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Sock Doc WorkshopsAn injured athlete is sometimes faced with the decision to go under the knife to hopefully rid you of your pain once and for all. With the multitude of diagnostic tests available today it’s often very easy to be convinced that surgery is the only way you will get better, even if it’s exploratory surgery. After all, if you see a bulging disc on your MRI, then that must be the cause of your lower back or sciatic-type pain, right? Or maybe you’ve been told that the loss of joint space in your knee is the reason for your pain and that you need to go and have it cleaned out so you can get back to running again. “There’s just no other solution” is what many are often told. Well, surgery is sometimes necessary but more often, it is not. When the recommendation is that you go under the knife, you should not only think twice, but ask twice, get a second if not third opinion, and consider all other options. The often promised positive outcome is typically not as rosy as it’s made out to be.
What’s That Film Say Again?
Although technology is a beautiful thing it’s not guaranteed to give you a precise diagnosis or solution to your problem. Just because something shows up on a film (i.e., CT scan, MRI, X-Ray), it doesn’t necessarily mean that that is the cause of your problem. Often the problem is distant to where the symptom is felt, yes even in the case of something sometimes staring you directly in the face as a result of an image on a film.
Take, for example, the classic lower back disc bulge or herniation. If you have lower back pain and your MRI shows a disc issue, then it’s often easy for medical professionals to convince you that the disc is causing pressure, perhaps on a nerve, and hence your pain. But this very sane reasoning is why most lower back surgeries fail – the person has the disc or some bone removed so the pressure is relieved yet their back pain is little, if any, improved. How can that be? I’ve actually seen patients come in to my office with a disc completely removed that was supposedly putting pressure on a nerve yet by surgically removing this pressure, it resulted in zero pain reduction. Yes, zero. This might sound crazy but it’s more common than you think and this result occurs not just in spinal discs but in many other areas of the body too.
Who’s Reading What? Get a Second Opinion
Realize that any diagnostic test is only as good as the person who takes it combined with the observation of the one who reads it. It’s not difficult to miss something on an X-ray if you’re not set up properly by the tech and likewise it’s not too hard to cast a shadow that someone might read incorrectly as a problem or hide a problem for that matter.
Reading a film is very subjective. One radiologist reading a film may deem that a problem is better, or worse, than another radiologist. I remember one case many years ago where I saw this guy who traveled to see me for his back ailments. He brought his films and his report in with him. The report made it sound like the discs in his back were severely herniated, yet I couldn’t see that on the MRI. I’m no expert at reading MRIs (at least not to the point that a radiologist should be), so I decided to call the center where he had the films taken. Another doctor there was nice enough to review the films with me and he too couldn’t understand why the report exaggerated the case. The report noted “moderate” and “severe” disc bulging while the doctor I spoke to said he would classify them as “mild” and “moderate”.
So the take home message here is that it’s always good to get a second, if not third opinion especially if you’re thinking about surgery. You don’t need someone telling you after the fact that your problem wasn’t as bad as it appeared to be. Once your surgeon is at the area of concern, it is not likely that he or she abort the procedure if the problem doesn’t correlate with the report or diagnostic study finding.
Look at the Other Side
It’s not uncommon for someone to have a complaint and the area of concern shows something rather remarkable just by pure coincidence. In other words, how do you know if what was discovered during a diagnostic study wasn’t already there before you had pain or loss of motion? Maybe that’s just how you were made and now it’s being cited as the reason for your ailment or inability to heal. I’ve seen this numerous times and very recently by a student of mine’s son.
Recently, his boy fell and hurt his foot so he took him into the orthopedic clinic and they did an X-ray and the doctor came back in stating that he had fractured his sesamoid bone. The dad told the doctor that he didn’t see how that was possible given the way his son described hitting it. So he told him he wanted an X-ray of the other foot also. The attending doctor looked surprised at this, but the dad insisted that he wanted to see if his other sesamoid was also split in half (bipartite). Sure enough, the X-ray of his other foot came back and showed that the sesamoid was also bipartite. He told the doc he didn’t think he broke it after all and that it was most likely congenital. His wife also had a foot injury about a year ago and the doc misdiagnosed her with a broken sesamoid, when in fact she also had a natural bipartite sesamoid in both feet. So, this doc told him that regardless his recommendation for treatment was the same, which was to put him in a boot and give him pain meds and to follow up in two weeks. So much for that doctor listening, looking at the facts, and trying to figure out the problem presented before him.
Don’t assume that something you see is the whole or complete reason for the problem. This is also very common with arthritis in joints. I’ve seen X-rays of bad knees that clearly show loss of joint space which just must be causing the person’s pain. Yet, when they have the other asymptomatic knee filmed, it’s often been just as bad if not worse.
