Are you over 50?
If so, you have a 1 in 4 chance of experiencing pain from degenerative knee disease.
That’s a term used for osteoarthritis.
Meniscal tears, locking, clicking, and acute onset knee pain are included.
In deciding on treatment options, you may be forced to make hard choices.
Among these is whether to undergo a type of knee surgery known as arthroscopy.
Some believe the alternative is lifelong pain. This either-or decision might help explain the high number of folks who elect surgery with hope of a quick fix.
Is knee surgery worth it?
Each year in the United States, surgeons perform more than 650,000 arthroscopic surgeries.
Each one costs an average of $5,000. That makes knee surgery a $3.2 billion business. Worldwide, each year it is performed more than 2 million times.
Over the years, researchers have tried to learn if surgery is fulfilling its promise relative to alternative treatments.
These studies serve as the basis for medical recommendations and advice.
Toward that end, a new “rapid recommendation” published in this month’s BMJ may help you decide among treatment options.
It’s based on the review of a randomized trial published in 2016 by BMJ.
A panel of 18 experts issued the recommendation. In it, they strongly suggest that arthroscopic surgery offers little to no benefit over exercise therapy.
The recommendation applies to nearly all people with degenerative knee disease.
In making their recommendation, the panel focused on patient perspective. The impact on society itself, including any cost savings for health funders, was not considered.
The authors feel certain enough in their conclusion that they wrote the following: “Further research is unlikely to alter this recommendation.”
It must be noted that the authors assumed certain lifestyle priorities regarding people’s choices and values.
Their recommendation targets those who they believe place greater emphasis on the downsides of arthroscopic surgery. Often, it was found, any benefit from surgery disappears within a year.
The downsides to surgery
Like most surgeries, arthroscopic surgery comes with a few downsides and some risk.
Among these are:
- rare but potentially serious complications from knee surgery
- a risk of complications from anesthesia
- recovery periods typically lasting from two to six weeks
- follow-up doctor visits
- time off from work following surgery
- limitations on driving and other daily activities
Healthline spoke with Dr. Loren Fishman with Manhattan Physical Medicine & Rehabilitation in New York.
He agrees with some, but not all, of the recommendations.
“With regard to osteoarthritis, I quite agree. With regard to meniscal tears, I do not agree,” he said.
Fishman went on to say that he has seen much success using arthroscopic surgery to repair meniscal tears.
Fishman said that he has also had success with more conservative, nonsurgical Platelet Rich Plasma (PRP) therapy.
Using a small sample of patient blood, platelet rich plasma is separated from other matter. It is then injected back into the patient.
In many instances the treatment appears to promote healing of the underlying physical problem.
Can’t stand the pain?
Conversely, the authors state that their recommendation is not for people who place greater emphasis and value on a small but uncertain reduction in pain or increase in knee function.
It’s also worth noting that the recommendation is not targeted toward people like Eva Doyle from Maryland.
She injured her knee in a skiing accident in 2002.
Doyle had arthroscopic surgery and it worked. That is, until she slipped on ice a few years later and had to repeat the surgery.
But now, nearly 10 years later, Doyle says her knee “now feels like [I] never had the skiing accident.”
Doyle also stated that her surgeon said that she would probably need surgery again at some point. In five years if she tried running again. In 15 or more if she didn’t.
So she “took up knitting.”
No matter into which camp one falls, it can be enlightening to learn that conservative management of knee pain may offer as much benefit as arthroscopic surgery.
Conservative management alternatives to consider include:
- waiting to see if the pain resolves on its own
- losing weight if necessary
- physical therapy
- oral or topical pain medications
Asked about the panel’s recommendation, Dr. Derek Ochiai, an orthopedic surgeon located in Virginia, suggested to Healthline that a more tempered viewpoint might be helpful.
“First you try anti-inflammatories, physical therapy, corticosteroid injections, other types of injections. I try all that first before working up to surgery. A lot of surgeons in the United States try all that first,” he said. “You try to see who can get better, as opposed to living with a locking knee or giving unnecessary total knee replacement. The surgery takes about an hour and you can go home the same day. It’s not something I would say you should never do, which is what they advocate."
Can shots help?
So, can corticosteroid injections help?
A group of researchers at Tufts Medical Center in Boston recently published a study in The JAMA Network that discounts the effectiveness of cortisone injections for knee osteoarthritis.
After two years of receiving shots every 12 weeks, no significant difference in the level of pain could be measured between knee patients and a control group that received only saline shots.
In addition, the group receiving corticosteroid shots lost more cartilage than the saline group.
The authors acknowledge the possibility that study participants may have experienced some pain relief in the three months between injections. However, the bottom line is that after two years their pain still remained.
Regarding cortisone shots, Dr. Carson Robertson, of Alpha Chiropractic & Physical Therapy in Arizona, writes “From my conservative therapy standpoint, when patients have cortisone injections during rehabilitation it always helps control the patient’s pain and accelerates their progress. Injections help create a time period where we can do more with the patient with less pain. However, cortisone without rehabilitation does not maximize the patient’s potential progress.”
The only surefire fix for degenerative knee disease is knee replacement.
This final solution is normally reserved for those who have unsuccessfully tried to resolve their pain using less drastic measures.