The HIGH ankle sprain.

 

New England Patriots TE Martellus Bennett went down early in Sunday’s game on this blocking play.

The New England fan base held it’s breath — would we ever get to see the powerful triumvirate of a healthy Bennett, Gronkowski, and Brady on the field together? The above replay on this injury isn’t ideal because the injury happens just as the video begins. Bennett’s right foot is caught lying against the turf as his right knee is forced to turn inwards by a Browns linebacker. He then pulls up on his right foot and goes down. This specific injury mechanism where the shin bones rotate inward while the foot rotates outward is classic for a high ankle sprain.

gronkhighankle

Above is a clearer photo of a high ankle sprain. Rob Gronkowski suffered a high ankle sprain to his left foot in the 2012 AFC championship game against Baltimore. You can clearly see his left foot is rotated externally (his instep is stuck against the turf) as a Baltimore player is tackling his left lower leg down to the turf. This causes the foot and shin to rotate in opposite directions and results in a high ankle sprain.

As fans and media, we have been conditioned to hear the words “high ankle sprain” and immediately throw up our hands in frustration over an injury that will surely result in many weeks lost. Fans all over the league felt this way in week 5 – Packers RB Eddie Lacy, Lions DE Ziggy Ansah, Ravens WR Steve Smith Sr, and Rams CB Trumaine Johnson all sustained what looked on film to be high ankle sprains. In week 4, Bears WR Kevin White suffered an extreme variation of the injury where the sprain results in a fibula fracture.

So, why all the hype? What is it about a high ankle sprain that makes it so different than a regular run-of-the-mill ankle sprain? First, the mechanism. A “regular” ankle sprain is usually a stretch of the lateral (outer) ligaments of the ankle caused by the ankle inverting, or turning inwards as shown below:

ankle-sprain

Notice that, while the lateral ligaments of the ankle (the anterior tabofibular [ATFL] and calcaneofibular [CFL] ligaments) are torn, the ligaments that hold the two lower leg bones together (the anterior and posterior tibiofibular ligaments) are still intact. These two important ligaments make up the syndesmosis of the lower leg. Injury to the syndesmosis is called a high ankle sprain. As you can see in the figure below, the syndesmosis is technically above the ankle joint, hence making it a “high” injury. In general, to generate enough force for the syndesmosis to tear you need to not only turn the ankle in or out. Rather, you need significant twisting of the foot and lower leg in opposite directions.

high-ankle-sprain(Image courtesty of royalsocceracademy.com)

The reason that an injury to the syndesmosis can be so significant is that it is very difficult to fully rest these structures. Any time an athlete bears weight on his or her leg, the syndesmosis must withstand a significant amount of force that wants to separate the shin bones from each other. Because of this, athletes with significant high ankle sprain are often initially treated by removing weight from the ankle and supporting it with a tall boot and crutches.

Or…the player can simply hop off the field for a few minutes, slap on some tape, and return to the game. Martellus Bennett did just that. When asked about his ankle after the game, Bennett said,

Oh, man. You know,  $#@* hurts. You lay down for a second, you feel sorry for yourself, then you think about all the people who were counting on you on the field, off the field. Then you kind of find a way to suck it up and go out there and play for those guys…They asked me if I needed a cart, and I’m just like, $#@*, I’m gonna look so weak And I’ve been watching Luke Cage, he’s the bulletproof brother from Marvel. I’m like, what would Luke Cage do right now? He’d get up and keep bouncing around.

Martellus Bennett definitely unearthed his inner super hero. He went back into the game to score 3 touchdowns, a first in his NFL career. In comparison, Steve Smith Sr was in for a few plays after his likely high ankle injury but eventually limped to the sideline in considerable pain. Kevin White will be having surgery this week once the swelling from his injury is down a bit. Why such a wide range of injury and recovery?

As with any injury, there is a range of severity. With a high ankle sprain the syndesmotic ligaments can be stretched, partially torn, one can be torn while the other is intact, both can be torn, or both can be torn and a bone can fracture. This is a pretty big range that can extend from one player running back onto the field to another having surgery and out for a minimum of 3 months. (Another ligament injury that has a similar range of severity and recovery is the shoulder AC joint separation…right, Michael Felger?)

Martellus Bennett has dealt with high ankle sprains before. In 2011 when he was playing for Dallas, Bennett suffered a high ankle sprain. Unlike Sunday, he left the stadium that day in a tall boot and missed the next week’s game. It will be important to watch how Bennett does in practice this week and whether or not he’s seen in the locker room wearing a boot. Swelling and pain could limit his ability to play. While it’s hard to imagine that a player can have the game of his career one week and be unable to dress the next, we have to remember – even superheroes can be more swollen and sore the next day.

lukecage              (Image credit: Marvel comics)

Follow me on Twitter @jessdeede

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