Real Madrid defender Eder Militao underwent surgery to repair the torn ACL he suffered a few weeks ago, an injury which will force him to miss the remainder of the season. Managing Madrid spoke to Dr. Ayoosh Pareek, MD, Sports Medicine Surgeon at Hospital for Special Surgery (HSS), who delivered some insight into Militao’s injury and the main concerns about his recovery.
Lucas Navarrete: This will be the second ACL tear for Militao (one on each leg). While these injuries appear to be not as career-altering as they were in the past, is the fact that he now has two surgically repaired ACLs a bigger concern than one (or two on the same leg)?
Dr. Ayoosh Pareek: We have learned over the last 10 years that high level athletes face a significant risk for a second ACL injury after an initial injury – this includes repeat injury to the same knee or the contralateral knee (in some research studies up to 20-25% of the time). Having two surgically repaired ACLs—one on each leg—poses a unique set of challenges. From a biomechanical perspective, the symmetry of movement is critical for elite athletes, and both knees now have a history of significant trauma. While modern surgical techniques and rehabilitation allow many athletes to return to their pre-injury performance levels, the cumulative effect of two ACL reconstructions may increase the risk of subsequent injuries though our understanding of that is currently limited. However, recovery and performance outcomes largely depend on the quality of surgery, rehabilitation, and the athlete’s ability to rebuild strength and confidence so our hope is that if the athlete, training staff, and medical staff all work together, we can get the athlete to their pre-injury level – which is always the goal.
What’s the biggest concern for a pro athlete like Militao when recovering from these injuries? Burst? Acceleration? Explosion? Physicality? Mobility and confidence on that repaired leg?
The biggest concern for any athlete recovering from an ACL tear is always the risk of re-injury. Returning too quickly or not addressing critical aspects of rehabilitation can significantly increase the chance of another injury, either to the same knee or the opposite one. Beyond that, regaining explosiveness and neuromuscular control is a primary challenge, especially for athletes like Militao, who rely heavily on their ability to accelerate, decelerate, and change direction rapidly. We know that athletes who are highly explosive sometimes take up to two full years to regain their pre-injury level of explosiveness, even if they return to competition earlier. Balancing this timeline with the need to get an athlete back to play—where inactivity is also not helpful to the athlete or the team—is a delicate process. Neuromuscular control for sport-specific tasks, like cutting and pivoting, is critical and must be trained rigorously in a progressive manner. Mental factors also play a significant role. Confidence in the repaired leg is key, as hesitancy or fear of re-injury can limit an athlete’s ability to fully trust their body. Rehabilitation must address both the physical and psychological aspects to optimize performance and reduce the risk of setbacks.
Why are we seeing these injuries more often in football (soccer) now? Is fatigue/lack of rotation/lack of proper rest a factor in this increase?
It’s not yet completely clear that injury rates—defined as the incidence of injury per player per time played—are actually increasing in football/soccer. However, the absolute number of injuries is rising. We think this is largely because more athletes are participating in the sport and playing for longer durations throughout the year, with more matches and extended seasons. The sheer volume of play exposes athletes to more opportunities for injury. The physical demands of modern football have grown substantially. Players now face intense training schedules and frequent high-stakes matches with less time for recovery. Fatigue can exacerbate injury risk as well, though again, the research remains mixed on this. Another factor is improved detection. Advances in diagnostics and imaging mean we’re identifying injuries that might have gone undetected in the past, contributing to the perception of an increase. Finally, there’s ongoing controversy around playing conditions. Differences in field surfaces—such as artificial turf versus natural grass—may influence injury risk. This is quite a complicated subject to investigate, but we hope to make progress on this in the coming years.