This week, a mom told me that she was considering surgery for her 13-year-old son due to a partial tendon tear. I’d like to discuss why I was appalled and why this is a bigger trend that’s very disturbing. We’re treating our teenagers like pro athletes trying to eek out a multi-million-dollar contract extension, and when we do this, the piper must be paid.
Paying the Piper When Bad Medical Decisions Are Made
My practice is full of 20- and 30-somethings who had bad medical decisions made for them when they were kids. Basically, they were injured playing sports, and a parent made a decision to proceed with a surgical solution. They show up in my office about 10–15 years later with that joint showing signs of early arthritis. It could be a knee, a shoulder, or an elbow. The story is so common that when I see one of these patients as I walk into a room, I can usually guess why they’re there.
Based on recent research, we know that these teenage operations have consequences. Take, for example, a recent study that showed that when teens had ACL surgery, they had a two in three chance of having knee arthritis by their 30s! Why does this happen? All modern orthopedic surgery is a proverbial bull in the china shop of the musculoskeletal system. Small changes in teen biomechanics add up over years.
So what happens when you get knee arthritis in your thirties? First, this is something that used to be unheard of but is now becoming more commonplace. If I can’t fix you, you get your first knee replacement 30 years too soon. You will also end up with at least three or four more (one every 10 years or so if you’re active) with each successive operation taking more bone and getting riskier due to dramatic increases in operative times. Somewhere around your third knee replacement, there won’t be enough bone to proceed with another knee replacement—that is, if you’ve dodged all of the big complications that can happen. So what do you do at that point? Nothing. You’re SOL.
Surgeries in Growing Kids Are Really Bad News
The kid who prompted this post about partial tendon tears in teens is 13. He’s about half of his final expected adult size based on the heights of other siblings and his mom and dad. He’s also still a “little kid,” so he has yet to hit his growth spurt. The injury is to his patellar tendon. which is 50% “torn” (a partial tendon tear). The surgeon stated he could operate and the kid would be back to sports in six weeks, or the parents could wait a year to see if it heals. In addition, oh, by the way, the surgeon had never done a procedure on a kid this young before.
First, the surgeon has purposefully created an easy “Hobson’s choice” by artificially shortening the recovery time for surgery and lengthening it for natural healing. In fact, tendon-healing studies show that tendons heal in three to six months, whether you operate on them or not. Hence, we have no data that shows that surgery will make this recovery go any quicker than if the kid was just to lay off the leg.
Second, a “50%” tear on MRI is not what most patients believe it to be. This usually only means that the MRI signal is abnormal in half the tendon, not that the tendon is snapped back like a rubber band. Meaning, that it usually means that half the tendon is weak, not broken.
Third, putting aside the surgical sales job, any surgery in a tendon that must lengthen 2X its current length as this kid grows is a bad idea. Why? Cutting through the skin, fascia, tendon covering, and tendon and then sewing it back together doesn’t produce normal organized tendon tissue. I look at these tendons many years later on ultrasound, which for this application has 100X the resolution of MRI, and these tendons are a mess. Add in that this tendon must grow and you have a recipe for an abnormal tendon that will haunt this kid’s knee for many years to come.
Finally, the way our muscles. tendons, joints and fascia move is tuned to micromillimeter precision. Alter that precise alignment by a few mm here and there as a surgery heals and over time, you get a disaster like the knee arthritis discussed above. In this case, the patellar tendon attaches to the patella. It’s likely this tendon will be forever a bit too tight from the surgery and that this will cause the kneecap to be pulled tighter into its groove and that this will cause cartilage loss (arthritis) under the kneecap. In addition, if you mess with one side of the tendon (the partial-tear side) by placing sutures there, one side of the tendon is likely to be impacted more than the other. This causes asymmetry, meaning that one side of the kneecap will load more than the other.
Are There Alternatives for Partial Tendon Tears in Teens?
In a kid this young, a precise platelet rich plasma injection (PRP) into this torn tendon area will likely heal it in the same time or quicker than surgery with far fewer side effects. In fact, the widespread availability of PRP injections are already reducing tendon surgery rates nationwide. Some of that comes from the enlightened surgeons themselves who are putting aside invasive surgeries to perform these procedures on partial tendon tears in teens. In fact, we had two in the office yesterday who I know would never think of operating on this kid until he had failed a precise ultrasound guided PRP shot.
The upshot? Why do we treat our kids like pro athletes? I see an entire generation of walking-wounded 20- and 30-somethings because they are the first generation to get the same hyperaggressive surgical care as teens that we provide to pro athletes. In this case, there is no justification in 2017 to operate on a partial patellar tendon tear in a skeletally immature 13-year-old.