”I don’t deserve this award, but I have arthritis and I don’t deserve that either.”
-Jack Benny
Before I dive into the findings of a recent New England Journal of Medicine study and how this connects to what is called “conservative treatment” (ie; non-surgical), here is a brief description of the medical terminology needed to understand the results and how this fits into your own treatment choices.
The two medical terms involved with this study are menisci and arthritis.
- Menisci are C-shaped cartilage structures within the knee joint which act like shock absorbers or cushions between the thigh bone (femur) and the shin bone (tibia). The menisci also provide stability with various motions of the knee including pivoting, twisting and squatting. Surgery for meniscal tears is the most commonly performed orthopedic surgery.
- Meniscectomy is surgically removing the torn part of the meniscus which takes out the “pain generator” and prevents torn pieces from breaking off and causing further injury
- Arthritis is a narrowing of the joint space associated with degeneration of the cartilage and bony structures of a joint.
Now to the findings of the study published in the New England Journal of Medicine, (NEJM, March 19, 2013 – http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 ). This study indicated that physical therapy vs surgery is no different in efficacy for the treatment of meniscal tears among patients with mild to moderate arthritis. In this well designed study, patients with an average age of 56 were randomly assigned to either the conservative treatment group consisting of physical therapy or the surgical group which was treated with a partial meniscectomy. Further results showed that 30% of the patients in the conservative treatment group receiving physical therapy “crossed over” to get surgical treatment within 6 months. At 6 months and 12 months, the conservative treatment group compared to the surgery group indicated no difference on the WOMAC pain and function scales (http://en.wikipedia.org/wiki/WOMAC ).
Furthermore, as cited in my December 2012 blog article:(http://pursuitsports.wordpress.com/2012/12/14/huh-an-introduction-to-making-sense-of-what-your-doctor-is-trying-and-failing-to-tell-you/ ), shoulder MRI’s in the general population of asymptomatic patients show a high proportion of rotator cuff tears. Similarly, 35% of patients older than 50 will have meniscal tears seen on an MRI, and 67% of them will be asymptomatic (this means that patients do not report any painful symptoms). So, it is worth mentioning again the importance of the physical examination to determine if the meniscus truly is the origin of the pain and then correlating these findings with the MRI before considering aggressive or surgical procedures.
So, what does this mean for patients? General recommendations can emphasize non-surgical treatments for meniscal tears first, as long as they do not have mechanical symptoms (ie; locking, catching or giving way). If the patient shows no improvement after non-surgical treatments or has mechanical symptoms, then considering surgical management would be the next step.
Finally, what about regenerative injections to optimize conservative treatments? There is mounting medical evidence that regenerative injections can be helpful in patients with knee arthritis, so why not engage in this non-surgical treatment for meniscal tears? At present, there are no studies in this specific population of patients who have meniscal tears without arthritis, however, I generally tell patients who want to avoid surgery that we can try non-surgical treatments as long as mechanical symptoms (knee joint locking or catching) are not present. In this New England Journal of Medicinearticle, the study participants will be followed into the future in order to answer the question as to weather surgery on the meniscus leads to a higher risk of arthritis. If this turns out to be so, then it would be another argument to treat these injuries conservatively with physical therapy and regenerative injections.
