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The Worst Kind of Ankle Sprain by Dr. Sean Sullivan, PT, DPT – Grand Central

Week 4 of the NFL season just concluded on Monday night following the Kansas City Chiefs last second win over the Washington Redskins.  As with just about every week of NFL games comes a host of injuries to key players on contending teams, often times of the season ending variety.  

Rookie running back Chris Carson of the Seattle Seahawks suffered a season ending left leg injury during the Seahawks win over the Colts on Sunday night.  What was originally diagnosed as a fracture of his left lower leg turned out to be more severe.  In addition to the fracture that he suffered in his fibula, Carson suffered a severe syndesmosis tear otherwise known as a “High Ankle Sprain”.  

The syndesmosis is a series of ligaments that connect the ends of the two lower leg bones, the tibia and the fibula.  A tear of one of these ligaments is a common injury in American football and is generally caused when the athlete’s foot/ankle is pushed into extreme external rotation.  It can also be caused by a blow to the lateral aspect of the knee/lower leg with the foot planted which causes the syndesmosis to be over stretched which is what happened in Carson’s case as seen in the picture below.

The  words “High ankle sprain” are words an athlete never wants to hear.  Unlike a typical lateral ankle sprain which is a tear of one of the lateral ankle ligaments, a syndesmosis tear takes more time to heal.  If there is a disruption of the any of the syndesmosis ligaments, these ligaments are stressed any time the athlete tries to bear weight on that limb as the athlete’s body weight and gravity put stress through the lower leg and tries to separate the tibia and fibula.  This is the primary reason why recovery from a high ankle sprain can take longer to heal and are prone to reoccurrence. 

MRIs are the gold standard for diagnosing a high ankle sprain.  Depending on the grade of the tear, a patient may or may not be instructed to bear weight following the injury.   Upon imaging, if there is no widening of the space between the tibia/fibula, the fracture is considered stable and are treated conservatively with rest/rehab and can weight bear as tolerated.  If there is mild widening of less than 4cm, then the athlete is generally immobilized in a walking boot.   If there is significant widening of the mortise of greater than 4cm, this will require surgical treatment which unfortunately is what will end Carson’s season.  Following surgery, Carson will likely be immobilized in a plaster cast for 2 weeks and transferred to a cast boot for another 4-6 weeks during which he will be non weight bearing to avoid stress to the healing fracture/ligaments.


From Playing Hurt To Surgery: Veldheer's Triceps & Taveras' Ankle

Left tackle Jared Veldheer of the Oakland Raiders is undergoing surgery to repair his partially torn triceps tendon. What never ceases to amaze is that though the injury caused the player sufficient pain to seek an MRI, he continued to play when the initial radiology report was negative.

In other words, pain + loss of function + no findings on MRI = pretend nothing is awry. Let’s get real here – it was preseason, not playoffs. The only positive thing to come out of Veldheer playing through his symptoms is that persistent pain motivated him to get a second MRI, which revealed the tear. Thus the equation changed, at least this time around.

Like Ray Lewis and Justin Smith – who recently had surgery to repair partial triceps tears – it seems prudent for Veldheer to forego an attempt at conservative management in an effort to both hasten and assure recovery.

By continuing to play until his diagnosis was official, Veldheer risked his partial tear becoming a complete rupture. That would have resulted in a more involved surgical procedure and a more extended recovery time. Justin Smith of the 49ers took that calculated risk when he opted to play through the Super Bowl – with what was reportedly a 50% tear – before undergoing surgery last February (Smith’s injury occurred in December).

Anatomy & Mechanism of Injury

The triceps muscle group (view image detail) is comprised of three distinct muscles in the back of the upper arm. All originate in different places but converge into one tendon that attaches at the elbow to the uppermost portion of the ulna – the larger of two bones in the forearm. The triceps primary role is to extend (straighten) the elbow.

In football, a player contracts his triceps when blocking or pushing an opponent. If impact causes sudden stretching of the tissue by forcefully bending the elbow while the triceps are active and in a shortened position, tears may result.

