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 pain killers. For a few hours, there is some relief although a dull ache is always there. How long can Joseph 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 her office, 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.
Elie is in chronic left shoulder pain. He was out hiking a few weeks ago and slipped while climbing down a hill. He used his hands and arms to brace his fall, but his rotator cuff, the 4 muscles that help with stability, was injured.
Joseph, Debra and Elie all are dealing with pain and all of them have been to an orthopedist. In each case, the option of surgery was mentioned. When should we use time, physical therapy or rehabilitative exercise to heal? When is surgery the best option?
Let’s take a look at each case and see what we can learn.
Joseph (knee pain)
Joseph, age 52, is active. He power walks each morning, uses staircases in his workplace to get from floor to floor, and always prefers walking from place to place when he can. Joseph’s pain came on pretty suddenly. Although he is doing his non-walking exercises 3 days per week, he isn’t getting his cardiovascular workouts.
MRI results showed there is some deterioration in Joseph’s meniscus and that the lack of cartilage between his bones is causing the pain. Joseph’s doctor said that his condition wasn’t as bad as he has seen in many other patients. Although arthoscopic surgery might help, there are other options to consider.
Joseph was very overweight for much of his adult life. He began a weight loss program 2 months before his knee injury. We discussed what we could do before the surgery option. Knee problems often occur or are exacerbated because of bad biomechanics. Biomechanics refers to the process of putting your foot down when walking and the resulting kinetic energy that travels up your leg. Bad biomechanics means the resulting kinetic energy that travels up your leg is misplaced. Your ankles, knees, hips and lower back are all shock absorbers for this 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.
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 the process. We also began a week long protocol of icing the knees 3 times a day for 6 minutes after any walk of more than 20 minutes. Of course along with all this, the goal was for Joseph to lose more weight. Every kilo of weight lost, is 4 kilo of downward pressure taken off the lower body. 5 kilo lost feels very good for your knees as it is 20 kilograms of pressure removed.
Debra (lower back pain)
Debra has been back to her doctor many times. All she ever ends up with is trying a different pain killer. The combinations of anti-inflammatory or muscle relaxants also make her feel woozy at times. When Debra 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 noticed that Debra was becoming slightly kyphotic, meaning her upper back was becoming hunched. I also saw she had very tight hamstring muscles, weak abdominal muscles, and flat feet. In addition, when we talked about Debra’s lifestyle, I detected higher than normal stress levels due to pressure at home and in the workplace.
After our initial session together, I sent Debra for a pair of orthotics, scheduled 4 sessions in the gym for lower back and pain relieving exercises (mostly stretching) and started her on a daily walking regimen (starting with two 10 minute bouts). She also chose to schedule several coaching sessions in order to help her manage her stresses.
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 effective eating program, we were able to concentrate on the other areas.
Elie (shoulder pain)
Elie’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 3 times a day icing treatments. I also gave him a very mild exercise to start doing at home. After a week there was some relief. I gave Elie two more exercises to add while he continued icing for another few days.
Although Elie 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 thought he had an inflamed rotator cuff sent him for an MRI. The results showed an actual tear. As Elie 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.
Deciding on surgery
Whether surgery is necessary will greatly depend on who you speak to. Orthopedist are often inclined to recommend surgery. Physical therapist will almost always tell you to try therapy first before invasive procedures. Therapy is certainly less dangerous as far as potential complications. Surgery, no matter how routine or not, always carries risks!
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. With regard to lower back surgery, it is estimated that of the 56 million Americans with lower back pain, no more than 5% really need to have surgery.
There are times when surgery is necessary and there is no choice. As one who encourages trying other options before resorting to surgery, I can tell you that there is often 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 knee has gotten better and better. The combination of proper exercises, orthotics and some good pain management, has served him well. As his weight continues to drop, his knee is getting even better. Debra’s pain is almost completely gone. When something starts to act up again, she knows exactly what to reverses the situation. Although we have been successful with rotator cuff issues in the past, Elie’s situation truly needed the surgery. He sought out an expert in shoulder repair with a good reputation. He is healing and rehabilitating and getting back to himself.
Surgery should be an absolutely last resort. The risk of complications and errors do exist. In any procedure you might be considering, go for the least invasive option. 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 will “add hours to your days, days to your years, and years to your life.”