Over the years, I have treated many recreational athletes and tennis pros alike at Methodist Sports Medicine / The Orthopedic Specialists. I had the great pleasure of serving as the orthopedic consultant for the Indy Tennis Championships (formerly the RCA Championships) for 13 years until it recently moved to Atlanta. The professional players sustain injuries that are primarily related to the extreme exertion they sustain over a season that now stretches over the entire year. Recreational players, on the other hand, sustain injuries that are primarily related to poor stroke mechanics, improper equipment, and suboptimal conditioning. Many common injuries can be prevented and that’s why we recently created three educational YouTube videos at the Five Seasons Family Sports Club in Indianapolis. The videos cover proper tennis mechanics, common tennis injuries and the benefits of youth tennis.

The Five Seasons tennis pros demonstrate some of the common mistakes made by recreational players that can lead to injury. They discuss the importance of footwork and balance as essential elements of putting the player into position to hit the ball properly. Additionally they emphasize the importance of the connection of the right and left sides of the body in producing smooth effortless strokes.

In the YouTube video about common tennis injuries, we explain the basic care of acute minor injuries following the R.I.C.E. (Rest, Ice, Compression and Elevation) treatment formula. Injuries which don’t resolve in a few days with the basic care may require the attention of a sports medicine physician.

Youth tennis is another important topic. I encourage parents to teach your children tennis at a young age because it’s one of the safer sports for them to play. In addition, there are long-term health benefits for children who start playing at a young age and continue playing as an adult. We discuss those positives and other benefits in the third YouTube video.

Visit our YouTube channel to watch the videos and tell us what you think in the comments section.

http://www.youtube.com/user/MethodistsSports?feature=watch

Read Dr. Sallay’s “Healthy Tennis” articles in Midwest Tennis Magazine.

http://www.methodistsports.com/physicians/peter_sallay/documents/Dr.SallayTennis_Articles.pdf

When:
Tuesday, Sept. 27, 2011 – 6 p.m.

Where:
IU Health North Hospital
Learning Center Rooms A & B
11700 N. Meridian Street
Carmel, IN 46032

Registration Information:
Contact Aimee Lacey at 317.962.2533.

Did you know?
• Most foot pain is caused by ill-fitting shoes, medical conditions, and high-impact exercise.
• Elderly people are at a very high risk for foot and ankle injuries and pain.
• An estimated 120,000 work-related foot injuries occur each year.
• Gaining weight puts added stress on the feet leading to foot and ankle injuries.
• Foot pain generally starts in one of three places – the toes, the forefoot or the hindfoot.
• Because the feet are very small compared with the rest of the body, the impact of each step exerts tremendous force upon them – about 50 percent greater than the person’s body weight.
• During a typical day, a person can take between 8,000 to 10,000 steps. This means that the feet support a combined force equivalent to several hundred tons every day.

A sprain is a stretching or tearing of one or more of the ligaments of a joint, as opposed to a strain which is a stretching or tearing of a muscle. One of the most common forms of an ankle sprain is a lateral ankle sprain, where the ankle is rolled and the body pitches over the outside of the ankle. In this instance, the ankle is put through a greater range of motion than normal and as a result, the ligaments on the outside of the ankle are put under stress, sometimes causing tears.  In most cases, the athlete is able to continue to play, but with pain and swelling.

Another fairly common ankle sprain is a high ankle sprain, where the ligament that connects the two bones of the lower leg, the syndesmosis ligament, is stretched or torn. This is usually caused by a sudden twisting outward of the foot and ankle. It is called a high ankle sprain because this ligament is situated above the joint of the ankle. This sprain can be slightly more serious than other ankle sprains, occasionally requiring surgery.

There are three classifications of ankle sprains:
• Grade 1 – the ligaments are only severely stretched, there is pain but the athlete can continue immediate play. Mild swelling usually occurs but the ankle is still stable. After about eight days of rest and ice, the athlete can return to play.
• Grade 2 – the ligaments are partially torn, and pain is more intense, usually to the point where the player cannot continue play at the time of the injury. There is moderate swelling of the ankle, but the joint is still stable. Usually with 15 days of rest, immobilization, and ice, the athlete can return to play.
• Grade 3 – the ligament tears completely. The athlete usually feels a ‘pop,’ and is unable to walk without assistance. There is severe pain and swelling, and the ankle is unstable. This injury is usually still treatable without surgery but it takes longer for the player to return; about 20 days with immobilization, rest, and ice.

There are several risk factors for ankle sprains that need to be addressed. The first is general ligament laxity, where an individual’s ligaments are naturally looser than usual, causing decreased stability in the ankle and greater possibility of twisting or rolling the ankle in a manner that would cause a sprain. Shoe wear that does not provide sufficient support for the ankle also puts the individual at greater risk for sprains. For athletes, irregular playing surfaces and activities that require cutting increase the risk of ankle sprains. Previous history of ankle sprains also increases the possibility of spraining the ankle again.

Prevention of ankle sprains is fairly straightforward. High top shoes, ankle taping and lace-up supports all help stabilize the joint so no injury occurs. A simple stretching of the Achilles tendon before exercise or competition can also decrease the chance of becoming one of the many people who experience this injury.

