Surgery For Achilles Tendon May Not Improve Recovery
Thursday, March 25, 2010
Jolie Bookspan, M.Ed, PhD, FAWM
Readers have been asking about fixing Achilles tendon tears. They ask if tears can heal without surgery. Tears, even complete tears, can heal with the right rehab therapy even without surgery. A recent study of 92 patients made news when it concluded, "Surgical and nonsurgical treatment were equally effective for patients with acute rupture of the Achilles tendon."
Dr. Katarina Nilsson Helander, MD, of Kungsbacka Hospital in Sweden reported at the March 2010 American Academy of Orthopaedic Surgeons meeting, that outcomes and rates of re-rupture did not differ significantly through 12 months between patients getting surgery and those with physical rehab alone. Within 72 hours of injury, the 97 patients were randomized to surgery (48 patients) or no surgery (49 patients), followed by two weeks in a firm cast, then six weeks in an adjustable brace that allowed some movement of the foot. Both groups reported increased physical activity over time. All underwent identical rehabilitation programs. Complications in the surgical group included one contracture of the tendon, two wound infections (one deep and one superficial), and two nerve disturbances. Thirteen patients had concerns about the scar, 10 for cosmetic reasons and three for scar contracture and pain. Both groups were still below pre-injury levels at one year.
Primary source: American Academy of Orthopaedic Surgeons. Nilsson Helander K, et al., "Acute Achilles tendon rupture: an RCT comparing surgical and nonsurgical treatments" AAOS 2010; Abstract 712.
There is currently no consensus whether surgery plus physical rehab, or physical rehab alone is the favorable approach. That means, if you go to a doctor with your Achilles tear, you may be told that surgery is the only way, even though you may get the same results without the surgery. Many people hope to have surgery and be done with their problem, not knowing they will need the same physical therapy either way. Complications such as incision-healing difficulties, infection, contractures, re-rupture of the tendon, atrophy, complications and illness from anesthesia, bleeding, clots, scar pain, nerve pain, can arise from surgery. Drugs required during and after surgery can create new illnesses and further drug prescriptions. Surgical and healing outcomes vary with the skill, luck, and patient load of the operating team that day.
It is not new information that surgery may not always be required. Several studies conclude that non-surgical treatment yields similar results:
Fruensgaard S, Helmig P, Riis J, Stovring JO. Conservative treatment for acute rupture of the Achilles tendon. Int Orthop. 1992;16(1):33-5.
McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am. 1997;79(12):1799–808.
van der Linden-van der Zwaag HM, Nelissen RG, Sintenie JB. Results of surgical versus non-surgical treatment of Achilles tendon rupture. Int Orthop. 2004;28(6):370–3.
Soccer player David Beckham underwent surgery last week after tearing his left Achilles' tendon playing for AC Milan against Chievo. The news reported that the surgeon, Dr. Sakari Orava, said that, "The operation went smoothly and nicely" but that Beckham would not be able to play in this year's World Cup, saying "No,....healing (from the surgery) takes a long time."
A study of men and women over age 70 found two to three times more bone fractures occurred following a hospital admission compared to not being in a hospital. The risk of new fracture was greatest during the first year after hospitalization and increased with the number of times a patient was hospitalized. This included increased numbers of hip fracture, which leads to a fatality within the year in about 30% of people over 50.
Study authors stated, "Because the risk of fracture is greatest soon after hospital discharge, assessment and interventions to reduce risk should be started during the hospital stay or shortly after discharge. Evaluations should include measurement of bone mineral density, assessment of the risk of falling and vision testing." According to the authors, appropriate treatment for these patients include calcium and vitamin D supplements; bisphosphonate drug treatment, such as alendronate (Fosamax) or risedronate (Actonel); vision correction if needed; and physical therapy, including walking programs and exercises to improve flexibility, strength and balance.
Being in a hospital is often joked about as being unhealthy. It is also a reality:
When people are sick, it is not the time to keep them sedentary, indoors, eating institutional food, out of fresh air and sunlight, and taking medicines that reduce bone density and increase pain syndromes.
Lack of standing and activity quickly reduce bone density.
Several commonly prescribed medicines directly reduce bone density and cause stomach and body pain. Instead of stopping these medicines, others are given, which further depress health, and the mistake of further unneeded and unhealthful drugs.
It is a circular problem when people feel they must reduce activity to prevent falls and injury.
What is needed is the right, carefully supervised, healthy movement to give the physical skills that prevent falls, the stiffness that results in more pain and lack of function, and reduction in bone density, balance, strength, and mobility crucial for basic health.
