Inside the ACL clinic that treats Rodri, Real Madrid stars

At the foot of the tallest skyscrapers in the business district of Madrid, you will find the sports clinic that operated on Rodri after he suffered his anterior cruciate ligament (ACL) injury in September.

The Ballon d’Or-winning Manchester City and Spain midfielder had been out for almost the whole season but returned to training earlier this month. On Tuesday, he made his first appearance in eight months in the 3-1 win against Bournemouth.

It has been a long process of recovery that started at the Olympia clinic, which has operated on players from 17 of the 20 clubs in La Liga and has become a go-to for the record 15-time European champions Real Madrid.

Split over three floors and covering 12,000 square metres in Spain’s capital city, Olympia employs more than 50 specialists in sports medicine — but what is most striking about the place is the 255 framed shirts hanging on the walls with dedications and messages of gratitude from different sportsmen and women. With names including Luka Modric, Sergio Ramos and Zinedine Zidane, it could be a Real Madrid hall of fame.

The Athletic is here to see Dr Manuel Leyes, a man whose name has become more familiar in recent years through his involvement in surgeries on high-profile players, particularly when it comes to the dreaded ACL rupture — the previously career-threatening injury that can lead to players missing entire seasons and that Leyes calls the “star surgery” because of how often it happens.

Leyes, 57, was born in the northern Spanish region of Galicia and early in his career, specialised in traumatology — the study and treatment of wounds and injuries caused by accidents or violence.

A fellowship at the Cleveland Clinic Foundation convinced him his future was in sport. While there, he treated basketball and American football players, including the Cleveland Cavaliers’ Zydrunas Ilgauskas and Shawn Kemp, along with the Cleveland Browns’ Orlando Brown and 1999 No 1 NFL draft pick Tim Couch.

More than two decades later, he leads the renowned Olympia project in Madrid, with Rodri one of his more notable recent clients.

“Rodri has a good head on his shoulders and is surrounded by a team that advises him very well,” Leyes tells The Athletic. “He likes to have as much information as possible to make decisions.

“Professional athletes are highly skilled decision-makers because they practise every day.”

Here, Leyes will take us through the stages of an ACL injury — from when it happens to the surgery and rehab that follows — and his team’s approach.

According to Leyes’ data, teams suffer an ACL injury every two seasons on average — but that risk can be mitigated.

“The intensity of the game now is higher and the speed is much faster than when it was played 15 years ago,” Leyes explains.

“You have to protect the player: you reduce the number of games or you increase the number of players in a squad.”

The Swedish national knee ligament registry found the risk of a player suffering an ACL injury was highest at the start of a football match, with 47 per cent of those injuries sustained in the first 30 minutes of games and 24 per cent in the first 15. The same data indicates that ACL injuries occur more in matches than in training.

It also suggests that players who tear their ACL in non-contact situations are more at risk of re-tearing it because that indicates a predisposition to this type of injury.

It is quickly apparent to a player and the medical staff when an ACL injury has occurred.

Dr Leyes outside the clinic (Dr Leyes)

“When the cruciate ruptures, it bleeds,” explains Leyes. “It swells quickly and often the players feel the snap.

“But the big clubs have amazing resources. Real Madrid has a very good MRI area in Valdebebas (their training complex) and the diagnosis is made on match day, even if the knee is very swollen.”

Before the player heads to Olympia for surgery, they must wait hours or days — a period that can also depend on associated injuries — for the swelling to reduce and for their leg to regain some mobility.

“In the initial studies, it was seen that if you operated on the player at a very acute stage of the injury, there was a higher risk of subsequent stiffness,” says Leyes. “The ideal situation is for (the player) to have acceptable mobility.”

When players visit Olympia for surgery, they enter directly through a private garage and go straight up to the consultation room by lift to avoid any waiting media outside.

Leyes carries out the operation with two other senior surgeons from his highly experienced team of Dr Eulogio Martin, Dr Antonio Cruz and Dr Cesar Flores, his business partner.

