Over the last nearly 2 decades of treating patients and clients, I’ve been often asked to answer a common question:
Should I get surgery?
It’s a question that frankly isn’t asked enough, however.
Most assume that when they have a joint that is damaged, and it can be fixed, then surgery seems like an obvious solution.
But the science shows that the decision to have surgery for a joint issue (including cartilage, ligaments, tendons, nerves, and discs) isn’t that simple at all.
This is something I teach to clinicians in my lectures throughout the country.
Deciding whether to have surgery or not is something I’ve had to address personally with my own injuries, and of course with hundreds of patients and clients. I have been involved in many cases where I saved someone from having a surgery that physical therapy alone fixed their problem. I’ve also urged patients to immediately get surgery as continued PT was going to be ineffective or even harmful. I’ve personally benefited from the marvels of reconstructive surgery when PT could not fix it and also escaped a rotator cuff repair and spine surgery because of proper physical therapy.
From that experience, and an extensive review of the evidence, I’d like to share some guidelines that I think will help address a really important issue.
It could save you a lot of pain, time, and function.
Rule one: Consider your unique situation
Your age, goals, health status, whether the injury was from a trauma or overuse, work status, and many more factors play into the decision to undergo surgery. So, deciding whether to have surgery is far from formulaic. That also means you can’t use what the experiences that your neighbor or your favorite professional athlete had as a guideline for your decision.
For example, a gentleman I was working with was seeing me for a neck issue. He revealed to me that he was also having shoulder surgery in a few weeks for a torn rotator cuff. Given he was a dentist, I asked who was going to cover for him when he was out. He mentioned that he had coverage for a week, then planned to be back at work. I told him that such a plan was completely unrealistic, as he would not be able to use that arm for best case 8-12 weeks after surgery. Shocked, he spoke to his surgeon, and reevaluated his plans for surgery, and instead opted for a trial of conservative therapy to address his shoulder before evaluating if a plan for a 3-month hiatus from work was feasible.
Rule Two: Always exhaust conservative care
This may be the most important issue that is overlooked when evaluating whether to pursue surgery to take care of a painful joint issue.
When you exhaust conservative care prior to surgery, consider the best case and worst case scenario of doing so.
Worst case, you get stronger, healthier, address some of the key causes of the problem, make your chances of a successful recovery greater, and go into the risky pursuit of surgery with a clear conviction that it is the only way to get to your desired outcome as you exhausted all other means of reclaiming your optimal function.
Best case, you get stronger, healthier, reduce pain, address many of the causes of the problem, restore your function, and avoid the surgery, including the often lengthy and painful required recovery.
Even the worst case is often a positive outcome. Exhausting conservative care is a win win, regardless of whether you choose surgery or not.
Rule 3: Make sure you know what exhausting conservative care really is
Conservative care usually means physical therapy, as it incorporates (or should) the most well-researched options: the use of activity modification strategies, manual therapy, ergonomic instruction, strengthening, soft tissue mobilization, and pain education. It can also mean the utilization of medications (pills/injections/creams), acupuncture, dry needling, and other modalities by other professionals.
But exhausting conservative therapy is more than doing the right things, it’s also about doing them long enough to see the benefit.
For example, consider someone with chronic shoulder pain with an MRI revealing a torn rotator cuff. Given that rotator cuff tears are common in those who do not have pain, and therapy for many rotator cuff tears is just as effective as surgery, exhausting PT is recognized as best practice. However, many people are told to spend only 4-6 weeks in therapy to exhaust conservative care. If they don’t achieve 100% restoration of function, it’s considered failure and they assume surgery is the only option.
4-6 weeks is not nearly enough time to address the habits, motor control errors, and strength deficits that are related to the cause of many rotator cuff tears. Also, if the activities that provoke the pain are not modified or eliminated, it’s not nearly enough time for the inflammation to subside and tissue remodeling to occur. It’s like determining that school isn’t working because a kid can’t read Shakespeare by second grade. In my experience, it takes 2-3x that duration to completely exhaust whether PT is effective in such a case, although indicators that things are going in the right direction are clear much earlier on.
Rule 4: Look at the evidence and get a few opinions
It’s shocking how much evidence is out there that people, including clinicians, are unaware of comparing the effectiveness or surgery vs physical therapy for the treatment of common musculoskeletal conditions such as arthritis, rotator cuff tears, back pain, carpal tunnel syndrome, etc.
Making an informed decision is vital when it comes to your body, especially if pain, time, and risks are involved.
There are many studies that have looked at a comparison of surgery vs physical therapy for the treatment of various joint related problems.
For example, studies have shown that surgical outcome for SLAP (shoulder labrum) repairs, Carpal tunnel syndrome, rotator cuff tears in older adults, and spinal fusion were no better than outcomes for those who had physical therapy instead. For some types of meniscal surgeries and arthroscopic debridement of the knee, physical therapy was even more effective.
Before you pursue a surgery, find someone who can show you studies comparing surgery vs non-surgery, and weigh those against the pros and cons, taking into account your unique situation.
You need to have a clear an unbiased appraisal of the evidence from someone familiar with your individual situation.
Rule 5: Consult with both an Orthopedic Surgeon and Physical Therapist.
