Jack Isenbarger: From Injury to Recovery
Updated: Sep 25, 2018
As many of you may know by following the Baseline Physio Facebook or Instagram page, I have been doing a lot of work with Jack following a serious leg injury he suffered on the 8th of July. This blog’s aim is to give a complete rundown ofJack’s injury, his early management and surgery, and what the future holds after he heads back to the US.
Before I say anything else, I’d like to thank Jack for allowing me to write up this blog, by giving me access to all of the medical records and data, access to the video of the incident and above all just for being a good friend and being so motivated through this whole rehab process!
Going into game 17 on July 8th against the Geraldton Buccaneers, Jack and the Lakeside Lightning had won 6 of their previous 7 games, with Jack averaging 27.3 points per game in his last 8 games.
Jack started the Geraldton game in a similar fashion to his previous 8, making 4 of 5 shots.
In the 9th minute of the game, during a fast break Jack went up for a layup. His leg got entangled in the air with the Geraldton defence, causing Jack to land awkwardly on his left leg.
From this point, because his leg is entangled he essentially has the defender’s whole body weight coming down with a shearing force on his leg.
The incident is shown in the video below. While the footage isn't graphic, it may be distressing.
A quick run down of ankle anatomy that is relevant for Jack’s case:
Your ankle is formed where the two bones in the lower leg - the tibia and fibula - meet to form what is referred to as a “mortise”. Essentially an inverted bowl that the rest of the ankle fits into. In this bowl sits your talus, which moves up and down as you point your foot to the floor, or lift your toes to the ceiling.
Below the talus sits your calcaneus which makes up your heel. Where your calcaneus meets the talus is known as the sub-talar joint, whose movement is primarily inversion (turning your foot in) or eversion (turning your foot out).
Around these bones are the ligaments which provide structural stability to the joint. Most of us have sprained an ankle by rolling our ankle inwards. This likely would cause a tear to one or more of the ATFL, CFL or PTFL ligaments. These are the ligaments on the outside of the ankle which are fairly small, and don’t require too much force (relatively) to tear in some way.
On the inside of the ankle are ligaments which we refer to collectively as a singular “Deltoid ligament”. These ligaments are bigger and stronger than the ligaments on the outside of the ankle and are far more difficult to tear. That is why so few people have ever had an EVERSION sprain of the ankle, but so many of us have had an INVERSION sprain of the ankle!
In terms of the structural support to the ankle a bit higher up, we have ligaments that wrap around the front and the back of the tibia and fibula that make sure they stay pulled in nice and tight together and don’t pull apart. We also have something that is called a “syndesmosis" or “aponeurosis”. This is essentially a thick membrane that looks like webbing that connects the tibia and fibula together. If someone sprains or tears these ligaments, they would have what we would refer to as a “high ankle sprain”.
Once Jack got to the hospital, his X-Rays which were taken looked like this:
Jack’s X-Rays showed he suffered a fracture to the middle of his fibula, to the bottom of his tibia, he sustained a full tear to his deltoid ligament, as well as tearing to his syndesmosis.
The likely chain of events which caused Jack’s injury are as follows:
Defender lands on outside of Jack’s leg, breaking fibula
Player’s momentum carries on, forcing Jack’s ankle into eversion
Jack tears his deltoid ligament
Continued momentum forces talus out of mortise, dislocating ankle
The twisting forces of the ankle causes fracture of the tibia close to the mortise
The tibia and fibula are forced apart, tearing the syndesmosis between them.
Surgery and Early Management (0-3 weeks)
Once at the hospital, Jack was put under anaesthetic and his ankle was “reduced”. This essentially means they pulled the ankle back into the mortise. He was also placed on strong pain medication, as you would expect. As they relocated the ankle, the break in Jack’s fibula was pulled into a better alignment. The surgeons were happy with the position of the fibula at this point and left it to heal naturally. The focus was now solely on the ankle joint itself.
On Monday afternoon they did surgery on Jack’s ankle. At this point, the biggest issue from the surgeon’s perspective was the high ankle ligament tears, causing the tibia and fibula to be unstable. If this was not fixed, essentially what would happen is every time Jack put weight on the ankle, the talus would be forced up into the mortise, splitting them apart with each step.
The surgery for this was actually very quick and simple: - the surgeon drilled two screws into the bones, holding them together until the high ankle ligaments healed. The surgeon also decided NOT to repair the deltoid ligament as he believed that this would heal naturally as well.
Jack was placed in a moon boot following the surgery and ordered to immobilise his foot entirely for 3 weeks. He was then released early on Tuesday July 10th. The plan was to review at 2 weeks, 6 weeks and 12 weeks. At the 12 week mark (not one day sooner!), Jack would have the screws removed.
Early rehab (3-6 weeks)
On the 31st of July, Jack finally got the chance to take off his moon boot and start some gentle rehab. He was told simply that he should only put 50% of his body weight through his injured side. His tentative date for returning to basketball was put at 1 year following the injury.
One of the first things we wanted to avoid with Jack was to force his ankle into dorsiflexion - by forcing that movement we would have been causing stress on the mortise of the ankle and weakening the hold of the screws that were in place.
