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Justin Britt injury update, plus explaining the different kind of ankle sprains

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NFL: Seattle Seahawks at Arizona Cardinals
I don't think that is legal.
Mark J. Rebilas-USA TODAY Sports

The Seattle Seahawks released their Wednesday injury report, and as expected Justin Britt did not participate because of the ankle injury suffered on Sunday against the New York Giants. Britt’s injury, according to Pete Carroll, is not a high ankle sprain, and thus should be expected to heal significantly faster than if it had been a high ankle sprain. In his Wednesday press conference Tom Cable stated that he expects Britt to be a go for the showdown with the Houston Texans this Sunday, which is good news for the team and fans. The plan remains for Britt to practice Friday and play Sunday, so as long as there are no setbacks fans should expect to see the same offensive line grouping as last week.

In the comments to the article earlier this week on Britt’s ankle, one commenter asked why it was that Britt was able to return to play with a sprained ankle while others, such as C.J. Prosise, have taken longer to return from a sprained ankle. The simple answer is that Britt suffered a lower ankle sprain while Prosise suffered a high ankle sprain, and the recovery time for the two is different. The type of ankle injury Prosise sustained requires a much greater recovery time, and while that has contributed to fans asking if he is simply injury prone, there are legitimate reasons why Prosise has been out longer.

To get more detail on the differences, I reached out to Dr. John Gilbert, a retired orthopedic surgeon, and asked him for the quick and dirty on the difference between a high ankle sprain and a low ankle sprain. This is how he responded:

Sprains are classified into three grades;

First degree sprains have enough injury to cause swelling and pain but not mechanical instability.

Second degree sprains demonstrate instability but a firm endpoint indicating partial disruption.

Third degree sprains show complete disruption of the ligament with gross instability.

The lower ankle ligaments are in two groups; the medial and lateral.

The lateral ligaments are the most commonly injured. They are the anterior talofibular, calcaneofibular and the posterior talofibular. These are relatively small ligaments and can be individually injured with variable degrees of instability, pain and treatment can vary.

The medial, or deltoid. ligament is functionally one large ligament although some people try and describe various segments, This requires much greater force to injure and is frequently associated with significant bony injury - more serious and longer to heal.

The High Ankle sprain involves large ligaments between the distal parts of the tibia and fibula. Injury here is going to require major force. I've not seen many MRIs of ankle sprains but suspect that the high ankle sprains involve significant bony injury which doesn't show on x-ray but will show on MRI. Before MRIs we clinically diagnosed them as bone bruises.

The lower ankle ligaments are all well surrounded by soft tissue and being soft tissue heal fairly rapidly. The high ankle injury is probably an occult bony injury and therefore requires bone healing time. In my experience those bony injuries which don't show up on x-ray but do show on MRI usually heal fine but take a long time.

That’s some great information and lays out the basics about the different types of ankle sprains and why they heal at different speeds, however, he wasn’t done. He authored that in the morning before hopping on a flight, and apparently in spite of being retired he was so annoyed with not being knowledgeable about MRIs of ankle sprains that upon arriving at his destination he sat down on the laptop and got to work researching the matter. His followup to me was thus:

I found a good discussion of ankle sprains by Googling "High Ankle Sprain MRI images" and found an article by JM Evans on imaging at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1618742/. See in particular case 9 which shows the acute bony injury.

MRI's have basically two modes depending on "which way the magnet spins the electrons" (my conceptualization) The are called T1 and T2. High signal means white on the image, low signal is black. T1 means fat is white and T2 means water (blood) is white. Tissues have varying contents of each.

(Author’s note: I looked at the image for case 9 and it meant nothing to me because I have zero experience reading MRIs and if shown that image I would have guessed it to be a misshapen skull.)

As I’m not in the medical field, much of the research article he referred me to went well over my head. However, there were a couple of things which did jump right out. The first is the opening two sentences of the section labeled Discussion which read, “Ankle sprain is the most frequent sports injury encountered today. The complications include prolonged ankle pain, a high rate of recurrence, and chronic ankle instability.” It is that last part, “high rate of recurrence and chronic ankle instability" that is troubling considering the number of Hawks that have suffered ankle injuries.

The second thing that jumped out to me is figure 6. This is a fantastically simple image which shows something relevant to both Prosise and Thomas Rawls which I do understand: the tight spacing within the ankle and how any kind of serious trauma can result in long term issues. Just looking at that image it is readily apparent that there is not a lot of room within the ankle to be messing around, and Rawls reportedly had to have a plate and screws put in to repair the broken leg he suffered in 2015. Trying to fit a plate and multiple screws into that picture of the ankle would be hard, as there is not a lot of room to fit much of anything.

In addition, because the ankle holds the entire weight of the body on a much smaller surface area than the knee, it makes the ankle significantly more susceptible to pain if the injury does not heal one hundred percent correctly. Pulling from another old email exchange with Dr. Gilbert, he had the following to say on this matter,

Mechanical tolerances in the ankle are tight enough that 1mm of displacement decreases joint contact area by 50% and pressure on articular cartilage conversely increases. With any residual displacement or instability the long term prognosis is for degenerative disease.

Basically, what that says is that following a fracture within the ankle, if the bone does not heal absolutely perfectly there is a very good chance for long term issues including pain and instability. That could be exactly what has led to the decline we have seen from Rawls since he returned to the field in 2016.

Now, Rawls and Prosise are both young, so hopefully they will recover and return to the field to dominate, but so far their injury histories are not indicative of this and they play one of the most injury prone positions in all of sports.