|Position||Average % Difference PPG Change From Pre-Injury Compared to 1st Game After Injury||Average % Difference PPG Change From Pre-Injury Compared to Games 2-3 After Injury||Average % Difference PPG Change From Pre-Injury Compared to Games 4-6 After Injury|
|Position||Average Change in Snap% From Pre-Injury Compared to 1st Game After Injury||Average Change in Snap% From Pre-Injury Compared to Games 2-3 After Injury||Average Change in Snap% From Pre-Injury Compared to Games 4-6 After Injury|
Anatomy of an ankle fracture
An ankle fracture is a relatively common injury in the NFL and accounts for 9.5% of all ankle injuries.1 This type of injury can occur in the tibia, fibula, or both. Tibial fractures are typically more severe and will take more time to heal since the tibia is the main weight-bearing bone of the lower leg.
The tibia is also commonly known as the shin bone. It comes directly in contact with the femur (thigh bone) and the talus bone of the foot, which is why it functions as the weight-bearing bone of the lower leg. The tibia is an attachment site for many muscles and ligaments, which work together to help stabilize the ankle and knee. The fibula only directly comes in contact with the tibia but provides stability to the lateral ankle and knee through muscle and ligament attachments.2
Cause of ankle fracture
The most common cause of injury is due to direct impact into the tibia when a player is getting tackled.3 Of all ankle fractures, 19.7% occur in the fibular shaft, 33.6% in the lateral malleolus (the portion of the fibula that is closest to the foot), and 23.2% in the medial malleolus. 1.46% had fractures in both medial and lateral malleoli, also known as a tib-fib fracture.1 Additionally, tib-fib fractures were the most common location for open fractures, which means the bone broke through the skin, which is what happened with Alex Smith.4
Many positions are at risk for this type of injury, but tibial fractures are most common in defensive backs (16%) and running backs (14%).3 38% of fibular fractures occurred on running plays, 24% on passing plays, and 16% on kickoffs.5 It is also of note that fractures were most commonly seen between weeks 13 and 17, indicating that fatigue and accumulated wear and tear throughout the season could play a role in this type of injury.3
The player’s position and time of the season are significant risk factors for ankle fractures. Other risk factors include the field/turf surface, insufficient warm-up, footwear, strength asymmetries, flexibility asymmetries, and decreased proprioception (your body’s sense of where it is in space), and previous injuries. The previous injury also increases the risk of further injury because the initial injury leads to decreased strength, muscular control, and decreased response times in the affected ankle.6
Ankle fracture rehab process
The rehab process is directly related to whether the fracture will require surgical or non-surgical treatment. Surgery will require more prolonged and more extensive rehabilitation, resulting in an increased loss of playing time. For tibial fractures, the median time lost for players that had surgery was 232 days, which is significantly higher than the 56 days lost for injuries treated non-operatively.3 The data is similar for fibula fractures as well, with missed time due to surgery being 123.8 days, while players that did not require surgery missed 75.3 days.5 Players who only suffered fibular fractures missed 93.6 days compared to 132.3 days if the player sustained a tib-fib fracture.5 Although the athlete may miss more time, it is often advantageous to pursue the surgical route due to the surgery allowing for better outcomes for return to sport.7
Phase 1 of rehab
There is very little difference between conservative and post-operative rehab during phase 1; either way, it will consist of immobilization with a cast and offloading the tissue using crutches or another assistive device like a scooter. However, with surgery, there may be an increased time in phase 1. Rest, ice, compression, elevation, and gentle massage will all be used to decrease swelling and pain.8 Phase 1 will often require gait training with the assistive device to ensure the protection of the affected ankle. In some cases, such as on open reduction internal fixation (ORIF) procedure, implementation of early weight-bearing even when the player has their ankle immobilized can be beneficial depending on how the bone is healing. This early weight-bearing has shown to improve ROM.7
The active phase of rehab will start once the physician has screened the bone for proper healing. Phase 2 will start with a gentle range of motion, beginning with a passive range of motion and progressing to active. This phase will also address risk factors associated with the injury, including strength, ROM, proprioception, and weight-bearing as tolerated, which typically begins around week 6.
Strength will start with light, open-chain exercises, which means the moving body part is not on the ground or another stationary object. Exercises will then progress to heavier closed-chain exercises, which means that the body part is connected to the floor or a fixed object. A simple example would be knee extensions (open-chain) compared to squats (closed-chain).
As needed, manual therapy to address soft tissue and joint restrictions will be employed.9 As with all surgeries, a surgical protocol will be designed by the surgeon that the physical therapist will help implement during the rehab process. The end of phase 2 and the beginning of phase 3 will be marked with the end of the athlete’s treadmill walking program and the beginning of a jogging program that will progress to sprinting.8
Return to sport/function
Once strength, ROM, proprioception, and weight-bearing have become symmetrical, or within 80% of the unaffected side, the player is allowed to initiate return-to-sport activities. This phase usually occurs around the 3-month mark.7 These activities will include agility, sprinting, cutting, jumping, and contact drills related to their specific position.8 Return to sport training will address any other asymmetries or contributing risk factors that have not been addressed through the rehab process.
|Rehab Phase||Treatment||Criteria to Enter Phase|
|Early Phase||RICE, NSAIDs, walking boot. |
AROM of toes, knee and hip.
Week 2-3: PROM progressing to AROM of ankle.
|Intermediate Phase||Early Intermediate: |
Weight-bearing as determined by physician.
AROM, stretching, foot intrinsic muscle strengthening
Soft tissue mobilization, joint mobilization.
Decrease boot wearing.
Progression of stretching, strengthening, proprioception, and balance exercises.
