Expectations

What do you expect to get from your surgical care? No one really asks this question, yet the answer determines your satisfaction. Surprisingly, the answers you receive from your surgeon, your physical therapist, your fitness trainer, and your coach may differ.

Let’s look at the case of an injury to a high school junior-year football player. The athlete, a wide receiver, tears his ACL in the first game of the high school season. His expectation, if anyone asks, is to return to play by spring training and be back at his full potential by late summer—with his college recruiting opportunities unaffected.

The young man is treated by the team orthopaedic surgeon. He is given an ACL reconstruction that uses his own patellar tendon with bone from his patella and tibia. The surgery goes well, and he is told by his surgeon and his parents that, if all goes well in physical therapy, he will be cleared to return for the next season. His surgeon expects a “good” outcome.

He sees a physical therapist a few times a week for six weeks—the maximum his insurance will allow. The therapist works on his range of motion, but tells him that after PT he will be on his own to regain strength, balance, proprioception, and all the components of fitness required by a successful football player. The therapist knows this amount of intervention is not enough, but her hands are tied.

Some of the player’s buddies who have undergone the same surgery tell him about a trainer at their gym who seems smart about fitness. The trainer works with the player whenever he shows up, but school and other obligations get in the way. The trainer knows the kid won’t make the team without a serious commitment.

The coach, who has been around for 30 years, knows the unfortunate truth: 30% of the ACL reconstructions in teenagers fail in the first two years. Harvesting the patellar tendon significantly weakens the front of the knee, and 50% of people with ACL reconstructions develop arthritis within 10 years. The playing time in the pros after an ACL injury is only 2-3 years. The data for a college athlete who has experienced an ACL injury in high school is not known, but it probably isn’t encouraging. The coach knows that the scouts will factor this in. He has also seen a lot of post-ACL surgery high school athletes drop their sport and observed others who return with a slight limp or favoring their surgical side. He tries hard to get more PT for those athletes who are motivated, connecting them with trainers who will work with them daily and inspire them to return fitter than they were before they were injured. He has seen the athletes who buy into this “better than ever” program actually do well in high school, college, and the pros.

So, if the surgeon knows the surgery is good but not perfect, the therapist knows that the time spent with the athlete is nowhere near enough, the trainer knows that it takes daily fitness coaching to excel, and the coach knows that the injury can be fatal to the athletic career; why do we persist with subpar solutions that lead to a low probability of success? Is it because this is the “standard of care” that the insurers will pay for? Perhaps. However, how often do we ask the question: what can I expect from this care and what can I do to exceed historical outcomes?

This applies not only to ACL injuries. It is rare that significant musculoskeletal injuries requiring reconstructions with replacement tissues or devices ever return the joint to completely normal functionality. Yet, the expectations of the injured patient are based on the hope that their medical and surgical care can restore them to normal. The expectations of the doctors and therapists are that they can do their best—and the rest is up to the patient. The expectations of researchers in this field are that applications of growth factors, native repair cells combined with engineered and donor tissues, will make the outcomes significantly better.

Once these expectations and therapies get aligned; doctors, therapists, and patients can work together to set achievable and superior goals. But if you don’t ask, and keep asking, you will never know.