The Treatment Gap: Is Surgery Really Your Only Option? with Dr. Aneesh Garg

Transcript

Speaker labels are inferred from the caption export’s turn markers (a short question is Nicole, the practice manager; the rest is Dr. Garg).

Hook: Is surgery really your only option? Once you operate, there is no coming back 0:00

Dr. Garg: Welcome to the Regen Doc podcast powered by DynamicAthlete.com. I’m your host Dr. Aneesh Garg. I’m Yale trained, Andrews trained, and a two sport US national team doctor here to help you make sense of regenerative medicine. Is surgery really my only option. Your surgeon might have told you that. And I’m not saying that you may not end up there, but there are a lot of other things that we can talk about before you go down that road. And remember, once you have surgery, there’s no coming back from it. So, you better make sure that’s the option that you want and need. I’m your host, Dr. Aneesh Garg, the Regen Doc, and we’re going to get into it. It’s variable every time. I don’t even there’s no consistency to it.

Why didn’t my doctor mention alternatives? Second opinions and when to walk out 0:49

Nicole: So, I have a couple questions for you. Why didn’t my doctor mention any alternatives before recommending surgery?

Dr. Garg: Yeah, I think I think it’s a really good question. Right? When patients go to a doctor, they’re hoping that they’re going to get every explanation and give get every option. They’re they’re relying on them to give them that information. And I think the challenge is there’s a lack of deep understanding of what regenerative medicine can do. So the default is well, I don’t want to talk about it. there’s a subject in our clinic that I don’t know, we go and try and find somebody that can help them. And so in those scenarios where people know that there are non-surgical options to treat things, they talk about physical therapy, they talk about some of these other things where they can make a really big impact and and and really really make a difference. So I think part of the challenge is the lack of deep understanding. That’s one. And then you get into, okay, I think I understand the basics. And then how do I determine what’s good? Does it really work? What’s what’s going on with it? And I think that’s the challenge. And so if you’re not trained on it and you don’t feel comfortable with it and say, well, there’s no other options for you, then I think that’s where it’s limited. And I think when you are getting surgery or looking at surgery, I would look at other opinions. And I said this where if somebody begrudges you for getting a second opinion, I’ll tell you guys this. If somebody begrudges you for getting a second opinion, they get their feelings hurt or whatever, walk out because they’ve made it about themselves and not you. We see a ton of second, third, fourth opinions in our office. And I remember every time when somebody asks me, “Okay, thanks for your input. I’m going to go get another opinion.” I say, “Great. Maybe they’re going to see something I don’t see.” And then you let me know so we can take care of you in totality. So I think that’s really a big thing in terms of options and why people are not recommending this before surgery.

The treatment gap: injury, a little PT, then surgery (the Underpants Gnomes) 3:25

Nicole: Okay. If I’m not ready for surgery, does that mean I just have to manage the pain?

Dr. Garg: I think that’s where people fall in this treatment gap. I think I think this is where people fall in the treatment gap where it’s injury, maybe some physical therapy and then surgery. This is where this is where I talk about this and you know our our practice is in Colorado. So, one of the more well-known Colorado based shows is South Park. And I always use this example where there’s an episode where they talk about the Underpants Gnomes. Can I talk about that? Is that all right? Can I talk about that on the podcast here for a second? Um,

Dr. Garg: and they talk about, well, we’re going to steal underpants. Step one,

Dr. Garg: step two, and then step three is profit. Nobody knows what step two is. We live in step two which is the gap, the treatment gap. That was the whole reason why I wanted to talk about that. But so it’s injury, maybe a little bit of PT and then huge treatment gap and then surgery. And I think that’s where we live is how do we get you better without surgery, right? So there are options. So, regenerative medicine options like PRP and stem cells, shockwave, there’s even working on other things that can help you avoid surgery. And then on top of that, even speed up your recovery from injuries or even your recovery postsurgery. So, there’s a lot of different things that can that play they play a role into whether or not you need to have surgery. And like I said in the open where once you have surgery, you can’t come back from that surgery. You’ve now physically changed

