In the 14th minute of Real Madrid’s match against Barcelona on May 8th, known as El Clasico, Cristiano Ronaldo ankle suffered an injury as he leveled the match 1-1.
Here’s video of when it happened (go to the 1:20 mark):
As Cristiano went to tap-in the centering header, Gerard Pique lunged to clear the ball off the line and inadvertently stepped onto the Ronaldo ankle.
Ronaldo played the rest of the half but was taken out at halftime. Afterwards, the Ronaldo ankle injury was diagnosed as a low ankle sprain (high ankle sprains are a different animal – that’s a topic for another post). Low ankle sprains are so common in sport – they account for nearly 20% of all sports related injuries.
Since that game, Ronaldo ankle kept him out of Real Madrid’s next two games, at Sevilla and against Celta Vigo, and played 60 minutes this past weekend against Villareal in the La Liga finale.
With the league decided, there are two major questions still in play, both pertaining to the Champions League final on May 26th against Liverpool:
- Will Ronaldo ankle keep him from being 100% fit?
- Is there a chance that he re-injures it during the game?
Through my lens as a DPT, Doctor of Physical Therapy, I’ll answer those questions by exploring the following:
- Anatomy and function of the ankle
- Specifics of the Ronaldo ankle sprain
- Symptoms of an ankle sprain
- Risk factors for the Ronaldo ankle sprain
- Ronaldo’s ankle rehab and recovery process
- The short and long-term implications
I. The anatomy and function of the ankle
The ankle is one of the most complex parts of the body. Let’s start with the bones:
A. The ankle bones
There are three bones that comprise the talocrural (ankle) joint: the tibia (shinbone), the fibula which runs down the lateral (outer) part of your lower leg, the talus which sits below both the tibia and fibula. Additonally, the calcaneus (heel bone) sits below the talus.
Here’s what they look like:
Mechanically, the talus slides forwards or backwards depending on the ankle joint movement.
Here’s a great video on ankle anatomy if you’re interested:
B. The muscles
There are 11 different muscles that originate in your lower leg, flow across the ankle, and insert into the foot. These muscles are responsible for all ankle movement – known as dorsiflexion and plantar flexion.
A visual of those two movements:
And here’s a picture of the muscles (it’s dense – should give an idea of how rich the ankle area is) :
Additionally, these muscles are the major shock absorbers for your foot and ankle. They help dissipate force each time the foot and ankle makes contact with the ground or other object. The muscles are critical for the overall function and health of the ankle.
C. The ankle ligaments
The ankle has 7 different ligaments that provide passive stability. Think of them like rubber bands that become tensioned when the ankle moves, twists, and bends in different directions.
There are four ligaments on the medial (inside) aspect of the ankle, and three ligaments on the lateral (outside) aspect of the ankle.
Here’s a picture of the lateral (outer) ankle ligaments:
And of the medial (inner) ankle ligaments:
For a much more detailed anatomy lesson of the ankle, check out this link.
Now that we’ve covered the basic anatomy and function of the ankle, let’s take a look at the Ronaldo ankle sprain in detail.
II. Cristiano Ronaldo ankle sprain
Here’s the moment when the Ronaldo ankle sprain occurred:
Pique lunges to deflect the centered ball and steps onto the outstretched (plantar-flexed) ankle of Cristiano, causing his ankle to invert (turn inwards).
When the ankle moves towards its end range of movement (in any direction), the ligaments are tensioned. If the force is too high and the ankle continues to move, ligaments fibers are damaged and torn.
In sports related ankle injuries, this force most commonly results from an external factor – like coming down awkwardly on the ankle or getting hit on the ankle as in Cristiano’s case. This is called an acute trauma and especially sucks because there’s nothing you can do about it.
Depending on which way the ankle twists, a different ligament or ligaments take the brunt of the force and be damaged.
For example, if the ankle is plantar-flexed (pointed down) and twists inwards, then the anterior talofibular ligament (ATFL) takes the brunt of the force. That’s what happened to the Ronaldo ankle.
However, if the ankle is dorsi-flexed (pointed up) and twists inwards, then the calcaneal fibular ligament (CFL) takes the brunt of the force.
