Manchester United and French international midfielder Paul Pogba has been diagnosed with a “microfissure” in his right foot – or as some outlets have called it a “cracked toe” – that originally manifested during ManU’s Carabao Cup match against Rochdale on 9/25. Pogba then played five days later against Arsenal on 9/30 but responded adversely with ankle pain which led to the medical staff shutting him down after the match.
In this piece, I’ll detail the injury, Pogba’s return timeline, and what to expect moving forward.
If you prefer a video version, I have you covered as well:
The injury
A symptomatic bone microfissure – most likely what’s medically known as a “bone stress reaction” – occurs due to repetitive microtrauma that creates an inflammation (swelling) response at a specific part of the bone and is considered the mildest form of a bone stress injury (BSI). That inflammation is likely why Pogba’s injury was initially thought to be a recurrence or add-on to the ankle injury that he picked up against Southampton in late August.
Additionally, you might think of a “cracked toe” as only pertaining to the far end of the foot but the toe bones – metatarsals – are much longer than most realize. These metatarsals are common sites of stress reactions, especially the 2nd and 3rd metatarsals because they absorb the most stress during the push-off phase of running and jumping.
Bone microtrauma
Normally, any microtrauma that is caused by running, jumping, kicking etc is mitigated by an equal remodeling/adaptation response by the bone. This process is really important because it’s how bone becomes stronger.
It’s the underpinning of a very important principle in orthopedics known as Wolff’s law which states that bone grows and remodels directly in response to the stresses placed upon it.
However, when that ratio of microtrauma to remodeling is thrown off, the microtrauma accumulates and creates a stress reaction in the bone that’s noticeable on MRI. This typically happens after a significant increase in activity quantity and/or intensity, particularly in running and jumping athletes. To that point, the underlying cause for Pogba’s injury could be playing the full 90 minutes vs Rochdale after having missed the previous month due to ankle injury.
Pogba playing vs Arsenal
Even though Pogba had pain and swelling after the Rochdale game, he still played vs Arsenal just five days later. It’s not uncommon that the pain and swelling from a stress reaction subsides very quickly which leads to a quick return without any games missed, with the medical team continuing to monitor the player’s response on a day by day basis.
In line with that process, Pogba almost certainly cleared all pre-match rehab protocols prior to the Arsenal game but when he complained of pain after the match, the medical team shifted their course of care and decided on a more conservative one.
Rehab and return timeline
Rehab: Phase 1
Following the Arsenal game, Pogba was sent to Dubai for warm-weather rehab. His right foot was immobilized for a week to modify weight-bearing on the foot and allow the bone to re-normalize the microtrauma:remodeling ratio I mentioned earlier (don’t tell me you already forgot about that bro).
During this period, Pogba maintained his fitness through lower impact training such as cycling and yoga along with ongoing mobility work.
Rehab: Phase 2
In phase 2, Pogba returned to full weight-bearing and began to gradually ramp up activity quantity and intensity, under careful supervision.
Additionally, the rehab staff may have begun to address biomechanical deficits that could be contributing to increased loading on Pogba’s foot. For example, working with Paul to soften his landing by distributing weight more equally side to side and absorbing more of the force with his upper legs
Lastly, depending on the specific location of the injury, Pogba may also be using custom-fabricated inserts to reduce stress on that part of the foot.
Return to play (RTP) timeline
The return to play (RTP) for stress reactions is highly variable, ranging from days to weeks. After the setback vs Arsenal, it sounds like ManU are being far more conservative with Pogba’s return, with the player potentially missing a total of three to four weeks – one week for phase one followed by two to three weeks of phase 2.
That timeline gives Pogba an outside chance to play against Liverpool on 10/20 but, in my opinion, the risk/reward of bringing him back in that high intensity of a match against an elite, aggressive, high press team tilts far too much towards risk. Accordingly, giving him an extra week and coming back on the 27th vs Norwich makes much more sense.
Risks moving forward
A bone stress reaction when left unchecked, untreated, and not rehabbed appropriately can potentially lead to higher severity bone stress injuries such as stress fractures. It’s that risk which likely led ManU’s medical staff to nip this injury in the bid right now with an extended rehab stint for Pogba.
When he does return – likely starting with shorter spells on the pitch either as a sub or being subbed off early – he’ll continue to be monitored closely on a day to day basis, constantly assessing for tenderness, swelling, and discomfort. It’s a relatively mild injury but something you really want to be proactive about and stay out in front of.
That’s a wrap for this piece. Thanks for reading. My goal is to provide you with in-depth, evidence based, narrative free analysis and you can always find me on IG, Twitter, and YouTube @3CBPerformance and feel free to contact me with any questions.
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