A recent article in the New England Journal of Medicine has attracted a lot of attention… and it should. The article focused on a group of patients with meniscus tears and osteoarthritis. The goal of the study was to determine whether or not surgery was necessary when compared to a group of patients who only had physical therapy. Although it was not the best study possible, the results are encouraging…. depending on your perspective :-) Physical therapy is equally effective at treating patients with both meniscus tears and osteoarthritis as surgery is. Imagine that!
The issues, however, run deeper than those studied by the authors. Those issues include:
- Why were the MRIs performed in the first place?
- Why is it easier to get permission for an MRI and surgery than it is to get permission for physical therapy?
- Kudos to Dr Jen Gunter for her thoughts on this!
- Why do many patients expect an MRI for every joint ache or pain?
- Why do providers agree to order that MRI?
- Are we treating MRI findings— or are we treating patients?
A meniscus is a cushioning disc found within our knee. We actually have two menisci. Osteoarthritis involves the loss of “articular” cartilage from the ends of our bones. As that cartilage erodes away our bones become exposed, and when the bones on opposing sides of the joint rub together… it hurts — occasionally it hurts A LOT.
What most people in their 40s and up do not realize is that many of you have meniscus tears, and perhaps even a rotator cuff tear and yet you have no pain. Which meniscus tears hurt and why is an area we’re still studying. There are many different types of meniscus tears. Most tears are degenerative because our parts wear out… and surgery for degenerative tears without loose flaps is very rarely necessary.
If you sustain an injury and your knee hurts… you stand a really good chance of feeling better if you allow the body to heal itself. On occasion we need some assistance and that might mean a visit to your primary care doctor. Hopefully your provider can offer you some tips to set you on the path to recovery… but very rarely should an MRI be ordered (or asked for) soon after the initial injury. MRI’s should be used to confirm diagnoses… not to make a diagnosis. They are most useful if you have failed non-surgical treatment and we are considering surgery. Even in the realm of professional athlete injury management the issue of over-utilization of MRIs has gained a lot of attention .
Given the insight gleaned from this paper, your primary care doctor should likely start you in physical therapy if they suspect that you have suffered a meniscus tear, and your X-rays show evidence of arthritis. But our primary care docs are getting squeezed… they need to see too many people each and every day just to be able to keep their doors open. That leads to rushed visits, easy scripts for MRIs and premature referrals to specialists. That opens the door for a specialist to then recommend an operation based on the MRI findings… and not necessarily because they are treating you as a patient. Many variables need to be considered whenever surgery is being thought of as the primary treatment modality. Your MRI finding is but one small consideration in that “shared decision making process“.
The big picture… many patients will have meniscus tears that will marginally affect their quality of life, if at all. Not all weekend injuries require an MRI … time heals most injuries alone. Surgery is not necessary for all meniscus tears. Doctors need to commit to be willing to spend as much time talking about the non-surgical treatments for meniscus tears as they do trying to explain what the surgery entails. While surgery might ultimately prove to be the proper course of treatment to pursue for certain meniscus tear… it should only follow a course of failed non-surgical treatments for your meniscus tear and osteoarthritis.
Questions? Why don’t you come in and discuss your options. :-)
Thomas Hall says
Aloha Dr. Luks,
I am 66 and have remained in good shape as a surfer etc. in Hawaii for the last 40 years. I have recently experienced a torn meniscus. My surgeon has given me advise to not have surgery because of my meniscus showing older damage and scaring (and the fact that I have arthritis present). It has been 3 months now and my knee has gotten a bit better BUT it occasionally gives out because of pain and a feeling that something is catching between the joint. The severe pain only lasts 5 or 10 minutes and then I am only dealing with the tenderness and am able to walk again. My question is: I can’t tell what is causing the episodes. I haven’t been able to completely bend my knee over the last 3 months (without pain, popping and crackling) and I am concerned that the meniscus is catching in between my joint and causing the problem. Would it be beneficial to have the floating parts removed or is the arthritis a factor (as my doctor mentioned) that superceeds any surgery efforts?
