When Jese made his comeback a few weeks ago from ACL reconstruction it looked as though all was well. After a long period of rehabilitation he made his return to Madrid's first team, scoring, and immediately running over to the physios in the technical area to acknowledge his recovery. However, since then, he's struggled on and off. From injuring his right year this time last year against Schalke 04 Jese went through the lengthy rehabilitation process that accompanies ACL surgery. Although he's now back playing; his return to form may take a little longer. It's never easy coming back from major surgery and the signs are there that Jese is finding this out for himself.
The ACL or Anterior Cruciate Ligament to give it it's full title, is one of two ligamentous structures found deep within the knee that connects the thigh and shin bones and prevents excessive movement of the shin in a backward or forwards direction. These two structure are arranged in an ‘X' shape, hence the term cruciate which indicated that the ligaments cross. The ACL prevents excessive forwards movement of the shin-bone (tibia) on the femur while the Posterior Cruciate Ligament (PCL) prevents excessive backwards movement. A torn or stretched cruciate ligament is therefore synonymous with instability.
Injuries to the Anterior Cruciate Ligament (ACL) are common in football but these are rarely injured in isolation. Normally, there is some degree of meniscal - or cartilage - involvement together with associated damage to the medial collateral ligament (MCL), which is the structure that limits excessive movement of the knee in an inwards or sideways direction.
Injuries to the ACL occur by two different mechanisms, either through direct contact with an opponent as in Jese's case last year with Schalke's Sead Kolasinac - or by non-contact mechanisms such as jumping and landing awkwardly. In both cases, there is usually a twisting mechanism leading to a rotational force through the joint which leads to either damage to the meniscus, a sprain of the medial ligament, or even sometimes to both at the same time. On jumping and landing awkwardly, the ACL can take all the force of the impact causing the ligament to stretch or tear and if injured in this way the knee is felt to ‘buckle' underneath on landing. This is the most common method of ACL injury in female athletes, particularly in football and netball, where the foot stops as you land but the rest of the body continues to move, leading to a tear of the ACL. If the injury is sustained through contact means, as with Jese, the forces are dependent on the angle of the tackle, whether the knee twists or buckles at the same time, the position of the knee when the challenge is made, and by how much the knee joint is forced into abnormal ranges of movement by the impact.
Dependent on which (or all) of these is applicable at the time will determine which structures are injured. Normally with a twisting, tackle-type injury which forces the knee into an abnormal range, the MCL will be injured and with that there is always the likelihood of meniscal cartilage involvement due to the rotational forces that occur. The ACL will be injured if the knee is forced beyond it's normal limitations and there is excessive movement between the shin and the thigh bones. Coupled with the rotational forces of a twisting injury, the ACL is likely to be subjected to a tear of varying degrees ranging from minor damage to a few fibres, to a partial tearing of the ligament, and finally to a complete rupture of the ACL itself. If all three structures are involved, the ACL, MCL and meniscus, this is known as "O'Donoghue's Triad"; which is common in American Football. With our type of football, i.e. soccer, ACL injuries are usually accompanied by lesions to either the MCL or meniscus but rarely both; although it does happen from time to time.
Minor ACL injuries can heal if correctly rehabilitated, but most of the injuries to the ACL will eventually require surgery. If surgery is indicated, then the ACL is normally repaired by grafting either a section of the patella tendon or a portion of the hamstring muscle as a replacement for the injured ligament. Both methods have their pros and cons; but in reality the ultimate decision usually falls to the operating surgeon who will tend to have his or her preference according to which method has been successful for that surgeon in the past.
The reason I mention all this detail is that it's much easier to understand what a player goes through with an injury of this type with a basic understanding of what the structures are and what they do, and also to illustrate the specific areas of focus needed if rehabilitation following ACL surgery is to be successful. It used to be that an ACL injury was a career-ending injury but things have moved on since then. Nowadays, although a lengthy period or rehab normally averaging nine months is required, an ACL injury for a professional player is something most players will take in their stride. The main thing to consider about ACL surgery is that for it to be successful, the knee needs to be 100% stable before returning to play. If the repaired ACL is not strong enough then the knee will be unstable; and you just cannot return to play at that level with an unstable knee. You can't actually return to play at any level in fact, since the stability provided by the cruciate ligaments is essential for any sports or activities involving changes of direction or continual stopping and starting.
