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Welcome, we'll try to make this as painless as possible. Buckle up, check your rearview mirrors, and join us on our journey to answer the million-dollar question:
If I have surgery, will my quality of life, pain levels, and ability to return to the activities I once loved significantly improve?
To get the ball rolling, let's set some ground rules:
1. The scope of this article is limited to musculoskeletal and chronic pain conditions. Shoulder impingement and chronic low back pain, apply here. Open heart surgery, not so much.
2. We love all our doctors, physical therapists, and healthcare providers we work with.
3. Making informed decisions about what’s best for you can be freaking hard. This is how we understand the information at this time.
4. There are plenty of situations where surgery is warranted.
Here is what you must know. With all the medical information floating around the internet and despite what your doctor, chiropractor, or knowledgeable second uncle who swears up and down about their success with what they did says, there is a vast gray area when it comes to surgical interventions for musculoskeletal conditions and improved quality of life. Stating it another way, surgery can help some people, but not all.
For starters, people are individuals - all with different subjective experiences, lifestyle habits, beliefs, and anatomical differences. Providing a standardized surgical procedure to a complex jumble of emotional, spiritual, and physical mess of humans and expecting the same outcome for everyone is unrealistic.
Secondarily, at least in the United States, we've been raised to believe doctors are the holy grail of health care. And they are. They have the most training, education, and rigorous standards that they adhere to. Their knowledge is essential and for the most part altruistic.
Here is where it gets tricky - Despite our best efforts, internal bias and ego is an inevitable truth of healthcare and any other profession.
Surgeons make a living being good at surgery, just like a physical therapist makes a career being good at rehabilitation. When seeking advice, these internal biases and the need for justification toward one type of treatment versus another can easily be projected onto you and your decision-making (we are doing it right now).
It's not uncommon to receive five different opinions from five different doctors for the same medical condition. Here is an example we see all the time for a nonspecific condition such as chronic low back pain:
Primary Care: "That arthritis you have in your back is the cause, here is some anti-inflammatory medicine."
Orthopedic Surgeon: "Well your MRI shows you have degenerative disk disease and you will probably need surgery."
Pain Management: "Let's do a series of three injections into your back and that should fix the problem."
Physical Therapist: "Your core is weak, we just need to get you stronger."
Chiropractor: " Your back is out of whack, let me put it back in place for you."
If we haven't made our point yet, the narrative healthcare professionals offer can quickly change our internal beliefs about ourselves and the treatment we receive. This can be dangerous. And for a multitude of reasons, surgery, many times, is recommended as a solution to complex musculoskeletal conditions we still don't fully understand. Taking the above into consideration, the million-dollar question now becomes:
How can we make informed decisions about whether surgery will help you, the individual, get out of pain and return to the activities you love?
To answer this question appropriately, the surrounding research must be considered. And while some of you may be saying, "Research just like humans can have its biases." We hear you. However, despite the risk of bias, research shines a light on the best information we have available, and disregarding this would be unethical. Also, using high-quality evidence like systematic reviews and meta-analyses can reduce the risk of researcher bias and offer a broader picture of expected outcomes over longer time frames and demographics. So there you have it. The rest of this article will look at the current research for common musculoskeletal conditions and hopefully expand on whether surgery is right for you.
And for those who hate reading about research or just want the answer, here you go:
"For most musculoskeletal and chronic pain conditions, current research is trending away from the use of surgical interventions as an effective solution for pain relief and improvement in the quality of life."
If the odds of a successful outcome based on the current research are not heavily weighted in your favor, you probably shouldn't have surgery.
Here are the three most common findings on an MRI:
1. Arthritis or degenerative joint disease
2. Degenerative disk disease
3. Herniated or "bulging disk"
What typically happens: Often these findings are reported to the patient by the doctor. And without the doctor ever explaining if said findings are relevant to the patient's condition, the patient heads home believing something is seriously wrong. This phenomenon is also known as the iatrogenic effect, or when a diagnostic tool such as an MRI creates the belief of a new illness or injury. Sometimes MRIs can open the door to more problems than they solve and the research backs this.
Fun fact, a 2012 study showed for those patients who received an MRI following an episode of low back pain, their chance of a successful outcome was much worse than those who didn't (1).
What the research really says about these findings: These "abnormal" findings on an MRI, x-ray, or CT scan are just as prevalent in individuals without back pain. These findings in asymptomatic individuals significantly increase with age as well. Akin this to wrinkles on your skin, the rest of your body does the same thing. Besides, as referenced by a 10-year analysis of people with these "abnormal" findings, there was no increased risk for the future possibility of back pain either (3).
