Anterior Cruciate Ligament Injuries In Football
Anterior cruciate ligament (ACL) injuries are by far the most common injury suffered by professional football players. Find out more about how they bounce back to play and what are their main barriers to return-to-sport after surgery and physiotherapy.
Introduction
Football, a sport celebrated for its exhilarating moments, strategic gameplay, and passionate fan base, also carries the unfortunate burden of a common and often debilitating injury: the Anterior Cruciate Ligament (ACL) injury. This injury has plagued players at various levels, from grassroots to professional.
The ACL Tear
The majority of ACL tears result from movements without direct contact, like a sudden twist where the player lacks sufficient muscle strength to counteract the twisting. Whether a player steps into a depression in the ground or lands in an awkward manner, the knee can shift, leading to an ACL tear.
During such incidents, players frequently describe hearing or feeling a distinct "pop”. In the hours following an ACL tear, swelling and blood accumulation in the knee are common. Many players also report a sensation of instability or "wobbliness" in the knee after experiencing an ACL tear.
Why Are ACL Injuries So Common In Football?
Football requires movement patterns that exert regular strain on the knee. The ACL is especially vulnerable in soccer due to two primary factors:
Swift changes in direction — Football involves rapid directional changes, rotational actions, awkward landings, repetitive motions, and pivots. These movements, combined with playing on artificial turf, impose significant stress on the knee. The abrupt force and velocity, surpassing the knee's accustomed limits, may result in an ACL injury or tear.
Player contact — In instances of player collisions, external force or impacts to the knee can be a catalyst for ACL injuries.
How Does It Happen?
According to a recent study published in 2020 where 134 ACL injuries in elite football were examined. They found:
44% of ACL injuries were non-contact
44% of ACL injuries were indirect
12% of ACL injuries involved contact to the knee
How Long Does It Take To Recover?
The typical recommendation for a comeback to the field after an ACL tear is a recovery period of approximately nine months. For example, Virgil van Dijk, from Liverpool FC, made his return after 9 months. Still, some players take 12-18 months to get back to full play as the severity of the injury varies.
Nevertheless, it is crucial to carefully weigh the timing of your return. The decision-making process is intricate and requires the involvement of various parties, and it also depends on your level of competition.
How Many Footballers Return To Football Post-Injury?
What are the odds of your comeback? A study published in the American Journal of Sports Medicine in 2012 delved into the speed of recovery for football players post-ACL reconstruction. The study discovered that 72% of football players successfully resumed playing after undergoing ACL surgery.
Intriguingly, the research also revealed the following:
Among the returning players, the average time for their return was 12.2 months post-surgery.
Impressively, 85% of those who made a comeback eventually reached or surpassed their previous level of football performance.
With that being said, some of you may be familiar with these particular real life examples:
Alan Shearer
Newcastle’s legend, Alan Shearer, ruptured his ACL in a game against Leeds United on Boxing Day 1992 while playing for Blackburn Rovers. The injury happened in the first half of the game, without his knowledge. Nonetheless, he scored 2 goals for his team and they won 3-1 in that game.
After recovering from his injury, the Newcastle legend returned in the 93-94 season to score 31 goals in 40 games. He then continued to smash other records over the years.
Shearer dedicates his post injury success to this quote, “Be patient, don’t cut corners, and do everything the physio tells you.” If he could do it in the 90s, surely you can in today's day and age!
Ruud van Nistelrooy
Dutch forward Ruud van Nistelrooy was on the verge of becoming Manchester United's most expensive signing in 2000 when a setback occurred during his medical due to an injury sustained while playing for PSV Eindhoven. Subsequently, he ruptured his ACL during a training session.
After a challenging nine-month recovery period, he successfully secured his move a year later. Van Nistelrooy went on to score 150 goals in 219 games for Manchester United. During his tenure, the club secured the Premier League, League Cup, and FA Cup trophies. Additionally, he continued to shine by winning La Liga twice with Real Madrid.
Zlatan Ibrahimovic
In April 2017, the then 35-year-old Manchester United forward Zlatan Ibrahimovic experienced cruciate knee ligament damage in the last minute of normal time during a Europa League quarter-final second-leg triumph against Anderlecht. Initially expected to be sidelined for a full year, there were concerns that this injury might mark the end of his career. However, he made a remarkable comeback after just seven months.
In his characteristic style, Zlatan remarked, "Lions don't recover like humans." Years later, at the age of 39, he continued to excel. In the 19-20 season, he scored 11 goals in 20 matches for AC Milan.
Xavi
Xavi stands as one of Barcelona's most significant players in the club's history, holding the record for the highest number of appearances.
In December 2005, a critical ACL injury required surgery, posing the risk of exclusion from the Spain squad for the upcoming World Cup in Germany. Remarkably, after only a five-month hiatus, he made a swift return, contributing to Barcelona's La Liga title victory and participating in the World Cup with Spain that summer.
His subsequent career was illustrious, accumulating five additional La Liga titles, four Champions League trophies, two European Championships, and one World Cup.
Francesco Totti
As the 2007/08 season was coming to an end, Roma's iconic captain Francesco Totti faced a devastating setback when he sustained a season-ending injury, tearing his ACL during a match against Livorno.
The AS Roma legend only spent 4(!) months on the sidelines because of the injury he sustained back in 2008. He went on to play for nearly a decade and eventually retired at the age of 40.
What Psychological Challenges Do Football Players Face During The Recovery Process From An ACL Injury?
Recovering from an ACL injury in football involves not only physical rehabilitation but also significant psychological challenges for players. Here are some of the common psychological hurdles that footballers may encounter during the recovery process:
Fear of Reinjury:
Players often grapple with a fear of reinjury, especially when returning to high-impact activities. The mental hurdle of trusting the knee again can be a significant challenge.
