Triad Injury, the footballer’s greatest fear

Triad Injury, the footballer’s greatest fear

A triad injury brings together three of the toughest injuries for the footballer, being linked to the knee. In this article, I tell you how it occurs, treatments for recovery and how you can prevent it. Always give your maximum on the pitch, and forget about injuries!

What is a Triad Injury?

A triad injury is a set of 3 injuries that occur in a chain in the knee joint with a common injury mechanism. More specifically, the knee triad, or the O’Donoghue Triad. It covers the following injuries:

  • Ruptured Anterior Cruciate Ligament (ACL)
  • Internal Lateral Ligament Injury (ILI).
  • Internal Meniscus.

Knee joint key in football

Is the footballer’s knee their key joint?

As we discussed in previous articles, the knee is one of the more complex joints and, in turn, more exposed of our body, so sometimes, as with the triad injury, the same injury mechanism ends up damaging different structures that act synergistically in the joint.

How does the triad injury occur?

The mechanism of the triad injury is similar to that of a rupture in the anterior cruciate ligament. As we discussed in the article on this injury, we need to differentiate the contact mechanism from the non-contact mechanism (which is usually the most common).

The most common injury mechanism in this injury occurs when there is an internal rotation of the knee while it is in a valgus position, which produces an excessive turn in the joint, with the foot fixed on the ground, which generates excessive traction in the ligament, impossible to support, resulting in a rupture in its eagerness to stabilise the movement.

In addition, this ligament rupture and excessive twisting also end up scratching the internal lateral ligament, allowing the femur to move over the proximal head of the tibia and causing a pinch that “pinches” the internal meniscus until it ruptures.

How does a triad injury occur?

What is the risk of triad injury to professional players?

The worst kind of injury for a footballer

When we talk about knee injuries, we know that recovery is usually a long process due to the heavy involvement the joint has in a sport like football. As a general rule, an anterior cruciate ligament rupture is usually referred to as the most feared injury, as it’s much more common than the triad, but the latter would be much worse than an ACL rupture.

While it’s true that at the level of recovery the timeframes of a triad and an anterior cruciate ligament are similar, as the other two extra injuries have recovery times generally lower than those of the ACL, the triad will have other repercussions in the knee joint.

Once the player has recovered from the triad, it is not only the anterior cruciate ligament that should be of concern, and where he should focus his prevention work, but he’ll also have two other structures within the knee that have recovered or undergone surgery, whereas in the ACL tear the rest of the structures are intact.

As such, the preventive work on the knee after the triad must be even more exhaustive and carried out conscientiously, as a poorly recovered knee can lead to relapses and even force the player to retire from professional football.

Retrieving treatment

Treatment for recovery from the triad will be very similar to that following an isolated anterior cruciate ligament reconstruction, as the biological timescales for healing of the graft replacing the anterior cruciate ligament will be longer than those for healing of the meniscal suture or recovery of the internal lateral ligament.

Triard Injury Recovery Process

Working alone for a long period of time will be require for the footballer.

After a period of immobilisation, in which alternative work will be carried out in order to lose as little muscle tone as possible, mobility will begin to be gained little by little with physiotherapy work. At the same time, isometric strength exercises (without shortening-stretching of the fibres), joint mobility of all the unaffected joints and aerobic work without impact or mobility of the knee (for example, rowing work with the legs stretched out) will be carried out.

Once mobility is gained, concentric and eccentric strength work will begin, as well as aerobic exercise with knee mobility, such as cycling, walking and going up/down stairs. Joint stability work will be vital throughout the recovery.

The next step will be to start jogging and touching the ball individually and without opposition, as well as performing more specific strength work with a higher level of demand. In addition, coordination exercises will be carried out, increasing the intensity and difficulty progressively.

Finally, we’ll begin specific work on the pitch with long shots, changes of direction and exercises with opposition. We’ll do plyometric work and reaction speed work, and the player will be able to start participating in unopposed group tasks.

When the medical staff deems it appropriate, the player may be progressively incorporated into training, always with the supervision of the entire team in charge of their re-adaptation.

Triad surgery intervention

As we’ve already mentioned, the triad is not an injury in itself, but a set of injuries of different structures, so we’ll treat each structure separately:

  • Anterior cruciate ligament: This ligament, once torn, does not heal or regenerate by itself, so, as a general rule, its treatment will be surgical. The intervention consists of placing a graft from the patient’s own body (generally from the patellar tendon) to replace the torn ligament. This intervention is performed by arthroscopy and small incisions.
  • Internal Meniscus: This is different from the anterior cruciate ligament because, although they coincide in that neither regenerates by itself, it will not be possible to replace the torn meniscus with a new one or with a graft that performs its functions. However, the good news is that, on many occasions, if the tear has been clean and depending on the size of the detached portion, it is possible to suture the torn portion back to the meniscus. If this is not possible, the intervention will consist of removing the detached pieces of meniscus so that they don’t block the joint and cause new problems.
  • Internal Lateral Ligament: In most cases, the injury to this ligament within the triad is usually a partial tear, although it is possible for it to rupture completely. Treatment is usually conservative, with surgical intervention being rare.

Complications of the injury

Any injury is likely to be complicated if we don’t carry out a correct recovery and a thorough subsequent readjustment, meaning a serious injury such as the triad, without a doubt, can lead to a lot of complications if the recovery isn’t adequate and not supervised by a multidisciplinary team of professionals.
Triad Injury Prevention in Football

When several structures are damaged, as we have already mentioned, the chances of complications increases, as there are several components to control at the same time.

On the one hand, like any surgical intervention, both the reconstruction of the anterior cruciate ligament and the suture of the meniscus run the risk of becoming infected, although with proper care this shouldn’t be a worry.

Alongside this, we’ll have to focus on two main aspects:

  • Don’t try to push deadlines. To run, we must first learn to walk. If we try to do activities for which our knee is not ready, it’s very likely some of the structures we’re trying to recover will be damaged again.
  • Constancy: recovery from a triad injury is a long-distance race, so we need to carry out exhaustive and conscientious work every day, following the programming of our physiotherapist and our re-adaptor at all times.

Prevention of a triad injury

It will depend on good knee stability, as well as the correct functioning of all its structures, as a chain is only as strong as its weakest link.

Because of this, we must pay close attention to joint stability work, both on its own in the gym and with sport-specific movements on the pitch.

In addition, we need to ensure the inter-muscular coordination of all muscles involved in the stability of this joint is perfect, since an asynchrony of them can lead, for example, to that dreaded knee injury that leads to the injury we are trying to avoid.

Within these muscles, we should focus on the activation of the gluteus medius (as it’ll prevent the valgus), on the coordination between the hamstrings and quadriceps as well as the coordination between the adductors and abductors.

Bibliographic Sources consulted:

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Review of The Triad Injury in Football

How it happens - 100%

Treatments - 100%

Surgery - 100%

Prevention of injury - 100%


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About Carlos Gallardo
Carlos Gallardo
Carlos Gallardo, in addition to working as a youth team trainer for Rayo Vallecano of Madrid, is passionate about scientific dissemination.
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