Exploratory Surgery
Exploratory surgery seems to be more common than you’d like to believe. Often, when a diagnostic film just doesn’t correlate with exam findings or identify a specific problem, the physician must use their own experience and hopefully a thorough exam to determine whether surgery is still necessary or not. Of course this aspect should always play a huge role in the decision process, as you should never go into surgery just because of a finding on a diagnostic test. (Yes there are exceptions of course – like a piece of glass sticking in your head.)
This Hail Mary approach to surgery is highly skeptical. If, for example, you are having shoulder problems and nobody can figure out why and a MRI, X-ray, or other study is unable to identify something remarkable, do you really want a surgeon to cut you open to see what they find? I realize that after perhaps months or years of pain and loss of mobility you may be at your wits end. Consider the possible consequences several times over because once you’re cut open, there is no turning back.
For two areas of the body – the feet and the jaw – I’d recommend that you are certain you have exhausted all your options even if that includes going to consult with some witch doctor on the top of a desolate mountain range. Those areas tend to be the most problematic when it comes to surgery; I’ve seen horror stories from botched TMJ and foot surgeries and some of them just can’t ever be properly corrected again.
If after you’re more informed by talking to more than one doctor and you’ve had your films thoroughly looked at, you’re still convinced you need surgery, you’ll want to know what to expect during and after surgery. In Part II I’ll discuss going under the knife, post-op recovery, and why more times than not, surgery won’t correct all your problems.
Dr. Stephen Gangemi "Sock Doc"
I'm a board-certified chiropractic physician and clinical nutritionist with a passion for true natural health care. I implement dietary & nutritional therapies, exercise & movement practices, and lifestyle changes along with manual therapy techniques to help the body heal and prevent illness and injuries.
Lindsay says
Hi Soc Doc
This article could not have been written at a more appropriate time for me. I have followed your articles and podcasts while running and have now been crippled in pain and had restricted movement for 5 months (not able to run) with a herniated l4/l5. I started doing physio and was getting stronger and things were going well and then was given a new exercise in physio and felt that electric shock up my spine again- new symptoms were then complete numbness and foot drop in right side and MRI showed the disc herniation had got worse and was compressing the thecal sac. Am now resting again not knowing where to go from here and terrified of this repeating itself again on rehab
Sock Doc says
Sorry to hear that. Of course there is a point where spinal surgery can be very necessary especially if you’re compromising the thecal sac surrounding the cauda equina. I’d definitely consult another physician if I were you.
Lindsay says
Thanks for replying and yeah I am terrified of cauda equina and will certainly have surgery if It becomes a risk. Just out of interest what do you recommend for rehab from a disc herniation as my experience with physio did not go quite the way I would have liked – was I just unlucky do you think?
Sock Doc says
Hard to say; it’s so individualized. I’m not a fan of most therapies because all they do is address the disc thru local therapies rather than the entire mechanics of the body.
Lindsay says
Should point out that the disc herniation was from a riding accident not running 🙂
Candace says
I had the same sesamoid issue that almost led to a removal of it. What started as ‘turf toe’ got diagnosed as a fractured sesamoid. I saw many Orthos and got many opinions ending up with an old time Podiatrist who suggested that I just had some inflammation from overtraining and that my sesamoid was always split (bipartite) and with rest and ice and taping it healed up. Some docs are just surgical salesmen and tell you the worst and before you know it, they take out a bone that is pretty needed for walking! A funny thing later…my oldest son had foot pain and after an xray taken was told he too has a bipartite sesamoid! So, it’s not uncommon and it is genetic. I bought him some minimals (Lems boots) put him in Correct toes, and his sesamoiditis went away! Great article, will share on my Pilates page on FB…thanks.
Aileen Reid says
The other thing that requires serious consideration is the possiblity of post-operative infection. I recently had a shoulder operation as did a colleague of mine about 10 days later. He got post op infection, ended up in ICU and back in surgery. Its a remote but a distinct possiblity and he has now lost a heap of weight and who knows what the future of his shoulder is. My FIL had a similar experience where they left a staple in after a knee replacement, Golden staph ensued and many years later he had his leg amputated when a fall dislodged the knee and reactivated the infection.
