Why my surgeon apologised to me

I had an MRI on my ankle earlier this year.

The report came back with bone marrow edema, which in plain terms means some cartilage damage and an irritated, swollen patch of bone underneath it.

I went in to see a surgeon about it and he only had the report text in front of him. He did not have the actual scan images.

Working from the words on the page, he walked me through what surgery would look like. The plan he described meant going into my knee first, taking cartilage from there, and using it to repair the ankle. Two separate surgical sites, a long recovery, with a lot that could go wrong.

I sat there and felt my stomach drop.

I’m not against surgery, I had surgery on a wrist cyst last year,. but still, listening to him describe it, I could feel the fear land in my body. The problem had just gone from “an annoying ankle” to “a high risk operation and a year of my life.”

We agreed to wait until he had the actual MRI images before deciding anything.

When he finally saw the scan, his whole tone changed.

He apologised and told me that if I ended up needing surgery at all, it would be a minor procedure. One site with a short recovery. But that first I should do three to six months of proper rehab, because there was a good chance I would not need surgery at all.

Nothing about my ankle had changed between those two appointments.

The only thing that changed was his words.

The word for this is nocebo

Most people have heard of the placebo effect. You take a sugar pill, you believe it will help, and you genuinely feel better. There is real research behind this.

Nocebo is the same mechanism running in the other direction. You are told something alarming, you believe it, and your symptoms and your fear both get worse. The expectation itself changes how you feel.

It is not a personality flaw and it is not you being dramatic. I felt it in that surgeon’s office as a fit, informed adult who coaches this stuff for a living. The words did that, before I had a single piece of new information.

Now think about what usually happens with a back.

The advice is almost always avoidance

When I got an L5-S1 disc bulge in 2018, the guidance I got was built almost entirely around what to stop doing.

Do not bend. Do not lift. Be careful. Protect it. Do not load it.

And it comes with a specific vocabulary.

Degeneration. Wear and tear. Bone on bone. Worn down.

The words a scan report and a doctor use are the exact words that stick in your head when you feel your back flare up again.

I hear a version of this from clients almost every week. They come in carrying a sentence someone said to them years ago.

“Your spine is like a 70 year old’s.”

“You have the back of someone who has done manual labour their whole life.”

“Maybe you’re just someone with a bad back.”

These are actual phrases they received from doctors or physiotherapists.

They stopped running, stopped lifting, stopped picking their kids up off the floor without bracing, because a professional they trusted made it sound like the next wrong move would be the one that finished them.

The scan did not tell them that, a person did, and often that person, like my surgeon, was working from a description rather than the full picture.

What the scans actually show

Here is the part that does not get said often enough.

When researchers take people with no back pain at all, none, and scan them anyway, they find “damage” everywhere.

In one large review of people with no back pain in their life, disc bulges turned up in 30 percent of people in their twenties, 40 percent in their thirties, and 50 percent in their forties. Disc degeneration showed up in more than a third of pain-free 20 year olds, and in almost everyone by their eighties. Dehydration, small tears, height loss, the same wording that reads like a horror story on your report, is extremely common in people who feel completely fine and have never had a single episode of back pain.

Which means a disc bulge on a scan is not, on its own, an explanation for your pain. It is a normal finding for a body that has been used. Two people can have a disc herniation and 1 can be pain-free and the other in chronic pain.

This is not me telling you scans do not matter

They do, sometimes. There are situations where imaging changes everything and needs to be acted on quickly.

Loss of bladder or bowel control, progressive weakness in a leg, numbness in the saddle area, unexplained weight loss, pain that is dramatically worse at night. If any of that is going on, that is a see-someone-now situation, not a rehab-at-home one.

For the large majority of back pain, though, the scan is a snapshot of structure. It is not a list of movements you are banned from for life.

The reframe

The question people carry in is “what does my scan say I am not allowed to do.”

The more useful question is “what can my back handle right now, and how do I build it back up safely?”

One question for you this week

What was the least helpful comment someone told you about your injury? And what have you stopped doing because of it?

Hit reply and tell me.

- Conor

If you want to see how this fits into an actual plan for rebuilding, rather than just a lighter list of things to avoid, I put the whole thing together here.