The Beyond Pain Podcast

Episode 59: Surgery vs. Rehab: What’s the Best Choice for You?

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca delve into the complexities of ACL and Achilles injuries, discussing the growing trend of non-surgical treatment options. 

They explore the factors influencing the decision to opt for surgery versus non-surgical routes, emphasizing the importance of individual goals and health status. The conversation highlights the uncertainty surrounding recovery outcomes and the need for realistic expectations in rehabilitation. 

Ultimately, the hosts stress that each person's journey is unique, and results can vary significantly based on numerous factors.


Takeaways

  • Non-surgical options for ACL and Achilles injuries are becoming more common.
  • Individual goals and health status are crucial in deciding treatment options.
  • Surgery is a trauma that can affect recovery outcomes.
  • Age and activity level influence the decision for surgery versus non-surgical treatment.
  • Recovery expectations should be clearly communicated to patients.
  • Healing can continue long after surgery, affecting long-term outcomes.
  • Not all patients will return to their previous level of activity after surgery.
  • Injury recovery is highly individualized and not guaranteed.
  • Patients should be educated on the risks and benefits of each option.
  • Understanding that results can vary is essential for patient mental health.


Joe Gambino (00:43)
Welcome back into the Beyond Pain podcast. am one of your hosts, Joe Gambino, and I'm here with the other half of the show, Joe LaVacca You can find this on Instagram at Joe Gambino DPT for myself at strength and motion underscore PT for Mr. Lavaca over there, Dr. LaVacca over there. A podcast is on YouTube, cups for Joe underscore PT and on Instagram as well, Beyond Pain podcast. And there is an application form and all of our handles down in the show notes. So if you are

Looking to have a deeper conversation with us, please feel free to reach out to us. We will get back to you, Joe. Welcome back. Didn't mess this one up.

Joe LaVacca (01:17)
Good to be back, yeah. We're now riding the streak of one ⁓ for the Joe Gambino intros. So I feel like we should have a sign behind me now. Like, streak of Joe's intros going well. We'll just put a number one there. Hopefully next week you get to two. But yeah, good to be back. Good to be back. Last week we talked a lot about political ranting and things that were in the news and...

Joe Gambino (01:22)
Yeah

that'd be fun.

Yeah.

Joe LaVacca (01:40)
This has been in the news, think, what our topic is going to be today, just not recently. But I will let you segue after that cliffhanger.

Joe Gambino (01:47)
Yes. So this is a kind of a question of the day type of episode from me to you. And we'll just let it spark a debate. I've had a couple instances where people have ACL injuries. They have not had surgeries yet. They have gone to their doctors. Both cases, the doctors were surprised that they even had an ACL tear based on how their function is, their range of motion, how much extension they have, how much strength they have, what they've been complaining about.

but one of them is actually ACL tear with also a little tibial fracture and the other one is just a pure ACL tear. But both cases, the doctors talked about options as far as one being surgical and one being non-surgical. And I think these non-surgical options are becoming a little bit more common as far as options for people. We're also seeing them with Achilles.

ruptures where it used to always be a surgery and now you have the option of not doing the surgery versus doing the surgery. So the question really is, is how much of these have you seen? Are you familiar with any literature out there that talks about, you know, how these do long-term and yeah, you know, how can people start to make some of these decisions for themselves if they do find themselves down this path?

Joe LaVacca (03:08)
Yeah, it's exciting to hear that people are at least getting options. When I first heard about the non-surgical ideas for Achilles, it was probably pretty early on in my career. I still remember working at my first job and seeing an Achilles rupture and this gentleman being offered that same process. Now,

10 or 15 years ago, that was pretty new. It was just emerging. And ever since I left that inpatient orthopedic realm, I'm sorry, in network rather than inpatient. So the in network orthopedic realm, I was seeing surgeries left and right. The thing with them not gaining popularity,

non-surgical route or a surgeon not wanting to probably offer non-surgical treatment to their clients. I didn't really see any non-surgical Achilles and really up until recently, the non-surgical ACL, I think what we were classifying people as, if you remember, were copers and non-copers with their ACL injury. But what has emerged recently is this idea of this cross bracing protocol.