In the article Kneecap Tracking - Don't Miss These Reasons It Doesn't Get Better, I listed common reasons knee pain doesn't resolve, including common bad stretches, bad shoes, treating the wrong thing, treating the right thing but returning to pronated, duckfoot or pigeon-toe gait (letting arches flatten or knees sag inward, and/or walking toe out or in), and omitting functional exercise and use. Fancy "supportive" running shoes, no matter how expensive or engineered often add to knee pain. I wrote that surgery for a tight lateral area isn't needed when you can stretch it. Readers wrote asking why stretch when you can just have surgery and cut it?
One common surgical procedures is an arthroscopic lateral release - surgical cutting of the lateral muscles from the patella (kneecap). The idea of the surgery is to decrease pull and pressure on the underside of the patella.
Studies following up people undergoing the surgery show, "The results are not always predictable or successful and in some cases, the surgery may have no effect on the patient's problem." http://www.arthroscopy.com/sp05032.htm
Another study from the Netherlands confirmed previous studies showing exercise therapy for patellofemoral pain was more effective to reduce pain and increase function than the often used "rest, wait and see." Science Daily.
Surgery often is made to sound like a quick way to get ahead, but numbers now confirm that you are restricted from full activity for enough time that your physical conditioning, flexibility, bone density, aerobic capacity, strength, and enthusiasm diminish. You will often be further behind, rather than quickly fixing a cause and going forward. Often, as much physical therapy is needed for full recovery after surgery as if you didn't go for the surgery. Stories are told of someone who had the surgery then went right back to skiing. I am the one who many of these people come to a year later. They say they are fine, but they still use pain medicine, still can't bend their knee enough to stretch enough to get relief of other tight areas and so on, and often haven't gotten back to previous benchmarks. To me, that is not "fine" enough. They slowly diminish in key areas of their life. They get new pain they don't recognize as related to compensating movement from the old ones. By the time they see me, they are often on several pain medicines, anti-depression medicines, and others that make new problems.
Surgical risks are also becoming better reported. Blood clot incidence is far higher after surgery than previous released. A study of nearly 1 million women tracked for an average of 6.2 years after surgery, showed risk continues for 12 weeks and includes minimally invasive procedures.
Not all patellofemoral pain is a tracking problem. Tracking pain is in the patellorfemoral area (where kneecap and top leg bone meet). However, other conditions besides tracking make patellofemoral pain. People with patellofemoral knee pain may be sent for tracking therapy even surgery, without needing it. Standing and moving allowing the knee to sag or rotate inward can also make rubbing. Surgery and tracking exercises do not address this. They may be done but yield no result. It is not a mystery.
--- Read success stories of these methods and send your own. See if your answers are already here by clicking labels, links in posts, archives, and The Fitness Fixer Index. Subscribe to The Fitness Fixer, click "updates via e-mail"upper right. For personal medical questions - Replies to Medical Questions. Limited Class spaces for personal feedback. Top students may apply for certification throughDrBookspan.com/Academy. Learn more in Dr. Bookspan's Books.
What does it take to sit up straight? Is it possible that the numbers of physicians, surgeons, instructors, and trainers who entered did not know? We now have five winners:
Paul J was first to write in to the contest with understanding,
"Brains are required to think and correct bad posture."
Steve Rice knew it when he wrote in the hints that first in importance, above doing any strengthening or stretching is,
"1. Engage the brain to develop better postural habits. No matter how strong the elongated muscles get, and how long the contracted muscles get, if the brain says "slouch" that's what the body will do. The other steps (stretch/strength) are necessary but not sufficient to fix the posture problem.
He also correctly stated that you use back muscles (not abs) to pull your spine back to straighten from rounded forward.
1. Only the brain is required. I simply have to do it! 2. Name the muscles -- lean back by stretching the pectorals, and maintain neutral spine in the lower back. All these years I was just too ignorant to use them until Dr. Jolie said so! 3. I think it's 'cause their chest is too tight from rounded shoulders. Good pectoral stretching, and remembering to maintain good posture will correct.
It's that remembering thing that's the problem. Fortunately my back keeps reminding my brain to use what I've learned! :-D
"Thanks, again, especially for what I've learned from you. My back is getting much better and I don't need a doctor!!!"
I learned things from readers:
Hopefully joking, were not one, but two surgeons who wrote that surgery is required to cut tight front (anterior) muscles.
Readers think abdominal muscles do every motion of all your limbs whether they do or not.
Readers think that somehow squeezing your abdominal muscles makes you move, and they think using one set of muscles magically makes you stop (inhibit) others. This is an often repeated bit of mythology, not true in all cases as previously thought. In fact, we couldn't move properly if it were true.
