It’s surprisingly difficult to find concrete information on professional athletes’ injuries. This week in the clinic, and the wider world, we’ve been talking about Rafael Nadal’s amazing efforts at coming back from 2 sets down to take the Australian Open to become the most awarded Grand Slam Champion at the ripe old age of 35. Not only is he 10 years older than his opponent, but also arguably past his physical prime.
The ‘physical prime’ part is by far the most interesting as Nadal’s career has been plagued by injury, most likely due to the tenacity with which he plays, and the grinding he is willing to do on the court to win a point. No doubt his training, which is 95% of the tennis he plays, is also played with the same intensity, putting extreme load through his body with hours on and off the court.
It was only in September 2021, 5 months ago, that he stood with crutches after having treatment on his left foot, his dominant foot, in Barcelona, and many thought this was the end of his career after such a long slog managing his injury. And to add insult to injury, in mid-December he tested positive for COVID suffering moderate symptoms, before outlasting the whippersnappers of the ATP Tour, to win Australia in magnificent fashion.
Firstly, we know it was what took him down in 2005 at the age of 18, and almost ended his career, at the height of his career. We also know the condition is called Müller Wiess Syndrome which is a degenerative disease in the foot, where the Navicular bone, at the top of the arch area, degenerates.
SO WHAT DO WE THINK WE KNOW ABOUT THIS FOOT INJURY?
This bone sits near the ankle on the inside of the foot and takes a lot of load when we weight bear and when we change direction. Now if you’re a tennis fan, you’ll know that Nadal’s genius is his speed around the court and quick feet, explaining why this condition is so debilitating for him. His tennis didn’t cause the condition as Müller Weiss Syndrome is a random onset condition however, the excessive overload his career has put through his foot, could certainly be the reason the condition was so severe in someone so young.
No doubt Rafa has had the very best assessment and care of this condition since 2005, and in a way, he’s lucky they found it so young, because he will have managed it carefully throughout the past 17 years of his career, and hopefully into retirement.
Most likely, the treatments he will have tried would include the full gamut of physiotherapy – mobilisation, taping, foot/ankle/lower limb strengthening, balance and control, strength and conditioning, return to sport protocols, dry needling, massage, biomechanical assessment with technique changes in his footwork, linked with his coaching. As well, he probably had all the electrotherapy in the world thrown at the foot. He would’ve consulted with a mechanical podiatrist to look at foot function and support, possibly getting passive supports in the shoe to offload the midfoot, and different ones for sport and day wear. And medically, over the past 17 years, he has probably tried interventions like PRP (platelet-rich plasma injections), prolotherapy, steroid injections for short term pain and inflammation reduction, and maybe even some micro fracturing to the area to encourage the proliferation of cartilage over the bones. Everything he has will have been aimed at offloading the joint in the foot, strengthening the foot and promoting a healing response in the joint.
We think it’s also possible Rafa was in Barcelona to get Stem Cell treatment to ‘repair’ the cartilage in the midfoot, much like the Stem cell treatment he had in 2014 in the same city for his low back injury, to promote a healing response
What’s the future for Rafa’s foot?
It’s likely he will have a fusion on the joint once he retires. This will involve surgeons pinning or wiring the navicular bone to the talus, the bone next to it, to prevent movement and provide stability, thereby reducing pain. Rafa will still need to do work on the foot and his legs to keep them strong, as one of the downfalls of a fusion, is the normal spread of load through the foot is altered, and the other joints are taking more load, and in different ways. If patients don’t look after this, they can end up causing trouble above and below the original injury, which can be hard to manage.
WHAT DOES HIS INJURY MEAN FOR US MERE MORTALS?
Quite a few things.
1. Medical conditions can happen to anyone – sometimes it’s just bad luck.
2. Good management is imperative.
3. Taking time to heal may seem difficult at the time, but you can still win Australian Opens at 35 years of age.
4. Addressing a medical issue early on might be scary, but will usually lead to better results.
5. Even sporting legends go through the same physio rehab as you do.
WHAT ARE THE BEST FOOT PHYSIOTHERAPY EXERCISES?
Well, it’s important to remember that the muscles in your feet are just as important as your hamstrings, quads and glutes when you are exercising, so not overlooking these muscles can not be underestimated, especially for injury prevention.
Often referred to as the ‘foot-core’, these intrinsic foot muscles are responsible for maintaining the shock absorption and the arches of your feet. These muscles are smaller than global lower limb muscles, which are responsible for moving the ankle and the extension of your toes.
Weak foot muscles may lead to poor biomechanics, unable to support the foot correctly or over-correction leading to a higher chance of stress fractures, plantar fasciitis (heel pain) or even compromised global muscles. So here are some of our exercise recommendations.
1. Calf raise to big toe press – find some stairs and in bare feet stand on the edge of the stair. Slowly, let your heel drop below the level of the stair. Then do a calf raise, finishing by pressing onto your big toe. If you need to, hang on to something if you feel you need assistance.
2. Big toe press – with this exercise press your big toe into the floor while lifting your other four toes. Try and hold each press for around eight seconds and do 12-15 reps per foot.
3. Toe Splaying – whist flat on the ground, try pulling your toes apart as while as you can without curling or extending them. The focus here is to move your big toe away from the other toes. When you do this exercise you will feel your foot arch muscle contract, making this an effective way to activate your arch. Try and hold for eight seconds and relax. We would recommend starting with five repetitions and building up to twenty-five to 30 in time.
4. Short foot exercise – sit in a chair or even practice this sitting at your desk at work, in bare feet, form a 90-degree angle at your knees and ankles. Without crunching your toes, try to shorten your foot by bringing the ball of your foot toward your heel, doming the arches in your feet. You can focus on one foot at a time or do both at once. Try not to curl or extend your toes and make sure to keep your foot neutral, not rocking inward or outward—it’s harder than you think. Note that being completely barefoot will enhance your ability to feel sensory input from the bottom surface of the foot, and help you develop the sense of creating the short foot posture. Hold for 8 seconds and relax. Repeat five to fifteen times.
5. Leg swings – do these legs swings with a small amplitude to challenge your balance and hip and ankle stability. Stand on one leg in your bare feet and create the short foot posture. Swing the non-stance leg forward and backwards 15 times. Without rest, swing the same leg left and right in front of your stance leg, also 15 times. Repeat this sequence without resting, then repeat on your opposite leg.
Are you facing issues with your feet? Please feel free to contact us to make a booking here.