Knee
Meniscus Injuries in Arthritic Knees: To Arthroscopy or Not?
Modern imaging techniques like MRIs often show meniscus injuries in middle-aged or older people who suffer from osteoarthritis and knee pain. When you experience knee problems and knee pain with arthritic-degenerative changes combined with meniscus signs/symptoms, arthroscopic surgery on the meniscus is widespread and often the first choice in conventional medicine. According to the literature, an estimated 4 million knee arthroscopies are performed worldwide each year.
As manual therapists, we often naturally ask ourselves whether surgery is truly always directly necessary. And how much better do you actually feel afterwards? Was it worth it? What exactly has improved? What can surgery influence the most?
This question is not entirely easy to answer. Naturally, knee pain can have many different, mutually influencing causes. And it is not easy to distinguish the clinical symptoms of meniscus tears from osteoarthritis. [1]
In conventional medical science, clinical examinations and studies evaluate the effectiveness of different interventions or treatment methods. Care must be taken not to compare apples with oranges: only identical injuries should be compared with one another.
That is why the correct medical diagnosis right at the start is the most important thing: if it is incorrect or misinterpreted, a good outcome cannot be guaranteed because an inappropriate form of therapy might be chosen. These factors make it difficult in medicine to collect clean, exact, and truly meaningful studies.
Henry Vandyke Carter Henry Gray, Gray348-en, marked as public domain
Moreover, you as a human being are at the heart of these studies. Every single person brings their own unique physiological prerequisites, which influence the exact prognosis regarding the healing process, whether after an injury or surgery. That is why studies need clear and proper inclusion and exclusion criteria for the subjects being compared (diagnosis, age, sex, extent of Conditions, range of motion, duration of Conditions, etc.), a sufficiently large and meaningful population (with an appropriate comparison cohort), and correctly applied statistical methods and tools so an evidence-based recommendation can be made.
At BodyLab osteopathy and Physiotherapy, we searched the medical literature for reviews and meta-analyses to get a clear picture of the current state of research. We focused on four papers that deal exclusively with degenerative changes of the knee (not traumatic injuries!).
First of all, it must be said that the studies do not produce unambiguous results. In our specific case, as mentioned, it is not always easy to differentiate and diagnose meniscus problems from degenerative arthritic knee problems. [1]
Based on our papers, the following evidence appears to exist for meniscus injuries in an arthritic or degeneratively altered knee:
Regarding pain and mobility, there is no significant difference between arthroscopic surgery and conservative treatment with Physiotherapy when it comes to long-term outcomes. [2]
There appears to be no clear benefit from arthroscopic surgery compared to conservative treatment with Physiotherapy. [3, 4]
A conservative approach should be considered first-line treatment. Having surgery at a later stage after starting Physiotherapy has no negative impact on long-term progress and does not delay healing. [4]
However, it appears that certain contributing factors clearly negatively impact the outcome of knee arthroscopy for degenerative meniscus injuries: for example, pain duration (> 1 year), involvement of knee osteoarthritis, and how much of the meniscus needs to be removed. [5]
Degenerative changes (arthrosis and arthritis) that occur with age are one of the primary diagnoses and a very common cause of knee pain. And as mentioned, it is not easy to distinguish the clinical symptoms of meniscus lesions from osteoarthritis. [1]
This needs to be kept in mind, because in arthritis, due to anatomical proximity and meniscus function (see our Meniscus blog), the menisci are usually affected and damaged as well, or rather the entire functional unit of the affected joint (everything connected to it) is involved. Age-related changes in the meniscus often go hand in hand with knee osteoarthritis!
A conservative approach aimed at full mobility of your knee joint, along with targeted muscle strengthening, often lays the foundation for a positive recovery—even if it is later interrupted by surgery. That is why, as physiotherapists and osteopaths, we recommend starting with a conservative approach whenever possible and not rushing into surgery too quickly or too early.
Whenever you need us, we are here for you!
Your BodyLab team, your team for a resilient knee without premature surgery
osteopathy and Physiotherapy | Rehabilitation and Training
Zurich Altstetten
Find out more on our knee osteoarthritis page.
References
[1] The role of the meniscus in knee osteoarthritis: a cause or consequence?
Englund M, Guermazi A, Lohmander SL
Radiol Clin North Am 2009; 47:703–712.
Brignardello-Petersen R, Guyatt GH, Buchbinder R, Poolman RW, Schandelmaier S, Chang Y, Sadeghirad B, Evaniew N, Vandvik PO.
BMJ Open. 2017 May 11;7(5):e016114. doi: 10.1136/bmjopen-2017-016114.
Khan M1, Evaniew N, Bedi A, Ayeni OR, Bhandari M
CMAJ. 2014 Oct 7;186(14):1057-64. doi: 10.1503/cmaj.140433. Epub 2014 Aug 25.
[4] The METEOR trial: no rush to repair a torn meniscus.
Hwang YG, Kwoh CK
Cleve Clin J Med. 2014 Apr;81(4):226-32. doi: 10.3949/ccjm.81a.13075.
[5] Can we predict the clinical outcome of arthroscopic partial meniscectomy? A systematic review.
Eijgenraam SM, Reijman M, Bierma-Zeinstra SMA, van Yperen DT, Meuffels DE.
Br J Sports Med. 2018 Apr;52(8):514-521. doi: 10.1136/bjsports-2017-097836. Epub 2017 Nov 28.
Cover Image Credit
Henry Vandyke Carter Henry Gray, Gray352, marked as public domain, details on Wikimedia Commons
All images used here are marked as public domain; further details on Wikimedia Commons.