If a tear pulls off a portion of the bone where the tendon attaches, it is called an avulsion. In the case of a complete rupture, the triceps muscle retracts because there is nothing to anchor it to its attachment. Immediate surgery is required in order to have the best possible outcome. In the case of a non-operative partial tear, full healing may take up to a year and also depends on the extent of the injury. As after most soft tissue injuries, the involved area may never be the same. There are no guarantees.

Healing of the soft tissues must be sufficient before the surrounding muscles are strengthened. After triceps surgery, rehab also focuses on restoring full mobility at the elbow as well flexibility and strength throughout the extremity.

Similar But Different – Oscar Taveras

One of the baseball’s top prospects, Cardinals’ outfielder Oscar Taveras, will reportedly have ankle surgery this week. Taveras continued to perform well after sustaining a high ankle sprain in May, until symptoms forced him from the Triple-A lineup. He played in only one game after June 23rd while focusing on rehab to avoid surgery.

A high ankle sprain is a tear – ranging from minimal to partial or complete – of the ligaments that connect the two bones of the lower leg just above the ankle joint. Disruption of these ligaments creates instability.

Might Taveras have avoided surgery had he managed his condition conservatively from the outset? We can only speculate. However, with post-injury stats that kept him running the bases – even stealing a few in the process – it seems that he didn’t do himself any favors. Why would the Cardinals organization risk the health of a player who had risen from Baseball America’s third best prospect in the pre-season to their second best in by midseason? It doesn’t compute for me. Clearly, playing hurt might have caused Taveras further injury – not only to his ankle, but to any number of muscles weakened by his injury, those forced to compensate or to joints sustaining undue forces due to altered mechanics. The kid is fortunate the only thing requiring surgery now is his ankle.

Follow Abby Sims on Twitter @abcsims.


Rob Gronkowski: Back Under The Knife

Rob Gronkowski, 24-year-old New England Patriot tight end, is scheduled to undergo back surgery tomorrow to address chronic back pain. It will be his seventh surgery, and the second to his back, the first, having been a microdiscectomy, performed in 2009 while still a student at Arizona. This procedure is generally performed to decompress a nerve in the low back in order to relieve nerve pain that radiates to one or both of the lower extremities.

The specific nature of tomorrow’s procedure has not been disclosed, though Brett Logiurato of reported that a recent MRI revealed damage to a disc other than the already injured one that had supposedly caused Gronkowski’s distress last season.

Gronkowski underwent his first surgery as a pro in 2010. It was an arthroscopic procedure to repair ligaments torn when he sustained a left high ankle sprain in the AFC Championship game in 2012. A high ankle sprain is a tear – graded from 1 being minimal, to 3, a complete rupture – of the ligaments that connect the bones of the lower leg just above

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the ankle joint. Naturally, Gronkowski played in the Super Bowl anyway, though at limited capacity, despite the injury occurring two weeks prior. Only he and his inner circle know if he might have avoided surgery had he remained off the field and party circuit.

More recently, Gronkowski underwent a series of four procedures to address his twice-fractured left forearm, and the infection that was discovered to be impeding his recovery after the second surgery. After the initial fracture and surgery, which occurred on November 18th, Gronkowski missed only five games before re-fracturing the arm, though reportedly in a different place; this time it was at the end of the plate that had been inserted to stabilize the original fracture. His second forearm surgery took place on January 14th, and the third surgery was in late February to address the subsequent infection. The most recent procedure, performed on May 21st was to remove the hardware that had been installed. Each time, his recovery began anew. The good news was that Gronkowski’s infection has finally been pronounced cured. Now, on to the next


Speculation as to when Gronkowski is likely to make his 2013 debut has varied widely. Realistically speaking, it would be unwise to rush his back rehab to the point that he is participating in football activities before three months time, even if he is progressing without complications. For normal humans that timetable would be even more extended. Significantly. This means the tight end would not be competing before the four-month mark, though a more accelerated scenario would not surprise me. It just doesn’t seem worth the risk to rush him back out there only to regret it later because his pain returns or he suffers another injury. The Patriots aren’t big on sharing details, so real assessments of Gronkowski’s post-op progress will likely remain a mystery until he is back on the field. His initial time off to allow his body’s healing response its natural course – as well as the resolution of all symptoms – will guide the nature of that progress, ultimately setting the stage for his return.

Follow Abby Sims on Twitter @abcsims.