Episode 254 | An Orthopedic Surgeon’s Perspective on What Matters More: Surgery vs. Rehab

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Because last week was super long and unanticipated, this week is going to be nice and short. Today, I wanted to bring in a post or a quote that has a lot of depth and meaning, and I want to read it to you guys and talk about it for a second. But before I do that, I do want to give a little context on it. This post is something that I saved, and it’s all from Howard Luks. He’s an orthopedic surgeon, based in New York. And he has been in this space for quite a long time. He was the Chief of Sports Medicine and Arthroscopy at New York Medical College for over 20 years. And he has been someone who is focused on different joints, the shoulder, knee, ankle, and elbow. 

He was actually in a conversation about quad grafts that I just recently had, which I posted about. And he had also shared some thoughts in addition to that, which I thought were really awesome. But his focus is a lot on longevity, and you can find out more about his information. I will tag the link of the post that I’m going to read from in the show notes, and I’ll also tag his profile. You guys should follow him. 

He’s such a pro-positive surgeon. He is very pro-rehab. Obviously, that is my bias is to do physical therapy to be very pro-rehab versus thinking surgery is the end-all be-all. And I think that there’s just these perceptions in the space that are a little challenging to navigate, and it’s really refreshing to hear this from a surgeon, especially an orthopedic surgeon who has such a big influence in this space. He has so much experience and is just so grounded in this.

I’ve heard him talk. I’ll listen to podcasts with him. Hopefully,  maybe I’ll ask him to see if he can get on the podcast here and talk through his experiences of ACL surgery. But I just wanted to dig into this and just really share this particular post because I think it’s super awesome, a lot of insights. I’m going to read from it. 

He first starts off by saying I’ve been a surgeon for over 30 years. There are many lessons that I’ve learned. And the main thing here is that rehab works more often than you think. Surgery helps less than you think, but rehab helps more. I’m going to read the rest of this word for word:

“After three decades in the operating room, I’ve come to a surprising conclusion: One, I wish more patients had heard earlier. Surgery is often the least important part of recovery.”

That may sound strange coming from a surgeon, but it’s true. The scalpel can remove degenerative tissue, replace a joint, or stabilize a fracture. But the outcome, the real recovery, is shaped by everything that happens before and after the procedure.

Sometimes we suspect that it wasn’t the surgery that helped, but rather the commitment to rehabilitation following the surgery that helped. We would have appreciated seeing that commitment before surgery, or perhaps the surgeon said, “It probably won’t work, but try PT first.” Or your insurance may only approve the surgery if you attempt rehabilitation first.

Those phrases don’t improve your mindset going into rehab. Too many people believe that surgery is a finish line—it’s not. It’s a turning point. The patients who thrive after surgery aren’t the ones with the most pristine implants or perfect MRIs. They’re the ones who show up early to prehab, who stay consistent with the rehab. Those who understand the strength, balance, mobility, and endurance are the real factors that determine whether surgery changes their life or fixes a joint. 

I’ve seen perfect surgeries yield poor outcomes in deconditioned, disengaged patients. I’ve also seen average surgeries lead to remarkable recoveries in those who move, train, and rebuild. Many surgeries are less effective than we would like to think, but rehab helps more than most people realize. Here’s the shift we need to make from passive procedures to active participation. Because long-term function isn’t something I can give you; it’s something we build together. [Mic drop] so good.

He added a post right after this that follows it and says, “If it took you eight months to recover from a knee arthroscopy, a knee scope, essentially, you didn’t get better because of the surgery.” 

This is a very profound statement, just a narrative from this surgeon because he’s got the experience, he’s done a lot of ACLs, he’s done a lot of different joint replacements and whatnot through his experience, and clearly educating other professionals in this, being a chief of sports medicine and arthroscopy.

With that said, this is something that I think is really important. And while yes, this may apply a little bit to okay, a meniscus tear, should you have had that surgery on that, maybe a degenerative disc where it’s in your spine, and the MRI showed a bulging disc, and was it getting that improved through surgery? Or, was it actually committing to rehab? And there’s so many other different types of things that our bodies show on imaging or even flare-ups, if you will, and whether surgery improved it or not. It’s crazy to look at the research. If you look across any type of procedure, there are certain ones where they do sham procedures, where they fake doing the procedure. And there are ones where they do it, and they track the outcomes from short-term and long-term.

It’s pretty crazy to see that, let’s say, for a meniscus in certain situations, if it’s not an acute injury, if it’s not mechanical, where you’re showing blocking, and maybe it’s just more degenerative (it’s worn down over time). And then people get an MRI, and they see that, and they’re like, Oh, that’s my problem. And it doesn’t necessarily all pan out, but then maybe the surgeon is like, let’s fix the meniscus. 

In reality, they’ve done tests on that. And that’s one of those things where it’s interesting. Because in reality, the people’s outcomes don’t necessarily differ that much, and it ends up being more so coming back to did they rehab and get this need back in a better place. Improve the mobility, improve the strength, and be able to build that thing up again. I think with ACL it’s a little bit more clear-cut. Of course, more people are going non-operative or maybe just not getting a new graft. And they may try this path. But still, the majority of people they’re going to go through and they’re going to have the ACL procedure. And that’s just the most common thing with this. 