Frustration and Impatience:
The lengthy rehabilitation process can lead to frustration and impatience. Players may feel a sense of restlessness as they navigate through the slow and gradual stages of recovery.
Loss of Confidence:
Suffering an ACL injury can shake a player's confidence in their physical abilities. Regaining the mental strength and self-assurance to perform at pre-injury levels can be a psychological struggle.
Addressing these psychological challenges requires a comprehensive approach, including mental health support, communication with teammates and coaches, and setting realistic expectations for the recovery journey. Mental resilience is a crucial aspect of overcoming an ACL injury and returning to peak performance on the football field. Physiotherapists also play a pivotal role in this by offering emotional support, motivation, and encouragement. This holistic approach helps players maintain a positive mindset during recovery.
In conclusion, while an ACL injury may initially feel like a setback, it's important to recognize that it is by no means the end of the world for athletes or individuals passionate about staying active. The journey to recovery may be challenging, but embracing rehabilitation with dedication and a positive mindset can lead to not only a full recovery but also improved strength and resilience.
With that being said, the treatment approach for each individual varies from person to person. Some require surgery while some might not, depending on their lifestyle. While surgery may offer a more direct route to stabilising the knee and potentially hastening the recovery process, it is not the only solution. Non-surgical methods, including physical therapy, targeted exercises, and lifestyle adjustments, can lead positive outcomes for many individuals, particularly those with partial tears or less active lifestyles.
What are the risks of returning to football too soon?
Returning to football too soon after an ACL injury poses various risks. The ACL, vital for knee stability, requires time to heal properly. Premature return increases the risk of incomplete recovery, re-injury, and compromised stability, heightening susceptibility to further injuries. Inadequate healing may lead to cartilage damage and long-term consequences.
Comprehensive rehabilitation, guided by healthcare professionals and adherence to recommended timelines, is crucial for proper healing and the development of strength and stability needed for a safe return to football.
Andrew’s Thoughts & Reflections On Anterior Cruciate Ligament (ACL) Injuries And The Physiotherapy Process
Find out about Andrew’s thoughts on Anterior Cruciate Ligament (ACL) injuries and the physiotherapy process, watch a video of our patient’s recent physiotherapy session, and read the top ten questions asked by patients who suffer an ACL injury.
Over the years, I have been part of the decision-making process for many patients after their ACL injury. It is very rewarding to be part of a patient's return to sport or activities of daily living pain free. My goal as a physiotherapist is to always to get the best possible outcome for all patients.
Surgery is not for everybody, and rehab is not for everybody either. Not everybody wants or should expect to return to sport post-ACL reconstruction surgery. There are many factors which will affect the decision to go for surgery or choose standard rehab.
I have recently managed a high performing football player, Charlie, who will return to play in the next few weeks. Charlie's injury happened while playing a football match in Singapore. While pivoting to shoot, and his knee gave way into a bend and inward twist, a classic mechanism of ACL injuries. For the reconstruction, Charlie decided to use a hamstring autograft approach. Charlie's most recent physiotherapy session can be seen in the clip below.
Here is a list of the top ten questions that I have been asked over my years of work about ACL reconstruction surgery and the subsequent physiotherapy process.
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A: Simply put, anybody suffering with instability post-ACL injury. Sometimes the instability can be present with a partial tear but more likely to be present with a full tear of the ACL.
There are other factors like age and the presence of degenerative cartilage which are predictors of outcome.
A detailed discussion is required to determine suitability and is done with advice of physio and orthopaedic surgeon.
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A: Scans, being static in nature, will never be able to fully reveal whether a patient is unstable. There are clinical tests that can be done. These tests are usually done during rehabilitation. If the patient shows instability signs during rehab testing then that can be an indication for surgery.
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A: There is a new approach the “Cross Bracing Protocol” recently published by researchers from The University of Melbourne (Fibay et al., 2023).
This approach restricts range for a period of 12 weeks and aims to allow the ACL to heal. There are also case studies where patients have made a recovery.
This is all very new at the moment and the jury is out as to whether this will be a viable option with excellent long-term results. More research is required.
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A: 9 to 12 months is required to make a full recovery back to sports. Rehabilitation without surgery will usually take place over 4 to 6 months.
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A: Prehabilitation (“prehab”) is certainly valuable. Patients who have gone through a structured physiotherapy programme before their surgery have been seen to have better outcomes post-surgery.
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A: I would strongly discourage surgery for a patient who cannot commit the time to rehabilitate and recovery. Patients who travel frequently for work should also consider this, adequate rest and time spent in the gym is required to make a full recovery.
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A: ~65% return to their previous level of sport post op. There are a lot of factors which predict whether you will make it back to previous level like age, secondary knee damage, attitude to rehabilitation, stress, and overall general health.
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A: Most people are on crutches for a few weeks post-surgery and will be able to return to work after a few weeks all going well.
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A: Studies have shown that there is a 6% chance of re-tearing the ACL after surgery.
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A: There are pros and cons with each graft option.
Hamstring grafts have been shown to reduce anterior knee pain and knee stiffness but can cause reduced hamstring strength post-surgery.
Quadriceps tendon has limited research and can cause reduced quadriceps strength post-surgery.
The allograft option is very popular as it results in less knee pain and does not impact the hamstring strength. It can however be a weaker graft overall.
The decision to choose a graft is made with the surgeon and surgeons will have their own preferences depending on the patient's injury and history.
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A: It will be very helpful to have access to a gym but you can complete a home exercise program without ever leaving the house.
I would always recommend patients signing up for gym 3 months post-surgery. I would also recommend patients borrowing or renting a static bike for home use if space allows.