Derek Jeter returns - why did it take so long?

Sydney Yau, DPM @sydneyyau on twitter

New York Yankees shortstop Derek Jeter broke his left ankle during the ALCS last October and has yet to return to play 9 months later.  The initial injury didn't seem too harmful but he wasn't able to get up from it.

Jeter had been nursing a bone bruise and had cortisone injections in the ankle prior to his injury.  This may account for why the ankle broke.  A bone bruise can actually be a developing stress fracture that may have weakened the bone.  Cortisone injections - although they provide pain relief and allow athletes to play in important games like the ALCS, may also further weaken the bone if done excessively.  Those two factors may have contributed to why Derek Jeter broke his ankle in the first place.

Ankle Fractures

There are several types of ankle fractures - some require surgery and others do not.  When there is a broken bone in the ankle, we look at the position of the bones and alignment of the ankle joint.  If the bones are angled, shortened, or out of anatomic position, surgery is often indicated to realign the bones. If there is a mal-alignment of the ankle joint, surgery is indicated to realign the bones so that the ankle joint can be realigned.  If the ankle is not fixed, the ankle may undergo arthritic changes from abnormal pressures.  Generally, ankle fractures heal fairly successfully after surgery.  The bones will take about 6-8 weeks to heel and most people will need about 1-2 months of rehab.  With that timeline, Jeter would have likely have been ready for spring training and opening day.  However he suffered a setback.

Jeter's setback 

In April, it was reported that a new break was found in the ankle.  How could this be?  April would have been at least 5 months after his injury and the bone would have had plenty of time to heal.

Here are 3 reasons why it broke again:

1.  Certain types of cortisone injections used to help provide pain relief may stay in the body's system for several months and delay or impede the ability for bone to heal - especially early on in the healing process.

2.  As the bone heals after surgery, patients are often immobilized and non-weightbearing in a cast.  This immobilization can cause "disuse atrophy" of the bones - which is a weakening of the bone because there are no weightbearing forces put on it.  Bone is very dynamic and requires pressure for it to remodel and grow stronger.  Therefore if Jeter returned to heavy activity too soon, the bone might not have been able to sustain the pressure put on it initially.

3.  Screws and plates are used to fix ankle fractures and are necessary to hold the bones together as it heals.  However, once it heals, the hardware can cause increased stress in the bone called "stress risers".  If the bone is already weak, weightbearing activity may cause a fracture along one of the screws because the bone is weaker there.

What will he be like in his return? 

Reports indicate that Derek Jeter will be returning to the lineup tonight after doing a rehab assignment.  Broken bones heal well and we shouldn't see any residual problems in the long term.  However, in the short term, it may take him some time to get his quickness and agility back.  With a period of immobilization it takes time for the muscles to regain their strength and muscle memory.  Other than that broken bones that heal correctly generally do not give any long term problems.  I believe Jeter will return and be an effective Major League player.