We hear from so many people struggling with chronic ankle pain. Maybe you’re facing an ankle fusion, stuck on a waiting list, and desperately searching for ankle surgery alternatives. Or perhaps you’ve been told you’re “bone on bone” and have lost hope for relief. We get it. This is why we focus on regenerative options like stem cell therapy for your ankle injury. This innovative approach uses your body’s own healing power to address the root cause of the pain. Let’s explore how an ankle stem cell treatment could help you.

I usually respond asking about the limitations the person has. If the ankle can still bend and rotate? Generally speaking, if your ankle is not locked in place by bone spurring and you can still move your foot around, we would think that stem cell therapy could help. I discuss this below.

What Are the Top Ankle Surgery Alternatives?

A study published in March 2019 (1) discusses the problem orthopedists and surgeons have in presenting treatment options to their patients with advanced ankle osteoarthritis. As many doctors and patients are aware, ankle osteoarthritis treatment protocols have no real guideline recommendations of its own. Researchers say most doctors treat an ankle problem as they would treat a knee or hip and follow hip or knee treatment protocols when treating the ankle. Is this really such a bad thing?

It is when you consider that these are the same guidelines of conservative care protocols that ultimately lead to patient pain management programs until such time that the knee or hip can be ultimately replaced.The difference in treating an ankle like a hip or an ankle like a knee is that doctors feel that if conservative care options do not work for knee or hip osteoarthritis, there is a reasonably reliable surgical option in total joint replacement. The same reasonably reliable surgical option, researchers suggests, may not be available for ankle replacement.

Recent research in the British medical bulletin (2) discuss the risks and rewards of ankle arthrodesis or ankle fusion and total ankle replacement.

  • Total ankle replacement while an accepted treatment for end-stage ankle osteoarthritis has a higher need for revision surgery than ankle fusion.
  • While surgical outcome results are gradually improving, Total ankle replacement cannot yet be recommended for the routine management of ankle osteoarthritis. 

In the medical journal Foot & ankle specialist, Duke university doctors wrote as the number of total ankle replacements performed has risen, so has the need for a specialty medicine to perform secondary or revision surgery to fix the primary ankle replacement failure.(3)

These are the people studied in this report:

  • 193 patients
  • The majority of the revision surgeries had:
    • hardware component loosening, frequently of the talar component (38%).
    • In the cases that were revised to an ankle fusion, 81% fused after their first fusion procedure.
    • The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%.

Interventional Orthopedics

Given the significant downsides of ankle fusion and replacement, it’s natural to wonder what other paths are available. This is where the field of interventional orthopedics comes in. Instead of surgically removing or fusing parts of your ankle, this approach focuses on using your body’s own healing abilities to repair damage and reduce pain. These minimally invasive procedures are designed to help your tissues regenerate, potentially offering a way to heal from an injury without the long recovery times and risks associated with major surgery. It’s about working with your body, not against it, to restore function and get you back on your feet.

Stem Cell Therapy

One of the most promising options in interventional orthopedics is stem cell therapy. This procedure uses your body’s own healing cells to repair damaged tissues in your ankle joint. Think of stem cells as your body’s internal repair crew; they can transform into other types of cells, like cartilage, to help rebuild what has been lost to injury or arthritis. At the Stem Cell Institute, we use a precise, injection-based procedure to deliver these concentrated repair cells directly to the source of your pain. The goal of Stem Cell Therapy is to promote natural healing, reduce inflammation, and improve function, offering a powerful alternative for those told that surgery is their only choice.

Platelet-Rich Plasma (PRP) Therapy

Similar to stem cell therapy, Platelet-Rich Plasma (PRP) therapy harnesses your body’s natural healing power. This treatment involves drawing a small amount of your own blood, spinning it in a centrifuge to concentrate the platelets, and injecting this platelet-rich plasma into your injured ankle. Platelets are packed with growth factors that act like signals, telling your tissues to start the repair process. PRP Therapy is excellent for reducing pain and inflammation associated with conditions like chronic ligament sprains, tendonitis, and mild to moderate osteoarthritis, helping to kickstart healing without surgery.

