Scheduling an appointment with a doctor to discuss surgery

[jeromedawg]

Hey all,

So I've been having a persistent and ongoing issue with my wrist and my current ortho doctor thinks it's likely a torn ligament. There was a ganglion cyst forming so he popped it a couple weeks ago and there was some relief but there's still persistent pain. I don't know how or when I tore the ligament in my wrist but he's saying that outpatient arthroscopic surgery (under general anesthesia) is an option for this. Currently I've been communicating with him and his PA via an online portal but the both he and the PA keep saying that I should come in to talk with the doctor face to face, which means another appointment and more billed to me (I've seen him like 3-4 times in the past year, the last visit was the one where he popped the cyst - prior to that was just looking at the wrist, prescribing PT, and taking xrays. I also had an MRI done and from that he thinks there's likely ligament damage).

Is it really necessary at this point to schedule ANOTHER appointment with him? It just seems like a bit much... I've not done a surgery like this so not sure what I should be expecting. I'm probably going to defer it to January since my wife also has an endoscopy scheduled and we might as well max out our HDHP deductible.

[MayDay]

If you want to discuss it with him I'd expect you to have to make and pay for an appointment.

If you trust his medical opinion and want to schedule the surgery, just schedule it.

[secondcor521]

With non-emergency procedures, the doctor needs to obtain a patient's informed consent.  This normally means reviewing the benefits and risks of surgery, including complications that might occur, mistakes that might happen, making sure you're still qualified for the surgery based on your health, medications, and medical history, as well as any alternatives to surgery that might not have been yet discussed, and maybe other things I'm not thinking about.

While in theory those could be done immediately before the surgery, when a surgery actually happens there are resources assembled and set aside for the surgery.  If they reviewed the risks and alternatives and the patient decides then to follow a different course of action, those resources (which are expensive), would have been assembled wastefully.

You may think you want the surgery, but the surgeon needs to go over all that stuff mentioned above before scheduling it, both to give you the best possible health outcome and to protect themselves from liability.

[Metalcat]

I'm confused, which doctor is trying to talk to you? You're existing doctor or the surgeon?

[Blue Skies]

I needed an endoscopy for diagnosis.  I knew I needed it, the Dr knew I needed it.  I still had to wait 3 months for an appt with the Dr to talk about it and then another 2.5 months after that before they could get me on the schedule.  I wish you could just say hey I know I need it, you know I need it, let's just schedule it without the preliminary 3 month wait, but no.  Not possible.  The scheduler won't even talk to you unless you have had the appt with the dr.

[jeromedawg]

I'm confused, which doctor is trying to talk to you? You're existing doctor or the surgeon?

It's the orthopedic doctor I'm talking to - I think he would be the one performing the surgery on me too.

[jeromedawg]

What I may do in this case is just push *everything* to next year. So I'll schedule the talk with the doctor in early Jan and then maybe schedule the surgery for mid-to-late Jan. It seems like they have openings to provision this. My wife has to do an endoscopy next year as well, so we're kind of planning ahead and, at this point, trying to maximize on appointments visits if we know we're going to hit our deductible and or out of pocket.

[fuzzy math]

Generally the Dr has to have physically seen you / written a History and Physical in your chart within 30 days of the surgery date etc for surgery to proceed. He will also have to file an insurance claim for pre approval for your surgery during that time. You won't be able to get around this.

[jeromedawg]

Generally the Dr has to have physically seen you / written a History and Physical in your chart within 30 days of the surgery date etc for surgery to proceed. He will also have to file an insurance claim for pre approval for your surgery during that time. You won't be able to get around this.

Thanks. When you say "written a HIstory and Physical" does this mean I'd also need to get my annual physical/checkup from my PCP as well, prior to the surgery? Should I be consulting my PCP regarding all of this? He referred me to this ortho surgeon/doc.

[jeromedawg]

At this point, I'm trying to figure out if this is something I should 'rush' to do ASAP or if I should take my time and consider pushing it out. I do have the option of schedule the pre-op appointment to January 10th of next year. This would likely mean that surgery would end up being in February. Versus now, the pre-op I scheduled is 12/9 but the scheduler was suggesting to push it to 12/12 since he was able to pencil in a surgery slot for 1/12.

I currently can't decide if I want to just get this taken care of ASAP vs deferring it a bit.

[Metalcat]

I'm confused, which doctor is trying to talk to you? You're existing doctor or the surgeon?

K, well whomever does the surgery needs to go over the risks and benefits of this with you in order to obtain informed consent. And yes, they are going to want to bill for that time.

So yeah, you probably have to have a consult to officially discuss and consent to surgery.

I know it's functionally as though surgery is recommended and you just do it, but legally it isn't. They can't actually note that you've consented until they've theoretically thoroughly discussed it with you.

[jeromedawg]

I'm confused, which doctor is trying to talk to you? You're existing doctor or the surgeon?

K, well whomever does the surgery needs to go over the risks and benefits of this with you in order to obtain informed consent. And yes, they are going to want to bill for that time.

So yeah, you probably have to have a consult to officially discuss and consent to surgery.

