Saturday, February 13, 2016

Meniscus tears: Surgery or physical therapy?

You are 45 years old and the inside of your knee has been hurting during and after exercise. Recently, just walking is painful. After x-rays and an MRI, the orthopedic surgeon says you may need surgery but physical therapy may relieve your symptoms. You choose the surgery option-are you doing the right thing?

Meniscus tears: Surgery or physical therapy?


You are 45 years old and the inside of your knee has been hurting during and after exercise. Recently, just walking is painful. After x-rays and an MRI, the orthopedic surgeon says you may need surgery but physical therapy may relieve your symptoms. You choose the surgery option—are you doing the right thing?

According to recent research in the New England Journal of Medicine, you might not.

The study revealed that after one year, patients with a meniscus tear who had "sham" surgery followed by physical therapy improved just much as patients who had meniscus surgery. The patient population included individuals between the age of 35 and 65 who have degenerative meniscal tears without knee joint osteoarthritis. “Sham” surgery refers to patient who had an arthroscopic exam of their knee but no trimming or removal of the meniscus.

At first glance, one could conclude that patients did as well without surgery as those who had surgery. But did those in the "sham" group really not have surgery?

Each patient had an arthroscope placed in their knee and saline circulated in and out of their knee joint. Although nothing was done to the meniscus, the saline flush may have removed loose bodies and tissue irritants. Just flushing out the joint could have been a symptom improving treatment.

You could also conclude that patients treated with physical therapy did as well as those treated with surgery followed by physical therapy. But how do you know whether to get surgery?

The old adage of "go to the source" should be followed. Did the information come from valid research? The gold standard in research is a prospective, randomized, blinded study with a large enough study population to have a meaningful outcome. Valid and reliable outcome measures should be used—the measures used to quantify the information studied have themselves undergone scientific scrutiny.

The meniscus study was indeed a prospective, randomized, blinded study of 146 individuals who met the appropriate criteria—this is very good research. They used reliable and valid outcome measures to measure pain, symptoms, function and effect on quality of life. Some other secondary outcome measures/questions were also used. The source was a good one.

But to have surgery or not to have surgery? We have to define the study population a little bit better to see if it matches your problem.

Do you have a degenerative meniscal tear or did you experience the symptoms after a traumatic event like falling or twisting your knee playing basketball? The study only reported on individuals who did not have trauma and had degenerative tears occurring over time and with age. So if a traumatic episode resulted in your knee pain, the conclusion of this article only partially applies.

Do you have knee joint osteoarthritis? Again, the article only looked at patients with degenerative meniscal tears without knee joint osteoarthritis.

We also should consider other literature similar to the recent article. Never make a decision based on one piece of literature, even if it's well done. The conclusions of good research should always be respected but one should wait for others to perform similar research and determine if the conclusions are similar.

So what other literature is out there to help us determine if you should have surgery? Plenty of good morsels:

A study in the July 2013 American Journal of Sports Medicine used an almost identical patient population and compared those treated with physical therapy to those undergoing a partial meniscectomy and physical therapy. The author found at 2 years post intervention, there was no significant difference between the two groups in pain and function.

Another study published in the May 2013 New England Journal of Medicine found no difference in outcomes in patients with a meniscal tear and osteoarthritis if treated with physical therapy compared with arthroscopic surgery and physical therapy.

A third study was published in 2013 using a similar patient population and came to the same conclusions. These three studies were of the highest quality.

So, the answer to "should you get an arthroscopic meniscectomy if you have a degenerative (non-traumatic) meniscal tear without or even with some level of osteoarthritis" is: only after you've attempted a short course (6-8 weeks) of appropriate physical therapy and don’t improve. This was the conclusion of each of the studies mentioned. Before you jump on the operating table, try physical therapy!

Marty Kelley is an advanced clinician and site manager for Penn Therapy & Fitness at Penn Presbyterian Medical Center. He is the past-president of the American Society of Shoulder and Elbow Therapists. He writes about therapy technology and new research.

Read more Sports Doc for Sports Medicine and Fitness.

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J. Ryan Bair, PT, DPT, SCS Founder and Owner of FLASH Sports Physical Therapy, Board Certified in Sports Physical Therapy
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Desirea D. Caucci, PT, DPT, OCS Co-owner of Conshohocken Physical Therapy, Board Certified Orthopedic Clinical Specialist
Michael G. Ciccotti, M.D. Head Team Physician for Phillies & St. Joe's; Rothman Institute
Julie Coté, PT, MPT, OCS, COMT Magee Rehabilitation Hospital
Justicia DeClue Owner, Maha Yoga Studio
Peter F. DeLuca, M.D. Head Team Physician for Eagles, Head Orthopedic Surgeon for Flyers; Rothman Institute
Brittany Everett Owner, Grace & Glory Yoga Fishtown
Joel H. Fish, Ph.D. Director of The Center For Sport Psychology; Sports Psychology Consultant for 76ers & Flyers
R. Robert Franks, D.O. Team Physician for USA Wrestling, Consultant for Phillies; Rothman Institute
Ashley B. Greenblatt, ACE-CPT Certified Personal Trainer, The Sporting Club at The Bellevue
Jon Herting, PT, DPT, CSCS, HFS, USAW Physical Therapist, Partner at The Training Room
Eugene Hong, MD, CAQSM, FAAFP Team Physician for Drexel, Philadelphia Univ., Saint Joe’s, & U.S. Lacrosse
Brian Maher, BS, CSCS Owner, Philly Personal Training
Julia Mayberry, M.D. Attending Hand & Upper Extremity Surgeon, Main Line Hand Surgery P.C.
Gavin McKay, NASM-CPT Founder/Franchisor, Unite Fitness
Heather Moore, PT, DPT, CKTP Owner of Total Performance Physical Therapy, North Wales and Hatfield, PA
Justin Shaginaw, MPT, ATC Athletic Trainer for US Soccer Federation; Aria 3B Orthopaedic Institute
Thomas Trojian MD, CAQSM, FACSM Chief of the Division of Sports Medicine at Drexel University
Robyn Weisman, ACE-CPT B.S., Exercise Science & Physiology, Certified Personal Trainer, Fitness and Lifestyle Coach
Sarah M. Whitman, MD Sports Psychiatrist; Clinical Assistant Professor, Drexel University College of Medicine
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