When to try physical therapy before surgery
Sometimes going under knife truly needed, but many cases warrant less invasive path
Growing up as a competitive soccer, basketball and volleyball player, Lindsey Plass was familiar with minor injuries, aches and pains. But it wasn’t until she was 26, after getting into running, that she received a diagnosis of femoroacetabular impingement syndrome, a common hip condition that develops in puberty but may not cause pain until later in life.
As a physical therapist, Plass wanted to explore all treatment options, and met with a surgeon who recommended a hip arthroscopy. “He told me I wouldn’t be able to get back to marathons if I didn’t have the procedure,” she said.
However, Plass knew there was uncertainty around which patients benefit from the surgery. She decided to take some time off from running and go through a physical therapy program to strengthen her hip. She slowly eased back into the sport, eventually returning to marathons.
Orthopedic surgery has revolutionized the treatment of many common injuries and offers incredible benefits. But some experts worry that many popular surgeries are overprescribed — and even ineffective — when simple physical therapy might be the best solution.
“Once you’ve figured out that a condition isn’t serious and in immediate need of attention, your first line of action should be PT,” said Dr. David Matusz, a spinal surgeon at NY Orthopedics in Manhattan.
Deciding to start with physical therapy or with surgery requires an informed approach, and patients must have the right facts to make the best choice. Here’s what to consider.
Surgery or physical therapy?
According to some experts, there has been a decadeslong history of health care providers choosing a “surgery first” approach, particularly for common spinal surgeries to relieve back pain, meniscus repairs and certain hip surgeries.
“This is the ‘find it, fix it,’ or biomedical model, of pain,” said 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.
In addition, many providers have a financial incentive from insurance companies to recommend surgery. Some 750,000 Americans undergo a surgical treatment for simple meniscus tears each year, at a cumulative cost of about $3 billion. Yet in 2017, an international panel recommended against the procedure.
“Our health care system isn’t always focused on a proactive approach like PT,” said Johnson. “If you’re working within that system, it can be challenging.”
What’s more, in the U.S., surgeries sometimes roll out to the general population before the clinical trials on them are complete; unlike pharmaceuticals, surgeries are neither approved nor regulated by any agency. It can take a decade or longer for research on the surgery’s effectiveness to catch up.
In some cases, surgery is the only option, especially in the case of a traumatic, acute injury that may indicate a full ligament or tendon rupture. “Say you’re skiing, fall and hear or feel a pop in your knee, that’s probably going to be a case for surgery,” said Johnson. “There are times when you need a doctor to jump in and operate immediately.”
In other cases, a less invasive approach with physical therapy can lead to equal, if not better, outcomes. Take the case of meniscus tears — knee injuries that are considered minor and common.
Evidence increasingly suggests that surgically repairing a torn meniscus offers no more benefit than physical therapy to help strengthen the surrounding tissues and support healing.
Additionally, the surgery may lead to faster onset of osteoarthritis, as well as increase the risk of other conditions that come with an operating room, like staph infections. In 2017, an international panel recommended against the procedure and in favor of physical therapy and other conservative interventions, like activity modifications and lifestyle changes.
Matusz sees a few dozen patients on the average day and sends the majority to physical therapy. He said this is a change in his approach over the 18 years he has been practicing.
“People find it startling because I’m a surgeon,” he said. “But most patients my partners and I see don’t need a surgical intervention. They need PT.”
How to decide
If you have a lingering or acute injury, find the right specialist for your condition and body part, and then gather all the relevant information and options. With your clinician, determine whether the joint was damaged from trauma, or if the issue stems from chronic issues like strength imbalances or age-related changes that were exacerbated by physical activity.
If you’re considering surgery, go in with questions for your doctor: “Make sure they understand your goals, life demands and activities,” Johnson said. “Learn whether you have an isolated injury, like a small tear to your ACL, or multiple, such as a couple of ligaments or your meniscus, too. In those cases, surgery might be best.”
You and your doctor should also take into consideration your age and activity level. A 20-yearold Division 1 soccer player with an ACL tear might want a repair, for instance, so that they can return to the field at or near 100%. A 50-year-old runner, though, can likely avoid it, regaining enough stability through PT to allow them to return to their sport, since it is less demanding on the knee.
Not all types of injury are created equal, said Dr. Allison Fillar, an orthopedic surgeon at MedStar Health in Baltimore. Take a meniscus “buckle tear” or a full-on ACL rupture. In those cases, surgery is required. But with other meniscus tears PT alone can work, she said.
If you are leaning toward PT, request a full battery of medical tests from your physician or physical therapist, including functional assessments of the damaged joint and strength tests, Johnson said.
If you decide on physical therapy, different clinicians will have varied approaches. “What works for one patient might not work for another,” Matusz said. “Sometimes I’ll even have a patient switch PTs if they’re not getting the results they want before we take the step of surgery.”
From where Matusz stands, even if you end up in the operating room, if you’ve first tried physical therapy, you’re ahead of the game by having given it a chance to work. “By the time you get to surgery, whether for the spine or something else, it should be your last resort,” he said.