I know it's functionally as though surgery is recommended and you just do it, but legally it isn't. They can't actually note that you've consented until they've theoretically thoroughly discussed it with you.

Thanks for clarifying. Good to know how it works now. I think I'm going to keep the appointment as-is and not defer currently. At first I was motivated to defer because it would count towards next year's deductible but at this rate, I don't want to defer the pre-op appointment and then find out that they have to push the surgery schedule out even further (the scheduler told me it's basically first-come first-served). That said, I'm also wondering if there is still any chance of alternative recovery (because the more I think about it, the more I get freaked out about going under). I tried PT for a bit but the experience was just off-putting and it just felt disorganized as far as scheduling was concerned. I only went a few times but it just felt like a temporary fix and very watered-down version of PT that I received for RSI years ago. I have also tried acupuncture but that didn't do anything. Other than that, I've generally tried to limit use of my hand (this has been an ongoing issue coming up on 3 years now...!!!

[Metalcat]

So you haven't tried doing high quality PT first? As in, you gave up on PT because the PT office you were going to wasn't good enough? Why not just find a better PT?

[fuzzy math]

Generally the Dr has to have physically seen you / written a History and Physical in your chart within 30 days of the surgery date etc for surgery to proceed. He will also have to file an insurance claim for pre approval for your surgery during that time. You won't be able to get around this.

Thanks. When you say "written a HIstory and Physical" does this mean I'd also need to get my annual physical/checkup from my PCP as well, prior to the surgery? Should I be consulting my PCP regarding all of this? He referred me to this ortho surgeon/doc.

No, they'll likely only list whatever you have told them in that office  and the reason for that visit- unless its with the same medical system that you have your PCP with and they can pull it up. You won't need your most recent H&P from them.

If you have a HMO your PCP might have to be the one to approve (gatekeep) surgery. If not there's no reason he would have to get involved.

[jeromedawg]

So you haven't tried doing high quality PT first? As in, you gave up on PT because the PT office you were going to wasn't good enough? Why not just find a better PT?

I checked with the PA and both she and the doctor were saying that considering I was still experiencing pain after the cyst being popped, it's indicative of a torn ligament based on the MRI (fluid leaking past a joint where it shouldn't be). I asked if PT would have helped with 'healing' or repairing the ligament and she indicated that PT would only help with function of the hand, but not actually heal the tear, and the only way to fix it is via surgery. I was doing self-therapy and massaging the joint (heating and icing it) consistently for weeks and making sure to rest it btw. If my pain has persisted for this long, it really sounds like any amount of PT wouldn't have helped. I probably tore the ligament before 3 years ago when the pain started becoming more pronounced.

[Metalcat]

So you haven't tried doing high quality PT first? As in, you gave up on PT because the PT office you were going to wasn't good enough? Why not just find a better PT?

I checked with the PA and both she and the doctor were saying that considering I was still experiencing pain after the cyst being popped, it's indicative of a torn ligament based on the MRI (fluid leaking past a joint where it shouldn't be). I asked if PT would have helped with 'healing' or repairing the ligament and she indicated that PT would only help with function of the hand, but not actually heal the tear, and the only way to fix it is via surgery. I was doing self-therapy and massaging the joint (heating and icing it) consistently for weeks and making sure to rest it btw. If my pain has persisted for this long, it really sounds like any amount of PT wouldn't have helped. I probably tore the ligament before 3 years ago when the pain started becoming more pronounced.

My point was that you were sent for PT, but don't seem to have actually gotten any good PT. So you don't know what the impact of good PT would have been when you were sent.

To be fair, I am not an expert in torn ligaments, but I've torn several non-wrist ones and managed almost all of them with PT.

I'm having surgery in Jan to repair my torn hip labrum, but that's only because it's totally macerated and the torn bits are catching and getting stuck, so we're going to cut those off so that the joint. An move smoothly again.

I am personally extremely cautious about surgery because what a surgeon considers a "success" is not at all the same thing as a patient considers success.

Not saying you shouldn't get surgery, but you should definitely be having a detailed and thorough consult and finding out what the probability of the surgery resolving your pain is. As this is a very different question from what the rate of "success" is for this surgery.

[jeromedawg]

So you haven't tried doing high quality PT first? As in, you gave up on PT because the PT office you were going to wasn't good enough? Why not just find a better PT?

I checked with the PA and both she and the doctor were saying that considering I was still experiencing pain after the cyst being popped, it's indicative of a torn ligament based on the MRI (fluid leaking past a joint where it shouldn't be). I asked if PT would have helped with 'healing' or repairing the ligament and she indicated that PT would only help with function of the hand, but not actually heal the tear, and the only way to fix it is via surgery. I was doing self-therapy and massaging the joint (heating and icing it) consistently for weeks and making sure to rest it btw. If my pain has persisted for this long, it really sounds like any amount of PT wouldn't have helped. I probably tore the ligament before 3 years ago when the pain started becoming more pronounced.

My point was that you were sent for PT, but don't seem to have actually gotten any good PT. So you don't know what the impact of good PT would have been when you were sent.

To be fair, I am not an expert in torn ligaments, but I've torn several non-wrist ones and managed almost all of them with PT.

