1
Tennis Injuries of the Lower
Extremity: “The Tour is Tough”
Alex Kor, DPM, MSFroedtert and the Medical College of Wisconsin
Milwaukee, WI
---------------------------------------------------
“THE TOUR IS TOUGH”
Whether you are a podiatry
resident, a podiatrist in private
practice, a podiatrist in a multi-
specialty clinic, a podiatrist in
an orthopedic group, etc. you
are likely to encounter a tennis player that has
lower extremity pain.
“THE TOUR IS TOUGH”
The United States Tennis Association
sponsors junior, open, and senior tennis
tournaments in addition to year long leagues
for different levels, and ages.
“THE TOUR IS TOUGH”
Palm Springs, CA. Baton Rouge, LA. Atlanta,
GA. Austin, TX. Wheeling, WV. Indianapolis,
IN. Portland, OR. Jackson, MS. New Haven,
CT. Tel Aviv, Israel. Philadelphia, PA.
Alexandria, VA. Sarasota, FL. Las Vegas, NV.
Scottsdale, AZ. Pittsburgh, PA. Savannah,
GA. Naples, FL Ft. Lauderdale, FL. , Park
City, UT, La Jolla, CA, Santa Barbara, CA.
Boise, ID, Seattle, WA, El Paso, TX, etc.
“THE TOUR IS TOUGH”
It is estimated that 7,416 unique players
competed in national adult Cat 1 and 2
tournaments in 2016, and 7,241 played in
2017. A unique player is a person who plays one or more of these tournaments. They are only
counted once regardless of how many Cat 1 or 2 tournaments they played.
• Source: Doug Wenger, Manager, Adult/ Senior
Competition, USTA Office, White Plains, NY 10604
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• The USTA League Program had this # of
participants in:
A. 2016 = 915,860 The unique # of
players was 312,447.
B. 2017 = 928,292 The unique # of players
was 313,885.
• Source: Bonnie Vandegrift, Chair, USTA League
Committee
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“Despite a slight decline in key “core” player
category, the latest research shows 1 %
overall growth (i.e. 17.9 million players) with
another 14 million Americans showing an
interest in playing tennis…”
• Source: tennisindustry.org, March 12th, 2018
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Whether one plays recreationally,
competitively in USTA Leagues or at National
Senior events, injuries of the lower extremity
will occur.
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“…Tennis players at all competitive levels
sustain overuse injuries. Lower limb injuries in
these tennis players are nearly equal to or
exceed upper limb pains...”
Pluim, B, Staal J, Windler G, Jayanthi N. Tennis Injuries: Occurrence,
aetiology and prevention. British Journal of Sports Medicine. 2006; 40(5):
464-468.
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ATP sports medicine officials conducted a
study of the injuries for which professional
players seek treatment from officials They
found that 35-50% of all injuries were to the
lower extremities,
Source: Bastholt P, ‘Professional tennis (ATP tour) and number of medical
treatments in relation to type of surface , Society for Tennis and Medicine and
Science (www.stms.nl)
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• According to a review article by Bylak J. and
Hutchinson, junior tennis players are two
times more likely to injure the lower
extremity than the upper extremity or spine.
• Source: Bylak J, Hutchinson MR. Common sports injuries in young tennis
players. Sports Medicine. 1998; Aug. 26 (2):119-32.
“THE TOUR IS TOUGH”
The Distance Run Per Game in Various Sports
1. Baseball= 0.0375 miles,
2. Football= 1.25 miles (receivers, DBs),
3. Basketball= 2.55 miles,
4. Tennis= 3 miles (varies with style, level)
5. Field Hockey = 5.6 miles
6. Soccer= 7 milesFrom: Fox, K. Runner’s World, June 29th, 2016, “The Distance Run Per Game in
Various Sports”.
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Before we look at some of the
more common lower extremity
tennis injuries (aka horses), let’s
discuss a few unusual injuries
(aka zebras).
