Physiotherapy may be a more efficient option than surgery – 04/15/2023 – Equilibrium

Growing up as a competitive soccer, basketball, and volleyball player, Lindsey Plass was used to minor injuries and soreness. But it wasn’t until age 26, after she started running, that she was diagnosed with femoroacetabular impingement syndrome, a common hip condition that develops at puberty but may not cause pain until later in life.

As a physical therapist, Plass wanted to explore all treatment options and consulted with a surgeon who recommended a hip arthroscopy. “He told me I wouldn’t be able to go back to marathons if I didn’t have the procedure,” she says.

However, Plass knew there was no certainty about which patients would benefit from the surgery. After consulting with a colleague, she decided to take time off from running and undergo a physical therapy program aimed at strengthening her hip. She slowly got back into the sport, eventually returning to marathons as well as triathlons to give her body different stimuli.

Orthopedic surgery has revolutionized the treatment of many common injuries and offers incredible, even transformative, benefits. But some experts worry that many popular surgeries are overprescribed — and even ineffective — when simple physical therapy may be the best solution.

“Once you find out that a condition is not serious and needs immediate attention, your first line of action should be physical therapy,” says David M. Matusz, spine surgeon at NY Orthopedics in New York. “It will work in most cases.”

Deciding to start with physical therapy or surgery requires an informed approach, and patients must be armed with the right facts to make the best choice. Here’s what to consider if you find yourself in this situation.

Surgery or physical therapy?

According to some experts, for decades, healthcare professionals have preferred the surgical approach first, particularly for common spinal procedures to relieve back pain, meniscus repairs and certain hip surgeries.

“This is the ‘find it, fix it,’ or biomedical model of pain,” points out Chris Johnson, a physical therapist in Seattle. This model suggests that pain is primarily a physical phenomenon caused by tissue damage or dysfunction, which can be identified and resolved through surgical repair.

Additionally, many providers have a financial incentive from insurance companies to recommend surgery. About 750,000 Americans undergo surgical treatment for simple meniscus tears each year, at a cumulative cost of about $3 billion. But in 2017 an international panel opposed the procedure.

“Our health care system is not always focused on a proactive approach like physical therapy,” says Johnson. “If you’re working within that system, it can be challenging.”

In some cases, surgery is the only option, especially in the case of an acute traumatic injury that could indicate a complete tear of the ligament or tendon. “Say you’re skiing and you fall and you hear or feel a pop in your knee. It’s probably going to be a case for surgery,” says Johnson. “There are times when you need a doctor to step in and operate right away.”

In other cases, a less invasive approach with physical therapy can lead to equal, if not better, results. Take the case of meniscal tears – knee injuries considered minor and incredibly common. Evidence increasingly suggests that surgically repairing a torn meniscus offers no more benefit than physical therapy to help strengthen surrounding tissues and support healing.

In addition, surgery can lead to a more rapid onset of osteoarthritis, as well as increase the risk of other conditions that come with an operating room, such as staph infections. In 2017, an international panel recommended against the procedure and in favor of physical therapy and other conservative interventions, such as activity changes and lifestyle changes.

Dr. Matusz sees a few dozen patients a day on average and sends most of them to physical therapy instead of the operating room. He said it represents a shift in his approach over his 18 years of practice.

“People find it surprising because I’m a surgeon,” he said. “But most of the patients my partners and I see don’t need surgery. They need FT.”

How to decide which approach is best

If you have a persistent or acute injury, find the right specialist for your condition and body part, then gather all relevant information and possible options. With your doctor, determine things like whether the joint was damaged by a traumatic event or whether the problem stems from more chronic issues like strength imbalances or age-related changes that have been exacerbated by an increase in physical activity.

If you are considering surgery, ask your doctor questions. “Make sure he understands your goals, demands, and life pursuits,” Johnson says. “Know if you have an isolated injury, like a small ACL tear [ligamento cruzado anterior], or multiple, like some ligaments or meniscus too. In these cases, surgery may be best.”

Before deciding on surgery, you and your doctor should also consider your age and activity level. A 20-year-old professional soccer player with an ACL injury might want a repair, for example, so he can return to the field of play at or near 100 percent. A 50-year-old runner, on the other hand, can probably avoid it, regaining enough stability through physical therapy to allow him to return to the sport, as it is less demanding on the knee.

Not all types of injuries are created equal, points out Allison Fillar, an orthopedic surgeon at MedStar Health in Baltimore. See a meniscus tear or a full tear of the ACL. In such cases, surgery is required. But with other meniscus tears, physical therapy alone can work, she says.

If you’re inclined to try treatment, you should order a full battery of tests from your doctor or physical therapist, including functional assessments of the damaged joint and strength tests, says Johnson. This can also include performance tests involving movements such as jumps, calf raises, squats, push-ups and more.

If you decide to have physical therapy, different doctors will have varying approaches. “What works for one patient may not work for another,” says Matusz. “Sometimes I even have a patient switch physical therapists if they aren’t getting the results they want before we take the step to surgery.”

In Matusz’s opinion, even if you end up in the OR, if you tried physical therapy to begin with, you’re ahead of the game in giving it a chance to work. “When you get down to surgery, whether it’s for your spine or anything else, it should be your last resort,” he says.

Translated by Luiz Roberto M. Gonçalves