NFL Injury Series- High Ankle Sprain

Read the latest article in the NFL Injury Series on High Ankle Sprains.

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.

Credit: loptonline.com

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.

Credit: http://www.premierortho.com

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. 

Credit: physioworks.au

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 http://www.bangedupbills.com. As always, thank you for reading and GO BILLS!

Cordy Glenn-Perpetually Injured

Analyzing/speculating on the lingering ankle injury and how it impacts Glenn’s performance

Cordy Glenn injured his ankle in the preseason of 2016 and has been dealing with the injury ever since. Due to the rigors of the NFL schedule, it is common to deal with nagging injuries that never fully heal during the season. However, due to the Bills ongoing playoff drought, Glenn has not seen the post season since joining the team which means that Glenn has extra time to rehab his ankle. It has been nearly a year since his original injury and yet he still has not returned to full health according to reports. High ankle sprains can fully heal without complication typically, but in Glenn’s case, it continues to be an ongoing issue.

Usually, high ankle sprains require 6 weeks to heal, but can take longer depending on the severity of the sprain. A sprain occurs when the ligaments that stabilizes the connections between the bones becomes damaged which results in instability and an inability of the joint to function properly. In the case of a high ankle sprain, the top of the fibula, the bone that connects on the outside part of the leg near the knee to the tibia via the syndesmotic ligaments, becomes damaged. This is due to stress being placed on the outside part of the ankle, higher than where an individual would roll the foot under during a true ankle sprain. Stresses at a higher level either forces the higher portion of the fibula to pull away from the tibia, causing a sprain. If the foot is fixed into place and the force is great enough, the fibula can break. These forces during the injury are typically seen as external rotation, also known as outward twisting of the foot. Considering the movement of the guard position, plus the 300 lb. bodies falling on top of each other into a massive heap explains why he injured the ankle in the first place. Glenn was placed in a walking boot to stabilize the initial injury and appeared to heal enough to start Week 1 of the NFL season. Glenn then re-injured it during the season opener which caused him to miss the next 3 games. Most likely Glenn originally sustained a Grade 2 injury leading him to sit out the preseason, re-aggravating the injury to a possible Grade 3 later on. Glenn was able to play the rest of the season, missing several games, but clearly not at 100%.

With Grade 3 sprains, the presentation is where the ligament has ruptured, in which the attachment has completely torn or has become so damaged that it can no longer provide effective support. If Glenn did sustain a Grade 3 sprain, surgery is usually recommended, though not always a given. There has been no reports out stating that Glenn had surgery to stabilize the ankle, but considering he is still dealing with the injury, it is quite possible it was not publicly disclosed. The healing time can be anywhere from 3 to 6 months depending on severity of injury. Considering that the Bills season ended at the end of December and that he was not a full participant for OTA’s, the timeline would fit as to why he is not at full health.

Another possibility is that Glenn may also be dealing with chronic ankle instability. This is the result of a recurrent injury leading to deficits in posture control, proprioception, muscle reaction time, and strength leading to a delayed recovery time. This is also more likely due to the demands of the offensive lineman position. Most actions require strategic blocking performing lateral shifting, re-positioning his stance, and driving forward to maintain balance and power required for the position. Rehab for this involves significant focus on balance retraining on the involved foot, progressive loading, and bracing.

Based on the available reports published, it is possible that it is either one of the two scenarios. Both have positive outcomes, but does explain why Glenn is not at 100%. As of August 4th, Glenn is still continuing to deal with potentially the same issues. He has been held out of practice, citing “foot soreness”. It was reported that he went to Charlotte, NC to see Dr. Robert Anderson, a nationally known physician specializing in foot and ankle injuries. Glenn has since returned to practice since the evaluation. While this is continually frustrating being a Bills fan; as a professional, I would rather have the athlete ensure that they are at 100%. At this level, it is not wise to ignore nagging pain, soreness, or small injuries that can lead to further complications down the line. Expect him to be limited in the preseason so as not to aggravate the healing injury. Ideally, Glenn returns to full health for Week 1 and stay healthy to provide effective blocking for the offense to perform at its best.