Readers think abdominal muscles somehow stop you from rounding forward and make you sit straight if you just do something called "engage." I have no idea how or what that would be. Abdominal muscles are flexors (bend the spine forward - not the body as a whole). Fourth winner Mr. Georges Nakhlé, my Academy instructor and manager of the Middle Eastern division was one of the two entrants who knew that abdominal muscles do not straighten you from a rounded forward position. Your back muscles are needed to pull back enough to straighten you (only if you use them). He names them in the Hints. Abdominal muscles do not attach to your legs. They cannot pull your body closer to your leg (or leg closer to body) if you are sitting with your hip slouched back away from your leg.
A helpful comment from Anonymous in Contest Hints enlightened me about a major source of the problem - readers honestly don't know what muscles do, and they feel like outsiders when hearing names of muscles and their actions. This is important. It opened a large door for me.
Thanks to these reader comments, I know to start writing articles explaining actual muscle use. No one should need any medical degree or training to know your body, names of parts, and how you move. Just like if you are not a mechanic, by knowing simple car parts, you can save much money and pain and being fooled by fancy sales talk.
Fifth winner was reader Sister Mary Smackham Witherstick of the Royal Order of Order,
"Quit yer sorry whining. Straighten up laddies!"
How hard was that?
Maybe our slogan for this contest could be the zombie cry from Return of the Living Dead,
--- Read success stories and send your own. See if your answers are already here - click Fitness Fixer labels, links, archives, andIndex. Subscribe free - "updates via e-mail" upper right. For personal medical questions - Replies to Medical Questions. Limited Class space for personal feedback. Top students may earn certification throughDrBookspan.com/Academy. Learn more in Dr. Bookspan's Books.
Poor tracking is not a disease or a syndrome, or that you are doomed to arthritis. Usually it is a simple injury process that can be stopped. Tracking problems are often given several names: Lateral Facet Syndrome, Chondromalacia, Anterior Patello-Femoral Pain Syndrome, Lateral Pressure Syndrome, Malalignment Syndrome, Maltracking Syndrome, Patello-femoral Degenerative Arthritis, and other scary names. Not all of these are due to poor tracking. Calling something tracking when it is not, often leads to much time trying tracking "cures" when you need other things.
Instead of surgery, you can stretch the tight side areas and retrain the weak ones, so the kneecap slides normally instead of grinding sideways in its channel. Stopping causes stops need for surgery, or even bracing and pain pills. The knees heal and you go back to all you want to do, using the new healthy mechanics.
What can you do when pain continues after physical retraining? Captain Scott wrote that he had been to physical therapy for his knees "for a few months without much success." He had previously endured ongoing treatments for back pain, then discovered Fitness Fixer methods and resolved the pain. He came back to see if he could do the same for his knees.
Kneecap tracking should begin normalizing within days of stopping causes - far sooner than "a few months." If not, one obvious thing to check is if you have the right re-tracking stretches, exercises, and functional retraining. After that, here are four common reasons when PT does not "work."
Tracking Exercises That Don't Fix Tracking. A common PT scenario is doing 10 (or however many) repetitions of straightening the knee against resistance of a stretchy band, called "terminal extensions," "setting" exercises such as squeezing things between the knees, stretching the lateral (side structures), and small leg lifts with ankle weights to strengthen inner thigh muscles (VMO)s. Without retraining gait and knee use during real life movement, the person often gets up from the PT session and walks away and goes back to their activities with the same poor tracking. PT needs to look at and fix specific use during real life activity - do you turn your knee inward or your feet outward, do you let your foot flatten, do you let your upper leg bone rotate, do you walk with your feet turned outward (duckfooted) or inward (pigeon toe). Weight or resistance used is often far less than what the knee encounters when the person stands up and uses their knees to walk away from their exercise session. Tracking angles should monitored during rehab. Not just during standing or during leg lifts, but during the patient's customary activities. If they are not changing, and they are the confirmed cause, then you may not be changing tracking.
Are You Sure It's a Tracking Problem. Knees can hurt for other reasons. Not all patello-femoral pain is from tracking. You can go for the best re-tracking programs, but if your knee does not have an actual tracking problem, it is no mystery when tracking exercises do not help. You have not spent time fixing the cause. Make sure that tracking is the reason before treating for tracking. Tracking can be identified with specific patellar x-rays or other scans that can clearly include position during several points of motion. Tracking also can be visualized - look at kneecap path during quadriceps use during several kinds of movement. The kneecap slides up and down obviously under the skin at the knee during use. There is a variable degree of normal angle at the knee. Human legs are not straight from upper to lower leg. That angle at the knee allows us to walk upright on two legs in a smooth gait. The angled knee is one of many markers that tell forensic scientists and anatomists if the leg bones they are looking at are human. Sometimes a normally tilted kneecap slide is misidentified as a tracking problem when it is a normal angle in line with the joint.
