Arsenal Medical expert outlines issues Hector Bellerin and Rob Holding face during Arsenal injury return
Hector Bellerin and Rob Holding have had tough roads to recovery at Arsenal.
In the midst of Arsenal's rotten luck with injuries post-lockdown, Mikel Arteta is overseeing the return of two potentially key players from injury nightmares of their own.
Both Hector Bellerin and Rob Holding suffered anterior cruciate ligament injuries in the 2018/19 season. Both returned early in the 2019/20 campaign only to receive unwanted setbacks but now, with the Gunners' defensive corps running thin, the pair have been thrust back into action and with that, has come the expectation to perform.
With Arsenal as a whole off the boil, neither have been immune to criticism. However, with the road to recovery, especially from ACL injuries, not a journey very well known to the public, a better understanding of the troubles each player has faced may help put their situations into perspective.
"There's a conception that when a player is cleared to return, it's like a switch that now they are 100 per cent ready," sports scientist Dr. Rajpal Brar DPT told football.london .
"People ask 'why do they get cleared to play then?' but health is not binary, you're not healthy or unhealthy, it's a spectrum, a process."
For both Bellerin and Holding, there have been roadblocks along that path to becoming more healthy.
The former seemed to be back and ready to help steer Arsenal back into the right direction as one of Unai Emery's five captains, only to suffer a hamstring injury in early December. Upon his return a flare up of a thigh injury in February put further strain on the Spaniard's return.
As for Holding, bruises to his knee in late 2019 as well as the emergence of Shkdoran Mustafi and David Luiz in central defence left him somewhat in the cold pre-lockdown.
Despite these setbacks, what needs to be made clear is that neither are at the stage of their intial recovery times to where they would be considered to be 'back to normal'. Following the three-month layoff and the fixture schedule being condensed so heavily post-lockdown, there may be an adverse effect on the pair.
“What people don’t realise is that the research shows it can take up to two years after an anterior cruciate ligament rupture to see side-to-side symmetry, meaning that the injured leg is equal to the uninjured leg," Brar continued.
“Medically, what they look at is it [the injured leg] within 10 per cent, is it 90 per cent of the uninjured leg? That means that there’s no asymmetry. It could take up to two years to get to that point so it’s an extended process.
“Now with Bellerin and Holding, you have the COVID-19 delay. I thought it actually hurt Bellerin because he was finally getting some consistent games - even though he had a little adductor groin issue which was pretty minor - I thought it really hurt his rhythm and confidence.
"You want consistency of games but you also want them to be somewhat spaced out. Right now the Bundesliga are showing four times the injury rate with soft tissue [muscle, ligament, tendon injuries] so there is inherent increased risk when you have this many games in a shorter timespan. It reminds me of the Christmas period in the Premier League when they have so many games, except in this case it's after being off for three months.
"Whenever you have these quick ramp up times after time off, you're always going to have an increase in injury risk and that's what we're seeing. In Arsenal's case, some of it has been bad luck like with Xhaka but the Mari and Leno injuries are contact injuries with nothing much you could do about them."
Especially in Holding's case, missing out on consistent game time has had a massive effect on his performances during the 2019/20 season. Although he impressed when he first retured to the side in September, playing just five first team games between November and March didn't in the slightest.
His FA Cup performance against Leeds United was the most blatant example that he was off the pace as his decision making on the whole was off and was caught trying to undo errors on multiple occasions.
In that game in particular, the 24-year-old looked as if he was still adjusting to his post-injury body. After such a severe injury and the setbacks on top of that, he wouldn't have the same sensations on the pitch [the feeling in his knee when running or passing, for instance] as he did before the injury.
Although this may seem like more of a physical barrier to overcome, Dr. Brar expresses that it has just as much to do with the mental side of the game as anything else.
"There’s a term called Kinesiophobia [fear of movement] which means whether a player has full confidence back," he adds.
"On the psychological side, one of the last things to come back for players, especially after ACL injuries, is that fear of reinjury. If you have a 50/50 ball is it in the back of your mind ‘should I actually go 100 per cent after this?’ because when you’re healthy, you don’t even think about it.So you definitely need that consistency to get back to 100 per cent."
This viewpoint isn't just coming from dr. Brar's medical standpoint, however, as he himself plays sport and recently had a first-hand experience of dealing with a knee injury and the mental strain it can bring
“It has a significant impact because in the back of your mind, you’re thinking ‘is my knee right’. Especially when you’re in a game," he says.
"It’s one thing if you’re off the pitch and you have a physio telling you that it’s normal but when you go back on in the game and you’re on you have that feeling on your lonesome, of course it will give you some trepidation.
“I had a knee injury recently and I experienced that for the first time and it’s pretty disconcerting. Even knowing what I know, it’s still disconcerting because you think ‘is this normal’ and you have fear so I can’t imagine what it’s like for someone who doesn’t have that understanding so it has to play a part."
Of course, with the sheer competitive nature of professional sport, however, not every player will accept they could be set for an extended period of time away from the game. Players across the world through a variety of sports play through pain to ensure they don't lose their place in the team or to be one of the lucky few that experiences the glory of lifting a trophy.
It's not just the motivation of being part of a winning side that may lead to players wanting to play through pain but also the potential of labels like being 'injury prone' being stuck on them which is where the understanding between player, coach and physio becomes crucial.
"That’s where that relationship is quite critical and I think we see with Arteta compared to Emery is he’s much better at the personal management side and I think that plays into injuries as well," Brar adds.
"Someone else who I see that with is Jurgen Klopp who actually has a background in physiology [a degree in sports science], I [used] to listen to him and think ‘he has a really good insight into medical’ and didn’t know about his background until somebody told me and it all made sense.
“Having that relationship with individuals you trust on the medical side as a coach gives both sides piece of mind. Arteta will trust them to make decisions without him interfering and I'd guess they trust him to listen and not overstep.
"The hardest part of professional sport is the push and pull - you see it a lot in the World Cup - when you have an external pressure from non-medical personnel to let the players play and I think it's important Arteta is understanding that. It shows me he's really trying to change the club."
With the understanding between players, clubs and their medical departments becoming more fluent, that shouldn't stop the media and fans alike trying to have a better understanding of what players may be going through when returning from such severe injuries.
Bellerin and Holding are examples specific to the present day but in the 2020/21 season, Bernd Leno and Calum Chambers will be further along in their journeys back to the pitch and will require the same understanding.
"There's a lack of medical knowledge [among the general public] which is not a negative thing, it's just a reality so it [medical knowledge] exists in a lot of grey area which is tough for fans to understand but even more if you just don't know. That's a big reason why I try to release videos and why I'm on twitter, to try and educate people on that," dr. Brar concludes.
"It's important because the average fan may not fully understand how difficult it can be to come back from long term injuries.
"Bellerin had some very good vlogs about his return and some of the concerns he was having during his rehab and how frustrated he was. There's more access to it now but there's still a big blind-spot that needs to be addressed with fans and the understanding of where a player truly is on the spectrum of 0 to 100 per cent.
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