Is Surgery The Answer?!

A common question from many patients coming in for physical therapy is, “Will I need surgery?” Most injuries that we see in endurance athletes and runners, are overuse injuries and will heal over time if we provide the right healing inputs and conservative treatment. Sometimes, though, either a patient will come in with an injury associated with an acute trauma or may have an injury that is more severe, where surgery may be a realistic treatment option. Also, there could be a belief that if an injury has not healed with a period of “rest” that surgery may be necessary (SPOILER: this is not necessarily true!). In the case of many longer standing injuries that did not start with a trauma, for example posterior tibialis tendinopathy or IT band syndrome, pure rest does not necessarily lead to recovery! More active treatments like physical therapy, with a combination of prescriptive loading exercises and hands on therapy usually is the answer. But, individuals with these injuries need to be patient (no pun intended) and put in the work to see progress!

Another factor to consider is that the amount of “damage” seen on an X-ray or an MRI does not necessarily dictate the need for surgical correction. This can sometimes be confusing or a surprise for some individuals. Especially, because our society perpetuates this belief of a more “mechanical” or “pathoanatomical” view of the body where if something is broken or amiss it may need to be fixed. We must remember, though, that our bodies are not machines, human beings are not robots, and more and more research suggests that pain and dysfunction (for example: limping or favoring one side of your body) may NOT actually be due to a tissue at fault (e.g., a torn meniscus, disc herniation etc.). This is not only true for those with back pain, many studies show that people can have “disc degeneration or “herniations” (Brinjikji, 2015) that show up on imaging and NOT be in any pain, but it is also true for conditions such as partial rotator cuff tears (Minagawa, 2013), labral tears in the hip or shoulder (Girish, 2011; Register, 2012) , or meniscus tears (Beattie, 2005).

Another factor to consider if you have an injury and are considering surgery is if there is research to support the effectiveness of that surgery! There are generally good outcomes from surgeries to repair ligaments in the knee or ankle because those tissues provide needed restraints to excess joint movement and so the stability from a surgical repair, assuming rehabilitation is undertaken, is usually productive. This may be different from an injury such as a meniscus tear, in which newer research is showing that those that get surgeries such as “meniscectomies” don’t necessarily have better outcomes from those who do not get those surgeries (Sihvonen, 2018; Wijn, 2023).

What to do?

If you think you have an injury that may need surgery, the best next steps would be to consult with a physical therapist, orthopedic doctor and at least one person in your support network (friend or family member) to come up with the best treatment plan that makes sense for you as an individual given your job and lifestyle and your specific injury. If you have not tried physical therapy and you think it may be appropriate and helpful to get you back to the activities that you love, we are here to help! Our physical therapists often go to great lengths to help patients avoid having surgery and in many cases that is the last treatment option that is offered because patients have such good success with conservative care. You can really make significant progress if you give your body the right inputs to heal including high-quality exercise prescription, training plans, and hands on therapies. Please get in touch if this sounds like you and we can help get you going in the right direction!

References:

Beattie KA, Boulos P, Pui M, et al. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis and Cartilage. 2005;13(3):181-186.

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.

Girish G, Lobo LG, Jacobson JA, Morag Y, Miller B, Jamadar DA. Ultrasound of the Shoulder: Asymptomatic Findings in Men. American Journal of Roentgenology. 2011;197(4):W713-W719.

Louw A, Diener I, Fernández-de-las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. Published online July 11, 2016:pnw164. doi:10.1093/pm/pnw164

Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal of Orthopaedics. 2013;10(1):8-12.

Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of Abnormal Hip Findings in Asymptomatic Participants: A Prospective, Blinded Study. Am J Sports Med. 2012;40(12):2720-2724.

Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthopaedic Journal of Sports Medicine. 2016;4(1).

Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis. 2018;77(2):188-195. doi:10.1136/annrheumdis-2017-211172

Wijn SRW, Hannink G, Østerås H, et al. Arthroscopic partial meniscectomy vs non

surgical or sham treatment in patients with MRI-confirmed degenerative meniscus tears: a systematic review and meta-analysis with individual participant data from 605 randomised patients. Osteoarthritis and Cartilage. 2023;31(5):557-566.