In about 5 to 15 percent of cases, the cause of pain from posterior ankle impingement is due to the presence of an extra, triangular shaped bone called the Os Trigonum. This extra bone is typically small, round and sits just behind the ankle joint. An Os Trigonum occurs when one area of bone does not fuse with the rest of the ankle bone (talus) during growth. Interestingly enough, the size of the Os Trigonum does not correspond to the level of pain a patient may endure.

Fortunately, it is rare for an athlete to experience pain from an Os Trigonum – even dancers, a group in which posterior ankle impingement can cause the greatest amount of problems. However, when ankle impingement does become problematic, treatment is usually taken in stages with surgery being a last resort.

Typically, the first step I take in treating patients with posterior ankle impingement is to recommend that they change activities, concentrating on avoiding the activities that cause pain. Combined with anti-inflammatory medication and physical therapy, this first course of treatment can be very effective.  However, when it doesn’t diminish the pain, a steroid injection can be administered and may have a drastic and lasting effect in relieving symptoms. Usually, an Os Trigonum is not a surgical problem but there have been situations where it does need to be surgically removed from the ankle. As stated before, this is only a last resort if conservative treatments fail. Only you and your orthopedic surgeon can truly determine the best treatment option for your individual condition.

However, the bone spurs on the front of the ankle are hard to spot, since standard x-rays cannot visualize them. In fact, in order to surgically remove this spur, the surgeon must hold the ankle so the toe is pointed up, called dorsiflexion, just to be able to see the spur and eliminate it. Classically, anterior bone spurs occur in the front and center of the ankle, quite the attention hog if you ask me.

However, not all cases of anterior ankle impingement involve bone against bone. If impingement occurs on the outside front of the ankle, it is usually due to one of two conditions: Bassett’s ligament or Ferkel’s phenomenon.

Bassett’s ligament occurs when one of the ligaments of the anterior ankle slips downward out of its normal position. Previous ankle sprains and chronic instability usually are the cause of this abnormal slip.  When the foot is pointed downwards, the talus (one of the bones of the ankle) impinges against the rouge ligament, causing pain. If you are diagnosed with this condition, congratulate your doctor because Bassett’s ligament can be difficult to identify. Once it is discovered to be the source of difficulty, it can be fixed with a scope, without an open incision.

Ferkel’s phenomenon is an accumulation of scar tissue in the ankle, usually as a result of a fracture, sprain, or other ankle trauma. Symptoms are similar to Bassett’s ligament and likewise can be fixed with a scope.

Needless to say, if you do experience any ankle discomfort you should consult an experienced orthopedic surgeon, who can help evaluate your individual situation and recommend appropriate treatment options.

Items that are meant to be stuck together: stapled sheets of paper, peanut butter and jelly sandwich, duct tape and pretty much anything. Notice that ‘bones of the ankle’ are not on that list. However, there is a rare condition called tarsal coalition where two of the many bones of the ankle are fused together from birth. It is estimated that this phenomenon occurs in only about one percent of the population.

The union between the bones can be made up of bone, cartilage, or fibrous tissue, but the condition only causes symptoms when the soft tissue of the coalition becomes bony, which happens between 8-16 years of age. Before this time, the flexible nature of the coalition allows some degree of motion at the joint but afterwards symptoms can include pain, stiffness, and deterioration of athletic performance. However, these symptoms are often not severe enough to warrant a visit to the doctor until trauma to the ankle causes a flare-up of pain.

In athletes, tarsal coalitions often cause recurrent ankle sprains because the abnormal joint cannot transfer the force of athletic activity to the other joints, so the surrounding ligaments take the strain, causing injury.

In treatment of a tarsal coalition, a trial of non-operative treatment is attempted before resorting to surgery. These conservative treatment options includes anti-inflammatory medication, orthotics (shoe inserts), and for severe symptoms, 6 weeks in a short walking cast may be used for immobilization.

If these treatments do not succeed and pain continues, surgical intervention is needed, which usually involves taking the coalition out and putting soft tissue between the bones.

If you think you have tarsal coalition or that your child’s ankle bones are not developing properly, you may want to consult an orthopedic foot specialist for treatment.

However, few people really understand the injury that made the story so newsworthy. The peroneal tendons run down the outside of the ankle, behind the bony round projection called the lateral malleolus, and attach to the bones where the heel meets the arch of the foot. These tendons fit into a groove in the bone behind the malleolus and are held in place by tissue called the Superior Peroneal Retinaculum. If this retinaculum is ruptured, the tendons will snap in and out of the groove, causing pain and discomfort.

This condition is called Chronic Peroneal Tendon Subluxation, and it can be, as in Curt Schilling’s case, a disabling condition for athletes. It is usually caused by an acute (sudden) injury followed by chronic (repeated) displacement of the tendons. Swelling, bruising, and tenderness behind the malleolus are signs that this injury has occurred. There are ways to treat this injury without surgery such as cold compression, special wrapping techniques with a brace, and immobilization in a walking boot. However, surgical intervention is recommended for reoccurring tendon displacement, especially for athletes because of the decreased rehabilitation time and therefore quicker return to play. Also, we have observed that operative (surgical) treatment is more successful in general than non-operative treatment.