Multiple Causes. Sometimes tracking mal-alignment is confirmed and rehab done. The patella tracks normally and stops wearing the area, but pain continues from other causes. No mystery. Check for other poor knee mechanics that cause injury. Check if your shoes are too hard. Many people paying for "good supportive shoes" get knee pain from the hard shoe. Often the pain from bad shoes is sharply outlined around the kneecap with deeper aching. Check your bending. If you have pain with knee bending (squatting), fix that. Check your stretches. Some twist the knee joint, such as lotus and hero poses in yoga, hurdler's stretch and others. Stretches should stretch muscles, not cartilage in joints. Fitness Fixer articles summarize and my books detail more.
Medicines that Cause Pain. Whether you have tracking problems or not, common prescription medicines cause pain that does not respond to PT. Look into stopping reasons you need the medicines in the first place, and save yourself time, money and pain.
My idea of health care is a quick, straightforward assessment of causes and intelligently addressing them. That beats having someone stick a knife in your knee and charging you for it.
Health&Fitness in Plain English THIRD edition - How to Be Healthy, Happy, and Fit for the Rest of Your Life. Both available from www.DrBookspan.com/books.
How Effective Are Medical Treatments For Back Pain?
Monday, July 13, 2009
Jolie Bookspan, M.Ed, PhD, FAWM
Many well-known conventional treatments for injured athletes and military personnel came from ways to keep wounded combatants able to continue fire, not to maximize their long-term survival or later health.
Years of my career laboratory research was improving physical training for athletes and military, and developing injury protocols that were healthy, not just a remedy for the moment. I also found that much good sports medicine for athletic motion was never applied to the more common body motions needed all day. Not only can the athletes benefit, but everyone else. Many patients and readers have success using my improved non-surgical methods, and write us their stories (click for reader stories). Many more have success without writing about it. Other readers asked about various medical (surgical/drug) treatments, and why don't I use them.
Thank you to my colleague Fabrice Czarnecki. M.D. emergency room physician, for sending me a report, recently published in a prestigious medical journal. The work was a systematic review of the "benefits and harms of nonsurgical interventional therapies for low back and radicular pain."
The medical methods they looked at were local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation.
Their results: "For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.
What does all that mean? They summed it up in their conclusions: "Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials."
Report name: Nonsurgical interventional therapies for low back pain: a review of the evidence for an American pain society clinical practice guideline. Published in Spine. 2009 May 1;34(10):1078-93.
Medical reports on these methods (as well as general strengthening exercises) frequently show what is called a scattershot success - meaning if you try it on hundreds of people, it's bound to hit a few of them. Often these hits (moderate improvements) are about the same as chance or as time passing and the person heals on their own over the weeks of the treatment and recovery. Use those medical treatments if you believe in them and prefer them.
I prefer a direct approach:
Instead of shots to anesthetize the area, or surgery to remove or fuse an area, retrain movement to be healthy so that you no longer injure the area and it can heal.
Instead of medicines to mask the damage you cause, stop the damage.
Stopping damage does not mean stopping movement, activity or fun. Use healthy body mechanics to become able to do more than before.
Questions come in by hundreds. I make posts from fun mail. Before asking more, see if your answers are already here - click labels under posts, links in posts, archives at right, and the Fitness Fixer Index. Why not try fun stuff, then contribute! Read success stories of these methods and send your own. Subscribe to The Fitness Fixer, free. Click "updates via e-mail"(under trumpet) upper right. See Dr. Bookspan's Books, take a Class, get certified - DrBookspan.com/Academy.
Knee Surgery - Arthroscopy Results No Better than Pretend Surgery
Wednesday, May 27, 2009
Jolie Bookspan, M.Ed, PhD, FAWM
A study of arthroscopic knee surgery found that the surgery was no more successful than pretending to do the surgery.
Arthroscopic surgery for knee arthritis is performed in substantial numbers. Why? The patient's doctors said they needed it. Where did the doctors get that opinion? It is taught in medical school and repeated at medical conferences. Repeating things is not evidence-based medicine (which is key) but vehemence-based medicine. When highly paid people repeat things without even knowing if it is true, that is eminence-based medicine.
Studies are now following up the same patients who had the surgery. Numbers show that often the surgeries are not needed, and people can do as well without surgery, and with intelligent non-surgical rehab.
This is not new. In the 1930's, patients being prepared for the rigors of surgery through exercise, often found that by surgery time, they didn't need it. Other patients without receiving exercise went straight to surgery. They may have had continuing pain and damage after surgery or later in life, but patient tracking was not done. Doctors just reported that the surgery was done, the patient lived, and that was all, and on to the next paying job.
Then studies compared surgery to physical rehab without surgery. Improvement rates were found to be about the same.
Then came an even more interesting study in 2002 of 180 patients that compared knee arthroscopic surgery to cutting the patient but not doing the knee surgery. Sixty patients in the placebo group received skin incisions and underwent a simulated surgery without insertion of the arthroscope. Two other groups had one of two typical knee procedures: Sixty-one patients had arthroscopic lavage group, and 59 to had arthroscopic débridement.
