Discussing Marco Asensio's ACL rehabilitation at Real Madrid
It's one injury that no player wants; but often the difficulties after ACL surgery arise as players enter the functional stages of rehabilitation.
The incident in which Marco Asensio tore the anterior cruciate ligament (ACL) in his left knee against Arsenal on a pre-season tour with Real Madrid in the USA illustrates the innocuous way in which football injuries can be sustained.
Often it’s those injuries that don’t appear to be too serious when viewed from a distance that can be the most complicated; but when looking at the reaction of the players in close vicinity to Marco, it quickly became apparent that this was more than just a straight-forward twist of the knee.
As we now know, Real Madrid’s medical team didn’t waste any time in initiating the investigative process. Unfortunately for Marco, the working diagnosis of an anterior cruciate ligament rupture combined with a meniscus – or cartilage – injury was soon confirmed.
The last thing any player wants to hear is the diagnosis of an ACL tear. That’s usually because ACL injuries are associated with a lengthy period of rehabilitation once the operation is over; but also because the final stages of rehab can be the most challenging.
Coming to terms with the fact that you are going to be out injured for around six to nine months is bad enough on its own; but when you factor in how many players go on to sustain repeat ACL injuries it’s easy to see why there are doubts in players’ minds about whether they will recover to pre-injury status.
As is the normal, Marco went through ACL surgery a short time after the injury was sustained. He's now finished with the early stages of rehabilitation and is moving on to more functional work under the guidance of Madrid's medical team.
Although everything is reported to be going to plan at the moment, the real challenge for Marco may lie in a few month’s time as he steps up his running and enters the functional stages of rehab.
That's when he’s going to be thinking about his return to training – and that can often be the most difficult period.
The key to managing ACL injuries often lies in understanding how the rotational movement of the knee relates to the demands of the game; and in particular, the position of the knee at the time an injury is sustained.
It is the rotational - or twisting - movements associated with football that often put the knee under the most stress. We frequently refer to a ‘twisted knee’ when describing injuries of this nature and this equates to how most forms of internal derangement occur.
Anatomically, the ACL is one of two strong ligamentous structures deep within the knee joint that connects the femur and tibia with the purpose of preventing excessive knee movement in a backward or forwards direction, the other being the posterior cruciate ligament (PCL).
In football though, the movements of the lower limb don’t fit into such specific categories. The actions of the knee joint are not just confined to forward and backwards movements as described above; there are sideways movements as well which stress the collateral ligaments situated on either side of the joint.
When rotation is added and the movements of the knee are all combined, there’s a lot of stress placed on the joint itself. This stress is increased by the repetitive actions of football which involve twisting and turning, running and jumping etc.
Despite recent advances in the modern game, the components of fitness for football as defined by Coutts and Grant, (2005) and Bordon, (2006) of speed, strength, agility, power and flexibility still stand; all underpinned by a strong capacity for aerobic endurance.
So in order to successfully return to football successfully after ACL surgery, all these components have to be addressed progressively during the rehabilitation period.
Marco Asensio’s concern will be that although he is able to address two or three of the above components at a time during his rehabilitation period, there will be situations where he will be required to address most of these in one play - such as when making a multi-directional sprint or taking a tackle on the turn at high speed.
Another risk is in jumping and landing at an awkward angle or having some slight but important muscle imbalances in and around the operated knee.
If you add coordination and balance to the mix, and include proprioception (which is the sense of knowing where your limbs are without actually looking at them), then there’s a lot of fine-tuning to be done in the later stages before Marco is actually able to return safely to the full squad.
In practical terms, muscles and ligaments all work in tandem with their opposites; such as the quadriceps muscles of the front of the thigh and the hamstrings at the back of the leg for example; and all are at their most effective when the balance between both groups is correct.
If the balance between both is disturbed and results in certain structures being put under more stress than its opposite, that’s where the risk of injury recurrence increases dramatically. This partially explains why players being rushed back from injury are at a disadvantage.
Although Marco’s injured ACL or meniscus may have recovered the muscle balance may not be at the correct ratios; and when discussing the knee joint getting this balance correct is essential. This is particularly important after something relatively major like an ACL injury.
Another risk following successful ACL surgery is again evident at the return to training stage; and that is in a player’s timing and sharpness.
Reactions, like everything else, have to be developed and you can usually spot the player who has been out of action for some time because they react that fraction of a second slower in uncontrolled situations on the field which again often leads to recurrence of injury.
This last aspect of returning to play is often the one that’s most evident. I know it’s months away but Marco will already be thinking about his return and counting the days, weeks and months until he’s back in the team.
It’s only natural to do this but he won’t be fully recovered until that sharpness returns and that will be the main challenge to Real Madrid’s medical and fitness team. Often the hardest part of returning to play is in regaining that essential reaction time and total match fitness.
The latter is difficult; and the problem affect everyone involved in the rehab process. For the rehabilitators, the issues lie in integrating both training for match fitness and working towards improving reaction times effectively enough to allow a player to return to full contact training.
The problems for Marco will be in having the patience and self-discipline to avoid the temptation to try to make too early a return when the time comes and remaining positive throughout the latter stages of his rehabilitation programme.
Bordon C (2006). Training Methods. In Football Traumatology; Current Concepts from Prevention to Treatment. Volpi P (2006). Milan; Springer. Pp 23 – 31.
Coutts AJ, Grant A (2005). Training aerobic capacity for improved performance in team sports. Sports Coach Australia. Vol. 27 (4).
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