Why Lamar Jackson and the Ravens must be cautious with his unique ankle injury

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When Tennessee Titans defensive end Jermaine Johnson dove at the right foot of a scrambling Lamar Jackson late in the first half of Sunday’s game, he missed.

In Johnson’s attempt to corral the Ravens quarterback’s right foot from behind, he’d landed on the back of Jackson’s left foot. And as Johnson fell, Jackson’s ankle twisted.

The human body is predisposed to inversion, a movement where the sole of the foot turns inward, toward the midline of the body. Imagine a typical rolled ankle in a pickup basketball game.

Jackson experienced the opposite. In an eversion of the foot, the sole turns outward, away from the body’s midline. The ankle ligaments at greatest risk are not the lateral ligaments, which start at the end of the fibula that forms the bony bump on the outside of the ankle, but rather the medial deltoid ligament, a strong triangular band of tissue on the inner side of the joint.

“Most people, when they are spraining their ankle, they are spraining the lateral side,” said Dr. Amiethab Aiyer, a professor of clinical orthopedic surgery at the Johns Hopkins University School of Medicine.

Jackson is believed to have suffered a medial sprain, according to media reports, an uncommon ankle injury that could sideline him for Sunday’s game against the Atlanta Falcons — and perhaps longer. Coach Jesse Minter has not specified Jackson’s injury or recovery timetable, except to say that he’s not expected to be out “crazy long-term.”

“When he’s ready to play,” Minter said after Jackson missed practice Wednesday, “he’ll be ready to play.”

The deltoid is the ligament most responsible for stabilizing the ankle, Aiyer said. That also makes it harder to tear and potentially more significant when it is damaged.

The severity of a medial sprain depends on the damage to the two layers of tissue in the ligament — one deep in the ankle, the other more superficial. A Grade I sprain, the least severe, applies to a ligament that is stretched but not torn, resulting in mild pain and swelling. A Grade III sprain, the most severe, applies to a completely torn ligament and is associated with significant instability.

“The more of the ligament that is involved, whether it’s the more superficial part of the deltoid, or the deep part, or both, that is what will help to dictate to what extent is the ankle increasingly unstable,” said Aiyer, who is not involved in Jackson’s treatment.

High-ankle sprains, which typically sideline players for over a month, can also accompany medial sprains, Aiyer warned. Sprains can damage ankle structures such as the syndesmosis, the group of ligaments that connect the tibia and the fibula at the ankle joint.

Dr. Kyle Yost, an assistant professor at the University of Maryland School of Medicine in orthopedics and family medicine, said medial sprains typically take longer to heal than low-ankle sprains.

“You tend to be more conservative, a little bit, in the beginning,” said Yost, who is also not involved in Jackson’s treatment. “So you’re talking more like weeks versus days for this type of injury.”

Jackson left the Ravens’ win Sunday over Tennessee in a protective boot, which Yost said would help relieve any potential stress on the syndesmosis and stabilize his injured ankle. Jackson then underwent an MRI on his ankle Monday; Aiyer and Yost said the results of the imaging would help guide his treatment and recovery, from range-of-motion exercises to physical therapy.

“With momentum here, it would be very easy [for the Ravens] to say, ‘Let’s just go,’” Aiyer said. But he urged caution, saying Jackson could “run the risk of making an injury, whatever it is right now, into a worse one.”

He added: “That is the very fine line that becomes a very important conversation between whoever the player is and their team physicians — and the coaches, for that matter — about, ‘Hey, how do we get this player back on the field?’ … I think that’s really the tough call here.”

If Jackson returns before his ankle is fully healed, the effect on his game could be noticeable. Yost, a team physician for Maryland and UMBC, said Jackson’s mobility would likely be limited “for a while” if he’s recovering from a medial sprain.

“That’s what really kind of gets zapped a lot of times with these ankle sprains on the medial side, is your explosiveness,” he said. “So he’s probably not going to be doing that as much.”

Minter indicated Wednesday that Jackson could play without practicing, but Aiyer said more deliberate ramp-ups would help with recalibrating his body’s readiness for certain movements: “OK, this is what you need to do. This is how you need to do it.”

Injuries were a hindrance last season for Jackson, who was limited to 13 games and career-low rushing numbers. But only Jackson knows how painful this latest injury is. And only Jackson knows how much pain he could play through. The challenge for him and the Ravens now is figuring out an acceptable level.

“You want to make sure that he’s doing well and that he’ll tolerate the load before you send him back,” Yost said. “You don’t want to make it worse or send him back too early.”