Results showed, "At no point did either of the intervention groups report less pain or better function than the placebo group." Conclusions were, "In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure."
Source: A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. New England Journal of Medicine. Volume 347:81-88. July 11, 2002. Number 2. NEJM.
This does not mean that surgery does not "work" but that you do not have to have it or be rushed into it, if it is not right for you. There are other ways, often as quick, and less expensive and painful and without the limitations following. Take your time. Don't let anyone push you into something not right for you. Medical claims that you will get worse if you do not have immediate surgery have not turned out to be factual.
Read success stories of these methods and send your own. Before asking questions, see if your answers are already here by clicking labels under posts, links in posts, archives at right, or in the Fitness Fixer Index. For personal medical questions - Replies to Medical Questions. Subscribe to The Fitness Fixer, free. Click "updates via e-mail"(under trumpet) upper right. See Dr. Bookspan's Books. Get certified - DrBookspan.com/Academy.
A news report published in several publications including The Wall Street Journal stated that anesthesiologist Scott S. Reuben faked data so that it would seem that benefits occurred from painkillers like Vioxx and Celebrex. The studies had been published in several anesthesiology journals between 1996 and 2008.
Dr. Reuben had been a paid speaker for Pfizer, a powerful pharmaceutical company, and Pfizer paid for some of the research.
The journal Anesthesiology has retracted three of Dr. Reuben's articles. The journal Anesthesia & Analgesia has retracted 10 of Dr. Reuben's studies and posted a list of 11 of his studies published in other journals.
Jacques E. Chelly, head of acute interventional postoperative pain service at the University of Pittsburgh Medical Center, said that the situation has prompted his hospital to review the protocols it uses to treat patients for pain, because Dr. Reuben's work was so influential in establishing them.
Editor James C. Eisenach warned in an editorial in the journal Anesthesiology, stating:
"these retractions clearly raise the possibility that we might be heading in wrong directions or toward blind ends in attempts to improve pain therapy."
Other Problematic Drugs. Vioxx and Celebrex are not the only highly prescribed drugs that have been found less effective than advertised. Several major drugs prescribed for pain/fibromyalgia and headache were later ordered by the FDA to carry a Suicide Risk Warning:
Healthy Ways To Stop Sources of Pain. Specific well-known medications and surgeries have found to be no more effective than less expensive and disruptive methods:
Questions come in by the hundreds. I make posts from selected ones. Before asking, see if your answers are already here by clicking labels under posts, links in posts, and archives at right.
Subscribe to The Fitness Fixer, free. Click "updates via e-mail"(under trumpet) upper right.
Fast Fitness - Better Legs and Pain Relief Comes From You Not The Exercise Ball
Friday, April 03, 2009
Jolie Bookspan, M.Ed, PhD, FAWM
Here is Friday Fast Fitness - Be healthful when you do health activities. What a concept.
How fit is it to use fitness equipment in unhealthy ways?
When you pick up and put down an exercise ball, or any exercise equipment, how do you bend? Unhealthfully? During an activity you use to improve your health?
Robert Davis sent in this change of bad bending to good bending . Good bending shifts weight and leverage off lumbar discs and onto leg, hip, and back muscles.
Robert Davis wrote. "I had to use my cell phone on timer so the pictures are not the greatest quality."
Here is the ouchy
Here is the squat
Robert Davis was a weight lifter with a painful back injury from conventional lifting. He fixed his back pain with Fitness Fixer, intelligently applying principles of healthful movement for everything during exercise and also daily life. He wrote:
"I took a picture of what was causing "ouchy" because it is so normal in America *for adults!*.. (upper photo of forward bending). Then ouchy started to go away the more I did, 'ah much better' (squatting)... Pretty soon ouchy was gone from the bad forward bending.
"I am now doing a complete head to toe revision... Point was that my back stopped hurting, and as you said, heals when I let it, with better movement.
"I am glad there is someone out there like you who tells you how it is. It gives encouragement and hope. I have seen people my age already with a few surgeries (and they are in the 20s to 30s!). They were from injuries, and sadly they never had a chance to find that they didn't need it.
