Surgery may not be the answer for many orthopedic procedures. A recent study assessed the effectiveness of the ten most common orthopedic procedures in the US and found only two were superior to non-operative care (carpal tunnel decompression and total knee replacements).
Two of the surgeries on the list of “no benefit compared to non-operative care” were arthroscopic anterior cruciate ligament (ACL) reconstruction and arthroscopic rotator cuff repair.
Surprised?
Let’s take a closer look at the studies showing the value of conservative care.
The value of wait and see
We are seeing more baseball players, including major league pitchers with multi-million dollar salaries, attempting conservative rehab for UCL tears. If a 6–8 week rehab doesn’t work, they elect Tommy John surgery, putting them on the shelf for 14–16 months. More often than not surgery is required, but successful conservative care is no longer a rarity. Why can’t the same occur for the ACL?
More research is coming out in support of conservative care for ACL tears. The idea is not simply to support the knee with strengthening, writing off the ACL as a thing of the past, but rather to facilitate healing of the ACL as well.
So there are two parts to this: building up the body to support the injured area and facilitating natural healing.
The first thing to tackle is the capacity of the ACL to heal, which historically was believed to be impossible without surgery.
“Research is creating new knowledge.” — Neil Armstrong
Can the ACL heal?
In this study, 102 patients underwent conservative rehabilitation for ACL tears. Conservative treatment began with mobilization of the knee, muscle strengthening exercises, and full weight-bearing. Each patient received a knee brace for 3 months. Patients were allowed to begin running after 5 months and participating in contact sports after 12 months of treatment. Of the 61 patients who underwent MRI assessment after 6 months, the subsequent assessment of the grade of tearing changed in 18 patients. Outcomes were poorer in patients less than 20 years old compared to those older than 20, but the younger group also had more severe injuries on average. The best outcomes were in injury grades I and II.
While the rates are not strong, the study shows a capacity for the ACL to heal within 9 months.
Another study showed greater success over a long time period. The study only included 14 patients — it did not have patients use a brace in the early stages of rehab — and the follow-up was 25 months.
All 14 patients demonstrated full end-to-end healing of the ACL and they all returned to the previous level of activity — including high-intensity sports involving cutting (13 soccer players and 1 gymnast). While two of the participants re-tore the ACL, the rate is comparable to surgical re-tear rates.
The healing of the ACL backs up the research that shows conservative care matches the outcomes of operative care. So, why don’t more athletes elect the non-operative route for ACL?
First, there is not enough data on non-operative care to make sweeping changes to the status quo. Second, the timeline is roughly the same for returning to sport. The operation is often considered the safer choice. Ironically, surgery carries far more risks.
With UCL tears, wait and see usually last six to eight weeks, then the pitcher attempts a return to throwing program. If it fails, adding eight weeks to a 14–16 month recover time isn’t very costly If rehab succeeds, you shave a year off of the recovery time.
Conversely, conservative ACL rehab is tested until 5–9 months post-injury. If you fail, you start from scratch. If you succeed, you maybe shave a month off of surgery recovery time — maybe. The cost-benefit analysis with respect to time missed isn’t great.
Until conservative ACL repair gains more traction in the research, I don’t think you will see massive spikes in its occurrence. If I tore my ACL, I would go the non-operative route as I have confidence in my ability to rehabilitate and no timeline to return to a sport. That can’t be applied to all cases.
How does this research apply to other areas of the body?
“Science is the knowledge of consequences, and dependence of one fact upon another. “ — Thomas Hobbes
As I mentioned, ACL tears are not the only injury in which surgery should be questioned.
Rotator cuff tears likely do not need to be surgically repaired. Systematic reviews and meta-analyses show outcomes are similar between surgical and non-surgical options. With outcomes being the same and costs and risks differing greatly, non-surgical routes are often the best choice.
For the ACL and UCL, traditional thinking suggests repairs are needed because the ligament lacks the ability to heal on its own. Research has since debunked that belief. For other surgeries aiming to repair tissue, the target is often pain.
Surgery does not address the causes of chronic pain. Pain is more complex than tissue damage. Pain is the result of biological (e.g. tissue damage, genetics, etc.), phycological (e.g. mood, personality, etc.), and social factors (e.g. cultural, socioeconomic, etc).
Pain in “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” — International Association for the Study of Pain
Even when damage is present, pain may not be. Many people with pain have clean MRIs and vice versa. This is true in the back, neck, hip, and shoulder.
I am not saying surgery is never indicated or supported, but I am saying surgery is not necessary if you suffer a tear or damage to your body.
Before going under the knife, explore all of your options. If conservative care is an option, I encourage you to pursue it. In most cases, if conservative care fails, it will not hinder the overall outcomes. In fact, it will help the rehabilitation process.
Prehab for strength and addressing fear of movement improves surgical outcomes.
New research that challenges current assumptions is published daily. Before making medical decisions, make sure you and your provider have all of the information to make an informed choice.