Tuesday, October 21, 2008
Every injury has its own time frame to resolve and Mother Nature has her own schedule to allow return to play. Often, it’s the injury least expected to keep a player out of the game that does exactly that. In the past, I’ve been amazed by pro athletes who can perform 5 or 6 days after knee arthroscopy and then wonder why a simple sprain can take weeks to resolve. Deron Williams of the Utah Jazz is a testament that even elite athletes may not be able to play through pain after sustaining a second degree ankle sprain.
The ankle joint is held steady by two sets of ligaments. Laterally, on the outside when you look down your leg, there three ligaments that connect the fibula, the strut bone of the lower leg to the talus and calcaneus, two bones in the foot. The ligaments attach at the lateral maleolus, the large bony protrusion, and are damaged most commonly when the ankle rolls or inverts.
On the medial side, a thick band of connective tissue called the deltoid ligament, runs from the tibia or shin bone to the talus to hold the ankle stable. Damaging this ligament may have much more serious consequences because of other associated injuries. Often this ligament tears in association with fractures of the lateral maleolus.
In the real world can make the diagnosis of an ankle sprain pretty easily. The ankle rolls, a pop is felt and the dreaded swelling and pain occur. Most people don’t seek medical care and know that RICE (rest, ice, compression, elevation) will cure most injuries within a matter of days. X-rays often aren’t needed. In fact, the Ottawa Ankle Rules were developed to guide doctors in deciding which ankle might need an x-ray to look for a fracture. Based upon where the tender spots are and whether the patient can walk, an x-ray may or may not be obtained.
Elite athletes live in a different world and NBA ball players are an extreme example. With contracts worth tens of millions of dollars and more, they are treated like prized jewels. Deron Williams rolled his ankle as he landed on another player’s foot in an exhibition game and part of his evaluation included an MRI, a magnetic resonance scan which is very good for looking at soft tissues like muscles, tendons, ligaments and cartilage. His diagnosis was pretty reasonable, a second degree sprain and he may be out for a couple of weeks.
Flash back to the real word. There are three degrees of sprain. First degree means that ligament fibers are stretched but not torn. Second degree sprains have torn some fibers but the ligament is table. The ligament is completely torn in third degree sprains. Most often, the care provider can determine whether the ligament is intact and the joint stable. Not so long ago, in the pre-MRI days, that was how it was done and is still done for the vast majority of patients. Most don’t need plain x-rays let alone an MRI.
A sprain heals slowly. The ligament needs to lay down collagen to re-establish its integrity and there is little difference in healing between sprains and bone fractures. The bone does add calcium to the healing mix but the time frame is the same. A sprained ankle may take a couple of weeks to allow return to play but the ankle itself hasn’t returned to its pre-injury state until six weeks have passed. It won’t be able to withstand another potential injury force as easily. In the athlete, early return to play is balanced against repeat damage.
This also happens in the real world where people are athletes in different ways. Construction and factory workers are paid to use their bodies just like the pro athlete and need to decide when their body can return to their field of play. Ankle sprains may be the Rodney Dangerfield of athletic injuries; they get no respect. It may be time to give them their due.