A typical ACL reconstruction surgery lasts between 60 and 90 minutes and consists of making tunnels in the femur and tibia to insert the new tendon.

As these are high-level athletes, it is not enough to repair the ACL: a new one has to be made. In the case of footballers, Leyes and his team take out the central third of the patellar tendon.

The other thing that Leyes inserts is an extra joint reinforcement (with another tendon) that controls the rotation of the knee and reduces the risk of rupturing the cruciate.

Leyes also offers the player the opportunity to create a WhatsApp group with their agent, club doctors, physiotherapists and physical trainers so that everyone is kept abreast of the process.

“It is very important to have a single means of communication,” Leyes says. “Everything is sent (to the group). A video of the surgery, the progress of the rehabilitation… it works well.

“It is sensitive information, so the player creates it (the group) and he decides who enters. Once the process is closed, the group is closed.”

Rodri has been out since September with his ACL injury (Robbie Jay Barratt – AMA/Getty Images)

The average recovery period for an adult male player is eight months. If he is under 20, the period of absence then goes up to a year because some players are still growing.

Patients rarely require an overnight stay. Once the player has taken fluids and been to the toilet, they are discharged. In the past, the player was hospitalised for several days, but most now leave on the same day.

In the first week of recovery, very little is done while the inflammation and pain go down. For this, the players use cryo-compression machines to cool and ease the pain.

During recovery after ACL reconstruction, it is essential to control pain and swelling in the first few weeks, while working on regaining knee mobility. As the recovery progresses, players improve their range of motion, build up leg muscles and work on stability.

In the more advanced stages, the goal is to regain full strength and improve their tolerance of certain exercises, while continuing strengthening and stabilisation. After three months, the focus should be on specific training for agility, speed and neuromuscular control.

The player has to wait five to six months to make sudden changes of direction. As the player makes tentative steps towards training again, Leyes visits the relevant clubs at their training grounds.

“It has advantages because you normally deal with patients who have very good genetics, they have all the means in the world at their disposal and then they are very eager,” Leyes says. “You don’t have to insist on their recovery.

“For example, Dani Carvajal told me at the start of his rehab, ‘Doctor, I’m at my best’. The truth is that he works very well but you have to take it easy.

“Then there are some disadvantages: you have a bit more pressure, not so much from the player but above all from the environment (around the player), from the representatives, rushing to return to competition.”

Leyes had to tell Carvajal to have patience in his recovery (Angel Martinez/Getty Images)

At Olympia, players can also be treated by top-level physiotherapists and rehab experts who work closely with the doctors and have advanced tools including gravity-free running machines, cryotherapy chambers and specialised swimming pools.

Leyes’ team recommend different rehab programmes tailored to the players’ position. As a centre-back, Eder Militao had to be more reactive in his movement, so he worked on his initial acceleration after surgery. Forwards, such as Villarreal’s Yeremy Pino, have needed to get used to changing direction again when they drive forward.

Patience is needed to avoid a relapse.

“The trend is the opposite of a few years ago, when there were players coming back after four months,” says Leyes. “Now we are delaying it more and more because we see that a lot of them are breaking (down).”

When the player has taken part in full training sessions and just before he starts playing again, the Olympia medical team take into account three parameters to give the definitive green light to return to the pitch: strength, scans and what they call the ‘fear scale’.

“The fear scale correlates with subsequent performance,” says Leyes. “If they score badly, you have to focus more on psychological treatment. When you play, you remember what happened to you.”

The player can complete his long-awaited return to the field of play but that does not mean his recovery is complete. In fact, in the first few months, there are risks.

“It is very important that the return is progressive because the probability of rupturing the cruciate muscle increases with fatigue,” says Leyes. “Normally the level is usually reached in the following season, not in the season of return.

“We are good at getting players back on the pitch but we have to improve on getting them back to their best. It’s really more important that you get back to being the player you were before, (become) just as decisive and that you don’t shorten your career, which happens over time.”

And with that, Leyes returns to the operating theatre.

(Top photo: Dr Leyes operating on a player; courtesy of Olympia Clinic)

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