To Knee Or Not To Knee?
I can't tell you how many times I have seen someone come in for physical therapy (PT) evaluation and stop after the 1st week when the results of their imaging come back with a meniscus tear. They immediately schedule surgery before even giving PT an honest try. Then they return after going under the knife, with the same pain and a new trauma to their knee. But what if that surgery was never "kneeded" (sorry, I couldn't help myself) in the first place?
Before everyone panics, know that I do believe surgery is helpful and can be successful in many cases. But science and personal experience have shown me it isn't appropriate all of the time. There has been some interesting research over the last few years that has shown PT to be just as effective at treating knee pain when compared to surgery when a meniscal tear is suspected to be the source of pain. And a recent article published in the journal of Skeletal Radiology may offer a clue as to why. In this study 230 knees from 115 uninjured adults were studied by MRI and 97% of them had abnormalities. Yes, you heard me correctly, 97 PERCENT! And 30% of those injuries noted on MRI were meniscal tears. (Click on the link below to see the article for more details.)
So let's think of a scenario. You are walking down the street, you fall on your knee, and you do all the good things you are supposed to do after an injury: rest, ice, etc. But it still hurts so you get it checked out by your doctor and they order an MRI. The reports shows a meniscal tear, so the doc sends you to an orthopedic specialist (aka: bone and joint doc). The orthopedist decides to do surgery, and it sounds like a reasonable idea because you have no reason not to trust this suggestion, so you go under the knife.
***Before we continue any further with this scenario let me make a very important note. Any good primary doctor or orthopedist would never proceed by immediately opting for surgery in this type of scenario. They know that PT is very successful at treating and evaluating body pain. They will always refer to PT for at least a few visits before surgery and most of the time before they even do imaging. This is also why some insurance companies refuse to pay for surgery or imaging before attempting PT. ***
Now, back to our scenario. So, what if that meniscus tear had been there for years and wasn't really the cause of your pain??? You just underwent a costly surgery, both in terms of money and time. What if you could have avoided this by getting a more thorough assessment of your symptoms and joint mechanics? Now, you need a PT.
This is where the art and science meet. A PT can do special tests, proven by research, to help determine what your source of pain might be. Maybe it's actually inflammation of the fat pad under your knee cap, or maybe the muscles around your knee became inhibited and stopped contracting correctly after you fell because your knee was so swollen. Trust me I see it all the time. To be honest, most of use have faulty joint mechanics even without an injury.
So when in doubt, if you have a musculoskeletal injury, try PT first and forego costly imaging. You might be surprised that your body had all it needed to be pain free inside it already. It just needed a little help and a high-five.
Take home message: Imaging can be very helpful but just because something shows up as atypical on the results, doesn't mean it is the cause of your pain. Try conservative methods of healing before opting for surgery.
Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI - PubMed (nih.gov)
Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI.Horga LM, Hirschmann AC, Henckel J, Fotiadou A, Di Laura A, Torlasco C, D'Silva A, Sharma S, Moon JC, Hart AJ. Skeletal Radiol. 2020 Jul;49(7):1099-1107. doi: 10.1007/s00256-020-03394-z. Epub 2020 Feb 14. PMID: 32060622