Why is the World Cup so hard on the knees?

We explore why knee injuries at this year’s World Cup are (almost) as inevitable as England losing to Germany on penalties – and what’s being done to change the situation.

It won’t have escaped your notice that the 2018 World Cup is about to kick off. Every four years, the lead up to the tournament is punctuated by announcements about players who won’t be at the tournament, often through knee injuries, and this year is no exception. Alex Oxlade-Chamberlain (England), Sergio Romero (Argentina), Jakob Johansson (Sweden), Aleksandr Kokorin (Russia): you could virtually field an entire team of players sporting knee injuries – not that they’d be able to run very far.

Knee injury

Knee injury inevitability

When your country’s talisman is sidelined by injury it can be tempting to assume the World Cup exerts some sort of malign influence on players at the end of hard seasons. In reality, UEFA’s own research suggests that knee injuries are statistically inevitable.

As we wrote ahead of Euro 2016, football related knee injuries are common, but the one that draws most attention is a tear to the anterior cruciate ligament. A complete ACL tear usually causes a long absence from football and is associated with an increased risk of new knee injuries and early development of osteoarthritis. UEFA’s report on elite footballers found that about 7% of reported injuries are to knee ligaments. Of these, 0.7% of all injuries are torn ACLs. With more than 100 hours of football set to be played (assuming the odd spell of extra time here and there), statistically there is a 30% chance at least one player will sustain a tear to their ACL during the World Cup.

The most common knee injury, to the medial collateral ligament, is unlikely to require surgery but will still be enough to rule a player out of tournament contention. There’s a reasonable chance that virtually every squad will have a player who currently has or will sustain such an injury over the next few weeks.

Why knee injuries occur

Most knee injuries are non-contact and occur after landing awkwardly from a jump or rotating on a fixed foot. An unmistakeable ‘pop’, a rapid swelling and a substitution inevitably follow. Yet, although ACL and other knee injuries are to some degree inevitable, the prevalence of injuries is not. As this post explores, work has been ongoing for some years now to identify the activities that can reduce the risk of knee injury. No strategy can remove the risk entirely, but when programmes such as the ‘FIFA 11+’ initiative are shown to reduce knee injuries by 30-50%, it’s clear that half the battle against ACL injury isn’t being fought by knee surgeons on the treatment table; it’s in preventing those injuries in the first place.

Professor Nick London

Professor Nick London is a Visiting Professor of Sports Medicine at Leeds Beckett University, and is part of the Leeds Beckett Sports Medicine Research Group.

He works at Harrogate District NHS Trust and with the Yorkshire Knee Clinic in Leeds and Harrogate.

He has extensive experience of managing all orthopaedic knee conditions, from those developing in children and adolescents, through to sports injuries in athletes of all abilities and knee replacement/resurfacing procedures in patients with severe arthritis.

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