Torn Ankle Ligament Surgery: The Hammer and the Nail Effect

Published on Dec 6, 2018

It’s almost an everyday occurrence for me that a patient shows up with invasive orthopedic surgery scheduled who is at my office for another problem. When that happens, many times I find that the surgery isn’t really needed. This morning I’d like to tell Mary’s story, who was told that she needed torn ankle ligament surgery, but that turned out to be fiction. She was the victim of what I call “hammer and nail syndrome.” Let me explain.

Your Ankle Ligaments

Your ankle ligaments are strong pieces of tissue akin to duct tape on the side of your ankle. They hold everything together and allow certain movements and disallow others. They also protect your ankle joints. They can be torn and/or stretched, and this can lead to excessive motion in those ankle joints, leading to arthritis.

The outside ligaments are traditionally called the ATF (anterior talofibular), CF (calcaneofibular), and PTF (posterior talofibular). In addition, there’s a recently discovered ankle ligament complex here that we didn’t know existed. This really changes the concept of trying to surgically replace torn ligaments, because it turns out that because we didn’t account for these newly discovered bands of ligament, we’ve been doing it all wrong for decades.

Because we all want to prevent arthritis, many patients will sign up for torn ankle ligament surgery. There’s just one big problem. These patients are often told that their ankle ligament is torn and retracted back like a rubber band, but many times that’s more of a sales tool for a surgery than reality.

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Be Very Careful with the Term “Torn”

One of the biggest problems in medicine is hyperspecialization. This means that each doctor specializes in something that’s very specific. One of those specialties is radiology, where doctors read things like MRIs all day. While this creates physicians who are super knowledgeable about reading images, it also creates a dangerous disconnect. Why? The doctor on the ground who ordered the film may not be able to read the image and as a result, he or she relies on the radiologist’s report instead.

When it comes to a torn ligament, the fact that the doctor who ordered the film doesn’t understand how to read it is a big problem. Why? Because torn ligaments come in many flavors and only one type (completely torn and retracted) needs surgery, all of the other types of tears will either heal on their own or can be healed with a precise ultrasound-guided injection. This brings us to Mary’s story and how she avoided torn ankle ligament surgery through a correct diagnosis and a precise injection.

Mary’s Story

Mary is a patient whom I was seeing for other problems when she mentioned during a visit that she needed torn ankle ligament surgery. I was intrigued as she said that her surgeon had told her that her ligament was completely torn in half and there was no other option. I first looked at her ankle ligaments using ultrasound imaging in the office, and while they were stretched, they were not completely torn. I then asked to see her MRI, and while the radiologist had read out a complete ankle ligament tear, the ligament was still there. Meaning, the reason the radiologist used that term was that the ligament had a complete “signal change” (it was a lighter shade than a normal ligament, and this was all the way through the thickness of the structure). However, the ligament wasn’t torn and snapped back like a rubber band. Why is that critical? Because the former type can normally be healed with a precise injection of the patient’s own platelets or stem cells versus the latter type, which can only be treated with surgery.

Because Mary still had a ligament that was just stretched and damaged and not “gone,” she was a candidate for a platelet-rich plasma (PRP) injection, so this is what I did. I targeted the damaged parts of the ankle ligaments with high-dose PRP. This is a comment she just posted on our blog commenting platform:

“I had Dr Centeno inject my right loose ankle ligaments with PRP both in August and October of this year (2018). I am now 98% pain free. Let me give you some background. I had a bad high ankle sprain in Feb of 2017. I dance and mountain bike a lot and had to take off about 9 months of dancing because of ankle pain. When I would mountainbike my pain level was an 8/10! I hurt!!! I had visited the orthopedic surgeon in Denver, during the early summer of 2018, and he was talking surgery for my ATFL ligament. He said it was completely torn. However, when I had an ultrasound stress test with Dr Centeno in August of 2018, I could see that my ATFL was still intact. I had other stretched posterior ankle ligaments that were causing me stress. Thank You Dr Centeno for all of your knowledge and helping me return to an active lifestyle. I will be 52 years old in January and I am so happy to get back to my passions. Also, thank you for helping my back spine injury this summer. I hurt myself from 2 bad falls wakeboarding. Dr Centeno injected PRP and Protein Lysate into my back. Mark Reilly his physical therapist is phenomenal too! I am now dancing, lifting weights, and very active. I also love your clinic staff. I have never felt more at ease with going to the doctor’s office. THANK YOU!!!!”

Cautions

First, it’s critical to note that most orthopedic surgeons or podiatrists wouldn’t have a clue how to inject PRP into Mary’s ligaments. Why? It’s just not part of their training. In addition, we used high-dose PRP that isn’t often available at places that claim to be able to offer PRP injections. Next, please be wary of chiropractic, alternative-medicine, and other offices offering cosmetic or antiaging services that claim to be able to heal things like this with an injection of young stem cells from amniotic, cord blood, or placental sources. These clinics rarely have the expertise to do this procedure correctly, the “stem cells” they claim are plentiful are really dead, and they will charge you 3–5 times as much as the procedure should cost.

Why Is This Still Happening?

As stated above, many surgeons don’t read their own MRIs. In addition, there is what many call the “hammer and nail syndrome.” When all you have is a hammer (surgery), everything looks like a nail (a completely torn and retracted ligament). Hence, we tend to see many unnecessary surgeries happening. In Mary’s case, this would have been awful, as they would have removed a fixable ligament and installed a tendon in its place that would only ever be a fraction as good as the original equipment!

The upshot? Please be careful out there! As I showed Mary, many surgeons don’t really look that closely at whether an injured ligament might respond to things like PRP injections. Also, many may not know about what these procedures can do. Finally, many others never look at the actual images, as I did here. So if you’re told you need torn ankle ligament surgery, please get a second opinion from someone who offers more than just surgery. If you don’t, you may just be the nail in this analogy!