Explaining Rodri's serious ACL and meniscus injuries and why Manchester City aren't rushing his return

New York Times

5 hours ago

Manchester City have spent around £315million on eight new players in the past six months — but welcoming back the Ballon d'Or holder from the best part of a year on the treatment table is priceless.
After nine months out following a serious knee injury sustained last September, Rodri made his return to the pitch in the penultimate Premier League fixture of the domestic season, then played the final half an hour in City's opening two Club World Cup group games.
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But Guardiola, who confirmed at the time the Spaniard had undergone surgery on his 'ACL (anterior cruciate ligament) and some meniscus', tempered expectations that Rodri will begin the Premier League season at full capacity, reiterating that the midfielder is some way off being ready to start a game.
'Do not forget that it is almost nine months since the day it happened,' Guardiola said. 'It is a recovery between 10 and 12 months. It is a long, long injury.
'He is getting better, he wants to play and help, but we want to protect him and feel good in his knee. Hopefully, one day soon, he can play from the beginning.'
The timeline will depend on how Rodri's right knee responds as he steps up his game time but what does recovery from a serious ACL and meniscus injury look like?
There are two menisci in each knee, the medial on the inside and the lateral on the outside, with the ACL, one of the major ligaments of the knee, connected above. The menisci are C-shaped pieces of cartilage that act as shock absorbers between the shin and thigh bones to help stabilise the knee, distribute weight, and protect the joint from excessive wear and tear.
The worst-case scenario is rupturing the ACL and tearing both the medial meniscus and lateral meniscus. This is known in medical circles as 'the unhappy triad' or 'the terrible triad'. Whichever term is used, it represents a significant injury.
'It is variable, but often in football, a non-contact injury can involve just the cruciate,' says leading ACL surgeon Gordon Mackay.
'The higher-energy injuries, when really pivoting forcefully, can damage these other structures. It can end up being potentially a bigger pathology than it might have been if it was just one clear episode.
'There's a higher chance if you repair a cartilage that it'll re-tear again once you're back into action in a fully competitive way. So these additional pathologies carry the risk of making it more challenging or slower for Rodri, but he will be very pleased, at nine months, that he's playing at an elite level with a stable, healthy joint after such an extensive injury.'
UEFA's 'elite sports injury study' found that in elite footballers, an ACL tear is accompanied by a meniscus tear in around 50-70 per cent of cases, but tearing both menisci at the same time only occurs around a third of the time.
'There is a big difference between them,' Mackay says when asked about the medial and lateral menisci.
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'The tearing of the inner cartilage is much more forgiving and can more frequently be trimmed, whereas the outside it's a more challenging recovery, more challenging surgery, and a less predictable outcome.
'If it's just a modest tear of your inner cartilage, it's just trimmed and it doesn't really affect your recovery. If it's a serious tear of the outer cartilage, that's different, because you (as the surgeon) want to do everything you can to preserve it, as it will not only improve function and stability, it can also reduce the risk of arthritis going forward.
'So you have an obligation to save it if you can, because if they lose too much cartilage, you can increase the wear within the joint, it can cause recurrent swellings, it can increase the risk of future instability. If you do, that factors in the delay at the start, because the first 12 weeks are really focusing on making sure the cartilage is healed robustly, and then picking up and progressing with more of a standard ACL recovery.'
Rodri was treated by Spanish surgeon Dr Manuel Leyes, who is Real Madrid's go-to man for treating ACL injuries and opened his doors to The Athletic in May.
His approach consists of making tunnels in the femur and tibia (thigh and shin bones) to insert a new tendon and take out the central third of the patellar tendon. Leyes then inserts an extra joint reinforcement (with another tendon) that controls the rotation of the knee and reduces the risk of the player re-rupturing the ACL.
It is a more traditional approach than what is used in the United States and by Mackay, whose pioneering method reconstructs or repairs the ligament as soon as possible, augmenting it with an 'internal brace'. He uses a second brace laterally as an alternative to a second graft.
'We all take slightly different approaches, but the surgeon he went to obviously has a very good reputation,' says Mackay.
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'Based on what I've read of this surgeon's approach, he will have tightened up the structures on the outer side of your knee. If you do that at the same time, then it can reduce the risk of re-rupture significantly, but it can cause irritation around your IT band (which runs from the hip to the knee), a bit of scarring, a bit of stiffness.
'It's got to be done carefully, as it means you're taking one bit of tissue and moving it to another location. It's an investment in the longer term.'
Leyes' method may take longer than Mackay's internal brace method, which has successfully returned some footballers within four and a half months, but the extra surgery on the outside of the knee with either approach can reduce the risk of re-rupture by as much as a third.
'With U.S. colleagues, we're looking for alternatives to reduce the surgical insult, which speed recovery and allow us to customise care to the individual footballer. It's anticipated that in the future, we'll have significantly lower re-rupture rates and accelerated recovery as a result of this,' he says.
The progress on treating an ACL ruptures has improved dramatically from the time when they would regularly end careers, but it is still one of the most devastating injuries for a player in terms of the time out of action and the mental challenges it poses upon their return.
As with all his patients, Leyes created a dedicated WhatsApp group with Rodri and his closest advisors, and visited City as the Spain midfielder approached a return to training.
Rodri has been the pivot of this City team for so long that they looked unidentifiable without him. Spanish midfielder Nico Gonzalez was signed from Porto in February to fill the void and looks set to play a prominent role in the first months of the season as he covers for Rodri. Gonzalez was asked whether Rodri was as good as he expected.
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'Even better,' he said.
'He is an amazing player and really good in everything that can be good in a midfielder. I am trying to learn the most I can and I am starting to watch him at his best level. I am seeing things that I haven't seen in a lot of midfielders.'
It may take some time before he is back to the player who ran football games as if he were watching from above, but Rodri being back on the pitch after such a traumatic injury is a reason for the club's fans to be optimistic.