when an ankle sprain isn’t

Monday, January 30, 2012

Playing in the championship game is the goal of any football player who puts on shoulder pads and a helmet. From Pop Warner football to the NCAA and the NFL, running out of the tunnel onto a field with the Super Bowl logo is the stuff of dreams. For most the dream doesn’t come true, for the few whose teams win, the experience is the highlight of a lifetime. And then there is Rob Gronkowski, receiver for the New England Patriots and while his teammates are celebrating their good fortune and skill, his road to the stadium has taken a detour because of a high ankle sprain that has kept him from practice.

The bad news for Mr. Gronkowski is that a high ankle sprain really isn’t an ankle sprain at all, but rather a tear in the interosseous (between bones) band of tissue that connects the tibia and fibula, the two bones in the shin. The syndesmotic ligament keeps these bones aligned as they run from the knee joint to the ankle. If there is a torque or twist injury, the syndesmosis above the ankle can be torn, sometimes splaying the bones apart. Usually the injury occurs when the foot is forced upward (dorsiflexed) and outward (everted} and is common in football, snowboarding and skiing.

Syndesmotic joints, where a ligament attaches from the rough edge of bone to rough edge of bone are unusual in the body. Most other joints are synovial where the joint has a capsule that contains fluid that lubricates the joint and ligaments stretch across the jint to provide stability. On the lateral aspect of the ankle (the side aligned with the little toe), the anterior talofibular ligament is the most common type of ankle sprain, where the foot is forcibly turned inward (inverted) and the ligament fibers stretch or tear. Two other ligaments provide stability on the lateral side, while on the medial side of the ankle (aligned with the big toe), the thick deltoid ligament does the stabilizing.

The term high ankle sprain should instead be called a syndesmotic injury since it doesn’t involve the ankle joint. The pain and swelling is above the ankle joint often between the tibia and fibula, the two shin bones. It is well away from the swelling of a “routine” ankle sprain, which tends to be associated with the ankle ligaments. For the talofibular ligament, that ends to be below the lateral malleolus or large bony bump on the outside of the ankle.

The severity of the syndesmosis tear depends upon whether there is diastasis or splaying out of the ends of the tibia and fibula at the ankle. Plain x-rays may show a widening of the gap between the bones but sometimes, the bones are stressed to see if a hidden diastasis can be uncovered. If there is instability, an operation may be needed to realign the tibia and fibula. Missing this injury can cause the bony surfaces at the ankle to be poorly aligned and cause long term pain and arthritis in the joint.

If no surgery is required, the syndesmotic tear (or high ankle sprain if you can’t ignore the term) is treated with rest and immobilization. A cast boot and crutches may be needed foroa few weeks and with physical therapy, the complete healing may take three or more months. Of course, RICE (rest, ice, compression and elevation) are always indicated.

Timing is everything when it comes to injury. For Mr. Gronkowski who has missed practice and has been seen walking in a cast boot, having but a few days to recover from a syndesmotic tear may not be possible. He may play if his mind can overcome the pain, but his body will continue to favor the injury and his performance on the field will not necessarily be what he expects. However, there is no doubt that he will run out of the tunnel onto the field emblazoned with a Super Bowl logo and live the dream that began in Pop Warner.

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