Other Minimally Invasive Procedures

Beyond regenerative treatments that use your own cells, other advanced procedures offer less invasive alternatives to traditional ankle surgery. These techniques are also designed to preserve your natural joint and avoid the complications that can come with fusion or replacement. They work in different ways—some by physically creating space for cartilage to regrow, and others by addressing the pain signals directly. Exploring these options can give you a more complete picture of how you can manage ankle pain and maintain your mobility for years to come.

Ankle Distraction Arthroplasty

Ankle distraction arthroplasty is a unique surgical procedure that can help restore the joint rather than replacing it. During this procedure, a surgeon attaches an external frame to the bones of your leg and foot. This frame gently pulls the bones apart, creating a small gap within the ankle joint. This space relieves pressure on the damaged cartilage and can stimulate the growth of new, healthy cartilage over time. It’s a compelling option for younger, more active individuals with advanced arthritis who want to avoid a joint fusion or replacement and preserve the natural motion of their ankle.

Nerve Resection and Electrical Stimulation

When ankle pain is persistent, sometimes the problem lies with the nerves themselves. For these cases, procedures that target nerve pain can be highly effective. Nerve resection involves surgically removing a small portion of an irritated nerve to stop it from sending pain signals. Another approach is electrical stimulation, where a small device is implanted near the ankle. This device sends gentle electrical impulses that interfere with pain signals traveling to the brain. It’s a non-opioid solution that can provide significant pain relief while allowing you to keep your natural joint and stay active.

Why You Should Consider Ankle Surgery Alternatives

Research in the Journal of Foot and Ankle Surgery (4) examined why a patient will still have chronic ankle pain following ankle replacement:

The researchers suggested:

  • “Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out.”
  • The researchers then initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior (rear) ankle during total ankle replacement. They found:
    • High rates of posterior structural injury from the surgery was found.
    • Pins inserted during the surgery represented a high risk of damage to the tibial nerve  posteromedial tendinous structures, in particular, the flexor digitorum longus tendon.
    • The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve.
  • The researchers concluded: “Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.”

### Understanding the Risks of Surgery

When you’re living with chronic ankle pain, the idea of a surgical fix can sound like the ultimate solution. However, it’s essential to look at the full picture of what these procedures entail, including their potential downsides. The two most common surgeries for advanced ankle osteoarthritis are ankle fusion and total ankle replacement, and they represent very different approaches with unique trade-offs. Understanding these options, along with the general risks that come with any surgery, is the first step toward making a decision that feels right for you and aligns with your long-term goals for mobility and an active life.

Ankle Fusion vs. Ankle Replacement

When your doctor discusses surgery, you’ll likely hear about ankle fusion (arthrodesis) and total ankle replacement (arthroplasty). Ankle fusion is a procedure that permanently joins the bones of your ankle, which can be very effective at eliminating pain but also significantly limits your natural range of motion. On the other hand, an ankle replacement uses an artificial joint to preserve that movement. While maintaining mobility sounds like the ideal outcome, research has shown that total ankle replacements often have a higher rate of needing a second, or “revision,” surgery compared to fusions. This suggests that for some patients, the durability of a fusion may be a more reliable long-term choice.

Factors That Increase Complication Risks

Beyond the specific procedure, any ankle surgery carries inherent risks that are important to consider. As more ankle replacements are performed, we’ve gained a clearer understanding of the potential complications. One of the primary concerns is the loosening of the hardware components over time, which can lead to instability and a return of pain. Studies have shown overall complication rates approaching 20% in some patient groups, with other issues like nonunion—where the bones fail to fuse or heal properly—also being a possibility. This isn’t meant to be alarming, but to provide a realistic view of the challenges that can arise post-surgery.

The Importance of a Second Opinion

Given the complexities and potential for complications with ankle surgery, getting a second opinion isn’t just a good idea—it’s a crucial step in your healthcare journey. The fact that revision surgeries are a known outcome highlights that the first recommendation isn’t always the only path forward. A second opinion can confirm a diagnosis, offer a different perspective on your best surgical option, or introduce you to alternatives you hadn’t considered. Exploring non-surgical treatments, such as stem cell therapy, can provide a path to healing that avoids the risks of hardware failure and lengthy recovery times. Before you commit to an irreversible procedure, contacting a specialist in regenerative medicine can open the door to other effective possibilities.

