As the U.S. men's national team heads into its match against Portugal on Sunday, there is still some question as to just how much Clint Dempsey will be affected by the broken nose he suffered in the Americans' World Cup opener.
In that match last week, a 2-1 win for the USMNT, Dempsey took a shin to the face from Ghana defender John Boye. The medical team immediately responded, working to control the bleeding and evaluating the severity of his injury. Dempsey was escorted off the field for further examination, but eventually returned to the match.
Dempsey's injury may not fully heal until after the World Cup is over, but each day allows for some functional improvement. Decreasing swelling in the area helps with discomfort and breathing, so targeting inflammation is the priority. Improved breathing will also allow Dempsey to sleep better, equally critical in enabling him to be fit for competition.
So how effective can Dempsey be for the U.S. just six days after the injury? And what risks may he face by playing so soon?
Beginning with the basics, breathing will likely be a challenge. After Monday's match, Dempsey said he had difficulty breathing, and later told ESPN's Jeremy Schaap he could only breathe out of one nostril as recently as Thursday. And that's just breathing at rest.
Running nonstop -- as soccer players are required to do during matches -- increases the body's demand for oxygen. One of the consequences of a nasal fracture is inflammation and swelling in the area, effectively obstructing the nasal passages. Clogging of these passages makes it difficult to breathe through the nose, and that can translate into difficulty achieving adequate oxygen exchange (the body's trading out of carbon dioxide for incoming oxygen) for an athlete in high-demand cardiovascular activity.
As long as the swelling persists, so will the clogging. Inadequate oxygen exchange will make it difficult for an athlete to perform at the level to which he is accustomed. Simply put, Dempsey may struggle to keep up through the match if his breathing is significantly compromised due to swelling.
ESPN soccer analyst Taylor Twellman broke his nose, orbital bone (the bone that forms the eye socket), sinus bone (bone of the skull) and simultaneously sustained a concussion in 2003 while playing with the MLS' New England Revolution. When Twellman returned to play a couple of weeks after the injury, he was not able to breathe normally. "I had about 80 percent of my normal airflow," Twellman recalled.
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As if the challenges of running up and down the pitch weren't enough to stress Dempsey's impaired nasal airway, the weather will also be a factor Sunday in the tropical climate of Manaus. Humid conditions can make it difficult for an athlete's sweat to evaporate, particularly in hot temperatures, impeding the body's self-cooling mechanism and potentially resulting in dehydration and cramping.
Humid air, however, can sometimes be a benefit for someone with a nasal injury. As was visually evident with Dempsey's injury Monday, a broken nose can result in substantial bleeding. Unfortunately, the nasal passages are not an area where clots form particularly well, meaning they bleed more easily. Hot and dry conditions can cause weak clots to crack, resulting in repeated bloody noses and associated swelling. The moisture present in humid conditions may actually protect the nasal passages to some degree.
Twellman had a different experience; the humidity compounded the discomfort he felt upon his initial return to play. "It felt like there was an intense pressure in my head," Twellman said. He noted that his injury and Dempsey's were not identical and that some of the other components involved in his case may have contributed to his symptoms. Still, Twellman expects the hot and humid weather conditions to ultimately make it more difficult for Dempsey to run. Given that any blockage of Dempsey's nasal airways will not likely allow him to operate at maximum efficiency, it remains to be seen just how hard Dempsey can go, especially in a hot, humid setting.
There is also Dempsey's potential for contact during play. While the exact mechanism of his injury is not likely to be replicated, he is certainly bound to incur some contact. Whether there is direct contact via a header or with another player when challenged, Dempsey's chances of going through an entire match without some form of contact to the head are slim. Even if he doesn't take a direct blow to his damaged nasal area, any force to the general area could jar the injury site and at the very least cause increased discomfort. A scarier scenario for Dempsey would be a direct blow to an unprotected face, which brings the potential of incurring further pain or deformity to his nose, or simply sparking more nosebleeds.
If Dempsey were not an elite athlete playing in the biggest tournament of his sport, the recommendation would likely be to avoid contact for several weeks. In the absence of avoiding all contact, a face shield or mask provides some protection; but some players prefer to play without a mask, even if it means exposing the vulnerable area. In fact, Schaap reported Thursday that Dempsey probably won't wear a mask against Portugal:
Clint Dempsey says he probably won't wear a mask against Portugal to protect broken nose. Has a nice bright shiner too.- Jeremy Schaap (@JeremySchaap) June 19, 2014
Dr. Riley Williams, an orthopedic surgeon at Hospital for Special Surgery in New York and team physician for the New York Red Bulls (MLS) and Brooklyn Nets, has extensive experience with players in both sports wearing masks following similar injuries. Williams said the shield affords the athlete some protection, but acknowledges there is an adjustment required to get comfortable playing with it. He said the biggest issue for most athletes who wear a mask is humidity and sweat causing the mask to fog up.
"You can use a mist similar to what is used with underwater and ski goggles to help clear the mask," Williams said, "but it is a problem."
"It would take only about 20 minutes before the mask would fog up on me when I tried it in training," Twellman said, noting that it was enough of a problem for him to decide to play without it.
Another issue for some athletes who wear a mask is infringement on their peripheral vision. Teresa Schuemann, a board-certified sports physical therapist and athletic trainer who works with a range of extreme and endurance athletes, notes that while masks do protect against direct blows, some athletes find they hinder their ability to anticipate contact.
"If a soccer player's peripheral vision is impaired, he might not be able to see someone coming in to challenge him as early," Schuemann said. "In that regard, he may actually be somewhat susceptible to more contact."
In Dempsey's case, since he reportedly has no associated skull fractures, Williams points out that the mask could be constructed so that the eye holes are somewhat larger to help minimize any visual constraints. Some athletes Williams has treated feel more confident returning to play with the mask, knowing there is a layer of protection between their face and potential contact, while it makes no difference for others.
In the end, it comes down to Dempsey's preference.
"It's like putting on a pair of shoes and seeing whether they fit," Williams said. "You try out the mask in training, see how you feel in it, then make the decision."
Dempsey is expected to take the field Sunday, even at less than 100 percent. The hope is that he can perform well enough to present a threat to Portugal while not suffering any form of setback.
Then everyone, including Dempsey, could breathe a little easier.