Hey, it’s Raj from 3CB Performance.
Barcelona winger Ousmane Dembele injured his right hamstring - diagnosed as a “complete
rupture of the proximal biceps femoris tendon” - on Monday Feb 3rd, 2020 during the final
stages of recovery from a previous right hamstring injury that has kept him out since November
28th, 2019. The medical team decided this most recent injury required surgery which
took place the following day on Feb 4th, 2020.
In this video, I’ll delve into the injury, surgery, potential underlying causes of Dembele’s
brutal injury-reinjury cycle, and what it all means for his career.
The biceps femoris muscle is one of the three muscles that make up the hamstring group on
the backside of the leg. The biceps femoris has two heads - long and short - with the
former being the most commonly injured hamstring muscle.
The long head begins as a tendon at the ischial tuberosity, widens and flattens into a muscle
belly, and then ends as a tendon at the head of the fibula (bone on the outside of the lower leg).
Dembele’s injury - a “complete rupture of the proximal biceps femoris tendon” - means
the tendon at the near end tore completely off the bone with part of the bone potentially
being chipped off as well, known as an avulsion fracture.
Typically, if the gap - medically termed “displacement” - between the remaining tendon and the tuberosity
is greater than 2mm, surgery is indicated. Dembele underwent surgery the next day so
it’s a safe assumption that’s the case here.
The surgery will reattach the torn tendon to the ischial tuberosity via suture anchors.
The main precaution with this surgery is making sure to protect the sciatic nerve - the largest
nerve in the body - which also runs down the backside of the leg.
The average return to play timeline in elite athletes is around six months but can be as
quick as four months with elite level of care.
However, even once Dembele gets back, he still faces many of the same re-injury risks that
have put him on the brink of his Barcelona career in the first place.
Dembele’s extensive injury history at Barcelona is no secret. This is his ninth injury in
two and a half years, his eighth muscular injury, his fifth overall hamstring injury,
and the third hamstring injury - and most severe - on his right leg in a span of nine
months.
There’s multiple potential reasons for Dembele’s constant injury-reinjury cycle:
The most predictive risk factor of future hamstring injury is by far previous hamstring
injury, with nearly 30% of hamstring injuries recurring - most within the first two weeks
after returning to play - and nearly 3x higher risk for hamstring injury up to a year after
the initial injury.
One potential positive for Dembele with this most recent injury is that there’s potentially
less scar tissue development after surgery compared to the scar tissue that develops
after partial hamstring tears. To that point, Ousmane’s extensive partial tear hamstring
history may have resulted in significant scar tissue build up in his hamstrings leading
to chronically weaker tissue.
Dembele’s positional running demands on the wing and extreme pace both increase his
hamstring injury risk.
Higher running quantity is a hamstring injury risk factor for footballers because running
puts additional stress on the hamstrings as they serve to serve to decelerate the front
leg by contracting while lengthening - known as “eccentric contraction”.
Further, the faster the sprinting speed, the higher the stress on the hamstrings. Accordingly,
sprinters have by far the highest rates of hamstring injuries.
Ousmane playing for arguably the highest profile club in the world in FC Barcelona naturally
leads to higher intensity matches - whether in-season, cup tournaments, Champions League,
and so on. These higher intensity matches are linked to higher risk for hamstring injuries.
There’s some research showing that players of African or aboriginal descent - Dembele
is of mixed Mauritanian & Senagelese descent- have a significantly higher rate and risk
for hamstring tears. We’re not quite sure why but one theory is due to a higher proportion
of type 2 - aka “fast twitch” muscle fibers.
There have been multiple reports that Barcelona’s coaching staff and management were concerned
with Ousmane’ poor sleep and nutrition habits. Both have been linked to increased injury
and reinjury rates with slower recovery across the entire body, let alone for hamstring injuries.
They’ve also been linked to impaired performance.
To help address these lifestyle factors, Dembele’s agent Mousa Sissoko reportedly moved to Barcelona
this past summer.
The body is a series of interdependent chain links so when one link is injured or weakened,
the others have to make up for it which can result in compensatory injuries, particularly
in the lower body.
Dembele’s extensive lower body injury history lends itself to significant compensation and overstress.
The stark reality for a player like Dembele who’s suffered this many muscular, non-contact
injuries in quick succession - and just having suffered his worst one - is that we just don’t
know if he’ll ever fully recover or stay injury free for long enough to reach the potential
of the player we saw at Dortmund.
It’s truly an uphill battle because in addition to the re-injury risks, he’s also dealing
with multiple other factors:
His fitness levels are likely fluctuating due to constantly being in and out of rehab
with huge gaps between games played. Impaired fitness can lead to ramping up activity too
quickly and/or fatigue, both of which are injury risk factors.
The cumulative mental and emotional toll of having to battle through so many injuries
and lonely long rehab stints cannot be understated, especially for a young player who just realized
a dream of playing at Barcelona. We’re seeing more and more research on how a positive vs
negative mindset can impact recovery and rehab outcomes.
Interestingly, former Espanyol player Jacinto Ela wrote an open letter to Dembele and touched
on this very thing, writing :
Kinesiophobia - aka fear of movement or reinjury - is common after serious lower body injuries
and particularly after a series of recurring injuries.
What concerns me most about this injury is that Dembele was simply participating in training
when he felt tightness in the hamstring and that tightness ended up being a complete rupture
of the tendon.
That mismatch between mundane mechanism of injury and severe severity is a huge red flag
that hints at serious underlying deficits.
A significant positive for Dembele is that he’s only 22 years old. This helps for two
key reasons - the first is that players under 25 have less hamstring reinjury risk and secondly,
perhaps more importantly, he has time to address the deficits, get back on the pitch, and get
his career back on track.
I’d love nothing more to sit here and say that I can be optimistic about Dembele’s
career moving forward. Although outcomes for his surgery are very good for elite athletes,
he has so many potential yellow and red flags at play.
I sincerely feel for Ousmane and I truly hope he’s able to put this last setback behind
him, eliminate any thought of external expectations or pressure to return and perform because
as it stands he’s out of contract at Barcelona after next season, view the injury with a
growth mindset of overcoming another challenge, and simply focus all his daily energy & passion
into each step of the rehab process and let the chips fall where they may without any regrets.
That’s a wrap for this video. Thanks for watching. My goal is to provide you with in-depth,
evidence based, narrative free analysis and you can always find me on IG and Twitter @3CBPerformance.
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3CB out.