"I was encouraged by others' stories and with your statement, "don't let them scare you" because I was a bit scared. I have never been injured before with that much pain. But, I was more then willing to try this because I did not want limitation as I had seen in my friends who had surgery. Some multiple times. "
Mr. Davis has been sending in success stories one after then next. Here are some of his Inspiring Functional Fitness:
--- Read and contribute your own success stories of these methods. Before asking questions, see if your answers are already here - click labels under posts, links in posts, archives at right, and the Fitness Fixer Index. Subscribe to The Fitness Fixer, free. Click "updates via e-mail"(under trumpet) upper right. For answers to personal medical questions - Replies to Medical Questions. Limited Class spaces for personal evaluation. Top students may apply to certify throughDrBookspan.com/Academy.See Dr. Bookspan's Books. ---
Surgery for Knee Arthritis, Meniscus, Not Needed To Stop Pain, Restore Function
Monday, January 19, 2009
Jolie Bookspan, M.Ed, PhD, FAWM
Good news. If you don't like or want knee surgery for most arthritis or meniscus injury, you don't have to have it. Lack of need for surgery has been demonstrated over many years in rehabilitation populations, and in a mostly ignored older clinical study. Recent studies confirm you can stop most pain and restore function just as well without surgery through good physical rehab.
Millions of Americans undergo arthroscopic surgery for knee pain every year. Over the last 30 years, arthroscopic surgery has been routinely accepted and prescribed for knee pain without undergoing rigorous evaluation.
Even when a 2002 study published in the New England Journal of Medicine (NEJM) found that results of arthroscopic surgery for knee osteoarthritis were no higher than medicine and physical therapy alone, the surgical community "remained unswayed."
Dr. Brian Feagan, co-author of a study in the Sept. 11 2008 issue of the NEJM stated, "It really didn't change practice that much. That's why this second [study] was really important."
Feagan's randomized, controlled trial involved 178 patients, average age 60. All had moderate-to-severe osteoarthritis of the knee. Half underwent arthroscopic surgery plus medical and physical therapy. The other half used medical and physical therapy alone. After two years, both groups' scores on a measure of arthritis severity were about the same.
A second study also published in the same journal issue, found that meniscal tears are common in the general population and, "may not, in fact, be responsible for painful symptoms." That means that if you have knee pain, and have scans and imaging which show a meniscus tear, it may not even be the tear that is causing the pain.
"There's going to be a swing in practice," said Dr. Feagan.
Study authors stated that meniscal tears detected on MRI may confuse matters and lead to unnecessary therapy. This is a similar finding to back pain where patients with pain are shown to have a herniated disc, stenosis, or other finding, but the pain is not from the anatomical finding, but the same bad movement habits, slouching, and lack of good movement that make anyone hurt. Discs also often appear herniated, and spines compressed by stenosis on scans of people with no back pain. Don't base your treatment and future on a picture. Scans are not tea leaves.
Supportive and inflexible shoes are often prescribed in the belief that they restore healthy tracking, but studies show that these shoes increase knee load and tendency to arthritis. You may do rehab for the meniscus that shows up on x-ray, but still have pain that may only be from the from hard "supportive" shoes. You can "support" and align and stabilize your own feet and ankles and knees using good mechanics and your own muscles.
Poor knee stability increases risk of developing arthritis, and increases wear on the meniscus. Studies tracking results for years following surgery are finding that surgery "adds no benefit over rehabilitative training alone." That means you don't need the surgery to fix or prevent possible future arthritis.
--- I make posts from fun mail and success stories. Before asking questions, see if your answers are already here - click labels under posts, links in posts, archives at right, and the Fitness Fixer Index. Why not try fun stuff, then contribute! Read success stories of these methods and send your own. For answers to personal medical questions - Replies to Medical Questions. Subscribe to The Fitness Fixer, free. Click "updates via e-mail"(under trumpet) upper right. See Dr. Bookspan's Books, take a Class, get certified - DrBookspan.com/Academy.
Anterior Cruciate Ligament (ACL) Surgery Unnecessary
Monday, December 22, 2008
Jolie Bookspan, M.Ed, PhD, FAWM
After injury to the anterior cruciate ligament of the knee (ACL) it is common to be told that surgery is the only way to restore function. Is it?
Ninety percent of ACL injuries in the U.S. are treated with surgical reconstruction. A study reported in the Dec. 15 issue of Arthritis & Rheumatism found that, "Two to five years after treatment, patients had similar muscle strength and function whether they had training alone or with surgery." The study concludes, "Reconstructive surgery is not a prerequisite for restoring muscle function." That means you can have good results with good rehab and without surgery.
A second question is development of ostoarthritis following ACL injury. Poor knee stability increases risk of developing arthritis. Studies tracking results for years following the surgery are finding that surgery "adds no benefit over rehabilitative training alone" and that surgery is done, "despite an absence of evidence to suggest that reconstruction of the ACL prevents or reduces the rate of early-onset osteoarthritis." That means you don't need the surgery to prevent possible future arthritis.
A persistent myth is that supportive shoes prevent injury, when they are commonly a source of leg tightness and knee pain. You may do rehab for an ACL injury but still have pain, and think the pain is from the ACL injury when it may be from hard "supportive" shoes. Another common myth is that knee injury comes from "muscle imbalance" in the thigh from too much strength in the quadriceps muscles over the hamstring muscles. The strength of a muscle does not make you move it. That means you control whether you overstraighten a knee or not. It is a use issue, not a strength ratio. Click the articles below for issues of quadriceps to hamstring ratios, injury to the ACL and other knee structures, and healthy ways to fix them.