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Not all injuries encountered are the typical
injuries that you and I would expect. That is,
unusual lower extremity can sideline even the
top players in the game.
Serena Williams – 1. In July of 2010, after
winning Wimbledon, she lacerated her EHL
Tendon while celebrating her victory in
Munich.
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2. On July 15th, 2010, she
had surgery to repair the
EHL Tendon.
3. Returned to practice in
Sept. 2010.
4. Had a second surgery
on foot in October.
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5. In March of 2011, she was diagnosed with a
PE .
6. She returned to competition in June 2011.
7. She advanced to the Finals of the 2011 US
Open Finals before losing to Stosur.
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Kim Clijsters, a three time US Open winner,
hurt her right ankle in April 2011 while dancing
in high heels at her cousin’s wedding.
She sustained a soft
tissue injury that
Included a partial tear
of ankle jnt. capsule/
tendon sheath.
“THE TOUR IS TOUGH”
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Jo-Wilfried Tsonga, in August of 2012 required
10 stitches (in Toronto) to close a laceration
near his knee when he walked into a fire
hydrant on a street.
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IN JULY 2012, AT THE QUEEN’s CLUB (IN
ENGLAND) , DAVID NALBANDIAN KICKED A
CHAIR & LINE JUDGE WAS INJURED.
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As a podiatrist, we should tell our tennis
players:
1. Avoid dancing
2. Avoid fire hydrants
3. No kicking
“THE TOUR IS TOUGH”
Common tennis injuries of the lower extremity:
1. Achilles Tendinitis,
2. Tennis Leg
3. Achilles Tendon Rupture
4. Plantar Fasciitis/ Tear
5. Ankle Sprain
6. Peroneal Tendinitis/ Tear
7. Jones Fracture
“THE TOUR IS TOUGH”
Case #1 (S.B.): The current #4 (55 and over)
men’s singles player in Florida (and # 17
nationally) has recurrent achilles tendinitis and
hamstring issues.
“THE TOUR IS TOUGH”
And he wears these shoes :
Rigid Shank
25
AVOID ANY TENNIS
OR GYM SHOES
THAT BEND HERE
BAD FLEXION IN MIDFOOT
SHOE FLEXION STABILITY
“THE TOUR IS TOUGH”
“THE EFFECTS OF A
RIGID SHANK SHOE
ON PLANTAR
FASCIITIS IN
RUNNERS”
Susan E. D’Andrea1, Kasey R. Parker1, 3,
Jason Novick2, Michael Kahelin1, Patrick
McKee2 and Alex Kor2
Departments of
1 Biomedical Engineering and
2 Orthopaedic Surgery, The Cleveland
Clinic Foundation, Cleveland, OH
3 School of Human Kinetics, University of
Ottawa, Ottawa, Ontario, CANADA
“THE TOUR IS TOUGH”
X-rays of an athlete with Achilles Tendinitis
– 30-40 % of the
general population
has a heel spur on
X-ray and yet has
no pain.
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Treatment for Achilles Tendinitis:
1. NO HEAT
2. Ice Applications (use a towel between heel
& ice) x 20 – 30 MIN. , once per day x 4
weeks
3. Heel lift(s)
4. Modification of shoes.
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5. Modification of activity level.
6. Anti-inflammatory med. X 3 weeks
7. Never a cortisone shot.
8. Boot/ Night Splint
9. Physical Therapy (Home Stretching
Program)
10.Shock Wave/ PRP
Stretching Exercises
30
NON-WEIGHT BEARING (A.M.)
(Do this exercise in the morning prior to getting out of bed)
Sit with one leg bent, the other leg straight. Use a towel
around the ball of your foot to pull your foot toward the
knee. Hold for 30 seconds. Repeat 5 times.
Stretching Exercises
31
WEIGHT-BEARING (P.M.)
Face a wall. Bend one knee and
bring it toward the wall with foot flat
pointed straight. The back leg
should be straight. Slowly move
your hips forward, keeping the back
leg straight and feet flat until
you first feel a stretch. Hold for 30
seconds. Repeat 5 times.