And that seems to be the way that most people recover from this non-surgical route. So it is important to think that when you are making this decision as a client, it's not like you're just living your life waiting for your ACL or your Achilles to heal. If you go the non-surgical route Achilles way, you're going to be in a boot.

with your heel kind of really elevated and then over the course of a few weeks, you're gonna let your heel sort of kind of drop back down to more of a neutral position. So the idea for people watching, you're trying to shorten the tissue that has been damaged in order to bring a lot of these connective tissues back together, make it easier to repair and then gradually expose load.

It's the same thing with the ACL. So you're actually braced at 90 degrees, kind of walking around like a pirate for several weeks, and then gradually let yourself kind of get back to full extension. the protocol is still going to affect your life no matter what. I would say your personal decision-making, what you want to get back to, how old you are, how healthy you are, are all going to be really big factors.

Joe Gambino (05:11)
Mm-hmm.

Mm-hmm.

Joe LaVacca (05:33)
So if you're younger and you have no previous injuries, if you're not smoking, if you're not overweight, if you don't have cholesterol and other issues like blood pressure and things like that, then you could probably do very well from a surgery and be very happy with your outcome. Like we've mentioned before though, surgery in and of itself is a trauma. So if you're a little bit older, if you have a history of injuries,

Joe Gambino (05:57)
Mm-hmm.

Joe LaVacca (06:01)
if maybe you're a little bit more overweight, if you smoke and drink and partake in other social habits, then maybe you don't want to expose yourself to something as big of a surgery because your body won't really recover as well and as effectively. So I think that's sort of like step one, knowing that no matter what you pick, your life is going to be significantly affected and it's going to be affected for a long time. So what other contexts should

Joe Gambino (06:14)
Mm-hmm.

Joe LaVacca (06:30)
we be on the lookout for, because I know you've seen a couple of these clients roll through. So I'm sure you've been kind of digging a little bit scouring, answering some questions. Are there other things that people should really consider?

Joe Gambino (06:42)
Yeah, I think you you mentioned one thing as goals. I think that's the biggest one. Whenever I'm having someone make a decision on a surgery or not a surgery or what they need to do next, it's always risk reward, right? Like what are you looking to accomplish? What do you want to be able to put your body through weighing that versus the two options and what the longer term outcomes are going to be? And I'll just ask you this, Joe, because

You you brought up age is one of the factors and that is one of the factors that have popped up in the conversations and why the doctor would steer them in one direction versus the other. When it does come to age, what would you say would be the age where, you know, like an older age where you would start to lean non-surgical versus surgical?

Joe LaVacca (07:23)
I'll throw myself in the bucket. Maybe over the age of 35 or 40 is probably where I'm probably going to steer a little bit more non-surgical. But I wouldn't even be surprised if it's younger than that.

Joe Gambino (07:34)
What would you say? if you were the doctor and you were going to pick the H.

Joe LaVacca (07:37)
⁓

if I was a doctor picking the age. ⁓ I think age, yes, is obviously a significant variable, but I do think that there's a difference between the age of a 40 year old who has been active versus a 40 year old who has, you know, again, flew off a bike, stumbled down some steps, you know, and tore their ACL or their Achilles on a night out.

Joe Gambino (07:40)
Yeah, yeah, yeah, you know.

Yes.

Joe LaVacca (08:02)
Versus on the soccer pitch or the the basketball court or something like that So I guess if there was a specific age cutoff maybe there is a little bit more influence in my tone on Pushing someone a certain way because I think that the outcome would be a little bit better suited for them But it is really hard to know what surgery so I guess that would be a contextual thing of what 40 year old I might looking at

Joe Gambino (08:26)
Yes.

Yeah, that's very fair. Because both these doctors both referenced 40 as the the cutoff. And I'm like, man, this is a conversation I literally had with my client who I was like, I'm literally two years from 40. I couldn't imagine 40 being, you know, two years from now, it's being so different that well, now I'm just not going to be active anymore. I'm not going to really be playing golf or going for a run or going on hikes or whatever. And then like, I don't need to have an ACL surgery. Right. So

Joe LaVacca (08:36)
sucks for me.