Surgery changes your biology: the partial ACL tear healed without surgery 5:27

your body in a way that you can’t come back from, right? And so give you an example, right? Somebody somebody breaks their collar bone typically you need to have surgery in that regard. There are some instances where you can do things and heal it non-surgically and you’ve potentially saved some I don’t like that example. Um, you know, there’s an example where if you have a partial ACL tear and you get surgery, you’ve now changed the bi you’ve now changed the biology in your knee. We’ve had we had a soccer player who came in and had a partial ACL tear and I looked at her and I said,”I don’t think you need surgery here.” I said, ‘We can we can heal this. And so we end up doing uh a series of our shockwave protocol and we end up doing stem cells and PRP combo into that torn ACL and she’s been doing great. And so, you know, we we get her into PT afterward and we have our whole recovery component afterward. But there’s an example that this is a mid20s female who had a partial ACL tear that still had fibers and part of her ACL intact where we could make a difference. So now we have not fasttracked her to arthritis or some of these other things that you can that you can get postsurgery uh especially after an ACL tear. So I think that’s a huge impact that you can that you can make if you delay some of the surgeries and and the surgery will always be there. It’s not like somebody’s going to say well I don’t want to do it for the most case for the most part but the surgery will always be there by and large. So, make sure you’ve done everything you can do from a non-surgical standpoint before you go down the surgery path.

Nicole: Great. How do I know if I’m actually a candidate for regenerative medicine instead of surgery?

Dr. Garg: Uh, so let me go back. So, I’m going to end I want to put this in before you before you ask that question. So, um, we have a lot of really good information on our website. So, if you go to DynamicAthlete.com, read up about some of these non-surgical options, get yourself acquainted with some of the things that you may have never heard of, and then see if it’s a good fit for you, and certainly happy to help, but really educate yourself before you dive fully in there.

Am I a candidate? It starts with the right diagnosis 8:09

Dr. Garg: Great. Question three, how do I know if I’m actually a candidate for regenerative treatments instead of surgery? I think it comes down to an evaluation. You got you have to know what you’re doing to know if the person in front of you is a true candidate. I think the first and foremost thing for any treatment, whatever you’re doing, it could be even orthopedic surgery, you have to know what the diagnosis is. And if you get the diagnosis wrong, then you’re going to have significant consequences down the line. We saw a patient today before we came on the podcast here. She had been told that she had thoracic outlet syndrome. I’m not going to get into it. They they took out a pec muscle thinking that it would relieve her symptoms. They took out a muscle and it didn’t help her. She went to go get another opinion and they said, “You don’t have thoracic outlet syndrome.” So, imagine going and getting a muscle removed that will now have downstream effects because they got the diagnosis wrong. And I think that’s a that’s a huge challenge, right? where we did a little bit of work with her today and she was 50% better just after a small little diagnostic treatment in terms of what we were doing. So I think and again for me it was about targeting the right area and I told her I said I want to see you back in a couple of days because I want to see how you responded before we jump into PRP before we jump into stem cells before we’re jumping into shockwave whatever everything else that we have in our office. I think you have to make sure you’re doing things for the right reason. Otherwise, you’re destined to fail. You may get lucky one, two, a hundred times, but eventually you’re going to fail if you’re not getting the right diagnosis and you’re not really hunting for what’s wrong. Right? And I think that’s the piece that gets me super fired up. I love going to hunt for what’s wrong. I don’t hunt in real life, but boy, when we’re in the room, that’s what that’s all I care about. And so when we teach our students and we all we try to change the way people think in a way where what’s the problem? What are we trying to get after here? And then how do we solve it? So I think that’s where the candidacy of somebody for regenerative medicine is the same way from a surgery standpoint. You have to know what the problem is and then what are the solutions to that. So, um I think really really everybody’s a candidate, but is it the right thing to do? And I think that’s that’s where some of that expertise comes into play. And I think I think that’s really a big thing. I I give you a story where we had a woman who called on behalf of her collegeage son. She was in Texas and our clinic’s in Boulder, Colorado. And so, so she called, she said, you know, I know he has a fracture and I know you can help heal and don’t you do stem cells and PRP to help him? You know, does he really need to have surgery? And I said, yeah, of course we do stem cells and PRP all day, every day. And and in this situation here, your son needs surgery. He had a depression in his fracture and it was a surgical indication. And so for me, he was going to be better off getting surgery. and certainly we can help him afterwards. So to the financial detriment of our clinic, I told her, I said, “Please don’t do this. I think your son’s going to be better off getting surgery here.” And and that’s the path forward. And I think you have to look out where would you do this on your own family member or not, right? Like would you have your own family member go through this process or an alternative process? And that’s sort of the way that we approach it. I mean, from our standpoint is how do we make sure that we’re doing things for the right reason. So, that’s how you know if you’re a good candidate for regenerative medicine or surgery. And I think the more questions you can ask and be prepared and talk about, is this just masking my symptoms much like a steroid injection does, or are we trying to take care of what the problem is? And I think once you can figure that piece out, then I think that’s really the how you get to the bottom of of what the problem is and then how you get to the solution.