When is Ankle Surgery Necessary?

While the goal is often to avoid invasive procedures, there are times when surgery is the most practical path forward. If you’re dealing with persistent ankle pain, understanding when an operation might be on the table is a key part of making an informed decision about your health. Surgery is typically considered a last resort, but for certain acute injuries or advanced conditions, it can be the recommended approach. These situations often involve significant structural damage where the ankle’s stability is severely compromised, and non-surgical methods may not be enough to restore proper function and prevent long-term issues.

Conditions That May Require Surgery

Your doctor will likely discuss surgery if you’re facing a severe injury or a degenerative condition that hasn’t responded to other treatments. This includes situations where the ankle joint is dislocated or if broken bones have pierced the skin, known as an open fracture. Surgery may also be necessary if the ankle has become deformed over time. For those with advanced ankle arthritis, an operation might be considered if you experience intense pain and swelling that conservative care can no longer manage. In these cases, the primary goal of surgery is to stabilize the joint, correct alignment, and reduce pain to improve your overall quality of life.

What to Know About Ankle Ligament Injuries

Ankle ligament injuries are incredibly common, whether from a misstep on an uneven sidewalk or a sudden pivot during a sports game. These injuries occur when the strong, fibrous bands of tissue that connect your ankle bones are stretched too far or tear. The result is often immediate pain, swelling, and a feeling of instability, making it difficult to walk or put weight on your foot. While many sprains heal with time and proper care, severe tears can lead to chronic ankle instability if not addressed correctly. Understanding the extent of the ligament damage is the first step in determining the right treatment plan for you.

Types of Ligament Tears

Not all ligament tears are the same, and the type of tear you have will heavily influence your treatment options. A partial tear, or Grade 2 sprain, means some fibers are damaged, but the ligament is still in one piece. These often heal well with rest, ice, and physical therapy. A complete but intact tear (Grade 3 sprain) means the ligament is torn through but hasn’t pulled away from the bone; this can sometimes heal without surgery using a brace or cast. The most severe is a complete and retracted tear, where the ligament snaps and pulls away from the bone, creating a gap. Surgery is often discussed for this type of injury because it has a much harder time healing on its own.

Surgical Risks and Recovery Timelines

Even when surgery is deemed necessary, it’s important to go in with a clear understanding of the potential risks and the long road to recovery. Procedures like ankle fusion and ankle replacement are major operations that come with inherent challenges. For instance, research from Duke Health has shown that revision surgeries for ankle replacements can have an overall complication rate of 18.2%. Furthermore, in cases revised to an ankle fusion, the nonunion rate—where the bones fail to fuse together properly—was 10.6%. These statistics highlight why many people seek less invasive options first, hoping to avoid the potential setbacks and lengthy rehabilitation associated with surgery.

Exploring Conservative, Non-Surgical Treatments

Before jumping to surgery, there is a wide array of conservative treatments that can provide significant relief and promote healing for many ankle conditions. This approach focuses on reducing pain and inflammation, restoring function, and strengthening the joint to prevent future injuries. For many people, a combination of these methods is enough to manage their symptoms and return to their daily activities without needing an operation. Exploring these options with your doctor is a proactive step toward recovery. It allows you to take control of your treatment plan and see if your body can heal with less invasive support.

Physical Therapy and Bracing

Physical therapy is a cornerstone of non-surgical ankle treatment. A skilled therapist can guide you through targeted exercises to regain strength, flexibility, and balance, which is crucial for stabilizing the ankle joint. This process not only helps you recover from your current injury but also helps prevent future ones by correcting any underlying mechanical issues. Your doctor or therapist might also recommend an ankle brace to provide external support, especially during activities that put stress on the joint. This combination of strengthening from the inside with physical therapy and supporting from the outside with a brace can be a powerful strategy for recovery.

