CURRENT TOPICS IN SPORTS PODIATRY

Doubles Partners: Common Lower Extremity Tennis Injuries You’ll find these on the professional tour and in your community.

By Alex Kor, DPM, MS ing the Bryan brothers, Stan Smith Williams, Gil Schuerholz and Kim and Bob Lutz, John McEnroe and Clijsters, Daniela Hantuchova and This article is provided exclusively to Peter Fleming, Martina Navratilova Ken Barnas, Jordan Corey and Podiatry Management by the American and Pam Shriver, etc. These partners Rafael Nadal, and Alex Kor and Academy of Podiatric Sports Medicine. selected each other because their John Isner are NOT “household The AAPSM serves to advance the un - styles complemented the other names.” They would not strike derstanding, prevention and manage - player and usually the “sum of its much fear in the hearts of the ment of lower ex - tremity sports and fitness in - juries. The Academy believes that providing such knowledge to the profession and the public will optimize en - joyment and safe participation in sports and fitness activities. The Academy accom - Figure 1 plishes this mis - sion through professional education, sci - parts is greater than the whole.” world’s best. But for purposes of entific research, public awareness and The game of tennis is a very this article, these doubles “part - membership support. For additional in - physically demanding activity. The ners” have been created because formation on becoming a member of the ballistic nature of the sport that in - each “team” has been affected by a AAPSM please visit our website at volves sudden stops, starts, lateral similar lower extremity injury. www.aapsm.org or circle #151 on the movements, jumping, quickness, reader service card. speed, etc., lends itself to lower ex - Calf Injuries tremity injuries. Whether you are ingles play receives publicity, competing for a local USTA team or Doubles Team #1—Serena notoriety, and fanfare on the trying to win a third round match Williams and Gregg Wollard SAssociation of Tennis Profes - at the French Open, injuries are ob - (Figure #1) sionals (ATP) and the Women’s stacles that ALL tennis players are At the July 2007 Wimbledon Tennis Association WTA) tours as trying to avoid. Once such an in - Championships (in the fourth well as at every level of the United jury is encountered, regardless of round), Serena Williams, the for - States Tennis Association (USTA). the level, his or her play will be ad - mer #1 female player in the world, But many would argue that the versely affected. suffered a calf injury that contribut - game of doubles involves more ed to her eventual loss in the next strategy, intrigue and competition. Fictional Doubles Teams round to Justine Henin. The same Over the years, there have been The fictional doubles teams of week, Gregg Wollard, a 43 year old many great doubles partners includ - Gregg Wollard and Serena Continued on page 92 www.podiatrym.com APRIL/MAY 2011 • PODIATRY MANAGEMENT 91 Tennis Injuries... play the next round after her in - On Aug. 14th, 2009, Gil felt a jury. But a Grand Slam title was at “snap, crackle and pop” within his airport engineer from Reston, Vir - stake. On the other hand, Gregg left heel while playing in a USTA ginia sustained the same injury. was NOT battling to stay at the top team tournament. He attempted to Having a history of a previous of the world rankings. He was play the remainder of the event, Achilles tendon rupture four years “sidelined” for six weeks, did not but could not continue. For one previously, Gregg promptly discon - require surgery, and successfully re - week, he utilized frequent ice appli - tinued his 4.0 USTA tennis match. turned to the courts of northern cations, an over-the-counter orthot - He was unable to walk, and was im - Virginia. ic, and did not play. With the Na - mediately concerned that he would tional 45 and over Grass Courts need more surgery. Thus, whether Rupture of the Plantar Fascia slated to start on August 23rd, you are a world class player or a 2009, Gil was unsure if he could local player trying to win a league Doubles Team #2—Kim play singles and doubles. He and match, this injury can hamper any Clijsters and Gil Schuerholz his partner (Andy Stoner) had en - tennis player. (Figure #2) joyed previous success by winning In order to understand the de - Most tennis fans are aware that the 2008 45 and over Indoor Dou - gree of injury that Serena and Kim Clijsters, from Belgium, is one bles Championship. But playing on Gregg experienced that summer, it a partially ruptured plantar fascia is essential to review the anatomy was not the ideal scenario for any of the calf and etiology of the in - player, including Gil Schuerholz. jury. The calf musculature is com - prised of the gastrocnemius muscle (more superficial and larger) and the soleus muscle (deeper). These two structures then join to com - prise the Achilles tendon which at - taches into the back of the calca - neus. When the foot is dorsiflexed during an impact activity, the two calf muscles will become taut. If the knee straightens during this mo - ment, the gastrocnemius may be - come so taut that a strain, or a par - tial tear or a rupture may occur. Figure 2 This calf injury, known as “tennis leg”, most commonly affects the of only a few mothers to be playing When any athlete tears a por - medial head of the gastrocnemius on the WTA tour. After a two-year tion of the plantar fascia, the usual muscle. absence (to have her baby), Kim re - presentation is localized erythema, turned to win the 2009 U.S. Open edema, echymosis, intense pain, Tennis Leg in New York City. But not many and difficulty in full weight-bear - The treatment for “tennis leg” observers know ing. As with “ten - depends on the severity of the in - that on two sepa - nis leg”, a defect jury. Most players will respond to rate occasions, can be palpated three to six weeks of rest, frequent Kim has sustained The ballistic nature of within the fascia. ice applications, no heat (unless a partial rupture X-rays and an the player wants to “warm up” the of the plantar fas - the sport that involves MRI will rarely muscle before playing), compres - cia, and eventual - sudden stops, starts, alter the initial sion of the calf, and a heel lift (to ly returned to the therapy. If the reduce tension along the gastroc - court. Gil Schuer - lateral movements, athlete does not nemuis/soleus complex) in the holz, a 47 year desire to return to shoe(s). Depending on the athlete’s old local tennis jumping, quickness, play and the fas - skill level, motivation, pain thresh - professional from speed, etc., lends itself cial rupture is ex - old, and other factors, the response Ellicot City, tensive, the best to treatment varies. Examination Maryland will ob - to lower extremity treatment would of the injured site will, at times, re - viously never be injuries. include: no im - veal a palpable defect near the me - able to fully ap - pact activity for dial head of the gastrocnemius. A preciate the de - six to eight weeks, MRI may allow for better visualiza - mands of child a weight-bearing tion and, in very elite players, may birth. But based upon his 2009 ex - boot for six weeks, soft tissue mas - provide more information in order periences, Gil can indeed appreciate sage, ice, physical therapy, and cus - to predict when the tennis player how tough it is to return to playing tom made orthotics. can return to the court. In 2007, tennis after injuring one’s plantar If the athlete (like Gil) is moti - Serena unsuccessfully attempted to fascia. Continued on page 94

