ROYAL COLLEGE OF PODIATRY
Rafael Nadal’s podiatric legacy
Rafael Nadal was one of the most successful tennis players of his generation. At age 19, however, his career was seriously threatened by chronic midfoot pain. He chose to play on, adopting a highly unconventional – and potentially controversial – approach to pain management.
Roland Garros, Paris, 2022. 36-year-old Rafael Nadal drives a two-handed backhand beyond the outstretched reach of Casper Ruud. The ball bounces twice. Nadal drops his racket, wipes the sweat from his brow and raises his arms skyward on the the sun-drenched clay of Court Philippe-Chatrier. He has just won a record-breaking 14th French Open title and his 22nd Grand Slam in total. To all onlookers, this is a win like any other, achieved by a sportsman of seemingly unparalleled athleticism. And yet, there was nothing ordinary about this victory or, indeed, any aspect of the veteran Spaniard’s 23-year career which cemented his position as one of the greats of the game.
The onset of debilitating chronic pain
What those celebrations concealed was the extraordinary physical cost of simply stepping onto the court. It has recently been brought into full focus in Rafa, a Netflix documentary, that Nadal played all seven matches of the 2022 French Open with an anaesthetised foot to counteract the debilitating impact of chronic pain.
"I have been playing with injections on the nerves to sleep the foot, that's why I was able to play during these two weeks,” he said.
“The foot was numb, so I didn't feel anything."
In order to understand why this was necessary, we must return to the very beginning of Nadal’s tennis career, to the source of his chronic pain and the underlying pathology that plagued him for more than two decades and makes his achievements all the more remarkable: Müller-Weiss disease.
A fracture leading to diagnosis
It was during the 2005 Madrid Open, only months after claiming his first French Open title at the age of 19, that Nadal fractured his foot. It was this injury that prompted further investigation and ultimately led to the diagnosis of Müller-Weiss disease. It was a diagnosis which confounded his specialists.
Although the incidence and prevalence of Müller-Weiss disease remain poorly characterised, at the time the young Nadal presented with the signs and symptoms of this condition, it was thought to principally affect women between 40 and 60 years of age.
That a 19-year-old elite male athlete should develop Müller-Weiss was, epidemiologically speaking, deeply anomalous.
Paradoxically, however, it may have been his exceptional athleticism that contributed to its development. Dr Ernesto Maceira, the orthopaedic surgeon involved in Nadal's treatment, pointed to Nadal's intensive childhood training as the primary cause, arguing that the 'abnormal forces that act on an immature bone' were principally responsible for the onset of Müller-Weiss.
The evidence behind the diagnosis
The most recent academic literature on this condition lends support to Dr Maceira's assessment.
For example, a 2024 article suggests that the aetiology of Müller-Weiss disease involves both genetic and biomechanical factors and draws particular attention to athletes who have trained from childhood in high-impact sports requiring rapid and successive changes of direction, as is the case in tennis. This activity, it is thought, contributes to the progressive deformation of the navicular, which is the last tarsal bone to ossify and therefore, the one most susceptible to excessive mechanical loading during skeletal development.
In Müller-Weiss disease the blood supply to the malformed navicular becomes progressively compromised. The result is osteonecrosis, fragmentation of the bone and arthritic degeneration within neighbouring joints. Pain is typically focal to the midfoot and worsens with weight-bearing activity. Patients also report difficulty when walking and swelling of the foot. Joint stiffness and a limited range of movement are also common.
The long-term consequences of Müller-Weiss disease
It will be familiar to many podiatrists that, although Nadal's primary pathology originates in a single small bone of the foot, its consequences were far from localised and were felt throughout much of his body.
By the time of his retirement in 2024, he had sustained a catalogue of injuries that many clinicians and commentators have linked to the biomechanical consequences of his foot condition, including ipsilateral knee tendinitis, hip flexor pathology and gastrointestinal complications secondary to prolonged analgesic use.
Nadal himself drew this connection explicitly. "The origin of all my problems in my body [came from] the foot,” he said.
“That really affected me to the rest of the body."
Standard treatment for Müller-Weiss, and can surgery help?
For the typical patient presenting with Müller-Weiss disease, management of this condition is guided by severity. In the early stages, conservative measures are likely to be explored, including activity modification, anti-inflammatory medication, rest and ice.
Custom orthoses may provide pain relief, alongside guided corticosteroid injections. However, where conservative management fails, surgery remains the only definitive means of halting disease progression. Interventions typically involve debridement of necrotic bone, internal fixation of the navicular and joint fusion, most commonly of the talonavicular joint.
Treating an athlete who just wants to compete
Rafael Nadal, however, is not a typical patient. The surgical option that may have been warranted for other patients was ultimately decided against, as his ability to compete and win depended upon explosive lateral movement and rapid changes of direction. Such movement would likely have been impossible following surgical intervention. Gilbert Versier, former chief of orthopaedic surgery at Vincennes military hospital, was unequivocal: a procedure of this kind "jams up the foot, leaving the patient able to walk but not run."
Nadal himself understood the impact of this decision with painful clarity. Yet, he pressed on, driven, as he put it, by the conviction that "the suffering was less than my passion and my happiness for what I was doing."
Faced with this reality, he and his medical team pursued an approach that went beyond standard care: repeated nerve blocks to anaesthetise the foot entirely. Although this intervention facilitated a remarkable French Open victory in 2022, it is one which raises several unavoidable ethical questions.
The ethics of pain management
The first question concerns subjecting young children to the kind of intense physical training that may precipitate a condition such as Müller-Weiss in susceptible individuals.
