How to know when to have surgery is one of the most common and challenging questions that a Physical Therapy Clinic sees. Here in Raleigh and Cary, we see tons of active individuals who hurt themselves playing golf, tennis, running and any number of other activities at local parks and courses. The number one thing on their mind is “how quickly can I get back to doing what I love?”

The answer usually is simple. For most people who experience acute injuries playing sports, the answer is between 2-6 weeks depending how quickly they came in after the injury and how well they do sticking to the protocol. The first step is helping the body through the initial inflammatory phase and then assisting it with tissue healing and strengthening. Follow that up with some movement re-training and sprinkle on some sport specific training to finish off the rehab and usually the individual is back doing what they love in some capacity relatively quickly. There might be some continued follow up and high level rehab or strength training recommended to prevent future injury from happening again, but overall they are back at it.

But, what if you aren’t one of those lucky majority? What if you really hurt yourself and you aren’t responding to rehab? Below are some steps that you should follow or “boxes” you should check on your road to recovery.

  1. Seek Out Conservative Treatment First

I am not talking about your political point of view here. I am talking about Physical Therapy or other methods that don’t require you to get cut on. That should be your first stop unless you are concerned about a fracture, in which case your first stop is to get an x-ray to rule out the fracture and then proceed to Physical Therapy assuming everything is in one piece relatively speaking.

When you go to the Physical Therapist, they are able to assess your injury and give you an idea of what it is. They should provide you with an expected plan of care complete with cost expectations, time requirements both in terms of number of visits to the clinic and also time commitment at home. You should hold them accountable to being able to show you objective progress every session and measurable progress that is meaningful to your recovery every 2 weeks. If neither of these is being done, retry step 1 with a different therapist 🙂

2. Pursue Non Surgical Orthopedic

In some cases, even good Physical Therapy will not work. Quick side note….”Good” Physical Therapy means you were able to receive hands on care for more than 10 minutes in a session and that you were progressed through an exercise program by the therapist. Your 1 on 1 care was consistent throughout care and often lasted up to 1 hour with the same therapist that did your evaluation. You did not need to go more than 1-2x/week and were encouraged to come in as little as necessary in order to foster independence and empower you to get yourself better.

It is NOT going to the clinic, getting on a bike or an arm bike or pulleys for 10 minutes, getting some modality for another 10, maybe a quick chat with the therapist and then going to do the same exercises you do at home with a tech for 20-30 minutes with 2-3 other people. Repeat 2-3x/week for 6-8 weeks and then see if you got any better. If that was similar to your experience, return to step 1 and find a better clinic.

If you did complete step 1 with a solid Physical Therapy program and did not improve, then a non-surgical orthopedic doctor should likely be your next step. Here they might do in clinic imaging such as diagnostic ultrasound to see more clearly what is going on. They might offer you some medical solutions such as an ultrasound guided injection or other pain medications or anti-inflammatories to help allow you to be more successful with the Physical Therapy. An MRI might be recommended at this time too if the doctor thinks it is necessary.

Quick note…those people who get imaging first, before even going to PT, spend on average almost $2,000 more before they get better!

It is totally possible a Physical Therapist might recommend this step before working with them in some cases, however, if they feel your injury needs some help calming down to allow the Therapy to have a chance at being successful.

One thing to watch out for in the non-operative orthopedic world is the injection happy doctor. Do your homework and ask your Therapist for a recommendation. In our experiences, the best doctors actually will often talk us out of injections and view it as something that is only used when absolutely necessary. As always do your homework.

3. Surgery

Unfortunately, if you have been through solid Physical Therapy, worked with a good non-operative Ortho MD and tried all that they could think of, you might end up in the surgeon’s office. The key here is that it should be the last stop and last resort in almost all cases. Once they cut, there is no going back.

In an ideal scenario, all three of the providers discussed here would be communicating with one another about what has been tried and what has been successful and unsuccessful. Continuity of care is always helpful when it comes to establishing great outcomes and this doesn’t mean that all of the providers need to be at the same practice. Many surgeons will be part of bigger Universities or groups that may have the above two providers in them. Just because you decide to have surgery in one system does not mean that you can not have your rehab and subsequent care or other team members from outside the system. Chose the provider, not the system.

We have seen personally how well a multidisciplinary approach can be accomplished with simple emails and phone calls between healthcare professionals outside of systems where documentation is what ties everyone together. Honestly, having worked in some of these bigger systems, being outside of the system and having to actually discuss with the other providers what they are seeing and what is going on leads to a deeper level of information sharing than just documentation which can often leave out critical details, judgements and assessments due to time constraints when writing or dictating them.

STOP for a second….If you remember or get nothing else from this section, please get this…

When selecting a surgeon, you want the one who does hundreds of your procedure every year! You do NOT want the surgeon who only does a few each month. You want the one who eats, sleeps and breathes your issue. The more they do it, the better they are likely going to be. It also does not hurt to always get two opinions on the approach, the plan and the post-surgical plan for rehab. You would be surprised how different two surgeons may approach the same issues.

Finally, also ask them about costs and check with your insurance company as well. If surgery is on the table (no pun intended!) then your insurance is likely going to come into play and you want to shop around like you would for a new car. Ask them about all the costs associated with the surgery and recovery and compare costs. Factor those in to who will be cutting on you and who will be rehabbing you. This will give you the clear view of total costs as well as what your experience will look like.

As with shopping for anything else as a consumer, you will need to be able to compare that value adds one provider may give you if they are more expensive and figure out if it is justified for you to pay more or not.

For some reason, the majority of the population forgets that this is a business as much as any. For years we have just selected providers based on simple recommendations and no homework or shopping around. Would you send your kid to a private school without ever touring the facility, looking at graduation rates and getting an exact quote about how much it cost? Of course not! So why do we sign up for surgery after one clinic visit and meeting a person for less than 15 minutes without looking at their success and infection rates or getting an exact cost quote?

Doesn’t make much sense does it?

Hopefully this article gives you a general overview of who the players should be, the steps you should be taking and the types of traits you should be looking for as you go through this process. This is never an easy journey, but you do not have to do it alone! We are always here for guidance in whatever form it may be.

We always offer free discovery visits and/or calls if you simply just have questions about what to do, who to see or just want some other thoughts. Don’t be shy, give us a call!