Sunday 24 June 2012

Knee arthroscopy in arthritis: an evidence-practice mismatch


Osteoarthritis, where the cartilage lining a joint gets worn down, is common (Australian data, UK data, US data). Most people will get it if they live long enough, and the knee joint is commonly affected. There is little that can be done to repair or reverse this process, and a related paper that covers many osteoarthritis treatments shows that most of the things we do (analgesics, anti-inflammatory medication, injections etc.) only provide temporary relief, and many of them hardly work at all. Treatment, if severe enough, often means a knee replacement.

Knee replacement surgery is major surgery so it is only reserved for those with severe osteoarthritis. So what do surgeons do with patients who have knee pain and mild or moderate arthritis? They often do an arthroscopy: a low risk, day-only procedure that pays well and seems to work some of the time. Hundreds of thousands are done in the US every year, and in my state the rate of arthroscopy is high and is rising.

The trouble is: it doesn’t work. Most patients still have pain, some get worse, and about 20% will end up having a knee replacement within 2 years anyway. Feel free to skip to the last paragraph for the Bottom Line, or read on for the details.

There are many studies that show that some people feel better for a while after an arthroscopy, and this matches the experience and opinion of many surgeons, but that does not constitute evidence that the arthroscopic procedure (cleaning up the knee and removing debris and torn meniscus fragments) actually improves the patient’s condition. In clinical trials comparing arthroscopy with anything else, arthroscopy never wins.

An early study showed that arthroscopy was not as good as just washing the knee out with a needle, but the bombshell article from Moseley came in 2002, in the New England Journal of Medicine. The researchers compared arthroscopic debridement (‘cleaning up”) and lavage (‘washing out’) with a sham procedure. A sham procedure, in which an incision is made and the patients are blinded (unaware of which treatment they received), is a good way of controlling for the placebo effect of surgery. The researchers measuring the outcomes did not know what group the patients were in, and when they asked the patients which group they thought they were in, they had no clue. So this study was randomly allocated, had a good placebo arm, and involved effective blinding of the patients and the assessors. They measured many outcomes (pain and function) at several times points over a two year period and found that the arthroscopic (active) groups did no better than the placebo group for any outcome at any time point. Criticisms, centred around the ways they measured pain, or on the age or gender of the patients (for example) seem a little desperate.

A later trial from 2008 comparing arthroscopy combined with medical management to medical management alone (without a sham procedure) addressed some of the criticisms of the earlier trial by using validated outcome scores, by including more women and younger patients, and by excluding those with deformity. They showed no difference between the two groups for any of the outcomes, except for a brief improvement in the operative group post-operatively, which was an expected result of the placebo effect of surgery.

When faced with evidence like this, many surgeons state: “Everybody knows that the procedure doesn’t work for everybody. It works for some, and the trick is to do this operation on the subgroup of patients for which the surgery will work.” The problem with this is the reason why it works in some people. It is quite possible that some people improve because of fluctuations in the disease, or expectations, or concomitant treatments, and not because of the procedure. Some patients improved in all of these studies – that doesn’t mean that they improved because of the surgery. The only conclusion we can make on this point is that the patients who had the surgery were no more likely to improve than the patients who did not have surgery.

The subgroups usually targeted by surgeons are those with mild arthritis and those with meniscus tears (or mechanical symptoms). Both of the studies above looked at different subgroups of arthritis severity (and excluded the severe cases) and found no correlation. In Moseley’s article, 172 of the 180 patients had mechanical symptoms and most of the patients in the later article had their torn meniscus removed. And the procedure still didn’t work. The arguments about age and gender are equally invalid, as there is no difference in the results in these groups, and there is no reason to expect a difference. Every way you look at it in every study, arthroscopy doesn’t help the patients any more than NOT doing an arthroscopy, for every outcome in every study.

Yet surgeons still say arthroscopy works for meniscus tears in younger patients. If you want to make the argument that arthroscopy will work in patients aged between 45 and 64 with mild arthritis and a confirmed meniscus tear on MRI, you will need to do a clinical trial to test that hypothesis, rather than just assume that you can pick the winners. Oh, wait: that study has been done. In a 2007 study from Sweden those exact patients were randomised to either an arthroscopy or physical therapy alone. No advantage was shown for those treated with arthroscopy, for any outcome measure, at any time point.

What about pain from arthritis behind the knee-cap, maybe there is a role for arthroscopy for those patients? In this initial study, and the later follow up study, there is no advantage in doing an arthroscopy in those patients.

The Cochrane review of arthroscopy for knee osteoarthritis can be accessed here.

The bottom line
If you have pain and osteoarthritis in your knee, then regardless of the kind of symptoms you have (‘mechanical’ or not), regardless of what your X-rays look like, regardless of where the arthritis is, regardless of how bad your pain is, and regardless of whether or not the MRI scans show your meniscus to be torn, having an arthroscopy will not increase your chances of getting better. It will not arrest or reverse the degenerative changes in your knee, nor will it “create an environment in which healing may occur” (as one surgeon states in his reports in order to justify the procedure). At this point, most patients say: “But what can I do for the pain, it’s really bad?” All I can say is that the severity of your pain does not change the fact that the operation does not work. You will have to try something from the list of (much less expensive) non-operative treatments available. I will say what surgeons seem reluctant to say: “I am sorry, but for this condition, surgery is unlikely to provide any benefit over the non-operative alternatives.”

Addit 19 Oct 2013:
In a multicentre randomised trial published in the New England Journal of Medicine in 2013 (here), patients aged 45 and up with mild to moderate osteoarthritis and a proven meniscal tear were randomised to arthroscopy or physical therapy. The results at 6 months by intention to treat analysis were not statistically or clinically different.
Within 6 months, 6% of those randomised to surgery did not have surgery, and 30% of those randomised to physical therapy had surgery. However, when analysing this study in an "as-treated" manner, it is open to bias. For example, those who believed surgery was better, or who had friends who had surgery who felt better, might not have been "satisfied" with non-operative treatment and were only satisfied when they got what they wanted. This is why blinded, placebo trials are much more effective at differentiating effectiveness between treatment options.

Addit 31 August 2014:
I wrote another post on arthroscopy here, which was prompted by yet another sham surgery trial on arthroscopy for meniscus tear WITHOUT osteoarthritis. Once again, there was no difference.

152 comments:

  1. Knee replacement surgery can be extremely painful. But now there are many knee replacement alternatives that help to relieve pain and correct the problem faced.

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    1. Tahera,
      You are correct, there are many alternatives to knee replacement surgery, and most people will agree with me that knee replacement surgery should be the last option. Unfortunately, many of the alternatives available don't actually work - at least not when pitted against a placebo in scientific tests.
      Your link goes to a site that suggests stem cell therapy. My earlier post (http://doctorskeptic.blogspot.com.au/2012/04/stem-cell-therapy-still-science-fiction.html) provides a perspective on stem cell therapy. It has never been shown to be effective for osteoarthritis.

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    2. I had a torn meniscus and osteoarthritis in my right knee. I started with an injection of cortisone. That helped for exactly 10 days. I then had arthroscopic surgery to repair the meniscus and clean up the arthritis. The pain after that surgery just increased. Seven months later I opted for total knee replacement, that was Sept. 2012. I have had no pain relief whatsoever... the pain just continues to increase. I also have a torn meniscus in my left knee and arthritis in it as well. There is no pain relief for me... and I will not go the surgery route again.

      I hear I am the exception to the rule regarding the knee replacement, that most people do get relief with it. I have personally talked with about 12 to 15 people that have had total knee replacement, they all sing it's praises. I just happen to be the one person it hasn't helped.

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  2. This is an interesting article regarding the ethical issues surrounding sham surgery, definitely worth a read -

    http://www.ncbi.nlm.nih.gov/pubmed/14986782

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    1. I have osteoarthritis in the knee. For the last 6 weeks I have had severe, disabling inflammation after a minor incident (walking down a steep hill) I have a complex tear in the mensicus, which I believe was excerbated when I was jogging three months ago, and now have stopped. I am 53. KNee replacement surgery seems drastic at my age. I have some healthy cartilage but also calcium deposits. I haven't straightend my leg for 5 weeks, and standing more than 10 min tires me. Walking a block is a major setback. Physio isn't helping. I thought 35% of patients with my symptoms could be helped with partial menisectomy. IF not, I will have to go on long term disability as I cannot work like this. Thoughts?

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    2. I don't know where you got the 35% figure from. If you have an acute exacerbation of =knee pain with those underlying problems, it is likely to settle over time, with or without surgery. If you have a locked knee from a bucket handle meniscus tear, it may benefit from surgery. I can't give specific advice but your orthopedist should be able to talk you through the option.

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  3. What about the fact that a torn meniscus (fixable with arthroscopy) induces in time knee arthitis ? Is this true? Can arthroscopy stop the arthrits?
    Ioana

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    1. My meniscus surgery (removal of 50% of the meniscus and debridement) allowed not only the progression, but the rapid advancement of arthritis producing joint deformity and much pain. TKR is the only solution now, I am told.

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    2. The question you raise is an interesting one: does arthroscopic meniscectomy increase the progression of arthritis. Like many things, I could make a theoretical argument for it, but I am not aware of any hard evidence that this is the case.

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  4. I had osteoarthritis and two of my runner mates advised me to have a stem cell therapy, which I had with my ortho surgeon, Dr Grossman. I was about to believe that the treatment was not for me. My friends only waited 2 months to get the final beneficial results and I was on my fourth month that time. I called my doctor and he said that some patients may take several months to get the effect of stem cell treatment. He also advised me few things to help boost its effect like the suitable exercises for my knees. On my 5th month, I noticed some changes. The level of pain dropped, as well as the soreness. The benefits of having stem cell therapy took effect on me on my 6th month and I really think it was worth waiting. It has been 4 years now and I am still joint pain free, despite of my very active lifestyle. I am a runner and a ballet dancer. :)

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    1. Thanks Kirsten,
      Unfortunately, the causal link between the injection and your symptomatic improvement is weak. Many things happened to you in those 6 months, and knee pain is unpredictable and variable over time, so to say that the improvement you felt at that time was due to an injection 6 months earlier might 'sound' right, but no such causal link has ever been shown previously, and there is no biological plausible mechanism for such an association.
      I think we need to be more objective (read: scientific) about things so that we do not jump to endorsing every apparently effective treatment, and then paying for it at the cost of true therapies.

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  5. There may come to a point where there is no alternative option than Knee surgery. It's important to know that with medical breakthroughs today, knee replacement has become a routine procedure and is now relatively risk free.

