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Matt Schaub: High Ankle Sprain and Injections That May Speed Recovery

Unfortunately, the entire nation has now seen and reacted to the injury to Matt Schaub’s leg last Sunday and the aftermath which followed. As a sports medicine physician and quite frankly as a human being, I’ll go on record saying that in no instance is it warranted or acceptable to cheer/boo an injured athlete. From the perspective of a die hard Houston sports fan, which I also am, I would like to think that those who were cheering weren’t actually cheering that Schaub was hurt but rather that a quarterback change was imminent. As distasteful and ill-timed as it was, I have enough faith in the decency of Houstonians to assume that those cheers were a knee-jerk expression of relief and not thankfulness that he was hurt.

As for the actual injury, the replay demonstrated that his knee and ankle both were awkwardly caught and twisted by a defender’s contact. In many ways I think he is fortunate that his ankle was in a twisted position and absorbed the brunt of the torquing force. Had his foot been firmly planted on the ground he might have sustained a very serious injury to the ligaments of his knee. We have been told by the Texans organization that he has sustained a “high ankle sprain.” This is classically a more severe type of ankle sprain that involves not only the ligaments that connect and stabilize the joint between the lower leg and the foot, but also the ligaments that connect the two major leg bones (tibia and fibula) just above the ankle joint. All of the body’s weight is transferred through these ligaments and stability here is essential for the ankle joint to be able to support the body, which is why these injuries have historically been treated more cautiously and required longer healing times than typical ankle sprains. As with all injuries, there are varying degrees of severity of a high ankle sprain, and from his demeanor shortly after the injury (walking around without assistance and preparing to re-enter the game) as well as in the days following it sure appears that Schaub suffered a relatively stable variant of the injury.

Coach Gary Kubiak mentioned in a media session that Schaub had received “injections” and is getting treatments for the injury. While I have not personally treated this athlete nor am I in any way privy to any more knowledge regarding the medical treatments any of these athletes are actually receiving than are the rest of you, I can infer from the information available that the most likely injection he received was a corticosteroid (steroid) injection. This type of steroid is not considered anabolic and is not a banned substance when used for treatment of injuries. It has also been used in other injuries such as hamstring strains and hip pointers to hasten recovery. A recent study of this treatment by Dr. Alfred Mansour of Houston, Texas was published in the journal of the American Orthopedic Society of Sports Medicine this summer. Comparison of 31 NFL athletes treated with steroid injections for high ankle sprains plus a standard rehab protocol versus a standard rehab protocol without the injection was reviewed. The study revealed that athletes who received the injection were able to return to play in an average of 15 days versus 25 days for those who did not. In the NFL, 10 days can mean at least one less game missed, and so the significance of this improvement can not be understated.  Unfortunately, what we don’t really know is what the trade-off of the treatment and early return is in terms of long-term health and recovery of that ligament, re-injury rates, and collateral damage. The normal healing response for an injured ligament is initiated by an  inflammatory reaction which brings swelling to the area with which come growth factors critical for ligament repair. When a corticosteroid injection is given, it essentially shuts-off the inflammatory response which may make the injured area feel better but may also be inhibiting normal healing. This is similar to taking Tylenol when ill with a fever to make you feel better, even though the fever is part of the body’s normal reaction to fighting an infection. We are fairly certain that controlling the fever doesn’t shut off the whole immune repsonse, however, we are not yet as clear on whether blocking the inflammatory reaction will impair normal healing of the injured ligaments in a high ankle sprain.

The long-term sequelae of these treatments are unknown and thus while the potential unknown risk may be something a professional athlete is willing to accept to return to his or her livelihood, I don’t recommend this treatment to the high school athlete or weekend warrior who shows up in my office with a similar injury. So whether you are in the camp that wants to see Matt Schaub back on the field as soon as possible or not, this is a good example of how professional athletes regularly do things that can potentially have long-term negative consequences for their health and well-being, just to try to get back on the field and help their team while protecting their livelihood. Not that we really should need it, but this is yet another reason one should never cheer an injured athlete.

Written by Vishal Michael Shah, M.D.

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