What is the Müller-Weiss disease that Rafael Nadal suffers from and causes him acute and chronic pain

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Against his expectations and those of his team -in August he ended the season due to the pain he was experiencing and

, against the circumstances -two sets against and a rival who imposed an uncomfortable game- and against the algorithms -which only gave him a 4% chance of winning-.

once again managed to turn the situation around and won the Australian Open, becoming the first male player to win 21 Grand Slams.

The "greatest in the history of tennis" is not due exclusively to his titles and achievements with the racket, but also.

that he was diagnosed with at the age of 19.

"Some told me they didn't think he could play at high intensity again," Nadal himself has once said, but he has done much more than just play at high intensity.

Müller-Weiss disease is a

and falls within the conditions known as avascular necrosis of the foot bones.

"In its origins, it is surely produced by an increase in pressure received by the lateral half of the scaphoid, between another bone that is the talus, which is behind, and another bone that is the cuneiform, second and third, that are in front. This increase in pressure generates transitory episodes of

the weakening of the bone will produce a progressive crushing, a progressive loss of shape of the scaphoid, which is the most incipient radiographic finding that we observed in these patients", explains

, professor of the Degree in Podiatry at the Complutense University, who was precisely present when Dr.

, one of the greatest experts on Müller-Weiss, diagnosed Nadal.

Orejana indicates that as the disease progresses, the crushing of the scaphoid is greater and sometimes

.

"These fracture processes are nothing more than an evolutionary radiological image of the disease. As it progresses, osteoarthritic processes begin to form between the joint that forms the astragalus with the scaphoid and the scaphoid with the wedges and it is at that moment -well in the of the fragmentation that a fracture line appears or in that of osteoarthritis, more or less advanced- when most of

, "he adds.

In other words, it is a disease that causes pain.

If left untreated, it can

.

"The disease is progressive, like all osteoarthritis, and the evolution is particular to each subject, it cannot be predicted but, if it is not treated in the stages where there is still more mobility of the joints and, therefore, it is easier For conservative treatment to have good results, the prognosis is that a painful foot will develop with significant functional limitation for daily life and

in these joints".

The diagnosis is made because the pain leads them to consult a specialist.

"It is true that when you ask them they have other symptoms, some complain of

or even some, when you ask them, confirm that they suffer from

, fundamentally in the internal half, because one of the clinical associations that this disease has is the predisposition to knee problems that mainly affect the internal half of it," Orejana points out.

In elite sports, many other names with similar injuries have not emerged, but the specialist points out that

, there are sure to be cases.

Typical profile of these patients

dropdown

"The

of these patients were middle-aged patients,

in which the aforementioned signs derived from the osteoarthritic process that forms in the talus-navicular joint began to appear. At that time they consulted and a osteoarthritis of that joint together with an alteration in the shape of the scaphoid, which sometimes has a comma shape and produces crushing and loss of size in the anteroposterior direction Generally middle-aged with a

" says Orejana.

The specialist refers to some graphs of the first more or less advanced records on the disease, which were made by Dr. Ernesto Maceira, in which it is observed that the birth of these patients coincided with the postwar period and their places of birth " in areas with a rather low economic profile or had been immigrants or had lived with very large families, etc., with which one of the hypotheses that was established is that the scaphoid, which

, in these patients suffered greater deforming forces and that could predispose them to develop this disease in adult life", says Orejana.

The Complutense professor emphasizes that

"not so much related to economic hardships or wars or situations of this type, but rather with

. In this sense there are some sports that involve impact, where lateral displacements are generated, where there are turns, where there are rotations of the foot or technical gestures that imply rotations, in which the presence of this type of disease has also begun to be seen. They would also be linked by stress, by the forces to which the scaphoid is subjected during periods of growth".

According to Orejana, it is a Müller-Weiss that appears earlier:

.

"It is not the majority profile, the most abundant is still the other, but it is seen more frequently than it could be seen 20 years ago and surely the intensity of the sports activity together with some

, because it is necessary for the foot to have a supinator nuance so that the injury can also be triggered".

To treat this disease

.

"The conservative line is based on reducing the compressive force that supports the scaphoid by placing orthopedic elements, orthopedic

. It is necessary that the insole pronates the foot, although clinically we see in many of these patients have a tendency to flat feet, but they are paradoxical flat feet because, although the shape is a little flattened, the operation of this foot is just the opposite, it is supinated, turned outwards, therefore the orthopedic treatment must turn towards inside the foot, fundamentally the tarsus", explains Orejana.

It is precisely the solution that Nadal followed in 2005, special insoles (and shoes).

"It is important that the insole positions the foot in this pronated situation because it is the only aspect that allows us to reduce the deforming forces that the scaphoid supports. If we achieve this normally

, and if we get into the sports world, these patients also need shoes, especially in sports where there are lateral displacements, to have greater support on the outer edge.

