Hey everyone, it’s Raj from 3CB Performance.
The Niners overall #2 pick Nick Bosa suffered a right high ankle sprain during training
camp on August 7th when, according to GM John Lynch, his right leg got rolled up on during
a big pile up. In this video, I’ll explain the injury, Nick’s return timetable, and
a few things to think about moving forward.
A high ankle sprain refers to tearing of the ankle ligaments that sit above the talo-crural (TC) joint
which is the joint that most people think of when referring to the ankle.
These higher ligaments are known as the ankle syndesmosis & connect the tibia ( shin bone) and the
fibula (outer lower leg bone).
The syndesmosis stabilizes the tibia and fibula at the distal (far) end and
provides added support and stability to the ankle joint complex.
There are four primary stabilizing ligaments: The anterior-inferior tibiofibular ligament (AITFL)
the deltoid ligament
posterior-inferior tibiofibular ligament (PITFL)
and the interosseous ligament (IOL).
A syndesmotic tear (high ankle sprain) most commonly occurs when the leg or ankle externally
rotates (turns outwards) on a planted foot.
Most commonly, that happens due to an external force - like being rolled up on from behind
- which is what happened to Bosa.
Considering the amount of contact and risky situations, it’s no surprise that American
football has one of the highest rates of high ankle sprains.
The highest you ask? Ice hockey.
The Niners announced that Bosa will miss the rest of pre-season and are targeting a week
1 return. That four week timeline aligns with the average return to play for a grade 1 syndesmotic
tear, which involves partial tears of the AITFL, anterior deltoid ligament, and distal IOL.
With a grade 1 tear, the ankle is considered stable whereas most grade 2 and 3 syndesmotic
tears are considered unstable joints and are operated on, typically a season ender.
Recently, we’ve seen expedited return to play protocols that have players back as early
as two weeks but research is still limited on their effectiveness and safety moving forward.
There are rare instances where players with an extremely high pain tolerance have been
able to play through a high ankle sprain under the watchful, attentive eye of elite rehab teams.
One example is Eagles right tackle Lane Johnson who didn’t miss any time last season
after suffering a high ankle sprain in week 5, albeit he was noticeably hobbled and his
performance took a major hit.
An even more extreme case was Golden State Warriors guard Klay Thompson who had a high
left ankle sprain in game 1 of the 2018 Finals and played in game 2 a mere two days later
and the rest of the series.
With the Niners and Bosa, however, the risk/reward calculation doesn’t make sense to rush or
hurry the rehab.
With the appropriate rehab, there are no major risks moving forward for Bosa and the injury
isn’t too concerning in isolation.
However, what is concerning is that he’s had a series of injuries over the past three
years, including a partially torn right ACL tear in high school, an abdominal muscle tear
at OSU which needed surgery and ended his season
a right hamstring tear on the first day of OTAs
and now this high ankle sprain.
With each injury comes a loss of fitness and an increased risk for compensatory injuries.
Adding to that is each of his lower body injuries have occurred on the right side. Further,
the hamstring tear and the high ankle sprain come at particularly inopportune times because
Bosa will miss extremely valuable OTA and training camp time which are key for building
up gradually towards the regular season, doubly so for rookies who are learning new playbooks
and acclimating to the NFL.
All in all, there’s obviously no doubt about Bosa’s talent level and he’ll be effective
in the league but the team will certainly have to keep a close eye on his health as
he’s recovering from the high ankle sprain and especially guard against the high risk
of hamstring re-injury, mainly through targeted strengthening and gradually ramping up of activity.
That’s a wrap for this video. Thanks for watching. My goal is to provide you with in-depth,
evidence based, narrative free analysis and you can always find me on IG and Twitter @3CBPerformance.
Make sure to sub to the channel for the latest updates. 3CB out.