I'm having surgery in Jan to repair my torn hip labrum, but that's only because it's totally macerated and the torn bits are catching and getting stuck, so we're going to cut those off so that the joint. An move smoothly again.

I am personally extremely cautious about surgery because what a surgeon considers a "success" is not at all the same thing as a patient considers success.

Not saying you shouldn't get surgery, but you should definitely be having a detailed and thorough consult and finding out what the probability of the surgery resolving your pain is. As this is a very different question from what the rate of "success" is for this surgery.

I actually saw a couple different therapists. First one, through Kaiser, the appointments were spread out over the course of several months and it was more like "here are some exercises, do them at home" which did not work well for me. I had no other choice besides the Kaiser OT/PT at that point in time and it wasn't very helpful at all, so I think that kind of put a sour taste in my mouth and probably made me less optimistic about PT in general. I ended up switching off Kaiser after starting the new job and got a referral to my current orthopedic doctor who recommended one rehab place that has good reviews. I went and it was a little better than Kaiser but I probably didn't give it enough time either - the annoying part was the up-in-the-air scheduling with them. You never knew when you'd be able to get on their schedule or who the therapist was that you'd be working with. I tried acupuncture after this which obviously didn't help and then did the MRI after all of that (admittedly, I should have done the MRI months ago when the doctor ordered it but I wanted to give acupuncture a go as well). Anyway, all of this was so spread out and took time that I just didn't get around to researching and trying multiple PTs; and frankly, I was just tired of it all (especially being on an HDHP/HSA and paying for literally everything out of pocket). I suppose I could have asked for a specific PT reference but the place I went to seemed to have decent all around reviews/word of mouth, aside from my doctor referring me to them, so I figured I would just try it out. I'd much prefer to work with the same person and on a consistent basis however, and that therapy place didn't seem to offer such a thing.

When you say you have "managed" other torn ligaments with PT, do you mean that the ligament is actually still torn but PT has helped from it worsening? Or are you saying that PT actually helped heal the torn ligament? Or both? I'm thinking that even if they fix the torn ligament, it may be 'too late' in the sense of remediating all pain because my ortho doctor also indicated that I likely have arthritis (probably from this not being resolved early on when it first popped up). Anyway, I'll be discussing all of this with them in the pre-op.

I am also going to be talking to a sports medicine doctor friend of mine later today to get some input from him - granted he's not an ortho doctor but he is a doctor and I'm certain is familiar with all sorts of sports related injuries involving torn ligaments, etc... I still have no idea how I tore this particular ligament. Several theories but nothing conclusive...

[Metalcat]

So you haven't tried doing high quality PT first? As in, you gave up on PT because the PT office you were going to wasn't good enough? Why not just find a better PT?

I checked with the PA and both she and the doctor were saying that considering I was still experiencing pain after the cyst being popped, it's indicative of a torn ligament based on the MRI (fluid leaking past a joint where it shouldn't be). I asked if PT would have helped with 'healing' or repairing the ligament and she indicated that PT would only help with function of the hand, but not actually heal the tear, and the only way to fix it is via surgery. I was doing self-therapy and massaging the joint (heating and icing it) consistently for weeks and making sure to rest it btw. If my pain has persisted for this long, it really sounds like any amount of PT wouldn't have helped. I probably tore the ligament before 3 years ago when the pain started becoming more pronounced.

My point was that you were sent for PT, but don't seem to have actually gotten any good PT. So you don't know what the impact of good PT would have been when you were sent.

To be fair, I am not an expert in torn ligaments, but I've torn several non-wrist ones and managed almost all of them with PT.

I'm having surgery in Jan to repair my torn hip labrum, but that's only because it's totally macerated and the torn bits are catching and getting stuck, so we're going to cut those off so that the joint. An move smoothly again.

I am personally extremely cautious about surgery because what a surgeon considers a "success" is not at all the same thing as a patient considers success.

Not saying you shouldn't get surgery, but you should definitely be having a detailed and thorough consult and finding out what the probability of the surgery resolving your pain is. As this is a very different question from what the rate of "success" is for this surgery.

I actually saw a couple different therapists. First one, through Kaiser, the appointments were spread out over the course of several months and it was more like "here are some exercises, do them at home" which did not work well for me. I had no other choice besides the Kaiser OT/PT at that point in time and it wasn't very helpful at all, so I think that kind of put a sour taste in my mouth and probably made me less optimistic about PT in general. I ended up switching off Kaiser after starting the new job and got a referral to my current orthopedic doctor who recommended one rehab place that has good reviews. I went and it was a little better than Kaiser but I probably didn't give it enough time either - the annoying part was the up-in-the-air scheduling with them. You never knew when you'd be able to get on their schedule or who the therapist was that you'd be working with. I tried acupuncture after this which obviously didn't help and then did the MRI after all of that (admittedly, I should have done the MRI months ago when the doctor ordered it but I wanted to give acupuncture a go as well). Anyway, all of this was so spread out and took time that I just didn't get around to researching and trying multiple PTs. I suppose I could have asked for a reference but the place I went to seemed to have decent all around reviews/word of mouth. I'd much prefer to work with the same person and on a consistent basis however, and that therapy place didn't seem to offer such a thing.