Continue to check back for regular updates and as always, thank you for reading. Follow me on @kyletrimble88@gmail.com on Twitter for the latest updates. Thank you and GO BILLS!

Week 10 Injury Breakdown- Saints

Analyzing the Bills injury report including Glenn and Jones ruled out and how the rest of the report looks.

With today being Veteran’s Day, I would like to start this post off by thanking our nation’s veterans. You are the reason we are free, you are the reason we are able to enjoy our lives and watch football, you are the embodiment of this great nation. There can never be enough thanks for what you have sacrificed personally; with your family and friends; and for those no longer with us, their lives. As I grow older, I have come to realize and respect every day the efforts our veterans have put forth in order for the United States to be who they are. Thank you for your service, we as a nation are forever indebted.

Going into the showdown with the New Orleans Saints, the Bills were looking to get healthy and contend with their best talent out on the field. However, the injury report is looking a little longer from the beginning of the week with some of the key starters out for Sunday’s game. Today’s post will explain why the injury report isn’t sunshine and rainbows and the impact it will have on the game.

Already ruled out is OT Cordy Glenn and WR Zay Jones. Glenn has already missed some time this season to his forever injured ankle. I had detailed what I believe is going on during training camp and I believe this is an aggravation of this issue. If you would like to read up on more, please check out the article here; my opinion has not changed.

WR Zay Jones is out due to a newly diagnosed ankle injury. Yes, he injured his knee in the Jets game, that’s a fact. But as a result of the knee hyperextending, I believe that he suffered a high ankle sprain due to the excess force from the knee injury itself. The reason for this injury has been greatly detailed in my previous article and is well worth your time. As for return to play, until more is known, this is murky at best. A mild high ankle sprain will take 6 weeks to heal; if he only sprained his ankle by rolling it, it could be less, such as 1-2 weeks, but still miss some time. If you would like to read up more on high ankle sprains, click on this link or check out the previously linked Cordy Glenn article. Either way, Zay is missing this week and could miss more time once more information is released.

As mentioned often, TE Charles Clay has been dealing with a sprained MCL and torn meniscus. He had surgery to shave down the meniscus and has been rehabbing to regain the motion and strength in the knee to return to normal. Sunday will be 6 weeks since he originally injured the knee and is within line of expected recovery for this type of injury. I had originally anticipated that he would be out until the Colts game, however that was with IR to return designation. He was limited in practice this week, but barring any pain or swelling, should be able to return without any loss of function. He may be wearing some type of compression sleeve, but should not require any bulky bracing to prevent re-injury. As of today, he is listed as questionable going into Sunday.

CB E.J. Gaines has been dealing with soft tissue injuries all year including groin and hamstring injuries. This was clearly the right move to shut him down until he was fully healthy; nothing good comes from trying to play through injuries such as this. He was also a limited participant in practice but should return to bolster the secondary, especially with how much emphasis the Saints place on their passing game. He is also questionable for Sunday.

Finally, OT Seantrel Henderson found his way onto the injury report this week with a back injury. It is unknown when he sustained his injury, but as he has not appeared in a game this season, it most likely occurred in practice. He may be dealing with a pulled muscle in his back or a muscle contusion, but as there is little information on this, I can only speculate as to how it will affect him come Sunday if he even plays at all.

Clay, Gaines, and Henderson should play unless they do not feel they are ready when they are warming up Sunday. The team does have the depth required to keep up with some teams as they have shown already, but the Saints are a formidable opponent and the Bills even when healthy will have to bring their best in order to compete. The Bills are 4-0 at home and with the Saints being a dome team along with the poor weather bodes well for Buffalo in their chances at winning this game. As is every week in the NFL, any game can be won and this is no different. The Bills are coming off of a 10 day rest break and their poorest performance of the season. This should allow them to retool and find ways to win.

Continue to check back following the game with further injury updates and analysis. As always, thank you for reading, I enjoy writing these articles to educate my fellow Bills fans. For up to date reactions and news, follow me on Twitter at @kyletrimble88. Thank you for your time and GO BILLS!

Zay Jones Ever Changing Injury Diagnosis

Following today’s injury report and Zay Jones new injury diagnosis, this post will identify why it is an ankle injury and not solely a knee injury.

