Fantasy Impact
As shown in the data tables below, across all positions we see a majority of players fail to reach their pre-injury baseline points per game in their first game back after a high ankle sprain. However, by games, 2-3 back from injury most QBs, RBs, and WRs have met or surpassed their pre-injury baseline.
Quarterbacks appear to be the least affected, as we actually see a slight increase in points per game in the first game back, and average missing the least amount of games compared to other position groups.
Running backs and receivers both show a notable decline in performance in the first game back from a high ankle sprain, but a return towards their pre-injury averages in subsequent games.
Athletes Who Have Had a High Ankle Sprain
Quarterbacks
| Quarterbacks | Games Missed | PPG Prior to Injury | PPG 1st Game After Injury | PPG Games 2-3 After Injury | PPG Games 4-6 After Injury |
|---|---|---|---|---|---|
| Baker Mayfield (2022 week 5) | 12.3 | ||||
| Mac Jones (2022 week 3) | 3 | 13.9 | 2 (-11.9)β | 12.4 (-1.5) | 15.3 (+1.4) |
| Sam Darnold (2022 preseason) | 6 | 9.2 | 17.5 (+8.3) | ||
| Jalen Hurts (2021 week 12) | 1 | 18.6 | 28.6 (+10) | 14.9 (-3.7) | 16.8 (-1.8)*ρ |
| Carson Wentz (2021 preseason) | 0 | 19 | 18.3 (-0.7) | 13.2 (-5.8) | 19.2 (+0.2) |
| Jimmy Garoppolo (2020 week 8) | 7 | 14.5 | N/Aμ | N/Aμ | N/Aμ |
| Jimmy Garoppolo (2020 week 2) | 2 | 15.8 | 1.1 (-14.7) | 16.5 (+0.7) | N/Aμ |
| Daniel Jones (2019 week 13) | 2 | 18.1 | 35.3 (+17.2) | 15.6 (-2.5) | N/A |
| Matt Ryan (2019 week 7) | 1 | 24.3 | 15.6 (-8.7) | 12.5 (-11.8) | 19.7 (-4.6) |
| Patrick Mahomes (2019 week 1) | 0 | 25.5 | 27.3 (+1.8) | 29.8 (+4.3) | 18.8 (-6.7) |
| Average | 2 | -0.2 | -2.9 | -3.3 | |
| Number of Players Who Have Met Their Baseline at Current or Previous Time Points | 4/8 (50%) | 5/8 (63%) | 7/8 (88%) |
Running Backs
| Running Backs | Games Missed | PPG Prior to Injury | PPG 1st Game After Injury | PPG Games 2-3 After Injury | PPG Games 4-6 After Injury |
|---|---|---|---|---|---|
| Jonathan Taylor (2022 week 15) | N/A | 14.5 | N/A | N/A | N/A |
| Dameon Pierce (2022 week 14) | N/A | 8.3 | N/A | N/A | N/A |
| Rhomandre Stevenson (2022 week 14) | 0 | 15 | 25.8 (+10.8) | ||
| DeeJay Dallas (2022 week 13) | 2 | 1.2 | 7.2 (+6) | N/A | N/A |
| Clyde Edwards-Helaire (2022 week 11) | N/A | 9 | N/A | N/A | N/A |
| Chase Edmonds (2022 week 11) | 4 | 3 | 6.8 (+3.8) | N/A | N/A |
| Jonathan Taylor (2022 week 8)μ | 1 | 14.6 | 25.3 (+10.7) | 16.1 (+1.5) | |
| Jonathan Taylor (2022 week 4) | 2 | 13.8 | 12 (-1.8) | N/Aμ | N/Aμ |
| David Montgomery (2022 week 3) | 1 | 13.2 | 16.2 (+3) | 10.4 (-2.8) | 5.6 (-7.6) |
| Tyrion Davis-Price (2022 week 2) | 3 | 3.3 | 0 (-3.3) | ||
| Kyren Williams (2022 week 1) | 7 | N/A | 5.4 | 6.2 | |
| Joe Mixon (2021 week 15) | 0 | 20.1 | 28.5 (+8.4) | 12.1 (-8) | 12 (-6.1)ρ |
| Michael Carter (2021 wek 11) | 3 | 14.8 | 2.5 (-12.3) | 10.1 (-4.7) | 1.9 (-12.9)* |
| Cordarelle Patterson (2021 week 10) | 1 | 17.6 | 26.5 (+8.9) | 12 (-5.6) | 5.8 (-11.8) |
| Chase Edmonds (2021 week 9) | 4 | 10.3 | 5.3 (-5) | 16.7 (+6.4) | 3.3 (-7)* |
| JaMycal Hasty (2021 week 2) | 3 | 6.3 | 3.1 (-3.2) | 3.6 (-2.7) | N/A |
| Zack Moss (2020 playoffs) | 0 | 6.2 | N/A | N/A | N/A |
| Darrell Henderson (2020 week 16) | 3 | 4.9 | N/A | N/A | N/A |