You

Joe Gambino (08:55)
You know, to your point, right? It's very dependent on the person and the goal, right? Because I think there is, you know, uh, someone who's 40, who's in poor health, who's never really been active in their entire lives and don't plan on being active thereafter. Right? Like they could, you know, no surgery is probably going to be the best option for that person. Um, but on the flip side, you know, if you're someone who's very active and you look on continuing to be active and you want to go run marathons, you want to go ski or you want to go do some, things that are going to require your needs to be able to rotate and absorb force.

And, you know, you know, doing the surgery and going through that, process of the recovery makes a whole lot of sense for you because you're to be able to go right back into doing almost all of those things down the line. So I think that's really kind of the decision. And it just goes back to what are you what are you looking to do with your body? And based off of that, that should help you kind of push. you know, I've talked to both those people and said, you know, most likely with what you like to do.

You know, the surge is going to be the better option for you because it's going to allow you to, you know, wanted to go ski again. Um, want to, I want to continue to play basketball. And if you want to continue to do those things, right. Like making sure that knee is, is going to be underneath you and you're not going to have a chance of re-injuring it, you know, and all that stuff down the line because you want to stay active. That's the way to go.

Joe LaVacca (10:11)
Yeah. And you know, I think with all this stuff, you probably just want to come, what was the standard treatment? So the standard treatment has always been surgery, right? And, know, off the top of my head, I would probably say that, you know, maybe half of all athletes really get back to their prior competitive level.

Joe Gambino (10:20)
Hmm.

Joe LaVacca (10:30)
after a lot of these surgeries, know, feeling like they did not adjusting their game, you know, showing no signs of slowing down. So it is a little bit of a coin flip just in general, like injuries really suck. That's what people have to realize, right? It's bad luck. It happened to you. I know you love basketball. I know you love football, but we have to consider all these other things now in your life that make you you.

What was special about football? What was special about basketball? Because again, now if you were thinking of going pro, well that was a 0.00002 % chance of that happening. So.

Joe Gambino (10:58)
Hmm.

Joe LaVacca (11:10)
This injury may not really have affected that outcome for you because that was going to be hard to attain anyway. But if it's you like the camaraderie, you like the game planning, you like the speed, you like the excitement, you like being with your friends or like one of my other clients, I like to run because my best friend likes to run and it's how we bond. Well, I would hope that you can also bond along other things, not just the sport that you guys play together. Right? So there is a little bit of that factor going in there too.

Joe Gambino (11:18)
Hmm.

Mm-hmm.

Joe LaVacca (11:40)
but knowing that just because you opted for surgery or just because you opted for a cross-bracing protocol or a heel lift protocol, you're not guaranteed to get back to where you were. So yes, if you are younger, if you are healthier, then yeah, I'm probably gonna say there's no downside really to the surgery as it stands today.

What will it mean for you in the long run? Remember, our bodies are not necessarily supposed to be exposed to air and the environment. So even though these environments are sterile and doctors do their best case to make sure everything is clean and there's no germs, the minute you enter an OR room or a hospital, you're at higher risk for infection, right? What happens then? So if you love something so much, is...

number one thing in your heart that makes you who you are, then as long as you understand the risks of any treatment you pick, I'm going to support you because it is your decision, not mine.

Joe Gambino (12:43)
Mm-hmm.

Joe LaVacca (12:43)
And I think again, that's where a lot of us as clinicians get all up in arms like, well, I wouldn't do this. I wouldn't do this. It doesn't matter what I would do because it's not my body. So this clinician, this person in front of us understood the risks, understood that, you know, I am willing to play with this outcome if this gives me the best chance for succeed, even if it is slightly better than what they're going to go get a surgery and then they come back and I'm like, well, you know what? I'm not treating you anymore because you disagreed with me.