When you say you have "managed" other torn ligaments with PT, do you mean that the ligament is actually still torn but PT has helped from it worsening? Or are you saying that PT actually helped heal the torn ligament? Or both?

I am going to be talking to a sports medicine doctor friend of mine later today to get some input from him - granted he's not an ortho doctor but he is a doctor and I'm certain is familiar with all sorts of sports related injuries involving torn ligaments, etc... I still have no idea how I tore this particular ligament. Several theories but nothing conclusive...

Yes, managed means that the symptoms are managed. The tears don't repair themselves, but repairing tears often doesn't actually resolve the symptoms. When it comes to soft tissue management, the goal is to manage the symptoms, not the damage.

I have a supraspinatus tear that if I were to have "repaired" would most likely permanently make my pain worse. The solution is to strengthen the surrounding muscles to stabilize the joint and just *not* do the repetitive movement I was doing previously that caused the tear.

I have a half dozen torn ligaments and only two are projected to improve with surgery and that's only because they are horrifically bad and guaranteed to keep getting worse and to cause horrible arthritis and ultimately make the entire hip joints useless, so in that case, even if surgery makes the pain worse, it's still necessary.

For the rest of them? The risks of "fixing" the problem far outweigh the unlikely benefits. This is why you have to have a clear conversation with your surgeon about what *their* version of "success" looks like vs your expectations. They are not always aligned.

As for PT, I'm not quite understanding your problem with being given exercises to do at home. That's kind of the entire point of PT. You strengthen the teeny, tiny little muscles around an injury to stabilize the area and improve the biomechanics over time. You *have to* diligently do the exercises on your own daily and then the PT re-evaluates where your function is and adjusts your routine accordingly.

Sometimes they do some manual interventions themselves, but 99.999% of the benefit of PT comes from the work you do at home. I only see my PT a few times a year, but the exercises I do keep me functional.

[jeromedawg]

So you haven't tried doing high quality PT first? As in, you gave up on PT because the PT office you were going to wasn't good enough? Why not just find a better PT?

I checked with the PA and both she and the doctor were saying that considering I was still experiencing pain after the cyst being popped, it's indicative of a torn ligament based on the MRI (fluid leaking past a joint where it shouldn't be). I asked if PT would have helped with 'healing' or repairing the ligament and she indicated that PT would only help with function of the hand, but not actually heal the tear, and the only way to fix it is via surgery. I was doing self-therapy and massaging the joint (heating and icing it) consistently for weeks and making sure to rest it btw. If my pain has persisted for this long, it really sounds like any amount of PT wouldn't have helped. I probably tore the ligament before 3 years ago when the pain started becoming more pronounced.

My point was that you were sent for PT, but don't seem to have actually gotten any good PT. So you don't know what the impact of good PT would have been when you were sent.

To be fair, I am not an expert in torn ligaments, but I've torn several non-wrist ones and managed almost all of them with PT.

I'm having surgery in Jan to repair my torn hip labrum, but that's only because it's totally macerated and the torn bits are catching and getting stuck, so we're going to cut those off so that the joint. An move smoothly again.

I am personally extremely cautious about surgery because what a surgeon considers a "success" is not at all the same thing as a patient considers success.

Not saying you shouldn't get surgery, but you should definitely be having a detailed and thorough consult and finding out what the probability of the surgery resolving your pain is. As this is a very different question from what the rate of "success" is for this surgery.

I actually saw a couple different therapists. First one, through Kaiser, the appointments were spread out over the course of several months and it was more like "here are some exercises, do them at home" which did not work well for me. I had no other choice besides the Kaiser OT/PT at that point in time and it wasn't very helpful at all, so I think that kind of put a sour taste in my mouth and probably made me less optimistic about PT in general. I ended up switching off Kaiser after starting the new job and got a referral to my current orthopedic doctor who recommended one rehab place that has good reviews. I went and it was a little better than Kaiser but I probably didn't give it enough time either - the annoying part was the up-in-the-air scheduling with them. You never knew when you'd be able to get on their schedule or who the therapist was that you'd be working with. I tried acupuncture after this which obviously didn't help and then did the MRI after all of that (admittedly, I should have done the MRI months ago when the doctor ordered it but I wanted to give acupuncture a go as well). Anyway, all of this was so spread out and took time that I just didn't get around to researching and trying multiple PTs. I suppose I could have asked for a reference but the place I went to seemed to have decent all around reviews/word of mouth. I'd much prefer to work with the same person and on a consistent basis however, and that therapy place didn't seem to offer such a thing.

When you say you have "managed" other torn ligaments with PT, do you mean that the ligament is actually still torn but PT has helped from it worsening? Or are you saying that PT actually helped heal the torn ligament? Or both?

I am going to be talking to a sports medicine doctor friend of mine later today to get some input from him - granted he's not an ortho doctor but he is a doctor and I'm certain is familiar with all sorts of sports related injuries involving torn ligaments, etc... I still have no idea how I tore this particular ligament. Several theories but nothing conclusive...

