Here’s what could give Chiefs QB Patrick Mahomes the most trouble with his ankle injury

The quarterback who will soon win his second NFL MVP award operates outside the position’s intended residence more frequently than any other quarterback in the league.

By a wide margin.

He’s better at it than the rest of them too.

By a wide margin.

That’s all to say that the out-of-the-pocket, off-script, spur-of-the-moment brilliance is a significant part of what makes Chiefs quarterback Patrick Mahomes unlike the other guys.

And it’s the part we can’t be certain we’ll see Sunday.

Look, it’s hard to imagine even the high-ankle sprain keeping Mahomes out of a playoff game altogether, let alone an AFC Championship Game, and particularly an AFC Championship Game against this team.

The question, in that case, is not whether Mahomes is probable to play against the Bengals but whether he’s probable to play like, well, Mahomes.

And let’s just get this out of the way early:

“Those ligaments that have been damaged,” said Dr. Kirk McCullough, an orthopaedic sports medicine and foot-ankle surgeon at the Kansas City Orthopaedic Institute, “will not be healed by Sunday.”

In the few days after Mahomes suffered the injury in the AFC Divisional Round victory against the Jaguars, I spoke with a handful of medical professionals, including doctors who specialize in ankle ailments and a former NFL trainer. Before we move any further here, the obvious needs to be underscored — none of them have personally treated Mahomes’ injured ankle, which Chiefs coach Andy Reid termed a high-ankle sprain, and they are therefore not privy to his test results nor the grade of the sprain.

But they can provide an important education, even if a generalized one. These conversations centered on typicalities with high-ankle sprains in high-performing athletes, rather than the diagnosis of a patient they have not treated, but it allows the rest of us to connect the dots to gauge some answers to a couple of key questions:

What might Mahomes’ week look like as he attempts to prepare to play?

And where might he be most limited Sunday against the Bengals?

To answer that, it’s important to understand that a high-ankle sprain is much different than the more common lateral ankle sprain, typically taking two or three times as long to heal if graded similarly. Those are estimates, of course. But there’s a primary reason for that timeline.

A lateral ankle sprain results from the inversion of the ankle, while a high-ankle sprain is a rotational injury. In layman’s terms: There are more mechanisms at play with the high-ankle injury, and it’s affected in more movements.

“The problem with a rotational injury is that while possible, it’s much more difficult to brace, to tape, to do these things that limit the motion that causes all the strain,” said McCullough, also a consultant with the NFL Musculoskeletal Committee. “Some people with chronic lateral ankle instability, by comparison, you can give them really good tape jobs and put a brace on them, and they can still perform pretty well.

“With a high-ankle sprain, a rotational injury, how do you prevent the foot from rotating relative to the leg? That’s much, much tougher to do.”

The pain from such a sprain arrives when the ankle exercises a rotational movement, in other words. So with the sprain in Mahomes’ right foot, if he turns his right foot outward or bends the ankle, the pain will follow.

For most, that would make certain movements particularly difficult.

Such as …

“Guys can run hard straight forward with high-ankle sprains. They just can’t stop very well, and they can’t cut very well. Those are the two things that are the hardest when you’re talking about a high-ankle,” said Aaron Borgmann, a former NFL physical therapist/athletic trainer for 12 years. “Deceleration is one of the worst parts of the injury, and so is cutting. It’s either cutting away from the injured ankle, or it’s cutting over the top of the injured side. That hurts like hell.”

Deceleration.

And cutting.

Two things most quarterbacks do a lot. Two things this one does more than any of his peers.

Mahomes has left the pocket on 121 dropbacks this season, most in the NFL, per Sports Info Solutions. He’s successfully evaded sacks on all but one of those. He also consistently turns them into big plays — 25.6% of them result in “boom” plays, as SIS frames it, or plays that add at least one full expected point to the game. That also leads the league.

He does it with the most frequency. He does it with the highest success rate.

And that part of his game could be limited. Or let’s put it this way: It’s what is most likely to be limited, because it requires cutting.

It was noticeable, for example, that on Mahomes’ first drive of the second half Saturday, he was able to scramble for a first down, but his ensuing slide was awkward. That’s typical. Stopping was visibly difficult.

The alterations to his throwing motion were just as evident. The sprain is to his backside leg as he throws, which essentially threw his base off-kilter. There were some plainly-obvious errant throws Saturday — even Mahomes admitted it after the game.

“One of the big things about that injury and one of the (reasons) it’s hardest to get back is because it gets inflamed — your big toe tendon, the flexor hallucis longus, gets inflamed and it gets irritated from this injury,” McCullough said. “So the ability to get up on your toes is one of the last things that people really feel comfortable doing. And it’s one of the hardest and last things to get back.”

How much can eight days change all that?

Well, it’s a rushed timeline with most high-ankle injuries, even if we’re not privy to the specifics of this one. Most don’t finish the game. Even among those who do, a high percentage still will not play the following week. While most other types of injury recoveries move in a somewhat linear progression — things such a muscle strain or standard ankle sprain — high-ankle injuries can often be worse 48 hours after the incident due to building inflammation. Players can be aided by adrenaline during a game, adrenaline that is absent the following days.

But the rehab process begins immediately. Borgmann outlined what the type of treatment he has implemented in the past.

The key mechanisms in that process involve either an underwater treadmill or an AlterG, a version of an anti-gravity treadmill. Those items remove weight-bearing, designed to get a player moving at a fast speed without the weight before gradually raising the treadmill and eventually returning that work to land.

Simultaneously, athletes will progress through single-leg balance work, then exercises like squats and lunges and others, and then mixing in angles and increasing the difficulty of the movements.

That’s a brief synopsis. There are layers to it.

“When I’ve worked with high-ankles in the past, all of that is done in overlapping Venn diagrams and all at the same time,” said Borgmann, who now has his own private practice, Borgmann Rehab Solutions. “So you’re constantly pulling levers and flipping switches to see what works and what doesn’t.”

Yet early in the week, the Chiefs will need to gather some sort of forecast for where they expect Mahomes to be by Sunday — because it will greatly affect what kind of game plan they implement on Tuesday, Wednesday and Thursday.

In news conferences, the questions for Reid this week will center on whether his quarterback will play. Whether he will practice.

His internal questions will differ.

How much do we think he can do on Sunday? Which plays will need to be thrown out?

“This is the art of sports medicine,” McCullough said. “This is an injury where you look at a player and (analyze) how did he look today, how does he look tomorrow, how does he look the next day. How do we minimize inflammation and irritation that might be occurring? From a medical standpoint, yes we have some objective criteria, but there are a lot of structures at play that factor into a dynamic assessment.”