An Underappreciated Aspect of Joint Surgery Is the Likelihood that Post-Surgery Performance Will Be Permanently Decreased (Compared to Pre-Injury Levels) in a Significant Proportion of Athletes — an Essay on the Utility of Avoiding Injury and the Psychological Helpfulness of Gratitude in Coping with Reduced Function Afterwards

14 February 2012

Themes

This essay addresses three overlapping themes:

(i) medicine’s sometimes disappointing inability to fix us completely,

(ii) orthopedic surgeons’ occasional failure to prepare us for less than 100 percent recovery of previous high-level function,

and

(ii) the spiritual utility of substituting gratitude for expectations.

These ideas may be most pertinent to high-achievers.

Given patients’ often high expectations, medical providers have a foreseeably difficult time bringing us back to medical realities

This essay was prompted by a recent Australian study that demonstrated that anterior cruciate ligament reconstruction — “ACL surgery” in the knee — was noticeably less successful in returning patients to their previous athletic performance levels than previously thought.

Orthopedic surgeons used to think that up to 90 percent of patients regained one-hundred percent of their pre-injury athletic activity levels. However, this Australian study of 314 ACL patients found that only 45 percent had, even after 2 to 7 years.

Only 29 percent of the post-operative patients were playing competitive sports 2 to 7 years afterward — which, of course, raises the obvious question of how many had been before they were injured.

The study’s authors remind us that our activity level at 12 months is not indicative of where we will be still longer down the road.

Citation — to Australian study

Clare L. Ardern, Nicholas F. Taylor, Julian A. Feller, and Kate E. Webster, Return-to-Sport Outcomes at 2 to 7 Years After Anterior Cruciate Ligament Reconstruction Surgery, American Journal of Sports Medicine 40(1): 41-48 (January 2012)

Citation — to an excellent lay overview of the Australian study’s findings

Lindsay Barton, Less Than 50% Return To Sport At Pre-Injury Level After ACL Surgery, Moms Team (25 September 2011)

A reality check — medicine can fix only so much

As the Australian ACL study appears to bear out, my personal experience with decades of frustrating injuries, athletic self-abuse, and occasional surgeries is less optimistic than other people's in regard to the potential for medical repair.

Avoiding injury may require more emphasis than many of us recognize, especially while young.

For example, could I go back in time, I would moderate my addictive tendency toward exceeding my body’s structural limits.

And I would pay more attention to warning levels of pain. The motivational phrase, “no pain, no gain,” is intended for underachievers, not performance addicts.

A related issue — surgeons tend to downplay the inevitable price of serious injury and surgery

Part of what keeps American medicine from evolving efficiently is its generalized avoidance of doing scientific evaluations of what works over the long term and what doesn’t.

The Australian ACL study highlights this lack.

Why did — assuming the Australian survey is accurate — most orthopedic surgeons think that ACL surgery had a higher rate of athletic function-restoring success than it actually does?

One answer (obviously) is that surgeons simply did not have the follow-up data necessary to come to accurate conclusions.

But there other reasons, as well. Some of these have to do with the difficulties of medical practice and doctor-patient communication.

Surgeons (very sensibly) define surgical success differently than most patients do. Medical practitioners know the limits of their techniques and the body’s ability to heal. Most are pleased with returning patients to day-to-day function, as opposed to necessarily re-attaining Olympic heights.

This difference in perspective can make for occasional, and usually un-dramatic, miscommunications between doctors and patients.

In my experience, even athletic surgeons tend to downplay the post-operative/post-rehabilitation gap between patients’ previous performance levels and what their post-surgical future most probably holds.

Part of this “too rosy an outcome” characteristic is due to the surgeon’s ignorance regarding the patient’s actual former ability. People’s self-perceptions are usually skewed. And the higher our previous athletic level actually was (in absolute terms), the less likely the surgeon is to recognize what our unspoken post-surgical expectations might be.

Medical professionals are also characteristically reluctant to play the part of a psychological downer. We generally do not see surgeons under low-stress circumstances. I suspect that most American medical providers think that painting a gloomier future than necessary is not in patients’ best interests.

Added to this is providers’ (statistically supportable) unwillingness to predict outcomes in individual cases. There is always the person who does significantly better and worse than average. But forecasting who these people are going to be is often impossible.

Perhaps a better source of outcome predictions — experienced physical therapists and their assistants

Over years of experience, I have come to the conclusion that highly competent physical therapists and their assistants know more about post-injury and post-surgery rehabilitation prospects than the majority of surgeons.

The difference between the two groups is not one of intellect or insight. It is simply one of day-in and day-out experience with the healing process, as it manifests over time. And, though surgeons would be loath to admit it, physical therapists deal with the way the musculoskeletal system actually works in individual patients every day.

Furthermore, an often personal relationship develops between physical therapists and patients, due to treatment durations. Patients occasionally visit therapists on a personal basis long after treatment has expired. As a result, physical therapists frequently have significantly more experience with the progress of patients’ wellbeing over the genuinely long term.

When I want to know something reasonably definitive about post-surgery orthopedic prospects, I ask a competent physical therapist or assistant. Like pharmacists, they are underappreciated resource.

Gratitude — another underappreciated resource

This (completely unoriginal) thought comes from more than six decades of comparatively frequent and frustrating orthopedic injuries — many of which were occasioned by a combination of less than genetically ideal connective tissue and excessive exuberance in bouncing my carcass around.

Looking at the enormously more difficult physical and psychological struggles of those who have been grievously wounded, I think that:

Troubles are inevitable.

Some people have more than others.

Medicine generally does not work miracles.

Gratitude for what medicine can achieve is psychological helpful.

Spiritually successful aging emphasizes gratitude, rather than expectations.

Taking inspiration from the courage and optimism of the world’s most wounded people, puts comparatively trivial obstacles into perspective.

The morals? — In the face of medicine’s limitations, substitute gratitude for expectations — and “see” those who carry Life’s most significantly painful burdens

Gratitude smooths Life’s hike — when we can access it.

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