Manchester City’s players were ridiculed for wearing “Gundogan” shirts as they lined up in the Etihad before their game against Arsenal in December. Ilkay Gundogan himself tweeted in mock response: “Don’t worry, I’m still alive.” Whether paying such a tribute to their stricken colleague was over the top or not, the City players displayed a degree of solidarity with Gundogan and showed an understanding of the long rehabilitation he faces as he recovers from an anterior cruciate ligament injury.
Gundogan faces at least six months out of action, as do Crystal Palace’s Connor Wickham, Sunderland’s Duncan Watmore and Everton’s Yannick Bolasie, who have also suffered ACL injuries, which are now among the most common causes of lengthy lay-offs for footballers. There are currently 36 players from Europe’s five biggest leagues out with ACL injuries, which on average require 269 days’ recovery. With months of inactivity and isolation stretching out in front of these players, they not only have to recuperate physically but also need to preserve some mental equanimity in the long, lonely days.
ACL injuries are nothing new, with high-profile casualties Paul Gascoigne and Alan Shearer both suffering from serious injuries in the early 1990s. Gascoigne’s was self-inflicted after his poor challenge on Gary Charles in the 1991 FA Cup final and it took him almost a year and a half to recover fully. Shearer suffered his injury while playing for Blackburn in the first season of the Premier League. He was injured in December 1992 and did not play again until the start of the next season. Shearer was only 22 but there were times when his career looked under threat. He found it difficult to cope with the lengthy absence and his manager at the time, Kenny Dalglish, had to restrain him from returning too early.
Recovery periods have been reduced but care is still taken to not rush a player back too early. Bolasie, for example, may be facing a year on the sidelines according to Ronald Koeman with a second operation required a month after sustaining his original injury. “The surgeons really want you to take it steady these days,” says Neil Sullivan, the former head of physiotherapy at Derby County, Oxford United and Peterborough United. “There was a trend about 10 years ago when you used to get brownie points for the quicker you got somebody back from a cruciate injury. It’s not quite the case anymore as research has shown that the longer you leave it the safer you are.”
Wickham’s prognosis is slightly better than that of Bolasie, his former team-mate, with an expected return at the beginning of next season. When Wickham was injured he immediately received the support of fellow Palace players who had experienced similar injuries, such as Wayne Hennessey, who understood the need to keep his spirits up, especially at the beginning of the recovery process. “We’ll all be there for Connor, we know he’s going through a tough time,” Hennessey said.
Just as Wickham and Bolasie were facing up to their lay-offs, a player who had suffered an ACL injury returned to first-team action. Kurt Zouma had been out of action since last February until he came through Chelsea’s FA Cup tie against Peterborough earlier this month. The 22-year-old credited the positive influence of his manager, Antonio Conte, who included Zouma in Chelsea’s pre-season tour of the US even though he was still midway through his recovery. Conte also insisted that Zouma was involved in tactical training sessions as he explained his philosophy to the players and introduced the idea of playing with a back three. That encouraging approach means Zouma is now up to speed on the team’s tactics as he competes for a starting place.
Injured players face an inevitable sense of separation from their team-mates so clubs are keen to provide them with companionship. Leading sports psychologist Michael Caulfield explains how he helps players deal with the loneliness. “When everyone has left the building to train, warm up or go for a team meeting, I always stay with the player. I don’t tell them what to do and, when and where possible, the vital ingredient and timing of humour is necessary. I try to do a combination of listening and saying very little as they are frequently angry, low, even lower than low and often depressed.”
It is important for injured players to feel involved in the club but Caulfield also likes to take them out of their normal environment so they are not cooped up for too long. The recovery process from ACL injuries is painfully slow, so players are set realistic targets. Reaching these targets, however small, provides minor achievements on the path to recovery, such as walking a bit further each day or getting an angle or two more when bending a leg. These small steps keep players going in the tough times, reassuring them that progress is being made even if they still feel a long way from returning to full fitness.
Recuperation methods were markedly different 25 years ago, when there was far less reliance on conditioning and hardly any consideration for the psychological damage being inflicted on the player. Brian Clough used to ignore injured players as he deemed them worthless, which cannot have helped those struggling with their self-esteem and insecurities. Clough’s own playing career was cut short after serious damage to both medial and cruciate ligaments in his right knee. Perhaps his behaviour towards injured players concealed a deep resentment over his own injury.
Sports science and medical support have also advanced exponentially. As soon as a player is injured, staff will have a video clip ready so they can look closely at exactly what happened and assess the situation before the game has even ended. The technology helps surgeon to make an informed call within hours of the incident.
Highly qualified staff, such as strength and conditioning coaches, doctors and physiotherapists, will produce a detailed, tailor-made programme of activities for each player. The first week after surgery is generally quiet, which gives the player a better foundation to progress. The next 12 weeks or so “are really all about reducing the swelling, maintaining as much muscle bulk as possible and working on that range of movement,” Sullivan says. “One of the things about post-ACL surgery that the surgeons always require the physios to address is the extension of the joints.”
Following this initial period, work is stepped up in the gym to focus on strengthening the joint so it can take more weight. Anti-gravity treadmills allow players to exercise without loading the joint too much and develop running patterns that would not be possible on grass. Electrical stimulators are used to load the muscles without loading the joint itself. From the first month onwards there is a high degree of intensity in the regime. “The days are quite full and long, involving swimming, gym-based activities and cardio-vascular drills,” says Sullivan.
When the player is deemed fit enough to return to outdoor training, GPS data allows careful monitoring of the individual player, including “the type of movement, the intensity of their runs, the number of jumps and landings so you can identify their weaknesses and work with them to ensure they are fully recovered so you can ensure there aren’t too many blips,” Sullivan says.
As players approach their return, they often feel a sense of trepidation about suffering a reoccurrence of their injury. They go through a rehearsal process for a month or so before making a full return to action but may still worry about making that final step. Sometimes they need to be convinced that their body is up to the task, as Robert Snodgrass described earlier in the season. Coming off the back of a 16-month lay-off because of a serious knee injury, he was surprised at how the Hull City physios primed him for his return. “The way they train you back up is unbelievable. They get you running at high intensity and then they start barging into you. You’ve got these 14- or 15-stone lads banging into you, knocking you off balance, but it gets you ready.” If that does not have you prepared, nothing will.
Fortunately the days when players were hurried back into action too quickly or expected to play with multiple painkilling injections that caused long-term damage are largely gone. As is the idea of being shunted off into the sidelines. That may not justify the tribute laid on for Gundogan but that togetherness will be integral to his successful rehabilitation. Today’s injured players can look forward to the paternal consideration of Conte rather than Clough’s cold-shoulder approach.
The Guardian Sport