Buying back time: ACL recovery, race season, gardening season 12:55

Nicole: Great. Question four. I’ve heard you say that regenerative medicine is buying back time. Can you explain what you mean by that?

Dr. Garg: It’s one of my favorite phrases that I say all the time in the clinic. If used correctly, regenerative medicine can buy back time. I’ll say it to you guys even just looking at that. If used correctly, regenerative medicine can buy back time. What do I mean by that? Imagine this ACL tear that we were talking about. We’ll stick to that one. Imagine you’re going to get an ACL repair and you’re looking at six to nine to 12 months of recovery versus what we’re doing. And can we get you back in three months because now we’ve healed that tendon. Sorry. Now we’ve healed that ligament. It’s an ACL. It’s a ligament. So now now we’ve healed that ligament and now you’re ready to go. And so we’ve now just bought back three months. So what’s your most valuable resource? It’s your time. And so if we’re able to buy back time, literally, then that’s what we’re able to do. So, imagine if you’re if you’ve got imagine that you’ve got a race coming up and you need six weeks to train, but you’ve got an injury that has been bugging you for months or even years and you don’t have time to let this continue to linger because it’s affecting your training. What if we were able to get you back in six weeks when you come and see us 12 weeks before your event and then it gives you six weeks to train and then you’re right on schedule or you’re just trying to limp along and trying to get through. A lot of times what we do in our clinic is are we just trying to compete or are we trying to win? I think I think you show up to win, right? I mean, anybody can just show up to to be a part of it. I think the big thing is what’s the difference between getting you on the podium where you can make money or finishing 10th. And I think that for us is our drive. That’s the thing that we go after quite a bit. So, it could be it could be an Olympian, could be a professional triathlete, or it could be somebody who’s has something else that’s going on that’s important to them. I’ll tell you the very first person that we did our pro procedure on. So the very first person that we did a procedure on after starting dynamic athlete was a woman who I told in her in her I don’t want to I don’t want to age her when she listens to this but let’s just say a very healthy uh late 50s we’ll say uh late 50s female who came in and said you know my knee’s bothering me and we took a look at her knee scanned it with the ultrasound And I told her, I said, “I think you need PRP into your patella tendon. You got some thickening there. I think this is going to really help you out and I think this is this is the pathway.” I said, “You know, you let us know what when would work for you.” I said, “You know, we’re still figuring out our clinic and and make sure that we had everything that we, you know, needed.” And she asked and she said, “Well, do you have everything you need?” And I said, “Well, technically yes, but we were in a temporary space and and everything like that.” And and she said, “Well, okay, let’s do it. And I said, “You don’t want to wait. You want to make sure like we’re in our new space and everything like that.” She said, “No, gardening season’s coming up.” So that’s her season. Injuries are injuries. I think if gardening season’s important to you and you want to be right for gardening season, what’s the difference between gardening season and coming up for your soccer season? To me, there’s no difference. it’s what’s important to that person is the same as what’s important to the other person. So that’s where having an understanding of your people and understanding what they’re trying to get ready for is huge. And that’s when we’re buying back time. It’s one of my favorite phrases, if used properly, regenerative medicine can buy back time. And I’m not overstating it. I’m not saying it’s going to cure everything, but the ability to buy back time is phenomenal. So I’m going to play the role of