Medications and Lifestyle Changes

Your doctor might first suggest simple, effective strategies to manage your pain and inflammation. This often includes over-the-counter anti-inflammatory drugs (NSAIDs) or, in some cases, steroid injections to provide more targeted relief. Alongside medication, certain lifestyle adjustments can make a huge difference. Losing excess weight can reduce the daily strain on your ankle joints, while switching to low-impact activities can prevent aggravation of the injury. Sometimes, custom-made shoe inserts or more supportive footwear are all that’s needed to correct alignment and alleviate discomfort, allowing the healing process to begin without the constant stress of improper foot mechanics.

Other Supportive Therapies

Beyond the standard conservative treatments, other therapies can support your body’s natural healing processes. These methods can be used alone or in conjunction with physical therapy and lifestyle changes to help manage pain and improve function. Regenerative medicine, for example, offers promising options that work to repair damaged tissue from within. Treatments like Platelet-Rich Plasma (PRP) Therapy use concentrated platelets from your own blood to accelerate healing in injured ligaments and tendons. For more advanced conditions, Stem Cell Therapy may be an option to help regenerate cartilage and other tissues, offering a path to recovery that avoids surgery.

Acupuncture

Acupuncture is a technique rooted in traditional Chinese medicine that is gaining acceptance in Western medicine as a complementary therapy for pain management. It involves inserting very thin needles into specific points on the body to stimulate nerves, muscles, and connective tissues. This stimulation is believed to release natural painkillers and improve blood flow to the injured area. For those dealing with chronic ankle pain from arthritis or an old injury, acupuncture can be a gentle, non-invasive way to find relief and may help reduce reliance on pain medications while you pursue other healing modalities.

Taping and Shoe Modifications

Sometimes, simple external support can make a world of difference. Kinesiology taping is a popular method used by physical therapists to provide stability to the ankle without restricting its range of motion. The tape gently lifts the skin, which can help improve circulation and reduce pain signals. Similarly, modifying your footwear can have a profound impact. This could be as simple as choosing shoes with better arch support or using custom orthotics to correct your foot alignment. By relieving pressure on the injured parts of your ankle, these modifications can create a better environment for healing and reduce pain during daily activities.

Does Stem Cell Therapy for the Ankle Really Work?

As mentioned at the top of this article our paper “Treatment of Ankle Osteoarthritis with Bone Marrow Concentrate Injections,” is awaiting publication. There have been studies already published that suggest bone marrow derived stem cells are an effective treatment for ankle osteoarthritis patients.

December 2016 research in the Journal of experimental orthopaedics from doctors at the Steadman Philippon Research Institute (5) reviewed the research in the treatment of ankle osteoarthritis with bone marrow derived stem cells.

The goal of this study was to review outcomes of bone marrow aspirate concentrate (bone marrow derived stem cells) for the treatment of chondral (cartilage) defects and osteoarthritis of the talus of the ankle.

The researchers noted that there is not much research (at the time of this paper’s writing). . . Nonetheless, the evidence available showed varying degrees of beneficial results of bone marrow derived stem cell therapy for the treatment of ankle cartilage defects.

  • The researchers hypothesized that bone marrow aspirate concentrate may be useful in regeneration of tissue, enhancing the quality of cartilage repair. As a result, BMAC promotes a potentially healthy environment for hyaline cartilage growth and repair.

Research cited:

  • A 2009 study published in Clinical Orthopaedics and Related Research, reported that 94 % of patients returned to low impact sports activity at an average 4.4 months after bone marrow aspirate transplantation and 77 % of patients returned to high impact sports activity at an average 11.3 months. (6)
  • The same researchers in 2013 reported that 73 % of the 36 patients playing sports before surgery were able to return to sports. They also reported that 22 % of these 36 patients were able to return to sport, but at a lower level than before surgery. (7)
  • A 2011 study reported that 95 % of patients who had undergone bone marrow concentrate treatments  returned to their pre-symptom level of sporting activity at an average 13 weeks.(8)

A 2016 report in the Journal of experimental orthopaedics (9) examined ways to save the ankle from fusion and replacement. In this study, Italian researchers discussed joint saving procedures such as:

  • Surgical procedures such as Arthroscopic debridement, arthrodiastasis, and osteotomy are the current joint sparing procedures, but, in the available studies, controversial results were achieved
  • Better results for patients they speculated could be achieved with Mesenchymal stem cells (MSCs). They write that stem cells may be a good solution to prevent or reverse ankle degeneration, due to their immunomodulatory features (able to control the catabolic joint environment) and their regenerative osteochondral capabilities (able to treat the chondral defects).