Thanks for your help.Tom
Howard J. Luks, MD says
Great question … your surgeon is correct. Tread lightly when arthritis is present, especially if it is moderate or severe. If it is mild to moderate in severity and your instability persists then it is ok to consider an arthroscopy as long as you clearly understand that it may not work. IF the arthritis is severe and the knee is bone on bone, then an arthroscopy will not help you.
Good Luck
Iaman Alkhalaf says
Dr. Luks,
Thank you so much for spending the time to help people and provide insight. I am a 22 years old active male recently diagnosed with meniscus tear as a result of knee twisting whild doing Taekwondo in my right knee. The orthopedic surgeon suggested examining my MRI and then decide to have a surgery or not. I looked at the study linked in Dr.Jen Gunter article and it seems like the study examined the effectiveness of PT for patients above 45 years old. Do you believe that the same conclusion of the study can be applied to younger patients ? How can we draw the line between going for PT and the the necessity of having a surgery ?
Best regards,
Howard J. Luks, MD says
Usually no harm in trying PT first.
Jean Rajotte says
Hi Dr. Luks. It is a very valuable initiative to share your time and expertise to explain the pros and cons of meniscus surgery. I am a 58 years old Canadian male who had partial meniscectomy 15 years ago on my right knee after a hockey injury. Although this knee has always been more fragile or weak during training, il remains pain free. The problem is that I now experience severe pain and instability in my other knee when I make torsion moves or I am descending stairs. Just a light pain when I climb stairs. In line with your recommandations, my doctor does not anticipate the same outcome of meniscectomy on my left knee as OA is likely to be a factor now. The main question is: Can an imagery exam provides a good assessment of the OA on the joint to make a decision or should I undergo an arthroscopy to view the condition of the cartilage? Accessory question: If the surgery does not work, what are the chances that the meniscectomy procedure worsen the symptoms and the evolution of the OA?
Thanks again for your valuable opinions.
Howard J. Luks, MD says
Yes… A well performed MRI will show the status of the articular cartilage and whether or not any arthritis is present.
Lori says
Dr. Luks,
My husband has an inside left knee meniscus tear with arthritis and on small bone spur on the other side. Significant arthritis behind the kneecap.
Surgeon read MRI and the X-ray (showed arthritis).
He’s 5’9″, 400 lbs, 51 and his BMI is too high to risk knee replacement surgery. Offered every six months for a year or two cortisone shots.
He injuried it helping someone move it didn’t tear but just was like not stable (11/2015) and it healed around March 2016.
July 4, went to sit down and heard the pop in the knee and X-ray were clean except the arthritis. MRI done two weeks ago…showed the tear and the bone spur and arthritis and very little cushioning on right side of left knee.
Surgeon said no arthroscopic surgery because that will not solve issue because of the right side little cushioning. Because of that recommends knee replacement but will not do it because of BMI and success rate is 75% by year five. Suggested Bariatric surgery and then he would see.
Nothing was offered as PT or brace or not so drastic. He’s working on his weight.
Found this article and a brace (web style) on Better Braces.com.
Would the brace and getting hydro PT help?
And we know the weight loss will to
Opinion?
Howard J. Luks, MD says
PT, pool therapy could work well. It might be difficult to fit him with a brace. Weight loss and appropriate lifestyle changes ( no sugar, pool based walking, etc) are critical.
Dara says
Hi Doctor, I am usually very active and unfortunately injury prone. I ran through the pain in a half marathon in April 2016, medial left knee. Ran light miles in May. Stopped running in June because it wasn’t getting better. Biked all summer with an occasional tester run. Finally went to Doctor in September, he said he thought arthritis but nothing on X-Ray and/or maybe a slight tear to miniscus. Is there any real point of the MRI? Will the knee heal enough to exercise without pain? If I start running again will I just make it worse? Thanks for your time.
Howard J. Luks, MD says
For runners with persistent medial pain, a stress reaction or fracture is also a possibility. After a few months of persistent symptoms it’s likely time to see if an MRI helps shed light on your issue.