When a sprain isn’t

Tuesday, March 25, 2008

Big men fall to the floor routinely in an NBA game, they get up, run down the floor and do it over again. Sometimes they don’t. Dirk Nowitzki didn’t. Playing defense, this weekend, Notwitzki landed awkwardly and lay on the floor grabbing his leg in pain. The diagnosis from the locker room was a high ankle sprain plus a knee sprain and the prognosis for return in a couple of weeks.
It’s tough to make a diagnosis from a press report, but a high ankle sprain is a bad term, since it doesn’t directly involve the ankle, rather it’s a tear of the ligament (the syndesmosis) that holds the shin bones (the tibia and the fibula) together in the lower leg. And syndesmosis injuries may take significantly longer to heal, some even requiring surgery.
A sprain is the term given to stretching or tearing the ligaments that stabilize a joint. Most ankle injuries occur when the foot rolls to the inside and stretches the outside ligaments that attach the fibula, or strut bone, to the talus, the top bone in the foot. The treatment is ice, elevation, compression, rest and rehab.
A syndesmosis tear, or a high ankle sprain, occurs with the opposite mechanism of injury, an outward rotation of the foot. This stresses the ligaments between the tibia and fibula. The two bones tend to work together and need a little flex and rotation in normal walking and running to take the stresses off the knee and ankle. The force of the twisting, tears the two bones apart resulting in the injury. High ankle sprains can be stable or unstable. It is unstable if the syndesmotic tear is significant enough to splay the two bones apart, causing the tibia to sit improperly on the talus. This causes the ankle joint to be at risk for instability and in the short term swelling and pain with activity. Longer term, if the joint doesn’t work properly, significant arthritis will develop.
The diagnosis of syndesmosis tear is sometimes hidden, since regular x-rays may be normal, just like in a regular ankle sprain. The key is that in a syndesmotic tear, the pain is felt in the lower calf area, higher than the ankle joint. Squeezing the calf may cause significant pain. MRI confirms the diagnosis and helps the doctor decide whether the injury is stable.
If the high ankle sprain is stable, then casting for up to 6 weeks is a common treatment. If it is unstable, then an operation may be considered to put a screw across the two bones (a syndesmotic screw) to hold the bones in place until the ligament heals. This is often followed by a smaller operation to remove the screw.
There is no doubt that elite athletes have the drive, the devotion to rehabilitation, the capacity to train and play through pain, and the ability to return to the playing field more quickly than expected. But if Mr. Nowitski does have a high ankle sprain, then two weeks may be wishful thinking.
He will probably be torn between two goals. The Dallas Mavericks, his NBA team, will want him back for the playoffs and the German National team will want him ready for the Beijing Olympics this summer. Regardless of what others want, Mr. Nowitski should want to properly heal his leg so that he can teach his grandkids how to play the post.

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