A doctor's view: Does LeBron James's ankle injury put his season in jeopardy?

Indefinitely. That is the word athletes hate to hear when they have an injury. Usually they just want to know, Can I play through it? Otherwise, when can I be back? Indefinitely is not a good word. On Saturday, LeBron James went down with an ankle injury. The injury is more striking given that he recently voiced his distaste for this month’s All-Star game, which he believed put more wear on players who had already had a shortened offseason due to the Covid-19 pandemic.

Nevertheless, he made it through unscathed – or at least until the second quarter of the Los Angeles Lakers’ game against the Atlanta Hawks on Saturday. While trying to grab a loose ball, he collided with Hawks forward Solomon Hill. James’s right leg began to roll in, but then his ankle forcibly rolled outward, which can be a recipe for a high ankle sprain.

To understand what a high ankle sprain means, first it’s important to define the difference between a tendon and a ligament. A tendon is how a muscle attaches to the bone it needs to move. Muscles are meaty structures but not very strong. In order to pull a bone, the muscle transitions into a thick rope-like structure called a tendon that then inserts into the bone so that the body can move. A ligament, on the other hand, is like a tendon in its rope-like consistency, but it isn’t attached to a muscle. It simply runs between bones to help stabilize a joint. The ACL in the knee is a well known example.

So when James rolled his ankle outward, he stretched or tore the ligaments in his ankle. In his case, it wasn’t the ligaments that stabilize the ankle to the foot, but instead the ligaments that connect the two leg bones together. This ligament runs up and down the leg below the knee to the ankle like a broad sheet and is called the syndesmosis. That’s why it’s called a “high” ankle sprain – it’s not by the foot, but higher up on the leg bones.

When James was taken to the locker room, reports are that he received x-rays and an MRI. It’s rather important to note if anything was seen on the x-rays, because that could mean he needs surgery. If the bones appeared wider apart on x-ray, that is usually a much more significant injury than one that needs a higher tuned MRI to see. An ankle joint that is widened from a syndesmosis injury can’t heal back in place on its own. If it widens with stress, it also may need surgery.

Surgery entails placing hardware across from one leg bone to the other. This was traditionally done with the screws for a long time, especially if there are broken bones involved. The screws are strong, but the downside is sometimes they can break so often they are removed with a second surgery. A more sports-friendly technique evolved in which a small rope is attached between the two bones to help recreate the stability and motion of the ligaments. It may not be as stiff as screws, but it doesn’t need to come back out.

If James needs a tightrope-type surgery, he may be out between four and six weeks, but some nagging ligament injuries can last up to 12 weeks, which means he would not be back until well into this season’s playoffs. Not all players studied, though, are million-dollar franchise players destined for the hall of fame. So these numbers may be thrown out the window if an athlete feels they need to get back sooner. A classic example of this was when Terrell Owens played wide receiver for the Philadelphia Eagles. He suffered a high ankle sprain towards the end of the 2004 season and needed surgery. Just seven weeks later, his team played in the Super Bowl. He returned against doctors’ advice for the big game and had nine catches for 122 yards.

Ligaments can be stubborn when it comes to healing. They may not heal as quickly or reliably as bones, and other factors like bruising of the bone can also linger. Coming back too quickly can prolong the time it takes to fully heal up, leading to subpar performance or a series of ups and downs. James, at the age of 36, is someone who has his career longevity down to a science, often counting up number of games played and minutes on the court. Nevertheless, when the playoffs come, he has been known to push through pain to carry his team over the threshold. With the second half of the season just kicking off and two months before the playoffs, he should have plenty of time to rehab.

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