Do you really need surgery?

  • Thursday 30 October 2014

It's a fact that the majority of musculoskeletal conditions presenting to sports medicine practices (and I include physiotherapy practices) do not require surgery, at least in the initial management. To prove this point, I made a list of cases I saw on a reasonably busy afternoon at my sports medicine clinic:

  • Anterior knee pain
  • Mechanical low back pain
  • Medical meniscal tear of knee
  • Adhesive capsulitis of shoulder
  • Achilles tendinopathy
  • Plantar fasciitis
  • Full thickness tear of supraspinatus
  • Calcification of supraspinatus tendon
  • Post-traumatic synovitis from ankle inversion injury
  • Common extensor origin tendinopathy
  • Morton's neuroma of foot
  • Plantar fasciitis
  • Patella tendinopathy

Out of 13 patients, I saw one patient that required a surgical referral (rotator cuff tear), one patient that may need a referral in the next 4 weeks (medial meniscal tear) and 11 patients that will (hopefully) never need a referral.

But it gets even more interesting when one considers whether there is any role for surgery in many musculoskeletal cases. Take anterior knee pain as a prime example. A recent study looking at the role of knee surgery (arthroscopy) in the management of anterior knee pain found that physiotherapy was as effective as a combination of knee arthroscopy and physiotherapy. In other words, knee arthroscopy did not alter outcome. However, the story doesn't end there. In another excellent study comparing arthroscopy to sham arthroscopy in knee osteoarthritis, patients who had sham surgery had a better outcome compared to patients who had surgery. I'll repeat that just in case you missed it: patients who thought they had surgery (where the surgeon pretended to perform the operation) did better than those patients who actually had surgery. I could say the same about many other conditions.

So should we be referring most musculoskeletal cases to an orthopaedic surgeon? As a Sports and Exercise Physician, I have my obvious biases but I think we should question whether the first line of referral for musculoskeletal injuries should be to a practitioner who wants to take a knife to your shoulder or ankle.

Tags: surgeryosteoarthritis

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