A visual showing both of those tears:
Generally, the ATFL sprain is the most common ankle sprain and the CFL sprain is the 2nd most common ankle sprain.
Further, the severity of damage depends upon the amount of force. Ankle sprain severity is categorized into 3 different grades of tear (don’t let the word tear fool you because any sprain involves some fibers tearing):
- Grade 1
- Slight stretching and tearing (<25%) of the ligament fibers, like a rope that has slightly frayed.
- Mild tenderness and swelling around the ankle.
- Grade 2
- Moderate stretching and tearing (25-75%) of the ligament fibers, like a rope with significant fraying.
- Moderate tenderness and swelling around the ankle.
- Abnormal laxity (looseness) in the ankle joint.
- Grade 3:
- Complete tear of the ligament, like a rope that has snapped.
- Severe tenderness and swelling around the ankle.
- Substantial laxity in the ankle joint.
- Most likely requires surgery to reattach the ligament
A great visual summary:
The Ronaldo ankle injury was diagnosed a grade 1 “mild” inversion sprain (more details on the specific diagnostic process in a second).
As anyone who’s had an ankle sprain can attest to, even a mild ankle sprain can be painful. Here’s a list of symptoms that can accompany a grade 1 ankle sprain…
III. Symptoms of a grade 1 ankle sprain
- Mild to moderate pain, as Cristiano felt during and after the game.
- Mild swelling, like Cristiano had after the game.
- Mild bruising
- Pain with weight bearing
- Tenderness over the outer part of the ankle
After Ronaldo was removed from the game at halftime, the Real Madrid medical staff likely performed a series of tests to diagnose the type and severity of ankle injury…
IV. Diagnosing the Ronaldo Ankle Sprain
A. Range of motion
The medical staff would have Cristiano move his ankle in different directions and based on the pain response, it gives a good indication of which ligaments may be injured and to what extent. In Cristiano’s case, the most painful movement would have been been plantar-flexion and inversion (foot pointed down and in) because that specific movement is what caused the injury.
Based on the pain response in part A and visual swelling/bruising, you can palpate (manually touch) the area around the ankle and pinpoint the areas of tenderness. For Cristiano, that spot was very likely in the sinus tarsi of his ankle.
To find that spot, trace your finger down to the bottom of your lateral malleolus (the bone on the outside of the ankle), then slightly forward toward your toes, and then upwards until you feel a divot – that’s your sinus tarsi, where the ATFL resides Here’s a visual:
C. Laxity testing
You can manually test the integrity of any ankle ligament. Based on laxity (looseness) and the amount of joint movement, it gives you a good indicator of severity.
Here’s a video of a test that assesses the lateral ankle ligaments:
D. Ottawa ankle rules
The Ottawa ankle rules are a set of indicators that immediately rule in or out a fracture of the fibula (the bone on the outside of the lower leg).
The intent of the Ottawa ankle rules is to reduce the need for X-rays and therefore reduce unnecessary medical costs. This is a good visual summary:
In the case of a professional sports team, cost is no object so Cristiano had an x-ray to rule a fracture in or out. The X-ray could have been be static and/or dynamic. The latter is called a stress x-ray and the foot is pushed in different directions to evaluate the stability of the joint.
Additionally, the Ronaldo ankle got an MRI to evaluate its soft tissue – the ankle ligaments, cartilage, surrounding musculature.
After all the manual testing and imaging, the Ronaldo ankle injury was diagnosed as a grade 1 ankle sprain. Now that we’ve covered the injury itself, let’s take a look at Cristiano’s rehab and recovery process and timeline.
V. Ronaldo ankle rehab & recovery
The general recovery timelines for an ankle sprain, categorized by grade of tear are:
- Grade 1 tear
- Approximately 2-4 weeks to heal fully
- Grade 2 tear
- Around 6-8 weeks to heal fully
- Grade 3 tear
- Variable depending on the specific ligaments torn and chance of an accompanying fracture (often times of the fibula).
- Recovery can take from 12 weeks to upwards of 6 months.
