On Sunday Man Utd met Chelsea in the Premier League in what was an important game for both sides considering their rather poor league positions, especially the latter. The game wasn’t the best and ended in a one all draw, thanks to an injury time equaliser from Diego Costa, which piled further pressure on Louis van Gaal amid speculation he is set to leave the club in the summer.
The game however will be remembered for something else in that of the injury sustained by Kurt Zouma in the 56th minute, landing awkwardly following an aerial challenge.
We wanted to investigate the injury in a little bit more detail to understand the nature of the injury, how it could be treated and if there was an opportunity to prevent it.
What went wrong?
From the initial footage the prognosis was never going to look good, with a hyperextension of the leg which effectively saw his knee bend the wrong way (the images are not for the faint hearted).
As you can see the knee bends beyond its normal range of motion which instantly takes Zouma off his feet. When you consider the anatomy of the knee joint it is impossible for your leg to do that without something having gone seriously wrong.
The anatomy of the knee
The knee joint is created through the joining of the Femur (thigh bone) with the Fibula and Tibia, with the knee cap called the Patella. In order to stabilise the joint there are four ligaments (tough bands of tissue connecting the bones) which work to control the range of motion i.e. keeping you mobile, which are the ACL (Anterior Cruciate Ligament), PCL (Posterior Cruciate Ligament), LCL (Lateral Collateral Ligament) and MCL (Medial Collateral Ligament). These reside at each side of the knee.
Damage to any of these ligaments can be quite serious, with three different grades of severity. A grade one is a mild sprain and whilst painful you should be back on your feet in a few days. A grade 2 normally involves some tearing of the ligament which compromises its integrity and results in a longer lay off. A grade 3 is the most serious, where there is a rupture or complete tear of the ligament which affects your ability to walk, run and jump. In the case of a grade 3 surgery is normally offered which involves the repair of the ligament or even the creation of a new one by taking a graft from the hamstring or groin.
Initially Zouma had hoped to be back in action towards the end of the season given the impending tournament in France as it was his hope to add to the two caps he has received already and play in his first major tournament. He had also been an integral part of the blues defence this season with 32 appearances so will be a big loss to the club in the final run in of the season.
Unfortunately the diagnosis was the worst it could have been for the player with a rupture of the ACL. This ligament sits at the front of the knee and effectively stops your knee from moving forward beyond the Fibula and Tibia. It is also one of the most important ligaments in the knee as it is responsible for your overall stability, essential regardless of whether or not you are a footballer in being able to walk, sprint and jump.
Damage to the ACL is very common with footballers, with Zouma joining 9 fellow Premier League professionals with similar conditions including Danny Ings, Carl Jenkinson and Callum Wilson.
Given the severity of the injury it is projected that Zouma will be out of action for up to 6 months and requires immediate surgery to remedy the problem, something which he will not have wanted to hear but surgical techniques and success rates have increased massively in allowing a patient to return to sport at the highest level following such a catastrophic injury.
Treatment depends on the severity of the injury. In Zouma’s case the grade 3 condition requires surgery to repair or even replace the ligament. A surgeon will either attempt to repair the original ligament but in most cases they will take a graft from the hamstring or the groin. In addition to replacing the ligament many surgeons now opt to add a second ACL for additional stability and to increase the chances of a successful operation.
What can help however is having good quad muscles which can work in conjunction with your ligaments (and is something which is normally focussed on during pre-hab or the time before surgery). Strong quad muscles can help offer stability to the knee joint and in some cases you can continue to be ACL deficient providing you have strong quads, though this is not recommended in football.
Post surgery the knee will need to be immobilised whilst it heals fully before the rehabilitation programme can begin. Typically a patient will be able to walk without crutches after the second or third week.
The key to returning to action post ACL damage is in strengthening the joint once again. Premier League clubs have an arsenal of doctors, surgeons and physiotherapists at their disposal and will create a custom training plan for Zouma to work on his overall fitness and strengthening the knee joint once again. These sessions normally start to take place between 7 and 14 days post surgery.
Following the start of training a knee brace may be used to restrict the range of motion of the joint, as you don’t want to hyper-extend again and be back at square one. A range of 0 to 140 degrees is normally recommended for the first couple of months and the brace will physically stop you from stretching beyond this range.
Whilst building strength in the quads is important, post surgery it should not be the sole focus as this can stretch your new ACL therefore it is recommended that you focus on static bike riding or lightweight leg presses which indirectly strengthen the quads whilst using the hamstrings to protect the graft. This routine should be the focus during the first few months post surgery.
Zouma will no doubt be advised to avoid running or swimming for up to five months (though with athletes this time may be reduced). Swimming is normally a very good way of exercise without weight bearing though following ACL surgery it is recommended to avoid for up to five months, but if you do fancy a dip then just use your arms after about two or three months.
Whilst the above treatment looks at the average person, Chelsea will have a team of medical personnel to assess his recovery on a day to day basis and will be able to alter the programme depending on his development.
Unfortunately there is no real way of preventing this type of injury on the football pitch, with damage to the ACL normally occurring following a slip, fall or bad landing rather than a poor tackle.
Statistics show that 40% of all ACL injuries occur in extreme sports, with this market looking to manage the injury prophylactically (prevention) through the use of bracing. Carbon fibre braces are popular in motocross, snowboarding and wakeboarding as they protect the knee and associated ligaments, perfect from staying clear of injury or avoiding a repeat. Premier League rules however forbid the use of such braces as if you were to go into a tackle wearing a carbon fibre knee brace then the opposing player would come off alot worse.
The important thing to remember following an injury is to stop what you are doing and obtain a professional diagnosis. When considering knee ligament damage a grade 1 can soon become a grade 2 or 3 should you fail to manage it properly, which is the difference between a few days out or in Zouma’s case, 6 months.
The coming months for Zouma will be difficult however we wish him a speedy recovery and hope that he returns for the 2016/17 season even stronger.