Cutting injury time: the calf tear back in 9 days 17:41

Dr. Garg: oh let me get sorry let me get into all right so we talked about that case the other component is how can we cut injury time we had a high school basketball player who had a calf tear seen on ultrasound that’s about a three to six week injury and we used our dynamic shockwave plus protocol and he was back playing in 9 days. So much so that we scanned him again and the tear was gone. His father was sitting there and he couldn’t believe what had happened. And had he not seen the original one and the followup, he would have said there’s no way. But again, right, you’re doing you’re trying to go after things and you have technology that maybe some other people don’t have access to. But that’s how we’re speeding up recovery. That’s how we’re cutting injury time in some instances by 50%. So that’s really important to me. How do I get my athlete back doing what they want to do as quickly and safely as possible? So that’s one thing. And I think that you we talked about the recovery time from a surgery standpoint. That’s another thing. There are things that we can do from a regenerative medicine standpoint in season to help people get through their season and then do something offseason that may require a little bit more recovery time. So if you’re banged up during your season and you need help and again you’re in that treatment gap, that’s where you would look at some of the things that we have to offer. And so I think that’s really a big thing. And then at the end of the day, you got to know what your person in front of you is trying to get ready for and then work backwards from there. So that way everybody’s on the same page.

Skeptical patient: insurance pays for surgery, range of motion, and the takeaway 19:33

Dr. Garg: Okay. I’m going to play the role of a skeptical patient for a minute and ask you some difficult questions. So, if my insurance is going to pay for surgery, why would I not just go that route and instead pay out of pocket for some of these regenerative treatments you’re talking about?

Dr. Garg: I think you’re going to pay either way. I think just because something’s covered by insurance with high deductibles and out-of-pocket expenses anyways in that regard. So I think you have to sort of look at it in a way where are you looking at things from a pure cost perspective rather than downtime and other associated risk factors from surgery. General anesthesia, your incision, could there be nerve involvement? What is your post recovery look like? There’s a lot of things that go into it. So it’s not without cost going down the surgery route. And so my surgical colleagues, nothing against them, I think they do great work. I think when it’s indicated and I think what the challenge has become is perhaps too many people are getting surgeries that they don’t actually need. And so that’s the option in terms of of why would I pay out of pocket? And I think I think if you’re able to get a faster recovery and to be able to avoid some of those potential downfalls, I think the value in your time certainly is worth it. And so that’s a that’s a judgment call that people have to make and and certainly respect whatever situation they’re in. But I think that’s where if you want the ability to heal faster and to be able to decrease your recovery time, there are options to do that. It may not be covered by insurance. And I think insurance is designed to manage your decline, not necessarily keep you active. And so those are two different things. So insurance is there to manage your decline rather than to keep you active in most cases. So I think that’s that’s where that’s what an answer would be in terms of at the end of the day first and foremost what’s what’s going to be in your best interest. What’s the diagnosis and and what’s going to be in your best interest. So there’s no guarantee that the surgery is going to work. I think and then now you’ve had surgery and then you got to go fix something that’s still not corrected.

Nicole: Is that what you were looking for? I don’t know. Was there something else I was supposed to say on that?

Dr. Garg: No, that was good.

Dr. Garg: Okay.

Nicole: Um, so if I have limited range of motion, surgery will just fix that no problem, right?

Dr. Garg: Yeah. So, for those of you that that are in the office and you have a frozen shoulder and you’re listening to the Regen Doc podcast, the greatest indicator of post, I’ll even say procedure, be it surgery or one of our regenerative medicine procedures, the greatest predictor of postprocedure range of motion is preceded range of motion. So, we had another one today who we were talking about doing stem cells and PRP for a torn rotator cuff, a superpinatus tear, and a torn labum in the shoulder. But he couldn’t move. And I told him, I said, “I can’t do anything here. We have to get you moving first and then we can do this because if you can’t move your shoulder, no surgery, no regenerative medicine procedure is going to be helpful unless it’s targeting that component, right? So me just fixing a rotator cuff tear or or trying to heal a laboral tear won’t be beneficial unless we get that motion going. So I think that’s that’s a huge factor in that. So I think that’s you know at the end of the day for me surgery typically isn’t your only option. So when somebody says you need to have surgery here like I’ve told some other people it’s because I’ve gone through all the non-surgical options and it’s not a good fit. It’s not the other way around where let’s look at the surgical options first and then look at non-surgical options. I think that’s backwards and that’s what we’re trying to correct here and and really be a resource for people in that regard. If any of this stuff resonates with you, I encourage you to go to DynamicAthlete.com and make sure that you get yourself educated and certainly happy to help if we can. And thanks to dynamic athlete for sponsoring this podcast and um and we’ll see you next time. Thanks.