| Cam Akers (2020 week 15) | 1 | 11.5 | 8.6 (-2.9) | 20.4 (+8.9) | N/A |
| Clyde Edwards-Helaire (2020 week 15) | 3 | 10.8 | 1.8 (-9)ρ | 9.7 (-1.1)ρ | N/A |
| Raheem Mostert (2020 week 15) | 2 | 7.4 | N/A | N/A | N/A |
| Damian Harris (2020 week 14) | 3 | 10.3 | N/A | N/A | N/A |
| Kenyan Drake (2020 week 7) | 1 | 12.8 | 9.4 (-3.4) | 18.4 (+5.6) | 11.1 (-1.7) |
| Jeff Wilson Jr. (2020 week 7) | 3 | 9.5 | 2 (-7.5) | 7.9 (-1.6) | 20.4 (+10.9) |
| Devonta Freeman (2020 week 7) | 2 | 7.8 | N/A | N/A | N/A |
| Raheem Mostert (2020 week 6) | 4 | 16 | 9.3 (-6.7) | 6.4 (-9.6) | 6.8 (-9.2)* |
| Christian McCaffrey (2020 week 2) | 6 | 22.9 | 32.1 (+9.2) | N/A | N/A |
| Darrell Henderson (2019 week 16) | 1 | 0.4 | N/A | N/A | N/A |
| Miles Gaskin (2019 week 16) | 1 | 3.1 | N/A | N/A | N/A |
| Blial Powell (2019 week 14) | 1 | 2.5 | 1.3 (-1.2) | 2.7 (+0.2)* | N/A |
| Adrian Peterson (2019 week 7) | 0 | 6.7 | 11.3 (+4.6) | 8.8 (+2.1) | 11.6 (+4.9) |
| Alvin Kamara (2019 week 6) | 2 | 18 | 11.4 (-6.6) | 16 (-2) | 8.7 (-9.3) |
| Saquon Barkley (2019 week 3) | 3 | 18.4 | 15.5 (-2.9) | 18.4 (0) | 8.5 (-9.9) |
| Tevin Coleman (2019 week 1) | 2 | 9 | 15.7 (+6.7) | 10.1 (+1.1) | 16.9 (+7.9) |
| Royce Freeman (2018 week 7) | 2 | 8.2 | 9.5 (+1.3) | 2.3 (-5.9) | 2.3 (-5.9) |
| Average | 2.3 | +0.4 | -0.8 | -4.2 | |
| Number of Players Who Have Met Their Baseline at Current or Previous Time Points | 11/24 (46%) | 12/18 (66%) | 11/17 (65%) |
Wide Receivers
| Wide Receivers | Games Missed | PPG Prior to Injury | PPG 1st Game After Injury | PPG Games 2-3 After Injury | PPG Games 4-6 After Injury |
|---|---|---|---|---|---|
| Mike Williams (2022 week 11) | 2 | 15 | 22.6 (+7.6) | ||
| Romeo Doubs (2022 week 9) | 4 | 8.4 | 8 (-0.4) | ||
| Mike Williams (2022 week 7) | 2 | 15 | N/Aμ | N/Aμ | N/Aμ |
| Randall Cobb (2022 week 6) | 4 | 8.1 | 10.3 (+2.2) | 4.7 (-3.4) | |
| N’Keal Harry (2022 preseason) | 6 | 1.5 | 1.9 (+0.4) | 5.3 (+3.8) | N/A |
| Adam Thielen (2021 week 16) | 2 | 16.1 | N/A | N/A | N/A |
| Adam Thielen (2021 week 13) | 2 | 16.1 | 5.5 (-10.6)*μ | N/A | N/A |
| Jerry Jeudy (2021 week 1) | 6 | 7 | 5.9 (-1.1) | 9 (+2) | 6.8 (-0.2) |
| Michael Thomas (2021) | 17 | N/A | N/A | N/A | N/A |
| Brandon Aiyuk (2020 week 16) | 1 | 17.1 | N/A | N/A | N/A |
| Terry McLaurin (2020 week 15) | 1 | 10.7 | 13.5 (+2.8) | N/A | N/A |
| Michael Thomas (2020 week 14) | 3μ | 9.7 | N/A | N/A | N/A |
| John Brown (2020 week 10) | 5 | 6.5 | 15.2 (+8.7) | 5.1 (-1.4) | 3.4 (-3.1) |
| Desean Jackson (2020 week 7) | 7 | 5.7 | 14.6 (+8.9) | N/A | N/A |
| Chris Hogan (2020 week 5) | 6 | 3.8 | N/A (cut) | N/A | N/A |
| Michael Thomas (2020 week 1) | 6 | 18.3 | 7.6 (-10.7) | 9.3 (-9) | 11 (-7.3) |
| TY Hilton (2018 week 14) | 0 | 16.2 | 11 (-5.2) | 12.2 (-4) | N/A |
| Quincy Enunwa (2018 week 6) | 2 | 8.9 | 5.5 (-4.4) | 6.6 (-3.3) | 2.8 (-6.1) |
| Jameson Crowder (2018 week 5) | 7 | 8.8 | 5.1 (-3.7) | 11.2 (+2.4) | 5.8 (-3) |
| Odell Beckham Jr. (2017 preseason) | 1 | 16.8 | 5.6 (-11.2) | 18.5 (+1.7) | 19 (+2.2)* |
| Average | 4.2 | -1.2 | -1.2 | -2.9 | |
| Number of Players Who Have Met Their Baseline at Current or Previous Time Points | 6/14 (43%) | 8/12 (66%) | 6/10 (60%) |
tight Ends
| 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 |
|---|---|---|---|---|---|
| David Njoku (2022 week 7) | 2 | 10.2 | 2.7 (-7.5) | N/Aψ | N/Aψ |
