One of the fastest growing sports in the United States, tennis is also one of the few sports that people can play throughout their lives. More and more seniors are active tennis players and they have their share of foot and ankle injuries. Other tennis players are very similar to most weekend warriors in other sports such as running, aerobics and volleyball. It is very difficult to slow them down even if they become injured. This is the challenge for the foot and ankle specialist. How can we treat injured players and keep them on their feet? What alternative forms of exercise can we offer them that may not aggravate their current injury? If they compete in local tournaments, how can we keep them playing and still improve their symptoms? There have been many new advances in equipment over the past decade and they have dramatically changed the nature of the sport. The racquets are lighter with more shock resistance and they generate much more power. As a result, the ball moves more quickly and may result in more sudden reactions and sudden movements by an opposing player. This may cause a variety of injuries but the lower extremities are particularly vulnerable. A prior study on the prevalence of lower extremity tennis injuries surveyed nearly 400 recreational players about their types of injuries.1 The most common injuries were subungual hematomas, muscle cramps (particularly calf and foot), muscle strains (particularly groin and calf), knee injuries, ankle sprains, plantar fasciitis, Achilles tendonitis and a heel bruise (see “Prevalence Of Lower Extremity Injuries In Tennis” below).
Pertinent Pointers On Treating Subungual Hematomas
The sudden movements of starting and stopping that occur while playing tennis often cause the foot to slide forward within the player’s shoe, resulting in trauma to the toenails. The force of impact from the end of the toenail transmits proximally along the nail, resulting in disruption of the nail plate from the underlying vascularized nail bed. The painful symptoms that ensue are related to the increased pressure on the nerve endings produced by the pooling of blood within the nail bed.2 Several factors may contribute to this injury. These include improperly sized shoes, loose-fitting shoelaces, long toenails or digits, movement of the foot if wearing two pairs of socks and the hardness of the playing surface. When an injury occurs during a match, it is a very difficult problem to treat immediately. It will often prevent the player from being able to play at that time. Ideally, one would treat this injury by using a sterile 18- to 22-gauge needle to drain the fluid in the center of the nail. Once the fluid drains, the patient often has enough pain relief to keep playing. If the patient presents to the office, one should tape the toe circumferentially after drainage in order to keep the nail in place unless it is very loose. Performing a total nail avulsion will alleviate the pain but the player may not be able to play tennis for a few days after the procedure. It is important to advise the patient that if he or she leaves the nail intact and simply tapes it, it may come off on its own or develop underlying fungus.
Stressing The Prevention Of Muscle Cramps
Muscle cramps can often prevent a player from completing a match or result in limited movement for the remainder of the match. A cramp results from decreased blood volume due to an excessive loss of body water from sweating.3 Factors that influence the degree of sweating include increased heat, electrolyte loss, poor conditioning, inappropriate clothing and the duration of the match. Calf and foot cramping are particularly prevalent due to the physiologic demand athletes place on these muscle groups in tennis. This is most common when a player propels forward into the court when serving, when rushing the net, when moving laterally to retrieve a wide shot or when changing direction. The best way to treat muscle cramping is to prevent it from happening in the first place. Players should stay well hydrated and can do this by drinking water the night before playing as well as before, during and after playing a match. Physical conditioning and wearing a white shirt or cap are also very helpful in minimizing dehydration. If a cramp occurs during a match, stretching the affected muscle is vital and athletes should do this repetitively.
Understanding The Relationship Between Strained Muscles And Biomechanical Issues
Groin injuries most often result 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.4 Groin strains are most common in tennis and are usually the result of being wrong-footed when attempting to change direction or being unable to stop one’s lateral momentum by planting the leading foot. The most common calf strain is a partial tear of the medial head of the gastrocnemius muscle. Patients will often describe this injury as feeling like they have been struck hard with a club on the back of the calf. It may occur while attempting to serve, performing an overhead smash or chasing after a ball that has fallen short. The open stance forehand shot has become the most common technique in recent years. This may lead to one leg becoming stronger than the other, which can lead to injury. Also keep in mind that a muscle imbalance may predispose the player to injury. The hamstrings should be at least 60 percent as strong as the quadriceps or injury to these muscles is likely.5 Muscle strains will often prevent the player from participating for several weeks. When a player continues to play with a strained groin, hamstring, quadriceps or calf muscle, it will certainly prolong the time to recovery and may further tear the muscle, which may require surgery. Treatment usually begins with antiinflammatory medications and ice but should include non-weightbearing range of motion exercises. A well-trained physical therapist should supervise the exercises. This will help prevent scar tissue, muscle contraction and muscle weakness. Additional physical therapy may include phonophoresis with hydrocortisone cream or dexamethasone, electric stimulation and massage. Once the acute pain cycle resolves and the player can bicycle or jog without pain, then he or she should begin performing strengthening exercises. It is very important to write a specific prescription for physical therapy. If therapists do not receive written instructions, they and the patient commonly will attempt to strengthen the injured muscle too soon and wind up prolonging the injury.
