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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2022 Five Year Follow-up on Physical Therapy vs Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: ESCAPE RCT Results by Karen Napierala MS, AT, PT, CAFS What would you do? A 52 year old male limps into your office after stepping on an uneven muddy surface, slipping, and feeling pain in his medial knee. He is lacking full knee extension by 50 degrees with a springy empty end feel. End range flexion is painful/limited, as is full weight bearing. He denies any frank locking symptoms. A small effusion is present and tenderness is isolated to the medial joint line, especially posteromedially. Plain films show very mild joint space narrowing. McMurray’s provocative testing reproduces pain with tibial ER + varus compression. The patient is eager to return to hiking, and outdoor activities as soon as possible. I would prescribe… “RICE”, NSAIDs, and gradual activity return as able over 2-4 wks - call if problems persist. Order MRI for suspected medial meniscus tear. NSAID’s and 3x PT visits based on ease of location for HEP training. Intra-articular steroid injection and reassess in 2 weeks. Customized biomechanical PT to include Class IV laser, manual therapy as needed, customized exercise for off-loading medial knee. FU 4-6 weeks. Refer for or schedule knee Arthroscopy for expected partial medial meniscectomy and chondral debridement. CURRENT EVIDENCE Rhon DI, Fraser JJ. et al.“.Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People with Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial, JAMA Network open, 2022:5(7), 2022, 2021; 619-27. SUMMARY: Meniscectomies for degenerative meniscal tears are performed throughout the United States but more recently have been recommended less routinely than in the past due to numerous studies showing no clear clinical benefit over non-operative care in the first two years. Debate is ongoing, however, regarding the implications that arthroscopy vs rehabilitation choices may have on subsequent cartilage degeneration over a longer period of time. Some have suggested that addressing unstable meniscal tissue will reduce the potential for abnormal stresses on the articular cartilage. A multicenter randomized clinical trial (RCT) on arthroscopy vs exercise therapy for degenerative meniscus tears (ESCAPE Trial) was conducted in the orthopedic departments of 9 hospitals in the Netherlands. Recruited subjects had symptomatic, MRI confirmed degenerative meniscus tears - 321 patients aged 45 - 70 years participated between 2013 and 2020. Patients were randomly assigned to arthroscopic surgery + written HEP or 16 sessions of exercise based PT. The study was non-inferiority RCT after 5 years following up on the original ESCAPE Trial group of which 278 of 321 patients completed the study. Neither IKDC nor radiographic knee OA indicators (OARSI and Kellgren-Lawrence scales) showed statistically significant differences at five year follow up. It should be noted also that as-treated analysis also showed no differences, with 32% of the PT group subjects’ crossing over to delayed surgery but still never achieved significant improvements over the PT-only group for function. Comparable rates of progression of radiographic knee osteoarthritis were noted between treatments. Noorduyen et al concluded that exercise-based PT remained non-inferior to arthroscopic partial meniscectomy for patient-reported knee function and radiographic knee OA during the following five years. They concluded that “PT should therefore be the preferred treatment over surgery for degenerative meniscal tears”. While the PT program that included simple ROM and generic squats, step-ups and lunges was as helpful as the surgery. There was a significant amount of patients from the PT groups that were unsuccessful. Our experience has shown that numerous biomechanical factors must be considered to optimize and expedite patient recovery. These focus both on potential underlying contributing factors that accentuate forces through the medial or lateral joint and also include specific techniques used to off-load the medial or lateral joint tissues during otherwise limited and painful squat based WB strengthening exercises. These are not commonly addressed in traditional physical therapy programs. The addition of Class IV laser has also proven helpful for many patients having degenerative meniscal tear diagnoses. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Recommendations for care of degenerative meniscus tears has changed toward non-operative PT/exercise based on studies comparing arthroscopic partial meniscectomy (APM) outcomes over two years. A significant reduction in APM, however, has not been seen. Neither surgery nor conservative treatment (exercise) necessarily prevents the development of OA. Conversely, some studies have shown APM in these degenerative knees to accelerate this articular degenerative process. Purpose: This study looked to compare patient-reported knee function at the 5 year follow-up mark after APM and exercise-based PT in patients with a degenerative meniscal tear. Secondarily, it looked to assess the radiographic progression of knee OA. Their hypothesis was that exercise-based PT is non-inferior to arthroscopic partial meniscectomy after 5 years. Type: Non-inferiority RCT Methods: This study followed up on the ESCAPE Trial or “Cost-effectiveness of Early Surgery versus Conservative Treatment” begun in 2013. In this study, 321 patients aged 45-70 were recruited who had MRI confirmed degenerative meniscus tears. They were randomized to APM within four weeks or PT exercise groups within two weeks of injury. APM included a written HEP (after 8 weeks access to PT only for delayed recovery) and PT was BIW x 8 wks + HEP training for 16 sessions of supervised exercise. IKDC self-report instrument was the primary outcome, checked at 3.6.9.12. 