I want to show you a quick example

23 April of 2008

I want to show you a quick example here of doing a quadriceps setting exercise but doing it in the functional position, so the person is standing and they are getting the motor learning they need to contract the quadriceps at the proper time and gait. We did our best, we did all we could, however after four weeks of doing his exercises there was still pain and swelling, minimal strength gains and no change in his sense of stability. So I referred him back to my favorite rheumatologist.

Disappointed patient post arthroscopy is something else going on. Unfortunately it is not an uncommon reason for an occasional visit to a rheumatologist. This 33-year-old man does have some issues. Certainly there are other more common causes of post arthroscopy persistent troubles. More serious ones at least, concern about infection, concern about bleeding. We are not going to address those here. We are going to look and try to answer the question of what else might be going on. One of the first thing to do is to review the arthroscopic data if available. The report on this man was that what he actually had was a partial medial meniscectomy of his posterior horn, along with chondroplasty and there was mention by the orthopedist of focal grade III changes in the medial tibiofemoral compartment. This means disruption of cartilage almost down to bone, quite fibrillated but no exposed bone. And the physical findings were indicating that he had arthritis in his knee, had a slight warmth, some wall effusion, medial joint line tenderness and medial tibiofemoral crepitus. Although his plain films didn’t show osteoarthritis, taking him into the most sensitive x-ray view, that is a skiers view where they bend about 45 degrees bearing weight, showed narrowing of the medial joint space. So what this man had is not this. This might have worked out better after an arthroscopy. This is a traumatic flat tear of the medial meniscus and during arthroscopy that is resected to a stable edge and they usually do quite a bit better. His was probably more like this. This is degenerative tear of the posterior horn of the medial meniscus, a very common finding in a painful osteoarthritic knee. Whether it causes pain or not, whether or not it should be removed, is still rather controversial. Although the trend is towards leaving all of this alone. There is also disruption here at the cartilage on either side and what this is, is this is probably the first thing to degenerate in response to altered biomechanics that eventually produce osteoarthritis.

The use of arthroscopy in osteoarthritis is still pretty common. It is perceived as a minimally invasive procedure, certainly compared to other operations. And yet the data that supports its use is actually not very good. What often prompts the arthroscopy is a study such as this. This is an MRI done on somebody with osteoarthritis and knee pain. The report comes back where you have a tear on the posterior horn of the meniscus. Meniscal tear equals need for surgery, correct? Well this particular MRI is not one of my patients. It’s actually from an older paper by Felix Fernandez. It was written in nearby in Wayne State who looked at the knees by MRI of patients with OA which included a lot of asymptomatic knees. What he found was that many of the findings that we might be considering pathologic on the MRI are in fact very common and not associated with pain. Meniscal tears are extremely common in these asymptomatic knees. About the only difference is whether or not there is an effusion, although that was present in the asymptomatic knees as well. So basically, the recommendation for surgery on an MRI may be in error. Certainly in people with osteoarthritis.

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