Secrets To Treating Ankle Sprains
This injury is not only very common but may prevent the player from playing for several weeks depending on the severity of the injury. Many competitive players wear an ankle brace simply for prevention due to the high risk of this injury. Rapid changes in direction and jumping are the most common motions leading to injury. While playing, an athlete may need to recover from a wide shot on one side of the court and rapidly changes direction to get to the next shot. The leg follows the upper body as the player attempts to change direction. This causes the plantarflexed foot on the playing surface to invert relative to the leg. Treatment depends upon the severity of the ankle sprain. Mild ankle sprains with attenuation of the anterior talofibular and the calcaneofibular ligaments should not limit the player too much. Treatment of these injuries begins with contrast baths, NSAIDs and physical therapy. The most helpful modalities seem to be phonophoresis with hydrocortisone cream and electrical stimulation. Iontophoresis is often too painful over an acutely injured ankle ligament. Proprioceptive training should begin three weeks after the injury. If the athlete starts too soon, it may aggravate the injury. Players should utilize a tape strapping or lace-up ankle brace for at least two to three months. In cases of a more severe injury, in which the ankle ligaments are more severely attenuated or torn, we recommend our patients stop playing. This is difficult for many of them. However, we simply explain that if they play on the ankle now, they will certainly make the injury worse, which could lead to a need for surgical repair in the future. This usually convinces them to take care of the ankle for at least a few weeks. In terms of treating severe ankle sprains, clinicians should emphasize the use of below knee CAM walker immobilization for two to three weeks in a grade 2 injury and four to six weeks in a grade 3 injury involving torn ankle ligaments. After this, players should wear an ankle brace for at least one month. We prefer to use the ASO ankle brace for tennis players because it is supportive and very thin, which accommodates better than other braces for rapid side to side movements and changes of direction. Players with grade 2 injuries should not return to the court for at least one month and athletes with grade 3 injuries should stay off the court for two months. Upon returning to the court, they may not be able to play with the same quickness they once had for an additional one to two months. (If the player is an intermediate, advanced or tournament player, clinicians should encourage him or her to continue wearing the ankle brace for four to six additional months after the injury has healed. Recurrence is very high in tennis players who do not use a brace when there is a history of a severe sprain.) In more severe ankle sprains (grades 2 and 3), we recommend continued physical therapy for four to six weeks after the injury has healed. It is critical for tennis players not only to resolve their inflammation and stiffness but to improve their proprioception to help prevent a recurrence. While the “wobble” board is often used to improve proprioception, I find the mini trampoline to be the most helpful. Patients can utilize this with closed eyes initially and then open their eyes. Ask patients to balance on one foot and slowly turn their heads side to side and up and down. If they do not have access to a trampoline at home or at the gym, then they should stand on a thick pillow. If the player is an intermediate, advanced or tournament player, then he or she should consider using the ankle brace for four to six additional months when playing after the injury is healed. Recurrence is very high in tennis players who do not use a brace when there is a history of a severe sprain.
A Step-By-Step Approach To Handling Heel Pain Syndrome
Heel pain syndrome occurs primarily due to a strain of the plantar fascia. It may result from chronic overuse caused by microtearing of the fascial fibers. Predisposing factors associated with plantar fasciitis include leg length discrepancy, ankle equinus, increased training intensity, calcaneal valgus, a plantarflexed first ray and the type of tennis shoes worn. This is a very difficult injury to treat in a tennis player who does not want to take time off to heal. The biomechanics of tennis place constant tension on the fascia and aggravate microtears and inflammation. Treating heel pain syndrome in a tennis player or a competitive runner may require different methods than one might employ in treating this condition in a non-athlete. I have found that a stepwise approach is the most successful for these athletes and it is critical for them to understand that it will require a combination of different treatments to make them better rather than a single technique. Prior studies have demonstrated that nonoperative care will resolve the heel pain and fasciitis more than 80 percent of the time.6,7 Step 1: Shoe recommendations (New Balance, Adidas and K-Swiss are the most supportive), OTC orthotics (Spenco Polysorb Crosstrainer and Superfeet are the most effective), stretching exercises, NSAIDs, ice for 15 minutes tid, avoid walking barefoot and weight loss Step 2: Corticosteroid injection, tape strappings (patients may perform them daily) Step 3: Night splint, physical therapy, custom orthotics Step 4: Cast immobilization (traditional fiberglass weightbearing cast or a below knee cam walker) for three to six weeks Step 5: Extracorporeal shockwave therapy Step 6: Surgical repair (endoscopic or a minimally invasive technique) Practitioners should see these patients every three weeks prior to proceeding to the next step. Patients should utilize the night splint for at least one month and they can use it as needed for post-static or morning pain.8 In regard to physical therapy, patients should avoid strengthening exercises but stretching plays a vital role along with iontophoresis and massage. Custom orthotics may play a very important role in resolving the heel and/or arch pain. Softer orthotics made of an EVA shell or black plastazote can be helpful. However, be aware that they lose their support after one month in a competitive player. The ideal material for a tennis player is a semi-rigid polypropyelene shell with a 4/4 degree rearfoot post made of EVA and a topcover to the toes made of a firm Neolon or Soft EVA. Cast immobilization is sometimes necessary to break up the pain cycle and it is common that patients may not tolerate custom orthotics well initially until there is minimal fasciitis in the arch. Shockwave therapy has demonstrated mixed results but seems to be an excellent alternative to surgical repair for the competitive tennis player. Ultrasound guided shockwave therapy has demonstrated similar results to the Ossatron and is less traumatic to the heel. Both techniques seem to have a greater than 50 percent success rate.9,10 Surgery should always be a last option for these players as it will keep them off the court for at least two months.
