Sunday, July 31, 2016

Yet Another Study Weighs in Against Surgery for Knee Pain

On knee pain, two solid, almost unassailable truths have emerged:

(1) If you want to reduce your pain and you’re overweight, lose weight. I’ve given up citing all the new studies that link excess weight to knee pain, as I could probably mention one every month, but what’s the sense? The message is always the same. If you’re still debating this one, you probably still think the earth is flat too.

(2) Surgery is a bad idea for most cases of chronic knee pain. This is more an emerging truth, but the evidence just keeps stacking up. Most recently was a study summed up by the Washington Post with the headline “Maybe You Don’t Need That Knee Surgery After All.”

The study included 140 adult subjects, averaging 50 years in age, with knee pain from a tear in the meniscus. (Important: the tear was degenerative, as opposed to the result of a specific injury.) The participants either had arthroscopic surgery followed by a daily exercise regimen or worked with a physical therapist on neuromuscular and strength exercises a few times a week for 12 weeks.

At the final two-year checkup, the researchers found basically no difference between the surgery and physical therapy groups in their level of pain, ability to function in sports, and quality of life.

For the full study (as of this writing, it’s not paywalled), go here.

Saturday, July 16, 2016

Scott F. Dye on Why Your Knee Pain Diagnosis Stinks (And Why You’re Not Getting Better)

You MUST watch this. Honestly. TriAgain left the YouTube link in the comment section. When I finally got time to view the whole thing, Dr. Dye's remarks left quite an impression and actually left me wanting more.

This is unvarnished, straight-talking Scott F. Dye, who has been described as a “renegade knee theorist.” He calls himself a “surgical minimalist” as well. Most importantly, he has thrown his weight behind the only medical theory of understanding chronic knee pain (“the envelope of function”) that makes sense, at least to me.

The YouTube video is a 56-minute presentation (and q&a session) that he gave that I could write pages and pages about. Instead, I’ll just touch on some highlights.

* The worst cases of knee pain he sees are “iatrogenic.” That’s a very significant word to know. Because it means, basically, the surgeon caused the problem. Well, not the initial knee pain, but the surgery to “correct the problem” made it worse.

He shows a slide of several knees that went through multiple surgeries. Each knee got worse after all the operations.

* Chondromalacia is not a death sentence (he has asymptomatic grade three chondromalacia, he tells us). Also it’s not the same thing as patellofemoral pain syndrome. This common confusion clearly irks him; he even mentions that the Mayo Clinic website wrongly uses the two as synonyms.

“This is total and utter nonsense,” he says.

* Patellofemoral pain syndrome does NOT correlate with malalignment. There’s one study I usually cite as evidence to support this; he lists what appears to be a dozen or so studies.

What’s more, he makes the point that it’s dangerous to try to make adjustments based on perceived malalignment. He shows an X-ray where the kneecap looks tilted – but if you look at a different image that includes the cartilage too, you see the cartilage on the patella and end bone actually mate perfectly.

So what if a surgeon had gone in and tried to shave off some cartilage or perform a lateral release to “fix” that kneecap, which was actually perfect for that particular person? That’s how you get iatrogenic problems.

* He believes the key to understanding what’s wrong with painful knees is through a bone scan. This I find quite intriguing. I often thought that some kind of bone scan would have revealed the problem in my knees that the X-ray and MRI didn’t really detect.

(Yes, I blamed bad cartilage, and I still think there’s some truth to that, as excessive force on the joints may reduce the ability of cartilage to absorb shock, but I think a bone scan may have found other problems.)

* He is incredulous when talking about “PT Nazis,” who encourage patients to work through their pain threshold. I almost stood up and cheered. This approach is just nuts. I know it now, you should too, and Dye remarks, “This is just sickening.” He’s right. “No pain, no gain” makes sense for muscle growth, but not for a sore and aching joint.

* Then, finally, on being a surgical minimalist, he says “less is more.” He also conjures up a really neat image when he says, “Sometimes we surgeons have to get the pebble out of the shoe.” Notice the implied modesty there. This isn’t surgeon as superman, trying to remodel your entire joint. Rather, he’s trying to remove something small that doesn’t belong in a well-functioning joint.

Watch it. You’ll be glad you did.

Saturday, July 2, 2016

Acupuncture Is Probably Another Dud for Treating Knee Pain

I have a colleague at work who swears by “needles.” When he’s tired and stressed, he vanishes for an hour or so and returns from his acupuncturist feeling revived.

Is acupuncture useful for knee pain?

Evidence-based science indicates probably not. Here’s a summary for a recent study, published in a very reputable periodical (the Journal of the American Medical Association). Now of course it’s only one study, but everything on the subject that’s landed in my inbox over the last few years generally agrees with these conclusions.

First, 282 patients over age 50 with chronic knee pain were divided into four groups. The researchers were interesting in finding out whether traditional acupuncture or laser acupuncture helped alleviate pain. So two of those four groups were controls that received either no acupuncture or sham laser acupuncture.

Over the course of three months, patients received as many as 12 20-minute treatments.

After a year, there were “no differences between any of the groups on measures of knee pain and function.” The researchers suggest there were no real or direct effects of the acupuncture sessions.

I found this quote, from Rana S. Hinman, the study's lead author, most telling:
"Acupuncture tends to be more effective for people who believe in the benefits of acupuncture."
In other words: this is classic placebo effect.

One footnote that may comfort acupuncture believers: it was suggested the treatment may be effective for some people with neuropathic (nerve-related) pain. They weren’t included in this particular study.

And also, let me chime in: If acupuncture works for you, keep doing it! There’s no harm that I can tell. Even if 80 scientific studies say it’s worthless, if your knees feel better after being stuck with needles, that’s good enough. Who cares if it’s the placebo effect, really?