Rafael Nadal returns the ball to Novak Djokovic during their final match of the French Open. (Thibault Camus/AP)
June 12, 2014 3:33 p.m.
This past weekend, the tennis world witnessed Rafael Nadal win his ninth championship on red clay at Roland Garros — a remarkable accomplishment. Nadal is recognized as the King of Clay and on his way to becoming the best ever. Interestingly, a November article in The Best You Magazine pointed out that Nadal is the combination of "brilliance and vulnerability." The brilliance is evident, but his vulnerability has been well-disguised. As it turns out, Nadal has a history of foot problems that has been nagging him since he was 19. Like athletes in all sports, Nadal is not bulletproof. His playing time is not infinite and at the French Open, you could see his sense of urgency.
Professional tennis is incredibly demanding on your body. Serves are launched at speeds as high as 120 to 140 MPH with “now you see it, now you don’t” spins that vanish off the court. The pros are masters at moving their opponents from corner to corner or from the baseline to the net. Matches can be grueling, sometimes lasting more than three hours in the blistering heat. Winners advance to play the next day with little rest. Some players even compete in doubles matches that are scheduled simultaneously with singles play. More than any other sport, tennis is probably the most demanding on a player’s feet and ankles.
Nadal has been managing a painful problem in his right foot since he was 19 years old. The weakness in his tarsal navicular bone above the arch was so bad his specialists thought he might never be able to play again. In order to prolong his career, Nadal worked with shoe companies to redesign an inner sole that would offset the pressures on his bone. Since then, Nadal has been able to play but his foot condition is a work in progress for the trainers and medical team. Healthy feet are critical for Nadal’s career to advance.
Many of my patients who participate in competitive sports have Posterior Tibial Tendonitis. This is especially common in soccer, tennis and basketball; however, it can also result following activities such as running, climbing stairs, walking, doing a new activity, overdoing an old activity, walking on uneven terrain or wearing improper footwear. Overuse and lack of treatment can result in crippling pain.
The posterior tibial tendon is probably the most important tendon in the leg. It extends from the medial tibia around the inside of the ankle into the foot. It starts just below the knee. Basically, it’s the main support for the arch and the foot.
Problems tend to occur underneath the inside of the ankle, often leading to an unstable gait. As the posterior tendon loses its ability to support the arch, the foot flattens and toes spread outwards. Other causes are related to long-term wear and tear of the tendons and ankle trauma from a sprain.
Posterior Tibial Tendonitis can be a tenacious injury but it can also be resolved with time and treatment. The goals of conservative management are to stop the symptoms and reduce the forces that are damaging the tendon, and to prevent arthritis from progressing. Here are some of the treatment options that are routinely done depending on the severity of the condition.
• Stop or decrease any activity that increase pain and worsens the tendon;
• Cold therapy. Apply ice regularly to the posterior tibial tendon for 15-20 minutes 3-4 times a day;
* Nonsteroidal anti-inflammatory medications to reduce swelling;
* Over-the counter shoes inserts or custom orthotics to provide arch support;
* Casts or boots to immobilize the ankle;
* Low-impact exercises that are non-load bearing like swimming, biking and elliptical machines;
* Physical therapy techniques including acupuncture (to relax muscle knots), ultrasound (deep heat), cold therapy (reduce swelling), electrical stimulators (soft tissue mobilization), corticosteroid injections (anti-inflammatory) and platelet rich plasma (restorative process to promote healing);
* Proper footwear to provide support and cushioning;
* Alternate footwear after workouts and change out gear after 300-500 miles;
* Conditioning and balance routines to strengthen tendons;
* Alter fitness activities and incorporate non-impact activities to promote cardiovascular endurance and strength;
* Working out in moderation and in a gradual manner;
* Cutting Edge MLS Laser therapy to reduce inflammation and pain and to kick-start the healing process.
Sometimes surgery is necessary to remove tissue that has degenerated in the tendon. The type of surgery varies depending on the severity of the deformity and dysfunctions. The surgeon must take into consideration such things as the position of the heel, deviation of the joints and forefoot, soft tissue condition, quality of the tibial tendon, and level of arch collapse. There are many surgical techniques used to treat soft tissue repairs (minor PT tears, PT tear with weakness of tendon, spring ligament and deltoid repair, and Achilles lengthening or gastrocnemius recession). Other surgical techniques are used to correct a supple foot (deformity, valgus heel, naviculocuneiform fusion, forefoot varus with bunion or hypermobility) and a rigid foot (ankle fusion, hindfoot fusion, midfoot fusion and forefoot lapidus).
There are a number of new modalities and trends that are emerging as well as the combination of new modalities to accelerate healing. Some of these include use of platelet rich plasma and stem cell aspirate therapy; use of tissue augmentation materials; use of allograft tendon and bio-tendonitis fixation technology; and bone-healing biologics.
Dr. John Sigle is a board-certified foot and ankle surgeon with years of experience treating Posterior Tibial Tendonitis. Athletes who experience this problem are welcome to see him at the Foot & Ankle Center of Illinois for a diagnosis and treatment.