Knee pain: Physical therapy over Surgery?
By Taylor Lee, DPT
An article published recently in The New York Times is an excellent testimony to one of the most over-utilized and under-whelming methods of treating chronic knee pain: arthroscopic surgery. The author, Paul Rogers, relates his personal experience with arthroscopic surgery and subsequent research into the procedure’s success rate.
Rogers, an avid jogger, tennis player, and skier in his fifties, was encouraged to undergo arthroscopic surgery when it became clear that degenerative conditions such as osteoarthritis and a shredded meniscus were not going away. He underwent the surgery, a minimally invasive procedure performed with a scope, did the requisite post-operative therapy, and was soon back to pre-surgery activities.
Within several years, however, Rogers was suffering from bone on bone arthritis in the knee, and was forced to eventually resort to knee replacement surgery.
As more and more individuals have experiences similar to Rogers’, there are increasing questions about the efficacy of arthroscopic surgery for people suffering from degenerative knee conditions or meniscal tears. The BMJ makes a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, despite its currently being the most popular procedure in use.
Arthroscopy is not recommended because osteoarthritis is a degenerative condition that will eventually cause tears to the meniscus. There are no cures for osteoarthritis, unfortunately. Attempting to surgically repair a degenerating cartilaginous tissue is non-beneficial in many cases. The tissue will continue to degenerate assuming other factors remain the same post-surgery (ie. no weight loss, no physical therapy, etc.).
So, what can be done?
A study conducted by the New England Journal of Medicine indicates that physical therapy may be just as good as surgery in terms of pain alleviation and range of motion by the six and twelve-month mark. The study followed 351 adults with osteoarthritis and meniscal tear.
Half completed a six-week physical therapy program oriented toward easing inflammation, strengthening the knee, and increasing the knee’s range of motion. The remaining half had arthroscopic surgery followed by the same physical therapy program.
At the six-month mark, both groups had similar and significant improvement in both function and pain levels.
Increasingly, exercise is being recommended over surgery for degenerative meniscal tears. A licensed physical therapist and a weekly exercise routine established in concert with one can offer better long-term results and may help delay invasive surgeries such as total knee replacement.
A physical therapist will do a thorough examination and design a program of care that will likely include exercises designed to improve range of motion and restore strength, including a gradual return to normal activity if possible.
A visit to a physical therapist once a week will provide several benefits:
1. A set of prescribed exercises that should be done several times a week, and guidance on how to do them correctly.
2. Long-term solution versus a short-term fix. Surgery is more often than not a quick fix for a degenerative condition such as osteoarthritis and meniscal tears associated with such. Surgery for this involves removal of sections of the meniscus, which is already in a state of degeneration. Physical therapy does not replace it, but it will help you retain it for as long as possible.
3. Potential assistance with weight loss. Sometimes one of the most helpful things you can do for your knees is disciplining yourself to lose a few pounds. Excess weight puts pressure on your knees and results in pain even during simple activities like walking or climbing stairs. A physical therapist can help with tips and safe exercises to assist with this.
4. Instruction on how to avoid movements and activities that exacerbate knee pain and accelerate cartilage degeneration and avoid those that are unnecessary. An APTA study reports that "Many times knee pain is associated with abnormal movement patterns that cause increased stress on the joint. Arthroscopic surgery does little to correct the dynamic factors that may be contributing to knee pain and pathology.”
Our bodies are amazing machines that are well-equipped to adapt if given time. As tears and degeneration occur in the cartilaginous tissue of our joints, leaping to undergo surgical intervention may not actually be the best option. It may be more effective to take a more conservative route consisting of physical therapy and time to allow your body to adapt to its new state of structural integrity.