- Meniscal tears are present in 35 percent of people over 50 and anterior cruciate ligament ruptures occur between 100,000 and 200,000 per year
- Rehabilitation programs and exercise may offer you the same results as surgical repair depending upon several factors
- Strong rehabilitation programs also improve strength and stability of the joint, potentially reducing future injury
The knee is the mostly commonly injured joint by athletes, accounting for 2.5 million sports-related injuries seen in the emergency department annually. Meniscal tears occur in 35 percent of people over the age of 50.
Ruptures of the anterior cruciate ligament (ACL), important to stabilizing your knee, occur in 100,000 to 200,000 people each year. Knee injuries may be treated by a wide range of clinicians, from orthopedic surgeons to internal medicine physicians or Physical Medicine and Rehabilitation Specialists.
Your knee may suffer from an acute or traumatic injury or, through overuse, you may experience degenerative changes to your meniscus. How you treat these injuries may have an impact on your ability to return to your normal activities, and whether you experience degenerative arthritis in the future.
A recent randomized control trial demonstrated the effectiveness of using a structured exercise program to rehabilitate your knee either prior to surgical repair, or in many cases, instead of a surgical repair.
To take full advantage of rehabilitation it’s important to understand how the knee works and what key factors are evaluated to determine which option is best for your unique situation.
Anatomy of Your Knee and Meniscal Tears
Three bones meet at your knee to form the joint that is the largest and considered the most complicated joint in your body. Although your knee is a hinge joint, it must not only bend and be flexible to allow walking but also stable to allow you to stand stationary.
Between your thigh bone (femur) and shin bone (tibia) are two wedge shaped pieces of cartilage. The function of these tough and rubbery pieces are to cushion the two bones and keep them from rubbing against each other. These pieces are called your meniscus.
The menisci have blood supply to the outer edges but this supply rapidly declines as you move further toward the center of the cartilage located directly between the two large bones. Your menisci can tear in a number of different ways from either an acute injury or from degenerative changes over time.
The number of surgeries done each year to repair a meniscus tear has been on the rise. Recent findings in the American Journal of Sports Medicine demonstrated that meniscus repairs increased 100 percent between 2005 and 2011.
Additionally the research demonstrated that patient pain may not have been related to the meniscal tear in the first place.
The researchers found patients experienced pain relief despite the fact that the tear did not heal after surgery. The lack of healing was discovered during a follow-up arthroscopy. What did appear to relieve pain and improve function was immobilization and physical therapy.
Study Demonstrates Effect of Exercise Versus Surgery
Two studies demonstrated the effectiveness of using a structured physical therapy program to either eliminate the need for surgical repair or to improve outcomes when therapy was done prior to surgery.
In the first study, researchers followed participants for five years with minimal follow up loss. The study participants had suffered an ACL injury. The researchers found that results between those who had surgical repair and those who were treated with rehabilitation alone were near identical.
Another study released in 2016 followed participants for two years who had suffered a meniscal tear in their knee. Again researchers found exercise and rehabilitation in middle-aged patients with knee damage was as effective as a meniscal surgical repair, which is an outpatient procedure.
Researchers estimate that 2 million people worldwide undergo arthroscopic surgery every year. But in their review of the literature, researchers did not discover benefits to the patient. This prompted scientists from Denmark and Norway to undertake this two-year study.
In this study, researchers identified 140 patients who had a meniscal tear, the majority of whom were without any osteoarthritic changes to the knee. Half underwent an intensive 12-week exercise program and the other half had arthroscopic surgery and given a home rehabilitation program.
No clinical difference between the two groups was found as it related to their ability to do daily activities, participate in sports or pain levels. Thirteen of the participants who were in the exercise-only group opted to have arthroscopic surgery during the study, but didn’t experience any additional benefits.
Additional Benefits of Exercise Versus Surgery
Arthroscopic surgery is considered a low risk procedure. The most common serious side effects are deep vein thrombosis, infection and pulmonary embolism, occurring only 0.4 percent of the time.
However low risk this procedure may be, surgical repair increases medical costs, insurance costs and doesn’t appear to produce superior results. On the other hand, a strong rehabilitation exercise program does produce increased strength in the large muscles supporting the knee joint.
In the most recent study, researchers tested the quadriceps (thigh) muscles of the participants at baseline, three months and 12 months.
They found the individuals who underwent rehabilitation not only experienced similar results to those who had arthroscopic surgery, but also exhibited increased strength. The authors, quoted in Science Daily, said:
“Supervised exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term.
Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no radiographic evidence of osteoarthritis to consider supervised structured exercise therapy as a treatment option.”
Strength improvements were demonstrated in the first 12 months of the study, but were not evaluated during the remainder of the study. Improved strength in the knee joint may reduce your potential for further injury and may also improve your ability to perform daily activities.
A placebo effect happens when you think you’re being treated with something, but the medication you’re given doesn’t have any physiological effect. This video describes what may be happening in your brain when you take a placebo. To gain approval by the U.S. Food and Drug Administration (FDA) a medication must prove it is more effective than a fake drug or placebo. However, when approving medical devices or surgical procedures for treatments, this proof is not required.
In 2002, research published in the New England Journal of Medicine proved the results people experienced from arthroscopic surgery for osteoarthritis were no better than those results you would expect from a placebo.
In another trial, conducted with 146 patients who experienced a meniscal tear without osteoarthritis, researchers found that a sham surgical procedure had the same results as those who underwent a meniscal repair. The study evaluated the participants over a 12-month period and found no significant difference between the groups.
The study proving the placebo effect in arthroscopic surgeries for osteoarthritis occurred in 2002. Unfortunately, to date this information has not changed the number of arthroscopies performed, costing insurance companies and individuals over $3 billion each year for a procedure that produces results individuals may experience with physical therapy and rehabilitation alone.
Consider These Important Factors Before Surgery
If you would like to consider a surgical option for your injury there are several factors that may improve or reduce the likelihood of a successful outcome.
While you may have changes to your meniscus on an MRI, if you don’t exhibit pain or functional changes to your gait, surgical repair is likely not necessary. Sports medicine physicians use a “duck walk” to evaluate the impact knee injuries have on your stability and strength. Squat and walk like a duck. If you aren’t able because of knee pain or weakness, consider a rehabilitation program to improve your joint strength and reduce pain.
Your weight is a significant factor in determining the potential success of a surgical repair. For instance, research has found significant changes in the curvature of your knee joint within the first three months after injury with an increased body mass. The results found those who underwent surgery experienced greater flattening of the knee joint than those who used rehabilitation without surgical intervention when their body mass index was higher.
•Size and Placement of the Tear
The reduced blood supply to the meniscus in the center of the knee increases the likelihood any surgical repair will not heal or will fail. The size of the tear and the placement — whether in the center of the meniscus or along the outer edges with greater blood supply — impacts the decision about surgery.
Repair of the meniscus has a greater success rate in younger patients with peripheral tears near the capsular attachment that are either horizontal or longitudinal. Even in these cases, success depends on compliance with post-operative exercise and rehabilitation, including non-weight bearing and bracing.