To Surgery Or Not To Surgery

Surgery has been a commonly used treatment solution to treat injuries of the knee and shoulder, and other joints. Traditionally, it was often thought that if abnormalities showed up on scans like an MRI, surgery was the only way to ‘fix’ the abnormality. But is this really the case? We will examine some reasons why this was the case.

The first reason that this might not be accurate is that the link between ‘damage’ on scans and the experience of pain is not a straightforward one. If you are in your 40s or over and have an MRI of your knee or shoulder, it will very likely show some abnormalities, and the older you get, the more common this is. This is even if you do not have pain and having these so called ‘abnormalities’ doesn’t mean you will develop pain either. It is a completely normal part of the process of getting older, just like the wrinkles on your face. However, this makes determining whether the changes seen on imaging are normal for your age, or something that could be responsible for your pain with a challenging task.

Secondly, pain is a multi-factorial phenomenon and doesn’t always only relate directly to anatomical changes. We know now that pain is a protective response which is influenced by many factors, such as stress, low mood, poor sleep, lack of physical activity and other lifestyle factors. This means that pain is not only a direct result of damage, but it is influenced an interplay of many different factors. It is possible to have a lot of pain without significant damage (think paper cut), or the other way around (there are reports of people living with a bullet in their bodies for years).

Another factor that can influence how we perceive pain is our beliefs about it. Believing that movement will create ‘wear and tear’ in the joints can cause a fear of movement, whereas we know that movement is beneficial for the lubrication and health of joints. It is important to understand that sometimes, working on the underlying beliefs about your pain and injury can actually help reduce your pain itself.

So, is surgery effective at relieving my pain?

Many surgeries were once thought of as being highly effective. But one of the reasons this may be the case is that surgeries can create a ‘placebo’ effect. We know this because in certain clinical studies they randomly assigned patients to the actual surgery, or a sham surgery where the surgeon makes incisions but doesn’t change anything about the anatomy. The outcomes between the two groups showed no difference between the group that had the real surgery and the group that had the sham surgery. Just the thought of having surgery was improving their symptoms, along with the often-associated recovery period after surgery potentially helping symptoms improve as well.

In addition, another phenomenon that may explain this perceived effect of surgery is called ‘regression to the mean’, a statistical term to describe ‘a return to the average’. People usually present to their doctor or physiotherapist when symptoms are particularly bad. However, knee and shoulder pain tend to have ups and downs and show a general improvement over time. If this improvement coincides with surgery, the credit usually goes to the surgical procedure.

It is also important to remember that surgery comes with an inherent risk. Risk of infection, bleeding, blood clots, nerve and artery damage, and side effects of anesthesia are not necessarily common, but they do happen. So, what if there is a way to have similar improvements in pain and function, but without the risks associated with surgery? This is where physiotherapy can be helpful. A group of experts examined the evidence for keyhole surgery for “wear and tear” knee and shoulder problems. They strongly recommended that surgery should be avoided, preferring lower risk alternatives, such as physiotherapy, exercise therapy or lifestyle change, before committing to surgery as a last resort.

If you have been told you need surgery but have concerns over this, one of our expert physiotherapists can help you make sense of your pain, help create a plan focused on evidence informed treatment options and monitor the improvement. Contact us today for an appointment to help ease your pain and keep you on the road to recovery.