“THE TOUR IS TOUGH”
Case #2 – G.W. , a 43 year old airport
engineer was playing a 4.0 USTA match in
northern VA. With a previous history of a
achilles tear that required surgery, he was
unsure what had happened to his calf muscle
when he felt a “pop” in his left calf (medial
head of the left gastrocnemius). He was
unable to finish the match.
“THE TOUR IS TOUGH”
• Case #2 continued – So, he called the
volunteer podiatrist of “The Tour”. I
explained the injury to him.
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Case #2 continued – The treatments offered
GW included:
a. No impact activities x 3 – 6 weeks
b. Heel lift (in one or both shoes)
c. Ice / No heat
d. Boot x 2 – 4 weeks
e. Compression of calf
f. Physical Therapy
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CASE # 3 – K.B., a 51 year old business
owner from LaPlata, MD and a national ranked
player was hitting a service return and then
took a step forward.
“… My leg felt like it exploded !
It was like someone hit me on
the back of my ankle...”
“THE TOUR IS TOUGH”
Case #3 continued – When a patient has a
suspected achilles tendon rupture,
Thompson’s test is usually performed.
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• Thompson’s Test
*In a patient with a ruptured
Achilles tendon, the foot will
not move. That is called a
positive Thompson test.
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CASE #3 continued – Less than 2 days (Aug.
2003) after having the rupture, Ken underwent
successful surgical repair. He returned to
playing in June 2004 and continues to play
competitive tennis !
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CASE #4 – G.S., a 50 y/o teaching
professional and nationally ranked player from
Ellicott City, MD was playing in a USTA match
on Aug. 14th, 2009 when he felt a “snap,
crackle, & pop” in his arch.
“THE TOUR IS TOUGH”
CASE #4 continued – He could not continue
his match and was unsure if he could
compete in the upcoming national grass courts
in Philadelphia (singles and doubles).
“THE TOUR IS TOUGH”
• CASE #4 continued – So, he called me a
few days prior to the tourney (that I was
playing in, as well).
• He and his partner had won a national
doubles tourney in 2008.
• Because, he was still having pain, I
suggested that he not play singles and only
play doubles (which started on 8/26)
“THE TOUR IS TOUGH”
CASE #4 continued – Beginning on Aug. 26th,
G.S.’s treatment included:
1. Cross Friction massage
2. NSAIDs
3. In – shoe orthotics
4. Taping of the foot
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CASE #4 Continued – Fifteen days after
partially tearing his plantar fascia, G.S. and
his partner won the 2009 45 and over Grass
Court Doubles Championships.
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• # This compares favorably to a study by
Saxena and Fullem who followed 18
athletes who suffered same injury and
returned to competition in 9.1 weeks (+/- 6.0
weeks).
Source : Saxena, A. and Fullem, B. “Plantar Fascia Ruptures in Athletes.” .
American Journal of Sports Medicine, 2004; April – May , 32(3): 662-5.
“THE TOUR IS TOUGH”
CASE #5 – Ankle Sprain
According to a paper in the British Journal of
Sports Medicine (from 2006) ankle sprains
accounted for 20–25% of all acute injuries
on a tennis court.
• Source :Van Zoest WJ, Janssen RP, Tseng CM. An uncommon ankle sprain.
British Journal of Sports Medicine. 2007; Nov. 41(1): 849-50.
“THE TOUR IS TOUGH”
CASE #5 – Alex Kor and John Isner
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• By definition, an ankle sprain is an
acute soft tissue injury that results in damage
to the ligaments, tendons, and associated
soft tissues of the ankle.
“THE TOUR IS TOUGH”
CASE # 5 – On August 18th, 2010, John Isner
sustained a severe ankle sprain at the
Cincinnati tour event. He was forced to default
his match after this injury. His playing status at
the 2010 U.S. Open was questionable, at
best. But on Sept. 2nd, 2010, he miraculously
won his first match at the U.S. Open. An MRI
found no fracture but there was significant
ligament damage.
