Pain is the single biggest driver of elective modern orthopedic surgery. Despite this, research of the last decade or so has shown that surgery is really bad at treating pain. A recent study on shoulder surgery outcomes and rotator cuff tear biology illustrates this nicely.
The structural model of pain is really what started the misconception that surgery is the best option for treating pain. When physicians first peered into early X-rays more than a century ago, they were hooked. In fact, Willhelm Rontgen (the father of the modern X-ray) had the medical community at “hello.” The ability to see inside the living body was a miracle that allowed doctors to easily diagnose broken spines and mangled hands. In treating orthopedic problems such as trauma, radiographic imaging was a godsend. Then came MRI in the 1970s and 1980s, and the medical landscape again changed with the ability to find tumors early. Somewhere along that road doctors began to conceptualize that what they saw on those images could predict why a patient hurt. This turned out to be about as accurate as a roll of the dice in a Vegas casino, but the allure was just as intoxicating. It still is today. At any major convention of family doctors, most still would believe that imaging joints, bones, ligaments, and tendons is a highly accurate way to diagnose pain, despite hundreds of research studies showing the exact opposite.
A paper published in the March 2015 American Journal of Sports Medicine is a great example. Its authors looked at 40 patients undergoing rotator cuff surgery for tears, and took a sample of the tendon cells that make up that structure. Researchers then looked at the cell activity in the sample and followed up on all of the patients two years after their surgical repair. There was no correlation between pain reports and the patients whose tear had healed. The problems that the patients reported two years after surgery were not related to any visible healing on MRI. Patients whose tear had healed were as likely to report pain as the patients whose tear had not—and vice versa.
Pain is a neurologic phenomenon. It happens because nerves are activated and irritated. While structure and pain can intersect (for example, you tear a tendon and it hurts for a few weeks), most of the time structure and pain are agnostic to each other. An entire medical industry has grown up around treating knee meniscus tears, but research shows that just as many middle-aged and elderly people without pain have meniscus tears as those reporting pain. It makes little sense to operate on patients with knee pain who also happen to show a meniscus tear on MRI, and this likely is why the most recent outcome studies show that such surgeries are no better than placebo surgeries or physical therapy.
Operating on pain because of something that appears in a picture is a practice not supported by any science. Pain is a complex issue involving the nerves, and it doesn’t respond to the quick knee-jerk decisions common in modern surgical care. Final pain outcome isn’t determined by whether your shoulder rotator cuff heals. It’s more likely determined by what’s happening with the nerves and the environment in your body around the tear. While healing the structure may be important for continuing to perform high levels of physical activity at maximal efficiency, there also are plenty of people out there with rotator cuff tears who are functioning at moderate levels with no pain.
“Shoulder Surgery Outcomes?” first appeared as a post on the Regenexx blog.