NFL Injury Series- High Ankle Sprain

Thankfully, we are in the midst of a bye week. This is a long deserved break from the rigors of the NFL season. While the players physically rest, as fans, we can mentally rest. This is a trying season and while there are some positives to take away from this season, we all still need a repose. We have seen flashes of potential from QB Josh Allen, the stellar play of a top 10 ranked Bills defense built for long term production, and the emergence of top draft picks growing into their positions. Along with growth, we have seen several moves made to improve and reshape the roster including the cuts of QB Nathan Peterman, WR Terrell Pryor, and LB Ramon Humber. The Bills have also brought back a familiar face in WR Deonte Thompson to give Allen another veteran weapon to stretch the field. As there is no game this week, today’s article will add to the NFL Injury Series with a review of the dreaded high ankle sprain.

The ankle is comprised of the distal end of the tibia which is the medial malleolus and the distal fibula which is the lateral malleolus. These structures articulate with the talus bone which connect the lower leg to the foot. Ligaments connect these bones together to create the ankle as seen below which allow the joint to move in a multitude of directions required for running, jumping, and cutting.


Additional tissues connecting the fibula to the tibia include but not limited to are the syndesmotic ligaments and interosseous membrane. The syndesmotic ligaments comprise of the anterior inferior tibiofibular ligament (ATFL), posterior inferior tibial ligament (PTL), anterior talofibular ligaments, (ATL), posterior talofibular ligament (PTL), and calcaneofibular ligament (CFL) as seen below. These structures connect the tibia and fibula to provide near immovable stability between the two bones so that the muscles that attach to the respective bones can allow the ankle joint to function as intended, prevent excessive movement, and tolerate weight bearing.


In the event of a high ankle sprain, the ligaments that attach the tibia and fibula above the talus become injured as the result of a fixed foot with sudden and forceful rotation to the leg inward, forcing the foot outward. Excessive dorsiflexion or pointing up of the foot can also injure the ankle significantly. These injurious motions do not have to be high speed but strong enough to cause damage. These are both commonly seen in football when bodies are falling on each other and feet are getting caught in the turf or getting hit falling forward, though not limited to those specific activities. To note, this motion does mimic the mechanism for an MCL/ACL injury though positioning of the knee/ankle during the activity affects which structure is injured. 


The reason these injuries are much more severe is due to the demands of the joint. In a low ankle sprain, the outside ligaments are typically injured below the lateral malleolus and make cutting difficult but preserve the plantarflexion/dorsiflexion required for running. Taping/bracing can usually provide the necessary support to complete the activity. In the event of the high ankle sprain to the syndesmotic ligaments, immense demand with the plantarflexion/dorsiflexion motion along with compression during weight bearing is put through the tibia/fibula and talus complex. This creates an instability when attempting to perform walking/running after initial injury. To give a real world example, imagine a wedge being placed into wood to split it, once external pressure is placed on that wedge, the log eventually splits. Turn that upside down in the ankle complex, but that is how motion and compression would affect the connection between the tibia/fibula connection, separating the two bones, leading to greater instability and loss of function in the ankle than a lateral ankle sprain. 

Once this injury occurs, there are a variety of special tests that can help determine the severity of the sprain. These include but are not limited to: anterior drawer test, external rotation test, and squeeze test. These all mimic the mechanism of injury and place stress through the suspected area injured with reproduction of pain noted. Also used is the Ottawa ankle rules in determining injury. The Ottawa ankle rules are a series of tests that involve assessing tenderness in specific parts of the ankle along with the ability to weight bear initially after the injury. This would assist with determining whether there was a suspected fracture or whether further imaging is warranted. As with any other strain or sprain, there are various grades of injury. Grade 1-2 are common and can be treated non-operatively, Grade 3-4 are more severe and surgery is considered in Grade 3 if conservative management fails or surgery is performed with significant damage to the surrounding ligaments along with a fracture in Grade 4. Imaging such as X-Ray and MRI are commonly used to assess the damage of the surrounding ligaments in addition to a physical exam.

Once the extent of the damage has been known, the athlete is typically put in a walking boot with non-weightbearing restrictions put in place to reduce stress on the injured structures and prevent further separation between the tibia and fibula region. With nonoperative conservative management, most recoveries are between 4-8 weeks based on severity of the injury according to research here and here.  Recovery consists of eventual weight bearing progression along with rehab focused on strength, range of motion, proprioception, and pain reduction. Once the athlete can perform activities such as walking/running without pain/limp, single leg hop/calf raise, and all position specific related activities, then the athlete can be cleared to return to sport. As with other sprains, there is always a higher chance to re-injure the ankle, but with proper rehab the first time, this can reduce the likelihood.

The most recent Bills player to suffer a high ankle sprain is DE Shaq Lawson in Week 13 of the 2017 season against the New England Patriots, placing him on IR for the remainder of the season. The Bills have been lucky to avoid these injuries more frequently as a player missing 4-8 weeks could be a huge blow to any team. To note, Buffalo Sabres C Jack Eichel also suffered the same injury back in February of 2018, missing 15 games. Overall, this is also an injury that cannot be truly prevented, but having good situational awareness during play may help a player avoid an unintended collision, leading to this result.

This wraps up another injury seen in the NFL and its implications on a player’s availability. Continue to follow for the latest updates and news coming out of One Bills Drive. Follow Banged Up Bills on Facebook, on Twitter @BangedUpBills, on Reddit u/BangedUpBills, and online at As always, thank you for reading and GO BILLS!

Published by Dr. Trimble

My name is Dr. Kyle Trimble and I am, first and foremost, a Buffalo Bills fan!! When I am not cheering on the Buffalo Bills, I am a Physical Therapist. To give a background on myself; I was born and raised in Erie, PA, moved to Buffalo in 2006 to begin my studies at D'Youville College towards becoming a Physical Therapist at which time I became a devoted Buffalo Bills fan.  I graduated in 2013 with my Doctorate in Physical Therapy and moved home for several years. Moving back to the Buffalo area in 2016, I have gained extensive experience in outpatient orthopedics, skilled nursing, acute care hospital, and home care. Having obtained a significant wealth of knowledge that continues to grow, along with a undying fandom of the Bills, puts me in the unique position to educate my fellow fans about our great team. 
I am currently an injury spotter working with Dr. David Chao, Orthopedic Surgeon @ProFootballDoc based out of San Diego. In this role, I provide real time updates regarding injuries during the game. I hope you enjoy what I publish and I welcome any comments or questions you may have.
Disclaimer: My opinions are my own.  Any thoughts I have on the injuries is based on media reports, my knowledge of the injury, and speculation based on the information currently available.

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