What to Know Before Getting Orthopedic Surgery: A Physical Therapist's Perspective

Prefer to listen instead? This article is adapted from Episode 10 of my podcast, Candid Conversations with Dr. Kelsey. Click the button to listen to the full episode, or continue reading below.

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I've been a physical therapist for five years now, and in that time I've helped rehab hundreds of people recovering from orthopedic surgeries like joint replacements, rotator cuff repairs, and ACL reconstructions. I've also helped many of those same people navigate disappointment with their surgeries because of a mismatch between what they expected—or what they were told—and what recovery actually looked like.

I'm not trying to throw orthopedic surgeons under the bus. The reality is that after performing your surgery, they're realistically only going to see you for about 10 minutes once a month, if that. But you're probably going to spend around 8–12 hours each month with your physical therapist.

We're the ones with a front-row seat to your entire recovery process. We see what recovery actually looks like after the surgery, how difficult rehab can be, and how long it really takes to get back to the activities you enjoy.

So here are the things I wish everyone considering orthopedic surgery understood before making that decision. Having realistic expectations before surgery can give you the best chance of a successful outcome.

Surgery Isn't Always a Shortcut

One of the biggest misconceptions I see is that people think surgery is a shortcut.

Sometimes it is, but only in terms of the total recovery timeline.

Take an Achilles tendon rupture, for example. Depending on how it ruptured, your goals, and several other factors, surgery may allow you to get back to a higher level of function sooner than non-operative treatment. In those situations, surgery can absolutely be the right choice.

But surgery is never a shortcut when it comes to effort.

A lot of people think they'll get the surgery instead of rehab, and then everything will be back to normal. Even when they're told they'll need rehab, I don't think many people fully understand what that actually means until they're living through it.

It's similar to becoming a new parent. Before my child was born, people told me how difficult the newborn stage would be. I thought I understood what they meant, but it wasn't until I experienced it myself that I realized nothing could have truly prepared me for it.

Rehab after surgery is often the same way.

You can learn about the process beforehand, but it isn't until you're doing the exercises, dealing with the discomfort, and slowly rebuilding your strength that you appreciate how much work recovery really involves.

If you have a choice between getting surgery or non-operative management of your injury, you need to consider the entire recovery process. Think about how long it will take not only for the tissue to heal, but also how long it will take to rebuild the strength and mobility you'll lose while your body recovers. Because even though surgery puts tissues together much faster than your body will naturally, there is still a healing process you have to go through post-op for the surgery to be successful. And sometimes the time it takes for that to happen is not much faster than just waiting for your body to heal on its own.

Be Wary of Getting Surgery Only to Improve Pain

I want to be clear that I'm not trying to trivialize pain. I have a front-row seat to what people are experiencing every day, and I know how much pain can affect your quality of life.

But if pain is the only thing you're struggling with, it's worth taking a step back before deciding on surgery.

Let's use the shoulder as an example. Imagine you're still able to reach overhead, lift weights, work, and do everything your shoulder normally does. The only problem is that it's painful.

If you're considering surgery only to improve that pain, you have to remember that surgery causes a different kind of pain.

In other words, by getting surgery, you’d be causing pain to improve your pain.

One of the reasons I see people become disappointed after surgery is because they expect the surgery to take their pain away immediately. Instead, they wake up with surgical pain, and if they had a repair, they often can't use their arm for the next several weeks while the tissue heals.

The same thing can happen when people decide to have surgery based primarily on what their MRI or other imaging shows.

Let's say you get your shoulder checked out because it starts hurting, but your pain is only a 1 or 2 out of 10. You're still able to lift overhead, exercise, and do everything you want to do, but your imaging comes back showing a rotator cuff tear.

In that situation, it's important to weigh the consequences of both options.

If you continue without surgery, maybe you have some mild discomfort but you're still able to use your shoulder normally.

If you choose surgery, you'll have to deal with surgical pain on top of temporarily losing the use of your arm as the repair heals. And there's no guarantee you'll immediately feel better after all this.

Sometimes surgery is still the right decision. I've also worked with people who completed several months of high-quality physical therapy, made little or no progress, and then felt significantly better after surgery. 

But I think a lot of people become so focused on "fixing" what the imaging shows that they don't fully consider what recovery from the surgery actually involves.

My point isn't that people should avoid surgery.

My point is that if pain is your only limitation, and you haven't already tried quality physical therapy, you may be setting yourself up for disappointment by jumping straight to surgery.

That's especially true because surgery isn't just repairing tissue. It's introducing controlled trauma that your body now has to heal from before you can start rebuilding your strength and mobility.

