Rams Wide receiver Puka Nacua was injured Sunday October 12th during the second quarter against the Baltimore Ravens while trying to make a catch in the end zone. After a visit from trainers, he was helped back to the locker room before returning to the sideline. He was found to have a grade 1-2 ankle sprain. The Rams have not provided a concrete timetable for Nacua’s return to action. He is set to miss Los Angeles’ Week 7 game before the team goes on bye in Week 8. That means the earliest Nacua could return to action would be in Week 9 against the New Orleans Saints.
Ankle sprains are commonly classified into three grades, depending on the severity of the ligament damage. Understanding the grade helps determine how long recovery might take and what level of care is needed.
Here’s a clear breakdown:
Grade 1 — Mild Sprain
- The ligament is stretched but not torn.
- Symptoms:
- Mild tenderness and swelling
- Slight pain when walking or moving the ankle
- Little to no joint instability
- Typical recovery time: About 1–2 weeks with proper care (RICE method is very effective here).
Grade 2 — Moderate Sprain
- The ligament is partially torn.
- Symptoms:
- Noticeable swelling and bruising
- Moderate pain and difficulty walking
- Moderate joint instability
- Typical recovery time: Around 3–6 weeks, sometimes longer depending on activity level and rehabilitation.
Grade 3 — Severe Sprain
- The ligament is completely torn or ruptured.
- Symptoms:
- Significant swelling, bruising, and pain
- Severe difficulty bearing weight or walking
- Obvious ankle instability
- Sometimes a “popping” sound at the time of injury
- Typical recovery time: Can take 8–12 weeks or more.
- Medical evaluation is essential — X-rays or an MRI may be needed to rule out a fracture.
- Often requires a brace, boot, or even physical therapy for proper healing.
Acute surgical intervention is rarely required for ankle sprains. Conservative treatment options are typically successful for these types of injuries. Operative management may be indicated in:
Chronic ankle instability
- The most common indication for lateral ligament surgery is not an acute sprain, but persistent instability after repeated sprains. Patients who continue to have pain, or inability to resume activities despite extensive nonoperative management, typically 3–6 months of bracing and therapy, are candidates for surgical stabilization. The gold-standard surgical option is an anatomic repair of the torn ATFL. The classic procedure is the Broström repair, which is often reinforced with the Gould modification, involving the suturing of the inferior extensor retinaculum to the fibula to strengthen the reconstruction.
Acute high ankle injury with instability
- If an ankle sprain involves the syndesmosis and results in diastasis of the distal tibia and fibula seen on imaging, surgical stabilization of the ankle mortise is indicated. Radiographic signs include widening the medial clear space or obvious instability on stress views. These injuries frequently occur alongside fractures, such as a high fibular fracture seen in a Maisonneuve injury, but even in isolated ligamentous syndesmotic ruptures, operative fixation with screws or suture-button devices is typically necessary to prevent long-term ankle instability.
Associated fractures or osteochondral lesions
- In some severe sprains, a fragment of bone may be avulsed, such as a piece from the distal fibula or tibia at the ligament attachment site, or a loose fragment of cartilage or bone may form within the joint. When these avulsion fragments are large and significantly displaced, or when an osteochondral fragment is inside the joint, surgical intervention is warranted to fix or remove the fragment.
Medial (deltoid) or combined injuries
- Isolated deltoid ligament sprains are usually treated nonoperatively. But if the deltoid ligament is completely ruptured in an unstable bimalleolar injury (medial clear space widening) or if chronic medial instability develops, surgical repair or reconstruction of the deltoid may be indicated.