It’s a new day and a new injury report! Going into the Week 10 match up against the New Orleans Saints, the Buffalo Bills continue to get healthy to rebuild their depth just in time to take on a suddenly resurgent Drew Brees led offense and a surprisingly stingy defense. This week’s game will truly be a test to see if the Bills is the team that started 5-2 or if they are the Bills that lost to the Jets on Thursday night.

Today’s post will deviate from a general review of the injury report due to new and unexpected information released today courtesy of Chris Brown. It has been reported that the initial knee injury that WR Zay Jones sustained in Thursday nights loss is now classified as an ankle injury. My goal is to explain why there is a change in injury designation despite the obvious original injury.

As reported before, Jones injured his knee with a rather gruesome fall to the turf last Thursday. He was able to return and play, but left towards the end of the game after re-aggravating the injury. In one of my previous articles, I detailed the possible extent of the injury severity. As there was not any additional news that came out regarding further damage, it was assumed that he merely hyperextended his knee and that he may be limited.

However, the Buffalo Bills continue to throw curveballs with Chris Brown reporting that Jones’ knee injury is actually an ankle injury. When it comes from the Buffalo Bills, I’m not going to question the source. Now, everyone must be thinking, this doesn’t make any sense. And you’re right, it doesn’t make any sense. However, as the reader, you clicked on the right article as I will determine how this could be an ankle injury despite what happened to his knee.

To clarify, Zay Jones did injure his knee in Thursday night’s loss to the Jets. That is a fact, but how severe? Apparently not that severe considering it’s not listed on the official injury report and he was able to return. As for his ankle, I have reason to believe it is a high ankle sprain. Let me explain. The knee acts as a hinge joint, but the ankle has multiple planes of motion allowing for greater mobility, but decreased stability. Upon initial viewing of the injury, there are forward and side views of the mechanism of injury which offer greater insight.

As the 14 second clip plays, at around the 4-5 second mark, Jones trips over CB Buster Skrine’s leg and steps awkwardly with his right leg. However, as he plants, all his weight is being placed through his right leg. His foot is planted directly in the turf as he begins to fall forward with his knee hyperextending. His foot is in maximal dorsiflexion and eversion which translates in plain speak to the foot is maximally bent up and turned out partially. Finally, the knee buckles backwards, Zay vaults forward, and Zay goes down in pain.

Fortunately for Zay, the knee has an ability to lock out which is known as the screw home mechanism. This allows the knee to fully straighten and stay rigid. During the process, as the knee goes into full extension, a rotational component assists in fully extending. In Zay’s instance, the screw home mechanism was forced into action with the femur (thigh bone) internally rotating with the tibia (shin bone) externally rotating. The hyperextension accentuated this mechanism, placing maximal force through the knee with the remaining excess stress left was displaced back into the ankle joint.

STJclosedKinematics.jpg
Credit: http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINlower/Foot.files/FootKinematics.htm

As seen above in the picture, during normal walking, the tibia externally rotates, placing stress through the talus and calcaneus. The calcaneus is the heel bone and this is the portion that makes contact with the ground as the foot is supinating or bearing weight as in the supination diagram. The calcaneus is turned inward and the talus is dorsiflexed and abducted or bent up and pulled outward. These are normal biomechanics of the foot, but if placed through excess stress as in the case of Zay’s injury, this can cause a high ankle sprain as the mechanism of injury is extreme external rotation and dorsiflexion, which is what I believe occurred with Zay to get him the ankle injury designation. Think of this injury as a chain is only as strong as it’s weakest link. As the ankle is naturally more unstable, it is more susceptible to injury which is what happened in this case.

Considering other injuries, he may have sustained a medial ankle sprain or bone contusion according to the video. It may never be fully known the extent of his injury. This injury is confusing as it is not apparent to the naked eye. The manner in which way the knee bent is the obvious part of the injury. To the untrained eye, its hard to see, but upon further evaluation, it appears this may be a likely injury.

