There were very few positives for the New York Giants following Sunday’s 27-21 loss to the Arizona Cardinals, but having No. 26 return to the offensive backfield may have been the team’s only good news.

Running back Saquon Barkley, arguably the team’s best offensive player, started for the Giants just four weeks after suffering a high ankle sprain in the first half of Week 3’s loss to the Tampa Bay Buccaneers. Barkley rushed for a modest 72 yards on 18 carries with one touchdown and also caught three passes out of the backfield, but leaving the field Sunday without re-aggravating his injury may have been his biggest victory.

The 6’0, 234-pound 22-year-old suffered the sprain after his ankle was bent in an awkward manner following a tackle. Barkley was helped off the field and later reappeared on the sideline in a walking boot with crutches. Initial talk was that his recovery period that could have stretched eight weeks, but Barkley sidestepped possible surgery and rehabbed quickly, amazingly returning in just a month. (New Orleans Saints running back Alvin Kamara missed Sunday’s game against the Chicago Bears with the same type of injury, and fans of the Alabama Crimson Tide may want to also pay close attention: Quarterback Tua Tagovailoa underwent surgery after suffering the same injury and will miss at least next week’s game against Arkansas.)

Board-certified chiropractic sports physician Dr. Rolland Nemirovsky of Manhattan Sports Therapy—an expert in these types of injuries (but who hasn’t treated Barkley)—breaks down the specifics of high ankle sprains, including how they happen, what it takes to treat them, and the risks of potentially returning to action too soon.

Saquon Barkley rushed for 72 yards against the Cardinals in his first game back after suffering a high-ankle sprain
Bill Kostroun/AP / Shutterstock

Bill Kostroun/AP/Shutterstock

What exactly is a ‘high ankle sprain’?

When we hear “ankle sprain,” we tend to think of the typical sprain that occurs at the ankle joint—either inversion, where our foot turns violently inward and damages the lateral ligament on the outside of the ankle (by that bony “knob”), or eversion, where our foot rolls outward and damages the inner, medial ligament.

A high ankle sprain, however, occurs a little higher up the leg, just as the name implies. “A high ankle sprain represents a tear in the connective tissue between the two long bones of the leg called tibia and fibula, located above your foot and ankle joint,” Nemirovsky explains. “The ligamentous tissue that is sprained is called ‘syndesmosis.’ The tear occurs with inversion and dorsiflexion—that is, bending the foot toward you.” Or, as in Barkley’s case, when his right ankle got caught underneath Buccaneers safety Mike Edwards during a tackle on a third-and-five play.

Barkley’s body clearly indicated after the play that something wasn’t right with his lower leg, but identifying the severity of the damage isn’t always so quickly obvious.

“When a tear exists in the syndesmosis, pain will be felt from the ankle and travel up the leg, but there’s typically little to no sign of tearing of this tissue, unlike the inversion/eversion sprain which shows immediate swelling and bruising,” Nemirovsky points out.

How does this injury typically happen? Does it typically require surgery?

“High ankle sprains occur with a sudden turning, twisting or cutting motion by the athlete,” Nemirovsky says. “High-impact sports—like football and basketball, to name two—are more susceptible to high ankle sprains.”

There are three types of tears: Grades 1, 2, and 3. Luckily for Barkley, his injury was lower-grade, eliminating the need for surgical repair, which in a severe high ankle sprain would have meant reaffixing the ligament to the bone. “For Grade 1, think of it as deep paper cut,” Nemirovsky says. “For Grade 2, now you’re ripping a piece of paper halfway. And Grade 3, you rip that paper into two halves.” (In a word, Ouch.) A Grade 2 or 3 tear may require surgery.

Although Barkley appeared to come out of Sunday in good shape, he along with any athlete suffering the same injury must avoid coming back too soon. A re-injury could cause further damage and keep him sidelined indefinitely, Nemirovsky says.

“If the fibers of the ligaments aren’t given ample time to heal, risk of re-injury increases,” says Nemirovsky. “Ligaments and tendons are avascular tissues. In other words, they don’t have their own direct blood supply, and this increases healing time and the chances of re-injury.”

What would a typical rehab look like?

Like most athletic injuries, recovery should immediately start with the RICE protocol (Rest, Ice, Compression, and Elevation), with follow-ups over the ensuing days and weeks including modalities like electric stimulation, ultrasound, cold laser, moist heat, and taping. “Then, you induce motion of the ankle, followed by band-resisted exercise, and finally, balance work,” Nemirovsky says. This can all take as little as a couple of weeks for Grade 1 sprains, to 6-8 weeks for Grade 2, and months for Grade 3s.

Can anyone return to the playing field as quickly as Barkley?

When it comes to a high ankle sprain, advanced, elite athletes can’t heal any faster than the average person. However, athletes do have some advantages, Nemirovsky admits. “[Elite athletes] have the ability to take rest time, and have access to high-quality care and nutrition,” he says. “These factors might improve how the healing process goes but will not always change the length of time required for healing.”

Bottom line: While you can’t protect yourself from suffering a high ankle sprain, improving your lower-body strength, balance, and flexibility can help.