BEVERLY HILLS, California, July 11 (Reuters) - When soccer players collide in midair, the toll is not always counted in concussions, torn ligaments or twisted ankles.
Sometimes it is a broken nose - a burst of blood, a few minutes of treatment on the touchline, perhaps a protective mask and a swift return to play - that becomes the lasting injury, leaving an athlete struggling to breathe long after the match is over.
It is a risk that Dr. Farhad Ardesh, a Beverly Hills facial plastic and reconstructive surgeon, says remains one of soccer's most underestimated.
"Sometimes a minor injury on the outside can cause major damage on the inside," said Ardesh, who has treated professional athletes, including soccer players.
"You might have the nose that just looks a little swollen or a little crooked, but the inside of the nose actually has a zigzag pattern or an S-shaped deformity that's really affecting this player's breathing."
With several players at the 2026 World Cup competing in protective facial masks after jaw or facial injuries, soccer's hidden trauma has become increasingly visible.
England's Djed Spence, Austria's Stefan Posch and Algeria goalkeeper Luca Zidane have all played with facial protection. Other recent high-profile cases include France's Kylian Mbappe wearing a mask to protect his broken nose at Euro 2024, and Croatian Josko Gvardiol's protective mask at the 2022 World Cup.
To viewers, the mask may appear to be a badge of toughness. To surgeons such as Ardesh, it is often a sign of the effects of trauma.
"The face is very fragile after an injury, whether it's from trauma like getting hit with an elbow or if it's from surgery," said Ardesh. "We want to protect the bone."
'A RIGHT HOOK TO THE FACE'
Ardesh said the facial injuries suffered while playing the beautiful game can resemble those seen in boxing or mixed martial arts.
"People don't think of soccer as being a combat sport," he said. "But you've got elite athletes that are running as fast as humanly possible and jumping really high. When you're talking about an elbow or a shoulder directly to the nose, it's more or less like taking a right hook to the face."
The ball itself is rarely the main cause, he said. More often, injuries come from heads, shoulders, elbows, knees, feet or falls.
The nose is especially vulnerable because of its position and structure.
"The nose is what's sticking out from our faces," Ardesh said. "It's the first thing that's probably going to take any kind of impact."
A nasal fracture can lead to chronic obstruction, a deviated septum, long-term breathing problems, a visibly crooked nose or reconstructive surgery months later if it is not properly evaluated. For elite athletes, Ardesh said, airflow can affect performance.
"If patients are not getting good airflow through their nose, they're not going to be performing at their best," he said.
"The goal of rhinoplasty and septoplasty is not only to improve the aesthetics of the nose but also make sure they're getting the best breathing possible."
CONTROLLING BLEEDING
In the immediate aftermath of a blow, the first steps are controlling bleeding and ruling out more serious injury, leaning forward to prevent blood running down the throat.
Once an athlete reaches a specialist, one urgent concern is septal hematoma - bleeding inside the wall that divides the nose. Left untreated, it can cut off blood flow to cartilage and cause a collapsed, saddle-shaped deformity.
Swelling can make fractures difficult to evaluate in the first hours after impact. If the injury appears more than minor, Ardesh said imaging may be needed to check for orbital, cheekbone or jaw fractures, as well as concussion.
For an isolated nasal fracture, he may wait one to two weeks for swelling to subside before resetting the bones. More definitive surgery, including rhinoplasty or septoplasty, may come three to six months later depending on breathing, appearance and function.
"The goal for these players is that they want to get back on the field," he said. "But we need to assess all the injuries and come up with an individualized plan."
GOALKEEPERS AT HIGHER RISK
Goalkeepers are particularly exposed because they collide with players while challenging for saves.
"They can get elbowed, head-butted or kneed," Ardesh said. "They are at higher risk for taking on a straight-on facial impact."
Still, he does not expect mandatory facial protection to gain broad acceptance in a sport built on speed, vision and comfort. Optional masks for players recovering from injury make more sense, he said.
"These are fighters," Ardesh said of professional players. "They don't want to leave the field."
(Reporting by Rory Carroll in Beverly Hills, California, Editing by Rosalba O'Brien)