92 PODIATRY MANAGEMENT • APRIL/MAY 2011 www.podiatrym.com Tennis Injuries... forward toward the net. As he was cast for twelve weeks, followed by a about to hit a volley, he felt as if below-the-knee cast for four weeks. vated to play and can tolerate pain, the back of his right lower leg had By early 2004, Ken was able to begin the protocol can be drastically dif - “exploded.” His first thought was physical therapy. Although he was ferent, and is accelerated in an ef - that someone’s racket had struck eager to return to the court, he did fort to get the athlete playing ten - the back of his leg and ankle. But not begin playing until June 2004. nis. In Gil’s situation, he was unable to One can only hope that Daniela is he decided to not play stand and forced to not “sidelined” for as long as Ken was singles and to concen - default. in 2004. trate only on doubles at Generally, the National Grass when an athlete Lower Leg and Knee Injuries Courts. After the first seven days of inactivi - Doubles Team #4—Rafael ty, Gil attempted to get Nadal and Jordan Corey ready for the doubles (Figure #4) competition which The “doubles team” of Jordan started on August. Corey, a 36 year old Seattle-based 26th. On a daily basis, financial analyst and Rafael Nadal, his foot was taped, had the number one player in the cross friction soft tissue world, have both battled lower leg massage, he began to and knee pain. Although Rafa has stretch, and his pain enjoyed more success, both play gradually improved. Al - the game of tennis with “reckless though Gil and his Figure 3 abandon.” And, without doubt, partner lost a set in their grinding, “never give up” their first round match, they tears the Achilles tendon, there is styles have contributed to these emerged victorious, despite his no ability to plantar-flex the affect - overuse injuries. heel being very sore. Using grit and ed ankle (a positive Thompson’s Rafael Nadal’s foot problems determination, they managed to test). The exam finds a disruption began in 2004 when he developed advance to the finals. or attenuation of the substance of a stress fracture. Many so-called Fifteen days after partially tear - the Achilles tendon, edema, echy - “experts” said that this would ing his plantar fascia, Gil Schuer - holz and Andy Stoner won the 2009 45 and over Grass Court Doubles crown. This compares favorably to a study by Saxena and Fullem 1 that followed 18 athletes who returned to their athletic activity at approximate - ly 9.1 +/- 6.0 weeks. One can as - sume that even Kim Clijsters would have been impressed with Gil’s effort.

