Helping Albertans with Joint Pain and Disability
“Do I need an MRI?” “Do I need to see a surgeon?” “Is there anything else I can do?”
Every year thousands of Calgarians suffer joint and muscle injuries or experience joint pain.
Although the vast majority of patients get better within three months, there are some patients who don’t and they begin wondering if surgery might help.
This website is designed to help patients answer three questions;
Do I need an MRI?
Do I need to see a Surgeon?
Is there anything else I can do?
Problems in Orthopaedics today
1. There are thousands of Albertans who need to see a surgeon sooner-than-later but are stuck on a lengthy waiting list for their first appointment because their referral letter didn’t convey a sense of need or urgency to the surgeon on his / her first reading. These patients are at a high risk of missing a window of opportunity and developing permanent chronic pain that surgery can’t fix.
2. There are thousands of Albertans sitting on waiting lists to see a surgeon who will likely never be offered surgery. These patients take up room on waiting lists that could be filled by those who really do need to see a surgeon. Through sitting on waiting lists, with false expectations of a surgical solution, these patients are at a high risk of suffering more pain and disability than they should, if they had only been identified early as ‘non-surgical’ .
Have you seen a Medical Doctor?
Even though we often think joint or muscle pain is due to something “we did”, to ”growing pains” or a sport injury, there are many potential causes of joint or muscle pain that can be due to disease or another medical condition.
In order to avoid missing a serious disease or other conditions, physicians employ a process known as a differential diagnosis that starts with asking ‘what are all the possible causes for your symptoms?’
From this list of posssible causes, physicians will often order tests such as x-rays or blood tests to rule out there isn’t anything sinister present, such as a tumor or infection. As rare as a tumor or infection may be, this diagnositic process is the cornerstone of modern medicine in making sure that nothing is overlooked.
For this reason, the first step in the process of determining whether you need to see a surgeon, is seeing your family physician to ensure that this differential diagnosis process is executed. What tests your physician orders will depend on your symptoms BUT at a minimum, a plain film x-ray should be done in any persistent joint or muscle pain.
How Orthopaedic Surgeons determine “if” you need to be seen and “when”
Orthopaedic surgeons receive dozens and dozens of referral letters every week from family physicians on behalf of their patients.
Surgeons rank referral letters based on the probability of offering surgery to a patient.
Category #1 – high quality referral letter indicating high probability of surgery from an experienced healthcare professional – these patients are seen as soon as possible – this can still take months depending on the surgeon’s schedule.
Category #2 – moderate quality referral letter – may have positive MRI, but the referral letter doesn’t indicate surgery is the only answer – these patients are put on a waiting list – may not be seen for two years or longer – may be bumped down the list by a “Category #1″ referral.
Category #3 – low quality referral letter - considered premature or incomplete – these patients are not accepted by the surgeon’s office and are not put on a waiting list – for all intents and purposes, the patient is ‘rejected’ - they will not see a surgeon.
This process isn’t personal – surgeons aren’t ranking you, they’re ranking your referral letter.
What Surgeons look for in “ranking” your referral letter.
Orthopaedic surgeons don’t operate on pain, instead they operate on anatomical lesions (problems) they believe are the likely cause of a patient’s pain and disability.
The goal of surgery is to correct the anatomical problem and hopefully improve a patient’s function and reduce their pain BUT surgery is not without its risks and patients may not see the improvements they expected. Even after fixing the anatomical problem, some patients can continue to experience pain and disability. For this reason, surgery is always a last option and may help to explain why surgeons are cautious in proceeding to surgery without exhausting all other forms of treatment.
Every year more and more research emerges that patients with an abnormal MRI, can improve with a well designed non-surgical treatment plan that includes home based rehab exercise programs supervised by a experienced physiotherapist.
After reading your referral letter – if a surgeon has any doubt whatsoever over (a) the anatomical cause of our pain or disability, (b) whether you’ve been given a well designed treatment plan for your condition or (c) whether you’ve followed the treatment plan (including exercise) for a sufficient period of time, then you’ll likely be ranked as “Category #2 or #3″ and unlikely be seen within a year or even seen at all.
The consequences of an incomplete referral letter
Regrettably, most family physicians are very busy and lack the time at the end of the day to write lengthy referral letters. This isn’t to blame family physicians, it’s just the reality of today’s healthcare environment.
If your referral letter is incomplete and you need surgery, then a surgeon may incorrectly rank your letter as a low priority and you’ll likely be incorrectly put on a lengthy waiting list or may never see a surgeon.
The importance of a complete and accurate referral letter cannot be over emphasized, especially in patients with a high probability of requiring surgery.
Do you need an MRI in order to see a Surgeon?
The answer is no.
Although radiologists are skilled at interpreting MRIs, x-rays and ultrasounds, they do not make decisions on whether a patient needs surgery or not. Orthopaedic Surgeons are the only ones who know whether a patient would benefit from surgery or not.
