World Cup Injuries Test Sports Medicine

One of the most frustrating experiences an athlete can face is having to retire early or missing local tournaments or international competitions because of disabling injuries. At the same time, injuries represent a major challenge for coaching staffs and for specialists in sports medicine, physical therapy, rehabilitation, orthopedics, and traumatology, who are responsible for treating these cases and seeking an appropriate balance between overall health and peak physical and mental performance on the field.In contact sports that require a high degree of physical exertion and a wide range of movements, such as soccer and American football, the challenge is even more complex because a persistent injury or a recurrence can jeopardize not only a player’s physical integrity or cut short an upward career but also directly or indirectly affect a team’s strategy and performance and can even lead to millions of dollars in losses when major global stars are involved.Against the backdrop of the 23rd FIFA World Cup, the international soccer tournament organized by the sport’s world governing body and scheduled to be held in the US, Canada, and Mexico from June 11 to July 19 of this year, many examples can be cited of professional players (see Table 1) whose dreams were dashed when they were ruled out of this highly anticipated competition because of injuries that required surgery or made participation medically inadvisable.Table 1. Soccer Players Ruled Out of the World Cup Because of InjuryPlayerNational teamWorld CupClub at time of injuryType of injuryLuis “Chapito” MontesMexicoBrazil 2014León (Mexico)Tibia and fibula fracture (sustained in a friendly match against Ecuador)Radamel FalcaoColombiaBrazil 2014AS Monaco (France)Rupture of the anterior cruciate ligament in the left kneeMarco ReusGermanyBrazil 2014Borussia Dortmund (Germany)Partial tear of the ligaments in the left ankleNéstor AraujoMexicoRussia 2018Santos Laguna (Mexico)Tendinitis and joint injury in the kneeDani AlvesBrazilRussia 2018Paris Saint-Germain (France)Rupture of the anterior cruciate ligament in the right kneeJesús “Tecatito” CoronaMexicoQatar 2022Sevilla (Spain)Fibula fracture and rupture of the ligaments in the left ankle during trainingKarim BenzemaFranceQatar 2022Real Madrid (Spain)Muscle strain/left thigh quadriceps injurySadio ManéSenegalQatar 2022Bayern Munich (Germany)Injury to the head of the right fibulaPaul PogbaFranceQatar 2022Juventus (Italy)Meniscus injury in the right knee, along with thigh muscle problems and a recurrenceLuis Ángel MalagónMexicoUS, Mexico, and Canada 2026América (Mexico)Rupture of the Achilles tendon (during a CONCACAF Champions Cup game)Marcel RuizMexicoUS, Mexico, and Canada 2026Toluca (Mexico)Rupture of the anterior cruciate ligament in the kneeIn the case of Mexico’s national soccer team, the program reported more than a dozen injuries among players aged 17-30 years in the past year alone. Among the latest to stand out is Luis Ángel Malagón, goalkeeper for Club América, who in March suffered a ruptured Achilles tendon that led to him being ruled out and undergoing surgery, as well as Marcel Ruiz, midfielder for Club Toluca, who in the same month had a partial tear of the anterior cruciate ligament and a medial meniscus injury in his right knee.With the World Cup approaching, Marcel Ruiz initially received conservative treatment based on muscle strengthening in an attempt to return to the field as soon as possible because he still hoped to be called up. However, afterward, Mexico national team coach Javier Aguirre decided to leave him off the final 26-player roster because he was not considered to be in optimal physical and athletic condition.Finally, Marcel Ruiz underwent surgery and began his rehabilitation process just as the soccer World Cup was getting underway.These episodes have brought into sharp focus the essential role of sports medicine and rehabilitation professionals who work with high-level players and who frequently face dilemmas that go far beyond a simple clinical decision.“These kinds of decisions are very complicated. Since Marcel Ruiz suffered the injury back in March, there was no way to operate on him and rehabilitate him in such a short time so that he could play in the World Cup,” María Cristina Rodríguez Gutiérrez, physician specializing in sports medicine and physical activity and director of the sports medicine at the National Autonomous University of Mexico, Mexico City, Mexico, told Medscape’s Spanish edition. She served as a field doctor for the Pumas soccer club from 1990 to 2000.“According to the specialist, anterior cruciate ligament surgery requires at least 6 months to allow the athlete to recover to the same level he had before the injury, provided intensive rehabilitation sessions are carried out to reduce pain and inflammation, strengthen the muscles, and improve range of motion,” Gutiérrez said.She also added that if the player were only moving in a straight line, there would be no problem returning to the field even with this type of injury. However, she said the risk appears when changing direction because the knee may subluxate and cause instability.