You don't have to have ACL surgery to rehab a knee injury.
Fitness Fixers for Fixing Knee Pain Without Surgery:
Health&Fitness - How To Be Healthy Happy and Fit For The Rest of Your Life. THIRD edition.
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Questions come in by the hundreds. I make articles from fun ones. See if your answers are already here - click Fitness Fixer labels, links, archives, andIndex. Read success stories of these methods and send your own. For personal medical questions - Replies to Medical Questions. Limited Class space for personal feedback. Top students may earn certification throughDrBookspan.com/Academy. More fun in Dr. Bookspan's Books.
New studies have been making big health news. These studies conclude that knee surgery is not needed to rehabilitate after several kinds of knee injuries, and that "question the benefits of the surgery." This information is not new. How do I know this? Because of years of previous studies concluding that surgery "worked." Here is what those previous studies often meant:
About 10 years ago, I attended a sports medicine conference. A new line of knee surgeries had come out, and the surgeons and manufacturers of the products used were anxious to have their surgery accepted and endorsed. One of the clinical presentations of the conference was the results of a study that compared patient outcome after knee surgery to the outcome of physical rehabilitation without surgery.
The patient group receiving physical therapy had improvement of function and reduced pain over time. The sample undergoing surgery went through the risks of anesthesia and surgery, lost work and wages, pain controlling narcotics during surgery and recovery, reduced activity for a minimum of 2 months following surgery, and pain from the surgical area. They then underwent months of physical therapy to regain function lost from the surgery. Many had permanent reduction of knee range of motion, considered "standard and acceptable" for that surgery. The loss of range can reduce function of the area, and reduce ability to stretch the hip, which can cascade years later into further restrictions. The physical therapy group had improvements that started soon after beginning treatment. The surgical group initially had decreases in all measures of strength and function, then months of painful recovery, and further months of reduced physical condition while they worked to "get back in shape."
Patient outcomes of muscle strength and pain levels were compared after two years and found roughly equal. The conclusions of the study were that surgery was effective, since two years afterwards, patents in the surgical group had made gains equal to the therapy group. I raised the question to the presenters about the initial painful recovery, then months of recovery, which the therapy group never had to experience. They were angry that I could not see that the outcome measures were equal, so "all's well that ends well." They pointed out that their surgical patients often thank them because they, "wake up and the pain is gone." They omitted that post-surgical patients are on pain relieving drugs, often narcotics.
I do not judge my own patients to be fine, or a method to be worthwhile, if they have to endure loss of mobility and physical levels at all, let alone over two years.
What works better than knee surgery?
Physical retraining of how you use your knees in daily life when walking, bending, running, and other activities.
Checking other causes of knee pain such as hard "supportive" shoes, and many prescription drugs with pain as side effects.
It is common to do exercises to strengthen the legs, then walk away from those same exercises allowing the knees to sag inward, slide, or twist in directions different from the line of the joint. The chronic unequal loading grinds, stretches, and wears at various bands of cartilage that connect upper and lower leg bone (ACL and PCL), meniscus cartilage, can grind the inside of the kneecap causing pattelo-femoral pain, and can even wear away at the shiny smooth cartilage covering bone ends (the articular surfaces), predisposing to arthritis.
This is why much supposed knee rehab isn't " working" - it is being undone the rest of the day by continuing the causes of the problem. Physical retraining is for all real life, not just a bunch of "sets and reps."
You don't have to have surgery to stop pain. Here are Fitness Fixer posts on fixing knee pain without surgery:
For someone with "foot drop," the front lower leg muscles are too weak to lift the foot upward at the ankle. The foot hangs downward instead of lifting upward to take each step. Gait is altered and the front of the foot may slap the ground with each step. Fixing foot drop involves fixing three things - stopping the original cause, strengthening the (several) secondary effects of the weakened and tightened muscles, and retraining gait to normal. Common treatment options of braces to hold the foot up, canes or walkers to steady walking, drugs for the pain of whatever is causing it, reductions in activity, and certain surgeries, may all interfere with recovery and create new, and even more serious problems. Healthy treatment can be done without surgery, drugs, inactivity, or bracing.
One common surgery fuses the ankle so that the foot can't hang down. The foot can't move any other way either, causing new gait disturbance, and limitations in moving for health or fun. When foot drop comes from a herniated disc reducing nerve conduction, surgeries may remove the disc. However, discs are needed for healthy spine dynamics. Surgical spine fusion, even more drastically limits healthful movement, and ultimately health itself.