Surgery Is Controlled Trauma

One thing I think a lot of people don't realize is that surgery is still trauma; it's controlled trauma, but it's trauma nonetheless.

Even though the goal of surgery is to repair something that's injured, you're still being cut open with your tissues poked and prodded by the surgical instruments. Your body doesn't know the difference between a planned surgery and an injury; it simply recognizes that it needs to heal and starts that process.

I think this is one of the reasons people are often surprised by how they feel after surgery. Since something was "fixed," they expect to feel better immediately. 

In reality, it's common to feel worse before you feel better.

Take a degenerative rotator cuff tear, for example. Maybe your shoulder has gradually become painful over several years, but you can still use your arm for most daily activities. If you decide to have surgery to repair that tear, you're introducing a new trauma to the shoulder that wasn't there before. Even though the repair may ultimately help, your body still has to recover from the surgery itself before you can experience those benefits.

That's why it's important to remember that you’re not skipping the healing process just by getting surgery.

The first few weeks after surgery are often spent allowing your body to recover from the procedure itself before you can really begin rebuilding your strength and mobility.

Recovery Takes Longer Than Most People Expect

I've seen many people who genuinely expected to be back to normal a week or two after surgery. Even if their surgeon or physical therapist told them recovery would take longer, I don't think it's something most people fully understand until they're living through it.

For procedures that don't involve repairing tissue (i.e. "clean-up" surgeries) recovery is often quicker. Depending on the surgery and how you were functioning beforehand, some people recover within a few weeks.

But even then, your body is still recovering from surgery.

The tissues have been irritated, your body has started an inflammatory healing response, and those tissues need time to calm down. If you try to do too much too soon because you think you should already be back to normal, you can end up repeatedly irritating those tissues and making recovery take even longer.

Repairs are a different story.

For surgeries like tendon or rotator cuff repairs and ACL reconstructions, I generally tell people to expect at least three months before they're functioning well in everyday life.

And when I say "everyday life," I mean things like carrying groceries, lifting pots and pans, walking comfortably, and returning to work (depending on your job).

I do not mean returning to CrossFit, triathlons, Olympic weightlifting, or other sports.

Returning to your previous level of sport usually takes much longer.

For rotator cuff repairs, it's often closer to six months before returning to higher-level activities.

For ACL reconstructions, many athletes aren't ready to safely return to cutting and pivoting sports for around nine to twelve months.

One of the biggest mismatches I see is that people think three months means they're completely recovered.

In reality, three months is often just the point where you're getting back to normal daily life. Returning to the activities that matter most to you still requires several more months of rebuilding strength, mobility, endurance, and confidence.

The “Messy Middle”

Around four to six weeks after surgery, many people enter what I call the "messy middle."

The excitement of finally having the surgery is gone, but you're still nowhere close to doing everything you want to do. Maybe you're finally out of the sling or walking without crutches, but you still feel weak and limited.

This is usually when people start asking questions like:

"Why can't I do everything yet?"

and

"Shouldn't I be farther along by now?"

But you're simply one or two months into a recovery process that often lasts several more months.

Unfortunately, this is also when some people start losing motivation. Once they're able to cook, drive, work, and carry groceries again, they feel like they're "good enough." They're functioning well in everyday life, but they still haven't rebuilt the strength, mobility, endurance, and confidence needed to return to everything they want to do.

Months later they'll tell themselves,

"I guess I'll never get back to where I was before surgery."

In many cases, it isn't the surgery that prevented them from getting back to their previous level.

They simply stopped rehabbing before they reached it.

Now, I don't like to promise anyone they'll get back to 100%. There are too many variables for me to guarantee that.

But I do think many people are capable of getting back to 99% if they continue doing the work. The last 15–20% of recovery often takes the most patience, but it's also where people make the biggest gains toward returning to the activities they love.

Rehab Is Often Harder Than People Expect

Many people think surgery is the hard part, but it’s actually the easy part because it's being done to you.

The hard part is the rehabilitation afterward, because now you have to put in the work.

For surgeries that involve repairing tissue, like a rotator cuff repair, the surgeon's job is to put the tissue back together. But after that, your body has to heal the repair before you can start rebuilding the strength and mobility you've lost.

I like to think of it like welding two pieces of metal together.

The surgeon is essentially putting the two pieces back together. But even after they're welded, you can't immediately pull them apart and expect them to hold. You have to let the weld cool and set before it's strong enough to withstand force.

The same thing happens after surgery.

The surgeon repairs the tissue, but your body still needs several weeks for those tissues to heal together. That's why you need to wear a sling after a rotator cuff repair, for example. The goal is to give the repair enough time to heal before the muscles start pulling on it again.

