A few weeks ago, a typical 55-year-old “weekend warrior” came into my office complaining that his knee didn’t feel right. It was clicking. It just wasn’t as secure as it used to be.
I’m not talking “used to be” when he was 29, but when he was 49. He never played high school or college sports but was always active – tennis, skiing and golf. He used to jog, but he gave that up recently because his knee just wasn’t where he knew it should be.
I did my typical physical exam and took an X-ray that showed very minor changes, what you’d expect with a guy his age but no significant arthritis. So it was off to the MRI to see what was wrong.
The results were typical of men and women his age – a degenerative meniscus. That’s the padding we have in our knees that we love so much when it works. But that cushion, just like your couch cushion, degenerates with time.
The next step for this fellow was a visit to my friend, an orthopedic surgeon, who would scope the knee, trim the meniscus, clean out the debris and send him on his way.
To me this was the right treatment. Continuing medical education lectures, articles and books have taught me that the meniscus doesn’t get better (a true statement), so trimming it off would seem critical to getting this guy back into his active life.
But, lo and behold, a recent article in the British Medical Journal throws this theory out the window.
A very well-controlled study looked at 150 middle-aged men and women with an average body mass index of 26, or just slightly overweight. They all had this type of meniscus degeneration but no evidence of significant arthritis.
These men and women were put into two groups. The first group got arthroscopy of the knee, followed by physical therapy. The second group had no surgery, no scope, but did an intensive, three-day-a-week exercise program designed by physical therapists.
At 12 weeks, the no-scope group had stronger thigh muscles, which makes sense. They never had surgery so they never had to take time off from activity to recover from it, and they did their added physical therapy. When it came to function at home, work and sports, both groups were the same.
And here’s the bottom line: At two years after the initial treatment, there was no difference in pain, function in sports, recreation, home or work. With both groups, quality of life was exactly the same.
Now, some in the exercise group – about one in five – did eventually need to be scoped. So that shows exercise itself may not always be the answer. But, hey, it works for eight out of 10.
My spin: We are doing too many arthroscopies. You, the consumer, need to be given the data and a choice.
Rushing to scope when you have a meniscus that has become too frayed should not necessarily be the first step. Exercise is king and should now be considered the first choice for middle-aged people who meet the right criteria.
You might ask why hasn’t this study come out sooner? Why have we been jumping on the “a chance to cut is a chance to cure” bandwagon? That’s a complex question, but there are clearly two sides to the story.
As a clinician I like to interact, and frankly intervene, to see if I can get you better quicker. And trimming that meniscus seems to me logically the way to go. It’s a quick and easy day surgery that takes just a few weeks to recover from. Yes, you have some pain and need to work hard to get your strength back, but to me it’s just payment for freeing up that cartilage that’s frayed.
Right? No, wrong.
But many patients want this. They say, wait a minute, it’s frayed I should just get it removed. They often demand it. They want that cartilage out because it’s “bad.” They aren’t interested in just exercising with it, they think it has to come out.
Right? No, wrong again.
If you have knee meniscus degeneration and meet the right criteria – with minimal or no arthritis and not terribly overweight – then a conservative tailored exercise program may be the right choice. It’s an option we clinicians need to give more credence than we have been. Stay well.
Dr. Zorba Paster is a family physician, professor at University of Wisconsin School of Medicine and Public Health, and host of the public radio program “Zorba Paster on Your Health,” which airs at noon Wednesdays on 91.1 FM, and noon Sundays on 91.9 FM. His column appears twice a month in The Spokesman-Review. He can be reached at firstname.lastname@example.org. He loves mail.
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