Interchangeably called drop foot, it is not a disease by itself, but the result of something else. Foot drop can follow a herniated disc that presses on nerves that exit the lower spine. It may also come from an injury directly to the peroneal nerve behind the knee. Certain diseases of the nervous system such as multiple sclerosis, Parkinson's, and amyotrophic lateral sclerosis (ALS) may reduce signals to various nerves.
A disturbing and increasing number of foot drop cases come from back and knee surgery. Someone undergoing surgery for a herniated disc or a knee replacement may wake with foot drop when nearby nerves were damaged or accidentally cut during the surgery. Such "side effects" are regularly called unavoidable surgical risks. It is important to change understanding of medical practice so that it is understood that adding new problems is not healthy and so, isn't "health care." Tragically, surgery itself for disc trouble is nearly always unnecessary.
As foot drop continues, lack of stretching in back of the leg that would have naturally come with each step from lifting the foot results in Achilles tendon and other structural tightness. Tightness can increase until that alone restricts lifting the foot.
Reader Sylvia wrote me several notes of her success reversing the components of foot drop. She first wrote in August, after finding the post of Inspirational Ivy II - Beating Foot Drop and Sciatica, and Getting Healthier. Her photos walking with a cane and needing to ride in a golf cart are above, left.
In Sylvia's case, her physician told her that a herniated disc was preventing the nerve down the leg from conducting enough to the front lower leg muscles (usually the tibialis anterior), which lifts the foot. Sylvia wrote,
"The specialist orthopedic surgeon I was referred to fortunately said he would not operate and my subsequent follow up visit has resulted in him telling me to go away as I am no longer in pain although I still have no dorsiflexion (upward lift of the foot). If in a year I still have drop foot I should discuss again with my doctor. Not very helpful…Thankyou for the wonderful work you have done putting this web-site together Best Wishes from England.
Sylvia"
When a disc is involved, the first thing to do is to stop the reasons for discs pressing outward, such as bad bending and sitting, and use good bending and sitting instead. If it is slouching so that you have too much inward curve of the lower spine, and that is pressing on the nerve, or it pushes the disc which then pushes the nerve, then you stop that habit, so it can heal. Stop the source. Surgery is not necessary. This is explained more in the post Cauda Equina - Result Not Cause. Then you exercise the shin muscles that have weakened, and stretch the calf and Achilles and bottom of the foot, which has tightened. You also need to practice balance and gait.
Reader Ivy began corresponding in the comments of the post to tell Sylvia her specific events to first stop the disc herniation, which was pressing and constricting nerve conduction.
By October, Sylvia has done much to reserve several causes and results. She was walking without a cane (right) and wrote,
"Hi Jolie and Ivy "I really appreciate your support and enthusiasm. My badly herniated disc obviously impinged on the nerve causing the nerve damage. I know this is from years of bad posture. I have come a long way already but not too far in the lunging and balance areas yet.
"At the weekend I was seen to be dancing at my son's wedding and I realised that non-one would believe I am usually slapping along.
"Instead of wearing my usual flat shoes or bare feet I had some new ankle strap 2 inch heel sandals for the event. The strap helps to keep the shoe on and the height of the heel was just right to keep me on my toes ! So I have decided to find a dance class to supplement my pool and land exercises as I have rediscovered I love dancing !
"I am going to Florida for a couple of months and should be able to find some dance action there. I'm going to try and toe walk on the sandy beach too.
"In the meantime I will keep on trying to change my bad postural habits! Best wishes. Sylvia"
Sylvia and I also corresponded. She send a photo of her happy and healthy at her son's wedding (below, right), with this update:
"Dear Dr Jolie, "I have received the books today... Now I have no excuse for not stretching and correctly at that !
"I can't wait to get back in the water and see how my ankles are - they are probably quite stiff so will need some work.
"I have printed the Inspirational Ivy page with the pictures of her exercising and keep it in my purse as a constant reminder that my condition will improve. Everyone here whom I haven't seen for two months whilst in the UK, is telling me how much better I'm walking. I tell them what I'm doing and if they have any problems refer them to your web page. Best wishes for now." Sylvia
We will be hearing more wonderful things from Sylvia.
Disc Pain - Not a Mystery, Easy to Fix - When you stop bending wrong many times each day, which pushes discs outward many times each day, damaging forces will stop, and can heal.
Read success stories of these methods and send your own. Questions come in by hundreds. I make posts from fun ones. See if your answers are already here by clicking links and archives, and the Fitness Fixer Index. For answers to personal medical questions - Replies to Medical Questions. Have The Fitness Fixer e-mailed to you, free. Click updates via e-mail "Health Expert Updates" (trumpet icon) upper right column. See Dr. Bookspan's Books, take a Class, get certifiedDrBookspan.com/Academy.
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