The Buffalo Bills have had incredible luck in terms of health this season—no doubt a contributor to their 9-4 record. However, they’ve still had to endure several injuries that have dealt varying blows to their roster. From the hamstrings of Devin Singletary, Matt Milano, and Taron Johnson, to the season-ending injuries of LaAdrian Waddle, E.J. Gaines, and Harrison Phillips, each has forced the team to adapt. The recent ankle injury to Ty Nsekhe has been no different. His injury was thought to be at one point season-ending, and while it hasn’t ended his season yet, fans wait for his return. This article attempts to piece together a comprehensive timeline for his injury and eventual return that at the time of writing, has not occurred.
Nsekhe suffered a significant right ankle injury midway through the third quarter against the Denver Broncos. The injury occurred on a routine run play by Devin Singletary up the middle. During blocking, Nsekhe’s foot was caught from behind by Miami Dolphins defensive end Avery Moss that forced the ankle to roll under. Nsekhe fell violently to the ground and grabbed his lower leg in obvious pain.
Nsekhe was placed into an air cast and carted off displaying significant discomfort. At the time, it was feared he had suffered a dislocated ankle with resulting fibula fracture, similar to what Matt Milano suffered last year. This was the reason for the air cast and cart off. He was having difficulty placing weight through the leg and due to the acute trauma, rapid swelling began to take place. Placing an air cast around the ankle immediately after injury helps reduce the swelling, preventing delays in imaging and potential complications such as compartment syndrome.
Compartment syndrome occurs when the pressure in the tissues builds up to dangerous levels, compressing on the muscles, eventually causing tissue death due to cutting off the blood supply to the area. This is a rare condition, but is more common with trauma. Carting Nsekhe off was also necessary due to the initial inability to bear weight through the ankle indicating a possible fracture. Asking the player to walk on it could have created further damage, especially with a man his size and the sheer fact that it would have been extremely painful.
During the post-game press conference the following Monday, it was generally expected that Nsekhe would be placed on season-ending IR with a transaction taking place to replace him on the roster. However, it was announced that more tests were being performed with no concrete decision made.
#Bills HC Sean McDermott said Ty Nsekhe is still getting tests on his ankle. NCB Siran Neal is in the concussion protocol.— Joe Buscaglia (@JoeBuscaglia) November 18, 2019
Once that news broke, Rochester TV reporter Thad Brown released an alternative angle that showed that the ankle injury was not as severe and that he might have avoided a dislocation/fracture. The new angle appeared to show the heel slide out slightly, reducing pressure on the lateral ankle that gave Nsekhe the ability to fall over to further reduce pressure, likely avoiding the fracture. A video review is seen below.
Want to know why #Bills OT Ty Nsekhe was able to avoid a season-ending fracture? Then make sure to check out the latest video injury review below to learn why! #BillsMafia #GoBills pic.twitter.com/sZNfrVAXwq— Banged Up Bills (@BangedUpBills) November 21, 2019
It was eventually announced that Nsekhe had an ankle injury and that he would be week-to-week—encouraging news following the expected worst.
Bills RT Ty Nsekhe is wearing a walking boot on his right foot. He is still considered week-to-week with an ankle injury https://t.co/AKgtpnvroC— Marcel Louis-Jacques (@Marcel_LJ) November 21, 2019
The Recovery and Healing
This excerpt is taken from my article at BangedUpBills.com detailing a ligament injury.
“The reason this ankle continues to require more time is due to how ligaments heal. Like all tissues, they are made up of various building blocks. In the case of ligaments, water, collagen, and amino acids create the makeup of the tissue. During normal use, the ligaments crimp and uncrimp based on the tensile loads placed through the joint as they connect bone to bone for structural support. As the joint is progressed through the range of motion, the ligaments elongate until they are maximally stretched. Prior to the injury, the striations of the ligaments are linear and allow for support during the full range during joint motion. Think of the striations in a nice steak, all linear and uniform as seen below.
When an injury occurs, the ligaments are either overstretched or outright tear. When a joint is taken to its end range, the proprioceptive nerves in the ligament start signaling for the muscles around the area to contract to prevent the joint from injury. While this attempts to reduce injury, the muscles are not always able to overcome the forces from the injury. Based on the severity, anywhere from several fibers to the entirety of the ligament can tear.
