Surgery – Yes or No?

March 8, 2018

Joseph’s knee hurts, badly.  He can’t really get around pain free, let alone do his daily morning power walk.  He takes some non-prescription painkiller.  For a few hours, there is some relief although a dull ache is always there.  How long can he keep taking these pills?  They begin to bother his stomach by the third day of taking them.  Debra’s lower back is always in pain.  She has a special pillow for the back of her chair in the office she works in, but still has to get up every 20 minutes to walk around.  Sleeping is difficult for her and her quality of life has been deteriorating.  Elazer is in chronic left shoulder pain.  He was our hiking a few weeks ago and slipped while climbing down a hill.  He used his hand and arm to brace his fall, but his rotator cuff, the 4 muscles that help with stability, was injured and he always has pain in his upper arm especially upon certain types of motion.   Joseph, Debra and Elazer all are dealing with pain and all of them have been to an orthopedist.  In each case, the option of surgery was mentioned.  When do we use time to heal, physical therapy or rehabilitative exercise and when is surgery the best option?

Joseph, age 52, is active and not only does he do a power walk each morning, he uses staircases in his workplace to get from one floor to the other and always prefers walking from place to place when he can.  As long as the weather isn’t bad, he always walks to Shachris each morning. His pain came on pretty suddenly and although he is doing his non-walking exercises 3 days per week, he isn’t getting his cardiovascular workouts.  After doing an MRI of his knee, his doctor said that there is some deterioration in his meniscus and that the lack of cartilage between his bones is causing the pain.  He also said that it really isn’t as bad as he has seen in many other patients and that although orthoscopic surgery might help, there are other options to look at.  Joseph had been very overweight for much of his adult life.  We began a weight loss program 2 months before this happened.  Part of the program had Joseph doing all this walking. 

We talked about what we could do before the surgery option.  Many times, knee problems occur or are exacerbated because of bad biomechanics.  That means the process of putting your foot down when walking and the resulting kinetic energy that travels up your leg can be misplaced.  Your ankles, knees, hips and lower back are all shock absorbers for that energy.  When everything is aligned properly, there shouldn’t be pain.  If someone has flat feet or high arches and their walking gait is off, there can be pain in any of those locations.   So I sent Joseph to a podiatrist to see about correcting this potential issue with a pair of good quality, custom orthotics.  In addition, I suggested that he come in for a few personal training sessions so we could concentrate on building up the muscles that help the knee function, particularly the quadriceps and hamstrings.  He then could do exercises daily at home to continue that process.  We also began a protocol of icing his knees 3 times a day for 6 minutes and after any walk of more than 20 minutes.  We did that for a week.  The other goal was to lose more weight.  Every kilo of weight one loses, is 4 kilo of downward pressure taken off the lower body.  So if you lose even 5 kilo, that feels very good for your knees as it is 20 kilograms of pressure removed. 

Debra has been back to her doctor many times.  All she ever ends up with is trying a different pain killer.  The combination of anti-inflammatory or muscle relaxants also make her feel woozy at times.  When she came to see me, she told me that her disk between the L4 and L5 vertebrae in her spinal cord was protruding and possibly herniated.  We did an assessment as to what the root cause(s) might be.  We started with a postural assessment.  I did notice that Debra was becoming slightly kyphotic, meaning her upper back was becoming hunched, but we also saw she had very tight hamstring muscles, weak abdominal muscles and flat feet.  In addition, when we talked about her lifestyle in general, I detected higher than normal stress levels due to pressure both at home and in the workplace.  After our initial session together, I sent her for a pair of orthotics, scheduled 4 sessions in the gym for lower back and pain relieving specific exercises (mostly stretching) and started her on a daily walking regimen, starting with just two 10 minute bouts.   She also scheduled a package of coaching sessions in order to help her manage her stresses better.  One other potential cause of Debra’s back pain was the 15 kilo of extra weight that she was carrying.  As she had already seen a dietician and was beginning to execute an eating program to help her lose weight while maintaining good nutrition, we were able to concentrate on the other areas.

Elazar’s shoulder was greatly inhibiting his ability to function normally.  Certain motions with his arm would increase the already present pain.  We decided, with his doctor’s permission to start a steady course of anti-inflammatory medicine with 3x a day icing treatments.  I also gave him a very mild exercise to start doing at home.  After a week there was some relief and I gave him two more exercises to add with the use of an exercise band while he continued icing for another few days.  Although Elazar got some relief and his range of motion for his arm improved, he was not healing to the point of minimal or no pain.  His orthopedist, who originally though he had an inflamed rotator cuff sent him for an MRI and they found that it was more, an actual tear.  As Elazar was a young man and would heal relatively quickly from surgery, the doctor decided to schedule him for surgery and have him rehabilitate with a good physical therapist. 

Whether surgery is necessary will greatly depend on who you speak to.  Orthopedist may be inclined to recommend surgery.  Physical therapist will almost always tell you to try therapy first before invasive procedures.  It certainly is less dangerous as far as potential complications.  Surgery, no matter how routine or not, always carries certain risks!  Let’s take a look at some recent data regarding NOT doing surgery.  In a study done in 2016, 140 people with torn meniscuses were divided into two groups. Half of the people did strength training exercises and the other half had arthroscopic surgery.  The people were followed up periodically over 2 years.  There was no significant difference in the results of the two groups in many different categories of improvement.  As a matter of fact, the exercise group had better muscle strength even after 3 months.  Lower back Surgery—it is estimated that in the United States, of the 56 million people with lower back pain, no more than 5% really need to have surgery.  As a matter of fact, in the United States there are roughly double the amount of back surgeries as a percent of the population than any other developed country.  There are times when surgery is necessary and there is no choice but as one who encourages trying other options before resorting to surgery, I can tell you that like our client Debra, there is a lot to do before one goes under the knife.  The complications from back surgeries can be devastating and crippling if they occur. 

Joseph’s situation with his knee has gotten better and better.  The combination of the proper exercises, orthotics and some good pain management in the initial stages, have served him well.  As his weight continues to drop, his knee is getting better and better.  Debra’s pain is almost completely gone and when something starts to act up again, she knows exactly what to do at home and it reverses the situation immediately.  Although we have been successful with rotator cuff issues in the past, Elazar’s situation truly needed the surgery.  He sought out an expert in shoulder repair with a good track record and reputation. He is healing and rehabilitating and getting back to himself.   The pain is almost gone and he is working on getting his range of motion back.

Surgery should be looked upon as an absolutely last resort.  The risk of complications and errors do exist. In any procedure you might be considering, go for the least invasive first.  Physical therapy and similar disciplines have proved very effective.  Not only will this help you avoid surgery, it can alleviate your pain and keep you off excessive pain medicine.   Consider your options carefully and seek more than one opinion.  Choosing your options carefully willadd hours to your days, days to your years, and years to your life.” 

The words of this author reflect his/her own opinions and do not necessarily represent the official position of the Orthodox Union.