As I do not have insider information, only insider knowledge, I can say with only so much confidence that this is what occurred. Time will tell how this injury plays out and what further information is released. He may have also injured his ankle when he left the game the 2nd time and I have not seen video to support or refute the injury. I do not believe that this is something season ending or as serious as Clay’s injury in relation to time missed. He may miss some time depending on severity and how this week’s practice plays out.

Continue to check back for new updates and further analysis of Bills injuries. For more breaking and real time updates, follow me on Twitter at @kyletrimble88. As always, thank you for reading and GO BILLS!!

Cordy Glenn-Perpetually injured

Analyzing/speculating on the lingering ankle injury and how it impacts Glenn’s performance

Cordy Glenn injured his ankle in the preseason of 2016 and has been dealing with the injury ever since. Due to the rigors of the NFL schedule, it is common to deal with nagging injuries that never fully heal during the season. However, due to the Bills ongoing playoff drought, Glenn has not seen the post season since joining the team which means that Glenn has extra time to rehab his ankle. It has been nearly a year since his original injury and yet he still has not returned to full health according to reports. High ankle sprains can fully heal without complication typically, but in Glenn’s case, it continues to be an ongoing issue.

Usually, high ankle sprains require 6 weeks to heal, but can take longer depending on the severity of the sprain. A sprain occurs when the ligaments that stabilizes the connections between the bones becomes damaged which results in instability and an inability of the joint to function properly. In the case of a high ankle sprain, the top of the fibula, the bone that connects on the outside part of the leg near the knee to the tibia via the syndesmotic ligaments, becomes damaged. This is due to stress being placed on the outside part of the ankle, higher than where an individual would roll the foot under during a true ankle sprain. Stresses at a higher level either forces the higher portion of the fibula to pull away from the tibia, causing a sprain. If the foot is fixed into place and the force is great enough, the fibula can break. These forces during the injury are typically seen as external rotation, also known as outward twisting of the foot. Considering the movement of the guard position, plus the 300 lb. bodies falling on top of each other into a massive heap explains why he injured the ankle in the first place. Glenn was placed in a walking boot to stabilize the initial injury and appeared to heal enough to start Week 1 of the NFL season. Glenn then re-injured it during the season opener which caused him to miss the next 3 games. Most likely Glenn originally sustained a Grade 2 injury leading him to sit out the preseason, re-aggravating the injury to a possible Grade 3 later on. Glenn was able to play the rest of the season, missing several games, but clearly not at 100%.

With Grade 3 sprains, the presentation is where the ligament has ruptured, in which the attachment has completely torn or has become so damaged that it can no longer provide effective support. If Glenn did sustain a Grade 3 sprain, surgery is usually recommended, though not always a given. There has been no reports out stating that Glenn had surgery to stabilize the ankle, but considering he is still dealing with the injury, it is quite possible it was not publicly disclosed. The healing time can be anywhere from 3 to 6 months depending on severity of injury. Considering that the Bills season ended at the end of December and that he was not a full participant for OTA’s, the timeline would fit as to why he is not at full health.

Another possibility is that Glenn may also be dealing with chronic ankle instability. This is the result of a recurrent injury leading to deficits in posture control, proprioception, muscle reaction time, and strength leading to a delayed recovery time. This is also more likely due to the demands of the offensive lineman position. Most actions require strategic blocking performing lateral shifting, re-positioning his stance, and driving forward to maintain balance and power required for the position. Rehab for this involves significant focus on balance retraining on the involved foot, progressive loading, and bracing.

Based on the available reports published, it is possible that it is either one of the two scenarios. Both have positive outcomes, but does explain why Glenn is not at 100%. As of August 4th, Glenn is still continuing to deal with potentially the same issues. He has been held out of practice, citing “foot soreness”. It was reported that he went to Charlotte, NC to see Dr. Robert Anderson, a nationally known physician specializing in foot and ankle injuries. Glenn has since returned to practice since the evaluation. While this is continually frustrating being a Bills fan; as a professional, I would rather have the athlete ensure that they are at 100%. At this level, it is not wise to ignore nagging pain, soreness, or small injuries that can lead to further complications down the line. Expect him to be limited in the preseason so as not to aggravate the healing injury. Ideally, Glenn returns to full health for Week 1 and stay healthy to provide effective blocking for the offense to perform at its best.