September 23, 2021
Experts disagree on whether it’s worth going under the knife
You felt it on your last walk when you stepped off a curb the wrong way: a sudden pain and feeling as if your knee were about to give out. Swelling and more pain followed, along with worries that you may need knee surgery.
But would it even help?
Surprisingly, most knee injuries heal without surgery, says Dr. Steven Gausewitz, chief of staff at Hoag Orthopedic Institute, Irvine, Calif.
“For example, the medial collateral ligament (MCL) and many posterior cruciate ligament (PCL) injuries can heal with satisfactory stability and function without surgery even when completely torn,” he says.
Even when ligaments don’t heal, function often returns to a satisfactory level with time and physical therapy. So they still do not require surgery, Gausewitz says.
Injuries to the meniscus (a C-shaped shock-absorbing cartilage between the bones of the knee) and cruciate ligaments, on the other hand, require surgery most frequently, Gausewitz adds. Meniscus injuries can sometimes occur with a minor twist or a major sports injury. Cruciate ligament tears may happen in contact and non-contact sports injuries or any type of major trauma.
Meniscus tears are an extremely common injury, says Dr. David Geier, orthopedic surgeon in Charleston, S.C.
“A tear of the meniscus rarely heals on its own. Someone with pain with deep knee bending or with twisting motions often cannot perform the activities that he or she would like to do,” notes Geier. “Arthroscopic surgery to trim out the part of the torn meniscus can help alleviate symptoms and might allow the person to exercise and perform other activities.”
Not all experts agree, however.
“Degenerative tears (those that occur over time) of the medial meniscus in people over 50 often don’t require surgery,” Gausewitz says.
“In fact, results can be better without surgery,” Gausewitz says. “Also, acute tears of the anterior cruciate ligament (ACL) can usually be managed without surgery as well.” Typically, surgical reconstruction is reserved for patients who do not function well and do not respond to non-surgical care, he says.
“I have seen that people with a degenerative meniscus tear who have arthroscopic surgery not only experience little relief from their pain, but the surgery itself can speed up the arthritic process,” says Robert Fay, licensed physical therapist and clinical director and owner at Armonk Physical Therapy and Sports Training, Armonk, N.Y. (The results of the Danish review actually underscore this point because the studies involved surgeries for pain caused by degenerative conditions such as osteoarthritis, not surgery to repair injury to cartilage or ligaments.)
Try Non-Surgical Approaches First
If you have pain but no catching or locking of the joint, arthroscopic surgery can sometimes worsen symptoms, Fay says. “You may do better with good physical therapy first, and down the road some may need a knee replacement if the degenerative process progresses with age.”
The severity of the injury also determines the likelihood of surgery. Typically, meniscus tears longer than 1 cm are root tears, and those that involve greater than 50 percent of the meniscal thickness, for example, will require surgery.
As with other knee surgeries, knee replacement is a last resort for those with osteoarthritis as well.
“Advanced osteoarthritis often leads to partial or total knee replacement surgeries,” Geier says. But “prior to that advanced stage, surgeons often treat osteoarthritis with activity modification, medications, injections, braces and other remedies,” Geier adds.
The debate over whether knee surgery is needed for some conditions largely stems from the lack of effectiveness of arthroscopic knee surgery for “cleanup” procedures for degenerative conditions like osteoarthritis, Geier says.
“In the past, orthopedic surgeons would scope the knee and use a shaver to smooth out areas of damaged articular cartilage — one of the key components of osteoarthritis,” he says. “Unfortunately, these debridements do little to change the underlying degeneration, so the patient usually does not obtain much long-term benefit.”
Bottom line: Talk to your doctor. Most physicians will suggest trying alternative treatments first. These may include a combination of over-the-counter pain relievers, exercise/physical therapy, weight loss (every pound you gain puts an additional three pounds of pressure on your knees) and nutritional supplements such as glucosamine and chondroitin and/or SAMe.
If these do not bring pain relief, your doctor may suggest surgery in the form of arthroscopic surgery or knee replacement, depending on your individual situation.