It's been three weeks now since Cristiano Ronaldo injured his knee in Paris. As we know, that challenge from France midfielder Dimitri Payet ended CR7's participation in the Euro 2016 final; and despite coming back on to the field for ten minutes or so, he was unable to do anything else other than jog. Even that looked to be a struggle at the time; which wasn't surprising given the tackles he'd taken earlier. It was obvious right away that Ronaldo would be unlikely to continue; and despite lengthy treatment at the side of the pitch from the Portuguese medical team; that quickly proved to be the case. Since the match ended we've had almost every available permutation reported in the media regarding the likely structures involved but as yet, no definitive statement nor concrete diagnosis from Real Madrid as a club. The favoured diagnosis seems to be a sprain of the medial collateral ligament (MCL) which is universally suggested to be the main culprit; although the anterior cruciate ligament (ACL) has also been mentioned. Discussions at the time of the injury focussed on how damage to either of those structures at any level above a minor Grade 1 sprain would involve a moderate to lengthy period of rehab; and that's what it's turning out to be.
A sprain can be defined as the tearing of a ligament; which is the structure that joins bone-to-bone and prevents excess movements. The tear is then graded according to the severity of the damage. Grading of ligamentous injuries to the knee are classified according to the American Medical Association Standard Nomenclature of Athletic Injures (1966) although other grading scales exist which are less universally adopted. Basically, a simple Grade 1 ligament sprain results in the tearing of a few fibres only and rarely keeps players out of action longer than ten days. Grade 2 sprains take longer to heal since a large proportion of the ligamentous fibres will have been torn instead of just a few isolated fibres as in a Grade 1 sprain; and an average Grade 2 injury would normally be expected to take anything up to twelve weeks. In the case of a Grade 3 sprain, a severe tearing of the ligament occurs resulting in a complete rupture; and this leads to instability since the ligament will have been separated by the amount of force leading to the tear. Grade 3 sprains of any ligament frequently require surgical repair. Historically non-operative management of Grade 3 ligamentous sprains has tended to be favoured by most clinicians (Wijdicks et al, 2010); although individual treatment decisions should be based on the characteristics and nature of the injury presenting (Kovachevich et al, 2009).
Where the ACL is concerned, though, surgical repair is the treatment of choice for a sportsperson suffering a complete tear. However, it's normally the medial collateral ligament (MCL) which is the most frequent of the knee injuries sustained in football (Giannotti et al, 2006), and as stated, this is the favoured working diagnosis in CR7's case. Since other injuries including ACL sprains can commonly accompany MCL injuries, however, it's important to be aware of these right from the start. The classic signs of a torn ACL are of the knee giving way, the presence of immediate swelling, and hearing an audible ‘pop' or crack at the time of the injury, plus the sensation of something tearing. Despite the noise of the crowd in St Denis, Cristiano would likely have been able to hear the ‘pop' if it was present; although for sure he would have felt the sensation of tearing within the joint.
Cristiano's knee will have taken a lot of force based on the way the challenge went in on that Sunday night. As the MCL is primarily the structure that prevents excessive movement in an inward or medial (valgus) direction (Jacobson and Chi, 2006), this is normally the first part of the knee to give when hit with the amount the force that Cristiano's was; and from a direction that would stress the MCL and potentially affect the ACL. In addition to stressing the ACL, the slight rotatory component caused by the angle of the blow could also have potentially damaged one of the menisci. Meniscal injuries - or cartilage tears as they used to be called - are caused by excessive rotatory movements such as the leg spinning around a fixed foot. This is similar to the injury mechanics of a torn ACL which is often a combination of both an excessive valgus force accompanied by rotation. A pure valgus force can damage the MCL primarily, but the addition of rotation can tear the meniscus or ACL before the MCL is actually ruptured (Indelicato, 1995).
