When will Gareth Bale return from his ankle injury?

Differences of opinion over when Gareth Bale is expected to return to Real Madrid’s first team after his recent ankle surgery merely highlights how pointless it can be in making predictions. Recovery dates at this stage are dependent on several factors including whether any issues have arisen during the operation, the presence of swelling, and the (unlikely) risk of post-operative infection.

Estimates given before the decision to operate had even been made turned out to be way off mark and now it’s looking as though they’re not so accurate after the event either. Variations on Gareth’s anticipated return to full fitness have gone from six – eight weeks before surgery but are now quoted to be anything up to three – four months depending on who we listen to.

Clearly it’s a guessing game at this point. However, as the next few weeks unfold we’ll have a more accurate picture of the recovery timelines as the plaster comes off and Gareth gets down to work properly. At that stage, everyone will have a good idea of how effective the surgery has actually been and whether or not there are likely to be any ongoing concerns post-operatively.

The official statement from the club reported that Gareth’s injury was diagnosed as a “traumatic dislocation of the peroneal tendons of his right ankle” - surely a phrase with which most Real Madrid fans will now be familiar with.

Traumatic subluxation / dislocation of the peroneal tendons has been reported following a variety of sports-related activities (Brage et al, 1992) and is an uncommon injury for which numerous corrective procedures have been described (Sobel et al, 1990). The injury occurs when the peroneal tendons contract forcibly and thus place a stronger load on the restraining tissue than this is capable of withstanding. It therefore ‘gives’ and the peroneal tendons slip forward from their natural restraints.

Anatomically speaking, the peroneals as a group of muscles are thought to be the primary contributors to lateral ankle stability. Situated on the outer aspect of the lower limb and originating from the surface of the fibula bone, these are two long muscles which connect to the metatarsal bones in the foot. Peroneus Longus, which is the larger of the two, extends downwards and behind the fibula, winding around and below the distal tip of the fibula, passing underneath the foot to insert on the first metatarsal bone. Peroneus Brevis, which is the shorter of the two muscles, passes adjacent to Peroneus Longus behind and below the distal tip of the fibula to insert on the fifth metatarsal which lies on the outside of the foot.

A third muscle often overlooked is Peroneus Tertius; which also originates from the fibula bone but this passes in front of the ankle joint instead to insert alongside Peroneus Brevis on the head of the fifth metatarsal. Together, the main functions of the peroneal muscles are to stabilise the ankle and turn the foot outwards into eversion.

Without getting too technical or going too deeply into the realms of anatomy, the structure which binds the peronei in place is known as the retinaculum; of which there are two. The retinaculum are strong bands of fibrous tissue which are situated just behind and below the lateral ankle malleolus where the tendons wind around. They effectively form part of a ‘tunnel’ through which the peronei pass from their origins on the fibula as they wind their way towards their insertion on the bones of the foot (Athavale et al, 2011).

When dislocation or subluxation of the tendons occur, the peronei snap forward as the retinaculum tears and the tendons then move away from their normal anatomical position. Operative treatment consists of anatomic repair or reconstruction of the damaged part of the retinaculum with or without additional deepening of the groove where the tendons pass through (Heckman et al, 2008).

Current available evidence shows that peroneal tendon dislocations resulting from a damaged sheath respond well to early surgical intervention (Van Dijk et al, 2016). The subject of ankle arthroscopies in general has been well discussed in the medical literature and these are now regarded as commonplace (Pereira et al, 2016). Where instability is the concern, surgery appears to be the preferred route.

Real Madrid didn’t waste any time in opting to go down the surgical road. Once the diagnosis had been made by the club medical people the decision was quickly taken to intervene to repair the damaged structures. The operating surgeon this time was Dr James Calder in London, who has published widely on ankle arthroscopies and was chosen partially due to input from Gareth Bale himself. Dr Calder’s medical background and sporting CV have been well discussed in recent articles elsewhere; but there seems little doubt that he has the confidence of Real Madrid as a club.