And of course, it’s not nearly as clear-cut as okay, if you don’t get the ACL procedure, then oh, if you rehab your way there, you’ll get there with that ligament. There are certain categories of people when they’re going back to high-level sports, cutting and pivoting, and they don’t have it, then that is something that they will likely need. Not everyone. Some people can cope without it. But it’s still a smaller number of people, a minority of people, that it will fall under. And the majority of people will still go on to have the surgery. 

Here’s the thing that I want to hit home with what he expresses. Is that sometimes people think that because the surgery is done, the ligament is in there, you give it enough time, and a lot of times the surgeon or the PT or whoever it is will say, okay, this is a nine-month process, six-month process, whoever you’re talking to. We’re anchoring to a 9- to 12-month process, as a good rule of thumb with this rehab. But it doesn’t automatically mean that once you get to nine to 12 months, you’re in a good spot. It’s the same thing like whenever you go to school, and you try to go through the grade that you’re trying to go through, and you just let time pass. But if you don’t complete any of the assignments, you don’t do any of the work, and then by the time you get to graduation or the end of the year, it’s like you haven’t done anything, so that doesn’t necessarily mean you could just move to the next grade. You need to earn the right to be able to graduate and move to the next grade. And this is the same thing in ACL rehab. It’s not just a time-based thing. I think that’s what’s really important is that a lot of times, sometimes people think that ACL rehab could be this time point where it’s okay, I get the surgery. That grafts in there. And there is definitely a category of people who think that as long as that graft is in there, then the rehab is not going to be that big of a deal. I can get there or do it halfway and be totally fine. 

Working with so many ACL athletes at this point, myself and as a team, it makes or breaks the process. I appreciate the surgeon for just being so clear on that of like how much rehab will really shape your outcomes. I cannot confirm this enough, to be really honest, from my own personal experiences with two ACLs, my own hip surgery, so many other joints that I’ve had issues with broken bones, different strains in muscles and tendons, like I’ve had a whole host of injuries myself. But then working in this field and being a part of, especially working with ACL athletes for so long now, it is just so clear cut that the people who are in this process, who work really hard and who are the ones who do the prehab, of course, hopefully they’re educated on this and look like if you didn’t get to it, it’s okay. It’s not the end of the world. And there are some people whom I talk to, and they’re like, I didn’t do prehab, and that’s why I’m not successful now. There could be layers to that. Sure, but other people didn’t do prehab, and they go into surgery, and they do well. The thing is, what does that plan look like? What does it look like from your commitment level? And it has to be this perfect intersection between your commitment to play the long game and not to rush it, and to know that the ACL reconstruction, the surgery itself, was the starting line. It was not the finish line. I think that’s the biggest thing that’s important, there is that turning point that he mentions, and just knowing that even if that surgeon, I will see so many surgical reports where ACL is pristine, perfectly placed, flawless, unremarkable. All these terminologies are used. But the thing is, you can have the most perfect ACL and procedure, but if you have a subpar rehab, it doesn’t matter. If you have an average procedure, if you just go to a surgeon who isn’t the hotshot for the pro team, who even does an average job of the ACL procedure.

If you have impeccable rehab, if you have guidance, and if you have just clear structure and expertise along the way, y’all, and if you stay committed to that for the long game, not just be like, all right, I’m going to do this for three months. Play the long game and be able to hit it for the next nine months, 12 months, however long it takes to get there. Working with the right professional to guide you and to be able to show up every day. It doesn’t mean that you’re going to have successful days every single day. There are going to be hard days in there, and there’s going to be days where you might setback. There might be days when you don’t want to show up. I think that’s a part of this process, and there’s a lot of growth to this. But with that said, if you have average surgery and amazing rehab, you’ll get there. I’ve seen this time and time again with not the best procedures and even not the best rehabs. But the thing is like we can always tap in, even if you’re three months out, 12 months out, you’re two years out. We’ve worked with people who have been 5, 10, 15 years out from ACL surgery. They’re like, I want to get back. I never got back to it. Then, we’re able to rebuild these things. It’s not like there’s a stopping point where it just doesn’t work. 

I think that this is a very important message here. I just wanted to share that with you guys today because I think that there’s so much value in hearing from a surgeon, their perspective. It also made me super happy to hear this. I think it was the right timing to share this with you guys, of him sharing it. I would highly recommend reading about his stuff, Howard Luks. He does really good podcasts, and then also being able to put out good content and just really focus on longevity and health, and human performance. I really value that. It is just something wise to hear from someone who is 30 years in the space and continues to push the space forward. 

Anyways, if you’re listening to this, Howard, thank you so much for this and all the work that you do. If you guys got any value out of this, then please let me know. Share a message. But just know, like here, yes, the ACL surgery, in the sense, can be important. I’m not saying it’s not relevant; don’t go get the surgery if you need it. But in reality, what I’m saying is, the rehab will make or break the process, and checking the box won’t just do it. I think the big, important piece here is just making sure that you have an individualized approach, you have structure, you have testing, you have guidance that is dialed in and through this whole process. Don’t do it yourself, and just make sure that you show up and play the long game because that will be so key. It might be beyond 12 months. And that’s the thing that we have to know in this process. It really depends on many factors, but just know that it could be longer than that. But depending on your goals and connecting that to your why and what’s important to you, you can get there. 

I hope that this is helpful. Please reach out if you need anything. We’re always here. Until next time, this is your host, Ravi Patel, signing off.