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    1. Thanks, but I respectfully disagree. In the case of osteoarthritis and elective orthopaedic surgery, there is always an alternative option to knee surgery: not having knee surgery. The failure of non-operative treatments does not make and ineffective operation become effective.
      Regarding knee replacement surgery, it has certainly become commonplace, but is still plagued by a high rate of patient dissatisfaction (up around 20%) as well as persistent, but low, risks of infection and venous thromboembolism.

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  6. This comment has been removed by a blog administrator.

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    1. Weird. I published this comment by Anonymous (above) but it was "removed by a blog administrator" that wasn't me. I can't fix it so I have pasted it below, and then I will reply afterwards:

      Current Med J Aust 2013; 199 (2): 100.:
      Wayne Adams, Manager, Safety and Quality in Health Care
      Benefits Management, HCF, Sydney, NSW.

      "In their editorial, Buchbinder and Harris conclude that “The use of arthroscopy for knee osteoarthritis has been allowed to continue, exposing patients to an intervention that is at best ineffective, and at worst, harmful”

      "It would be fair to say that the patient’s view of the benefits of the procedure is a leading indicator and should form an integral part of assessing the success of knee arthroscopies for osteoarthritis."

      Rachelle Buchbinder and Ian A Harris, Med J Aust 2013; 199 (2): 100.
      "In reply: We thank Adams for providing private health insurance data that confirm the continued use of arthroscopic surgery for patients with osteoarthritis."

      "We do not doubt that many patients are happy with the results of arthroscopic knee surgery, but this does not necessarily imply that the surgery has had any specific effect, as satisfaction rates are high after many ineffective placebo treatments. Indeed, high-quality randomised controlled trials have consistently failed to demonstrate clinically relevant self-assessed benefits of arthroscopy compared with sham surgery1 or non-surgical comparators.2-4 Potential risks of arthroscopy are also an important consideration."

      An interesting, and revealing exchange. I am still baffled by Mr Adam's managerial position at Safety and Quality in Health Care. He is not working at the Headquarters of Placebo, so... yeah. Baffled.

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    2. Thanks,

      An interesting exchange, because Mr Adams was referring to patient satisfaction surveys - something that I use regularly and that I consider important. However, patient satisfaction surveys only measure perceived outcome, and if that outcome is the same with placebo treatment, then we have a problem.

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  7. I just had an Oxford implant put in my right knee after 3 previous scopes - over a 9 year period. After the 3rd scope, I felt better for a few months - but the pain returned worse than ever. My doc said that when she saw my knee during the Oxford surgery that is was apparent why I was in so much pain - my bones were grinding away. My question is this: why do they start cutting stuff away when they know what will eventually happen?
    I have the utmost respect for my doc and I trust her 100% - but my knee still doesn't feel right 3 months after the Oxford. I exercise every day - recumbent bike, stretching, weights, etc. I still can't squat or kneel at all - will my knee ever be fully functional?

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    1. Thanks Paul,
      You ask two separate questions:
      1. Why do doctors do surgery that doesn't work or even make sense (like arthroscopy for OA)?
      To answer that properly would take a whole blog - this blog. In general I do not believe that it is a conscious decision to deceive or harm. Doctors believe the treatment works because that belief is based on biased evidence from the literature and, most of all, from their own eyes. Many doctors who step back and think about it start to realise that a lot of what they do is placebo, but continue to use it as legitimate treatment (I am surprised at how many doctors know that their treatments are placebos but still use them).
      2. Why isn't your knee better?
      A tougher one, and a little outside the scope of this blog. Knee replacements are painful for some time afterwards. At 3 months you are only in the early stages. Also, knee replacement don't do as well as hips, and many remain painful. Also, you cannot get normal function from a knee replacement, so think about where you have set your expectations.

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  8. Hi I had and torn Menicus and had surgery it's been over a year . I'm still in alot of pain it's getting worse do you think I might need a knee replacement . I had a friend with the same problem he got the knee replacement done he says he feels much better .can I ask my doctor for the surgery or is it up to him in alot of pain

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    1. Firstly, I apologise but this is not an advice column. My ability to diagnose and treat you is hindered by the fact that I know very little about you or your knee.
      Secondly, in my experience nearly everybody who said they had a friend with the same condition didn't. Your friends are trying to help but usually they do not.
      Thirdly, having said all that, I can tell you that you don't need a knee replacement for a torn meniscus; you need it for arthritis. If you have arthritis, the meniscectomy was a waste of time. If your surgeon has offered a knee replacement as a reasonable treatment option, it is up to you to decide, based on a sound assessment of the relative risks and benefits as they apply to you, taking advice from reliable sources (like your doctor, not your friend).

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    2. You said, that you do not need a knee replacement for a torn meniscus, you need it (depending) upon the degree of arthritis. My question is, I have moderate meniscus tear (horn tear and through the body segment with minor extrusion) with moderate OA in knee, will (or rather can) the current meniscus tear contribute to the worsening of the OA of the knees? Certainly, it would seem from everything that I am reading including your wonderful commentary that having surgery for the tear would only expedite that OA but conversely is the same true and I am screwed either way? I can live with the god damn meniscus pain (which is 24/7 but fluctuates from severe to almost nothing) if it means "cutting and snipping and thus removing meniscus cartilage will lean in favor of negatively expediting the OA? My final question and forgive for the length, is it possible through yoga (which actually cause through wrong yoga the tear, then probably underlying mild OA to moderate), other physical exercises (walking, biking) and MSM, K2, intense Omega DHA, etc., including meditation help heal the tear? What does seem to be working is the natural synivisc injections? Thanks for your time.

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    3. If the meniscus is torn, it functions less effectively and may contribute to OA. Removing the torn piece, however, doesn't help that, and depending on how much is removed, it might even make it worse.
      For all the other things you mentioned, you would need to look for high-level evidence of their effectiveness (you can find a post on my site for synvisc), but once you have OA, there are no good treatments to reverse or slow the progress - only to make you feel better for a while. We are only lucky that progression is naturally slow anyway.

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    4. Thank you so much. I appreciate your quick reply and the breadth and depth of your responses throughout.

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    5. I had a scope done BC of a fall at work which my Mencius was torn my knee continued to hurt but my Dr was always like ya r ate up with arthritis... I feel I wasn't before...he sent me bak to work and 2 months later I fell again which I had shoulder surgery this was last July I also had a tear in my other knee but nothing has been done yet its the same thing arthritis... I feel being on it almost a year hasn't helped...I think my workman's comp is a problem...so as of now I have 2 messed up knees and a recovering shoulder...any advice?

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    6. Hard to give advice for this particular case. Can only suggest opinions from experienced orthopaedic surgeons.

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  9. I had a botched arthroscope on my right knee by a well known orthopaedic surgeon in Melbourne about 15 years ago while in my 30's, and have had much worse pain with it since. Both knees were in the same condition just before the operation, and the plan was to do one knee and then the other. A lateral release was done and roughness behind the kneecap smoothed. The surgeon explained that I just happened to be at the worst end of the recovery spectrum. Prior to the operation the surgeon had explained that he did these operations everyday and that there was no reason why I wouldn't be able to run, play tennis etc after the operation. In fact, by doing the operation then, he said it would help prevent arthritis later . I naively didn't get a second opinion. After months on crutches and having considerable intermittent swelling, I tried to have another surgeon in Collins St look at it but he would not comment on another surgeon's work. I eventually found a leading orthopaedic surgeon who was brave enough to state that the operation should never have been done, and that a lateral release should be anchored on the other side, which it wasn't. As the pain in my knees, most particularly my right knee, has heightened this year, I have decided against the cortisone-arthroscope- knee replacement process, opting to have a series of PRP injections instead . The left knee, which was never operated on, is manageable now, but the right knee is much slower to improve. I remain hopeful, as I am terrified of knee replacement surgery. Apart from the possibility of infection, I worry about the possibility of continued pain, and the prospect of having a knee which is probably functional for everyday living purposes, but will not allow me to do the non-impactful activities I love like pilates, yoga, brisk walking and cycling upright on a stationery bike. I don't want to become a sedentary old woman getting around slowly in flat, orthotic based shoes. How very depressing!! So I will persevere with the PRP's, and perhaps move to PRP with growth factor and then if that doesn't do the trick, stem-cell treatment. I need to have hope, and have seen encouraging stats. I have always made such an effort to keep fit and active, and I without that, my life will lose a great deal of it's mojo. There are both emotional and physical effects.

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    1. Thanks for commenting. If you have osteoarthritis, then the arthroscopy, the "smoothing over" (sounds so good, doesn't it?) and the lateral release are all a waste of time. Unfortunately, the evidence for PRP or stem cells providing any real benefit is just as bad (see my other blog posts here http://doctorskeptic.blogspot.com.au/2012/06/platelet-rich-plasma-continues-to.html and here http://doctorskeptic.blogspot.com.au/2012/06/platelet-rich-plasma-continues-to.html). The good news is that you won't need orthopaedic shoes, because they are also ineffective for knee OA.
      If you are doing pilates and yoga and brisk walking unaided, then you probably don't need a knee replacement.
      But don't fear a knee replacement just because of the complications. Weigh the potential complications against the potential benefits. For bad OA, it is much more effective than any of the treatments you have tried so far.

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  10. i do not have osteoarthritis in my knee, but i do have anterior and posterior meniscus tears with a fluid cyst. the problem presented itself quite suddenly with a great deal of swelling and pain. in this case, can arthroscopy, which my orthopedist has suggested, be helpful?

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    1. Arthroscopy is used for many different things. I cannot and should not give personal advice, particularly without all the information. I suggest you discuss it with your treating doctor and remember that you can always seek a second opinion if you are not satisfied.

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  11. Dear Dr. Skeptic, I can't imagine how arthroscopy could help knee OA--but what about Regenokine? If it's helping Kobe Bryant--it must have some merit? Can you prove that it does not? We aging but still fit, active and lovely baby boomers with knee OA must have something to hope for! I am bone-on bone in some focal areas (unicompartmental Patellar OA) --and I still run and hike and dance---although my ortho says if I keep on, it will make my OA worse and worse. What to do? Anyway, thanks for your blog.

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    1. Thanks, your post raises several issues that I would like to address.
      1. "if it's helping Kobe Bryant-it must have some merit?". The answer to that question is no. If you read my blog, you will know that just about every treatment you can imagine giving, from stem cells to copper bracelets, "helps". Usually, however the improvement seen is one or more of: natural history / fluctuations, placebo response, or concomitant treatment, and many of these things, including platelet rich plasma and stem cells are no better than placebo.
      2. "Can you prove that it does not?" I shouldn't have to. Otherwise every half-baked scam treatment out there will be accepted because we have not proven that it does not work. The burden of proof is on those who promote the new treatments. Given that similar treatments HAVE been shown to be no more effective than placebo, I am going to go out on a limb and sya that the same will go for Regenokine.
      3. "[we] must have something to hope for". No we don't, but if it was necessary for us to have something to hope for, that hope does not provide proof of effectiveness
      4. Keep exercising. You ortho has very little evidence that this is making your knees worse and it is probably helping you in other ways.
      Hope this helps, sorry if it sounded harsh.