Cause guess what? I'm wrong probably way more than I'm right day to day working with people and accepting uncertainty is really challenging, but we kind of have to learn to do it. So I think that from, you know, that standpoint, are you, let's say adamant about someone pushing themselves in either direction if they are on the borderline?

Joe Gambino (13:35)
No, think, you know, most people, when I, when I hear them talk about like, Hey, you know, like I want to be able to be active. It's because it's a lifestyle thing for them, right? There's a, there's an enjoyment about using their body, being outside, doing things, connecting with people. And it's more important than any one particular skiing, basketball, golf, whatever it is. Right. so based on like, if they tell me all that stuff, then I will, I will educate them. like, listen, this is, this is what

This is what the rehab process looks like. know, some people will say like, one of them told me it's like in nine months, you know, I'll be back to skiing. I was like, hold on a second here. Nine months, know, doctors will tell you this, like you'd be back in nine months, but that is not the typical case. You're going to be feeling pretty good in nine months, right? But you're probably not going to be back to the full return to activity. And if you also look at ACLs in football, they do pretty well.

but not same season. need over a year to be back to that level. Like if they come back nine months, which happens, they are not the same. They don't have the same explosiveness. They don't have the same. They don't trust in me as much. The decision making is different. So if someone's pure job is to just prepare and get back to the sport and they, they can get back in nine months, but they can't, they're not a hundred percent and their performance suffers and not until their next season, are they back to close to a hundred percent.

Well, then you should probably expect it's going to take a little bit longer for yourself because you have a job and you have other life stressors and it is not your full-time job to do rehab, right? And there's going to probably be even times in your life where you even just slack on your rehab stuff because you just have other shit in your life that you have to do in this place. So I think expectations really need to be had that needs to be walked through. They need to know what they're going to be experiencing. They need to know what the other option is.

Joe LaVacca (14:57)
Yeah.

Yeah.

Joe Gambino (15:17)
And what kind of limitations are going to have on that end? And then they can process that and make a decision. So I will lean them like, say, listen, if I were you, this is probably the route I'm to go, but I'm not you. So take this information, think about it, figure out what you want. One of them's not having a, their doctor meeting is not for two weeks because of the fracture. They want to see how the swelling comes down and everything. And we look at it. So you have, so you have time, you're to have like a month before the surgery to think about it, to figure out if you are going to do the surgery.

She lives by herself. Are you going to have to someone come and help you? These are all things you need to think about now as you're making the decision so that, you know, it's a scary process for a lot of people. You want to control what you can control now in the decision making process and make plans for that initial month or so, so that when it comes down to the surgery, you're as prepared as possible and you can kind of navigate those hurdles a little bit easier. So that's how I kind of go through. Is there anything different that you do or any conversation you have differently?

Joe LaVacca (16:12)
No, I think, you know, the expected outcome is always an important conversation too, because, you know, to your point, it'll be like, well, Saquon Barkley came back pretty quickly. It's like, well, John, you're a web designer, John. Okay. John, you're 43. Saquon's 25 in the peak of his life. And he plays football for a living, John. Okay. He was squatting 700 pounds before the injury. John, what are you squatting?

Joe Gambino (16:23)
Yeah.

Joe LaVacca (16:40)
Right? Like 25 % of your body weight. I think there's a difference. Um, so I think it's definitely worth, you know, maybe not as aggressively as I just did, uh, framing that out for people, but yes, that is a very important thing. And everyone wants to accelerate, accelerate, accelerate, accelerate. You cannot accelerate healing. You can accelerate function, which is wonderful.

Joe Gambino (16:43)
You

Yeah.

Joe LaVacca (17:06)
but your graft, your Achilles, your ligament is still only nine months old, regardless of if you've been braced or surgically repaired. So it's great you have your quad function back. That's awesome. You are going to probably have a lot less likelihood to be re-injured. It's great you can hit your calf raises. You'll have a lot less likelihood to be re-injured, but it does not tell me if you are going to be more

Joe Gambino (17:07)
Hmm.

Mm-hmm.