An important side note: These "abnormal" MRI findings aren't just limited to the back, they occur all over the body. Don't believe us, here are some numbers for you:
An average of 34% of people have rotator cuff tears as diagnosed by MRI. This number goes up to 54% for anyone over the age of 60 (4).
For the males in their late 30's, there is a 69% chance you have a labral tear in one of your hips (5).
And if you're 45 to 60 years old and have a labral tear in your shoulder, join the other 70% who do as well (6).
Have you been told you have a meniscus tear in your knee? Congratulations. These findings are often incidental as well (7).
Keep in mind, that these are all findings on MRIs for people without pain or symptoms.
What this means: We should tread very lightly when inferring that our"abnormal" MRI findings need to be fixed or corrected with surgery. Pain is complex, and imaging is just one piece of a giant puzzle. Special care needs to be taken when correlating pain to findings on an MRI. Having surgery for what could be considered a normal part of aging brings significant risk.
Surgery for sciatica, is it a good idea? Well in a systematic review done in 2012, the authors found mild to moderate benefits concerning pain levels in the short term. After a year, however, the outcomes were no better than conservative care as referenced by pain levels, functional status, perceived recovery, and lost days at work (8). What about surgery for Stenosis? According to a systematic review done in 2011, there is moderate support for a decompression-type surgery, only after 3 to 6 months of conservative care has failed (9). However, a Cochrane review done in 2016 refuted this and showed very little evidence to warrant surgery for those with lumbar stenosis (10). If you have stenosis, minimal other contributing factors, and have failed conservative care, talking to your doctor about surgery might be an option for you (9).
Surgery for Non-Specific Low Back Pain? This one is easily the most emphatic no. Studies like these (11)(12)(13)(14) repetitively show surgery offers no clinically measurable benefit over those who undergo conservative care. In this situation, there is no reason ever to have surgery.
Surgery for non-traumatic rotator cuff tears? This is a typical scenario - One morning you wake up with this random shoulder pain, and after a couple of days or months, it hasn't gone away. You decide to go to the doctor, and after a quick discussion, they order an MRI. You return to the doctor only to find out you have a rotator cuff tear. Your options are discussed and surgery is recommended.
Sound familiar? And is this something you should consider? As we said before, rotator cuff tears are very common in healthy asymptomatic individuals. We must be careful in correlating what an MRI shows to the pain we are experiencing. More importantly, the research shows no benefit in outcomes for those who had a rotator cuff repair surgery over those who chose conservative care after one year (15). And for anyone who's had shoulder surgery, you already know it's a pain in the ass.
Currently, there isn't conclusive evidence to warrant having surgery for non-traumatic rotator cuff tears.
What about labral tears? This gets a little more tricky as the research isn't as conclusive. If your doctor has diagnosed you with a superior labral tear extending anterior to posterior, also known as a SLAP lesion, surgery might be the best option only after conservative care has failed and:
1. There was a traumatic mechanism of injury to the shoulder, such as a fall.
2. You have re-occurring feelings that your shoulder "feels" weird, out of place, or you are apprehensive with certain motions.
3. You are younger than 40.
4. And you play a dominant shoulder sport like baseball or tennis.
If you don't fit the bill for any of the above criteria, conservative care is successful in 2/3 of the population (16). This is probably your best bet.
These are two prevalent reasons for knee surgery despite the poor evidence presented regarding their efficacy. Studies like these (17)(18) compared the outcomes of a sham surgery (meaning no operation was performed, but the individuals believed they had surgery) to those who underwent an arthroscopic partial meniscectomy for knee pain. The results were precisely the same over a 1 to 2-year period.
The group who believed they had surgery had the same outcomes as the group who did. Pretty trippy huh?
If you don't have knee osteoarthritis, are between the ages of 35 - 65, and have been diagnosed with a meniscus tear, surgery might not be for you.
What about arthroscopic surgery for knee osteoarthritis? The trend continues. Here's an excerpt from painscience.com explaining the history and current research:
"A fascinating 2002 experiment (see Moseley) showed that people who received a fake arthroscopic knee surgery had results just as good as people who received the real surgery for osteoarthritis. Six years later, The Cochrane Collaboration published this report, concluding that “there is ‘gold’ level evidence that arthroscopic debridement has no benefit.” A few months later in the summer of 2008, the New England Journal of Medicine (Kirkley) added more experimental evidence to the pile, reporting that “surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.” "
If your doctor recommends cleaning out your knee for generalized osteoarthritis, I would feel comfortable getting a second opinion(19)(20).