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  12. I am 77, suffered a torn meniscus, had xray, MRI and finally arthroscopic surgery. It is now 2 and 1/2 month since surgery, my knee hurts much more than prior to surgery. Doctor gave me a cortisone shot two weeks ago, no help at all. Pain goes from knee to ankle. Riding recummbent bike every day for 30 minutes and taking chair exercise class (this class initially helped but now it seems to be making things worse). Prior to surgery my pain level was one of discomfort and not all the time. My primary suggested only a cortisone shot but of course surgeons recommend what they do, cut...I would never tell anyone to get AS if they ask me. I wish I had never had it. All the anti inflammatory (I had tons of cartilage floating and hanging in the joint when they showed me the dvd) meds help little and also make me nauseous if I take them too often. I feel that all the cutting and vacumming of the cartilage made my knee worse because (and this is strictly a lay person's opinion) all the cartilage hanging and floating was actually buffering the bones and his cutting and sucking took that away and that is why I have such an increase in pain and stiffness. Sometimes when I get out of a chair, if there more than 30 minutes, I cannot walk for the first few minutes and use a cane for balance....prior to this I was extremely active, going to the gym three days a week, walking around my community and riding my bike every day. My vote for AS is a large NO!!!

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    1. Thanks. I think it is fairly well established that arthroscopy is no better than placebo for an arthritic knee at your age. However, arthroscopic surgery should not be completely discouraged, because for some conditions (not arthritis) it can be helpful.
      I would also point out that the cortisone injections are also a waste of time.

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    2. Part of my question that I posted a few minutes ago, includes a query./comment by Eileen. Is in fact however, painful more cartilage floating around due to a torn meniscus and OA knees acting a type of cushion nonetheless than cutting, sniping and removing?

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    3. Not sure of the exact question, but if there are fragments floating around your knee, they are not providing any cushioning. Also, unless they are getting jammed in the knee (locking) they are probably not doing a great deal of harm either.

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    4. Yes I strongly believe a knee athroscopy can MAKE THE PAIN WORST...I had a left knee athroscopy done on Sept 2015...after that I am limping to glory...sad but true...it seems my born cartilage has worn ...but I consulted another Surgeon in may 2016...he told me the athroscopy WAS A WASTE OF TIME for...my condition is bad...time for a knee replacement... Well I am still in dark if I should go for it..as d athroscopy was a BLUNDER...any advice Dr....

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    5. A knee replacement is different to an arthroscopy. A knee replacement is a recognised treatment for osteoarthritis with reasonable results. It would be a consideration.

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  13. I have had the Mako Knee partial done on my left knee 2 years ago and still in pain. I have Osteoarthritis in both knees. They gave me the cortisone injections in the left knee and even a more expensive shot in my left knee. All in all still have pain and knee does not feel right nor can I kneel. They are thinking of removing scar tissue arthoscopicly to see if that will fix the issue or is it worth doing?

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    1. I shouldn't really give specific advice, but I can state that in general, injections are not helpful for knee OA, no matter what it is: stem cells, platelet rich plasma, hyaluronic acid or steroids. And on average, arthroscopy is probably a little less useful than an injection.

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    2. I am sure you've learned of the Finnish study published this week in the NEJM showing that knee arthroscopy is not beneficial for many (if not most) patients. In this case, the subjects were only operated on (or received sham surgeries) if they did not have osteoarthritis. I was to have knee arthroscopy tomorrow, but realized I'd been negligent in not asking more questions about alternative treatments, etc., as well as getting a second opinion. I've postponed the procedure. Do you have any advice about finding a doctor for a second opinion? So many orthopedic surgeons are... well, keen to do surgery, and I'd like to find a doctor who's a bit of a skeptic himself.

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    3. A new blog post is coming regarding the new study.
      The only advice I will give is to get more opinions: 2nd, 3rd, 4th, whatever. Don't be worried about offending the doctors; we are used to patients wanting another opinion and we often recommend it if the patient is not satisfied.

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  14. I have had four othroscopys during my 45 years, two when I was 14 years old and two last year. I have meniscus tears. I have been pain most of my life and even walking gives me pain. I was told by my surgeon I am too young for a knee replacement and have heard good and bad stories about these. What other solutions are there?

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    1. There aren't many invasive alternatives. Injections (stem cells, platelet rich plasma or steroids) are no better than placebo. The best advice is anti-inflammatory and simple analgesic medication, activity modification and acceptance. If these are not enough, a knee replacement is an alternative.

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  15. Hi ,
    thanks for your views Dr Skeptic.
    I am aged 49 with mild osteo, male height 172 cm weight 88 kg My left leg is little deformed. my mechanical axis is deviated 2.5 on right leg and 3 cm on left. my right leg has no problem , but left was hurting after i run for 5 to 8 km. I have taken x ray, MRI etc.Physio after careful examination says it can corrected non invasively by doing proper exercise and weight reduction. Surgeon recommend HTA, so that I can resume my running.my cartilages are fine otherwise and I do not have much pain
    Can you pl give your views

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    1. Depends on what is wrong with your knee. If you have degeneration of the medial compartment, an HTO is an option. You need to discuss this with someone who can see your images and your knee.
      Having said that, keep your expectations reasonable. If you are 49 and have knee pain after running 5-8km, your knee is better than mine, which hurts after about 2km.

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  16. I am from India , seen reputed ortho Surgeon. upon through physical examination, X ray and MRI, he suggested that intensive 3 to 6 months Physio therapy may
    help quite well. But his charges are quite high, I am in dilemma. I have degeneration in the medial compartment only.

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    1. Physio may help, but there is very little evidence that it will. If you can cope with analgesics alone, then spend your money on something else.

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  17. hello i am 37 years old and grown up my right knee has dislocated my whole life like 2-4 times a day with any squatting bending lifting anything heavy,which i thought it was normal due to the fact you never went to the hospital unless you was dyeing back in them days.anyway i learned to put it back in and go on like no big deal .back in 2006 i was jumping on a trampoline once i went up my knee popped out and when i came down everything was cut ,so i had to go under surgery to fix everything,but one problem happened i woke up during surgery ,yes i said woke up,for some reason the stuff they use to knock you out only worked on me for like 10 mins and i came to ,all i remember is seeing the drill and hearing it then the doc and nurses screaming and they knocked me back out again,i had trouble with my right knee for sometime after that it just didn't work right,so i did therapy for 1 year ,2007 went to work and slipped on black ice had what they called bone bruising and some bleeding and now factor hip with a small tear in the acl,doc just had me do more therapy for the next year,so after all the therapy and surgery didn't change i still was having problems with right knee and hip,so went to another ortho doc in 2008 he said do therapy for awhile and lets see what happens on a mri it showed i still had the bone bruising and little tear on the acl and my hip was healing,2013 went to ortho surgent he did mri and xray on my right knee and said i have server ostoe.in right knee and also have some bleeding in there and a bone spur in there,he did a scope and cleaned it out also smoothed and also loosen out side tendent ,he also noticed that my right leg is 38 on a inch shorter then my left,i have always walked with a limp but never knew why til now,he also said i have no cartilage in my knee iam bone to bone,before he did the scop he did orhto visk injections but only made things worst,sorry for the story but what you to wrap your head around it,so question for you after doing everything i am getting ready to go back to him to have a talk about doing a part knee replacement or a full,taking into the fact i am 37 what would you do ? what are pros and cons to having this done ? also what to thank you for posting this info not to many people straight to the point ,and your right i felt like the scope thing was a waste of time and money and only made things worst ,i feel even more unstable now then before.thanks for you time.

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    1. Thanks. If you truly have "no cartilage" in your knee, arthroscopy and injections (of anything) are a waste of time. The decision to have a knee replacement (total or partial) is a big one and ultimately needs to be your decision, based on your acceptance of the risks and likely benefits. Discuss it with your surgeon and get more opinions and information if you like. Apologies, but it is too complex for me to give you any more advice on this.

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  18. I am 78, a former marathon runner, now a jogger. I am dealing with torn meniscus, baker's cyst, a bone bruise and very little cartilage (basically bone on bone) My ortho said scoping would only give me relief from pain for a short time. A knee replacement is really the only option; but I was told I would not be able to jog afterwards. Since exercise is important to me, I am choosing to do nothing at this time. It is a pain to not be able to squat and do deep knee bends, but as long as jogging doesn't hurt (only if I'm going downhill) I am going to continue it. The ortho says if I do the knee will get worse, but this is my choice. Just wanted to share my story

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    1. I agree with you. Arthroscopy will not be helpful, and a knee replacement is a big deal, and probably not necessary. Keep jogging, it got you this far and the evidence that it will make things worse is not good.

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    2. Sorry for a string of queries.comments here. But is it indeed true as you say that light jogging will not worsen conditions such above?

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    3. Yes. And there are other benefits (beyond your knee) from regular exercise.

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  19. Thanks Doctor! Appreciate your comment. In 1984 I broke my arm while marathon training. The ortho was very much against running and jogging and told me how bad it was for my bones. However, after I healed from the surgery he was so impressed with my rapid healing and told me "Keep on running."

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  20. I had one knee replacement. The other knee was sore but bearable. I opted for PRP trying to avoid the operation. Now the pain is unbearable and I am actually looking forward to the operation

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  21. Dear Dr. Skeptic, What do you think really causes knee osteoarthritis? I've heard the "wear and tear" theory---overuse, improper use--and I've also heard that it doesn't matter what you do--- its just a genetic problem. Also, do you think there is any significance to, or different causation inferred, if the arthritis is confined entirely to the patellofemoral compartment? Thanks for any info,
    JK

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    1. Probably a mixture of things.
      For example, medial compartment osteoarthritis is very common, particularly in some races, but some people never get it. Also, it is very common to see bad arthritis in someone who has previously had their meniscus removed, or who had a fracture in the knee joint. Patellofemoral arthritis can be associated with knee injuries or abnormal alignment. Cartilage ages and loses its mechanical properties as we age, but injuries that disturb the mechanics of the knee make cartilage wear out faster.
      I tend not to dwell on it. I am more interested in what works. I am not smart enough or young enough to find the answer to that question.

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  22. Thanks for your reply. Yes, I understand. Sometimes the "why" doesn't matter so much. Unless of course, the causative factors are still in progress and there is something one could do to modify them so as not to cause more damage! If you have advice about this, I'd appreciate hearing it. Since you are apparently not one to be easily impressed by new and untested treatments, if science ever comes up with a treatment that you will approve of, I will take note!! Hope you will post to your readers if there is something new that you think promising.

