Alexia Putellas said goodbye to the European Championship three days before it started.
He tore his anterior cruciate ligament in training.
"I look at the photo and I see how quickly everything can change in a support or in a second...", the winner of the Ballon d'Or vented on networks. "You will return", wrote Carolina Marín, who also broke the crusader two months before the Tokyo Games and knows what it's like to see everything black.
Alexia Putellas is 28 years old and Manuel Leyes, head of the Olympia trauma service, the same one who operated on Marín and hundreds of other athletes, says that he has a much better chance of recovering than if he were 13 or 14 years old.
“A hallowed figure like Alexia, it's easier for her to return to her level than not if a girl who is just starting out and has to reach a very high level breaks the crusader.
If you break your cruciate ligament when you are 12 or 13 years old, reaching the elite is very difficult, because you miss the boat.
It's a stagnant season and all the other players are ahead of you”.
More information
Carolina Marín: anatomy of an emotional recovery
For the drink of a long recovery -between seven and eight months-, they have passed in addition to Carolina Marín, Salma Paralluelo, also the Olympic sailing Silvia Mas this winter.
And in the Liga Iberdrola seven more footballers (the previous season the figure was 16).
Studies and experts say that cruciate ligament tears in women are three times more frequent than in men.
Other studies raise the number up to eight.
Women also have a higher risk of re-rupture: 35% are affected, according to traumatologist Luis González Lago, who was head of the medical services of Valencia for women.
Why is it a break that sports women suffer more?
The reasons are several.
The main one, according to González Lago, is anatomical.
“Women have a wider pelvis than men to be able to give birth, so they tend to bring their knees closer together when they run (the so-called valgus).
When the knee gives way in a dynamic valgus fall [like the one suffered by Carolina Marín, for example] what suffers the most is the crusader”.
Most breakages, and Alexia Putellas's is one of them, occur without contact.
Luis Serratosa, specialist in Sports Medicine at Olympia and Quironsalud University Hospital, agrees with Lago and graphically explains the morphology of the knees.
“On the one hand, women tend to have their knees turned in (valgus), unlike boys, who generally have them more arched outwards [like Isco or Raúl].
Additionally, with wider hips, the shift in center of gravity may also contribute to decreased knee stability.
These two factors influence the fact that the knee ligaments have to withstand moments of greater tension and therefore increase the risk of rupture”.
hormonal factors
The anterior cruciate ligament is like a rope that goes from the femur to the tibia, from bottom to top and back to front.
Serratosa and Leyes list more factors that increase the risk of breakage in women, including hormonal factors.
“When estrogen increases during the cycle phase, collagen synthesis decreases.
It has been seen that in these periods the risk of breaking the cruciate increases: in the end the ligament breaks because it is not capable of withstanding the tension to which it is subjected when the knee goes inward.
It is also more frequent, although in Alexia's case this has not been the case, that you break in competition than in training.
The demand is usually greater”, describes Leyes.
The morphology cannot be changed.
And everyone agrees that elite athletes know what a dynamic valgus is, that their knees are turned in and that they are at greater risk of injury.
Since this biomechanical factor cannot be altered, how can the risk of cruciate ligament rupture be reduced?
Prevention cuts the risk in half
Leyes answers: “With prevention.
There are studies, especially Norwegian, that are power in handball, which show that specific muscular work reduces the risk of breakage by 50%.
FIFA itself has two specific prevention programs, one for children.
It's called FIFA 11 and there are eleven exercises that lower the risk of you breaking your cruciate a little.
Serratosa points directly to three muscular chains: “Once the risks have been identified, those muscular groups that counteract both knee valgus and anterior displacement of the leg must be worked on.
Above all, it is about those that separate the thigh outwards, the gluteus medius, essential to provide greater stability to the hip and counteract the inward displacement of the knee.
The hamstrings are also very important, which, being knee flexors, will act to hold the legs back.
And finally all those muscles that contribute to greater stability of the pelvis.
These are the muscle groups that help the anterior cruciate ligament the most.”
what the brain says
Guillermo Sánchez, Carolina Marín's physical trainer, who has directed her two recovery processes, assures that reducing the injury to a muscle chain problem is insufficient and incomplete because it does not take into account the other aspects of an athlete's life.
“The most recent avenue of research points to cognitive aspects.
It seems that non-contact crusader breaks come more from forecast errors in the central system than from a purely biomechanical issue.
It is the predictive error of the brain that ultimately breaks the ligament and reaches that valgus.
They see that, for example, because when the cross breaks, that break occurs between 40 and 60 milliseconds after contact with the ground.
But there is a neuromuscular reflex called afferent from the lca [anterior cruciate ligament] that gives you information about what has happened and says that it occurs at 110 milliseconds, but the rupture has already occurred.
So it is not a mechanism of both
feedback
but
feedforward
.
The key point is that the cognitive demands of the game exceed the demands that the athlete can tolerate at the time.
And in the end there are those prediction errors of: Where do I put my foot?
How do I support it?
The body is continually adjusting the body image of what it's doing, without really thinking about it."
Jurdan Mendigutxia, physiotherapist and researcher, worked in the United States, at the Cincinnati Children Hospital, the center in which more scientific publications have been made regarding the prevention and rehabilitation of anterior cruciate ligament injuries in women.
In the United States, he says, there are 200,000 crossover operations a year on women.
“What is being seen is that those people who have less somatosensory information and less activation in the brain are those who are later injured more.
On the contrary, those who are injured lean more on the visual area and less on the sensory one, because as they have operated, the information does not reach the brain and that is what must be promoted during rehabilitation”.
What does that imply?
Mendigutxia says that a change of strategy.
“Before the thought was: you move with a lot of knee valgus, be careful, we are going to try to change you.
Now we ask ourselves: Who makes you move with knee valgus?
Brain?
Well, we are going to use virtual reality to diminish your vision and stimulate the necessary areas of the brain”.
Mendigutxia disagrees that what increases the risk of cruciate tears is the width of the pelvis.
“It is not clear, what is known is that anatomically women have a greater slope of the posterior part of the tibia.
If it is bigger, it makes the femur come out and break the cruciate sooner.
It also affects the intercondylar space, the properties of the ligament and neuromuscular control factors”.
They are, among others, those that Sánchez asks to be taken into account.
“Carolina has broken twice, I would think that she had an altered hamstring and quadriceps ratio the day she broke her knee.
But she had it that day.
The previous day.
The last month.
And two months before.
And this has been happening daily without any problem.
To reduce only to the risk of a break or a re-break coming from a muscular imbalance is to downplay emotional and environmental factors.
Muscle balance is the foundation, but it's just scratching the surface.
If you ask an athlete or Carolina herself why she thinks it broke, she is not going to tell you that it was bad muscularly, that her hamstring did not pull well or that her quadriceps was weak, but that she had slept badly, that she had a very high cognitive and sports stress load”.
González Lago does believe that, if this preventive work is not done, there would be many more ruptures of the cruciate ligament.
And adds Mendigutxia: "They are 90% effective if they are executed two or three times a week and have strength, plyometrics, agility, balance and landings as fundamental elements."
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