Personally, I’ve suffered a grade 3 tear and broken fibula while playing basketball in high school. It took me nearly 6 months to get back on the court and around 9 months to feel fully confident in it again.
B. The Ronaldo Ankle
In the case of rehabbing the Ronaldo ankle, there are multiple layers to consider. I’ve organized these layers into a micro (tissue and joint), mezzo (systemic),and macro (contextual) model.
Micro (the tissues and joint)
1 – Reduce pain
The first goal is to reduce pain. This is done by protecting the ankle and reducing inflammation. Generally, inflammation is a natural healing process of the body but Ronaldo who’s trying to get back to the field quickly, reducing inflammation and pain is tantamount.
Additionally, in higher severity ankle sprains that have more swelling, inflammation in the area can mechanically interfere with torn ligament fibers trying to re-attach to each other.
2 – Restore mobility
The second goal is mobility. Gentle passive range of motion and active range of motion, as tolerated, will be introduced as soon as possible to keep the muscles active and the joint from stiffening and losing range of motion.
3 – Improve strength
The third goal is strength. Once the ankle has full range of motion back, you start strengthening the surrounding musculature. Eversion strength – the key function of the peroneal muscles- is especially important as they help protect against future ankle sprains.
When the ankle bends inwards (inverts), the peroneals counteract that force and pull the foot back out (eversion). They run on the outside of your lower leg, across the ankle joint, and into your foot – here’s what they look like:
However, when an inversion ankle sprain does occur, the peroneals get stretched out and lose muscle strength. This can increase the risk of future ankle sprains. Therefore, it’s particularly important to re-strengthen them.
If you’re interested, here’s an eversion strengthening progression that I created:
B. Mezzo (systems)
The human body is an ecosystem and should be treated as such. It consists of multiple systems that are going to affect and be affected by injury. Addressing these systems can unlock gains and improve recovery.
1 – Bio-Mechanics
A critical early goal of rehab is to normalize Cristiano’s gait (walking) and running pattern. This protects against any compensations and overloading of other joints, muscle, or tissue.
2 – Central nervous system (CNS)
The CNS is comprised of two systems: the sympathetic nervous system (SNS) which creates the stress or “fight or flight” response, and the parasympathetic nervous system (PSNS) which creates the relaxation or “rest and digest” response.
A ramped up SNS makes healing and injury rehab more difficult by affecting you cognitively, physically, and emotionally:
- Cognitively: The brain’s main role is to anticipate and prepare for threat. When you’re stressed, the brain is on high alert which creates a heightened sense of threat and fixation on problems. In turn, the brain sends out more pain signals (aka MORE PAIN) to alert the body
- Physically: Stress results in a multitude of physical changes including increased systemic inflammation, increased muscle tension, deregulated immune response, etc. Each of these negatively impacts healing.
- Emotional/Behavior: Stress can alter major health drivers like sleep, nutrition (“binge-eating” for example), and exercise patterns. Changes in these key areas exacerbates all other existing issues.
Addressing and managing the CNS is key in creating an optimal healing environment.
3 – Proprioception and vestibular system
The vestibular and proprioceptive systems are both unconscious sensory feedback systems that provide information to your brain about where your body is in space. Based on this feedback, the body makes micro adjustments to make movement more efficient, effective, and safe.
The vestibular system is located in your inner ear and is the main organ of balance. It’s responsible for spatial awareness, temporal awareness, and maintaining equilibrium. Check it out:
The proprioceptive system consists of receptors in your muscles and tendons that provide information about joint angles and joint velocity. Here’s a basic overview of that process:
The simplest way to understand the proprioceptive system is to imagine if we didn’t have it. Try this: close your eyes and move your hands around up and down side to side. If you didn’t have a proprioceptive system, you wouldn’t be able to feel what your hands were doing.
The proprioceptive system is key in preventing ankle sprains. When your ankle turns or twists, the proprioception receptors (called proprioceptors) tell your brain “hey the ankle is moving”. If there’s excess movement, the brain activates muscles to counteract that movement and bring the ankle back into a safe position.
When the ankle inverts (turns inwards), proprioceptors in the the peroneal muscles (muscles located on the outside of your lower leg, ankle and foot) sense the movement and tell your brain “hey, the ankle joint is bending inwards”.
