Few injuries among famous athletes have generated as much interest this year as the ankle fracture of New York Yankees superstar Derek Jeter. Like the intense scrutiny of the ACL injury of his teammate, closer Mariano Rivera, questions about why and how Jeter’s injury could have happened abound.

How did he break his ankle when his fall seemed harmless?

Late in Game 1 of the American League Championship Series against the Detroit Tigers, Jeter moved to his left to field what looked like a routine ground ball. He stumbled and fell. While it did not look like an abnormally hard fall, Jeter’s face showed his tremendous pain. When he looked toward his left ankle, Yankees fans immediately feared that the captain was in trouble.

As he left the field, speculation about the nature of the injury dominated the television and social media discussions. ACL tear? Achilles tendon rupture? Ankle sprain?

Yankee StadiumSo many coaches and managers tell the media that an injured player has a “sprain” or “injury” and “needs further tests.” Yankees manager Joe Girardi instead broke the news quickly in the postgame press conference. The sure Yankees Hall of Famer had suffered an ankle fracture. He would be out of baseball for three months. His postseason was over.

Now we know that team doctors performed an MRI and CT scan on the shortstop’s ankle. Jeter traveled to Charlotte, North Carolina this week to be evaluated by Dr. Robert Anderson, a sports foot and ankle specialist.

According to some media reports, Jeter and the Yankees wanted to find out if any ligament damage occurred in addition to the fracture. Speculation centered on the possible need for surgery.

Sources have now confirmed that the shortstop will in fact undergo surgery. Instead of the initial estimate of a three-month recovery, he is now expected to miss four to five months.

Why does Jeter need ankle surgery?

Bimalleolar ankle fracture
This x-ray shows that the patient has a fracture of both the lateral malleolus (white arrow) and medial malleolus (yellow arrow).
Without knowing more of the details, I think the possibilities for his surgery fall into two categories. One possibility lies in a potential need to line up the bones better and hold them in place with either screws or a plate and screws. The other possibility comes from tears of one or more of the ligaments supporting the ankle. In those cases, a surgeon could repair the torn ligaments or even augment them with tendons to reinforce them.

Usually when a fracture occurs in one of the bones around the ankle, the ligaments remain intact. That is the idea behind the “Structures fail at the point of least resistance” theory. Dr. Anderson’s plan for Jeter’s surgery will shed more light on the injury in coming days.

Did prior foot and ankle problems lead to his fracture?

Bimalleolar ankle fracture after surgery
I fixed this patient’s fracture with two screws for the medial malleolus and a plate and screws for the lateral malleolus.
Another interesting controversy with Jeter’s ankle fracture centers on prior foot and ankle problems. Different media reports have suggested that the 13-time All Star had suffered a bone bruise in his foot and had received cortisone injections in his ankle.

To be fair, it is hard to comment without knowing the exact details of his case. I doubt that the team will release them. But even Girardi himself has speculated that prior troubles might have led to this injury.

If Jeter had a stress fracture of a bone in his ankle, then a twisting or inversion injury could break the bone entirely. Think of bending a paperclip back and forth. The metal gets weaker with overuse until a final stress causes it to snap.

It would also be hard to know if cortisone played any role. While orthopaedic surgeons worry that steroids, like cortisone, can weaken tendons, ligaments, muscles, articular cartilage, and even bone, that degeneration usually requires many injections. That would likely be more of a concern with using repeated injections for knee arthritis, rotator cuff impingement (“tendinitis” or “bursitis”), or tennis elbow.

Will Jeter’s age slow his recovery?

Finally, Yankees fans will surely worry about the chance that their leader, at age 38, will not recover as well or as quickly as would a younger player. Fans might even question whether the 18-year veteran will successfully return to baseball at all.

The Dr. David Geier ShowDerek Jeter’s ankle fracture: That’s Gotta Hurt segment from Episode 61 of The Dr. David Geier Show.

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That recovery and return will be closely followed, but I would point out that his chances are based in large part on the exact nature of the surgery. If the plan is to align the fracture ends and hold them in place until the fracture heals, then I would expect Jeter to recover uneventfully. Fractures, assuming they line up well and remain in the proper position, heal by the body laying down new bone. I think Jeter’s age would not prevent that bone healing process, or even delay it.

Ankle sprain rehab
Rehabilitation for an ankle sprain or ligament repair involves efforts to restore balance during sport-specific activities.
On the other hand, if he undergoes surgery to repair or reconstruct ligaments in his ankle, his timetable for return is potentially more tenuous. The surgeon would have to immobilize the ankle for a long time to protect the ligaments before slowly increasing motion, then strength, and then balance and functional training. Issues with ankle stiffness, later ankle degenerative changes, and even lesser ability to play once a player returns all become more possible, in my opinion.

Plenty of questions remain about Derek Jeter’s injury and treatment. Baseball fans in general, and not just New York Yankees fans, will anxiously await updates and hope he returns to full strength by spring training next season.