Arsenal's injury issues: why fitness is not black and white

One of the perks perils of being an Arsenal fan is that you get to hear a lot about injuries - recurring ones, major ones, all kinds of injuries. Arsenal seem to have more injuries than any major club, and have been that way for several years now.

Any time there's an injury, there is a flood of discussion about why the injury happened, why all injuries happen, and who is to blame for the injury/injuries.  99.99999999% of that discussion comes from non-medical folks, and 100% of it comes from outside the club, so at best it's wild guesswork and at worst it's affixing vitriolic blame somewhere that it doesn't belong.

In an attempt to help us all understand the medical side of sports a little better, we have enlisted the services of a couple Actual Medical Doctors, and we asked them some questions that might help us direct our discussions  a little better in the future. Before we begin, I cannot stress this aspect of our short series enough, so I'll put it in big font:

THERE ARE VERY IMPORTANT CAVEATS TO WHAT WE ARE ABOUT TO DISCUSS HERE!

Caveat the first: Our first guest is, in fact, a doctor, but in his own words:

being a hospitalist and an internist, orthopedics and sports medicine are not necessarily a strong suit

Caveat the second: We are not attempting to diagnose or solve any specific problem with any specific player.

Caveat the third, and probably most important: We are not attempting to reach a Grand Unified Conclusion about what is wrong with Arsenal's overall fitness/physio regime, nor are we trying to find where to pin blame when things don't go as planned. This is a 10,000 foot overview of medical science, if you will, in an attempt to clear up some of the general misconceptions around sports teams and health issues.

With all that in mind, then, allow me to present to you TSF commenter HoodRiverDuck, the aforementioned hospitalist/internist. He lives about an hour away from me, but I've never met him in person; he graciously agreed to answer our questions, and here are those questions and HRD's answers, unedited except for the occasional paragraph break.

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TSF: In general, how much do muscular injuries stem from overuse and how much can be attributed to bad luck and/or genetics?

HRD:
Smarmy answer A: 74.2% for the former.
Smarmy answer B: Absolutely, yes.

Nonsmarmy answer, in reverse order:

Genetics? You can sum up almost all medical illness by saying one with a genetic predisposition was exposed to the right environmental circumstances. Of course, almost all medical illness also leans pretty strongly towards one of those things or the other. When we are talking about highly trained athletes suffering musculoskeletal injuries, it's always going to essentially be non-genetic. If they had some genetic predisposition to muscle tears, it's hard seeing them get to the peak of their sport despite that.

Now, do some people have more pliable, stretchy cartilages and tendons than others? Sure they do. Illness tends to be on the bad end of a spectrum of normal. Maybe somewhere in that spectrum lies something making it more likely for Jack Wilshere to keep spraining an ankle or Harry Redknapp to keep destroying soccer teams. (Whoops, this is supposed to be the nonsmarmy answer.) But none that I'm aware have been scientifically studied, except for the true disorders like Marfan syndrome and the spectrum of Ehlers-Danlos diseases...to the WebMD, my lay Gooners!

Bad luck? Obviously partially responsible. Especially given the weird bodily contortions produced by chasing a round ball around a grass field while wearing cleats and having eleven guys, some of whom are Ryan Shawcross, try to prevent you from doing so.

Overuse? There's the rub. The thing a manager or a training staff could actually control. A fatigued muscle is more likely to cramp, or fasciculate*, or misfire just at the wrong instant. But there isn't an exam or a scan or a blood test that I'm aware of that'll tell Arsene's staff when Aaron Ramsey's hamstring is about to do so.

*ED. NOTE: fasciculate = twitch

TSF: Is it possible to determine if a person is more predisposed to chronic injuries than another person, or is that something that only reveals itself over time as injuries keep happening?

HRD: Clearly you're getting at Club Diaby Syndrome here. Again, scientifically speaking, I think the answer is the latter. I don't know if little 12-year-old Abou could've had some test to predict his legendary future injury record. But I would say it is very likely that some of his later injuries were in fact caused by former injuries. At the microscopic level, and eventually at the macroscopic level also, healed cartilages or ligaments are never going to look as good as they originally did. Which in practice means they're going to be less able to bear load or recoil in the manner required to to prevent reinjuring themselves, or to prevent some other part of the musculoskeletal system from injuring itself.

TSF: It was mentioned once in TSF's comment section that traumatic injuries can cause muscle injuries later on, as in Aaron Ramsey's case. Is this true, and if so, why is that?

HRD: It seems I keep teasing my answers to upcoming questions. I should really read ahead. Briefly: It depends heavily on the type of trauma. Did Aaron's horrific tibia-fibula fracture portend eventual recurrent hamstring problems? Is the shin bone, in fact, connected to the knee bone? It's hard to say they're unrelated, but even harder to say how much they are related, or more importantly, what to do about that other than the usual rehabilitative process.

TSF: Is there any way to reduce the likelihood of recurring injuries, or is that pursuit nothing but a long game of medical whack-a-mole?

HRD: Let's just say if I were an orthopedist, I would carry a huge, AWESOME rubber mallet in my leather satchel. Disclaiming point of fact, having been certified in internal medicine, I am the complete opposite of an orthopedist. Essentially, they specialize in external medicine.

TSF: If there was one misconception you'd love to clear up around how medical issues in soccer are reported or perceived, what would that be?

Man, there are a LOT. In general, I think the biggest misconception that non-medical people have about medical issues is that they assume a doctor's certainty level is much, much higher than is actually possible. Specific to soccer, my biggest gripe is how quickly they will assign blame to a manager or a training staff for an injury or a group of injuries. (YES, I AM TALKING ABOUT ARSENE WENGER AND ARSENAL HERE, EVERYBODY.) For the nerds: medicine is a heavily Bayesian world. For the normal people: It's a pretty soft science, y'all.

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Thanks, HoodRiverDuck, for taking the time to do this. We'll have another episode of this series coming up in the next week or two. If you're a doctor, particularly a doctor with experience in sports medicine or orthopedics, and you'd like to be asked some hopefully not-inane questions about sports team injuries and how they're dealt with, we'd love to hear from you - get in touch with one of us and we'll talk.