Recently I had a patient come to me complaining of right knee pain which started several months ago;
The patient is a female in her mid-fifties and recounted no trauma to her knee, but has been avoiding using her right leg in such activities as walking up/down stairs or getting in/out of a chair. She also reported of difficulty with bending/straightening her knee occasionally and a feeling of “weakness” in her knee with prolonged walking. The patient at this point in time did not have a consult with her primary care physician or orthopedic at this time, but was scheduled for an appoint in about 2 weeks. Objective findings included pain with active movement of right knee, especially toward end range knee flexion and extension, decreased strength in her right knee and hip without increase in pain levels, and decreased balance/proprioception as measured by single limb stance time and compared to the left leg.
The patient was started on a range of motion and strengthening program for right hip and knee within patient’s tolerance. The second visit the patient reported of decreased pain in her knee while trying to move the covers in bed with her leg. Fast forward a few weeks: the patient has had her X-ray/MRI and saw an orthopedic doctor. The imaging revealed a tear in her medial meniscus and degenerative changes in the right knee. Per the patient, the orthopedic doctor told her she needed to have surgery in order to have less pain in her knee. At this point, I have a long discussion with my patient regarding arthroscopic knee surgery outcomes and the research which does not support meniscectomy is appropriate for all patients with tears on MRI and further still the strong recommendation against arthroscopic surgery in degenerative knees.
Ultimately, the patient opted for the surgery because her orthopedic told her she needed it. I thought for some time about this particular situation. It is not the first patient I have seen who has had a positive finding on imaging for meniscal involvement who’s doctor recommended or insisted on surgery. Up until this point in time there had only been 1 other patient of mine who opted for surgery rather than a course of conservative care or physical therapy. I began to think, “what am I doing wrong in trying to educate my patients?” “what am I missing?” Then I thought, “why are there orthopedic doctors out there recommending a surgery that is not supported in the evidence?” So for this blog post I wanted to provide some educational information regarding evidence and knee surgeries. Please do not mistake me, there are definite indications for knee surgeries and knee surgery can be successful, but surgery is not indicated for ALL meniscus injuries or degenerative knee conditions.
Below is a link to a great podcast through ClinicalAthlete where an orthopedic surgeon discusses why he has changed his practice mentality and is trying to educate the public and doctors alike regarding evidence-based practice. The other is a link to a clinical practice guideline regarding recent recommendations for knee surgery.