennis. Clin Sports Med. 1988; 7(2):435–52.
18.     Milgrom C, Finestone A. Patellofemoral pain caused by overactivity: a prospective study of risk factors in infantry recruits. J Bone Joint Surg. 1991; 73A(7):1041–3.
19.     Ferretti A, Ippolito E. Jumper’s knee. Am J Sports Med. 1983; 11(2):58–62.
20.     Martens M. Wouters P. Patellar tendonitis: pathology and results of treatment. Acta Orthop Scand. 1982; 53(3):445–50.

For further reading, see “Key Insights On Treating Tennis Injuries” in the August 2005 issue of Podiatry Today or “Pertinent Insights On Preventing Injuries On Tennis Court Surfaces” at http://tinyurl.com/go7kd34 .

Your heels allow your feet to move around comfortably and provide crucial support when you’re participating in athletic activities. When your heels are painful, it limits your ability to walk, jump and perform other common actions. Learn how a foot doctor at Precision Foot and Ankle Centers in Torrance, San Pedro and Los Angeles, CA, can treat your heel pain and related foot problems.

Common Reasons for Heel Pain
A problem in the heel doesn’t always start there. Sometimes heel pain sources from problems in other parts of the foot. For instance, heel pain often occurs in patients who have a foot ailment called plantar fasciitis. The plantar fascia ligament runs under the arch of the foot—when it is irritated, it puts a strain on the heel. Painful heel (bone) spurs start to develop as the body tries to compensate for the damaged ligament.

Don’t Ignore It
No matter the cause, it’s not wise to ignore heel pain. Persisting pain is a sign that something’s not quite right and needs to be treated before it gets worse. In more serious cases, surgery becomes the only way to correct your foot problem, and that can take you off your feet for an extended period of time. So, it’s best to have your Torrance, San Pedro or Los Angeles foot doctor diagnose and treat your heel pain as soon as it starts to become a chronic problem.

Possible Heel Treatments in Torrance, San Pedro and Los Angeles, CA
There are a few helpful heel treatments that you should discuss with your podiatrist. They may resolve the problem without the need for invasive surgery:

- Physical therapy and special exercises to help heal foot ligaments.
- Ice pack therapy to ease inflammation and pain in targeted areas.
- Custom orthotic inserts designed to give you a proper arch and foot support.
- Shoes that are designed to cushion the heel and the sole of the foot.
- Foot taping to allow the muscles, tendons and ligaments to heal properly.
- Cortisteriod injections to reduce inflammation and pain.

Take Steps Toward Relief
If you’re feeling heel pain on a daily basis, pain that’s interfering with your daily routine, calling Precision Foot and Ankle Centers in Torrance, San Pedro and Los Angeles, CA, is a step in the right direction.

Could your foot or leg pain be caused by flat feet? The doctors at Precision Foot and Ankle Centers in Torrance and San Pedro explain a few signs you may notice if you have flat feet.

Flat feet signs and symptoms

If most or all of the sole of your foot makes contact with the ground when you stand, you have flat feet. Your arches help support the weight of your body. If the natural arch disappears or was never present, the tendons and ligaments in your feet become weak. You may notice several symptoms if you have flat feet, including:

• Pain: Pain is common in your foot, ankle and lower leg due to weak tendons and ligaments. If your posture is affected by your condition, you may also experience pain in hips and lower back.
• Uneven Wear on Shoes: Take a look at the heels of your shoes? If you see signs of uneven wear, arch problems may be to blame.
• Difficulty Standing on Your Toes: Can you stand on your toes to retrieve an item on a high shelf? If toe standing is difficult, you may have flat feet.

Common causes of flat feet according to your Torrance, San Pedro and Los Angeles, CA, doctors

Some people are born with flat feet and others develop the problem later in their lives. You may be more likely to develop flat feet if you:

• Are female and over age 40
• Have certain neuromuscular diseases, such as muscular dystrophy, cerebral palsy or spina bifida
• Are obese
• Spend hours on your feet every day
• Wear high heels frequently
• Have diabetes or high blood pressure
• Wear shoes that don't have adequate arch support
• Have sprained your ankle or injured your foot
• Have rheumatoid arthritis
• Have a tight Achilles tendon

How can a podiatrist help me?

