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The Surgical Innovation That Got Tua Tagovailoa Back on the Field for Alabama's Title Push

Tua Tagovailoa's impressive recovery from a high ankle sprain has brought a wave of attention to Alabama doctors’ preferred surgery technique.

SAN JOSE, California — The man who could be called the savior of Alabama’s season as much as any player or coach has spent this weekend buried in snow. Thomas Clanton does not describe himself that way, of course, but depending on your perspective, he has contributed to the Crimson Tide’s national title push as significantly as Nick Saban or Tua Tagovailoa or Quinnen Williams or Jerry Jeudy. Clanton is a foot and ankle surgeon living 1,300 miles from Tuscaloosa in Vail, Colo., where on Saturday evening he had two feet of powder in his yard. “We’ve had a good snow year this year,” Clanton says. “I’ve been skiing 12 times.”

Clanton politely scoffs at the notion that he deserves credit for where Alabama is this weekend. “I don’t need any publicity,” he says softly. “I’m 68 years old. I’ve done all the things I wanted to do in my career.” You probably don’t know much about Clanton, or Alabama team surgeons Norman Waldrop and Lyle Cain, and you probably don’t know about a company called Arthrex and a product named the Knotless Syndesmosis TightRope (hereafter referred to simply as the tightrope). But the contributions of all of the above will come to a head in Santa Clara on Monday night, when the Crimson Tide meet the Tigers in a title bout where so much hangs on an ankle held together by a surgical procedure now getting national attention. “It’s amazing,” says Alabama quarterbacks coach Dan Enos. “I don’t understand anything about it. I know this, though, it’s amazing.”

The tightrope is a relatively new innovation in the treatment of high ankle sprains, in which ligaments and tissues around the leg bones, the tibia and fibula, are loosened and become unstable. The tightrope offers an alternative to the traditional methods of treatment: rest and rehabilitation or the insertion of screws into the tibia and fibula, bonding them like one would a pair of two-by-fours with a nail. In tightrope fixation, surgeons slip a high-strength suture through small holes in the bone, fasten it with small metal buttons and then tighten it as you would a zip tie. The procedure takes about 25 minutes.

Once something of a secret weapon for Alabama, tightrope surgeries have been brought into the spotlight by the circumstances of the Crimson Tide’s 2018 season. Starting quarterback Tagovailoa and backup quarterback Jalen Hurts each suffered a high ankle sprain about six weeks apart. Within four weeks, they both returned from an injury that would normally sideline an athlete six to eight weeks, if not much longer. Hurts led a game-winning drive for the SEC championship against Georgia after Tagovailoa suffered his sprain on Dec. 1, and then Tagovailoa returned less than a month later to lead the Tide to a win over Oklahoma in the CFP semifinal on Dec. 29.

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The speed of Tagovailoa’s return sent a wave of astonishment through college football, shining a light on a procedure that the team has actually used for several years. Waldrop, an orthopedic surgeon at the Birmingham-based Andrews Sports Medicine Center who serves as an Alabama football team physician, introduced the tightrope to the team in 2014, three years after he learned about the mechanism from Clanton in Colorado. “I know all about Jalen and Tua. I was watching the [Orange Bowl] last week,” Clanton says. “I texted Norm and said, ‘You’re going to be in the spotlight over this.’”

In 2017, Waldrop explained in a video why he likes to use the procedure to treat elite athletes who suffer high ankle sprains:

Waldrop’s first patient was left tackle Cam Robinson, who sprained his ankle two weeks before a scheduled game in 2014 against his home-state school, LSU. Robinson was so motivated to play against the Tigers that he urged doctors to hasten the process, leaving them no choice but to treat him as a guinea pig for the tightrope. “Had a good game,” says Cain, Alabama’s team head orthopedic surgeon and the man Waldrop convinced to begin the tightrope treatments. “Cam didn’t have complications. We felt comfortable with it.” Since then, at least six Alabama players have undergone surgery to insert a tightrope, including four on the current team: Tagovailoa, Hurts, left tackle Jonah Williams and center Ross Pierschbacher. At the Andrews Sports Medicine Center, Waldrop performs at least two tightrope procedures a week, treating players at all levels of college and high school football. This fall, he hit a record mark for tightrope surgeries on FBS players at 30, including a few from Alabama’s SEC rivals.

