SURGERY
Whether it is your shoulder, elbow, hip, knee or ankle, musculoskeletal complaints are among the most common reasons for medical visits. Fortunately, many orthopedic conditions can be treated without surgery, although some require surgical intervention either acutely or when non-operative treatments fail. The good news is that the majority of orthopedic treatments both operatively and non-operatively are highly successful, and most patients experience major improvements in pain and quality of life, often leveraging the body's remarkable capacity for self-healing.
Understanding What a "Tear" Really Means
A "tear" can sound alarming, but not every MRI finding necessitates surgery.
Why “Tears” may not be a source of pain
· Modern Improved Imaging Sensitivity: MRI scans are incredibly detailed and can detect minor, age-related changes in tendons, cartilage, or ligaments that likely never cause symptoms. Many healthy adults show "tears" or fraying without ever experiencing pain.
· Incidental Findings: Many tears represent normal wear and tear, similar to developing wrinkles or gray hair. Examples include small knee meniscal or shoulder and hip labral tears or mild shoulder rotator cuff fraying—changes often discovered incidentally.
The Importance of Context
Orthopedic diagnosis requires combining four key elements:
· Patient History: Understanding how and when the pain started.
· Symptoms: Identifying what specific activities cause discomfort.
· Physical Exam: Clinically assessing joint function, stability, and range of motion.
· Imaging Results: Evaluating the MRI and other imaging studies.
When these elements align, doctors can determine the correct treatment path.
Surgery Is a Tool — Not Always the Only Solution
Surgery is one of many tools used to alleviate pain and restore function. For some patients, it is necessary; for others, excellent outcomes can be achieved without ever having an operation.
Common Non-Surgical Options
· Physical Therapy: Strengthening surrounding muscles, improving joint mechanics, and restoring range of motion.
· Activity Modification: Adjusting daily routines and avoiding painful activities.
· Anti-Inflammatory Treatments: Utilizing oral or topical medications to reduce swelling and pain.
· Injections: These can be both diagnostic and therapeutic. They may resolve symptoms or temporary resolve symptoms allowing doctors to find the source of your pain as sometimes there are overlapping conditions or possible response to a surgery
o Corticosteroids for immediate inflammation and pain relief.
o Viscosupplementation (“gel shots”) to enhance joint lubrication, commonly used for knee arthritis.
o Platelet-Rich Plasma (PRP) to potentially stimulate the body’s healing response (unfortunately this is currently an out-of-pocket cost, not covered by insurance)
These conservative treatments may not technically "cure" the tear, but they can significantly reduce pain and improve mobility, potentially making surgery unnecessary.
Surgery Is Always Individualized
No two patients, and no two tears, are exactly alike. The decision to proceed with surgery depends on a variety of personal and clinical factors such as:
· Age: Younger, more active patients may need surgery to restore full function, while older adults might manage symptoms effectively with therapy.
· Occupation & Lifestyle: Physically demanding jobs or high-level athletic goals may necessitate surgical repair.
· Activity Goals: Patient expectations and desired lifestyle
· Recovery Timeline: The anticipated time off work or away from activities
· Medical Conditions: Conditions like diabetes or heart disease can affect surgical risks and recovery success.
· Pain Impact: How severely symptoms impact daily life and quality of life
· Social: Excessive drinking or smoking can increased risk of complication
Ultimately, the choice to proceed with surgery is a joint decision between the patient and the surgeon in which it has been agreed upon that the benefits of surgery would outweigh the risk or are at least acceptable risk to the patient and surgeon.
When Surgery Does Make Sense
Surgical intervention is warranted in specific circumstances, including:
· Complete, non-healing tears: Injuries that structurally cannot heal on their own (e.g., certain tendon ruptures).
· Mechanical instability: Problems like joint locking, catching, or instability caused by loose fragments or displaced tissue.
· Persistent symptoms: Pain and dysfunction that continue despite a dedicated course of conservative treatment.
· Acute traumatic injuries: Cases where immediate surgery offers the best possible long-term outcome.
In these situations, surgery is often the most effective way to restore function and provide significant, lasting relief.
No Surgery Is Risk-Free
While most orthopedic procedures are safe and routine, every operation carries inherent risks, including:
· Infection
· Bleeding or wound complications
· Stiffness, joint contracture, or scarring
· Nerve or anesthesia issues
· Blood clots (DVT/PE)
· Persistent pain or incomplete recovery
Even patients who are extremely in shape, healthy (Patriots Greats Tom Brady and Rob Gronkowski both had orthopedic complication post operatively) or “heal fast” may be the unfortunate patient who sustains a complication postoperatively. Understanding these risks is essential for informed decision-making.
Complication Rates
Orthopedic surgery is generally safe, but complication rates vary widely. General procedures typically show complication rates around 4-6%, while more complex cases, such as trauma, may see rates closer to 10-15% (1). Complications that occur during the surgery itself (intraoperative) are also reported to range significantly, often depending on the specific operation being performed and local anatomical factors (2). Some individual surgeries may have more risk inherently.
Patient Recall and Understanding
Even when physicians provide thorough information, patient recall is often low. This is frequently due to factors like anxiety about their condition, the complexity of orthopedic treatment options, and time constraints during consultations. Studies consistently show that a better patient understanding leads to improved outcomes and satisfaction.
While patients are usually very good at remembering their diagnosis, they often struggle to recall specifics about treatment plans, procedures, and—critically—the risks and benefits of surgery. For example, one study found that while roughly 92% of orthopedic patients remembered their diagnosis, only about 22.5% accurately recalled the potential complications discussed (3).
Balancing Expectations and Outcomes
Most patients who truly need surgery do well, but outcomes vary based on age, underlying health, and adherence to the rehabilitation plan. Also outcomes can be measured by a variable number of functional and physical outcomes therefore choosing which outcome is more important or clinically relevant is difficult. Complicating matters even more there can also be a differences in what the surgeon and the patient feel are good outcomes. Surgery aims to improve function, provide pain relief, and improve quality of life however as with any injury or surgery it is important to understand that it may not restore the pre-injury status entirely.
The Bottom Line
A tear on MRI does not automatically require surgery. The decision must be personalized according to your unique goals and lifestyle. When imaging, history, and symptoms align—and conservative options have failed—surgery can be immensely beneficial.
By fostering informed conversations, we empower patients to take an active role in their musculoskeletal health.
References
1. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
2. Bozic KJ, et al. Intraoperative complications in orthopedic surgery: a systematic review. J Bone Joint Surg Am. 2013;95(18):1717-1723.
3. Dwyer T, et al. Understanding patient recall of surgical risks: implications for informed consent. J Bone Joint Surg Am. 2016;98(12):1026-1032.