| Zach Ertz (2020 week 6) | 5 | 6.5 | 4.1 (-2.4) | 4.9 (-1.6) | 4 (-2.5) |
| Jordan Akins (2020 week 4) | 3 | 7.9 | 2.9 (-5) | 5.9 (-2) | 2 (-5.9) |
| Drew Sample (2019 week 10) | 7 | 0.2 | N/A | N/A | N/A |
| OJ Howard (2018 week 11) | 6 | 9.9 | N/A | N/A | N/A |
| OJ Howard (2017 week 15) | 2 | 5.8 | N/A | N/A | N/A |
| Average | 4.2 | -5 | -1.8 | -4.2 | |
| Number of Players Who Have Met Their Baseline at Current or Previous Time Points | 0/3 (0%) | 0.2 (0%) | 0/2 (0%) |
Anatomy of a High Ankle sprain
The ankle joint consists of three bones; the tibia (shin bone) the fibula which is a smaller bone in the back outside portion of the lower leg, and the talus which is a bone in the foot that connects to the lower leg to make the ankle joint. These bones are held together by several ligaments as well as many muscles that attach from the shin to the foot. The main ligaments involved in a high ankle sprain are the Anterior Inferior Talofibular Ligament (AITFL), the Posterior Inferior Talofibular Ligament (PITFL), the Interosseous Membrane (which connects the tibia and fibula together), and the Deltoid ligament. A high ankle sprain is when one or several of these ligaments get injured.1-3
Like most soft tissue injuries there is a grading scale for high ankle sprains.4 Grade I sprain involves a partial tear of the AITFL, grade II sprains involve a tear of the AITFL and a partial tear of the Interosseous Membrane, and grade III sprains are a complete sprain of all the ligaments.4,5
Normally, the way the lower portion of the tibia and fibula bones connect with the talus bone of the foot creates a functional “mortise” where the talus bone is housed snugly between the tibia and fibula, and this is dependent on these ligaments being intact. This allows the ankle to be stable when pushing off such as sprinting, cutting, jumping, and many other explosive athletic activities. With a grade II-III high ankle sprain the injured ligaments no longer are able to properly hold the bones in place, therefore we see a gaping of the space between the tibia, fibula, and talus bones. This is both is painful and also impacts an athlete’s ability to generate force off of that ankle.4,6
Cause of a high ankle sprain
Ankle injuries make up roughly 29% of football-related injuries, with about a quarter of all ankle injuries being high ankle sprains.6 The cause of a high ankle sprain is quite clear and consistent. This injury occurs when an athlete’s foot is planted in the ground and the shin rotates inward or outward with the foot maintaining in a planted position either due to being stuck in the turf, or another player has landed on their foot.1-4,6 Injury can also occur when the foot is planted and the player gets rolled up on from behind causing their shin to propel forward over the ankle.4 Anatomically the mechanism that occurs is a rotational force through the ankle and shin that strains the ligaments mentioned above more than they are capable of handling.
Surgical Procedure for a high ankle sprain
The surgical procedure for high ankle sprains grade II or III was made famous in 2018 when Tua Tagovailoa suffered this injury while playing for Alabama. He underwent the “Tight Rope” procedure and returned to the field in only 4 weeks to lead Alabama to a national championship victory over Oklahoma.