“THE TOUR IS TOUGH”
Case #5 – On July 14th, 2008, while playing a
tourney in Bethesda, MD , I suffered a similar
injury. A lob was hit over my head & as I
reached the ball in the corner; my left ankle
inverted and I fell to the ground.
a. I continued the match with a
compression dressing,
b. X rays were normal,
c. Returned to playing in early August.
“THE TOUR IS TOUGH”
Initial treatment for an ankle sprain should
include:
P PROTECTION
R REST
I ICE
C COMPRESSION
E ELEVATION
“THE TOUR IS TOUGH”
Ankle sprain/ fracture:
After an ankle sprain, initial x-rays can be
normal and yet a subsequent x-ray or another
imaging option may disclose a fracture.
----------------------------------------------------
Thus, a conservative approach to treatment is
highly suggested.
“THE TOUR IS TOUGH”
• TESTS THAT YOU SHOULD PERFORM:
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Case # 6 – A 4.5 USTA 49 year old male
(“J.D.”) with a history of plantar fasciitis
presented to my office 2 days after sustaining
a right foot injury (on court) that resulting in
pain (that caused him to faint).
His exam found mild to moderate swelling of
the lateral aspect of the calcaneus with (2 +)
pain to the peroneal tuberacle .
“THE TOUR IS TOUGH”
CASE # 6 -
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CASE # 6 -
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CASE STUDY # 6 –
1. X rays were normal.
2. MRI Found a partial tear of the Peroneus
Brevis tendon at level of Peroneal tubercle
(with small avulsion)
3. Treatment – Immobilization
4. Physical therapy
5. Shoe Change/ Orthotics
“THE TOUR IS TOUGH”
CASE STUDY # 7 – 67 y/o
male (former college player) tennis player
recalls approaching the net
and feeling sudden pain to
the lateral 5th MT Base. He
continued to play and x rays
were obtained ~ 2 weeks
later.
“THE TOUR IS TOUGH”
CASE STUDY # 7 – Additional X-rays
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CASE STUDY # 7 (at “press time”)- The
patient has pursued conservative care:
1. Immobilization
2. Bone Stimulator,
3. Partial weight bearing
“THE TOUR IS TOUGH”
Changes in the game of tennis:
1. Tennis players are bigger,
stronger and more athletic
(from WSA, 2006, 12 4:12-14.)
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Changes in the game of tennis:
2. Grass courts are slower and hard courts
tend to be faster (from The Queensland Times,
2015, “Tennis biz: great change at
Wimbledon.)
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Changes in the game of tennis:
3. “..The strategy of the game has changed.
Less serve and volley play and longer rallies
involving more side-side movement of
players..”
from personal communication with Allan
Grossman, DPM , USTA Sports Science
Committee.
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Changes in the game of tennis:
4. According to Grossman, 70 – 80 % of the
baseline strokes are forehands and fewer
than 30 % are backhands.
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Changes in the game of tennis:
5. Perhaps, the biggest change in the last 5-10
years is the use of sliding on a hard court.
“THE TOUR IS TOUGH”
Traditionally, sliding on clay courts has been
commonplace. But as the game has become
more athletic, faster, quicker, the tennis player
has less reaction time to get to the ball and hit
the shot. Thus, the use of sliding on hard
courts is now a necessary skill at the elite
level.
“THE TOUR IS TOUGH”
So, what is sliding needed and does it affect
injury rates of the lower extremity?
With the increased power of the game, sliding
allows elite players to recover quickly for an
upcoming shot while maintaining foot position
and momentum.
“THE TOUR IS TOUGH”
In a 2014 paper in Procedia Eng. , Pavailler S.
and Horvais N. found that sliding does indeed
allow faster repositioning during tennis specific
movements on hard courts.
1. Backhand time for repositioning was
reduced by 21 %,
2. Forehand time for repositioning was
reduced by 42 %.
