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Should I have Physiotherapy or Surgery for my problem `?

My top 5 conditions where surgery may NOT be the answer.

It's the billion dollar question and one we get asked a lot in clinic.. " should I see about getting some surgery to sort it ? " Now clearly there are some conditions that absolutely NEED surgery - an unstable fracture or you have clear signs of caudae equinae syndrome - this article isn't about these kind of conditions. I'm talking more about those niggly pains or conditions which in the past have ' traditionally ' been operated on.

This is my opinion based upon what I have seen in my career and is NOT necessarily what everyone will say....particularly the surgeons. Thankfully the old surgeons mantra of " if in doubt, whip it out " is on the wane ! However they are not always fully aware of advances in our treatment techniques and I am not fully versed in the latest surgical techniques that may be on offer.

So read ahead for my top 5 ' to op or not to op ' conditions.

#1 - Arthritis

We'll start big !

Wear and tear arthritis or ' osteoarthritis ' is incredibly common with pain coming from damage to the crunchy type hyaline cartilage coating the ends of the bones and lining the joints. The underlying bone can eventually become involved and sensitised. Pain is never simple and we already know that the amount of damage to the cartilage does NOT correlate with the amount of pain experienced. I remember seeing patients with dreadful Xrays that were not in that much pain and vice versa. Pain is a very individual experience.

If the pain is such that it is limiting your activites a lot, regularly disturbing your sleep or there is any instability of the joint then a surgical opinion is a sensible option. However, we see many patients in clinic with arthritis that learn to manage their pain well with a combination of treatments. Surgery is not the only answer by any means, in most cases we can help stave off the surgeon for a reasonable time and help keep you doing what you want to do for longer.

Verdict : Only if you are desperate and the pain is severely impacting your life.

#2 - Back Pain

Not including slipped discs ( see below for that ! )

This section refers to what we call ' non specific low back pain ' it's defined as " low back pain not attributable to a recognizable, known specific pathology (eg, infection, tumour, osteoporosis, lumbar spine fracture, structural deformity, inflammatory disorder,radicular syndrome, or cauda equina syndrome) - pain with no structural, infection ,tumours, bony breaks, " .......... basically back pain with no serious or dangerous cause i.e the majority of low back pain. Probably 70% of what we see in clinic.

In my professional opinion surgery for this kind of back pain is rarely successful and should be avoided. ALL surgery carries inherant risk and spinal surgery carries the additonal, small yet significant, risk of paralysis or damage to the spinal cord. Conservative ( non-surgical ) treatment really is the best option in this instance and there are many different varieties of conservative treatment, not just Physio,

Verdict : AVOID like the proverbial plague !!!!

"For people with nonspecific low back pain in their 40s, 50s, or 60s, conservative measures are hard to beat,."
Dr S Atlas, Harvard Medical Professor

#3 - Knee cartilege ( Meniscus )

Generally speaking these problems fall into two camps. Either an acute sudden cartlage tear or a gradual wear and tear which usually progressively worsens. The meniscus are extra pads of squishy ( rather than crunchy ) cartilage sitting in the knee joint space. In an acute TEAR there is a sudden increase in the load often with an associated twisting motion which physically tears the cartllage often giving a ' popping ' sound and causing swelling, blocking and often a giving way. If it is still misbehaving and causing problems after six weeks or so despite physio then I yes, a surgical opinion is warrented.

For a wear and tear where there is no specific trauma or incident then we generally find they respond well to Physio and rehab. A big part of that treatment is identifying WHY the load has caused that wear and tear so you may find yourself doing exercises for your bum or foot muscles ( we really haven't lost the plot ) but generally they do well staying away from the surgeons table.

Verdict : For tears, yes, if not settling with lovely physio. For wear & tear, No

#4 - Anterior Cruciate Repair ( ACL )

Advice regarding this has changed more often than Lady Gaga's hairstyle over the years ! When I qualified a million years ago the advice was very much to operate on anyone under the age of 40 and then the pendulum swung towards avoiding surgery as much as possible and allowing the body to adapt. Thankfully advice today is more balanced and research based. The two biggest considerations being :

1. What do you want to do with the knee afterwards ?

2. Can you commit to six months of rehab ?

If you plan on playing sports to a high level ( especially involving lots of twisting ) or have a particularly physical job then surgery should be considered. However many bodies are able to adapt well and a missing ACL doesn't necessarily cause major problems with sport, providing physio rehab is done to improve the surrounding leg muscles to enable them to

' take over ' the majority of the ACL function and there is no noticable difference. Life however is never simple and some individuals tissues just don't adapt well despite tons of rehab and instability and pain can be persistent.

Post op rehabilitation is a good 6-months of hard work and then probably 6-9 months before playing any contact sports. It's not for the faint-hearted and needs to be bourne in mind before opting for surgery. No point going through the risk and hassle of surgery with no intention of committing to doing the hard work afterwards to get the full benefits.

Verdict : Depends what you want to be able to do afterwards.

#5 - Back pain with nerve pain included.

Remember above we spoke of ' normal ' back pain where nothing was structurally wrong ? Well this is a slightly different category. This group have problems directly involving the nerves and spinal cord and need separate consideration and once again they fall into two distinct groups. At the extreme end of the spectrum the spinal cord can become compromised causing symptoms such as changes in bladder and bowel function and a loss of sensation on your ' undercarriage ' ! This is non-negotiable - do not pass Go, do not collect £200, proceed directly to the MRI scanner and the surgeons office. This isn't appropriate for us to see without a medical review first. They don't always operate but there's a real sporting chance it may need it !

' Just ' nerve pain, without the extra muscle weakness element, is more of a contentious area. Most surgeons will tend to opt for a non operative treatment initially - no surgeon will happily start slicing around someone's nerves if they feel that improvements can be made with a less risky approach. There are many things that we can do in clinic from acupuncture, physical treatments to aid movement and reduce muscle spams alongside emotional and coping stratagies to help with managing the pain whilst Mother Nature does her job. If this doesn't work then surgery may be an option but I really do feel you need to give conservative treatment a good crack before opting for a surgical approach.

Verdict : Only as a last resort or in very special circumstances


This is MY list and advice but it's not gospel and ultimately everyone must review the evidence available to them and reach a decision that they are confident with and that works for them. If you are undecided or need any help managing your symptoms then do feel free to come and see us to ask any questions or see if we can help you dodge the surgeon.


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