Without getting too detailed, this diagnosis has skyrocketed in prevalence over the past decade. Advancements in research and imaging techniques have contributed to this effect. The question remains, however, just because we see it on an MRI or X-Ray, is surgery warranted? The evidence isn't clear, and surgery might be a viable option for those with FAI. Use these guidelines to help with your decision-making:
1. FAI is common among asymptomatic and symptomatic populations. This diagnosis alone is not enough to warrant surgery (5).
2. If you are older than 65 years old, this diagnosis is considered more of an anatomical variant rather than a symptomatic progressive disease. There is not enough evidence to warrant surgery in this population (21).
3. If you are young, active, have failed conservative care, and continue to have persistent limiting hip pain, talking to your doctor about surgery is a good option (22).
Outcomes following surgery in a younger, otherwise healthy population are favorable.. In a systematic review looking at roughly 1900 hips that underwent arthroscopic surgery for FAI, 87.7% of percent of patients were able to return to their primary sport (22).
Still confused? We can help! We are experts in recovery care and physical rehabilitation. The first thing you need to do is get assessed by one of our professionals. Everyone's different, and before we can create a game plan, we need to understand you.
We are the Vital Six, offering the best recovery, performance, and physical rehabilitation services in the Kansas City Metro.
We help our patients get out of pain and get back to doing what they love 2-3x faster than the industry average.
Call us at 913-303-0032 to learn more.
1. Graves JM1, Fulton-Kehoe D, Jarvik JG. et al. Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine (Phila Pa 1976). 2012 Aug 15;37(18):1617-27.
2. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2014;36(4):811-6.
3. Tonosu J, Oka H, Higashikawa A, et al. The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS One. 2017 Nov 15;12(11):e0188057.
4. Gill TK, Shanahan EM, Allison D, et al. Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Int J Rheum Dis. 2014 Nov;17(8):863-7
5. Register, B., Pennock, A. T., Ho, C. P., Strickland, C. et al. Prevalence of Abnormal Hip Findings in Asymptomatic Participants: A Prospective, Blinded Study. The American Journal of Sports Medicine, 40(12), 2720–2724.
6. Schwartzberg R, Reuss BL, Burkhart BG, et al. Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016;4(1):2325967115623212. Published 2016 Jan 5. doi:10.1177/2325967115623212
7. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108-15.
8. Jacobs WC, van Tulder M, Arts M, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2010;20(4):513-22.
9. Kovacs FM, Urrútia G, Alarcón JD. et al. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine (Phila Pa 1976). 2011 Sep 15;36(20)
10. Zaina F, Tomkins‐Lane C, Carragee E, Negrini S. Surgical versus non‐surgical treatment for lumbar spinal stenosis. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD010264. DOI: 10.1002/14651858.CD010264.pub2
11. Chou R, Baisden J, Carragee EJ, et al. Spine (Phila Pa 1976). 2009 May 1;34(10):1094-109. doi: 10.1097/BRS.0b013e3181a105fc. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline.
12. Koes BW, van Tulder M, Lin CW. et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-94.
13. Peul Wilco C, Bredenoord Annelien L, Jacobs Wilco C H. Avoid surgery as first line treatment for non-specific low back pain BMJ 2014; 349 :g4214
14. Helm II S, Deer TR, Manchikanti L, et al. Effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician 2012;15:E279-304
15. Kukkonen J, Joukainen A, Lehtinen J. Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up. J Bone Joint Surg Am. 2015 Nov 4;97(21):1729-37. doi: 10.2106/JBJS.N.01051.
16. Hester WA, O'Brien MJ, Heard WMR1, Savoie FH. Current Concepts in the Evaluation and Management of Type II Superior Labral Lesions of the Shoulder. Open Orthop J. 2018 Jul 31;12:331-341.
17. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26;369(26):2515-24.
18. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84.
19. A. Kirkley, T.B. Birmingham, R.B. Litchfield, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee N. Engl. J. Med., 359 (2008), pp. 1097-1107
20. https://www.painscience.com/biblio/review-confirms-arthroscopic-debridement-for-knee-osteoarthritis-does-not-work.html
21. Nardo L, Parimi N, Liu F, et al. Femoroacetabular Impingement: Prevalent and Often Asymptomatic in Older Men: The Osteoporotic Fractures in Men Study. Clin Orthop Relat Res. 2015;473(8):2578-86.
22. Minkara, A. A., Westermann, R. W., Rosneck, J., & Sean Lynch, T. (2019). Systematic Review and Meta-analysis of Outcomes After Hip Arthroscopy in Femoroacetabular Impingement. The American Journal of Sports Medicine, 47(2), 488–500. https://doi.org/10.1177/0363546517749475
