Is there anything wrong with Real Madrid's injury proneness?

A recent feature in Marca highlighted the number of injuries suffered by Real Madrid players this season. This has been a talking point in football forums and has formed the basis for many discussions and topical debate. However, if we analyse the injuries that Madrid players have sustained then it actually looks as though Real aren't doing too badly when compared to other clubs. Of the current batch of injuries, only Luka Modric has been out of action for more than a few weeks; all the others are recovering and are now either actively involved in squad training or have returned to play.

Injuries are part and parcel of the game and always will be. A UEFA injury study published in 2011 headed up by leading Swedish sports doctor Professor Jan Ekstrand showed that a player will sustain on average 2 injuries per season and that a team with a typical squad of 25 players can thus expect about 50 injuries each season.  The single most common muscle injury was the thigh strain, representing 17% of all injuries, with hamstring strains the most common sub-group.  Injury recurrences were noted to comprise 12% of all injuries; but were acknowledged to result in longer absences from training and playing.

References have also been made in the media to Madrid ‘outsourcing' the medical management of the players to Sanitas; a private medical company. Yet in reality Real Madrid are doing no more or less than any of the big clubs do  - they provide their players with private medical care.  Perhaps the only difference is that by using Sanitas the medical care comes as a complete package.  The injuries are managed from start to finish by the same group of professionals known to the club whether it be doctors, physical therapists, orthopaedic consultants or radiologists.  The emphasis though is placed on integrating the Sanitas services into the club.  The physical therapists work with the players as part of the backroom team at the training complex in Valdebebas and anyone needing further attention or a medical opinion will be quickly seen on the day by one of the club doctors.  By the same token if the medics then become an integral part of the management team, they will quickly develop their own specialised knowledge of individual players and personalities.  They will soon get to know which players go down injured more often than others.  Sergio Ramos and Iker Casillas rarely call for attention from the physios during matches so if either of these two go down injured then you know that there is a genuine problem.

The benefits of this all-in medical care are seen in the early management of injuries.  The most important period for any injury is during the first few days immediately after an injury has been sustained.  At this stage, an accurate and immediate diagnosis is essential in order for a correct injury management plan to be set in place and to allow appropriate treatment to follow.  Using Sanitas allows Real to keep the complete medical programme in Madrid without going elsewhere for any singular aspect of this.  We don't often hear of Real players flying overseas to ‘see a specialist' in order for an injury diagnosis to be made; this is simply because there is no need, as all the necessary care can be provided ‘at home' in Valdebebas.  The major problem with players making trips outside of Spain to see specialist consultants or to have surgery is that these consultants themselves will want to see the players for regular follow-ups.  This uses up a lot of valuable time that could otherwise be spent on treatment and rehabilitation.  Additionally, if a problem arises during rehabilitation following knee surgery for example and the physical therapist wants an opinion from the surgeon who performed the operation, the surgeon is unlikely to offer this over the telephone so therefore a further trip is required.  This can sometimes lead to a delay of several days before a player can be seen; and as surgeons in general like to follow up their own handiwork it's not so easy to be able to take a review opinion if it means a trip to a different continent.  It should be noted, though, that Madrid are not alone in using Sanitas; the company provide medical care to several other football clubs and also contribute to the game in many other ways through education and the provision of a level of medical care which extends beyond football and into youth sports in general.

The main talking point though has been about the number of injuries Madrid players have picked up this season.  The press have been speculating on the reasons why there have been so many muscle injuries in particular and various theories have been put forward including the amount of training, the training methods themselves, dietary considerations and so forth.  However, the majority of injuries have occurred in match situations with Sergio Ramos, Marcello, and James Rodriguez being the most recent and in each case a single specific incident has been identified as the cause of injury.

There are indeed many varied and potential reasons why muscular injuries occur, but the biggest risk of muscular or ligamentous injury is through having sustained a previous injury to the affected structure at some stage in the past.  This is simply because the body does not heal directly with like-for-like tissue therefore injured muscles, tendons and ligaments will always heal with an inferior substance replacing the original fibres of the affected structure.  This in turn explains why injuries no matter how well rehabilitated are always prone to recurrence; since any injured structure will always have a potential tendency to be vulnerable if overloaded in the future.

Hamstring muscles, for example, provide the explosive power required to make a sharp, sudden sprint, and are thought to be under more stress when changing pace.  Thus the most common mechanism of hamstring injury is that of a sharp ‘pull-up' while sprinting.   Hamstring strains are noted to be the single most common injury occurring at elite levels of the game; Sami Khedira sustained a hamstring string earlier this year, as did Marcello and Cristiano Ronaldo.  Hip and groin muscle injuries of the type which troubled Gareth Bale usually happen when twisting and turning.  Players are particularly vulnerable to such strains when they have to suddenly change direction; although an alternative mechanism for groin injury occurs through gradual development as a result of repetitive movements.  Injuries to the quads muscles at the front of the thigh are also very common in football and these tend to occur when muscle fibres tear due to the explosive sudden force involved in kicking the football.

When a muscular injury is sustained by any of these mechanisms it is not normally possible to ‘run off' such an injury in the same way as you can often do with routine bumps and bruises.   The skill then becomes being able to differentiate between what may be only a minor injury - such as that sustained by Sergio Ramos against Cruz Azul - or a more serious injury like that to Luka Modric which requires an extended period of rest initially to allow damaged tissue adequate time to repair.  Additionally, injuries like those sustained by James or Marcello may require ongoing strengthening work and attention well after they have returned to play.

Apart from the UEFA study, there's been quite a bit of extensive research carried out over the past few years into common football injuries, and Madrid's injuries don't really give too much cause for concern by comparison with the accepted stats.  Muscle injuries can first of all be split into two categories, training injuries and match injuries.  Of these, the injuries can be sub-divided into contact injuries or non-contact injuries - such as the hamstring and groin strains for example as opposed to the broken ankles or dislocated shoulders.  These can then be further divided into new injuries or recurrences of previous injuries.  We already know that the vast majority of muscle injuries in football are to the lower limbs; and also from previous studies that a high percentage of these are shown to be non-contact game-related recurrent injuries.  It used to be thought that these were more common in the latter stages of the match as tiredness and fatigue began to set in; however the study by Ekstrand et al in 2011 suggested that the incidence of match-related injuries showed no significant pattern and that injuries were reported to occur at any point in either half.  It was noted, however, that there was a general increase in the occurrence of injuries towards the end of each half; adding to speculation that fatigue can be a contributing factor.

Although injury prevention is a huge aspect of sports medicine nowadays, the fact that there are so many different aspects to consider virtually makes complete prevention of injuries impossible.  All we can do is to analyse the potential causes of injury and attempt to minimise the risks of these wherever possible.  Minimising the risk of avoidable injury, however, only goes part of the way.  There are some situations that you simply cannot legislate for such as a player kicking the ground just before taking a shot at goal or slipping on a wet surface and straining a groin muscle; a late tackle or an irresponsible challenge from an opponent.  If we are looking to analyse the reasons behind Madrid's injuries this season the key question would be whether the injuries sustained were avoidable or not.  Overall, though, it would appear that Madrid aren't really doing too badly at all based on recent research and current available evidence!