There are numerous surgical procedures that have been used to treat chronic Peroneal tendon displacement, but we have done research on the subject and now use a procedure where the groove is deepened and the retinaculum is repaired over the tendons. In addition to this procedure, the rehabilitation exercises we prescribe are designed to get the athlete back to play five weeks quicker than normal. This recovery plan includes getting the patient weight-bearing a few days after surgery, starting range-of-motion exercises one week after the operation, and weaning out of a walking boot and into a brace after about four weeks. The athlete can start running and other sport-related activities while wearing a brace after about six weeks, and full return to their chosen sport usually after three months.

So, if you ever join Curt Schilling in suffering this injury, have hope knowing that there are tried-and-true surgical and recovery treatments that should get you back to activity in no time.

The posterior tibial tendon is located on the medial (inner) side of the foot, and it is very important in keeping the shape of the arch. An injured post-tib tendon would affect push-off and jumping, and would therefore compromise level of play for the competitive athlete. Therefore, normal length, tension, and heath of the tendon are important, so early recognition and treatment is very helpful for the recovery of the patient.

As far as posterior tibial tendon injuries go, tendonitis of the tendon is much more common than an actual tendon rupture. When this is the case, non-operative (without surgery) treatments such as anti-inflammatory medications and a walking boot are usually adequate to heal the tendon. However, surgery may be required if the problem persists after 3 to 6 months.

Tears of the post-tib tendon are much less common and are especially rare in athletes under the age of 30. MRI scans reveal the tear, which usually occur over a long period of time and surgery is needed in most cases to repair the rupture. Athletes most commonly return to competition after about 4 to 6 months after the procedure.

According to foot and ankle specialists, they often see 3 to 5 new patients per week with heel related pain. Many of these patients have suffered from this pain for 3 to 6 months before seeking medical attention. The end result is that they are now suffering excruciating pain and can no longer perform the day to day activities they once enjoyed.

This formidable pain is most often caused by a condition called plantar fasciitis. The plantar fascia is the generally inelastic network of ligaments that maintain the shape of the foot’s arch, originating in the heel and extending to the ball of the foot. When the Achilles tendon (the tendon that runs up the back of the heel) is tighter than normal, it causes biomechanical errors in walking and running that put unnecessary stress on the plantar fascia. This stress causes micro tears in the fascia near the heel, which in turn causes inflammation and pain.

The pain is usually most severe while taking the first steps after waking up in the morning, since the tissues are still stiff. Once the individual begins activity, the tendons and ligaments warm up and become more elastic, which prevents additional micro tears. Tragically, after a rest period of only 30 to 60 minutes, the tissues begin to cool down and tighten, causing the discomfort to reoccur. Therefore, only those patients who are literally on their feet 24/7 can achieve pain relief without treatment.

Luckily, there is a plethora of treatment options that run the gamut from shoe implants and night splints to injections and a surgical procedure that involves releasing the plantar fascia. Usually, two or more of these remedies are used in conjunction with each other to relieve the pain. However, aggressive Achilles tendon stretching is perhaps the most natural regimen since it corrects the initial biomechanical cause of plantar fasciitis. Our research shows that as an individual with plantar fasciitis consistently performs Achilles stretches, their Achilles flexibility goes up and their pain level goes down.

We all know that getting out of bed in the morning can be hard enough without the dread of heel pain. Fortunately, plantar fasciitis can be prevented in most cases by adding Achilles stretches to the end of weekly exercises.

Often called ‘carpel tunnel of the foot,’ tarsal tunnel syndrome occurs when the posterior tibial nerve, which runs through the tarsal tunnel behind the bony bump on the inside of the ankle, is compressed and therefore irritated. Any activity that repetitively requires the inside of the sole of the foot to be weight bearing, such as long-distance running and cycling, can cause inflammation of the tarsal tunnel. A variety of other factors can also cause problems, such as benign tumors, varicose veins, bone spurs, and posttraumatic adhesion (immobilization intended to heal a fracture or sprain causes the nerve to attach itself to another structure to which it is not supposed to be attached). Basically, the nerve doesn’t have the space it needs, so it becomes irritated and consequently irritates the person whose foot it occupies. 

This irritation can include sensations such as burning, tingling and a zinging pain on the bottom of the heel, and sometimes slight numbness in the toes. With tarsal tunnel syndrome, the patient usually experiences tenderness directly over the posterior tibial nerve, which helps to distinguish it from other nerve entrapment syndromes.

There are both operative and non-operative means of treating tarsal tunnel syndrome. A heel wedge placed on the inside of the heel decreases tension on the nerve and can provide relief. A steroid injection into the tarsal tunnel can be helpful but will often bring only temporary ease of symptoms. Especially in athletes, surgical release of the nerve and removal of any tumors or spurs can become necessary for pain relief. If surgery is the only option to alleviate the pain, a qualified orthopedic foot surgeon will speak with you and select the appropriate procedure or procedures based on your individual situation and condition.