By Michael Hall,
Got knee pain? Think surgery is the answer? New research shows you might need to think again.
You have knee pain and you just want to get it better in the best, fastest way possible, right? Surgery would have to be the logical answer, given that it repairs the faulty structures and “fixes” the problem. Besides, it what all the AFL teams resort to when one of their players have got a knee “problem”. New research and multiple studies indicate that this may not always be the best course of action.
Knee surgery no better than sham?
The latest study was conducted in Finland on 146 patients with degenerative (wear and tear) menisci (cartilage) tears. The menisci are crescent shaped fibro cartilage disc structures that sit between the femur (thigh bone) and tibia (shin bone). They have two purposes, one to act as a cushion between the bones and two, to increase the surface contact of the bones and thereby provide increased stability to the knee joint. The classic way that they get torn is if you twist when your knee is bent. However, over time your menisci can also develop tears, especially if you have arthritis. Arthroscopies involve surgeons trimming these torn menisci and sucking out the “debris”. It is assumed that the tear is the cause of pain and that by smoothing out the jagged edges, the pain will go away.
In this study, patients were divided into two groups, one who received standard surgery and the other sham surgery, or surgery where surgeons made an incision under epidural anaesthetic, but didn’t do anything to the cartilage.
The result? One year later, both groups had the same outcomes, that of reduced knee pain. The researchers had to conclude that knee arthroscopies were no better than sham surgery.
Proven! – Physiotherapy may be just as good as knee arthroscopic surgery
This result has been confirmed by four previous studies, two proving that physiotherapy provides just as good outcomes as arthroscopies for knee pain:
1. In 2013, a study comparing the functional outcomes of physiotherapy against surgery and physiotherapy, found that physiotherapy alone provided just as good results as surgery and post operative physiotherapy.
2. In 2008, Kirkley and colleagues found the same result. That is, after comparing medical and physiotherapy with arthroscopic surgery for osteoarthritis (OA) of the knee, researchers concluded that medical and physiotherapy outcomes in terms of pain and stiffness were equal to those provided with surgery.
3. In 2002, in a landmark study in Texas, Moseley and colleagues compared arthroscopic surgery with sham surgery (i.e. the surgeons just made cuts in the patients’ knees) on 180 patients. They found no difference in self reported pain and function in a 24 month follow up.
4. In 2012, Bohensky and colleagues examined the results of all elective knee arthroscopies for patients 20 years or older with osteoarthritis of the knee from 2000 to 2009 in Victoria. They concluded that “despite the evidence questioning its effectiveness, there has been no sustained reduction in arthroscopy use for people with a diagnosis of OA.”
Given that arthroscopic surgery for knee OA cost Victorian taxpayers 180 million dollars last year, it would seem that this 180 million dollars could have been reduced.6 And this is not to mention the possible complications of superbug infections, medical mistakes, the risks involved with a general anaesthetic and the fact, the you are likely to need ongoing physiotherapy treatment for at least another six weeks.
Arthroscopic surgery an option, but perhaps NOT the first option
The evidence is clear. The management of meniscal tears depends upon the severity of the injury as well as the physical demands of the person. The reason for this is that the outer part of the meniscus has a blood supply and therefore can heal if it is damaged. In contrast, the inner, central part of the meniscus doesn’t have a blood supply and consequently cannot heal.
Hence, for small meniscal tears or osteoarthritic knees, physiotherapy has been shown to provide as good if not better results for much lower cost and much reduced risks. For optimal results to be achieved however, physiotherapy techniques and modalities must be combined specifically to optimise each stage of the healing process. Specifically, techniques must be directed towards protecting against re-injury (e.g. taping, bracing, crutches), reducing inflammation (e.g. Rest, Ice, Compression, Elevation), minimising swelling (e.g. Bodyflow), and then promoting healing and enhancing the tissue repair (e.g. Lipus Ultrasound). At the same time, function must be optimised with graduated movement (e.g. knee straightening and bending), strength (especially gluteal and quadriceps muscles), hip/knee control (with standing balance, squatting, walking, step-ups etc.) and functional/sporting activities (e.g. hydrotherapy, hopping, running etc.).
So when should you seek surgery?
Surgery is more likely to be indicated if you have sustained your injury with a severe twisting movement and are unable to continue with your activity. Other factors that may indicate whether surgery is required is if you knee is locked or has severely limited movement, has a palpable clunk or pain on minimal bending and / or there has been minimal improvement after three weeks of physiotherapy.
The final word
Please don’t misunderstand, surgery is a treatment option, but whether it should be the first or last treatment option depends upon the severity of the injury, the physical demands of the person and the outcome of physiotherapy management. Whether you have osteoarthritis or a less severe torn meniscus, physiotherapy and exercise has been shown to be just as effective as arthroscopic surgery and perhaps even more so in some cases. And with risks of anaesthetic reactions, superbug infections, drug reactions and medical complications, surgery costing about $2,000 compared to less than $1,000 for a typical course of physiotherapy, both the costs and the benefits line up heavily in favour of physiotherapy as being the treatment of choice for knee osteoarthritis and less severe meniscal tears.
For a FREE knee assessment or walking evaluation and advice, please call 1 300 BODYWISE (263 994).
1. Sihvonen, R, Paavol M, Malmivaara A, Itälä A, et al. for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group N Engl J Med 2013; 369:2515-2524
2. Katz JN1, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84.
3. Kirkley A, Birmiingham TB, Litchfield, RB, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2008; 359: 1097-1107.
4. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscope surgery for osteoarthritis of the knee. N Engl J Med 2008; 359: 1097-1107.
5. Bohensky MA, Sundararajan V, Andrianopoulos, N, de Steiger, R, et al. Trend in elective knee arthroscopes in a population-based cohort, 2000-2009. MJA. 2012; 197 (7) 399-403.
6. Brukner and Khan and Colleagues. Clinical Sports Medicine. McCraw Medical. 4th Edition, 2012.
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