About 20 FBS schools contacted him this fall regarding the tightrope procedure—“and that was before Tua’s surgery,” Waldrop says. “Some have sent me players. Some have picked my brain. One team physician called me: ‘I’ve got two of my starters out for seven weeks and I cant get them back. Talk to me.’” Waldrop is sharing information so regularly that Alabama head trainer Jeff Allen half-joked with him to stop. “I don’t want everyone to know about this. It’s an advantage for us,” Allen told Waldrop. In light of the recent high-profile surgeries with Hurts and Tagovailoa, “the cat is kind of out of the bag now,” Waldrop laughs.

Waldrop points to Clanton as the “root” of the procedure for him. He spent a year with Clanton in 2011 during a fellowship, a post-residency training for doctors. Clanton specializes in the tightrope. He started using the technique in 2005, around the time of its inception. While based in Houston as the team physician for the Rockets and the Texans, Clanton popularized the procedure in the NFL and NBA. He moved to Colorado in ’09 but remains one of the nation’s biggest proponents of the treatment, even writing a chapter of a yet-to-be-released textbook on the tightrope and promoting the tightrope through presentations at medical clinics, many of them designed to convince trauma surgeons to switch from the standard method of screws.

Some physicians have resisted the movement away from the traditional methods, and critics believe the tightrope surgery can be unnecessary, according to Clanton and Cain. “Those athletes Norm got to play so fast, people would say they didn’t need the surgery in the first place,” Clanton says. “That’s one of the negatives. I know Norm and I know that’s not true. We try to treat it non-operably and they’d have reoccurring problems with it.”

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Clanton estimates less than half of the NFL’s 32 teams use the procedure, with the Packers, Vikings, Colts and Giants among the growing number of converts. The tightrope received its biggest promotional jolt this fall. The prominent surgeries to Tagovailoa and Hurts have thrust the method under the brightest spotlight of its near 15-year history. Just ask officials at Arthrex, the Naples, Fla.-based company that manufactures the most widely-used tightrope device. “We’ve been excited about it for 10 to 12 years,” says Karen Gallen, Arthrex’s senior director of engineering. “It’s nice that it’s getting excitement outside of our walls.” Since its inception, more than 270,000 Arthrex tightropes have been implanted globally. “We met up with Dr. Waldrop,” says Pete Denove, the company’s senior director of product management for distal extremities. “He’s a good surgeon and he’s progressive. He saw the benefit for the patients.”

Clanton calls Waldrop a ground-breaker in the tightrope movement for accelerating the recovery process with an aggressive rehabilitation. Post-surgery swelling is usually gone within three to four days, running on an anti-gravity treadmill follows a few days later and then patients can move to cutting while running within 12 days. They must perform 15 single-leg hops as a test of their readiness to practice. Tagovailoa did that on Day 10. “It was quick,” Waldrop says. Some are even quicker. “It’s usually seven days to play,” says Williams, the Bama tackle who underwent the tightrope procedure last January after suffering an ankle sprain late in the national championship win over Georgia. “It’s cool. They say it’s nearly impossible to sprain that ankle the same way with the tightropes in there. I did have one play where I got rolled up on [earlier this season]. Stressed my ankle. I’m grateful. It sucks getting hurt in the championship game, but if that didn’t happen I would have probably had it earlier in the season.”

A quick recovery is secondary to the long-term health benefits of the tightrope, Waldrop says. In the traditional method, a second surgery is necessary to extract the screws, while the tightrope material remains in the person’s ankle. “We’ve had guys that came back pretty fast. Insanely fast,” says quarterback Mac Jones. “It’s unbelievable.” Stories like those from Tagovailoa and Hurts are making it more and more believable. Tagovailoa suffered his high ankle sprain on the fourth offensive snap of the SEC championship game, playing on the injury until he had his other foot stepped on in the fourth quarter and was sidelined for good. “It probably cost him the Heisman Trophy in a lot of ways,” Cain says. Using the old method to mend Tagovailoa’s ankle would have made his return for the semifinal a near impossibility, doctors say. “The tightrope,” Clanton says, “has changed things.”

From an Alabama perspective, Clanton is the godfather of the innovation, the man who passed it on to a young, up-and-coming surgeon who has advanced the treatment even further. And to think, Clanton says, the catalyst for all of this might just be Auburn, the Tide’s fierce in-state rival. During Waldrop’s fellowship with Clanton in 2011, an Auburn receiver that fall suffered a high ankle sprain, attempted to return and re-injured the ankle. “Some of Norman’s family is from the Auburn area,” Clanton says. “I said, ‘You know, if they would have fixed it with the tightrope, he would be playing by now.’ I think that stuck in Norm’s mind.”

And now, on college football’s biggest stage, the tightrope will be front and center, holding together the two left leg bones of the Crimson Tide’s starting quarterback.