Yes, managed means that the symptoms are managed. The tears don't repair themselves, but repairing tears often doesn't actually resolve the symptoms. When it comes to soft tissue management, the goal is to manage the symptoms, not the damage.

I have a supraspinatus tear that if I were to have "repaired" would most likely permanently make my pain worse. The solution is to strengthen the surrounding muscles to stabilize the joint and just *not* do the repetitive movement I was doing previously that caused the tear.

I have a half dozen torn ligaments and only two are projected to improve with surgery and that's only because they are horrifically bad and guaranteed to keep getting worse and to cause horrible arthritis and ultimately make the entire hip joints useless, so in that case, even if surgery makes the pain worse, it's still necessary.

For the rest of them? The risks of "fixing" the problem far outweigh the unlikely benefits. This is why you have to have a clear conversation with your surgeon about what *their* version of "success" looks like vs your expectations. They are not always aligned.

As for PT, I'm not quite understanding your problem with being given exercises to do at home. That's kind of the entire point of PT. You strengthen the teeny, tiny little muscles around an injury to stabilize the area and improve the biomechanics over time. You *have to* diligently do the exercises on your own daily and then the PT re-evaluates where your function is and adjusts your routine accordingly.

Sometimes they do some manual interventions themselves, but 99.999% of the benefit of PT comes from the work you do at home. I only see my PT a few times a year, but the exercises I do keep me functional.

Thanks. I just spoke with my sports medicine doctor friend and he was saying it's a hard call but it may be beneficial to surgically stabilize this joint even for the long-term and preventative. From the sounds of it, I have two things going on that should be considered: 1) surgical removal of the ganglion cyst which it sounds like came back after the doctor aspirated it a couple weeks ago and 2) ligament reconstruction and stabilization. He was saying I should perhaps consider getting a second opinion from another specialist so I will likely do that. I think this ganglion cyst though is very bothersome - my FCR tendon/area is swollen and my doctor, his PA and my doctor friend (without seeing) it all are seeming to indicate that it's all related to the ganglion cyst which hasn't completely been rectified (and the implication was that surgical removal of that would probably be a really good idea either way, considering aspiration likely wasn't effective... my doctor said there was a 50% chance it would come back).

As far as PT, I guess I didn't have the right expectations or understanding...  I'm comparing my most recent experience to years ago when I had RSI (and lost major grip strength), the PT who worked with me seemed more like a massage therapist and I was seeing him at least every other day and he would really work my arm/wrist/hand and have me do exercises. He did have me bring home the strengthening putty to use and he may have given me a brief handout to follow but I feel like most of the recovery came from the time I actually spent with him at the clinic. Then again, perhaps the therapy for RSI is much less involved than what I have now so the expectations should be different.

[jeromedawg]

Quick update but I got a second opinion from another hand specialist who was advising against full ligament reconstruction as with chronic ligament injuries the success rates are generally less. He did suggest having the cyst removed though. I had the pre op with my doctor the same day in the afternoon and he was in agreement but mentioned that in addition to the cyst removal he thinks I would benefit from a low-risk procedure called the Mathoulin procedure (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699260/), which is basically arthroscopic surgery that stabilizes the primary joint in question (scapholunate). He said he has done this before and found that it has been a success with a majority if not all of the patients who he has performed it on. I will clarify with him again on the surgical success vs patient outcome/success aspect but he sounded optimistic that it is something that would help me based on his additional assessment (he was manipulating my hand, outside of the cyst area, to see where I was experiencing pain and made this recommendation based on that). Apart from the cyst, the radiology read confirmed a partial tear in the scapholunate, which both docs agree is the more major issue, and a partial tear in the triquetral ligament (they said they really aren't concerned about this at all at least in comparison to the scapholunate).
Bottom line is that I can't even do a simple push-up without my wrist hurting badly enough (so I stop before I even try bending my elbows out).

[economista]

I might be a little behind just finding this today, but I wanted to confirm that I think you had the wrong expectations around PT. I was an elite athlete and I have had numerous injuries that required PT and every time I would meet with the PT on a scheduled basis (usually once every 2-4 weeks) and they would give me a list of exercises and watch me do them and assess my strength/range of motion/etc and then I would go home and do them on my own every day until I came back again. That's just the way it works.

My husband is a Paralympic athlete and lived at the Olympic Training Center for 2 years. When he had injuries he would see the PT and sports medicine docs there immediately and then follow the same protocol, although he would usually re-visit once a week to reassess.

If you do have surgery PT afterward is SUPER IMPORTANT. You have to be really diligent and make sure that you do the exercises afterward otherwise the surgery is basically pointless. I know someone who torn her ACL and had surgery and didn't do the exercises very well afterward and has had consistent knee pain constantly since then because the muscles around her knee atrophied and they aren't stabilizing the joint anymore even though the ligament has been repaired. My husband is 42 and tore his ACL in April. He did pre-op PT until his surgery in August and then did his PT every single day after surgery including riding an exercise bike for an hour every day. He just got cleared 100% to go back to full training, more than 6 months early. It is absolutely amazing what consistent PT will do.