The surgical procedure is relatively quick, often being completed in under an hour. With the patient under anesthesia, the surgeon will use a clamp on each side of the lower portion of this shin to bring the tibia and fibula bones closer together where they are supposed to be. Next, the surgeon will drill two holes into the outside lower portion of the shin. Wires are inserted through these holes to the inside portion of the lower shin, and when pulled will tighten the tibia and fibula bones together in their normal position.4
high ankle sprain Rehab Process
Rehabbing from a high ankle sprain is often a slower process than other types of ankle sprains. This is because of the amount of stability in the lower leg and ankle that is lost by this injury. Additionally, if an athlete rushes back to the field too soon they run the risk of further injuring the ligaments, creating more instability in the ankle joint and lower leg.7 This differs quite a bit from a lateral ankle sprain where it is much easier to use external appliances such as tape and braces, as well as muscular control to stabilize the joint.
Rehab is dependent on the grade of sprain with grade I injuries averaging 6-8 weeks to return to sport, grade II averaging 45 days, and grade III injuries averaging 10-14 weeks, however, some athletes have been able to return much faster.4 Age also appears to be a factor in return to sport. Some research has shown that every year under age 25 players return to games 1.1 days faster, whereas every year past age 25 players return to games 1.1 days slower on average.6
Grade I injuries can be easily rehabbed, whereas grade II injuries may or may not respond well to rehab alone and sometimes will need casting or surgery, and grade III injuries almost always need casting or surgery.3,5,8 Often even with a grade I injury there is a 2 week period of wearing a boot and using crutches to protect the injury. This progresses to gentle range of motion and weight-bearing, eventually progressing to strengthening and balance exercises before finally returning to sport-specific exercises.1 Grades II and III injuries follow a similar pattern of progression in rehab however have a longer period of protection phase, and as mentioned may include surgery or casting.
Interestingly, with new surgical advances such as the tight rope procedure mentioned above, some athletes (ex. Tua) are beginning to return to the field much sooner. Some surgeons following the tight rope procedure allow the entire rehab process to be sped up, which may include partial weight-bearing and some range of motion exercises right after surgery rather than waiting 2 weeks.5 It will be interesting to see over the next few years if this becomes the norm. Below outlines the current most frequent timeline for rehabbing from a high-ankle sprain with the understanding that surgically managed injuries will follow a similar timeline but a few weeks slower.
| Rehab Phases1 | Treatments |
| Phase I: Protection | Cast or boot with crutches progressing to brace or tape when able to tolerate weight-bearing. Ice, compression, elevation. Gentle cycling if pain-free. Strength of core, glutes, quads, hamstrings with exercises on a table. |
| Phase II: Restore Mobility | Progressively weight-bearing as tolerated. Continue with ice, compression, and elevation. Continue with cycling, strength of leg and core muscles. Begin ankle range of motion exercises progressing to light resistance bands, and eventually progressing to standing heel raises. Standing balance exercises starting on a firm surface, progressing to unstable surfaces. When able, initiate light jogging and hopping (ideally in gravity eliminating treadmill), |
| Phase III: Sport Specific Training | Aggressive strength training (squats, lunges, deadlifts, etc.) Jumping, agility ladder, plyometrics, hopping, cutting. Football specific moves (route running, QB dropbacks and throwing, RB taking handoff and running) |
Prior to returning to sport, there is a battery of tests that have shown to be correlated with readiness to play and reduction in re-injury risk. This includes strength testing of major lower body muscle groups, several different single-leg hop tests for speed, distance, and balance, and single-leg balance tests. Generally, the research shows that if an athlete’s injured leg scores within 95% of the uninjured side with these tests and they have no pain, they are safe to return to sport.
Tom Christ, PT, DPT, OCS (39)
References
- Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. 2007;35(7):1197-1207
- Lin CF, Gross ML, Weinhold P. Ankle Syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther. 2006;36(6):372-384.
- Press CM, Gupta A, Hutchenson MR. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep. 2009;8(5):228-233.
- D’Hooghe P, Grassi A, Alkhelaifi K, et al., Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIb and III) in 110 male professional football players: a retrospective cohort study. Br. J Sports Med. 2020;54:1168-1173.
- D’Hooghe P, Alkhelaifi K, Abdelatif N, Kaux JF. From “Low” to “High” Athletic Ankle Sprains: A Comprehensive Review. Operative Techniques in Orthopaedics. 2018;54-60.
- Knapik D, Trem A, Sheehan J, Salata M, Voos J. Conservative Management for Stable High Ankle Injuries in Professional Football Players. Sports Health. 2017;10(1):80-84.
- Houck J, Neville C, Chimentl R. The Foot and Ankle: Physical Therapy Patient Management Using Current Evidence. Current Concepts of Orthopaedic Physical Therapy. 2016(4).
- Taylor DC, Tenuta JJ, Uhorchak JM, Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35(11):1833-1838.