Sock Doc says
This is covered in Part II. 🙂
Jeannie Horton says
My right knee’s meniscus tore and flipped at the end of March of this year, just 4 days before I was to run the Zion 100 miler. I was swollen for a month, begun physical therapy. I saw 2 different Orthopedic doctors, got an MRI. With the MRI, I found out about my meniscus AND that l I had a 25 year old partially torn ACL on my right knee. I do? I never knew! I do remember the accident as a kid though.The doctors both suggested surgery, informed me that I could continue to have meniscus problems if I didn’t repair the ACL. In the mean time, I bought a road bike, walked, swam, went to WillPower and Grace and gradually things improved. I did a ton of research on old ACL tears and in the end decided to not have surgery to repair that. I mean I’ve run 7 50’s and a 100 with this knee and it has been 25 years! I went into my post operative appt for my meniscus in June, I was going to have that surgery. I told my doctor how active I’ve been and he examined me once again. He cancelled the surgery for me! I did a Sprint triathlon in July and a Olympic triathlon in August. I’m running high mileage again, ran 15 miles today! I’m still fine, no problems, nothing hurts. Lucky?
Menachem says
Are there any non surgical treatments for hip dysplasia?
Sock Doc says
You should always consult with a therapist or doc who treats such conditions regardless of whether you choose surgery, or are trying to avoid surgery.
Jason says
Hello sock doc,
I was first diagnosed (w/images) and otherwise w/ pubis symphisis. 15 months later of trying all sorts of PT w/my awesome chiro doc who does active release – activity modifcation, etc….I have been diagnosed w/images w/ femoacetabular hip impingement. I am in pain all the time now and after seeing two orthos and one DO and my chiro it appears that no one is sure that all my problem is from my hip but that i should get surgery any way and then see what happens. My chiro is a very – surgery is the last option – kind of guy and we have tried everything they can think of. I have deep pin in groin, where adductor attaches to pelvis and deep hip pain. All docs i see are totally baffled – but the FAI seems to be clear in images -but did not respond to cortisone shot- I got no relief.
So i have surgery scheduled at end of novemeber because i feel i have run out of options – but it seems like everyone has too much hope (myself included) about the surgery as opposed to answers. I havent run since january and the pain is always with me.
I am asking if you have any thoughts on where i might go for another look or any ideas on questions i might not have asked.
I hope you recieve this, your articles and insights are greatly appreciated.
Sincerely, jason in pain in alaska.
Sock Doc says
Well I would hope they know what they are cutting you open for – a release of some sort perhaps? I wish you were in the in the lower 48 I could perhaps refer you to someone else.
Jason says
The surgery is to stitch my torn labrum – hip – and modify the femur head – the FAI has led to pitting in the bone head of femur. The goal is to modify to “fix” bone to bone rub.
I just read your article 2 on surgery and muscle imbalance. I am fairly certain that i have a lot of pain, and inflammation from my surrounding hip muscles due to their constant attempt to stabalize the injured hip. I dont know.
Sock Doc says
It’s a tough call. I think the statistic is that 60% of people with labrum tears function fine and w/o pain. Unfortunately you won’t know until after you have the surgery if that is really the cause of your pain. I’ve seen plenty of people with low back pain, for example, who have a severe disc bulge and that is corrected via surgery and they feel little if no relief. It’s a tough decision on your part, as you already know. Good luck with everything.
pamela humber says
I have had plantars fascia in the past. In April 2015 I knew something else was the matter because my pain heel pain lasted all day not just in the morning or after I had been seated for a long time. X-rays were normal. I was placed in a boot for a month with no relief. I had an MRI which indicated a torn muscle on the bottom of my foot but fascia was intact. I was told to continue wearing the boot which I did for 4 more months with no relief. I was then put on a knee scooter for a month which didn’t help either. I had one cortisone injection that didn’t help much and was very painful. I was told I needed decompression surgery in the form of an open fascia resection which I had on 9/3/15. I was told it would take 10-12 weeks before I no longer had pain.
Today, 10/7/15 (5 weeks post surgery) I am using one crutch and wearing tennis shoes but can ‘t put much weight on my foot. It hurts worse in the morning and improves throughout the day. Ibuprofen also helps. What exercises should I be doing? What shoes are best? Now that I have had an open fascia resection I’m not sure if the exercises and shoes you recommend for plantars fascia would be the same for me.
I pray I will be able to walk normally again soon.
Thank you for any suggestions,
Pamela
Sock Doc says
Check out the PF and other foot videos/articles on this site.
gus peters says
Hello,
I read on your site that you don’t offer prolotherapy because you are not licensed for it and because you feel there are better options. Well, assuming someone has a torn hip labrum and assuming that that is the actually cause of their symptoms, what are some of the better options?
Thanks
Dr. Stephen Gangemi "Sock Doc" says
Correct, I’ve also had two colleagues in the past have patients who reacted severely to prolotherapy – deep burning pain that remained long after the shots. Better options are to have a doc/therapist evaluate the entire joint and connective tissues to figure out why the imbalances causes the failure in the labrum. And you’re right – it’s only an assumption that the tear is actually causing pain. I believe the statistic is that 60% of labrum tears are asymptomatic so the pain could be coming from another tissue in the same area.