“The specialist said it is not known exactly what percentage of fibers were torn in Ruiz’s ligament or how much instability the injury is causing. She noted that if there was not much instability in the knee, conservative treatment — which Ruiz initially received — could have worked to achieve adequate performance, but if not, surgery would be necessary,” the physician said.She added that this would only be the beginning because after surgery and physical rehabilitation therapy, the player would have to gradually return to training and game action, moving and kicking the ball again. In addition, other aspects that also require long periods to achieve full recovery would have to be addressed, including psychological support because injured players are always left fearing another injury.Ankles, Thighs, Knees, and Hips: The Most Frequently Affected AreasArticular injuries in joints such as the ankles, knees, and hips, as well as musculoskeletal injuries affecting muscles and tendons, especially in the lower extremities, are the most common among soccer players, Oswaldo Ballinas Ordóñez, specialist in traumatology and orthopedics, arthroscopic and joint surgery, and director general of the Institute of High Specialty Surgery, told Medscape’s Spanish edition.In the lower extremities, the thighs, knees, and ankles are the most commonly affected anatomic regions, accounting for between 67% and 88% of all injuries in soccer players of all ages and sexes. On this point, the specialist, who emphasized that injuries to the upper extremities should not be overlooked, explained that fractures of the medial malleolus or fibula, sprains, and ligament tears are common in the ankles, while tears of the anterior or posterior cruciate ligament and meniscus injuries are common in the knees.In both cases, injuries to the medial collateral and lateral collateral ligaments are quite common because of the kind of plays soccer players make: sprints, stops, or sudden changes of direction. The knee and ankle are the ones that suffer most when making these kinds of movements.The ligament tear that sidelined Marcel Ruiz from the current World Cup is among the most common injuries affecting the knee in soccer players, and it has a higher incidence among professional and semiprofessional players than among amateurs, according to a literature review published by members of the Department of Joint Surgery and Sports Traumatology at the Center of Medical Excellence at High Altitude Hospital in San Agustín Tlaxiaca, a town in central Mexico.The report said anterior cruciate ligament injuries account for 15%-48% of ligament injuries to the knee in these athletes. The study’s authors noted that the average career of a professional soccer player, a sport with more than 270 million participants worldwide, including 200,000 at the professional level and 38 million in competitive leagues, lasts 13.5 years.During that time, the authors said, professional soccer players are exposed to intensive training and very short recovery periods, punishing exercise loads, and repetitive rotational movements that create intense physical stress and equally significant biomechanical overuse of the cartilage in the lower limbs, especially in the knee and hip joints.The article’s authors pointed out that the most common injury mechanism among the cases analyzed was contact and that the tactical position a player occupies on the field is a determining factor in the type of knee injury he or she may suffer. According to the review, players in defensive roles are the most prone to knee injuries, followed by forwards. Goalkeepers, by contrast, have the lowest incidence of this type of injury.Ordóñez emphasized that even though pubalgia is no longer as common among soccer players, it often affects goalkeepers because of the movements they make. However, he said many orthopedists do not usually take this reality into account.“Because of the way they clear the ball from the area in front of the goal, pubalgia is common, and it causes intense pain and requires plenty of rest. By contrast, it is difficult for them to suffer ankle or knee injuries unless, during a clearance, they are poorly planted on the ground (on the left foot in the case of right-footed players and vice versa) and make a major turn that can tear a meniscus,” he said.He also said detecting injuries in the hand joints of these players, which are essentially synovitis of the radiocarpal joint or injuries to the carpal ligaments, can be a major challenge for sports medicine doctors.“The hands make many very fine movements, since they have a much greater number of joints and ligaments than any other part of the body. Therefore, the injuries goalkeepers suffer are often very difficult to diagnose and treat, and in those cases, we need to apply treatment as soon as possible,” he added.Finally, Ordóñez acknowledged that because of the circumstances surrounding professional soccer, making clinical decisions while seeking the right balance between a player’s health and his or her aspirations to achieve maximum physical performance during competition is a major challenge. When a very valuable soccer player is injured, there is a great deal of pressure on the medical staff from club executives to get him back on the field as soon as possible, so we must carefully assess each situation to avoid causing further damage to his health through the overexertion that is demanded.Gutiérrez and Ordóñez disclosed no relevant financial relationships.This story was translated from Medscape’s Spanish edition.