Not sure exactly where to put this but I assume this is appropriate as it does pertain to training.
Is there any merit to any of the general popular-but-not-necessarily-well-informed beliefs surrounding knee ligament injuries about when surgery is necessary? Mostly thinking of non-traumatic injuries without obvious red-flag symptoms (massive swelling, joint immobility, acute infection, etc), including but not limited to:
-If the tear is in the “white zone”, there “isn’t enough blood flow” and the injury won’t heal or rehab
-If you repeatedly load and experience tweaks and setbacks (i.e. “re-injure” it), it can “build up scar tissue” and “puff up the knee”, increasing the necessity of surgery
-If it is not rehab’d “quickly enough”, scar tissue will form inoptimally and require surgery
Based on what I’ve learned from you guys and from other research I’ve read, my inclination would be to conclude that none of this is true, but this kind of info does still persist on major medical and ortho site so I’m uncertain. I assume the approach to knee pain broadly is the same as your general approach to pain, barring some perhaps more specific targeted rehab work?
Thanks a bunch for the work you do! Been happily recommending articles and your approach to the plethora of people I run into with similar issues.
With respect to non-traumatic (so-called “degenerative”) meniscal tears, none of this is accurate.
Regardless of the endless list of claims you will find on the internet, a better approach to this issue is looking at research comparing surgical outcomes (typically arthroscopic meniscectomy/partial meninscectomy) versus sham surgery or alternative strategies. You will find that outcomes are typically no different. Through this lens, you can dismiss most made-up claims about things supposedly “necessitating” surgery for this particular issue.
Thanks doc. So when is surgery typically indicated for a non-infection, if at all? I assume the general procedure for lifting/dealing with re-occurrences is the general approach common to the osteoarthritis/LBP/tendonopathy/etc articles?
Also a bonus question: you mentioned previously that you don’t discourage NSAIDS in all situations. Do you have a brief summary of when you’d okay individuals to use them in a situation related to injury recovery?
I don’t mean for this to sound snarky/dismissive, but making these decisions this is the purpose of surgical residency training.
In general, surgery is indicated when the specific surgical intervention reliably and significantly improves a patient-centered outcome (things like pain, function/disability, morbidity, mortality) when compared with non-surgical management, with an acceptable risk profile. This applies to every surgical procedure – or indeed, every biomedical intervention in existence.
If sham-controlled trials of arthroscopic meniscectomy showed that the surgical procedure resulted in significantly better outcomes (pain, function/disability, etc.), then we would be recommending said procedure. Unfortunately they do not, so we don’t recommend it, broadly speaking.
In general, yes. In fact, many of the meniscal tears found in these kinds of scenarios are likely incidental and unrelated to the person’s pain, such that the pain can often be managed like any other non-specific knee pain with improvement. Of course, the things we tell our patients around this can influence their trajectory and outcomes as well.
I believe we discussed this on our pain meds podcast, and I’ve discussed the role of meds in the podcast I did on back pain with The Curbsiders. I do not have a standard summary to provide here, but there is ample evidence of their efficacy in reducing pain. To the extent they can reduce pain to facilitate sleep, activities of daily living, and/or return to physical activity, I am fine with them - although as with all medicines, I prefer the lowest possible dose for the shortest possible amount of time, in the appropriate patient (i.e., someone without strong contraindications to use). Among NSAIDs I typically prefer Naproxen over others in most situations (again, with occasional case-specific exceptions). If someone uses them to “mask” symptoms and keep overshooting in their training, I would recommend much more strongly against that.
I appreciate the courteous disclaimer, and that makes sense – was mostly wondering if there was some broadly acute-trauma case or severity where it was typically indicated around a typical range of severe symptoms, i.e. immobility, but that’s a helpful general summary. It seems as though there are still many surgeons (at least up in Canada) willing to do the surgery despite the lack of efficacy as per the traditional pipeline of family doctor → MRI → surgery as a reaction to MRI findings, but hopefully that’s less common now than some years ago.
In general, yes. In fact, many of the meniscal tears found in these kinds of scenarios are likely incidental and unrelated to the person’s pain, such that the pain can often be managed like any other non-specific knee pain with improvement. Of course, the things we tell our patients around this can influence their trajectory and outcomes as well.
Great, good to know this follows the same pattern as other issues!
I believe we discussed this on our pain meds podcast, and I’ve discussed the role of meds in the podcast I did on back pain with The Curbsiders. I do not have a standard summary to provide here, but there is ample evidence of their efficacy in reducing pain. To the extent they can reduce pain to facilitate sleep, activities of daily living, and/or return to physical activity, I am fine with them - although as with all medicines, I prefer the lowest possible dose for the shortest possible amount of time, in the appropriate patient (i.e., someone without strong contraindications to use). Among NSAIDs I typically prefer Naproxen over others in most situations (again, with occasional case-specific exceptions). If someone uses them to “mask” symptoms and keep overshooting in their training, I would recommend much more strongly against that.
Missed that one, will have a listen! Thanks for the summary, that’s quite helpful actually and makes perfect sense. Thanks for your time!