During healing, the body attempts to heal quickly by putting scar tissue down in a haphazard fashion to heal the tissue. Because the tissue is not linear, the elasticity decreases and the tissue is not as strong as what was originally torn. What happens then is if the tissue is reinjured, it takes less force for the tissue to tear or it stretches out and does not regain its normal shape as easily. You can see below how the makeup of the tissue changes with injury.
All this tissue healing takes time, anywhere from six weeks to a few years for the tissue to fully mature. Fortunately, progressive loading movements help remodel the tissue as it heals in order to return to activity sooner. This is why we are able to gauge return to play timelines based on the severity of the injury. At the end of the day, Nsekhe needs proper rest with increasing loading of the surrounding tissue and ankle joint to ensure that he regains full function in the ankle without causing further damage to the healing tissue.”
A week after the injury, Nsekhe was at practice in a walking boot, demonstrating no restrictions in weight bearing. This is due to the fact that if there is no fracture, then placing weight through the leg will help begin the healing process and avoid any further decline in function. He was also observed in Dallas walking around without a boot, but with a noted limp.
Also, Ty Nsekhe made the trip to Dallas and was walking with an obvious limp -- but without a boot.— Marcel Louis-Jacques (@Marcel_LJ) November 29, 2019
10 days to heal for Bills' game vs the Ravens in Week 14
Looking at a rehab standpoint, introduction of exercise and weight bearing after several days of rest helps reduce the healing timeline by up to a week versus true immobilization according to multiple studies. Placing weight through the joint allows for joint approximation, forcing the muscles in the ankle and lower leg to co-contract to increase joint stability. This allows the ankle to begin regaining joint proprioception, which is the body’s awareness of how it moves in space.
As these activities improve with weight bearing, balance and strengthening exercises are incorporated to begin restoring full range of motion with strength through the area and to begin the process of walking without the boot. Incorporating higher-level activities such as jogging, running, and football-specific drills will all increase in difficulty until he is cleared to return to play, which, as of today, still hasn’t happened.
Overall, the ankle injury appears to be a severe Grade 2 ankle injury with a timeline of 4-6 weeks. This is why Nsekhe was not placed on IR, knowing that there was a strong possibility he could return in time for the playoffs. Considering someone of Nsekhe’s size (6’8” and 325 lbs) he will be close to the six-week mark, which is supported by what he is doing now.
As of this writing, Nsekhe has now missed three games and hasn’t practiced all week prior to the Pittsburgh Steelers game—likely making it a fourth game he’ll miss. I had noted when there was confirmation of his exact injury that a reasonable return-to-play timeline would be the New England Patriots game in Week 16. This is all dependent on whether he begins practicing next week, even in a limited fashion. However, considering he was unable to practice prior to the Steelers game doesn’t have me hopeful now for a Week 16 return. He may return in time for the regular-season finale against the New York Jets. However, it all depends on when he’s able to begin practicing in full.
An injury of that magnitude may have sunk other teams, but thankfully the Bills drafted Cody Ford this past offseason and had him rotating with Nsekhe. Ford has been able to step up in his absence and play admirably, though no one expected him to perform with the abilities of the veteran. Nsekhe should return within the next two weeks, ideally with some regular-season games to play in order to gear back up for the playoffs.
There is concern that Nsekhe could suffer further injury or be limited despite taking the proper time off and rehabbing. As mentioned above, tissue healing takes anywhere from six weeks to a few years for things to fully mature. He will likely wear some type of bracing to provide extra support or have his ankle taped up. However, bracing will be able to be readjusted and tightened as the game wears on. Taping typically stretches out and loses its support due to lack of contractile materials in the tape.
Nsekhe won’t be 100% until the season is over, as most players typically are. But with the playoffs on the line and the ability to make a deep run in a thin AFC, his return even at 85% will be ideal not only from an experience standpoint, but depth, as this allows Ford to resume rotating at the position if the staff deems it necessary. No injury is well-timed, but considering Ford has played fairly well in Nsekhe’s absence along with the lack of concurrent injuries on the roster, this lessens the severity of impact for the injury.