In research from Korea, doctors found that after ankle surgery, such as osteotomy, ankle bones treated with bone marrow stem cell injections repaired significantly better. than those not treated (10)  My question is always, why not try it before the surgery?

Is Ankle Stem Cell Treatment Right for You?

Generally speaking, if your ankle is not frozen or locked up with bone spurs and can rotate, even thru the pain, then we can have a realistic expectation that we can provide some help. How much help? We can’t be sure until we do the examination.

A team of researchers from the University of Leeds in the Untied Kingdom (11) explored the use of stem cells as a means of not only preserving the ankle but as a means to rebuild and repair damage. The researchers focused on mesenchymal stromal cells (MSCs or stem cells). The researchers believed that  the regenerative therapies compared favorably against standard surgical treatment.

A recent study (12) also found that stem cell treatments were able to regrow cartilage in ankles and that patients experienced significant improvement in function and reduced pain levels. The ability to walk greater distances was seen as one of the outcomes leading to the favorable findings.

In a post-surgical study from December 2018, (13) researchers found the injection of bone marrow mesenchymal stem cells could improve the repair process of the osteonecrosis.

 

 

 

  1. Paterson KL, Gates L. Clinical Assessment and Management of Foot and Ankle Osteoarthritis: A Review of Current Evidence and Focus on Pharmacological Treatment. Drugs & aging. 2019 Jan 25:1-9.
  2. Maffulli N, Longo UG, Locher J, Romeo G, Salvatore G, Denaro V. Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status. British Medical Bulletin. 2017 Nov 23:1-22.
  3. Gross C, Erickson BJ, Adams SB, Parekh SG. Ankle arthrodesis after failed total ankle replacement: a systematic review of the literature. Foot & ankle specialist. 2015 Apr;8(2):143-51.
  4. Reb CW, McAlister JE, Hyer CF, Berlet GC. Posterior Ankle Structure Injury During Total Ankle Replacement. J Foot Ankle Surg. 2016 Jun 9.
  5. Chahla J, Cinque ME, Schon JM, et al. Bone marrow aspirate concentrate for the treatment of osteochondral lesions of the talus: a systematic review of outcomes. Journal of Experimental Orthopaedics. 2016;3:33. doi:10.1186/s40634-016-0069-x.
  6. Giannini S, Buda R, Vannini F, Cavallo M, Grigolo B. One-step Bone Marrow-derived Cell Transplantation in Talar Osteochondral Lesions. Clinical Orthopaedics and Related Research. 2009;467(12):3307-3320. doi:10.1007/s11999-009-0885-8.
  7. Giannini S, Buda R, Battaglia M, Cavallo M, Ruffilli A, Ramponi L, Pagliazzi G, Vannini F. One-step repair in talar osteochondral lesions: 4-year clinical results and t2-mapping capability in outcome prediction. The American journal of sports medicine. 2013 Mar;41(3):511-8.
  8. Kennedy JG, Murawski CD. The Treatment of Osteochondral Lesions of the Talus with Autologous Osteochondral Transplantation and Bone Marrow Aspirate Concentrate: Surgical Technique. Cartilage. 2011 Oct;2(4):327-36. doi: 10.1177/1947603511400726. PMID: 26069591; PMCID: PMC4297142.
  9. Castagnini F, Pellegrini C, Perazzo L, Vannini F, Buda R. J Exp Orthop. 2016 Dec;3(1):3. doi: 10.1186/s40634-016-0038-4. Epub 2016 Jan 15. Joint sparing treatments in early ankle osteoarthritis: current prochttps://web.archive.org/web/20201125194540/https://scholar.google.com/scholar?cluster=8098837350345275920&hl=en&as_sdt=0,31edures and future perspectives.
  10. Kim YS, Lee M, Koh YG. Additional mesenchymal stem cell injection improves the outcomes of marrow stimulation combined with supramalleolar osteotomy in varus ankle osteoarthritis: short-term clinical results with second-look arthroscopic evaluation. Journal of Experimental Orthopaedics. 2016;3:12. doi:10.1186/s40634-016-0048-2.
  11. El-Jawhari JJ, Brockett CL, Ktistakis I, Jones E, Giannoudis PV. The regenerative therapies of the ankle degeneration: a focus on multipotential mesenchymal stromal cells. Regenerative medicine. 2018 Mar 19;13(2):175-88.
  12. Emadedin M, Ghorbani Liastani M, Fazeli R, et al.Long-Term Follow-up of Intra-articular Injection of Autologous Mesenchymal Stem Cells in Patients with Knee, Ankle, or Hip Osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003.
  13. Hernigou P, Dubory A, Lachaniette CH, Khaled I, Chevallier N, Rouard H. Stem cell therapy in early post-traumatic talus osteonecrosis. International orthopaedics. 2018 Dec 1;42(12):2949-56.1767