An abnormal MRI does not mean a patient needs to see a surgeon or that surgery is required.
In a recent study at the University of Calgary. 70% of patients with chronic complete rotator cuff tears on MRI, improved so much they declined surgery after performing a home rehab exercise program for thre months under the supervision of an experienced physiotherapist.
The reality is, the majority of patients with an abnormal MRI are not offered surgery. For this reason, having an MRI before seeing a surgeon does not necessarily speed up the process of an initial appointment.
Everyday, patients with nothing more than an x-ray and a well written referral letter are seen by surgeons.
For these reasons, many surgeons consider a high quality referral letter from an experienced healthcare professional more important than an MRI in determining ”if ” and when you may be seen by a surgeon.
The realities of seeing an Orthopaedic Surgeon for the first time
Even with abnormal x-rays and MRIs, the majority of patients seen by orthopaedic surgeons are not offered surgery.
Common reasons that a surgeon may not offer surgery to a patient include;
- other non-surgical treatment options may exist to treat the patient’s problem
- the patient may have other medical issues that could be complicated through surgery
- the cause of the patient’s pain may be unclear or caused by another tissue that cannot be corrected by orthopaedic surgery
- the condition may not be within the surgeon’s area of practice or specialty
- the surgery may be premature for the patient, based on their age (too young)
- there may be a lack of peer reviewed evidence to support surgery for the given condition
Being referred to a surgeon does not mean you need surgery or will be offered surgery
We answer questions. We design and execute action plans for patients.
How bad am I compared to others? What should I do next?
We conduct comprehensive orthopaedic assessments to determine if a patient has (1) exhausted all appropriate non-surgical treatment options, (2) to calculate a Joint Severity Score for a patient’s condition and (3) to determine the most appropriate ‘next’ steps for the patient.
Scenario #1 - High Probability of Surgical Solution
If a patient (1) scores high on our Joint Severity Scale and has (2) followed a well designed treatment plan for their condition and for an adequate trial with no improvement and (3) may benefit from a known surgical procedure (i.e. repair, reconstruction, debridement, replacement, fusion, etc), then chances are they will be offered a surgical procedure. In this case, we will write a comprehensive referral letter on behalf of the patient to the most appropriate orthopaedic surgeon for their condition. The referral letter will be forwarded to the patient’s family physician for their records and so they can forward the letter as well.
Scenario #2 – Surgery would be premature
If a patient (1) scores high on our Joint Severity Scale but (2) hasn’t followed a well designed treatment plan for an adequate period of time, then chances are that the patient will likely be put on a waiting list and ultimately will not be offered surgery. Rather than wasting a year or more to learn this news, we’ll write a letter to the patient and their family physician with recommendations on the most appropriate procedures, treatments and rehabilitation exercises that may help the patients improve and no longer need to see a surgeon.
Scenario #3 – Surgery is not the answer.
If a patient (1) scores low on our Joint Severity Scale and (2) hasn’t followed a well designed treatment plan for an adequate period of time, then chances are they will not be put on a waiting list with no hope of seeing a surgeon. In this situation, we will write a letter to the patient and their family physician with recommendations on the most appropriate procedures, treatments and physiotherapy exercises that may help the patient see improvements and no longer need to see a surgeon.
The Benefits To You
1. High probability of surgery - If we believe you are a surgical candidate, we write a the most comprehensive and complete referral letter on your behalf to ensure it’s accurately evaluated by the most appropriate surgeon for your problem (i.e. ranked Category #1)
2. Low probability of surgery - Rather than waiting years to find out you don’t need surgery, more and more research suggests that the majority of these patients can improve their functional capacity through home based treatment treatment strategies and rehab exercises and avoid surgery altogether. In this case we provide you and your family physician, with an appropriate home treatment and functional exercise plan.
3. Monitoring and follow up. Regardless of whether a patient is referred to a surgeon or not, the status of every patient is tracked for a minimum of two years and all patients have the opportunity to be re-assessed at anytime. If your situation, does not improve we will work with you, your family physician to re-visit whether you need to be re-referred to a surgeon.
The Benefits to Alberta Health and Wellness
1. Reducing the volume of patients with unrealistic expectations of a surgical solutions caused by premature or incomplete referrals to Surgeons.
2. Early identification and re-routing of non-surgical patients to appropriate treatment and rehab exercise programs, that may improve their condition and the risk and the impact of developing chronic musculoskeletal pain.
3. Reduced waiting lists for Orthopaedic Surgical consults (unclogging waiting lists of non-surgical patients by potentially 70%).
4. Reduced waiting lists, means that high quality referrals will be seen earlier, thereby reducing the potential impact of chronic pain and disability, compounded by sitting on a lengthy waiting list for an initial surgical consult.
5. Reduced demand for premature MRIs.
The bottom line: Get answers. Get a plan. Move forward.
If you’ve got chronic joint pain that isn’t getting better, we invite you to put Terry Kane’s experience to work for you.
Make an appointment online 24 hours a day.
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