“THE TOUR IS TOUGH”
Injury rates: Nigg and Denoth (in 1980)
questioned over 1000 tennis players regarding
court surface and incidence of tennis injury.
They found that tennis players playing on
surfaces that allow sliding (clay courts) had
less pain and injury than their counterparts
playing on surfaces that did not allow sliding
(asphalt, synthetic surface).
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Cushioning/ Stiffness of court surface:
Nigg and Yeadon (1987) – The stiffness of the
court surface seems less significant than the
frictional properties for preventing tennis
injuries. The more the surface allows for
sliding, the less lower extremity injuries occur.
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According to a March 2016 paper in the
Journal of Medicine and Science in Tennis,
two other factors play a role:
1. Interaction between court construction (load
experienced by the body) and the shoe
construction.
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Therefore, one can assume that injuries in
tennis players may be dependent on the
advances of shoe gear technology (which has
not been as innovative as the running shoe
gear technology).
Sterzing et. al. ,in a 2014 paper in Footwear
Science, surveyed 1,524 tennis players from
China, Germany and the USA.
“THE TOUR IS TOUGH”
The tennis players in this paper reported:
1. Forefoot outsole durability issues,
2. Excessive sweating,
3. Blisters,
4. Increased ankle sprains,
5. Pain of the MT Heads
“THE TOUR IS TOUGH”
Sterzing concluded that: “ The creation of
innovative tennis footwear, providing forefoot
shoe comfort marks a strong request of tennis
players”
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I would agree with these recommendations:
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The latest tennis shoe trends suggest that the
emphasis is on making the shoes lighter and lower to
the ground. The hope is that this will allow for better
performance without sacrificing durability and
cushion.
Personal communication with David Sharnoff, DPM
and Arthur Gudeon, DPM
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Allan Grossman, DPM, using sensor tennis
technology in tennis and running shoes, wear tested
elite tennis players in 2011. Surprisingly, he found
that running shoes tested better than tennis shoes in
the same group of players. No one is suggesting to
play tennis in running shoes, but the tennis shoe
companies need to utilize more running shoe
technology in tennis shoes.
“THE TOUR IS TOUGH”
IN SUMMARY, AS I CONTINUE TO PLAY ON
“THE TOUR”, THERE IS NO DOUBT THAT I
WILL CONTINUE TO BE EXPOSED TO
UNUSUAL LOWER EXTREMITY INJURIES.
“THE TOUR IS TOUGH”
BUT, BEYOND OFFERING ADVICE AND
OCCASIONAL INTERVENTION, I WOULD
HOPE THAT I COULD OFFER “THE TOUR”
SOME PRO-ACTIVE & PREVENTIVE
MEASURES.
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“THE TOUR IS TOUGH”
A FEW YEARS AGO,
MY RT. SHOE HAD WORN
OUT. I CALLED MY TENNIS
SHOP AND WAS SHOCKED
TO FIND OUT THAT THEY
NO LONGER CARRIED MY
MID-TOP SHOE .
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I CONTACTED ALL OF THE TOP SHOE
COMPANIES, REPRESENTATIVES, ETC., &
DISCOVERED THAT THERE EXISTS NO
MID-TOP SHOES.
“THE TOUR IS TOUGH”
THEREFORE, I AM PROUD TO ANNOUNCE
THAT AS OF ,TODAY (JULY 13th, 2018), I
WOULD LIKE TO MAKE MYSELF (AND MY
LIKENESS) AVAILABLE TO ANY SHOE
COMPANY THAT IS READY TO LAUNCH
THE:
“THE TOUR IS TOUGH”
THE KOR-SWISS MID-TOP SHOE
“THE TOUR IS TOUGH- Got
Tennis?”
Thank you for inviting
us !
• REFERENCE: Kor, Alex. “DOUBLES PLAYERS: COMMON LOWER
EXTREMITY TENNIS INJURIES”, PODIATRY MANAGEMENT, April- May
2011, pp. 91-98.