Real Madrid’s Constant Injuries: EXPLAINED!

Normal ACL

The ACL, or anterior cruciate ligament, is the main stabilizer of the knee, especially during quick changes in direction. As clearly seen, the anterior cruciate ligament originates off of the posterior aspect of the femur (at the top of the image), and inserts on the anterior aspect of the tibia. This crosses in front of (anterior) to the posterior cruciate ligament, the main connection of your shin to your upper leg. The ACL generally controlled the back-and forth movement of the lower leg, and prevents the tibia from sliding or trans locating too far forward relative to the femur, which could be disastrous. Sudden stops and changes in direction, a plant injury with a twist, or head-on collisions can usually cause this to rupture, which is likely a 8 to 9-month recovery time. Generally, this requires reconstructive surgery, either from a cadaver, or taking a thread of the patellar tendon which connects the shin bone to your patella. The side view (sagittal T2) shows the ACL coursing from the back of the femur (top) to the front of the shin (tibia). The frontal view (coronal) clearly shows the insertion on the tibial peak (bump in the shin bone). This is a normal appearing ACL, something rare at Real Madrid.

Dani Carvajal

UGH: Below we see that the central stabilizer in the knee is gone. Unfortunately here, numerous people close to the situation suggest that this could take at least 12 months, and there is a good chance that he will only regain 50 to 60% of his peak performance level. This is because of the patient’s age, and the fact that Carvajal has more of a varus (bowlegged) anatomy. This is somewhat difficult to surgically repair given the course of the ACL now must be longer as there is rotation involved. This also makes the grafted ACL more tense (weaker), and is more likely to retear. To boot, Carvajal is 33 years old. The other ligaments and tendons in the knee have had 33 years of wear and tear, which makes his knee less strong, and more likely to fail. The beginning of June is 8 months since the surgery, and that is the time where we will need to see where Dani’s leg is.

Remember with David Alaba, the knee was nowhere near ready. This could likely last until next October, well into the 2025 – 2026 La Liga campaign. Finally, there is a psychological factor that plays into ACL tears, which likely suggest that numerous people have come back have been far more cautious, and less likely to exert fully with a fear of retearing.

Unfortunately, Carvajal fits into that mold.

David Alaba

Much like Dani Carvajal above, David Alaba has torn his ACL. You can see that below, the ACL normally within the notch is missing. This brings the two parts of the knee (the femur above, and the tibia below) closer together.

Unfortunately in David Alaba’s case, the ACL ruptured and pulled off likely a portion of the tibial plateau. In the normal knee, Covering all the ends of the bones in a joint, is something called cartilage. The cartilage acts as a lubricant so that the bones do not rub on or against each other, and it also protects the bones when there is impact injury so bone doesn’t hit bone and cause a fracture. Unfortunately as you can see in the photo, much of the cartilage has been pulled off, and now there is major chondromalacia (fancy word for cartilage loss), which usually happens with wear and tear of the knee, usually in older players.

David Alaba is 31, which in the regular world is very young, however in soccer years this could be ancient. Once the cartilage in the knee joint begins to go, bone-on-bone scraping, earlier osteoarthritic changes, and severe pain are likely. It can also cause changes to the bone as you see photo, when there is an ostial defect (Often referred to as an osteochondral defect: OCD) which is known as a microfracture.

If anyone is a fan of basketball, there was a famous #1 draft pick name Greg Oden. He had an OCD (also called a MICROFRACTURE), which ended his career. You can see that chondromalacia with a reconstructed ACL will be very tough to come back from. Since the time of this writing, Alaba has come back, however I expect him to be a fraction of what he was previously — though hopeful he can return to form despite the chondromalacia most likely getting worse.

Eder Militao

ACL reconstruction is done by 1 of 2 methods: 1) Either taking the ACL from a cadaver (unfortunately a person that has passed away with an intact ACL); or 2) taking it from the patellar tendon as you can see anteriorly which connects the tibia to the patella.

There must be screws that hold this new ACL in place. These are called interference screws, and there is a tibial (lower) tunnel, as well as a femoral (above) tunnel. The screws keep this tight ACL in place. As discussed with Dani Carvajal, the anatomy of the patient’s knee has a lot to do with the size of the ACL, which type of ACL repair they do, and the chance of re-injury.

Unfortunately, in Eder Militao’s case, the ACL was repaired which would be great normally, and very good outcomes in a regular population, however this is now retorn for a second time. What will have to happen is they will have to redo the tibial and femoral tunnels, regraft an ACL from likely the cadaveric site, and hopes that it remains intact.

But if anyone has ever drilled a hole and screwed in a screw to the wall, unscrewed, and then re-screwed, one can see that this has less of a chance to be as sturdy. The same thing is likely true in the knee. Unfortunately, the biggest factor in this instance is going to be his psychological return, which is going to be very tough. I am hoping for a speedy and full recovery, but in this case, I am less than optimistic. This could be a very difficult and rigorous come back, and I will likely see him only being a backup in the future. If Carvajal has a 50 to 60% chance of return, Militao’s is markedly less given he’s already torn his ACL once before.

Eduardo Camavinga

Eduardo Camavinga has been diagnosed with the biceps femoris injury, also known as a hamstring strain. In the picture below, in the arrow pointing towards the injury (high T2 signal at the edge of the arrow) is the strain in the back of the thigh or the hamstring: The biceps femoris origin. Depending on how bad this is, this can keep you out three to six weeks.

The more worrisome thing is strains can lead to tears and tears have longer recovery. We can see that if it is a strain, the muscle gets a little bit of fluid within it, and that causes difficulty in running, significant pain, and weakness. Most soccer players have significant hamstring injuries (we remember Vinicius Jr. had the same) because this is a very important piece of the quick acceleration or fast twitch muscles.

Also, overexerting, overstretching, and running at high speeds, usually cause hamstring injuries. While this is part and parcel and normal for the course of soccer players, it still something to keep an eye on, as hamstring injuries can be lingering. While we see that most players get back to normal levels, it can take a toll. Here is hoping for a speedy recovery.

Joan Martinez

Remember our old friend the ACL? Well here we can see it is completely gone, similar to Joan Martinez’s situation. Likely, Joan Martinez has a young healthy knee with normal anatomy, which is dissimilar to David Alaba, Eder Militao, and Dany Carvajal (just factoring in age). Hopefully this can be easily repaired, although crazier things have happened. We hope this is nothing like Lonzo ball, a famous NBA basketball player who had a meniscus injury, but given the extensive cartilaginous damage, he was out for two years.

Jude Bellingham

Here is a quick note on Jude Bellingham: We remember last year he dislocated his shoulder. The arrow points to a divot in the BALL portion of the shoulder joint, or the head of the humerus. This is because the humerus pops out of its normal ball-and-socket joint, and sits on the corner of the glenoid. Much like in the knee, there is covering of the bones, predominantly in the corners of the socket (glenoid) called the labrum which is represented by the two circles.

What we see here is that there is a nice black triangle that cushions the corners of the glenoid so the nice ball (humeral head) can sit softly in the socket (Glenoid). Unfortunately, when you dislocate, it can slough off some of the labrum (a labral tear), and can cause a bone contusion as seen at the arrow (called a Hill Sachs Fracture). While this is very painful, and normally when you run it causes pain, it is not something a soccer player generally needs. However, for Jude’s future self, he will most likely need surgery down the road either to repair a rotator cuff it has been torn because of the dislocation, or more importantly the labrum which has been torn. This will require lengthy recovery time and more importantly eventual surgery, which is not fun. Jude is young, strong, and more of a man that I will ever be, he is playing through this like it means nothing.