The brain processes this information and, if needed, activates the peroneals to counteract the inward force and shift your foot back into a safe position (which I mentioned above).
However, if the force is too strong and an inversion ankle sprain occurs, the peroneals get stretched out. This impairs both the proprioceptors and peroneal muscle strength – which increases the risk for future ankle sprains.
In turn, the vestibular system has to pick up the slack. That’s why any ankle rehab, especially for high level athletes like Cristiano, needs to include vestibular training and proprioceptive re-training.
If you’re interested in what that looks like, here’s a progression that I created:
C. Macro (contextual)
There are some overlying contextual (macro) factors that could impact Cristiano’s return and recovery.
1 – Pressure to return
Cristiano, being a star player and key cog for Real Madrid, will always be under pressure to return from an injury quickly. Additionally, Real Madrid are set to play in the final of the Champions League with eyes on a three-peat. That adds an incredible amount of pressure to return promptly.
This type of pressure can be a doubled edged sword. It could be detrimental to Cristiano’s recovery as it adds an extra layer of stress but, on the flip side, it can also be very motivating because, in his case, he seems to embrace the weight being on his shoulders.
2 – Cristiano’s commitment and general fitness level
Cristiano has arguably the greatest commitment and overall fitness in all of the sport. He reminds me of LeBron James with his unrelenting commitment to mental and physical fitness (if you’re interested in how Lebron turns back the clock, check out my piece). Cristiano’s dedication to the rehab process will be 100% and his pre-existing level of fitness is a huge positive factor in his return.
For example, Cristiano returned quickly from the MCL injury he suffered against France in the Euro 2016 Final and he didn’t miss a beat. Additionally, he was able to play 60 minutes against Villareal, scoring a goal and looking very sharp in his movement and decisiveness.
VI. Implications for the Champions League Final and onwards
1 – The Champions League Final (aka the short term)
Any ankle sprain, even a grade 1 sprain, increases the risk of future ankle sprain and they tend to occur in clusters. That means there is a higher risk for Cristiano to re-sprain the ankle during the match. Research shows that in the case of a grade 1 ankle sprain, about 10 to 15% are re-sprained.
This is likely due to an impaired proprioception system, and the ligament still not being fully healed, which results in ankle joint laxity. This decreases the threshold of force required to twist the ankle outside of its normal range motion.
Subsequent injury further impairs proprioception and ligament healing which further decreases the threshold to sprain the ankle – a vicious cycle.
This risk may be even higher for Cristiano because he’s constantly involved in dynamic activities and plays in a lot of traffic on the pitch which can lead to the ankle getting caught again.
2 – Long Term
A grade 1 ankle sprain is a relatively short term injury – when given the appropriate medical care and rehab. Unfortunately, the management and seriousness of a grade 1 ankle sprain is oft overlooked as multiple studies have shown that of individuals who suffer a grade 1 ankle sprain, nearly 30% go on to suffer from chronic ankle instability.
This instability can lead to higher severity grade two and grade three ankle sprains, reinforcing the cycle of recurrent ankle sprains and ankle instability. There’s research showing that nearly 73% (!) of individuals who suffer a grade 2 or 3 ankle sprain, go on to re-sprain the ankle.
However, in Cristiano’s case, I don’t expect this to be the case as he’s surrounded by a professional medical staff and he’s so dedicated to the rehab process and taking care of himself. I wouldn’t expect him to face any long-term implications unless his ankle directly gets hit again.
VII. All in all
Overall Cristiano is fortunate to have only a mild grade one ankle sprain but it’s still not an injury to be taken lightly. I’m happy to say that Real Madrid have taken a very conservative approach by holding him out for nearly 3 weeks and then only playing him for 60 minutes in his first game back. That extra caution combined with Cristiano’s level of commitment means he should be near 100% headed into the champions league game.
That being said, there’s still a an increased chance for Cristiano to re-injure the ankle during the match. That’s an inherent risk after any ankle sprain. However, considering the gravity of the match and making history, the risk/reward calculation tilts heavily towards reward.
Thanks for reading and until next time.
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