ACL Rehab is broken down into various stages. The first, post-operative stage lasts roughly up to 3 - 4 weeks and the target is to be able to fully straighten the leg and bend to 90 degrees after 14 days. Following on from that, when things have settled and these targets have been met, the next stage runs up to the three month point. During this time, players will develop and /or regain strength, flexibility and balance. This can be achieved by gym-based exercises and involve using an exercise bike, resistance bands, and lots of repetitive movements to retrain the body's sense of knowing where a limb is in space. This is known as proprioception and involves repeated exercises, often with the eyes closed to develop the senses, which are mainly performed on a single leg; the injured one is the focus but it helps overall to develop the opposite side as well. At the three month point, players recovering from ACL surgery should be able to run in straight lines. In this stage, the objectives are to develop overall strength and conditioning for the injured leg in addition to introducing basic ball skills and low-level football-type work towards the six-month stage.
Following on from that, the emphasis is all about developing football fitness in the final three months, increasing all the strengthening work performed in the previous stages, and concentrating on the specific muscle balance required to ensure the post-operated knee is strong and flexible enough to withstand the rigours of the game.
There can be problems, however, in any stage of the rehab. If you take into consideration that the whole period lasts around nine months, it's inevitable that somewhere along the line there will be a minor setback. In Jese's case, the setback was when he sustained an infection and although infections after ACL reconstruction can occur, these are relatively rare. Often the infection is thought to be a result of the operative technique used, although recent studies have queried this and provided evidence in support of ACL reconstructions using different surgical techniques which have become infected irrespective of the methods used. In all case of infection, though, early treatment with antibiotics is vital, and provided the infection resolves, there is usually no long-lasting effect on rehab apart from the time it takes for the antibiotics to work. The risk of infection is present to a degree in all surgical procedures, but it can complicate matters to the extent that sometimes even removal of the graft can be necessary if the infection doesn't completely resolve, although this is rare.
As we've discussed before in this column, sports-specific rehab is vital to making a complete recovery. Jese will have been focussing on the things he needs to do in a game and his rehab programme will have included simulated match situations in training. The problem, as always, lies in the fact that there is no real substitute for actual game time; and although the rehab may have been 100% successful according to the protocol followed, it's a totally different situation coming back into the team and playing in a proper game after almost a year out. Jese will have found out for himself that it's one thing doing controlled activities in simulated situations as opposed to the uncontrolled and often unpredictable nature of a real game. It takes time to get your timing right and to get your footballing eye tuned in to the pace of the game. At Madrid's level even a split-second can make a difference between making a perfect finish in front of goal and even hitting the target. When a player comes back after a long injury lay-off it is often the consistency in the quality of play that is most noticeable and most of this is affected by timing. As we said earlier, though, there is no substitute for game time and the answer is often just to grind away and the timing and therefore consistency will return.
The trouble is that at Madrid's level, you don't often get that time to ease back into the game since players are expected to be able to perform at a consistently high level from the minute they return to the team. The view is very much that if you are up for selection then your timing and everything should be 100% otherwise you shouldn't be in the first team. We all know that football doesn't work that way. Although a player like Jese recently returning from injury may be able to fulfil the technical requirements of his role, the key to a successful return is being able to consistently perform to a high standard; and often this is where the difficulty comes in.
It's the old ‘Cache 22'. Consistency only comes with game time and if you're not showing the consistency then you won't get the game time at the level it's needed in order to develop that consistency, and form suffers as a result. The only real solution is to keep playing and the consistency will return. As we said at the start, it's never easy coming back from a long-term injury and Jese is now finding that out for himself.