Analysis: are there less risky and cheaper alternatives to surgery and scans when it comes to managing shoulder and knee pain?
By Karen McCreesh, Helen O'Leary and Christina Maxwell, University of Limerick
Alan (52) has a niggling pain in his right knee. It clicks and grates when he bends it, and he has stopped playing golf, fearing it may make his knee worse. Jackie (56) has a sore shoulder that wakes her at night and stops her lifting and reaching overhead.
Both have seen their GP, who has advised an MRI scan. If the scan indicates some 'damage', referral to an orthopaedic consultant may follow, where Alan and Jackie will join a long waiting list in the public system.
The pandemic has led to the widespread cancellation of orthopaedic hospital appointments and surgeries. In May 2021, over 69,000 people were on orthopaedic waiting lists, by some margin the largest of any medical specialty. 30,000 people have been waiting over a year.
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From RTÉ Radio 1's Today With Claire Byrne, Prof. Alan Irvine from the Irish Hospital Consultants Association on the growing waiting lists for Irish hospitals
Many believe the answer to this crisis is more surgeons, more beds, more theatres. But what if quicker access to surgery was not the answer? What if there was a less risky and cheaper alternative to managing this problem?
Is surgery always the solution?
Surgery for cartilage tears in the knee and tendon problems in the shoulder have been studied in clinical trials where people have been randomly assigned to get the actual surgery or a "sham" procedure, where the surgeon cuts the skin, but does not do the surgery to the joint. The results have shown no difference between those who received the real or sham surgery.
What do these findings actually mean? In simple terms, if you are middle-aged and have a keyhole procedure to remove torn knee cartilage or 'clear out' your shoulder joint, the results may be no better than if the surgeon pretended to do the surgery. This strongly suggests the ‘placebo effect’ is at play. The routine that surrounds surgery can have a powerful pain relieving effect.
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From BMI Healthcare, consultant orthopaedic and knee surgeon Paul Gill on alternatives to knee surgery for managing joint pain
Another phenomenon that may explain this is called ‘regression to the mean’ a statistical term to describe ‘a return to the average’. People usually present to their doctor when symptoms are particularly troublesome. However, knee and shoulder pain tend to wax and wane, and show a general improvement over time. If this improved period coincides with surgery, the credit usually goes to the procedure. Surgery comes with risk; it is costly, with prolonged recovery times.
In response to these studies, a group of experts and patients examined the evidence for keyhole surgery for "wear and tear" knee and shoulder problems. They strongly recommended that surgery should be avoided, preferring lower risk alternatives, such as exercise therapy or lifestyle change, before committing to surgery as a last resort.
Are scans helpful?
The belief that torn tendons or worn cartilage are responsible for pain is a key force in driving people's desire to undergo surgery to have the problem fixed. The relationship between 'damage’ on scans and pain is not a straightforward one. If you are in your forties and have an MRI of your knee or shoulder, it will almost certainly show some abnormalities, even if you do not have pain. This makes interpreting scans a challenge, because in many ways they are more a sophisticated calendar of our age, than they are a way to understand pain. Those wrinkles on our faces are mirrored by the ones in our joints!
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From UL, Dr Karen McCreesh discusses musculoskeletal disorders and ageing research
Why does it hurt?
Focusing too much on the findings of scans can cause us to lose sight of the multiple reasons why we can experience pain. Our modern understanding of pain is that it is a protective response influenced by a broad range of factors related to the whole person. These factors include stress, low mood, poor sleep, lack of physical activity, increased body weight.
Things that might seem unrelated to our knee or shoulder, influence pain by making the nervous system more sensitive, so things hurt more when we move. Having extra body weight or poor sleep can also cause extra sensitivity by promoting inflammation. The key point to understand is that joint pain is often not a direct result of damage, but an interplay between many of these factors.
Our beliefs about pain can also influence how much we hurt. Believing that your joints will wear out the more you use them or that damage on a scan will get worse can lead to more guarding, and fear. The good news is that understanding and working on some of these reasons can improve the pain without ever altering the 'damage' deemed to be at fault.
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From RTÉ Brainstorm, all you need to know about back pain
Will delaying surgery make me worse?
The answer to this question is 'no' for many people with painful joints, particularly if the pain came on gradually over time. While you should still tease this question out with your GP, it is safe and probably wise for the most part to wait some time before consulting a surgeon.
Firstly, because we know trying lower risk treatments, such as exercise and weight loss, in advance of surgery is the best approach for most types of joint pain. Secondly, many of these conditions naturally improve over time, shown by studies where a 'wait and see' approach showed similar improvements over time to surgery or physiotherapy.
How can I get better?
(i) Taking part in an exercise programme of at least three months duration is of benefit to most joint pain problems. Our muscles, joints and tendons are designed to be loaded and get stronger in response to exercise rather than wearing out.
(ii) Maintain a healthy body weight, stop smoking, address hormone imbalances, and manage any other chronic conditions, such as Type 2 diabetes
(iii) Learn to manage your stress and work on establishing good habits around sleep.
(iv) Stay positive and confident in your ability to make a full recovery! Research shows that people who have positive expectations have better outcomes.
Tips to help you improve your confidence in making decisions together with your healthcare provider
(a) when discussing the findings of scans, ask your healthcare provider to put these findings into context, i.e. Are these findings what you might expect to see in someone my age?
(b) ask about the pros and cons, and alternatives, such as the 'wait and see approach', to determine what best meets your personal needs i.e. What will happen if I don’t have this scan/surgery right now?
(c) Use these BMJ infographics for knee and shoulder to facilitate discussions with your healthcare provider. You could also use surgery decision-aid tools for knee and shoulder to explore the evidence so that you are better able to make a decision.
Dr Karen McCreesh is a Senior Lecturer in Physiotherapy at the School of Allied Health and a member of the Ageing Research Centre at the Health Research Institute at the University of Limerick. She is an Irish Research Council awardee. Dr Helen O'Leary is a Clinical Specialist Physiotherapist at University Hospital Kerry and a Health Research Board Clinician Scientist Postdoctoral fellow at the University of Limerick. Christina Maxwell is a Senior Physiotherapist and PhD candidate at the University of Limerick. She is an Irish Research Council awardee.
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
