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Sports Medicine and The World Cup: Breaking Down The Science

Episode Overview With Dr. Drew Lansdown away (and reportedly playing golf in Scotland), Brian and Nirav dive deep into the sports medicine landscape of the FIFA World Cup 2026. The episode covers the unique injury patterns in soccer, what surgeons and physicians need to understand about treating elite soccer players, and the injury prevention strategies that have strong data behind them. Key Topics Covered 1. Why Soccer Produces High Rates of Non-Contact Injuries • ACL tears are the defining non-contact injury in soccer ◦ Soccer is the #1 sport played by female athletes — a population with well-established higher ACL tear rates ◦ Quick acceleration, deceleration, and multi-directional cutting movements are intrinsic to the sport ◦ Cognitive load during play (split-second decision-making while in the air) increases landing mechanics risk ◦ Classic example: the Wayne Rooney-type ACL — trying to split a defender while thinking two steps ahead leads to a mis-step • Game structure contributes to higher injury numbers ◦ 11 players per side means more total athletes on the field ◦ Longer games (90 minutes vs. basketball or football quarters) ◦ Combined effect: more player-hours of exposure per match 2. Load Management & the World Cup Context • The World Cup paradox: fewer games per week than top club players are used to ◦ Example: Erling Haaland at Manchester City — club season + qualifiers + Champions League stacks up to more games/week than the World Cup ◦ The bigger concern is cumulative seasonal load, not the World Cup schedule itself • The World Cup is essentially an off-season add-on for elite players ◦ Comparable to asking NBA athletes to play the NBA season and then immediately compete in the Olympics • Travel is likely less of a factor than commonly assumed ◦ Elite clubs already manage heavy international travel; accommodations are often top-tier • Early specialization a compounding factor ◦ Many World Cup players have been playing since age 10–13 with little cross-sport participation, contributing to long-term cumulative load ◦ Notable exception: Norway — athletes there tend to play multiple sports 3. ACL Surgery Considerations for Soccer Players • Graft selection overview ◦ Bone-Patellar Tendon-Bone (BPTB): traditional gold standard — caveat is patella fracture risk with early falls onto the knee ◦ Quad Tendon: recent JBJS meta-analysis showed marginal superiority, but difference not clinically significant; less commonly used in soccer given importance of quad strength ◦ Hamstring ± Lateral Extra-Articular Tenodesis (LAT): widely used in the Premier League, largely driven by the influence of Andy Williams' work with top clubs • Return-to-play timeline ◦ Uniformly 9–12 months regardless of graft choice ◦ Phased rehab: gait & coordination → strength → agility → sport-specific • Key structural differences in elite soccer player care ◦ Academy pipeline provides high-quality early medical access — similar to minor league baseball feeder systems ◦ Bracing: elite soccer players use far fewer post-op braces and return-to-sport braces vs. American football or basketball athletes ◦ Less post-op bracing is not associated with worse outcomes in this population 4. Hamstring Injuries in Soccer • Most common injury type in soccer globally • High-speed sprinting is the primary mechanism ◦ The hamstring functions eccentrically during the late swing phase of sprinting — peak load occurs just before foot strike ◦ The injury moment is often at the point of maximal lengthening under force • Grading and prognosis ◦ Grade 1 (mild strain): return in 1–2 weeks ◦ Grade 2 (partial tear): 3–6 weeks depending on location and extent ◦ Grade 3 (complete rupture or proximal avulsion): potentially surgical; weeks to months • Proximal hamstring avulsions deserve specific attention ◦ Complete proximal avulsions (from the ischial tuberosity) are increasingly managed operatively in athletes ◦ Strong evidence for surgical repair in high-demand athletes who want to return to competitive sport • Nordic hamstring curls: effective prevention tool (discussed later in injury prevention section) 5. Ankle Injuries • Lateral ankle sprains are extremely common in soccer ◦ The ATF (anterior talofibular ligament) is most commonly injured ◦ Mechanism: plantar flexion + inversion, often from landing on another player's foot • The challenge of ankle turf toe and high ankle sprains ◦ Syndesmotic (high ankle) injuries are less common but significantly longer recovery — 6–10+ weeks • World Cup-specific context: artificial turf used in some venues ◦ Turf surfaces change force transmission through the ankle and may increase injury risk compared to natural grass 6. Muscle Cramps: A World Cup Staple • Muscle cramping is ubiquitous in World Cup play — especially in heat/humidity ◦ Not a sign of poor conditioning — even elite players cramp ◦ Players accustomed to cooler climates (Northern Europe) are particularly susceptible • Mechanism: combination of dehydration, electrolyte depletion, and neuromuscular fatigue • Cramping is functionally debilitating even though it is not a structural injury • Treatment/prevention: aggressive electrolyte repletion ◦ Pickle juice: Brian and Nirav discuss — strong evidence in ultra-endurance contexts; electrolyte content is the likely mechanism ◦ Bananas, electrolyte drinks, gels — all have their place ◦ "Anything that repletes electrolytes" will help — athlete preference matters 7. The Theatrics — Diving, Flopping & the Mystery Spray • Why do elite athletes go down so dramatically? ◦ Getting kicked in an unprotected lower extremity genuinely hurts — shin guards are getting smaller (Nirav jokes about a quarter-sized guard his daughter uses) ◦ Foul strategy: falling can draw calls or stop play — gamesmanship is real • The spray — what is it? ◦ Best evidence: a topical cooling spray similar to Icy Hot or ethyl chloride ◦ Temporarily numbs the skin and superficial nerve endings at the contusion site ◦ Not a structural fix — purely symptomatic/neurological effect on acute pain ◦ The shock of impact often wears off naturally — the spray may assist with that transition 8. Injury Prevention — What the Data Actually Shows • FIFA 11+ Program ◦ Developed by FIFA and extensively validated in peer-reviewed literature ◦ Components: core strengthening, glute/hamstring activation, agility drills ◦ Consistent reduction in injury rates by approximately 50% ◦ How to find it: search "FIFA 11+ injury prevention" (not just "FIFA 11" — that returns the video game) ◦ Widely implemented at elite levels; underutilized in youth soccer where practice time is dominated by skill drills and scrimmaging • Nordic Hamstring Curls ◦ Strong and growing evidence for both hamstring injury prevention AND ACL injury risk reduction ◦ Works by strengthening the hamstring eccentrically — addressing the exact mechanism of hamstring strains ◦ Compliance challenge: extraordinarily difficult to perform correctly, especially in older athletes ◦ Brian and Nirav agree: nearly impossible to complete a full set, especially with added weight • Implementation gap: what gets done vs. what works ◦ Youth coaches prioritize the "fun stuff" — drills, scrimmage — over warm-up protocols ◦ 15 minutes of evidence-based warm-up is a hard sell when kids are paying for club-level coaching and want to play Clinical Pearls for Practitioners • Graft selection for soccer players is multifactorial — consider quad strength demands and fall-on-knee risk before defaulting to BPTB • Post-op bracing: the European/Premier League model of minimal bracing in elite soccer players is worth considering — less may be more in highly compliant athletes • Proximal hamstring avulsions in competitive athletes warrant surgical consultation — non-operative outcomes in this population are often unsatisfactory • Cramping ≠ poor conditioning — counseling athletes and families on this distinction is important • FIFA 11+ should be part of any soccer athlete's injury prevention conversation, especially in youth programs • Nordic curls: prescribe them, warn patients they are difficult, and set realistic expectations Quotable Moments "The World Cup paradoxically is actually fewer games per week than a lot of these players are used to." — Dr. Feeley "It's like asking NBA athletes to come in, play the NBA season, and then play in the Olympics." — Dr. Feeley on cumulative load "Our youngest now uses something the size of a quarter... that's her shin guard." — Dr. Pandya on evolving shin guard trends "Nordic curls are almost impossible. That's why you see people doing them." — Dr. Feeley "Anything that repletes electrolytes is going to be beneficial." — Dr. Feeley on cramping management Please subscribe to our podcast at  Apple Podcasts [https://podcasts.apple.com/us/podcast/6-8-weeks-perspectives-on-sports-medicine/id1523779833] Check out our website on Simplecast [https://peds-ortho.simplecast.com/]