Pain from flat feet can be eased by wearing orthotics, custom-made shoe inserts designed by your foot doctor. You may also benefit from toe exercises or exercises to stretch your Achilles tendon. Your podiatrist may also recommend that you participate in physical therapy in addition to performing exercises at home. Although surgery isn't usually needed, it may be recommended if your Achilles tendon is too short or if your condition is caused by an instability in the bones of your foot or ankle.

Find out how you can reduce your pain with a visit to the foot doctor. Call Drs. Feit, Feradouni and Kashanian, your Torrance, San Pedro and Los Angeles, CA, podiatrists at Precision Foot and Ankle Centers.

Do you think you have a toenail fungal infection? Find out why you shouldn’t just ignore it.

A toenail fungus can certainly be ugly to look at, causing your toenail to turn yellow and brittle. Of course, a fungal infection does more than just affect the physical appearance of your toenail, so it’s important that if you are experiencing symptoms of a toenail fungus that you visit one of our Torrance, CA podiatrists, Dr. Eric Feit, Dr. Armin Feradouni or Dr. Alona Kashanian.

If you ignore a toenail fungal infection then you could end up dealing with any of these potential health problems:

Foot pain: A nail that has a fungus can become malformed. The nail may also thicken, which can cause pain. You may no longer be able to comfortably walk around in shoes without experiencing discomfort. If you do notice this problem it’s time you visited our Torrance, CA, foot doctors for care.

The spread of infection: A fungal infection won’t always just remain concentrated in the nail of your feet. Sometimes it can even spread to the skin around your foot. This can cause a nasty little condition known as athlete’s foot, which causes skin to become red, cracked, itchy and irritated. How does this infection spread? Fungus loves dark, warm environments, so if you wear shoes and socks all day you could be creating a perfect environment for the infection to spread.

A systemic infection: If you are someone who has been diagnosed with diabetes or other health problems that affect your immune system, then it’s particularly important that you seek immediate treatment for a toenail infection. By not doing so, you leave yourself open to severe health complications like cellulitis, a serious skin infection that will require antibiotics.

Nail loss: One common issue for those with toenail fungal infections is that sometimes the nail will separate from the nail bed. If this happens, the loose part of the nail will need to be removed by a medical professional. In some cases, the whole nail may actually be removed if it isn’t responding to any standard treatments.

Don’t let a fungal infection affect your foot health. The experts at Precision Foot and Ankle Centers in Torrance, CA are here to help. Don’t hesitate to give us a call today!

It’s important to recognize when conservative treatments aren’t working and surgery is the best answer.

It can be difficult sometimes to know when it’s time to acknowledge that all the treatments you’ve been trying just aren’t enough to give you the relief or full results you need. Of course, our Torrance foot surgeons Dr. Eric Feit, Dr. Armin Feradouni and Dr. Alona Kashanian are here to help you decide when surgery is right for you. Find out the most common types of foot surgeries and when it might be time to consult us about surgery.

Hammertoes

This foot deformity causes one or more of the toes to become stiff and bent (the toe will look similar to a claw). While many patients can get relief and manage their symptom through more conservative treatment options, if you are still experiencing pain and are unable to flex or straighten out your toe then the only option may be to get foot surgery to correct the toe’s shape.

Bunions

This bony growth that juts out from the joint at the base of the big toe can sometimes respond to more conservative care but if treatments aren’t targeting your symptoms, and severe and constant pain is making it difficult to move around and perform your day-to-day activities, then it might be time to consider getting bunion surgery.

Arthritis of the ankle

Osteoarthritis is usually to blame for ankle arthritis. If pain, swelling or a joint deformity has become severe enough then you may need to get foot surgery in Torrance to get rid of your pain. Common surgeries for ankle arthritis include ankle fusion, triple fusion, and ankle replacement.

Achilles tendon disorder

As we age, the Achilles tendon starts to wear away. As this happens people often experience pain and swelling. If these symptoms are severe enough or if the Achilles tendon ruptures, surgery may be the chosen method for treating your condition and getting the tendon to fully function again. During surgery, the damaged tissue is often removed and then our Torrance foot and ankle surgeon will focus on repairing and rebuilding the tendon.

Don’t let foot pain and discomfort keep you from the life you deserve. If you’ve been fighting symptoms for too long then it’s time you called Precision Foot and Ankle Centers in Torrance to schedule a surgical consultation.