Achilles Tendon Figure 4 Doubles Team #3—Daniela Hantuchova and Ken Barnas mosis, pain, and inability to apply plague him for the rest of his ca - (Figure #3) weight. X-rays can be ordered to reer. Yet he went on to win the The Achilles tendon is a com - rule out bony pathology, and an French Open from 2005 –2008. But mon site for pain in many tennis MRI can confirm the clinical pic - in the last two to three years, a ma - players. The spectrum of pathology ture. Although conservative treat - jority of Rafa’s injuries are occur - can range from Achilles tendonitis ment is an option for a more seden - ring proximal to the foot. Al - to a rupture. Daniela Hantuchova, tary patient, surgical repair of the though he won the 2010 French a 27 year old Slovakian, initially torn tendon is the treatment of Open, Wimbledon and U.S. Open, had Achilles tendonitis but had to choice for any athlete hoping to re - shin splints, patellar tendonitis, a withdraw from this year’s Aus - turn to sports. knee injury and, most recently, tralian Open when an MRI re - Ken Barnas, a nationally ranked hamstring issues have affected his vealed a tear. Ken Barnas, a 51 year player, had every intention to return play. old business owner from LaPlata, to his beloved hobby. Less than two Jordan began to have pain on Maryland, was in the midst of a days after his rupture, Ken under - the lateral aspect of the left knee in match in August of 2003 when he went successful surgical repair. Post- 2009. This pain was reproduced hit a service return and took a step operatively, he was in a full length Continued on page 96

94 PODIATRY MANAGEMENT • APRIL/MAY 2011 www.podiatrym.com Tennis Injuries... author, suffered a similar injury ability to apply weight. Per the Ot - while playing a doubles match on tawa ankle rules, X-rays are NOT after playing multiple days in a row July 14th, 2008. During a “heated” always necessary for a suspected and improved with rest. After see - exchange” at the net, a lob was hit ankle sprain, but are usually or - ing his primary over my head. As dered for athletes. As with most care physician, I was making acute injuries, the regimen of rest, Jordan was sent contact with the ice, compression, and elevation is to a physical ther - The calf injury, ball, my left foot suggested. If the athlete does not apist whose eval - and ankle invert - respond in a sufficient period of uation revealed known as “tennis leg”, ed, and I fell to time, more advanced studies (MRI) ilio-tibial band most commonly the ground in are recommended. Other treat - syndrome. This is pain. Using a ments include physical therapy an inflammation affects the medial compression modalities, NSAIDs, ankle braces, of a band of tis - dressing, I was cortisone shots, orthotics, etc. sue that extends head of the able to complete from the lateral gastrocnemius the match. Unfor - Summary aspect of the tunately, we were According to a review article pelvis to the later - muscle. not victorious. by Bylak J. and Hutchinson, 4 ju - al aspect of the The pain and nior tennis players are two times knee. Pat Wempe, swelling contin - more likely to injure the lower ex - PT, 2 a physical ued for the re - tremity than the upper extremity therapist in Evansville, IN, specu - mainder of the month of July. X- or spine. And, regardless of age, lates that poor muscular control of the hip external rotators can play a role. Jordan’s treatment consisted of aggressive physical therapy, soft tissue massage, a home stretching program, and custom-made orthotics. At last re - port, on the hard courts of Seattle, Jordan is playing pain-free tennis but (unfortunately) has not cap - tured any major titles (as Rafa has) since his injury.