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  23. Found this thread to be interesting to read. I'm 35 and facing my own knee problems. Had arthroscopy 5 years ago and already having problems again. Seeing a different surgeon now and the osteoarthritis has gotten bad enough he's mentioning knee replacement. Recently had some cartilage snap off from behind the knee cap (we think, next step is MRI), but we are going through the "conservative phase" of treatment right now. Gives me time to weigh my options and think about the next steps before my next appointment. I'm thinking another arthroscopy isn't going to do me any good.

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    1. I'm thinking you might be right.

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    2. I am 63 years old wIth a moderate horizontal menicus tear with moderate arthritis. I am a 4.0 tennis player and in the past played three times a week. I was scheduled to have arthroscopic surgery but cancelled because after reading the info wasn't sure if I was doing the rift thing. I have been doing physical therapy and have little pain good range of motion of knee can go up and down stairs easily but am afraid to go back and play tennis because I do not want to injure it more. I have not played since dec because I hurt something bad then and that's when I had the MRI with the above diagnosis. I feel now it is better but don't know whether to proceed with surgery or just wait it out. Please help.. Very active person

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    3. If you now feel better, then why would you want surgery? Your knee will have its ups and downs. Having treatment that is timed to match the downs, usually leads to an "up" period, that can be attributed to the treatment.
      If you had pain, I wouldn't recommend an arthroscopy. If you feel OK, surgery is not even in the picture.

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  24. I'm 46 years old, I have baker's cyst's, bone spurs and almost no cartlidge in my right knee, I also had arthoscopic suregery in 1990. Doctor gave me two choices, arthoscopic again, or total knee replacement, I pretty much have bone against bone in my knee, not a pleasant feeling. So I was wandering if total knee replacement is best for me

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    1. Thanks. Total knee replacement can relieve pain from knee osteoarthritis. It has not been subjected to a randomised trial, but the differences in knee pain and function before-and-after surgery are large and consistent. The decision, however, is a big one and needs to e made with your orthopaedic surgeon. It doesn't sound like arthroscopy will be an effective option, though.

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  25. What about the meniscus "tear" that is causing "catching" or "locking" of the knee. My knee almost get hung up when I bend it back and forth and there is pain when I do this. Are you suggesting I just keep moving my knee back and forth until the cartilage wears down?

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    1. You are theorising about what is causing the pain and what may resolve it. This is sometimes a useful exercise, but is usually only useful in justifying our decisions. The only thing I can tell you (without taking a proper history and examination) is that unless you are experiencing true locking (which this doesn't sound like), your chances of getting better with an arthroscopy are not much better than placebo.

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  26. Hello Dr Skeptic,
    I had my first knee operation in 1995 whist serving in the British Army. Following the op my knee seemed okay however on returning to running I suffered from very severe Achilles tendonitis on my first run. I could not remedy this new condition and had to leave the Army with this impairment.
    A few years later I banged my knee after falling from a bike. Back in for my second arthroscopy to cut away ‘loose’ cartridge. Knee seemed okay.
    Fast forward to 2012 I felt a click in my knee whilst teeing off playing golf. Ouch here we go again. After resting for a while I managed to get back to normal activity in terms of cycling 3-4 times per week. However, after a long ride or a long walk I would be in pain the next day. I went to see Doctor and NHS physio and Surgeon. They said three arthroscopies were fine but that would be the last.
    They took an MRI scan; which subsequently went missing. I was booked in for the third arthroscopy. On arrival I met the surgeon and he said that the scan still hadn’t shown up but that he’d take a look anyway and “we’ll have you out riding you bike in no time”. After the op the surgeon said “your haven’t got much [cartridge] left have you”. This last statement made me worried. Why cut away what cartridge was left if there wasn’t much to start with? Why go ahead with the procedure without first obtaining the MRI scan image in the first place. If the surgeon had managed to viewer the image we he have gone ahead and advised surgery.
    Around 4 months after surgery I suffered terrible pain for about 3-4 weeks. The pain was unbearable. My Doctor proscribed very strong pain killers not available over the counter. By the time I got see to my original surgeon (another 4 months) the pain had gone. The surgeon was baffled – he’d never come across anything like that.
    In the period that followed I’ve cycled 3-4 times a week to work (20 mins each way) and alonger ride for 2 hours at the weekend for a year or so; but my knee is pretty numb and dead feeling and recently I’ve started to ache a lot; it’s especially painful after walking for short distances or say watching my son play football for an hour. Strage thing is that cycling seems to help curb the pain?

    My prognosis on my general detoriation is the onset of osteoarthiriuts.
    I’ve started reviewing online resources (hence finding your blog) about options such as total knee replacement which based on past experience fill me with dread. But the NHS treat these things as business a usual; which when viewing other articles is a very serious undertaking.

    I wish I’d never had the last op ;-( I’m only 44 and I’m really worried about what the future holds. I think we live in hope that there a cure for such conditions and we have high expectations - and that surgery is the solution. Not once has anybody in the NHS made a point of stating the risks associated with these procedures. It’s all on the documentation but never said face to face.

    Any advice in terms of moving on with a strategy for the future would be appreciated. Looks like a life on pain killers and the at some point a decision on knee replacement with the prospect of being worse than I am now.

    Regards BW

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    1. Thanks. Sounds like you are still pretty active. Keep it up. You will have exacerbations of pain every now and then - these will resolve, with or without an arthroscopy. You might need a knee replacement one day but that will be your decision, not mine.

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  27. How long does it take to get back to normal activities after a knee scope?

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    1. Hi. It depends on too many things, like what is "normal", why was the scope done, etc. Needs to be discussed with treating doctor.

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  28. I had as for a mm tear and had 20% of the posterior horn removed. The surgeon felt that I would have a great prognosis because I had no arthritis at all. I am a 52 yo avid runner and Boston marathoner. I waited 4 months before seeing the surgeon (highly rated at major University center) in hope of it resolving, had significant swelling and pain only after running a mile.
    Now almost 4 months post op I can not run even 1 mile without pain. I wish I had not had surgery and had second and third opinions.
    AS is a joke and there has to be a better solution with all the technology out there.

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  29. I had a meniscus tear and had surgery, shortly after i fell on ice at work, I did PT an it got better, no pain. We got new floors at work and i slipped on a puddle of water that you couldn't see, i feel on the knee cap, then landed on my leg like doing a jack knife in the water, instant pain, i did lots of PT and then had it scoped. Three years later and i am still in lots of pain. This is a workcomp issue and they are saying my pain is because i had arthritis to begin with and will do nothing else to help ease my pain. I did not have ANY pain prior to my fall, my question to you is, did the fall make my arthritis pain worse? I feel that if i had not fallen i would not be at the level of pain that i am at right now, ,maybe 10 yrs down the road but not now. Thoughts?

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    1. I cannot comment on your particular case, but I can tell you that for all patients with symptomatic osteoarthritis, the pain had to start sometime, and people often attribute that onset to a traumatic episode.

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  30. I had a meniscus tear repaired in my right knee by arthroscopic surgery at Beacon Clinic in Dublin Ireland in March 2013, at age 51. Prior to that I had significant pain and worsening pain on walking for almost a year and had reached the stage where I was having some pain at rest after walking. My leg always felt tired and I had to force myself to walk any distance.

    I had physiotherapy rehabilitation after the surgery which I took seriously. I made a very good recovery and I believe that the combination of the two things gave me a very good result. More than a year later my knee does not trouble me. I realise I am just one case, but for me this was not sham surgery, it has vastly improved my quality of life.

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  31. Hi Dr,
    I have a horizontal tear of the posterior horn and body of the medial meniscus with an associated parameniscal cyst. The OA believes that I need operative surgery but I have put it off with the hope that in 5 to 10 years regenerative medicine will be able to repair the meniscus in the avascular zone. What are your thoughts on this? Will regenerative medicine be able to fix this in a short time frame? I'm only 35 and don't wish to surfer a knee replacent at 50.

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    1. My thoughts? Regenerative medicine has not been able to produce anything close to this for 20 years and is no closer to ever being able to achieve anything useful.
      I have been hearing people say how things will be better in the future (knee replacements, meniscus replacements etc.) for 30 years. These things might occur, but they seem to be forever "in the future".

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  32. Hi Dr
    About 2 years ago I tore the posterior horn of my medial meniscus. I believe it is a flap tear which protrudes to the articular surface. I have noted your comments regarding sham surgery v Arthroscopy & am keen where practical to avoid surgery. However, I understand that it is possible with a do nothing approach that the flap tear could wear down some of the articular surface above to expose bone. Is Arthroscopy best avoided in this situation as by having a menisectomy I assume would expose some cartilage below the meniscus to rub & wear down on the cartilage above. Is it the lesser of two evils or is the flap tear unlikely to do that much damage?

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    1. Thanks. I think you are under the assumption that the meniscus tear is causing the pain. Arguments about future osteoarthritis and mechanics are largely theoretical. An arthroscopy is best avoided for no other reasons other than that it doesn't work.

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  33. What a great service you are doing here, Dr. Wish I had found your site sooner. I can attest that that "Platelet Rich Plasma" is useless. Spent over a $1,000 on it awhile back. Same with the other injections.
    I'm 59, female, had bilateral TKR 13 months ago. My extension and RMO is "better than someone who never had it" my P.T. said. Her words, not mine. Everyone thought my progress was/is great.

    My issue is that I never had pain to begin with, though I had no cartilage left on either knee. (or shoulders, but I won't be dealing with that anytime soon!) They weren't stiff, just very weak, which is why I did it. I had 3 doctor opinions and did all the research I could before. My insurance was ending, I had paid my deductibles for the year, so I went ahead and did it since I was not overweight and "fairly fit".

    I was religious in my P.T. and exercises, still do most of them. I have a physical job with much walking, carrying, bending, etc. I do fine. EXCEPT, I cannot squat as far down as I need to for everyday tasks. I do exercise squats and lunges everyday but at about a foot from the floor, it hurts in the back of the knees so I can't stay there. My surgeon said I would be able to squat and kneel, but I say, not enough. And the knees are as weak as before.

    Too late now, but I wonder if I did the right thing. Above, you mentioned the pain was coming with severe OA, whether someone felt it now or not. Most people seem so happy with their TKR's due to pain reduction, but I had no pain.

    Then, too, my P.T. said SHE could have cured my weakness with exercise alone. But I was already active, hiking, elliptical, physical job, strenth training, sooooo...seems like I made a mistake now. Maybe this will help someone else vascillating with this life-changing decision.

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    1. Thanks. Sometime people with OA don't have much pain, so if they can still function well, they don't need a knee replacement. Knee replacement is not normally done for weakness, and it is well known that you cannot fully squat with a replaced knee. As long as you are not worse, the decision wasn't a disaster.