The Psychology of Healing

How is healing impacted beyond surgical technique, post-operative physical therapy, and activity goals? Listen to our latest podcast as Dr Brian Feeley breaks down factors you may not think about after surgery. Please subscribe to our podcast at  Apple Podcasts Check out our website on Simplecast

Traveling Fellowships: Vacation or Learning Experience??

A Surgeon Goes to Europe The AOSSM/ESCA Traveling Fellowship Hosts: Dr. Nirav Pandya & Dr. Brian Feeley Guest: Dr. Drew Lansdown Episode Summary Drew Lansdown is back from four weeks abroad — and we have questions. He was selected for the prestigious AOSSM/ESCA Traveling Fellowship, which sent him to six orthopedic centers across Europe before capping the trip at the ESCA annual meeting in Prague. In this episode, Drew tells us what orthopedic sports medicine actually looks like on the other side of the Atlantic — the similarities, the surprises, and what the US could genuinely learn." "What Is the AOSSM/ESCA Traveling Fellowship? The ESCA (European Society for Surgery of the Knee, Shoulder, and Arthroscopy) and AOSSM (American Orthopaedic Society for Sports Medicine) run a competitive exchange fellowship every few years. A small group of American surgeons visits leading European orthopedic centers, attends the ESCA meeting, and builds lasting international connections. AOSSM runs parallel exchanges with APCAS (Asia) and SLARD (South America), and also hosts incoming groups from those regions in return. Applicants apply through AOSSM membership, and selection is competitive. Drew's Itinerary: Amsterdam  Oslo  Brandenburg (outside Berlin)  Milan  Barcelona  Lyon  Prague (ESCA Meeting)" "Key Takeaways from the Episode More similar than different. The biggest surprise? How closely European sports medicine mirrors what's practiced in the US. Senior mentor Kurt Spindler — who did the same fellowship 30 years ago — noted that it felt very different back then. Today, both sides are drawing on the same evidence base and reaching similar clinical conclusions. On stem cells and biologics. After our recent episode on stem cells, Drew asked the European surgeons directly. Their answer: largely the same as ours. Stem cell therapies are considered niche, evidence is lacking, and they're not part of mainstream practice there either. The grass is not greener. OR efficiency that will make you jealous. The Amsterdam center had a five-minute room turnover. Not five minutes with a full crew frantically scrambling — just five minutes, because everyone knows their role and the workflow is seamless. They pre-stage the next case in an adjacent room. For context, we're happy with 20–30 minutes here. Patients expect to stay overnight. In much of Europe, outpatient surgery as we know it doesn't fully exist for orthopedic procedures. ACL reconstruction patients commonly stay one or two nights. Surgeons privately agreed it probably isn't medically necessary — but patient expectation is baked in. Tell a patient they're going home the same day, and they feel like you don't care. Training and mentorship. European medical education: 6 years of medical school straight from high school, followed by a 6-year orthopedic residency. Attendings at these centers often operate together more collaboratively, and junior surgeons remain in a mentorship-like structure for years after completing training — closer to a prolonged chief resident than independent practice. Visiting residents. At several sites, residents from other countries (many from Italy) were spending months training abroad as part of their own program — a built-in international exchange at the trainee level. The Barcelona schedule. OR block time starting at 3 PM, running until 10 PM. The surgeons saw patients or operated at another hospital in the morning, then transitioned to the evening shift. For the OR team, this was simply the norm. Unclear if anyone recommends this for the US." "If Drew Could Practice Anywhere in Europe...Northern Italy. The food and culture of Milan/Lake Como make a compelling argument. (He was encouraged to pursue this fellowship by his very supportive wife Annalise, as evidenced by the Instagram photos from Lake Como that we're still not entirely sure were real.)" Please subscribe to our podcast at  Apple Podcasts [https://podcasts.apple.com/us/podcast/6-8-weeks-perspectives-on-sports-medicine/id1523779833] Check out our website on Simplecast [https://peds-ortho.simplecast.com/]

Blood Flow Restriction: Breaking It All Down With Johnny Owens

What exactly is blood flow restriction therapy? How is it used in rehabilitation? Listen to our latest podcast as we sit down with BFR pioneer Johnny Owens. Please subscribe to our podcast at  Apple Podcasts Check out our website on Simplecast

3 Cases and Lots Of Questions: Decision Making Around ACL Tears, Meniscus Injuries, and Rotator Cuff Pathology

Listen to our latest podcast as Dr Brian Feeley and Dr Nirav Pandya breakdown the decision making that goes into treating ACL tear, meniscus injuries, and rotator cuff pathology in our latest podcast. Please subscribe to our podcast at  Apple Podcasts Check out our website on Simplecast