Ankle Injuries Figure 5 Doubles Team # 5—John Isner and Alex Kor (Figure #5) rays were normal. But by early Au - we already know that an ankle John Isner, who stands 6’9”, is gust I was asymp - sprain is the most an American tennis player who is tomatic and grad - common acute most famous for winning the ually returned to injury in tennis. longest match in tennis history. At playing. When any Thus, one can as - the 2010 Wimbledon, he beat According to sume that all ten - Nicholas Mahut, 70-68 in the fifth a paper in the athlete tears a nis players, set of their first round match. But British Journal of portion of the young and old, John may be more proud that he Sports Medicine 3 must combat was able to play his first round in 2006, ankle plantar fascia, the lower extremity match at the 2010 U.S. Open after sprains account - injuries. A blister, sustaining a severe ankle sprain only ed for 20–25% of usual presentation is corn, callus, sub - two weeks before. On August 18th, all acute injuries localized erythema, ungual 2010, while playing a match at the on a tennis court. hematoma, and Cincinnati ATP tour stop, he was By definition, an edema, echymosis, an ingrown toe - forced to default his match after the ankle sprain is an nail may cause injury. His playing status at the acute soft tissue intense pain, and pain but are un - 2010 U.S. Open was questionable, at injury that results difficulty in full likely to prevent best. But on Sept. 2nd, 2010, he in damage to the any motivated miraculously won his first match at ligaments, ten - weight-bearing. tennis player the U.S. Open. Despite an MRI that dons, and associ - from being on showed no fracture but significant ated soft tissues the court. How - ligament damage, he was able to of the ankle. Typ - ever, other foot win two rounds in the tourney. ically, the athlete will experience and ankle maladies such as a neu - Five-foot-seven Alex Kor, your immediate pain, swelling, and in - Continued on page 98

96 PODIATRY MANAGEMENT • APRIL/MAY 2011 www.podiatrym.com Tennis Injuries... of the plantar fascia, or a more Dr. Alex Kor proximal injury (e.g. ilio-tibial has a BS in roma, metatarsalgia, stress frac - band syndrome), or a tear of the Chemistry from ture, tendonitis, etc. may indeed Achilles tendon, or a severe ankle Butler Universi - result in a longer lay-off. If the in - sprain, all tennis players can miss ty and an MS in Exercise Physi - juries that our “doubles partners” a majority of a season when con - ology from Pur - fronted with these significant in - due University. juries. However, once all of our He received his Generally, “doubles teams” are again healthy, DPM degree this tennis-playing podiatrist will from the Dr. when an athlete welcome the opportunity to battle William M. Scholl College of Podi - any of the other “teams” as long atric Medicine in Chicago. In 1990, tears the Achilles as his partner, John Isner, serves Dr. Kor completed a Podiatric Surgi - first. I cal Residency at Westside V.A. Medi - tendon, there is cal Center—University of Illinois. He has served as the team podiatrist at no ability to References the N.C.A.A. Division I level (Univer - 1 Saxena A, Fullem B. Plantar fascia plantar-flex the sity of Evansville), the NCAA Division ruptures in athletes. American Journal II level (Bowie State University in affected ankle of Sports Medicine. 2004; April—May, Bowie, MD) and at the NCAA Division 32(3): 662-5. III level (Knox College in Galesburg, 2 (a positive Wempe P. Personal Communica - IL). tion. Jan. 2011. Kor is certified by the American 3 Thompson’s test). Van Zoest WJ, Janssen RP, Tseng Board of Podiatric Surgery and is a CM. An uncommon ankle sprain. Fellow of the American Academy of British Journal of Sports Medicine. Podiatric Sports Medicine. In addition 2007; Nov. 41(1): 849-50. to his current duties at Bowie State sustained are again examined, it is 4 Bylak J, Hutchinson MR. Com - University, In 2010, Dr. Kor was the clear that whether you sustain a mon sports injuries in young tennis #59 ranked men’s singles tennis play - strain of the medial head of the players. Sports Medicine. 1998; Aug. 26 er in the 45-and-over age group in the gastrocnemius or a partial rupture (2):119-32. United States.

98 PODIATRY MANAGEMENT • APRIL/MAY 2011 www.podiatrym.com