An early observation was that 3 weeks in a moon boot had caused Jack to lose significant muscle mass in his left calf and lower leg:
Our early rehab focussed solely on ankle mobilisation. The focus was just on getting the joint used to movement again! Jack and I agreed that our benchmark for knowing if we were pushing the ankle too hard was simple:
If the joint swells up or becomes really sore after a treatment session, we pushed it too hard and have to back off for the next session.
Some swelling is to be expected and during rehab we have to push through some amount of pain, but the best determinant of what is too much is simply when our body tells us we have done too much!
With this framework in mind, Jack and I were both encouraged when after 1 week of gentle movements the joint never once flared up. Jack’s main issues at this point was some achilles tightness, and mild pain on the inside of his ankle around the region of the deltoid ligament tear. We agreed that the pain was likely because it was the first time in 4 weeks the ligament had been put on any level of stress.
At this point, Jack and I decided to become more aggressive in our approach to the rehab. The joint was responding well and Jack was chomping at the bit to get into some more challenging exercise.
We began isometric strengthening at this point, which is simply holding a muscle contraction without making the joint move. A simple example of this would be a plank - you hold the muscles in one place, but they are all having to work hard to keep the joint still!
We began strengthening the muscles on the outside of the leg, the inside of the leg and at the front of the shin. We began with 30 second holds of a 1.5kg weight, followed by 30 second rest. We did this for 3 sets. By the end of this session Jack had already doubled the weight to 3kgs, and holding for up to 1 minute!
By the end of the week Jack and I added in calf strengthening. Jack simply lay on his front, pushed down into my leg and held the contraction against my force for 30 seconds. It was gentle, but to give a sense of how hard this was on his atrophied calves, check out the video I took at the time below:
This video was taken on the 13th of August!
By the end of that week, Jack and I had already decided that we could begin to challenge the ankle with more weight and start gentle walking. This was sooner than the surgeon had suggested but again the ankle had responded so well to everything at this point we both knew he was miles ahead of where he was meant to be!
It was at the end of this week that I posted the following video of Jack walking at Lakeside:
On Wednesday the 22nd Jack met up with the surgeon for the first time since his 2 week follow up. His surgeon at this point moved Jack’s return date from 1 year to 7 months post injury! His restrictions for many things were then lifted:
Jack was allowed to wean himself off his moon boot
I was allowed to get Jack’s foot into dorsiflexion as much as he could tolerate now
He was allowed to do any strengthening he wanted, as long as the movements involved didn’t include heavy landing or anything too explosive.
The surgeon even said not to worry if anything we did caused his screws to break! Sounded like a blank canvas to Jack and myself! Additionally, the following X-Rays were taken, which showed that his fibula and tibia had healed up really well!
Early Strengthening (6-12 weeks)
The next day Jack and I got in the gym and began more functional movements (related to basketball) and really decided to challenge the ankle. We could now be really aggressive (without being reckless) in Jack’s rehab.
The following videos show the exercises we decided to start on:
Jack’s ankle was initially a little bit sore and did swell up, but again Jack was comfortable with the amount of pain and it never seemed to be over a particularly bad area. For example, If Jack’s pain was directly over where the break in the fibula had been I would have been quite wary of this, and eased back on the exercises.
Rather, Jack’s discomfort tended to be along the front of the ankle, or followed the tendons of the muscles on the inside of the ankle.
I then added more exercises, which were less focussed on the ankle itself but began to look at the “big picture” - Jack’s entire left leg would be significantly weaker than it should be - his tendons would also be weaker than they were, making it more likely that he would develop tendon issues once he got back on the court - these were just as important to begin to strengthen as the ankle itself at this point!
Jack has since moved on to more functional exercise, such as calf raises and step ups, which replicate layups as much as we're allowed within the surgeon's restrictions.
Jack has been struggling over the past week or two with stiffness more than anything else - we need to remember though that because Jack is so far ahead of schedule to this point, we may just be looking to improve a movement which is not ready to be improved just yet!
You can see that his left ankle is still signifcantly stiffer than his right side (5th September)
Back Home and Future Rehab
Now back in the US, Jack has begun doing some hydrotherapy, and is continuing to strengthen as much as possible. The next big date we are both looking forward to is 12 weeks post-op, where Jack has an appointment with the same surgeon who operated on Gordon Hayward's broken ankle.
Jack has increased the range of motion of his ankle really well! The photo below shows he's actually starting to get his knee beyond his toes now in the knee-to-wall test:
This appointment will be used to take the screws out of Jack's ankle, as well as determine if a further surgery is needed to repair the deltoid ligament. This may impact Jack's recovery time.
If the surgeon is happy and the screws are removed, then the next step of rehab will be working towards more explosive movements, as well as working on 'soft' landings on the left ankle.
In the meantime, Jack is continuing to get on the court, putting up some shots and working towards doing some more cutting and pivoting-type movements!
Jack has been an absolute champion with his attitude towards his injury and his rehab throughout. I will continue to post any updates as we get them! We are still aiming for a return to full fitness around January 2019.