The second, and perhaps more immediately pressing for the clinician, is whether it is ethically defensible to anaesthetise a foot, eliminating the proprioceptive pain signals that serve as the body's natural warning system, in order to compete in a sporting contest. In doing this, Nadal was not only exposed to the risk of compounding existing damage but was rendered unable to perceive any new injury sustained during play.
Nadal himself was candid about the complexity of the decisions he had made. In a recent interview with the BBC, he claimed: "I've had to make decisions about my health, where you are on the borderline between right or wrong. But if I hadn't explored all that, I probably would have had 10 fewer Grand Slams... this is the reality."
Many would argue that an athlete of his experience is best placed to weigh those risks himself, and that his autonomy as a patient and a competitor must be respected. Others would contend that the role of the clinician is to protect long-term health, not to facilitate short-term performance at the expense of it. It is a tension without easy resolution, and one that Nadal's case brings into unusually sharp relief.
What can we learn from Nadal?
Rafael Nadal's podiatric legacy is not merely a story of extraordinary sporting achievement. It is also a reminder that behind chronic midfoot pain may lie a condition that, when overlooked, can have consequences extending far beyond the foot itself.
Most of us will never treat a Grand Slam champion, but we may well see a perfectly normal person with chronic midfoot pain who has been either dismissed or misdiagnosed. Our patients will not be striving to win a 14th French Open title; they might simply need to get through.
Recognising Müller-Weiss disease
A practical guide from Professor Nat Padhir and Mr Abid Hussain, Chair and Vice-Chair of the Royal College of Podiatry’s Podiatric Sports Medicine Specialist Advisory Group on recognising Müller-Weiss disease.
Rafael Nadal's story highlights how difficult Müller-Weiss disease can be to diagnose and manage. While uncommon, it is an important condition for podiatrists to recognise because it can be mistaken for several more common causes of chronic midfoot pain.
When should you suspect it
Think about Müller-Weiss disease in adults with longstanding dorsomedial midfoot pain centred around the navicular, particularly if symptoms worsen with weight-bearing. Localised tenderness, swelling and an altered gait are common clinical features.
Although it most commonly affects middle-aged women and is often bilateral, cases have also been reported in adolescents.
The exact cause remains uncertain, although trauma, osteonecrosis, mechanical overload and congenital factors have all been proposed.
Conditions it can be mistaken for
Müller-Weiss disease shares symptoms with several other causes of chronic midfoot pain. Consider:
navicular stress fracture
Crisp-Padhiar Syndrome
accessory navicular syndrome
tibialis posterior tendon enthesopathy
midfoot osteoarthritis
inflammatory arthropathy
Osteonecrosis
tarsal coalition
Charcot neuroarthropathy
post-traumatic navicular deformity
Unlike Müller-Weiss disease, Köhler's disease is a self-limiting childhood condition affecting the navicular and should not be considered its paediatric equivalent.
Investigating Müller-Weiss disease
Take a detailed history, including previous trauma, sporting activity and symptom progression. Clinical examination should assess:
pain location
gait
hindfoot alignment
medial arch profile
navicular tenderness
midfoot deformity
Weight-bearing radiographs are the first-line investigation and may demonstrate navicular compression, fragmentation, sclerosis and collapse.
CT helps define bony deformity and joint involvement.
MRI can assess bone marrow changes and help exclude alternative diagnoses.
Management
Conversative
Management should begin conservatively and may include:
activity modification
physiotherapy
NSAIDs (non-steroidal anti-inflammatory drugs)
immobilisation in a walker boot if gait is significantly affected
rigid or semi-rigid orthoses to reduce talonavicular joint movement
Surgical
Surgery may be considered when symptoms persist despite conservative treatment or where deformity and joint degeneration are advanced. The choice of procedure depends on disease stage and joint involvement.
Five things to remember
Müller-Weiss disease is an adult navicular disorder and should not be confused with Köhler's disease, a self-limiting childhood condition.
Müller-Weiss disease should be considered in patients with chronic dorsomedial midfoot pain, particularly when symptoms are weight-bearing related and associated with navicular tenderness, swelling, altered gait or midfoot deformity.
The differential diagnosis is broad, and Müller-Weiss disease may be mistaken for navicular stress fracture, accessory navicular syndrome, posterior tibial tendon dysfunction, midfoot osteoarthritis, inflammatory arthropathy, Charcot neuroarthropathy or post-traumatic deformity.
Weight-bearing imaging is central to diagnosis, with radiographs used as the first-line investigation to identify navicular compression, fragmentation, sclerosis, collapse and altered talonavicular alignment; CT and MRI may provide further detail.
Management should be staged and individualised, beginning with conservative measures such as activity modification, physiotherapy, medication and orthoses, while surgical options are guided by symptoms, deformity, joint involvement, osteoarthritis and Maceira stage.
Why this matters
Müller-Weiss disease is uncommon, but recognising it early can help prevent prolonged pain, delayed diagnosis and inappropriate management. Weight-bearing imaging and careful clinical assessment remain central to identifying the condition.
About the authors
Thomas Collins is a Practice Manager at Sussex Foot Centre, an MSc Podiatry Apprentice and a Doctoral Researcher at The University of Sussex. He has covered history and sport for The New Podiatrist.
Mr Abid Hussain is a Consultant Podiatrist with more than 31 years' experience in musculoskeletal and sports medicine. He was Lead Sports Podiatrist at the Birmingham 2022 Commonwealth Games and is currently undertaking a PhD at Loughborough University.
Professor Nat Padhiar is a Consultant Podiatric Surgeon and Honorary Clinical Professor of Podiatric Sports Medicine at Queen Mary University of London. An internationally recognised expert in sports medicine, he was Clinical Lead for Podiatry at the London 2012 Olympic and Paralympic Games.
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