Along with two of his colleagues, Dr Calder recently published an update on the management of sports injuries of the foot and ankle (Ballal et al, 2016) which may have influenced Real’s thoughts on their choice of appropriate surgeon.

Also present in the theatre for Gareth’s operation were Dr Olmo and Real Madrid Sanitas surgeon Dr Mikel Aramberri. The concept of surgical ‘teams’ has replaced the traditional singular surgeon on operating days although Dr Calder will have led the proceedings just as Professor van Dijk headed up the surgical team that operated on Danilo and Keylor Navas in the summer.

FIFA orthopaedic specialist Dr Pedro Luis Ripoll, who was also involved in the ankle operations on Danilo and Keylor Navas praised Real Madrid Medical Services for their early diagnosis; citing that identifying a ruptured tendon sheath in the first place isn’t always so easy. Dr Ripoll advised that an injury of this nature can lead to ankle instability therefore it is better to be repaired now in order to minimise the risks of a repeat injury being sustained in the future. The bad news, though, is that the minimum recovery period is two and a half months; a figure with which most authors agree.

In practical terms, the whole procedure can be regarded as being in two parts; the operation itself over which the surgical team have full control, and the rehabilitation period thereafter - for which the responsibility falls to the Real Madrid medical team. That’s likely to be the most difficult part. Gareth’s going to be keen to get back on his feet and looking forward to making an early return; and this could well be where any potential problems are going to lie. He needs to return at the correct stage and not try to save a few days here and there if it means coming back before he’s properly ready to do so.

The peroneal muscles tend to waste quickly after ankle injuries and require intensive rehabilitation in order to restore their strength and reactive properties. The latter is vital as the peroneals are thought to engage sharply when the foot hits the ground and the ankle is about to ‘roll’; therefore the focus in rehabilitation lies in regaining these properties in order to help prevent inversion ankle injuries.

By all accounts Gareth’s injury turned out to be a lot worse than everyone expected. Nonetheless, the rehabilitation goals are exactly the same as they would have been following a simple ankle sprain or even after minor surgery; with the priorities lying in regaining balance and proprioception (the sense of knowing where the ankle is in space) in addition to strength and mobility.

With current medical opinion appearing to settle on ten weeks as an approximate date for Gareth to get back to full fitness that takes us into early to mid-February. Once full physical fitness has been achieved, then there’s the small matter of regaining match fitness to be considered; and if we give say two – three weeks for that then we’re not going to be too far off early March.

All of the above is dependent on there being no setbacks. Provided all goes well, then things should run according to plan; but if there are any hitches – albeit minor ones – then that’s where the additional time comes into play and if that happens then sadly an April return could well be on the cards.

References:

Athavale SA, Swathi MBBS, Vangara SV (2011). Journal of Bone and Joint Surgery of America. Vol. 93 (6); 564 – 571.

Ballal MS, Pearce CJ, Calder JDF (2016). Management of sports injuries of the foot and ankle – an update. The Bone and Joint Journal. Vol. 98 (B); 874 – 883.

Brage ME, Hansen ST (1992). Traumatic subluxation / dislocation of the peroneal tendons. Foot and Ankle International. Vol. 13 (7); 423 – 431.

Heckman DS, Reddy S, Pedowitz D, Wapner K, Parekh SG (2008). Journal of Bone and Joint Surgery of America. Vol. 90 (2); 404 – 418.

Pereira H, Vuurberg G, Gomez N, Oliveira JM, Ripoll PL, Reis RL, Esprequeira-Mendes J, Niek van Dijk (2016). Arthroscopic Repair of Ankle Instability with All-soft Knotless Anchors. Arthroscopy Techniques. Vol. 5 (1); e99 – e107.

Sobel M, Russell F, Brourman S (1990). Lateral ankle instability associated with dislocation of the peroneal tendons treated by the Chrisman-Snook procedure. American Journal of Sports Medicine. Vol. 18 (5); 539 – 543.

Van Dijk PA, Lubberts B, Verheul C, Di Giovanni C, Kerkhoffs GM (2016) Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Foot and Ankle International. Vol. 24 (4); 1165 – 1174.