Is Surgery the Solution? A Conservative Perspective

The Question Patients Actually Ask

"Should I just get surgery?" is one of the most common questions posed in a manual therapy clinic. It usually follows a period of conservative management that has produced partial or unsatisfying relief, or it is the first question a newly injured patient asks after receiving a structural diagnosis on imaging. The underlying assumption — that surgery provides a definitive solution that non-surgical management cannot — is both understandable and, in many clinical contexts, not well supported by the evidence.

This is not an argument against surgery. There are conditions for which surgery is the clearly indicated, evidence-based, and often urgently necessary intervention. The purpose of this article is to contextualise the decision — to outline the conditions for which surgery demonstrably improves outcomes, those for which the evidence is contested, and those for which conservative management is supported as the preferred first-line approach.

When Surgery Is Clearly Indicated

Several musculoskeletal conditions have strong evidence bases supporting surgical intervention as the primary or urgently required treatment. Cauda equina syndrome — compression of the lumbosacral nerve roots producing bladder/bowel dysfunction, saddle anaesthesia, and bilateral leg weakness — requires emergency surgical decompression. Delay measurably worsens long-term outcomes. Complete tendon rupture — distal biceps, Achilles, quadriceps, rotator cuff tears in young active patients — often requires surgical reattachment to restore mechanical function, particularly where the torn tendon ends are widely separated. Fractures with significant displacement, joint instability, or intra-articular involvement frequently require surgical fixation to ensure adequate anatomical alignment for healing. Advanced osteoarthritis with complete cartilage loss, persistent pain refractory to comprehensive conservative management, and significant functional impairment is the primary indication for joint replacement surgery — an intervention with strong evidence for pain relief and function improvement in appropriately selected patients.

Where the Evidence Is Contested

Several common surgical procedures have been subject to rigorous randomised controlled trials in recent years, with findings that have substantially challenged their accepted indications. Arthroscopic partial meniscectomy for degenerative meniscal tears — one of the most commonly performed orthopaedic procedures globally — was shown in landmark Finnish FIDELITY trials to produce outcomes no better than sham surgery (a skin incision without arthroscopic intervention) at two-year follow-up in middle-aged patients with knee pain. Subsequent trials and meta-analyses have consistently replicated this finding for degenerative tears, while evidence for traumatic tears in younger patients is more supportive of surgical benefit.

Subacromial decompression (shoulder arthroscopy) for rotator cuff impingement was similarly evaluated in the UK CSAW trial, which found that arthroscopic surgery produced no greater improvement in shoulder pain or function than either a sham procedure or physiotherapy alone at twelve months. Spinal fusion for non-specific chronic low back pain in the absence of instability or deformity has a highly contested evidence base, with several high-quality trials demonstrating equivalence to intensive multi-modal rehabilitation.

The Evidence for Conservative Management

Across most common musculoskeletal presentations — including rotator cuff tendinopathy, lateral epicondylalgia, plantar fasciitis, patellofemoral pain, non-specific low back pain, and degenerative joint disease — conservative management combining exercise therapy, manual therapy, load management, and patient education produces outcomes equivalent to or exceeding surgery in appropriately selected patients, without surgical risks, recovery periods, or costs.

The most important determinant of surgical outcome is patient selection. Surgery on well-selected patients with mechanical, structural problems that have a clear surgical solution produces genuinely good outcomes. Surgery on poorly selected patients with central sensitisation, psychosocial contributors to pain, or structural findings incidentally noted on imaging without a clear mechanistic link to symptoms tends to produce disappointing results and, not infrequently, new pain from post-operative scarring, deafferentation, and altered biomechanics.