Frequently Asked Questions

I’ve been told my ankle is “bone on bone.” Is it too late for regenerative treatments? This is a phrase we hear all the time, and it can make you feel like your options have run out. The good news is that “bone on bone” doesn’t automatically disqualify you from regenerative treatments. The key factor we often look at is whether your ankle joint is completely frozen or if you still have some range of motion, even if it’s painful. If your ankle can still move and rotate, there’s often a good chance that treatments like stem cell therapy can help by reducing inflammation and supporting your body’s ability to repair the damaged tissue.

What’s the real difference between PRP and stem cell therapy for my ankle? Think of it this way: Platelet-Rich Plasma (PRP) therapy is like giving your body’s existing repair crew a powerful shot of espresso. It uses the concentrated growth factors in your own blood to signal and accelerate healing in areas with mild to moderate damage, like tendonitis or ligament sprains. Stem cell therapy is more like calling in a specialized construction team for a bigger job. It introduces powerful, versatile cells that can help rebuild tissues like cartilage, making it a more robust option for advanced arthritis or significant joint damage.

How do I know if I’m a good candidate for stem cell therapy instead of surgery? A good rule of thumb is to consider your ankle’s mobility. If your ankle is not completely locked in place by bone spurs and you can still bend and rotate your foot, you may be a strong candidate. Regenerative treatments work best when there is still a joint to save. The goal is to repair the existing structure, so if the joint is fused or has no movement, surgery might be a more realistic path. The only way to know for certain is to have a specialist perform a physical examination and review your imaging.

What does recovery look like after a regenerative procedure for the ankle? Recovery is very different from the long and often difficult rehabilitation after an ankle fusion or replacement. Because these are minimally invasive injection procedures, you won’t have the surgical wounds or hardware to heal from. Most people can walk out of the office and are encouraged to begin gentle movement soon after. The process is gradual as your body begins to repair itself. While timelines vary, research shows that many patients are able to return to low-impact sports within a few months as their pain decreases and function improves.

If I try stem cell therapy and it doesn’t work, have I lost my chance for surgery? Not at all. Choosing a less invasive path first does not close the door on surgery later. In fact, many people see it as a logical first step. By exploring regenerative options, you are giving your body a chance to heal itself without the risks and permanent changes that come with an operation like an ankle fusion. If you don’t get the results you want, surgery remains an option, but you will have explored a powerful alternative first.

Key Takeaways

  • Rethink Traditional Ankle Surgery: Ankle fusion can permanently limit your mobility, while total ankle replacements often have high rates of failure requiring revision surgery. Both carry significant risks, making it essential to explore all your options first.
  • Explore Regenerative Alternatives: Treatments like Stem Cell Therapy and PRP use your body’s own healing mechanisms to repair damaged tissue at the source. This approach focuses on restoring function and reducing pain without the long recovery times and risks of an operation.
  • A Second Opinion is Your Best First Step: If you still have some range of motion in your ankle, you may be a candidate for non-surgical treatments. Before committing to an irreversible procedure, talk to a specialist to see if regenerative medicine can help you get back on your feet.

Related Articles