Following on from last months post – Physiotherapy vs Surgery – we delve into a little more detail into specific conditions to help you decide if surgery is the right way forwards. Either now, or in the future. For each condition I’ll give an opinion as to whether the many surgeries I have seen over the years have been more or less successful than conservative physiotherapy type treatment. We’ll start with a condition all of us may have, or fear we may get at some point in the future…
Should You Have The Op?: Only if you’re absolutely desperate
My favourite topic! I’ve done quite a few Blogs on the subject. Just because it is so relevant to all of us. In my more controversial moods I like to suggest that arthritis doesn’t really exist. That usually gets people attention! From a slightly more measured perspective I like to put it this way. Arthritis and the perceived pain from wear and tear on cartilage is a lot more complex than we all once thought.
There are many pieces of research to suggest that the amount of wear and tear we see on cartilage is not an accurate predictor of pain. At the clinic we consistently see people with severe arthritis (grade 4 if you’re into categories) who have little or no pain. Equally we see those with mild or moderate changes in their cartilage with severe pain and debilitation.
If you’re booked in to have your joint ‘washed out’ – debridement is the technical term – in our opinion don’t bother. It makes no difference to the underlying causes of the pain. Yes we’ve seen cases were debridement has helped someone. This could easily be placebo. And usually any improvements are short lived. That said if there are bits ‘floating around’ in your joint then debridement is an excellent intervention – but they need to be confirmed bits of debris. Not just based on speculation.
If you want more detailed information and evidence to back up the opinions above you can check out our two articles on the subject: Is Osteoarthritis Really To Blame For All Your Pain? and Would A Sports Therapist Get A Hip Or Knee Replacement? And an interesting article here comparing physiotherapy with arthroscopic surgery for osteoarthritis.
Low Back Pain
Should You Have The Op?: Avoid like the plague (unless there is something structurally very bad going on!)
We need a definition! Bear with the jargon, I’ll translate below. I’ve used the lovely Physiopedia website for this one:
“Non-speciﬁc low back pain is deﬁned as low back pain not attributable to a recognisable, known speciﬁc pathology (eg, infection, tumour, osteoporosis, lumbar spine fracture, structural deformity, inﬂammatory disorder, radicular syndrome, or cauda equina syndrome)”
In English this is back pain where nothing serious or immediately threatening is going on. You can always tell if you’re with a physio and you have one of these conditions as they’ll all of a sudden go ashen faced and very kindly offer to ring an ambulance for you! So for the rest of us that’s a no to the op.
Without anything severely structurally wrong with your back in my opinion surgery is not a good choice. For anything bad enough to require surgery you will either have to be very unlucky or have done something quite unnatural.
Any kind of back surgery holds some risk, however small, of paralysis. With improvement in surgical technology the number of cases continue to tumble. But there is always that risk and risk of other lesser post operative complications. It also can take quite a while to recover from any spinal surgery.
For the non-specific back pain sufferers out there – and that’s most of us – conservative treatment is always the best option. If one type of conservative treatment doesn’t work for you, try another. For more information on our approach to back pain check out our dedicated page.
Lower Back Disc Issues
Should You Have The Op?: Maybe, as an absolute last resort, or in very specific circumstances.
So this is a more specific issue for low backs. In our non-specific definition above it can cause ‘radicular’ or ‘cauda equina’ symptoms. In plane English this is when something bad is happening with your spinal cord in your back. The biggest thing to watch out for is if you can’t feel a seat when you sit on (saddle parathesia in the trade) and / or you’re having problems going to the toilet – that’s number ones or twos! Chance are, if you’ve got that, you won’t be wasting your time reading this!
The more ‘radicular’ type symptoms (in English nerve related symptoms) is more of a grey area for surgery. Generally speaking if the issue on your spinal cord is causing severe loss of function of muscles then you’re more likely going to be recommended the surgical option. And I wouldn’t disagree.
For those with ‘mere’ nerve pain down the legs you just need to toughen up! I jest. Though I have heard many stories about surgeons bedside manner! For those with standard nerve pain again conservative treatment is always preferred until no other option exists. If one conservative approach doesn’t work for you, try another one.
How sensitive your nerves are has a lot to do with stress levels. Whilst that’s not something we can particularly control that is something that we have significant influence over. We find a combination of reducing your sensitivity by managing your approach to stress and focusing on the physical aspect too gives you the best chance to avoid surgery.
Cruciate Ligament Rupture
Should You Have The Op?: Depends! Are you an adapter? What exactly do you want your knee to be able to do?
