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Neuer’s foot injury: understanding the challenges

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As Manuel Neuer at last returns to full training with the German national team, it is important to understand the complicated nature of his injury and recovery time table.

BOLZANO, ITALY - MAY 24: Goalkeeper Manuel Neuer of Germany controls the ball during the Southern Tyrol Training Camp day two on May 24, 2018 in Bolzano, Italy.
BOLZANO, ITALY - MAY 24: Goalkeeper Manuel Neuer of Germany controls the ball during the Southern Tyrol Training Camp day two on May 24, 2018 in Bolzano, Italy.
Photo by TF-Images/Getty Images

So, the news from the German National Team camp this week is that Joachim Löw is “optimistic” about Manuel Neuer’s participation in the World Cup. This is in line with Jupp Heynckes's comments that Neuer is “not in any pain and is in fantastic condition.” And on top of his time in goal versus the U20s, there even is a video of Neuer training with Die Mannschaft:

(That thing he’s lifting? It’s a SlashPipe!)

It’s easy to see this news and think some version of “finally.” There’s no denying that it has been a heck of a road for Neuer to get here, what with surgeries for a broken metatarsal, “setbacks,” and even a complication of bone marrow edema. Although some fans recently have questioned Bayern’s medical staff on account of a seemingly high incidence of injuries, Neuer’s metatarsal fracture is one case where the nature of the injury itself was particularly tricky and required cautious rehabilitation to keep Neuer safe and minimize his risk of a more serious injury.

What is a metatarsal?

As has been extensively documented, late in the 2016/17 campaign, Neuer fractured a metatarsal in his left foot that required the fixation of a plate to set the break. If you think about the foot as a hand, metatarsals are the bones that run from your wrist to your fingers (so, in the feet, from the “ankle bones” to your toes). Each of the five metatarsals have, essentially, three aspects, the head (the part closest to the toes), the shaft, and the base (the part closest to those ankle bones).

If a person breaks a metatarsal, most often he or she breaks the one associated with the pinky toe, aka the 5th metatarsal, and these are usually classified as either “avulsion” or “Jones” fractures. Very, very rarely does someone break the 1st metatarsal, the one associated with the big toe. Somewhere between these two incident rates is how often someone breaks the 2nd–4th metatarsals. From what we can gather about Neuer’s injury, since it wasn’t termed an avulsion or Jones fracture, and since there wasn’t specific mention of it being a 1st metatarsal fracture, most likely, it seems like it was a fracture of one of the 2nd–4th metatarsals.

Feet are notoriously complicated. There are 26 bones, 33 joints, and over 100 muscles, tendons, and ligaments in a foot. And, like a constantly changing jigsaw puzzle, these muscles, bones, ligaments, and tendons are deeply interrelated and delicately interact—dysfunction in one area can cause a cascade of compensatory actions in the rest of the foot. Under the best of circumstances, metatarsal fractures can result in about 3-month recoveries. If the fracture requires internal fixation (i.e. a plate), the rehab is often longer.

But an even more serious injury occurs if the fracture impacts not the head or shaft of the metatarsal, but the base, where the metatarsal interacts with the tarsal bones. These types of injuries are often called Lisfranc joint fractures, are commonly associated with metatarsal fractures, are extremely serious, and require extensive time to rehabilitate and heal.

But really, why has Neuer taken so long?

Without knowing more than has been published about Neuer’s injury—a metatarsal fracture that required internal fixation—it’s impossible to know exactly where the fracture was, and we do not know the “ins and outs” of Neuer’s daily rehabilitation plan. And, yes, it has been noted that there were a few setbacks during the recovery process, but this is not unusual for orthopedic rehabilitation programs in general.

All of this is to say, feet are complicated. Metatarsal fractures that require internal fixation have a host of potential complicating factors that make the rehabilitation process difficult, require subtle and expert oversight, and necessitate patience.

So, why has Neuer’s recovery taken so long? Because fractured metatarsals can take a long, long time to heal properly. Bottom line, it’s just great to see him back out there again.