But the tradeoff is while you're waiting for the repair to heal, you're also losing strength and mobility because you can't use that body part normally.

So by the time you’re able to start moving that body part again, everything is much more difficult because of that loss of strength and mobility.

Feeling like you’ve gone backwards in terms of function right after surgery is not a sign that something has gone wrong. It's simply a necessary part of the healing process.

Surgery Repairs the Tissue, but Rehab Restores Function

One misconception I hear fairly often is that once something has been repaired, everything will automatically go back to normal.

Unfortunately, that's not how it works.

Surgery repairs the tissue. But just because it’s repaired doesn't mean your strength, mobility, and endurance will be automatically restored.

Think about a rotator cuff repair.

The surgeon might repair your rotator cuff, but that doesn't instantly make the rotator cuff muscle strong again. In fact, because your shoulder has been protected while the repair healed, it's usually much weaker than it was before surgery.

The same thing happens with mobility.

In the early stages after surgery, we intentionally avoid being too aggressive with stretching because we don't want to put too much stress on a healing repair. That means it's normal for your shoulder to become a bit stiff while you're protecting it. 

But once the repair has healed enough to withstand some force, you’re now able to start rebuilding your strength and range of motion through physical therapy.

Surgery Doesn't Guarantee You'll Return to Your Previous Fitness Level

Even if your surgery is technically successful, it doesn't automatically mean you'll return to the same level of activity you were at before your injury.

By the time many people have surgery, they've already spent weeks or months modifying their workouts or avoiding certain activities because of pain. Their strength, endurance, and overall fitness have already started to decline.

Then, during the early stages of recovery after surgery, you're naturally going to lose even more strength and fitness because your body is focused on healing. So once everything has healed, your baseline is now lower than it was before your injury.

Just because the tissues have healed doesn't mean you're automatically going to be able to jump back to your previous level of strength or sport right away. It will take work to return there.

I saw this firsthand with one of my Olympic weightlifting clients. She had an elbow injury and spoke with me, her orthopedic surgeon, and even got a second opinion from another surgeon. After weighing the pros and cons, everyone agreed that trying non-operative treatment first made sense. If she wasn't happy with her progress, surgery would still be an option later.

She chose the non-operative route.

After gradually returning to lifting and progressive strengthening, she is back to her previous personal records a year later.

That doesn't mean surgery wouldn't have worked for her. It simply highlights an important point: whether you recover with surgery or without it, returning to your previous level will still take time and consistent rehabilitation.

Surgery is not a requirement for returning to a high level of performance if you have a choice between surgery and non-operative management.

If you don't have surgery, rehabilitation is your treatment.

If you do have surgery, you still need rehabilitation afterward.

Either way, if your goal is to get back to being active or return to your sport, rehab is what gets you there.

The Importance of Having a Return-to-Sport Plan

This is especially important if you're trying to return to CrossFit, triathlon, HYROX, Olympic weightlifting, or another sport.

One thing I see happen a lot is that people reach the point where they're independent in everyday life and are told they're cleared to go back to the gym.

But they aren't told how.

I can't tell you how many people I've met who said something like, "My physical therapist told me I could go back to the gym, but I don't know where to start."

Being cleared to exercise isn't the same thing as having a plan to return to your previous level of fitness safely.

A return-to-sport plan is still a part of rehab.

It just doesn't look like the early stages of rehab.

Instead of focusing on protecting the repair, you're now rebuilding strength, power, endurance, and sport-specific skills while gradually increasing the demands placed on your body.

That's why I think it's so important to work with someone who understands both rehabilitation and the physical demands of your sport, whether that's a physical therapist who specializes in return to sport or a knowledgeable coach who understands how to safely progress you.

The goal shouldn't just be getting you back to everyday life.

It should be getting you back to doing the things that matter most to you.

Conclusion

At the end of the day, surgery can absolutely be the right decision.

But before making that decision, I think it's important to also have a conversation with a physical therapist who understands what recovery actually looks like.

Physical therapists are who guide your recovery and rehab.

We’re the ones who witness the aftermath of your surgery: the challenges, the setbacks, the progress, and ultimately what it takes to get back to doing the things you enjoy.

Having realistic expectations won't necessarily make recovery easier, but it can make the difficult parts of recovery feel much less discouraging because you'll understand that they're a normal part of the process.

If you're an active adult preparing for surgery or trying to return to CrossFit, triathlon, HYROX, or another sport afterward, I'd be happy to help you build a plan that gets you beyond simply being "cleared" and back to performing at the level you want.

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