I’ve read quite a bit of conflicting research about this in the last few years. There was a phase whereby the over riding advice was not to have a reconstruction and let your body adapt. This was based on some fairly compelling research suggesting this was the way forward. More recently counter research has debunked these claims. We now have more balanced thoughts and advice.
Generally speaking if you do sport to a high level, especially sports involving rotation and or contact then advice is to have the operation. It is possible to compete without an ACL but that really depends on the person. Some people seem to adapt to the loss of their ACL really well. The muscles around the knee just adapt to give the knee the extra stability it needs without a cruciate ligament.
For those that don’t do sport or do less extreme sports then it may be a good idea not to have the operation. There is a slight caveat here is you simply are not an adapter. Some people when they don’t have an ACL are prone to episodes of giving way in their knee. It just buckles under them. This can be completely painless or it can be quite debilitating. Obviously, if you’re not adapting and the pain is significant then likely the operative option is best for you.
If you are considering an ACL reconstruction please bear in mind the amount of time it takes to recover. We can normally get people back to full competitive sport within 9-12 months. But equally this can be longer especially for those less active. Without the right management some people never regain full use of the knee again. We see a lot of those at the clinic but these tend to be years after the operation and tend to be the older operations.
The NHS page on the subject is a very good summary of these ideas.
Knee Cartilage (Meniscus) Issue
Should You Have The Op?: In severe cases, yes.
Firstly, education time. Two kinds of cartilage. One squishy, one crunchy. Crunchy in relation to arthritis (see above) – hyaline cartilage. Squishy in relation to helping a joint absorb load – meniscal cartilage.
Meniscal injuries can be of two types. One, you rotate your knee in an unnatural way and something goes pop. Two, it comes on gradually over time. A wear and tear type condition.
We generally find that the wear and tear type conditions respond well to our treatment at the clinic. They might even respond well to some of our competitors treatment too – although of course not quite as good! Generally speaking if you can identify and treat the reason there was increased load on the cartilage then that normally sorts it. This is backed up by this piece of research which “did not find significant differences” between surgery and physiotherapy.
It does go on to say that “30% of the patients who were assigned to physiotherapy alone underwent surgery within 6 months.” Which suggests these 30% were not happy with the outcome. It would be very useful to follow what up and ask if the surgery was a success for these people or not. Sadly the research didn’t get this far.
Those that have had a specific ‘incident’ to bring on their meniscal issues would fall into two categories. Ones that get better with time and respond well to our lovely treatment here at Brighton Sports Therapy. The same principles apply. Reduce the load on the ‘grumpy’ meniscus. Then there are those that despite everyone’s best efforts continue to misbehave. There are two symptoms that make us start to think surgery may be best way forwards. One, continuing to swell in a big way more than 6 weeks after injury. Two, a catching or giving way sensation that causes the knee to give way.
You can’t really miss these symptoms. If this is you I’d still try and see if we (or other such provider!) can work some magic. We’ll quickly know if we can or not. If that doesn’t work then likely surgery is the best option.
Should You Have The Op?: Only if it’s snapped in two, and even then it depends what you want to do with it.
All of the research I have read in recent years suggests that if your Achilles hasn’t snapped in two then put the scalpel down! Having rehabilitated many people over the years who’ve had surgery on their Achilles tendon I tend to find it just makes a mess. It’s just a really tricky area that’s super sensitive. So it’s a no from me.
If you’re unlucky enough to have snapped your Achilles in two then surgery still may not be the best way forward. Top end athletes tend to go the surgical option as they need maximum power and strength and are also under more pressure to get back to their sport. I know this was the option for David Beckham at the end of his playing days when he was playing for AC Milan. This option is a quicker fix but the Achilles is at increased risk of going again.
More and more people however are just being left in a boot which limits range of movement at the ankle and encourages the Achilles to re-attach itself. This is amazing successful and has much reduced re-rupture rates. So take your time and rehab it the right way.
There’s lots more information on Achilles tendons in our specific article you can find by clicking the link.
There you have it. That’s my musings on considerations on having your body parts operated on. There is more to come… but we’ll save that for another day. The whole point of these last 2 articles is to give you something to mull over. Operations aren’t always the best option. I can’t possibly keep up with all the developments from the world of surgery. I’m not a surgeon. But equally surgeons can’t keep up with what us as alternative therapists are doing too.
I’ve attempted to give an open, honest and balanced view of what we (that’s the royal we in terms whatever conservative treatment works best for you) can do for you. But equally where our limitations lie and then you’re best off letting a surgeon loose with a scalpel.
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