Will Cristiano Ronaldo come back the same player?

As the dust settles on what was an incredible Euro 2016 football tournament, one of the biggest news stories to come out of it (apart from England being knocked out by lowly Iceland) was the knee injury to Portuguese and Real Madrid superstar, Cristiano Ronaldo.

Reports in the media say he sustained a partial tear of his ACL and is likely to miss the first 4-5 months of the La Liga competition.

From a physio perspective, partial tears of the ACL are really tricky to manage because, more often than not, you try to mange the athlete conservatively. So it then becomes a 50/50 case of will they or won’t they have a successful conservative management.

I know this sounds terrible, but I’d rather the athlete completely rupture the ACL because the situation becomes very black and white. If the athlete wants to return to sport, they need surgery. They will have a 9-12 month stint in rehab and eventually return to competition.

With a partial tear of the ACL however, the scenario becomes a gamble. The best case scenario is that the athlete rehabs their knee really well and returns to sport within 4-5 months. The worst case scenario is that, after conservatively managing the athlete for 4-5 months, the athlete discovers that their knee doesn’t ‘feel right,’ has ongoing knee instability upon their return to sport and eventually proceeds to have reconstructive surgery anyway. This all plays out over 14-18 months.

Regardless of what happens with Cristiano Ronaldo over the next 4-5 months, I wish him all the best. He is an incredible player, and his individual awards (including three Ballon d’Or awards) and consistent playing performances over the last decade, all speak volumes. But what I’m interested in is will he ever be the same player again?

I posted a couple of times last week on social media about elite player performance following ACL reconstruction (ACLR). In one study it was found that 86 per cent of NBA players successfully made a comeback in the next playing season, but total games started, total games played and player efficiency ratings were all significantly lower in their first season back compared to age-matched controls. Their careers were almost two years shorter as well.

Conversely, I also wrote about the rise and rise of Australian Cricket Test batsman Usman Khawja, after he recently returned to sport following ACLR. Prior to his ACL injury in late 2014, he was in-and-out of the Australian team and had a Test batting average of around 24. However, only ten months after sustaining his injury, he was picked for the Australian team, scored 170+ runs in his first match back, and has been averaging over 100 ever since.

The obvious difference between these two case studies is the physical requirements and tightly packed playing schedules in the NBA requires the knee to function significantly greater than what is required for Test match cricket. Nevertheless, I was intrigued as to how one cohort of players can experience declines in performance after ACLR, and one cohort of players can seemingly thrive, so I went looking for more information and found some interesting results:

MLS Soccer players
•77% players returned to sport around ten months post-op
•10% re-injury rate
•Average career length after ACLR was four years
•ACL surgery had no significant effect on player performance in post-op follow-up period

NFL players #1
•82% of 559 athletes returned to sport after ACL at average of 378 days
•Career length following ACLR was only 1.6 years
•ACLR led to significantly worse performances in the first three seasons upon RTS (if able to continue to play that long)

NFL players #2
•63% RTS around 10 months post-op.
•Those that did return to sport played a significantly more amount of games prior to injury (ave 50) versus those that didn’t (ave 28).
•Players that were drafted in the first 4 rounds were 12 times more likely to return to sport, rather those drafted in rounds 5-7.
•Interesting conclusion that highly skilled and experienced athletes more likely to return to NFL than those that aren’t as skilled or have as much playing experience

NHL players
•97% players returned to sport at 7.8 months post-op.
•Re-injury rate was only 2.5%.
•Players that did RTS, played another 4.5 years post-op.
•Performance measures actually increased in ACL patients than age-matched player controls (mean goals and points per season, mean power play and strength goals per season, and mean shots and shooting percentage per season)

So there you have it, a bit of a mixed bag of successful and less successful return to sport performances across a number of different codes.

Being an eternal optimist, I guess the moral of my story today is that, despite what the research shows for NBA players and NFL players, an ACL injury doesn’t have to mark the start of a slow and steady decay in player performance and an early retirement from the game.

In fact, in some sports, an ACL injury can be the catalyst to spark or revive their career. The time spent on the sidelines and sitting in rehab allows them to work on the weaknesses in their game, not to mention work hard on their strength, power, agility, balance and speed so that they can come back, fitter, stronger and faster than ever before.

So I guess to answer my earlier question, “Will Cristiano Ronaldo come back the same athlete?”

My gut feeling is, regardless of whether he is lucky enough to avoid surgery, or if he has to have it a later date, he will come back faster, stronger and fitter than ever before.

And that’s a scary thing.