I also have issues with one of my wrists and I've never had the MRI but it is likely a torn or partially torn ligament. I do A LOT of pushups and I just make a fist with that hand so my wrist doesn't bend. It's been like this for about 6 years now and I just avoid doing things that will make it hurt when I'm having issues with it. If I wasn't able to avoid the positions that make it hurt due to job, life, etc then I would probably go further and investigate how to actually get it fixed but for now this works for me.

[GilesMM]

I would do the most robust home PT regimen possible for 2-3 months before going under the knife. There is no going back after surgery.

[jeromedawg]

I would do the most robust home PT regimen possible for 2-3 months before going under the knife. There is no going back after surgery.

In a case like this where it's more "minor" outpatient surgery, would you say the same thing?

[myrrh]

Jerome, make sure you are not confusing medical definitions with regular people definitions. They are not the same.

Medical definition:
Major surgery involves penetration of the body or body cavity, minor surgery does not.
Outpatient surgery means you don't have to go to the big hospital to get it done.

Regular people definition:
Major surgery is a big fuckin' deal, no matter where on your body it occurs, and involves a long recovery time.
Minor surgery is no big deal and easily recovered from.

[Metalcat]

I would do the most robust home PT regimen possible for 2-3 months before going under the knife. There is no going back after surgery.

In a case like this where it's more "minor" outpatient surgery, would you say the same thing?

Yes. 10000%.

Wrists are fucking ASSHOLES about surgery. Prehab all the way. Max out what PT can do for you and then do surgery unless there's a specific, time-sensitive need to step in sooner rather than later.

[Metalcat]

Jerome, make sure you are not confusing medical definitions with regular people definitions. They are not the same.

Medical definition:
Major surgery involves penetration of the body or body cavity, minor surgery does not.
Outpatient surgery means you don't have to go to the big hospital to get it done.

Regular people definition:
Major surgery is a big fuckin' deal, no matter where on your body it occurs, and involves a long recovery time.
Minor surgery is no big deal and easily recovered from.

Lol, so true.

I'm about to have two "minimally invasive" surgeries that are among the nastiest, most painful, most brutal, most difficult to recover from that exist, including cutting my femur in half.

They're called "minimally invasive" because the incisions are small.  Lol. The surgery fellow emphasized over and over again how amazingly minimally invasive the procedures are, and then the surgeon came in and said "I need you to prepare for how brutal this recovery is going to be." I love my surgeon, he's awesome.

But yeah, this is why I've emphasized MULTIPLE times to try and understand the difference between surgical terms and real human terms. And not all surgeons are even capable of understanding human terms.

For example, outcomes from my surgery are "excellent" on average. That means everything heals and technically works much better after surgery.

However, in human terms, pain is often worse after surgery, for years and years on end. This is not considered a poor outcome or a complication. Non-specific pain is not considered an outcome unless it indicates a specific problem.

So when an orthopedic surgeon says "98% of patients see an improvement in function" they are not saying that 98% of patient see a reduction in discomfort. They are saying that mechanically, the joint functions better, even if it now has severe, untreatable nerve pain and the patient can actually use the joint less.

Nerve pain is the secret asshole of orthopedic surgery. It's unpredictable, extremely difficult to treat, and then most dismissed symptom out there.

So yes, I would examine thoroughly if PT could alleviate your discomfort, I would also find out if prehab cold help your outcomes.

I'm a few weeks out from surgery myself and I'm going HARD on the prehab to give myself the best chance of recovery with the least amount of post-op nerve pain.

[jeromedawg]

Thanks all

I think the confusion right now is with deciphering this issue of "success". The last message the PA (who has been working closely with the doctor and myself on this) replied back to me with seems to be her indicating that this should be a successful surgery from a patient outcome perspective:

"In regards to the dorsal capsule repair, it is usually successful in terms of addressing the patient's symptoms and pain and therefore surgical perspective as well.
 
Based on Dr. X's note, the plan would likely be to repair the dorsal capsular avulsion and then possibly debride the lunotriquetral ligament (instead of repair it) since it is not as concerning as the issue with the scapholunate ligament. Debriding the LT ligament would likely be enough to address any pain that might be coming from there.
 
After you recover, I think you should be able to do those kinds of activities eventually. There will be a period of feeling stiff and sore, but hopefully in the future you should be able to return to those kinds of activities. As for feeling pain on the ulnar side of the wrist when you do pushups, the LT ligament is on that side."

This was her response after I asked specifically about patient outcome, resolving pain, and resuming prior activities. What other questions do I need to be asking if I'm serious about doing this?

That said, maybe I will consider going back to PT to try to see if any more can be done. On a side note: has anyone here had just a ganglion cyst removed and how was the post-op recovery?
 

[secondcor521]

That said, maybe I will consider going back to PT to try to see if any more can be done. On a side note: has anyone here had just a ganglion cyst removed and how was the post-op recovery?

I've had three or four ganglion cysts over the past five or ten years.  Mine usually occur on the palm side of my finger joints between the finger and the hand.

All of them have been removed by a very simple, quick, and easy in-office procedure.  They wipe the area with antiseptic or alcohol, jab it with a hypodermic needle, drain it, then inject it with something - a steroid, maybe?  "Removed" is a little bit of the wrong word though - they don't actually cut them out or anything.  "Deflate" is probably a better layman's description.

