Patients with chronic knee pain

Patients with chronic knee pain Blog  Physical therapy Knee pain

Is surgery the only option for those suffering
from chronic knee pain?

Chronic knee pain is a common problem that plagues much of the population. This long-term swelling or sensitivity in the joints can inhibit people, particularly older patients, from even the most everyday forms of physical activity. Climbing stairs, or even walking, can be a challenge. Most often caused by a torn meniscus or a rupture in knee cartilage, joint pain can be debilitating, causing patients to seek a variety of solutions to improve their quality of life.

For those who suffer from moderate to severe knee pain, surgery might seem like the only remaining option. With the advances made in physical and occupational therapy over the last decade, this is most likely not true anymore. Recent studies have shown that physical or occupational therapy can often be a more effective, less invasive way to decrease symptoms than surgery.

The article published in the peer-reviewed journal Age and Ageing reported that older men were most at risk of future injury if they did not seek attention for chronic knee pain. This 2013 article followed researchers at the University of Sydney in Australia as they reported data on 1,587 men aged 70 and older over two years.

A portion of the men followed for this study suffered from a torn meniscus or another knee injury. After two years, these men were far more likely than the control group to report decreased muscle mass, which had previously never been observed in men. Along with these findings, the study also reported that chronic knee pain put men in their 70s at greater risk for mobility disease and back pain.

Recognizing that chronic joint pain is an issue is usually not the problem, however. Once a patient presents with joint pain, treating it is much more complicated. Arthroscopic knee surgery is the most common way to treat a torn meniscus, but a study in the New England Journal of Medicine has swayed opinions somewhat on the efficacy of surgery. Following a group of 351 patients 45 and older, some of whom seeking physical or occupational therapy, others seeking surgery, researchers reported that both options reported a similar rate of recovery. Symptoms of pain were suppressed in both, and function returned at comparable rates. Published in 2013, this recent study has shown that regular physical or occupational therapy can be as effective as invasive surgery in returning patients to their normal lifestyles.

Because of information from this study and others, surgery is clearly the more complicated and dangerous option. The benefits of physical therapy can rival those of invasive surgery requiring anesthesia without many of the unwanted side effects. Complications from surgery are common and can include infection, bleeding, and failure of the wounds to heal. If the surgery is major and requires anesthesia, complications can also arise from that. The recovery period post-surgery can be prolonged and pose the further threat to health as well. Patients who opt for surgery will have to put a pause on everything in their life.

Knee surgery is also extremely expensive. In the United States, knee surgery averages about $11,900 and is not always completely covered by insurance. As an out-of-pocket cost, this can cripple any household budget. Further complications due to the surgery will only increase the cost and financial burden on the patient. Physical or occupational therapy often produces the same, if not better, results for a fraction of the cost.

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

image

Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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