Continue more aggressive joint and soft tissue mobilization.
|Physician determined the bone is healing properly.|
|Sports-Specific||Initiate jogging program- progress to sprinting.|
Continue to progress strength and ROM.
Progress proprioception, balance, agility, cutting, and jumping drills.
Initiate contact and position specific drills.
|Full weight-bearing and completion of walking program. |
Physician will continue to screen the bone for proper healing.
Although there can be a significant loss of playing time post-injury, the fantasy manager should feel confident in a full return to pre-injury status. Studies have shown no significant difference in post-injury career length and games played per season or a decrease in performance.4
Players who have had an ankle fracture
|Quarterbacks||Games Missed||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Trey Lance (2022 week 2)||15||11||N/A||N/A||N/A|
|Dak Prescott (2020 week 5)||11||27.7||28.4 (+0.7)||14.3 (-13.4)||25.5 (-2.2)|
|Alex Smith (2018 week 11)||26||14||14 (0)||12.7 (-1.3)||8.8 (-5.2)|
|Derek Carr (2016 week 16)||2||16.6||20.3 (+3.7)||16 (-0.6)||22.6 (+6)|
|Marcus Mariota (2016 week 16)||1||18.6||18.8 (+0.2)||16.4 (-2.2)||12.9 (-5.7)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||4/4 (100%)||4/4 (100%)||4/4 (100%)|
|Running Backs||# Of Weeks From Injury To Return||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Tony Pollard (2022 Divisonal Round)||34||18.1||21.2 (+3.1)|
|Rashaad Penny (2022 week 5)||47||16.8||1.9 (-14.9)||N/A||N/A|
|Kenyan Drake (2021 week 13)||40||10||5.1 (-4.9)||2 (-8)||12.1 (+2.1)|
|Chris Thompson (2017 week 11)||42||9.4||21.8 (+12.4)||9 (-0.4)||9.2 (-0.2)*|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||2/4 (50%)||1/2 (50%)||2/2 (100%)|
|Wide Receivers||# Weeks From Injury To Return||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Darnell Mooney (2022 week 12)||40||9.9||13.3 (+3.4)|
|Jamison Crowder (2022 week 4)||49||2.9||N/A||N/A||N/A|
|DJ Chark (2021 week 4)||49||8||13.2 (+5.2)||3 (-5)ψ||N/A|
|Amari Cooper (2020 week 17)||35||12.3||32.4 (+20.1)||4 (-8.3)||12 (-0.3)|
|Cole Beasley (2020 week 16)||36||13.6||9.2 (-4.4)||6.2 (-7.4)||N/A|
|Odel Beckham Jr. (2017 week 5)||47||14.4||16.5 (+2.1)||11.3 (-3.1)||15.1 (+0.7)|
|Curtis Samual (2017 week 10)||42||2.8||10.7 (+7.9)||4.5 (+1.7)||8.3 (+5.5)|
|Tyler Lockett (2016 week 16)||36||11.2||1.3 (-9.9)||6.7 (-4.5)||7.4 (-3.8)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||5/7 (71%)||4/6 (66%)||3/5 (60%)|
|Tight Ends||Games Missed||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Dallas Goedert (2020 week 3)||4||11.1||2 (-9.1)||10.8 (-0.3)||10.8 (-0.3)|
|TJ Hockenson (2019 week 13)||4||3.6||14.1 (+10.5)||7.8 (+4.2)||11 (+7.4)|
|Tyler Eifert (2018 week 4)||12||6.5||5.2 (-1.3)||5.4 (-1.1)||2.8 (-3.7)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||1/3 (33%)||1/3 (33%)||1/3 (33%)|
Mason Dwinnell (0)
- Mulcahey MK, Bernhardson AS, Murphy CP, et al. The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015. Orthop J Sports Med. 2018;6(7):2325967118786227. Published 2018 Jul 18. doi:10.1177/2325967118786227
- Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int. 2014;111(21):377-388. doi:10.3238/arztebl.2014.0377
- Knapik DM, Mack CD, Lee R, et al. Epidemiology of Tibial Fractures in Professional American Football Athletes From 2013 to 2019. Orthop J Sports Med. 2021;9(11):23259671211040878. Published 2021 Nov 11. doi:10.1177/23259671211040878
- Cotton MO, Sliepka JM, Klavas DM, McCulloch PC, Harris JD, Jack RA. Performance and Return to Sport After Open Fracture in National Football League Players. Orthop. J. Sports Med. September 2021. doi:10.1177/23259671211027862
- Werner BC, Mack C, Franke K, Barnes RP, Warren RF, Rodeo SA. Distal Fibula Fractures in National Football League Athletes. Orthop J Sports Med. 2017;5(9):2325967117726515. Published 2017 Sep 8. doi:10.1177/2325967117726515
- Manoel LS, Xixirry MG, Soeira TP, Saad MC, Riberto M. Identification of Ankle Injury Risk Factors in Professional Soccer Players Through a Preseason Functional Assessment. Orthop J Sports Med. 2020;8(6):2325967120928434. Published 2020 Jun 24. doi:10.1177/2325967120928434
- Del Buono A, Smith R, Coco M, Woolley L, Denaro V, Maffulli N. Return to sports after ankle fractures: a systematic review. Br Med Bull. 2013;106:179-191. doi:10.1093/bmb/lds039
- South Bend Orthopaedics. (2020, September 28). Ankle fracture protocol: Operative treatment. Retrieved May 26, 2022, from https://www.sbortho.com/pdfs/therapy-protocols/dr-thomas-b/tb-pt-ankle-fracture-protocol.pdf
- Lin CW, Moseley AM, Refshauge KM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2008;(3):CD005595. Published 2008 Jul 16. doi:10.1002/14651858.CD005595.pub2