Knee surgery is one of—if not the—most common operating room procedures in the US, and shoulder surgery doesn’t lag far behind.
Most patients assume the path to these and other joint surgeries is uncomplicated. Pain or discomfort leads to a doctor’s evaluation and medical imaging. If an MRI turns up sufficient damage or dysfunction, surgery is performed to clean up the mess.
But more and more doctors are questioning the value of this model. Their concerns are fueled in part by new placebo research that compares sham surgeries to real operations—with surprising results.
“In the sham procedure, the surgeon makes an incision and puts in the scope, but doesn’t clean anything up,” says Robert Sallis, a clinical professor at the University of California, Riverside School of Medicine and co-director of the Sports Medicine Fellowship at Kaiser Permanente. “What [these studies] found is that, in many cases, there was no difference between the fake and real procedures.”
In 2013, a Finnish team published of a double-blind, randomized controlled trial that looked at two-year outcomes for patients who had undergone arthroscopic surgery to repair a torn meniscus, compared to patients who had a sham procedure. “The outcomes after [real surgery] were no better than those after placebo surgery,” the study authors concluded.
Sallis says he’s seen at least three studies like this on knee procedures, and several more on common shoulder, hip, and back operations. In each case, the patient outcomes following placebo surgery mirrored the outcomes following legitimate surgeries. “These findings have been hard and confusing for all of us in sports medicine,” he says.
How could a sham surgery help a person as much as a real procedure? Sallis says it’s possible that the rest and physical therapy patients undergo following surgery may be the true healing elements. “Just putting a cut in a patient’s knee convinces them to rest and do physical therapy, where without the surgery it might be hard to convince them to do that,” he says.
“I think there are a lot of people who undergo surgery before they really need it,” says Brian Werner, an assistant professor of orthopedic surgery at the University of Virginia School of Medicine. “I also think many patients could avoid surgery altogether with appropriate conservative treatment.”
Werner is quick to point out that many joint procedures are absolutely necessary, and a patient would have no hope of recovery without some kind of surgical intervention. He mentions ACL tears and acute ligament injuries as two scenarios that often warrant surgical intervention.
But for many people with minor meniscus or rotator cuff tears, labrum injuries, or other joint-related issues, surgery may not be the best course of treatment. In some cases, it could even make things worse.
“Trimming the meniscus can actually increase contact pressure across the knee because the meniscus acts like a shock absorber,” Werner explains. He says this increased contact pressure can “hasten the arthritic process”—meaning a person could develop arthritis at a younger age than he would have had he not gone under the knife.
“There’s nothing you can’t make worse with surgery, which is why it should always be a last resort,” Sallis says. But many patients don’t want to hear that.
“Patients are often the ones demanding more aggressive treatments,” says Alan Reznik, a surgeon and chief medical officer at Connecticut Orthopedic Specialists. “They say they have a trip coming up or a golf tournament or a road race.” He says many insurance companies require physical therapy and other more-conservative measures before they’ll approve a surgical procedure. But patients often approach these as obstacles standing between them and surgery.
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MRIs can also be problematic. “A lot of people come to me and think an MRI is the answer to every question,” Reznik says. “But MRIs are very costly, and I’d say probably 90 percent of what I see, I can make an accurate diagnosis with a clinical exam and a plain [X-ray].”
Sallis agrees. “There’s such a reliance on imaging, but we know imaging often doesn’t correlate with symptoms,” he says. MRIs are so sensitive that they often reveal abnormalities that may have little to do with a patient’s complaints. “Especially over age 50, an MRI is almost always going to find something,” Sallis says. And a too-heavy emphasis on MRI can lead to surgeries that fix the issues the images revealed, but that don’t actually resolve a patient’s problem. “We say treat the patient, not the image,” Sallis says.
What’s the takeaway here if you’re in pain and considering a surgical procedure?
“I think it’s very reasonable to ask your doctor what will happen if you don’t have the surgery,” Werner says. “Ask if there are other non-operative measures you could try first.”
He stresses that most surgeons are trying to do what’s best for their patients. But he says there’s no getting around the fact that some surgeons are “compensated in ways that promote operative measures”—meaning they make more money if they perform a surgery than if they recommend less-aggressive treatments.
“All surgeons believe in what they do,” Sallis adds, “so it may be best to see a non-surgical person first—someone in primary care sports medicine—to evaluate you and give you your best options.” Finally, take all non-surgical treatment options seriously. As the research on sham surgeries suggests, rest, and rehab can work wonders. “MRIs and surgery are not always the answer,” Sallis says.
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