Here’s why you need both a Physical Therapist and orthopedic surgeon (or two) involved in this decision:
First, PTs and surgeons who are fellowship trained/board certified score the highest in knowledge of orthopedic issues, far ahead of other physicians or practitioners. Surgeons will have more knowledge of pathology, medication, and trauma, where as PTs will know more about the prevention, conditioning, and rehabilitation aspects.
But PTs have a few distinct advantages in helping you make decisions about surgery:
PTs get to spend more time with patients, not just because our evaluations take longer, but because we get to see you several times, usually 2-3 times a week. That means we can gather all the necessary information that is required to make the best decision. You need more than a 15-minute exam and some MRI films to tell someone whether a surgery is warranted.
You need time to exam them on multiple days. What your exam reveals on Wednesday am after playing tennis the night before can be different than on the next Monday afternoon when you’ve rested all weekend. It takes time to get to know what your goals are and what your life is like. Knowing that you have 3 young kids, are a single mother, and just started working part time is going to strongly influence how we advise you on the pros and cons of having surgery for your carpal tunnel syndrome. Seeing people multiple times a week also allows us to get a glimpse of their response to treatment.
Finally, follow-up treatments in PT allow the impairments that are often causing the problems to be revealed. You can not see faulty tennis swing mechanics in a small ortho exam room. But after fatiguing someone and performing multiple back swings with a lunge and rotation pattern, the decreased hip torque and weak scapula muscle impairments become apparent in a PT clinic after 30 minutes of treatment. Even the best surgery won’t fix that.
People forget that the evaluation is not a 15-minute snap shot. Rather, it is an evolving process that involves not only seeing how you move and react to stresses over time, but also knowing your goals, motivations, fears, and lifestyle factors. PTs are perfectly positioned to access this.
Also, let’s not forget the elephant in the room. PTs have little to gain whether you do surgery or not. If you do, you’ll need plenty of PT for recovery after surgery. If you don’t, well great because we can help you that way as well. PTs don’t have a strong bias, although there is a little potential for bias to promote getting surgery. It’s an easier sell and you need more PT for post-surgical rehab. But the potential for bias in favor of surgery is much stronger for surgeons for obvious regions. Although all professionals endeavor to minimize the influence of their biases which are natural to have, we all are vulnerable to bias and should be aware of them.
Who should you see first? Studies show starting with PT can reduce costs, reduces the likelihood of opiate use, and it increases the likelihood of effective outcomes without surgery.
Rule 6: Know that imaging is only part of the picture
With the increased availability of the high quality of imaging, it seems logical that identifying tears and damage to anatomy explains why you are in pain, and points to the solution. Fix the tear, problem solved, right?
Not at all.
Many studies show that the connection between damage on an MRI and pain or loss of function are not always clear.
For example, many studies show how common tears, bone spurs, and arthritis are in people that don’t have pain. In addition, the size of the tear or degree of degeneration doesn’t always correlate to the extent of damage. Finally, not all surgical repairs hold up, yet still people get good results.
Just about anyone who gets a CT scan or MRI will have some findings of degeneration or tearing that might seem abnormal.
These things don’t always predict function or explain your pain.
That can’t always be fixed with surgery either.
Good clinicians don’t treat solely based off the MRI findings. Informed patients don’t let fancy sounding “abnormalities” found on imaging tests push them into surgery.
Scores of people have played hockey without ACLs, played tennis with torn labrums, run with degenerative joint disease, and lifted with herniated discs without having surgery.
Others like myself are only able to jump and run again because of the unbelievable skill of excellent surgeons.
In my experience, however, people are moving prematurely towards surgery based on findings on the MRI that they don’t fully understand.
Rule 7: Treat the cause, not the pain
Regardless of whether you pursue surgery, the most import question to investigate is “why did it happen?” In cases of trauma, it’s easy… you fell on the ice and broke your arm.
But when there isn’t trauma, the question gets trickier. Some will say it’s “overuse”, but that doesn’t usually address the full picture. More often, it could be poor mechanics, weakness, habits, or ergonomics.
For example, if your shoulder hurts when you lift your grand kid, maybe that can be because your rotator cuff is simply not strong enough to regularly lift and carry a 20lb. toddler. Or if it bothers you with tennis, maybe it’s because you don’t rotate your hips adequately or use you shoulder blade improperly, increasing strain on your rotator cuff. Or if it bothers you during the night, maybe your habits of laying on your side while you read every night is compromising your rotator cuff.
These are factors that often won’t go away when you have surgery. So addressing them before hand will at least make your surgery go better, and at best eliminate the need for surgery at all.
Having an injury and being in pain is no fun. Even worse is when you have to decide whether or not you are going to have surgery. Many minimize the risks and are unaware of the extensive post-operative rehab. Others are exceedingly worried about surgery, even when thousands have been successfully performed.
But far too many are unaware of the effectiveness of the non-surgical options available.
Hopefully these 7 rules will make the decision clearer, so you can help determine the best option for you.
If you need some help just send me an email and I’d be happy to help steer you or any one you know who would need some help in the right direction.
Considering back or shoulder surgery?
I will answer all of your questions and show you all the evidence on the best solutions, comparing PT, meds, and surgery for fixing these so you can make an informed decision.