In fact, all tennis shoes have it because they are lateral displacements, an extension, an increase in the support base of the shoe on the external side to encourage the foot to go a little inside," Orejana develops.

The specialist emphasizes that, even so,

this type of injury and this type of feet generally have painful episodes.

"

it. It is true that they may have periods of less pain or even no pain, but throughout the season these types of feet always have some kind of painful manifestation".

These local therapies are "

, which is nothing more than the subcutaneous application of combinations of drugs that seek to control pain";

treatments

"Aimed at trying to reduce the edema, the inflammation that the scaphoid may have or to reduce the pain of the periarticular soft tissues."

There is no clear evidence, underlines Orejana, with what has been published to date that these patients can benefit from other therapies such as stem cells or platelet-rich plasma.

Nadal himself has said that he does not remember the last time he played without pain.

If it hurts for daily life, much more for sports practice and at this level.

"It has not prevented him from being number 1 in the ATP ranking, continuing to win tournaments at the highest level and continuing to compete at the age of 35. Anyone who knows and treats patients with this disease appreciates that the achievements and successes that Nadal has had in his career sports are not stratospheric only because of the dimension they have sportingly speaking, but because of the sacrifice and the constant and daily struggle that they have surely had to have to accommodate themselves to compete in a situation of disadvantage", emphasizes Orejana, who adds: "His achievements acquire a much larger dimension, in my opinion.

in his foot, it gives him an added value that I think most people are not able to understand ".

And with another handicap: all the years he has been enduring the disease.

Since 2005 (he was 19 years old), the year he won the first Roland Garros, his first Grand Slam.

and that has not prevented her from winning another 20 Grand Slams, with pain.

How can you play at that level with this disease?

"If I had that disease, it would be the first thing I would ask whoever treated me, how is it possible that this man plays at the level he plays, having this disease, and I can't stand walking for three hours in pain. People think that athletes they get up without discomfort, like any of us can get up on a good day, and no. There are athletes whose first hour is to gear up the body, you see them in the morning and you think 'I don't know if this person is going to be able to compete' and at night it is not that she has competed, it is that she has made a memorable match or has passed the round or has been the best of the team Elite athletes push their bodies to a maximum demand and many of them cohabit with some chronic pain derived from practice, sports gesture, old injuries...I think

For Nadal or other athletes of that level to compete with such pain, it

,

, beyond the fact that they can receive certain specific treatments to control it at important moments such as before a match, "explains Orejana.

The podiatrist underlines pain management as a reason for success.

"Obviously physiotherapy treatments help a lot, orthopedic treatments, local analgesic treatments: mesotherapy can give a plus, some selective punctual infiltration can help... But there is a part that is that

or in a problem beyond the usual pain.

In the case of tennis, Nadal's game at the first Roland Garros does not have much to do with the game technique of recent years because you are also looking for shorter points, less prolonged efforts... the athlete also adapts the technique a bit , the style that suits you best, adjust physical preparation with other types of exercise, adjust nutrition so as not to weigh 100 grams more than you should, in short, it is the work of many people who each help you with their granite so that you end up having a level of pain that you can end up managing mentally".

Surgery

The other line of treatment that Orejana mentioned is surgery, although the specialist emphasizes that the criterion is clinical, purely symptomatic.

"That 'since this is very bad, you are ready to operate' is not true in this disease. You see some highly evolved Müller-Weiss with a moderate symptomatic level that conservative treatment reduces enough so that the patient can do his life substantially well, with which there is no reason to operate. When is there a surgical criterion? When conservative treatments are

relatively well or have to limit or stop them. the case of athletes,

: if I have to stop every 3 weeks or a month and a half, if I have to stop for a month because the level of pain does not allow it, there comes a time when I have to shuffle surgical options," argues Orejana.

What are those surgical options?

According to the Complutense professor, classically they were

.

"You have a bone in your foot with severe osteoarthritis and what you do is clean the remnants of articular cartilage that remain and refresh the surfaces a bit so that they vascularize and you glue one bone to another so that they fuse."

Orejana indicates that this was done as the first option some 20-30 years ago, "this does not mean that they are not done now, but rather that

: you cut it in two and move one of the segments, either rotating it or moving it, and then in that new position in which you have placed part of the bone you fix it with a screw, with a plate, with whatever it takes so that the bone fuses .

It's creating a controlled fracture that allows you to modify the shape of the bone a little bit."

The osteotomies

, "but obviously since it is done at the bone level, the effect is much more important, larger. It can also be done in association with these osteotomies with some other surgical gesture, either of soft tissues or of another bone structure, since this is more dependent on the patient, it is not something so generic.When these osteotomies do not give as good a result or they give it but over time they lose effect is when one proposes arthrodesis , fusions. Today they remain as rescue solutions for patients with poor evolution with other surgical gestures", concludes Orejana.

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