I won’t include the video, a picture, or x-rays from a similar injury because I’d like most of you to get past the first paragraph without hitting the floor. You all know what happened though. Hudson goes running to cover first, Eric Young steps on the outside of his ankle, and snap, season over.

You’ve likely heard the phrase “sprains can be worse than breaks” in reference to ankle injuries. I suppose there might be situations where that’s hypothetically true but this is not one of them. Tim’s ankle injury was worse than any sprain. Sickeningly worse. Explaining why is going to require some anatomy though and I’m sorry. I’ll try and be quick.

(Structures boxed in red are the important ones for our purposes)

Title’s right up there on top, but that’s a rear view of a left ankle. If you watched last year’s March Madness you’re intimately familiar with the bones of the lower leg (fibula and tibia). They meet with a bone called the talus to form the “true ankle joint”, which allows up and down movement of your foot, like when stepping on the gas in your car. The talus meets with the calcaneus (your heel bone), forming the subtalar joint, which allows side to side movement of your foot, like when…shit, I cannot think of a single example of when you’d do this motion intentionally. When a fly lands on your foot and you’re trying to shake it off? That’s a pretty poor example. Like when you move your foot side to side but don’t rotate your lower leg because of some contrived situation where that happens.

That’s the gist of how your ankle works. As you can see in the picture, there’s a slew of ligaments holding all the bones in place (ligaments connect bone to bone, tendons connect muscle to bone). These ligaments serve to stabilize the joint and restrict inversion and eversion rotation of the ankle. Inversion is your typical rolled ankle, it turns the sole of your foot medially (toward the midline of your body). This motion can strain, or tear, the ligaments on the lateral side of your foot.

We’ll ignore almost all of the ligaments shown above, but the one boxed in red is important. The calcaneofibular ligament connects the fibula to the calcaneus and provides lateral stability (it’s also present in the rear view earlier in this post). Most of these inversion injuries aren’t too serious. A stretch of this ligament will hurt like all hell but might not restrict functionality…you can walk it off. A more serious inversion can snap or tear that ligament. You will not be able to walk this off, your entire foot will turn blue, green, and black, and you’ll spend a few months doing small range of motion exercises that leave you gritting your teeth and crying. Generally though, you’re still not talking about a fractured ankle here, unless the inversion is accompanied with some type of traumatic blow.

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Looking back at Hudson’s injury, we see his ankle rotated the other way. Young stepping on the outside of his ankle forced a massive eversion and pointed the sole of his foot laterally (away from the midline of the body). Here’s a medial view of the ligaments and bones of the ankle:

There’s only one multi-part ligament we’re concerned with here, the deltoid ligament. The name comes from the latin deltoides which means “delta (Δ) shaped.” This large triangular ligament connects the tibia to the calcaneus and navicular bones. For the calcaneofibular and deltoid ligaments, both medially and laterally, the tibio and fibular connections are made on the medial and lateral malleoli. You know the malleoli as the “ankle bones” sticking out on each side of your ankle, but they’re actually just knobs of bone projecting out from the ends of your lower leg bones. There’s not really any subcutaneous (under skin) tissue over these projections, and it turns out bones are full of nerves, which is why bumping this bone with a hard object causes holy-hell-hands-balled-in-fists-grit-your-teeth-close-your-eyes-and-tilt-your-face-to-the-heavens pain. If this malleoli description lost you, glance back at the initial rear view diagram again, you can see the malleoli and the ligament connections clearly.

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Alright, anatomy description over. On to what happened to Tim Hudson. I obviously haven’t seen his x-rays, and wouldn’t necessarily be able to read them if I did (not a doctor yet), but that particular type of massive eversion is famous for causing a very specific, very horrible, series of fractures. Massive strain is placed on the large, medially-located, deltoid ligament. While inversion will tear the smaller calcaneofibular ligament, the deltoid ligament is a different beast. Normally, that means your foot doesn’t turn that way, but given the right forces (like a professional athlete stepping on the outside of your ankle while your foot is elevated on first base), the eversion is happening. Unfortunately, that deltoid ligament is strong, really strong. It’s not tearing. Bones will break before the deltoid ligament tears. Tragically, this tends to cause a domino-effect of snapping bones in your lower leg.

First thing to go is the medial maleolus of the tibia. The deltoid ligament keeps its grip and rips off that portion of the bone. Unfortunately, that means the framework of ligaments holding your foot in place has lost its integrity. Second, the talus (the bone directly below the dual bones of the lower leg) will move laterally and snap the fibula above where the lower leg bones meet. The talus then acts like an internal wrecking ball and can continue anteriorly through the bottom portion of your tibia, snapping it as well. These combined fractures and forces will then tear the connection between the tibia and fibula (tibiofibular syndesmosis). Lastly, you drop to the ground, scream, and the guy who stepped on you and likely heard the twisting-bubblewrap-esque sounds coming from your ankle is tearfully asking if you’re okay. You're not okay. The bones of your lower leg have both snapped above the ankle, parts of one (or both) of them have been forcibly sheared from the bone, and the connection between the two of them has snapped. Your foot is connected to the rest of your body by the skin and possibly a ligament or two that survived the massacre.

The treatment and prognosis of Pott’s fractures are inherently unpredictable and determined on a case-by-case basis, since the range of possible severity is so expansive. A minor non-displaced fracture might be 6-8 weeks of rehab, a walking boot/cast, and crutches. A major displacement involving both bones, more likely in the case of an injury as traumatic as Hudson’s, is a different ballgame. At this point soft-tissue damage will play a large role in determining recovery time. Blood vessel, nerve, and lymphatic damage (caused by sharp ends of broken bones flailing around inside your leg) can all greatly prolong recovery. This type of injury requires careful anatomical reduction (a nice way of saying the patient is put under anesthesia and the bones are painstakingly realigned), the placement of pins and plates to hold the bones in proper locations, and the continual monitoring of healing to guarantee those bones are staying where they should.

Godspeed Tim, Godspeed.