The initial working diagnosis of an MCL sprain was reported by the Portuguese medical team, but at some point Real Madrid's medical services will want to ratify the diagnosis and most likely initiate further investigations of their own; with MRI scanning useful in identifying the location of the injury and therefore helpful in predicting the outcome (Nakamura et al, 2003). In a clinical sense, you don't always need an MRI scan to prove conclusively the presence of a partially ruptured MCL, since an experienced clinician will be able to distinguish the presence of instability through accurate examination (LaPrade and Wijdicks, 2012). However, the scans can reveal other associated injuries which may not be so obvious and can often be masked by swelling. To assist with arriving at an accurate diagnosis, Papalia et al, (2009) favoured MRI scanning together with stress radiology to assess the amount of laxity present in the medial side of the joint. However, most authors agree that the actual injury mechanics provide a reasonable indication of the structures likely to be involved; although this does not necessarily correlate to the degree of injury sustained.
As Cristiano fell, he could be seen to immediately begin holding the knee for support. Both MCL and ACL sprains are synonymous with the presence of instability; and it was obvious that the knee was unstable immediately after the tackle. Additionally, since Cristiano's foot was fixed at the moment of impact, it would have been impossible for there not to be some degree of knee rotation involved. Although it's much easier with the benefit of hindsight, the strappings applied would have been unlikely to support his knee to the extent that would have been required to participate in a game of football at the level of a major Championship Final. It's also probably safe to say that he's likely to have made the injuries worse by attempting to return to the game when he did. However, as we still don't officially know the true extent of the damage; a more accurate predication of the recovery time apart from "moderate to lengthy" cannot be made.
With very little information being released to date; it is difficult to arrive at a prognosis with any degree of accuracy. Although numerous sports medical people have commented on what the injury was likely to be, Dr José González pointed out on the AS Sports website within 48 hours of the injury being sustained, that CR7's knee was seen to rotate around the fixed foot. This added to the indications that Cristiano would have sustained some damage to the MCL but recognised the potential for injury to other associated structures at the same time. Dr González is a particularly experienced sports doctor with a long history in the professional game and regularly discusses medical matters on the AS website. Based at the Centro Médico Deyre in Madrid (www.deyre.com), Dr González is head of Rayo Vallecano's medical services where he oversees all medical and rehabilitation matters for the Vallecas club. Rayo Vallecano currently have first team goalkeeper ‘Toño' and midfielder Raúl Baena currently recuperating from ACL surgery, and as we know, knee injuries of this nature are all part and parcel of the game. Dr González and his team have looked after the medical side of Rayo Vallecano for years and their clinic is highly-respected in both the medical world and in professional football.
Of all those who gave an opinion on Cristiano's injury, Dr González sensibly pointed out that at that stage, with neither an MRI scan nor a full examination having being reported on, commenting accurately without having the full facts available is difficult. In some respects, then, not much has changed since the night of the original injury in St. Denis. It may be that Real Madrid as a club are becoming less inclined to discuss injury matters such as these in any depth, or it may be that Cristiano's recovery is being looked after by the Portuguese medical people. From the outside, though, the impression is that CR7 is managing his own recovery while recuperating on a short holiday at the same time; his recent statement via his Instagram account suggests as much. Reporting on private medical matters which are often regarded as a given right in the eyes of the public can be viewed in a different way by the players concerned. In addition to taking the responsibility for managing his own recovery, Cristiano may also prefer to control the amount of information released to the media and to be left alone while he gets on with his recuperation in private.
On this occasion it seems only natural that Cristiano will want to keep his treatment and rehab plans to himself. We've commented in the past in this column about the importance of keeping certain matters ‘in-house', and how it can be very easy to forget that players are actually people who have real feelings. There's a very fine line to walk between explaining about injuries and sharing medical information in public that perhaps should not be made available; particularly without the consent of the players involved. It's been three weeks now since Cristiano sustained the injury in France, and he'll be due back in Madrid shortly. If there are going to be any potential complications affecting the longer-term outcome of his recovery, he'll soon be approaching the stage where these will be likely to show.
We hope that is not the case; and for the moment, though, it looks as if all we can do is watch, wait, and wish him well.
American Medical Association (1996). Committee on the Medical Aspects of Sports. Standard Nomenclature of Athletic Injuries; p99 - 100. Chicago. American Medical Association
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