Post-op recovery is essentially nil for me.  The joint is a bit sore for a few hours from being jabbed.  They put a band-aid on to protect the needle prick from getting infected.  I use the hand as normal.  I might take a couple of ibuprofen that afternoon.  Next day I'm 100%.

My hand surgeons seem to think that more than one or two in a single patient is rather rare.  :shrug:

[jeromedawg]

That said, maybe I will consider going back to PT to try to see if any more can be done. On a side note: has anyone here had just a ganglion cyst removed and how was the post-op recovery?

I've had three or four ganglion cysts over the past five or ten years.  Mine usually occur on the palm side of my finger joints between the finger and the hand.

All of them have been removed by a very simple, quick, and easy in-office procedure.  They wipe the area with antiseptic or alcohol, jab it with a hypodermic needle, drain it, then inject it with something - a steroid, maybe?  "Removed" is a little bit of the wrong word though - they don't actually cut them out or anything.  "Deflate" is probably a better layman's description.

Post-op recovery is essentially nil for me.  The joint is a bit sore for a few hours from being jabbed.  They put a band-aid on to protect the needle prick from getting infected.  I use the hand as normal.  I might take a couple of ibuprofen that afternoon.  Next day I'm 100%.

My hand surgeons seem to think that more than one or two in a single patient is rather rare.  :shrug:

You had yours aspirated. Mine is in a weird location (on a tendon and by or on a nerve) and the doc did aspirate it. I think it helped a bit but he said it looks like its still there or came back (its a bit swollen still) so is now recommending surgical removal of it.

The other thing i forgot to mention regarding the procedure to stabilize the joint is that its also intended to be a preventative as far as arthritis is concerned. Destabilization of joints via ligament tears is a precursor to arthritis if not addressed earlier on per what three doctors have told me thus far.

[Photograph 51]

I know the conversation has progressed from the initial post, but I would like to address something from the original post:
You want a surgeon to do a surgery without ever having done a physical exam on you?  Do you realize that you are asking a medical provider to break with the standard of care and set himself up for a malpractice lawsuit and risk losing his license to practice medicine just so you can save a little bit of money?  Patients pressure me do do this kind of thing all the time.  They want, say, a full month's supply of a schedule II medication with high overdose and diversion potential while they are still using illicit substances because it's too much of an inconvenience for them to take the bus to the clinic more often.  They think their need to avoid incurring the cost of bus fare is more important than me being able to continue practicing medicine.  They tell me I am selfish because all I care about is my license. 
It is not okay to expect a medical provider to deviate from the standard of care just because following the standard of care requires you to expend a relatively minor amount of time and/or money.  Yes, the surgeon needs to see you in person to do a physical exam.  That isn't too much to ask.  The surgeon went through four years of medical school torment followed by at least 5 years of residency torment.  You do not get to coerce the surgeon into risking losing their livelihood after all that work just because you don't want a bill for one office visit.

[Abe]

Not an orthopedic surgeon but have a few points to note for surgery in general. Most of this everyone already said.

I agree that you should discuss potential outcomes with the surgeon. Most standard procedures will have at least some data published on outcomes, including pain, function/strength, complications. How does statistics translate to your situation is difficult to predict, honestly. Pain sensation is a very complicated series of events and is highly variable from person to person (or even situation to situation for the same person). So the best they can do is use statistics + judgement to give a general idea of what to expect.

In general, recovery to near-normal function depends on the extent of damage and the amount of redundancy a joint system has. The hips and shoulders have more redundancy than fingers, for example. The spine has quite a bit of redundancy in some ways (stability) but not in others (disc injury). Again in general, hands in particular are quite delicate and we notice functional deficits much more since we use them so much.

I would recommend seeing a Physical medicine and rehab physician regarding exercises for your hands, then follow up with occupational and physical therapists for a treatment regimen. Most ortho issues can be safely improved to some extent in that fashion pror to surgery, except for urgent operations for major bone trauma, complete ligament or tendon avulsion, etc.

We are legally required to see and examine you ourselves within 30 days of surgery. Also the physical exam now versus before PT may be informative. 

I know a lot of this is wishy-washy, but just want to temper expectations.

[jeromedawg]

Not an orthopedic surgeon but have a few points to note for surgery in general. Most of this everyone already said.

I agree that you should discuss potential outcomes with the surgeon. Most standard procedures will have at least some data published on outcomes, including pain, function/strength, complications. How does statistics translate to your situation is difficult to predict, honestly. Pain sensation is a very complicated series of events and is highly variable from person to person (or even situation to situation for the same person). So the best they can do is use statistics + judgement to give a general idea of what to expect.

In general, recovery to near-normal function depends on the extent of damage and the amount of redundancy a joint system has. The hips and shoulders have more redundancy than fingers, for example. The spine has quite a bit of redundancy in some ways (stability) but not in others (disc injury). Again in general, hands in particular are quite delicate and we notice functional deficits much more since we use them so much.