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  35. If you have a torn meniscus, trimming it can help with two things: 1) keeping it from tearing further causing more issues like locking etc, and 2) stop torn pieces from flailing around in your knee joint causing pain and inflamation which will eventually cause arthritis. There are a lot of variables, but if you tear your meniscus in the white zone, chances are that tear will never heal and is not going to do you any good flopping around in your knee joint.

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    1. Thanks. Allow me to respond to your two points because I think you are relying on what "sounds good" rather than what is true or what the evidence tells us.
      1. Excision prevents further tearing / locking.
      There is no evidence for this. Patients whose tears are excised often have further tears diagnosed later. Besides, having a tear is not correlated with pain.
      2. Stop torn pieces flailing about ... causing arthritis.
      There is no evidence for this. Many knee procedures (like retrograde nailing) produce large amounts of bone and cartilage debris in the knee, which are later absorbed. Not having a meniscus in place (as shock absorber, force distributor, nutrition etc.) causes arthritis, regardless of whether the torn fragment is floating in the knee or floating in the specimen jar after surgery.

      Also, we are talking about undisplaced degenerative tears (that are not associated with pain, based on population studies). Removing these is usual practice but is not supported by the evidence, and there is no evidence that suggests that removing an undisplaced tear prevents further tearing or arthritis.

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  37. Thank you for your wonderful blog. I have had a severe meniscus tear (lateral anterior horn) for seven months now. It has marginally improved, in that at the beginning it would lock and now it doesn't, but walking and standing on my feet for more than a few minutes it's problematic and eventually leads to the tear making itself know - unless I walk with a straight leg. I've seen seven consultants so far, all suggesting arthroscopy. The more incompetent ones did not propose anything else except cutting and reshaping the meniscus (mine is discoid). I've always strongly objected to the fact that a discoid meniscus that has never given me any problems for 43 years all of a sudden needs to be "reshapen" to make it "normal". Beside, I'm told I have little left therefore the argument that it should be resharpen doesn't make any sense.
    I wondered what you thought about polyurethane scaffolds. The 7th consultant I saw could do that, but would it really improve things?

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    1. Unlikely. These have not been subjected to the same rigorous comparative tests as those described above. Therefore, surgeons "get away" with recommending them - "We don't know, so we may as well try it". Unfortunately, these are being used prior to proper testing.

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  38. Very interesting and informative read. I just had my third scope on the left knee. I had a discoid meniscus that was corrected during the first scope, removed during the second. In your opinion, does this increase the severity of OA? How does a discoid factor in to this study? Or, is there really no distinguishable difference?

    Respectfully
    Christy tylman

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    1. In general, any loss of meniscus will increase your chance of getting OA in the long term, discoid or not. Having said that, discoid menisci are rare, so they don't pop up in the studies.

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  39. Hi, Doctor, thank you for your realism and honesty. Above, regarding future potential regenerative procedures, you seem rather stern. You write:

    "My thoughts? Regenerative medicine has not been able to produce anything close to this for 20 years and is no closer to ever being able to achieve anything useful. I have been hearing people say how things will be better in the future (knee replacements, meniscus replacements etc.) for 30 years. These things might occur, but they seem to be forever "in the future".

    I wonder what is your opinion in these possibly "exciting" advances like 3D printing of meniscus scaffolds, caking them with stem cells, then inserting these potential new shock absorbers into the body to replace what's been damaged? It appears to work in sheep, as I'm sure you've read and analyzed. Do you think these efforts are in vain? I've read enough of your writing to conclude that I think you'll probably say "...we don't know..." But I still wonder if you see ANY light ahead for those of us (millions) suffering from this injury. Thanks in advance :-)

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    1. Thanks. Firstly, I am am bit wary of the phrase "suffering this injury". I think that the link between having a meniscus tear and knee pain is not clear, and the link between having a source for pain one one hand, and patient suffering on the other, is even less clear. So we need to work out what the problem is that we are addressing with this technology.
      Assuming that meniscus pathology is a cause of suffering, then I see enormous potential from new technology. New technology has made enormous changes to many aspects of our lives. I guess my point is really a counterpoint to the prevailing message that is sold in the media and in medical science, that every experimental finding will lead to some great improvement in the human condition, because by and large these promises fail. That is why I don't get excited when I see the news and find out that a researcher in the UK has claimed to have cured paraplegia (which actually happened recently). The hype and overselling needs to be pointed out and put in perspective. As I always say, benefits are exaggerated and harms are minimised. I am just trying to correct that balance.

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  40. Thank you for your time and attention. I agree that the link between a damaged meniscus and pain is not clear. It depends upon the injury and person. In my case (obviously anecdotal), pain was effectively relieved following my arthroscope when roughly half of my medial (avascular white zone) tissue was removed. The pain is better; but the knee is not so great. For example, the tissue removal has altered the way I move. I can feel a slight inward "collapse" when I walk. Body weight that was once more or less evenly distributed now shifts onto the inner edge of my foot, ankle, and shin. I'm just enough off-balanced for effusion to set in -- more or less apparently at random. The arch of that surgically altered side has elongated due to the shift (my BMI is 20). I feel a line of discomfort and instability that runs from inner ankle to inner knee. My left foot has become more pigeon-toed, or inwardly rotated. None of this is "painful"; but it feels unbalanced (my arthroscope was four-years ago). The solution hasn't been physical therapy, "strengthening the quads" and muscles around the knee. Surgery may have removed "pain"; but the scope also changed the mechanics of my motion. So I guess I don't know why replacing that shock absorber in order to promote a more balanced weight distribution isn't an option. Wouldn't replacing that cartilege be similar to, say, replacing the half-worn rubber brake pads on an automobile? Replacing that knee's shock absorber with a 3D printed (grown together using my own stem cells) piece of material seems a great idea. But, like I've read you write quite often: "... that sounds reasonable, doesn't it?" It seems to work in sheep -- why not human beings?

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    1. Why not? Because most things do not translate from animal to human research, if they ever really worked properly in the animals in the first place (see blog post on animal research: http://doctorskeptic.blogspot.com.au/2014/06/animal-research-just-another-woftam.html).
      You know what has happened in your knee. What you are experiencing is influenced by what you expect (off balance, weight distribution etc) and if 'none of this is painful', then how much of a problem is this really causing?
      I also think you are making the mistake of thinking about this problem (perhaps a little too much) as being mechanical or structural, rather than biological. If it were purely mechanical, your knees would have worn out when you were a child and your bones would have all broken from the stress of taking a million steps per year. The fact that they haven't is because they are constantly changing: responding to stresses, repairing and regenerating. If it was as simple as putting a spacer in the joint we would have done that long before 3D printing.
      It sounds harsh, but if none of this is painful, you gotta move on.

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  41. Hi Doctor, I have just been to a specialist wants to book me in for a 'cleanup' as xrays and ultrasound suggest a small loose fragment above the kneecap, which to me feels like a firmish bulge/lump. I have been able to move the lump a little to get a range when walking over the past 2 months. In the past week it appears to be going down and not bothering me. In the meantime there seems to be a bit of a similar lump on the left of the kneecap which is causing some discomfort when walking and certainly stairs or stepping up. Not sure if the said fragment has moved etc...
    I had an acl reco about 12 years ago and it has been pretty good, I do get occasional swelling that takes a week to go down, sometimes for no apparent reason.
    Should I wait longer to see if the knee settles, its been 2 months now, or can a cleanup help. I'm guessing from the theme of the post, I should not do anything, and wait to see if it goes. The knee has never had locking.

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    1. I am sorry, but I am trying to avoid this blog becoming a clinic. I am happy to discuss the evidence, but it is obviously difficult for me to offer clinical advice to people I have not seen. My only advice is to clarify your question and then see someone you can trust (or more than one) to get their opinion. What do you mean by a "clean up"? meniscectomy? debridement? chondroplasty? There isn't much good evidence for any of them, but the way to approach any problem is to define the condition you want treated, define the treatment options, and then search for the best available evidence regarding their effectiveness for that specific condition. Sorry for not giving specific advice - hope you understand.

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  42. Perhaps mention this thread is closed if no longer responding to it, save people writing in long detailed questions

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    1. Thread is not closed. The answer provided above was given quicker than if you rang my office to make an appointment

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  43. Dear Dr Skeptic,
    I notice a general black and white/binary approach in your posts. Either something works or it doesn't. At the same time you rightly say that reality is complex. What I don't agree with is the outright dismissal of something for lack of a control trial. I think much progress in medicine has been made off the back of pioneering work when the notion of control trials didn't even exist. Of course it's unpleasant to admit that some patients' health had to be sacrificed in the name of medical progress and pioneering work. Perhaps if we keep waiting forever for a control trial to be done here and there and everywhere, we will be waiting a very long time if not forever. Anecdotal evidence might be preferable and quicker. For instance, you say that conservative treatments for a meniscus tear doesn't work that well. Granted. But saying that might reinforce the message that hydrotherapy and physiotherapy are a waste of time. So people might end up doing nothing, moving very little, and aggravating the problem. If something doesn't work very well it doesn't mean it doesn't work at all. Also I wonder why you discount meniscus transplant from a donor. Granted, there are no control trials and it can lead to various complications. But the option for those without a meniscus is to have a knee replacement. So why should they not try a transplant instead.

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    1. Thanks Selene. I agree. We cannot say that something doesn't work if there is no good supportive evidence. We should say that we do not know whether it works or not. My problem is that many physicians are black and white the opposite way, in that that firmly believe that things work when there is no good supporting evidence. Having seen so many things that were once thought to be effective. later shown to be of no benefit, I just want to stress the point that we should not ASSUME that something works just because we can justify it with a biological mechanism, or because it appears to work in our hands. I just want people to recognise the biases that can make things seem effective, even when they are not.

      And, yes, sometimes doing nothing is reasonable. I have seen enough patients in my career with severe arthritis who have never done anything about it and have coped very well. Medical intervention isn't always the answer.

      I do not accept your argument that the only option for someone with a torn meniscus is a knee replacement. Most people over 50 have a torn meniscus and the correlation between presence of a tear and pain is not clear. I think they shouldn't have a transplant for several reasons. Firstly, based on the history of tissue engineering and cartilage / meniscus transplants it will probably not work. Nothing like that ever has. I accept that it MIGHT work, but the probability is low. Also, there is a risk of harm associated with that procedure. Thirdly, I don't want to pay for it - I think that the money could be better spent elsewhere. Having said that, if you want to have it done, are willing to fund it without public money or insurance money, and are willing to accept the risk and the low probability of success, then I have no objection (or any right to object) to you doing what you want with your body.

