Meniscal surgery: pathology not related to pain and function
There is no clinically relevant association between preoperatively reported knee pain and function and structural knee joint pathology recorded during surgery. This is the outcome of a study conducted in patients who underwent arthroscopic surgery for meniscal tears.
These results challenge the assumption that: 1) symptoms are related to structural pathology in the knee joint; and that 2) arthroscopic surgery for structural pathology is a means for improving patient-reported outcomes for some patients with knee pain and loss of function.
Although arthroscopic meniscal surgery is one of the most common surgical interventions, the theory that served as basis for this procedure has been questioned. Several studies have found meniscal tears in asymptomatic knees in different populations, and therefore the idea that meniscal tears are the cause of symptoms and that addressing the tear during surgery is the solution is no longer a sure thing.
In this study, 443 patients who underwent arthroscopic surgery for a meniscal tear were included. Before the surgery, they completed an online version of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The subscales for pain, function in sports and recreation, and function in daily living were selected as primary outcome measures.
The surgeon who performed the procedure logged objective signs of knee pathologies according to a modified version of the International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification. The information that was documented included tear characteristics, cartilage grade, presence of plica and joint laxity. Supplemental information was taken from the patients’ surgery reports.
No clinically relevant association between preoperatively reported knee pain and function and structural knee joint pathology was found in patients who underwent arthroscopic meniscal surgery.
Synovitis explained a little portion of the variability of the patient-reported subscale for function in sports and recreation. A few patient characteristics (i.e. age, female gender, greater BMI) were slightly, yet consistently related to worse patient-reported outcomes.
Expert Opinion by Willem-Paul Wiertz
In this methodologically well-executed study with strict criteria for inclusion and exclusion, a large sample of patients was analysed. The results are noteworthy and can be seen in the light of a bigger movement, in which the association between tissue “damage” and actual symptoms is being reevaluated and adjusted, and a more biopsychosocial perspective is adopted.
This is once again a caution for physiotherapists to be mindful in their communication and not emphasize a biomedical point of view, but rather stress that there might very well not be a relation between the medical imagery and their condition: what you see is not always what you get.
> From: Tornbjerg et al., Br J Sports Med 51 (2017) 525-530. All rights reserved to BMJ Publishing Group Ltd. Click here for the online summary.