I would recommend seeing a Physical medicine and rehab physician regarding exercises for your hands, then follow up with occupational and physical therapists for a treatment regimen. Most ortho issues can be safely improved to some extent in that fashion pror to surgery, except for urgent operations for major bone trauma, complete ligament or tendon avulsion, etc.

We are legally required to see and examine you ourselves within 30 days of surgery. Also the physical exam now versus before PT may be informative. 

I know a lot of this is wishy-washy, but just want to temper expectations.

Thanks Abe! Per your recommendation, is that *instead* of going the surgery route or was that in the context of post op?? I have a sports medicine doctor friend so not sure if that would be along the same lines. I probably would want to get a referral from him though because it might be a little weird seeing him as my own doctor... 

I'll check in with my PCP to get his official opinion

[Cassie]

I have had PT for a broken finger and a few years later a badly broken wrist. I had extremely limited range of motion after the wrist cast came off. I went twice a week and the physical therapist warmed my wrist up and then did a great deal of physical manipulation. He also taught me exercises to do at home. All my appointments were like this and in a month I got my full range of motion back. I also did the home exercise.

 I also did PT when after a dental procedure I could barely open my mouth and had pain. The physical therapist did both dry needling and gave me exercises. Personally if a physical therapist did nothing but prescribe exercises I would consider that inadequate.

[Metalcat]

I have had PT for a broken finger and a few years later a badly broken wrist. I had extremely limited range of motion after the wrist cast came off. I went twice a week and the physical therapist warmed my wrist up and then did a great deal of physical manipulation. He also taught me exercises to do at home. All my appointments were like this and in a month I got my full range of motion back. I also did the home exercise.

 I also did PT when after a dental procedure I could barely open my mouth and had pain. The physical therapist did both dry needling and gave me exercises. Personally if a physical therapist did nothing but prescribe exercises I would consider that inadequate.

[/b]

It entirely depends on the issue.

I've been seeing PTs regularly for decades and 99% of what they do for me is assess and give me exercises to do at home. For DH, he has different issues and the exact same PT as I have does a lot of manual work on him.

There aren't always therapeutic interventions that will help in any meaningful way beyond giving exercises. I had a temp PT who always wanted to book longer sessions and do useless interventions that I already knew wouldn't help. I would rather pay for less time with my PT and pay for more time with my massage therapist, because dry needling, shockwave, etc, are all useless wastes of my time and I already have a TENS unit at home.

So I wouldn't necessarily generalize that a PT who only gives exercises is doing poorer work. I would actually say that a PT who always does interventions beyond exercises, regardless of the issue is likely the less skilled practitioner.

[Abe]

Thanks Abe! Per your recommendation, is that *instead* of going the surgery route or was that in the context of post op?? I have a sports medicine doctor friend so not sure if that would be along the same lines. I probably would want to get a referral from him though because it might be a little weird seeing him as my own doctor... 

I'll check in with my PCP to get his official opinion

If you could be seen before surgery that’d be ideal, but post op also is helpful. Sports Med friend is a good person to ask who to see (either his specialty or PMR, they overlap to some extent).

[jeromedawg]

Thanks Abe! Per your recommendation, is that *instead* of going the surgery route or was that in the context of post op?? I have a sports medicine doctor friend so not sure if that would be along the same lines. I probably would want to get a referral from him though because it might be a little weird seeing him as my own doctor... 

I'll check in with my PCP to get his official opinion

If you could be seen before surgery that’d be ideal, but post op also is helpful. Sports Med friend is a good person to ask who to see (either his specialty or PMR, they overlap to some extent).

I got a referral for a physiatrist and made an appointment to see her next Thursday (just under a week from the scheduled surgery) so will get her opinion. I'm thinking I'll get her input on the best way to proceed, and if she thinks I should hold off on surgery and proceed with a more aggressive PT regimen, before deciding whether to cancel or not.
I realize this is going to be an invasive procedure either way but I still wonder about the "preventative" aspect of it as far as keeping arthritis at bay. It sounds like if I don't do anything about it now, it will be a bigger problem later... The big question I suppose is if non-surgical intervention will do anything to prevent it to the same extent as surgical intervention

[jeromedawg]

I'm also checking with my uncle (anesthesiologist) and his kids (radiologists) lol. I'm fortunate to have doctors in the extended family. My uncle was saying that it's definitely a risk and reward thing and it's good that I'm researching. He was saying that it has been a while but he did work with a lot of hand surgeons years ago and back then open wrist surgery was a more common thing vs arthroscopic surgery, which was just starting to become more popular. He can't recall many specifics about the open wrist surgery but also affirmed that arthroscopic surgery is definitely less traumatic and with quicker recovery times in comparison (to open wrist). I'm thinking that it may be worth giving these procedures a shot. I still plan to meet with the physiatrist to discuss and get her opinion. I just don't know how viable PT can really be for these kinds of ligament tears, especially when it comes to preventing arthritis in the long-run but I feel that the discussion with the physiatrist will be focused around that and hopefully provide more insight. Otherwise, I feel like this may be one of those things where you just have to "buy once cry once"... relatively speaking of course. If this were full-on open-wrist surgery and reconstruction, I'd be much more apprehensive unless it were a very recent and major injury.