Joe LaVacca (17:33)
let's say likely than anyone else at nine months, to be, in a position where you're to find yourself torn. what I hit all my return to sport things, I hit this, I hit that, I hit that. Yeah. The tissue we were trying to protect still needed an extra three, 12, 36 months to fully mature. And I think those are the things we just don't have enough data on is yeah, I can test your function. can test your return to sport.

I can re MRI your Achilles, I can re MRI your ACL, but it doesn't tell me what that tissue can actually sustain before it tears again. And I think that's where, you know, maybe the missing link is. Hopefully we have a test for that. Hopefully we have some sort of way to measure that in the future. But right now, to my understanding, we do not.

Joe Gambino (18:18)
Yeah, I'll add two things here. And I don't know if I'll have too much more to say on top of it, but I'll be curious about your thoughts. One is I did come across a research article a while back that looked at a patella tending graft for an ACL five years down the line and found that there was still healing happening. So I always kind of bring that up to people and let them know like, listen, know, like if this is still happening, there's some healing happening five years down the line, even though you're a hundred percent.

Like imagine what happens nine months after the surgery, a year after the surgery, how much healing still has to happen if there's still healing going down at the bone level five years from now. So that's one. The other thing I always, you know, like we always compare, you know, like we're just comparing it to athletes, like the highest level there, there are N of ones, there are special breeds of human, right? At least from a performance perspective.

I've seen many times a person have the same surgery on one side and then on the other side and have completely different outcomes. You know, so I've seen a meniscus one, they did it like, super easy. I had a meniscus on my right knee. You know, I was back on my feet in like weeks and you know, it went super well. I had no issues in the recovery process. So I'm just going to get it done this time on my other side.

And then that process is like a six, seven, eight month drawn out process. Like, my God, what's going on? Like, why is this so much different? And there's so much more stress and anxiety over it. And another one, which was a bunion surgery. She did one side, did great. This is like 10, 15, maybe 20 years down the line. She had the other one done. And then, the hardware they put in, she had an allergy to it.

So now all of a sudden, it was like a systemic process going on that was really crushing her. She had to have all the stuff removed and something else put in. And that took while for them to even figure out that that process was going on. But so if that also happens, like your life changes as time goes on, right? You're older, there's different stressors, your body's been put under more wear and tear, right? Like just because somebody had a surgery and did something or you had a previous experience and it went well, it doesn't mean it's gonna be the exact same for you.

a second time around or when you compare it to your buddy who had the same surgery, right? It's going, everyone is different. Rehab is gonna look different. The process is gonna be different. It can be easier, it can be harder. You don't know what you're gonna get until you're actually in it. And I think people need to be aware of that as part of their decision-making process. But yeah, that's the last bit I have for people.

Joe LaVacca (20:39)
Yeah,

that's it, man. No, that's perfect. And you know, we joke that we shouldn't rename the podcast like what you want, what you need. The other one that really crossed my mind is results not guaranteed.

Joe Gambino (20:49)
Mm-hmm.

Joe LaVacca (20:49)
And you have to think that we are all humans who are imperfect, trying to help other imperfect humans the best we can. And it's just not perfect. It's not guaranteed. So yeah, your previous outcome doesn't predict your future one. Your friend's outcome doesn't predict yours. It is not fair, but it is the way it is.

Joe Gambino (21:10)
Mm-hmm. Yes.

That is correct. We are not a machine. We are living, breathing organisms that adapt in very, very different ways. But yeah, man, take us home unless you got something else for us.

Joe LaVacca (21:23)
No, no, no, that's it. No. And that's actually really good. I really like that. That is why the perfect example of why we're not machines, Joe, because results are not guaranteed. You can fix any machine and you know, my, my transmission and everything else, the tire I fix is going to be the same result every time it'll just work. so very good ending Mr. Gambino as always making me and everyone else better. Thank you. I love you listeners. love you. Thank you for tuning in to this week's episode of the Beyond Pain podcast. And remember.

Joe Gambino (21:31)
There it is.

Joe LaVacca (21:52)
You are not a machine.

Joe Gambino (21:54)
you