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  44. Dear Dr Skeptic,
    thank you for your prompt reply. I agree that it is very bad practice when a doctor overpromises and underdelivers. On the same topic, I heard recently on the BBC about the nocebo effect. Quoting from the website:
    Nocebo, meaning "I shall harm", it is the wicked sibling of placebo, meaning "I shall please". First remarked on in the medical literature in 1961, it took nearly 40 years for hard evidence to emerge when, on a hunch, an Italian physiologist, Fabrizio Benedetti, conducted a cunning experiment..."
    Incidentally I'm also Italian living in the UK. I think a self-fulfilling prophecy can work both ways. Somebody might never fully recover because they've been told by their doctor that their knees are a total write-off. You say that patients shouldn't look to get hope from their doctors. But hope has an important role in spurring us on in trying to find ways to improve our lives. The BBC programme is available on the link below and it starts, interestingly enough, with a made-up dialogue between a doctor and a patient about an arthritic knee. The doctor is very matter of fact, realistic verging on the brutal. The conclusion reached in the programme (which you probably won't agree with) is that doctors should pretend they know more they actually do in order to reassure the patient and have a positive effect on their health. This is the link to the "nocebo" programme: http://www.bbc.co.uk/programmes/b052j0ty (available for a limited time).

    I also thought I'd quote this interesting passage:

    "Nocebo is not only more powerful than placebo but it is likely to be more widespread and its implications are far more serious as it not only interferes with the existing treatments but it hinders the development of new drugs. And as clinicians and researchers become more aware of the consequences of nocebo, many reach the same uncomfortable conclusion - that patients are being given too much information about the risks of treatment - be it surgery or drugs - creating anxiety and fear which leads to physical distress. Doctors are caught between a rock and a hard place - First do no harm is the bedrock of medicine. As is informed consent. But what do you do when informed consent leads to harm?"

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    1. Excellent. Thank you very much for the link. I have not addressed the nocebo effect before, but I will try to write a piece on it in the future.

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  45. I recently had a scope to "clean" up my cartilage. I have grade 2 of the patella but the entire trochlear/patellar groove is grade 3. Before the scope I did viscosupplementation shots and cortisone injections. The cortisone was effective for about 3-5 days. I now have more pain but less swelling after the scope. I have been trying to strengthen my quads but I haven't made any progress and was put into aquatic therapy, where I am also making little progress. I have constant pain which is aggravated by activity and have difficulty working and sleeping. Am I nearing the point that a knee replacement is my only option for pain relief?

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    1. I would say that a joint replacement is never the "only" option. Grade 2, grade 3, aquatic, land-based etc is neither here nor there. You ability to accept and deal with your condition using your own resources is what is important. I have seen people cope very well with the worst knees imaginable - still walk unaided and never have surgery. I have also seen people with very little arthritis who are completely unhappy and perceive that they can't do anything and that their lives are miserable. I wouldn't spend too much time chasing medical treatments like injections, or worrying about whether my cartilage was grade 2 or grade 3. I would be thinking about whether or not I can cope with what I have. If you can't cope, then seek help, but remember, caveat emptor (buyer beware). See my recent post: http://doctorskeptic.blogspot.com.au/2015/05/my-right-foot-predicament-versus-illness.html

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  46. Dr. Skeptic..... what is a youngish active person to do when the post traumatic arthritis starts to severely limit return to high impact sports that are important to them? Are there any peer reviewed studies to suggest that arthroscopy might buy someone some good years with respect to higher impact (practiced at a high level) activity? My unofficial anecdotal survey of some ski instructor friends says yes.... when I asked if meniscectomy brought about a period of significant relief. They all encouraged me to go for the surgery since conservative treatment didn't help me and I had the most painful ski season I ever had. I actually had my knee drained and cortisone shot mid season which only reduced the pain and swelling to tolerable levels to finish out my season. BTW.... my post (20 years later) traumatic arthritis is largely in the lateral compartment with lesser effects in the medial compartment. I do have a science background and while I understand what the science says... it's hard to do nothing when nothing isn't working either. PS... giving up skiing is not an option (I also have friends that ski really well on their TKRs).

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    1. If you have had post-traumatic OA for that long, it is very unlikely that an arthroscopy will help. Even a placebo response is not likely to help you that much. By all means keep skiing, but use whatever else you can to help your symptoms. The failure of conservative treatment does not convert an ineffective operation into an effective one.

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    2. Maybe hope for the future... http://www.wsj.com/articles/new-fixes-for-worn-knees-1430761617

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    3. We have hope. Medicine and the media are FULL of hope. We have hope up the wahzoo. What we don't have is good science to test that hope. I don't want hope, I want results. I want clearly documented, reliable and reproducible improvements in pain and function. What happens is that we get so caught up in the hope, the possiblities and our wishes to make it work that these things get implemented without proper (blinded, placebo) testing and then an RCT becomes "unethical".

      You watch this space. They will do tests showing that it doesn't wear out or tear, but there will be no comparative blinded studies to show that patients are better off.

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    4. 1 year ago I decided to have the knee scoped... both menisci were trimmed and chondromalacia, scar tissue, synovitis etc.. where also removed. My knee stopped catching and waking me at night with pain. I still have arthritis... my knee gets aggravated easily... but I took very little anti inflammatory and had greater mobility and greatly reduced pain this past ski season. For me the scope was a success.... I believe surgery in the right patients with realistic expectations is still a viable option.

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    5. I should follow up for those that may be reading this.... 1 year ago I had the scope... both menisci trimmed, chondromalacia, scar tissue, synovitis also cleaned up. My knee doesn't catch or wake me up anymore (for now).. I had greater mobility and significantly less pain this past ski season. I still have arthritis and an easily inflamed knee (which improves more quickly when it does happen)... but I deem the surgery a success. I think it's still a viable option for the right candidate with the right expectations.

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  47. Dr skeptic,
    I am currently a patient who had arthoscopic surgery, had a loose body removed and was told I have no miscus along with osteoarthritis. He told me I have a 60-70yr old knee. I am 5'4 @ 278lbs and I'm 3 years old going to school to become a nurse. I've been a Aid for 12years. My doctor told me to not be a nurse and that I need to change my career. He told me after I had the arthoscopic surgery that he did not realize I had little to no meniscus and that I am bone on bone and that I need to make a decision, either have total knee replacement or continue with my career... I am in so much pain after 3 weeks of arthoscopic surgery ranging from level 2 pain on a consistent basis to a 9 when I am on it longer than 20 min or less sometimes.. I don't know if I trust my doctor. I have bruising 2 inches below my incision and servere bruising on my incision. He said it's normal. I also have continual oozing out through one incision. I am taking celebrex and still under his care. I want a second opinion but don't know protocol and proper etiquette. What do you think?

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    1. I think that the arthroscopy gave you no benefit. Regarding your current problems, you need to have an orthopaedic surgeon look at your knee, either your usual surgeon or another orthopaedic surgeon if you are unhappy with the opinion of the first one.

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  48. Had a torn meniscus in '04 that was wedged between leg bones such that I could not bend the leg ... plenty of pain too. Should I have NOT had the microsurgery to FIX this condition and just carried on for the rest of my life with a messed-up, unbendable leg? Of course not! So I had the surgery.

    But I chose the wrong doctor (his partner had great results, I later learned), and he REMOVED my meniscus while managing to damage NERVES in my knee, causing me pain and constant numbness ever since. Another thing: two days after the surgery, I noticed that the whole back of my thigh above the bad knee was BLACK, as in extremely bruised (and I NEVER bruise!). I asked the doctor if my leg was strapped down to the surgical table and, if so, could the strap have been too tight. He said it wasn't strapped. I asked him then what if my leg had jerked during surgery. He said it didn't. I asked if I FELL off the surgical table. He said no. He had no idea, he said, why my leg had turned black. Liar. So the whole surgery was beyond a bust, it was a DISASTER.

    It's been 11 years now, and the numbness has never left that leg (it drives me nuts), and pain varies but is generally present, and sometimes the leg suddenly gives out (haven't fallen yet, but I'm generally pushing a shopping cart when this happens). The bone-on-bone knee has ground itself down to the point where a knee replacement is the only fix, but I'm a 6'2" guy who weighs 330 pounds (don't move to Vegas ... I've gained ten pounds a year since I moved here seven years ago), and I think my weight would tear the artificial knee to bits in no time ... gotta get back to 250 or so before doing that surgery ... but how?

    So today my other knee (which has been getting worse for years) froze up (like the first one did when the meniscus tore), and it's going to be a rough road ahead. I"m a 35yo guy in a 74yo body and not liking it one bit. Stay THIN, people! And don't overdo stuff like I did (rode my bicycle about 50,000 miles since a kid ... across USA, Alps, west coast several times, etc. ... too much!). My heart doc (age 60+) just had BOTH hips replaced, and he has been a big time bike rider his whole life too. Easy does it, everyone ... and good luck!

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  49. Dr. Skeptic - any evidence that plica problems can be effectively addressed with arthroscopy? Very minor right knee injury occurred 4 years ago and healed quickly, but ever since then my superior and sometimes lateral patellar areas are frequently sore and have significantly limited my activity level. MRI shows plica, and mild-moderate lateral patellar arthritis. Only exercise I get now is walking on mostly flat surfaces 2 miles on a good day, no more hiking, biking, dancing; stairs are always a problem unless I do one step at a time. Have done 3 rounds PT, anti-inflammatory diet, acupuncture, and emotional/mental approaches; no lasting relief from any of these. Reluctantly am considering arthroscopy; surgeon wants to do patellar chondroplasty as well as address possible plica problems. Years ago, my first career was as a physical therapist. Thank you -

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  50. I had a Knee arthroscopy and a TTO neither one worked for me I am still in constant pain , I cant sit, stand, or walk for long and I have a limp. I wish I seen this article 3 years ago. All this happened after I fell off a stool at work.

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  51. I Have medial and lateral meniscus tears in right leg diagnosed (mri) approximately six years ago. Did physical therapy and have had essentially no problems since then. Fast forward three months ago, suffered a traumatic femur fracture,retrograde im rodding with screws. Fracture healing well. Problem now is intermittent knee locking and catching in Both flexion and extension. Usually i can wiggle the knee and unlock it, however yesterday had a 15 hour lock in extension and unable to unlock it. Difficult to use chair, bathroom, etc. finally, it relaxed. Would physical therapy help
    again or have tears/debris made repair something I really should consider?Cant imagine these locking episodes continuing particularly when I cant wiggle out of them. They are extremely painful. Thanks

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    1. My advice would be to see the surgeon who did your femoral nail. It looks like that is when your problems started.