What About Heel Bruises?
The heel bruise is an intracutaneous hemorrhage located at the plantar aspect of the heel. One commonly sees this among older players. Individuals with a highly mobile or thin calcaneal fat pad are at greater risk for heel bruises since they have less protection to the plantar foot structures. One can best treat this injury with a gel heel pad, ice and physical therapy. It is important to rule out a stress fracture of the heel when examining these patients but unlike a stress fracture, the pain is well localized to a single apex, usually at the plantar aspect of the medial calcaneal tubercle.
A Guide To Treating Achilles Tendinitis
The development of Achilles tendonitis 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.11 The injury most commonly occurs in tennis when landing from a jump. This is common when hitting an overhead smash or hitting a wide shot or approach shot on the run. Abnormal biomechanics including a plantarflexed first ray, flexible forefoot valgus, ankle equinus and calcaneal valgus may predispose the athlete to this injury. These predisposing factors may result in an increased whipping action of the Achilles tendon, producing an increase in friction between the tendon and peritenon.12 This injury may also limit the player’s ability to run and jump on the court, but the player will often continue to play even if there is pain. Treatment should begin with daily stretching exercises, ice and NSAIDs. In addition, patients should utilize a gel heel cup or lift when not playing tennis in order to alleviate tension on the Achilles. Post-static pain is also very common, particularly if there are adhesions between the Achilles tendon and peritenon. If the patient has post-static pain, using a night splint may be very helpful. In addition to the aforementioned modalities, the most vital part of the treatment plan is physical therapy. If the patient has an acute injury that may involve a partial tear, it is critical that he or she takes two to four weeks off and immobilizes the tendon in a below knee CAM Walker. During this immobilization period, the patient should have physical therapy three times a week. Treatments should include phonophoresis with hydrocortisone cream, electrical stimulation, massage and ice. They should begin a gradual stretching program once the acute pain cycle resolves. Once the injury greatly improves or resolves, employing a custom orthotic with a 4/4 rearfoot post is very helpful in preventing recurrence. It reduces the velocity of pronation and minimizes the whipping action of the Achilles tendon.
Over the past decade, tennis has developed into a sport of high physical demand and has seen an increase in lower extremity injuries. Children and women are now serving over 100 miles per hour. Players hit groundstrokes with more topspin and with much greater pace. Recreational and tournament players are adapting their games to assist with these increased physical demands, and the lower extremity is trained to change direction and absorb more power unlike ever before. It is important for foot and ankle specialists to modify their treatment plans when treating these athletes. This may result in the use of more night splints, different types of custom orthotics or simply discussing more treatment alternatives with patients. Tennis players are unique patients. Hopefully, this article has helped foot and ankle specialists understand the unique demands of the sport and facilitated some new treatment protocols for these athletes. Dr. Feit is a Fellow of the American College of Foot and Ankle Surgeons, and practices privately in San Pedro and Torrance, Calif. He is the Past President of the Los Angeles chapter of the American Diabetes Association.
1. Feit EM, Berenter R: Lower extremity tennis injuries: prevalence, etiology, and mechanism. J Am Podiatric Med Assoc 83: 509-514, 1993.
2. Kulund DN, McCue FC, Rockwell DA, et al: Tennis injuries: prevention and Treatment. Am J Sports Med 7:249, 1979.
3. Murphy RJ: Heat problems in the tennis player. Clin Sports Med 7: 429, 1988.
4. Balduini FC: Abdominal and groin injuries in tennis. Clin Sports Med 7: 349, 1988.
5. Casperson PC: Groin and hamstring injuries. Athlete Train 17: 43, 1982.
6. Wolgin M, Cook C, Graham C, et al: Conservative treatment of plantar heel pain: long term follow-up. Foot Ankle 15: 97-102.
7. Davis P, Severud E, Baxter E: Painful heel syndrome: Results of Nonoperative treatment. Foot Ankle: 15:531-535.
8. Powell M, Post WR, Keener J, et al: Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study. Foot Ankle 19:10-18, 1998.
9. Hyer C, VanCourt R, Block A: Evaluation of ultrasound-guided extracorporeal shock wave therapy (ESWT) in the treatment of chronic plantar fasciitis. J Foot Ankle Surg: 44: 137-143.
10. Wang C, Chen H, Huang T. Shockwave therapy for patients with plantar fasciitis: a one-year follow up study. Foot Ankle 23: 204-207, 2002.
11. Leach RE, James S, Wasilewski S: Achilles tendonitis. Am J Sports Med 9: 93, 1981.
12. Duddy R, Duggan R, Visser H, et al: Diagnosis, treatment, and rehabilitation of injuries to the lower leg and foot. Clin Sports Med 8: 861, 1989.