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When might Nicolas Lodeiro and Stefan Frei return?

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Our favorite “realdocfakename” gives his prognosis — from a distance — and thinks we’ll be waiting several months, at least.

MLS: Atlanta United FC at Seattle Sounders FC Jennifer Buchanan-USA TODAY Sports

Up front, I want to be clear that although I am a practicing physician in a Seattle hospital I have no direct knowledge of the players’ conditions, treatment, or prognosis. Some of you may recall this same disclaimer when I accurately prognosticated Clint Dempsey’s arrhythmia, so with that in mind let’s gaze into the crystal ball together.

First up, Stefan Frei. He had a knee injury on May 12 that he described as “a few tears, but nothing important.” After watching replays of the injury and studying the mechanism and angles I suspect it was a minor MCL tear, possibly with medial meniscus involvement. That would have put him on track for a 3-6 week return to activity without restrictions. Unfortunately, on May 28, head coach Brian Schmetzer informed us that Frei had a blood clot which changed his timeline to an indefinite one. Fancy doctor talk for a blood clot is a thrombosis, so our options are a superficial or a deep venous thrombosis. A superficial thrombosis (smaller veins, closer to the surface) wouldn’t change his timeline to return, so therefore it must be a deep venous thrombosis (DVT for short).

DVTs are, with only rare exceptions that wouldn’t apply here, treated with anticoagulation. Fortunately, modern anticoagulants are safer than older ones in terms of bleeding risk, and don’t require frequent blood tests for monitoring. They do, of course, prohibit contact sports since they would place a player at increased risk for symptomatic bruising, or worse, internal bleeding. Following an orthopedic injury, we would consider a DVT “provoked,” as opposed to one that just happened without any clear trigger. For a first-time provoked DVT the minimum duration of recovery is three months. Anything less than that is associated with an increased risk of recurrence. Occasionally there are times to extend the treatment to six months, but they are unlikely to apply in this case. Presumably, Frei would be able to maintain general fitness and participate in limiting training, but wouldn’t be able to do much diving or full-contact work. So could we see him back in time for the Aug. 29 match against Portland (3 months plus 1 day from Schmetzer’s presser)? Possibly, but I suspect Sept. 11 versus Minnesota is more likely.

Now we turn to Nico Lodeiro, for whom the outlook is appreciably hazier. Here’s what we do know: Nico hasn’t played since the May 2 match versus the Galaxy, and up until the day before the Timbers match on May 9 we all thought he’d be playing in that one, too. Then he was off the roster with “knee pain” and “inflammation”, but was termed day-to-day. Lagerwey initially said Lodeiro was “recovering” but then Schmetzer updated a few days later on May 18, saying that “it’s not looking great” and they’d be considering surgery. Cut to the May 28 press conference confirming Lodeiro had undergone surgery at some point earlier that week.

So what would cause inflammation that may be amenable to relative rest and therapy but would ultimately end up needing surgery? There’s really only one thing that fits that description in this case, and that’s a meniscal injury.

First off, unless the damage resulted in significant symptoms that weren’t improving without surgery they wouldn’t be proceeding to surgery. In the past the Sounders, with the notable exception of Jordan Morris, had their surgeries done by his father, Dr. Michael Morris. Dr. Morris has recently handed over the reins to Dr. Nigel Sparks. How do I know this? Because I was scheduled to see Dr. Morris for my own ACL tear a few months ago, and my care transitioned to Dr. Sparks, and while I was there I asked if he’d be “the guy” moving forward for the Sounders. So how’d my surgery go, you ask, anxiously awaiting a first-hand verdict? I can’t tell you because I didn’t have one. He walked me through the details of my MRI and symptoms as well as the evidence in the medical literature about my specific type of case and recommended avoiding surgery altogether. Granted I’m not an elite athlete, as my pub league performance would show, but it was very clear that he’s not the type of surgeon to operate unless it’s truly indicated as the best next step. All of the medical literature supports this approach to an injury like Nico’s as well, so it was very reasonable to give him a chance to avoid surgery and return to play sooner.

Alas, here we are. There’s no way to know the extent of it in terms of complexity of the damage or the details of the surgery, so let’s look at the range of possibilities. Depending on the nature of the injury they would pursue either a meniscal repair or, if not amenable to repair, a partial meniscectomy (partial removal). Partial meniscectomies are generally less likely to require reoperation, the plurality of which occur in the 4-10-year range. However, long-term outcomes of symptoms at 10 years favor repair.

So which one did Nico have? There’s no way to know unless the team tells us, and they probably won’t (unless Nico volunteers the information), but the return timeline is similar for either one. Standard initial rehabilitation postoperatively is a six-week program aiming for a 90-degree knee bend by six weeks. It doesn’t take a doctor to know that if you can only bend your knee to form a right angle you probably aren’t ready to take to the pitch. So what does the evidence show the real timeline is?

Promise not to shoot the messenger?

No, really, you promise?

Elite athletes undergoing meniscal surgery ranged from 3-8 months before returning to the same competitive level of sports, with an average of 5.6 months. A review of several studies that were not limited to elite athletes put the average at 4.3 months, but Nico is nothing if not elite. So where’s that put his return to the pitch? Likely about five months out, give or take a few weeks, which means (I assure you I’m wincing as I write this) they’re likely to save him for the playoffs rather than risk returning too early.

You promised not to shoot the messenger, remember?

Let’s hope I’m wrong and we see him back sooner, but like I said in my Dempsey articles — as both a physician and a fan, I wish him the best of health, as I know we all do.