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  52. After a sports injury, I had surgery by arthroscopic on my medial meniscus for a "large bucket handle tear" that was causing catching, clicking and popping in my knee and pain. I could only bend my knee to 100 degrees. I had full extension. And no issues with walking, standing or sitting or walking on a treadmill, stairs were easy. BUT THE PAIN from popping and clicking, catching hurt. It occurred on some days and on days it would not.

    The surgeon told me I had 40% meniscus left and told me that my prognosis is good.. I kept telling my OS that something is wrong with my knee and ask him why the limp and continued popping, clicking and catching.

    He says that all I need to do is keep working at strengthening by quads with PT. And I need to massage my incision sites to break up scar tissue which is causing the popping and clicking. I ask him how fast does scare tissue grow, because the popping and clicking, catching start 1 week after surgery.

    I ask for copies of my post-op photos and report. When I read my post-op report it stated that a subtotal meniscectomy was performed and only 20% of my medial meniscus is left. THEN I SAW THE PHOTOS OF AN EMPTY SPACE where my medial meniscus WAS. All I have left is the rim/edge of my medial meniscus left.

    The post-op report also states that my ACL, MCL, PCL, condyle surfaces all are normal, no arthritis or no defects of articular cartilage of tibia plateau or femur plateau and photos taking during my surgery show no arthritis and no defects to the articular cartilage on my femur or tibia.

    It's been 3 months and I have worst pain, my knee is unstable with loud popping, clicking, clicking. I can only bend my knee to 114 degrees and I get a burning sensation when sleep at night. I have difficulty when I walk, sit, stand more than 10 minutes. I have NOW have a limp and can't fully weight bear, if I full weight bear I get a tingling sensation down to my toes. It feels like I feel my bones touching when I walk or stand. I have been in PT for 12 weeks and the Therapist says something is wrong and feels that with 20% meniscus left that I'm on my may need a partial or full knee replacement in the future

    Is there ANYTHING that will help? I'm in PT and starting water PT next week because Land PT is hurting my knee.

    I've tried all types of pain meds with NO relief. THE MECHANICS OF MY KNEE FEELS LIKE A TIRE OUT OF ALIGNMENT ON A CAR causing scrubbing against the break pads.

    The surgeon keeps telling me it's because my quads are weak and that more PT is going to resolve my pain and but says the clicking is going to remain for awhile.

    ANY Insight that you can share is appreciated?

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    1. The only thing I can suggest is a second opinion. I think you are convinced that there is something mechanically out-of-whack in your knee. I wouldn't know what a tire out of alignment feels like, and it is clear that your bones are not rubbing together. I would want to know exactly what your symptoms are and would need to look at your knee. I can't do that, but another (closer) orthopaedic surgeon can.

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    2. A) Would a bucket handle tear of the medial meniscus be so bad that the OS would have to cut so much of my meniscus out and leave me with only 20%? The post op report states that my medial meniscus was reduced by 80%. The photos of my post op surgery show the a small portion of the outer rim of my left medial meniscus remaining. It looks like someone bit out a chuck of my meniscus leaving only the edge/rim. I have photos if you would like to see them.

      B) What's the prognosis of someone 5'9 123 lbs with only 20% of their medial meniscus left? I understand that everyone heals differently.

      C) Is there anything that can be down to replace my meniscus? because I only have 20% of my medial meniscus left, Do you feel that a meniscus transplant an option?

      My exact Symptoms:
      1) My left knee makes clicking and popping sounds and catches when walking sending a tingling down to my toes.

      2) when I walk my knee starts makes crunching sounds then starts to have a warming sensation, then when I touch my knee it's very warm.

      3) Burning sensation down the back of left knee when lying in bed.

      4) Pain when I weight bear on my left knee (can't stand up more than 10 minutes)

      5) Pain when I sit too long

      6) After walking or standing my knee cap gets puffy

      I am on crutches 3 months after surgery for a medial meniscus bucket handle tear. The OS keeps saying I need more PT.

      **My post-op report also states that my ACL, MCL, PCL, condyle surfaces all are normal, no arthritis or no defects of articular cartilage of tibia plateau or femur plateau and photos taking during my surgery show no arthritis and no defects to the articular cartilage on my femur or tibia. No evidence of chondromalacia patella. I have copies of the report and photos taken during my arthroscopic surgery that confirms what the report says.

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    3. The % meniscus removed is not the issue. The surgeon would have excised whatever was torn and has little control over how big that is. Whether you are left with 10% or 90% is unlikely to be related to your symptoms. There is no evidence that a meniscus transplant will help. I cannot give you specific advice about what to do unless you see me in my office. Given that I probably live a long way from you, I suggest you see another orthopaedic surgeon for a second opinion.

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  53. I had a chondroplasty last year on the patella and trochlea. Afterwards my patella sometimes catches when I straighten my leg. All other areas of my knee appeared normal, maybe some possible grade 1 changes in the lateral compartment. I had a diagnostic scope recently to see if I was a candidate for ACI of the trochlea. My doctor found a grade 3 lesion the lateral femoral condyle that was from 20-70 degrees that engages the lateral patella facet, now grade 3, and a grade 3 fissure in the midportion of the lateral tibial plateau. Could my scope from last year accelerated these degenerative changes in the lateral compartment? One year seems to be a quick time period to from grade 1 to grade 3. He also removed unstable cartilaginous edges removed - can this cause more degeneration?

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    1. Any disturbance of the anatomy inside your knee can accelerate degenerative changes, but the relative contribution to that process from the arthroscopic procedure would be difficult to determine.

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    2. Before the scope I noticed some very mild lateral joint line pain that was assumed to be referred pain from my patellofemoral joint. Now the pain is moderate with painkillers and I am walking with a cane. I can hear and feel cracking from the lateral area now. How arthritic is this area? Any chance it will get back to how it felt before the scope?

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    3. I now feel constant pain in the lateral joint line that is moderate-severe without strong painkillers that I didn't have before the scope and need to walk with a can for longer distances. I have clicking there in addition to the clicking I already had in my PF joint. How arthritic is my knee and what is my prognosis?

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    4. I'm sorry but I have no idea. You have to make a decision between putting up with your condition or seeing a doctor and getting their advice. I am in no position to comment.

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  54. I have a torn medial meniscus root tear and mild arthritis, age 61 female. 3 surgeons said I had to have a "scope." Then I called an orthopedic surgeon friend from out-of-state. He said everything you have said! He told me he has the same thing for 5 years and is still not having surgery. He said the shots are a waste of time too. Most alarming, he said if I got the scope, I may need a TKR in two years. I'm so grateful I spoke to a friend. Thank you for spreading the truth about the waste and damage the arthroscopic procedure is. I feel all these other surgeons just want a quick dollar.

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  55. What is your opinion on unloader braces? I have moderate osteoarthritis in my medial right knee. The doctor said it would put more of the pressure on the good side of my knee, and help create a space for a future injection of Synvisc. After reading your blog here and other information, I am no longer interested in injections and arthrocopic surgery.

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    1. THanks. The evidence for bracing is weak, and they are a hassle. See link to COchrane review here: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004020.pub3/full
      "Create a space for a future injection of Synvisc". OK, now I am worried. That is rubbish. Don't have a brace, don't have synvisc and don't have an arthroscopy. you will be no worse off and a little richer for it.

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  56. i wonder why can't they do surgery on a 23 year old. can anybody tell me. I have a swollen knee thats been going on for almost 3 years

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  57. i wonder why can't they do surgery on a 23 year old. can anybody tell me. I have a swollen knee thats been going on for almost 3 years

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    1. Your age is not an obstacle to surgery. The question should not be "can" they operate. OF course, we "can" operate on anyone. The question is: for the condition you have (which I don't know), is surgery more likely to provide you with benefit compared to a non-operative alternative?

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  58. Thank you so much for this blog and this insightful and thought provoking information. I would GREATLY appreciate any advise you may be able to give me.
    I am 48 yo, and have long given up any impact activities for close to 15 yrs d/t some knee arthritis (cant bend, sqauat, etc..). I have stayed active in the gym doing mainly weights and the elliptical. Over the last year I have developed stabbing type pains in the lateral portion of my knee, just doing random activities. 4 months ago, I moved "wrong" and had another sharp pain, and... whammo!... my knee blew up like a giant balloon and I had no ROM, couldn't walk. Could not get rid of the pain and swelling. Went to PT faithfully for 2 months with no change. Had a cortisone injection which also did nothing. Was on crutches this whole time. My quad pooped out. MRI showed pothole in cartilage, synovitis, and arthritis. Ended up having arthroscopic surgery and they "smoothed" pothole in meniscal cartilage, and scraped the grade 4 arthritis under patella. They told me it was "bone on bone". (no other tears). It has now been 8 weeks since the surgery and I am still in a lot of pain, stiffness and intermittent swelling. Still in PT. I tried to get off crutches for a couple weeks, but now am back on them, as the pain under my knee cap is intense. (??) The annoying thing is.. I never HAD pain under my knee cap before the surgery! I experienced the aching and throbbing feelings d/t the arthritis and couldn't do any impact stuff.. but never had the pain under the patella like this. (Like I said, it was on the lateral side where I was hurting before). So now, I feel like I have a NEW problem that I didn't have before. I'm still going to PT 2xs a week, and scheduled for gel injections in a month. (which I think I read that you stated don't really help that much?) I am SO frustrated... I don't know what to do.
    Is 3 months post surgery too soon to be expecting to be better? I feel as if it shouldn't be still in this condition after this time.
    I am meeting with a surgeon who does TKR in December. I have been out on disability since the injury in May.. (btw.. Im a floor nurse in a hospital). I don't know if this is ever going to heal?
    I am not looking for a diagnosis... just thoughts? Im so discouraged.. :(
    If you have read to the end..thanks for your time and consideration. I value your input

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    1. Thanks. Unfortunately I can't really give you any advice without seeing you and your scans etc. All I can say is to see another surgeon for a second opinion. TKR may be a option but that is a big decision and I would get more than one opinion on that.

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  59. I had torn cartilage removed from my left knee 48 years ago, it was never the same afterwards, but I had more movement and much less pain.
    It has troubled me for years, stiff, achy, locking etc but not really painful. Over time the range of movement has become less and less, I can't squat to do simple chores etc, have to bend from the hips now to do anything low down. This knee has OA now and has become knock kneed, if I stand with my knees together my feet are about 4 inches apart, and it aches constantly especially at the back of the knee. It really gets me down and makes me feel so much older, I am limping all the time,mainly with my leg held straight as bending it is worse,and I'm now getting pain in my right hip too because of the way I walk. Even preparing dinner in the kitchen for an hour I can hardly bend it enough to sit down without holding onto the table. I don't expect to be able to squat or kneel down but really hope a TKR will make a difference if I can get it done.

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  60. I had torn miniscus which was repiared via arthoscopy, then within a few months tore again (which my Dr says is very rare) since second arthoscopy, now almost 11 months post op, knee is severly swollen and ache's constantly. He did find osteo while in and "smoothed" the OA during first and second surgery, most severe behind knee cap, says next step is most likely stem cell injections (steriods did nothing) but insurance wont pay for stemcell injections and he says if i was 20 yrs older would recomend TKR. Im 43 & have to use a cane now. How old is old enough for a TKR!!

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    1. Thanks. It is likely that the arthroscopic procedures added no benefit and may have contributed to your decline. There is no good evidence that stem cells will help you and some evidence that they will not. You can have a TKR at 43, but there are risks involved and it will be up to you whether or not you are happy to accept those risks.
      A TKR may be effective (there is evidence that it can be) but injections are unlikely to help you.

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  61. Thanks for your really great blog. I've carefully read several posts of yours and your thoughtful responses, and I'd appreciate if you would be able to answer a question of mine.

    I am 38, 6.2 feet, 200 pounds, athletic. I've been very active (Brazilian jiu jitsu, some running, a gym) all my life and beside some minor knee aches and clicks here and there have never had serious problems with my knees. Unfortunately, it all changed in the last year after I started doing Crossfit. First, I developed quadriceps tendinosis which refused to go away. After studying the issue, I began “treating” the problem with isometric heavy barbell holds on my ankles with legs in full extension, putting pressure on my quadriceps. Only later did I realize this exercise might lead to the softening of the patella cartilage in the knee. But at the time, the exercise was able to help me with my tendinosis, which is no longer a problem for me. BUT, about 6 months ago there was a workout with heavy lunges (where you hold weight above your head and then place your knee on the ground and step forward and so further). I didn't lend too hard on the floor with my knees but I still landed hard enough--the next morning I found out I developed crepitus (a rice krispies sound) in both of my knees (much more serious in the left one). Since then my knees have been clicking and grinding (mostly when I extend my leg from flexion) much more than before and the crepitus has never gone away. The knees would click and the kneecaps would track incorrectly at times and at other times they won’t. Stretching quads would help one day and would help less another one. Likewise, at times, several "clicks" would seemingly stabilize the kneecap and there would be no clicks anymore.

    Even though I have a fool ROM, can easily squat and do pretty much everything and feel no pain, all this clicking and crepitus has finally led to me to realized that I most probably have damaged my knees to the point that I now have chondromalacia, perhaps even at an advanced stage. Curiously, only after discontinuing all activity and starting PT have I also started feeling some minor aches around my kneecaps, and though I am not certain what they are about I've become even more concerned.

    So, I've been thinking of what to do next. Firstly, I started a PT regimen and started avoiding all exercises that put pressure on my kneecaps in a flexed position. But I was also thinking about having something else done (perhaps some injection or whatever) in order to prevent further deterioration and was thinking about having my knees MRI'ed to see what's going on there.

    But if I get you right, an MRI is not such a good investment right now, and I should just stick with the PT and avoid exacerbating activities (like squatting and lunging with weights). That’s because even if I find I have mild or advanced chondromalacia it won’t matter because at this point there isn’t much that can or should be done besides PT to prevent its further deterioration anyway. Am I right or would you still recommend I do MRI due to some benefit I might have from it? Like, for instance, if I have some torn pieces of cartilage in the knee, perhaps removing them might be beneficial? I am afraid that if I find out I have some bad cartilage changes “there,” it might have a negative psychological effect on me and future exacerbate my situation.

    Thanks

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    1. Thanks, and apologies. I can't really give good advice for individual cases without examining them properly. It sounds like an MRI will not help and if pain is not a big issue (not stopping you from doing daily activities) then the crepitus doesn't worry me that much.
      The only exercise I do is run. Why not give the gym and PT a rest and just do what you like doing and see how it goes? Like your quads tendinitis (and most other tendinitis) it will get better in time.

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    2. Thanks. After reading your blog and giving some thought to the issue, I understand that you are of the opinion that for some (many?) people PT has the same placebo effect that many other possible "treatments" (surgery, injections, etc.) out there that seemingly help but when tested thoroughly are no better than sham treatment. I tend to agree with you and there is indeed a very good possibility PT is not beneficial in my case too. But I want to keep my muscle tone and I do enjoy working out, so I guess PT fits into that picture, as long as it doesn't exacerbate the problem (I judge it by the amount of pain during and after workouts). And, of course, I try to avoid knee-stressing activities. Do you think there's actually a reasonable chance that crepitus and grinding might actually get better in time?

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    3. Possible, but difficult to predict.

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    4. Hello Dr Skeptic,

      Thanks a lot for you responses so far. I know that you aren't in favor of giving medical advice, and so I will put it as a general question of the applicability of arthroscopy, not whether I should or should not do it.

      You mention in your responses that debridement might indeed be useful in some cases though not in general. What is your opinion about its possible relevancy for someone who had sustained a traumatic articular cartilage defect that had led to chronic, four-five months long "catching" and grinding of the patella on the femoral condyle at the end of knee extension and to further irritation of patellar articular cartilage at the point of contact? If such catching doesn’t seem to be alleviated by rest and has only become more prominent and has eventually led to lateral patellar pain, wouldn't gentle debridement, if possible and if the articular damage isn't too severe, be of use in stopping the catching in such particular case and therefore stopping or slowing further patellar attrition? And if you believe rest is still the best option, how long do you believe the rest should be before jumping to conclusions?

      Thanks

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    5. I don't think rest does anything at all. And debridement may remove a loose body (locking), but as far as 'smoothing out' the cartilage defect, surgery will not help. It will not slow down eventual attrition, it will only remove more cartilage in the process and, if anything, accelerate degeneration.

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    6. Thanks again Dr Harris. I've read your book--it's great, and accidentally I've also stumbled upon "Wasted" just today--a great watch too.

      After giving the issue a great deal of thought and reading about it rather extensively recently, I can now see your point more clearly. I realize what a huge risk any kind of knee surgery is, especially as it may disturb the gentle balance of tissue homeostasis and lead to unintended grave consequences. There's some chance I might end up okay, but even that will only "buy" some time at best.

      I now hope my knee issues do not get worse and I am able to restore the "envelope of function" as per Dr. Dye, with whose approach you might be familiar, by avoiding aggravating activities and moving my knees in a gentle manner (mostly walking). Sadly, the idea that any kind of surgery (or any medical treatment out there) might bring me back to where I was a year ago--able to life heavily and do Olympic weightlifting--now starts seeming further and further less viable. I will now be glad if I am able not to degrade into a more severe arthritis form. I am thinking of having an MRI to see the extend of damage though.

      In your last sentence you sound as if the eventual attrition is inevitable, but from what I've read not all people, even those with advance chondromalacia, advance into "eventual attrition." Do you believe cartilage can restore itself or at least stop deteriorating? There's some research there claiming hyaline cartilage restoration even where the subchondral bone isn't exposed. Most of sources claim it's impossible though. There are also people who seem to have had their cartilage restored without surgical or any other kind of intervention.

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    7. I am not sure of how much healing is possible, particularly because in many cases the factors that caused the problem (whether it be malalignment, obesity, age etc) are still present.
      I would not get an MRI to determine the "extent of damage". The MRI can't even diagnose "damage" from natural changes, let alone the extent of them. Correlation between MRI and clinical findings are minimal.

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    8. Thanks Dr Harris.

      Frankly, I was surprised to read about your negative assessment of the MRI. From what I have read, the accuracy, especially if it's a high-grade lesion, is relatively high. Anyhow, if the MRI isn't informative enough, is arthroscopic surgery simply to have a look inside without performing any kind of shaving and trimming a viable option? Or does the procedure bear with it some serious potential complication that outweigh the benefit of knowing what goes on inside my knees?

      My knees don't seem to be improving (it's actually the opposite, sadly), and my thoughts about some kind of surgery for cartilage restoration have been steadily growing. Here in Ukraine where I live it isn't too expensive to have investigative arthroscopy but I am not sure what to expect and what the real risks are.

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    9. The MRI is very accurate at seeing things, but the things it sees are not necessarily the cause of the pain, and even if degeneration was correlated with pain, arthroscopic surgery (and injection therapies and anything that uses the phrase "cartilage restoration") are ineffective. It's not a matter of risks - risks are only important if there is some real benefit against which to weigh them.

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  62. Hello Dr Skeptic, What is your opinion of abdominal fat (stem cell) transfer to knee for OA. I was referred by my OS (who does sports medicine) to see one that does replacements. I was told by that one that I was "too early" for a replacement and he recommended the fat transfer procedure (Lipogems). He also said that patients that have a replacement "too early" do not do as well as patients with more advanced disease-that surprised me-as I would think the less damaged your joint is-the better outcome you would have? Thanks in advance!

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    1. Most people who have a knee replacement end with about the same function, regardless of where you started off. Therefore, people with worse knees to start with have a much greater degree of functional improvement than people with only mild problems.
      As far as the stem cells go, see m blog post on that one but there is no good evidence that it is helpful

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    2. Thanks so much!

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  63. Not sure if you can give me advise but here goes. Trauma to the posterior aspect of both knees in 2012. Diagnosed with complex tear of the meniscus that would require surgery. In the interim, 2013, 6 weeks post trauma, DVT & pulmonary emboli diagnosed. Also CRPS. Arthroscopic medial meniscectomy & chondroplasty & R/O plica deferred for 7 months until DVT stable. Knee never the same. Further MRI 2014 showed knee complicated by a new posterior horn root attatchment tear of the medial meniscus. Also new radial tear involving the free margin of the body of the lateral meniscus. Pain Dr advised they were non surgical... Fast forward 2017 mobility compromised, arthritis both knees, and tears reactive to the point on some days, the pain can literally stop me in my tracks. Having a follow up MRI and believe Pain Dr got the non surgical part wrong. Opinion please

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    1. I think the pain Dr nailed it. Sounds like you have arthritis and degenerative tears, in which case arthroscopy is no more effective than placebo. Follow up MRI is a waste of time - you already have the diagnosis.

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  64. I am scheduled to have arthroscopy for OA next week. I am now wondering if this is a bad idea. The doctor told me it would be 50/50 if I have success. I was willing to take the chance but now wondering if it will make it worse. My biggest complaint is a catching feeling when i walk. My meniscus is intact. Most people that post have had meniscal tears? Is there any difference?

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    1. Is there anything to be found in your knee on the imaging that has been done? If not, the arthroscopy will be a fishing expedition (a 'diagnostic' arthroscopy). This may be considered reasonable if your symptoms are particularly bothersome and have not resolved over time or with alternative treatments. If it is not too bothersome and has not been present for that long, then doing nothing is may also be considered reasonable.

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