18 and 24months and secondary outcomes were radiographic knee OA measures (OARSI and KL scores). At 3 month patients visited the outpatient department for physical examination. At 24 months plain films were obtained. A follow-up questionnaire, exam, and radiograph were also obtained at 60 months. Knee locking or subsequent trauma, or failure to progress in PT were grounds to consider APM surgery. Findings: Of the 321 patients (mean age=58 yr), 278 completed the 5-year follow-up. The mean IKDC improvement was 29.6 points in the APM group and 25.1 in the PT group. The crude between group differences was 3.5 in both which did not exceed the non-inferiority measure of 11 points on the IKDC. Radiographic OA changes were not statistically significantly different between groups at 5-year follow up. In a previous study, those who received physical rehab between 8 and 12 weeks had 1.97 greater odds of recurrence compared to those who received immediate physical rehab within 4 weeks. Author's Conclusion: Exercise-based PT remained non-inferior to APM for patient-reported knee function. PT should therefore be the preferred treatment over surgery for degenerative meniscal tears of non-obstructive nature. THE PEAK PERFORMANCE PERSPECTIVE: My last doctor's newsletter also focused on long term health care costs being reduced with PT vs arthroscopy for degenerative meniscal tears. Historically speaking, meniscal surgery is the most performed orthopedic surgical intervention with 30,000 procedures annually (van Arkel ERA, Van Essen, et al) in 2013 the U.S. There was a 49% increase in arthroscopic partial meniscectomies (APM) between 1996 and 2006 (Kim S Bosque, et al). Half of these were performed in patients over 45 years old. These numbers continue to rise since the proportion of the population over 60 years will double from 11% to 22% between 2000 and 2050 (WHO). APM therefore contributes significantly to healthcare costs. Meniscal surgeries range from $5,000 to $30,000 depending on insurance coverage status. Sudden onset knee pain with some swelling and painful/limited knee motion in patients over 35 years without significant associated trauma is a common finding and often considered a potential degenerative meniscus tear until proven otherwise. Physicians and surgeons see these patients frequently for evaluation. Clinical decision making has changed over the years regarding best practices for these cases. First, I really want to stress that although cost can be a large factor driving decisions, quality of healthcare is of primary influence here at Peak. Noorduyn et al showed here that both surgery or exercise yield similar outcomes on the IKDC and regarding radiographic changes in knee osteoarthritis following 5 years after a meniscus injury, based on their non-inferiority RCT with 278 patients following up (87%) at 9 centers over that time. While APM has decreased in popularity (due to research supporting non-operative care - Herrli and, Hallander et al NEJM 2013; Kise and Risberg et al, BMJ 2016) in the past years, there remain some physicians/surgeons and certainly patients who would tend to prefer surgery over formal PT/exercise. In cases when symptoms persist or in cases of mechanical obstruction (locking and limited range of motion) APM has been proven to be an effective treatment to restore knee function. Although arthroscopy for obstructive meniscal tears in patients over 50 are widely accepted, knee derangement symptoms may be triggered by meniscal tears, or by early onset osteoarthritis (OA). A study by Englund (2008) identified meniscal tears on MRI in 61% of nearly 1000 asymptomatic volunteers over 50 years old. If treatment of non-obstructive meniscal tears focuses primarily on reducing symptoms, first the symptom producing tissue needs to be idefined. Are we really sure that knee pain is from the meniscus, or is it generated from the chondral bone below, or other innervated structures? Shvonen et al looked at the long term changes in osteoarthritis of the injured knee joint and showed slightly increased risk of radiographic knee OA following APM compared with exercise therapy. Katz et al found a 5 times higher risk for total knee replacement after surgery vs an exercise-based PT program. While a subset of patients with degenerative meniscus tears initiated with non-operative care do move on to arthroscopy we also have seen cases as described above, where an otherwise routine and “minor” APM and associated chondral debridement led to an exacerbation of DJD symptoms and in a number of cases resulted in far earlier than expected transition to TKA. Faster progression to OA will lead to more patients desiring to stop the pain thru knee replacement (which results in more medical cost). Preventing this acceleration of OA may result in people with increased function, independence, and less chance for early total knee surgeries. This will trigger a substantial reduction of costs of healthcare while maintaining patients' outcomes and independent lifestyles. Traditional physical therapy, while proven effective in many studies for degenerative meniscus tears, often neglects key components that can shorten the time needed to move to an effective independent HEP. This is based on customized PT utilizing Applied Functional Science (AFS ®) biomechanical approaches being able to adjust body/limb segment postures and paths/directions during especially WB exercises to lessen medial or lateral compartment stresses. For a medial meniscus injury, for example, oftentimes traditional PT squat based exercises like common step ups or step downs or various lunges would be limited and painful, delaying recovery. Utilizing biomechanical approaches, however, AFS trained PT’s would likely find foot ER, tipping the ipsilateral hand / shoulders down laterally and drifting the opposite foot 15-200 off midline all serve to decompress the medial joint and typically allow patients to train their quads and squatting like movements much earlier and much more effectively. Let's consider that same patient who has a medial meniscal tear. There are other biomechanical factors that can accentuate medial joint loading that must be addressed. Typical step ups, step downs, lunges often continue to produce discomfort or must be constrained to very shallow depths due to symptoms. Tight ITB/TFL will contribute to knee varus tendencies, as will retroversion or lack of hip IR (tightness of ER’s). At the foot, a lack of calcaneal eversion and general foot pronation, or a short leg can add to varus knee forces that may enhance medial joint forces and thus pain at the degenerative meniscus and related subchondral bone and/or synovial area. If the foot allows, a neutral or 2 degree valgus forefoot/rearfoot wedge may be used to unload the medial knee joint. The opposite idea, yet the same biomechanics can be applied to the lateral joint issues with the focus being on limiting the causation of pronation from the foot to the hip. THE PEAK PERFORMANCE EXPERIENCE: Nicolas said: “After 5 years I am still out in the wilderness leading boy scouts and leaders. Just last month I was out kayaking across Greenland with kayak portages and climbing mountains! I have no pain in my knee joint as of today!” History: Nicolas was a 50 year old Boy Scout leader who spent many weekends roughing it in the wild and training other leaders. He went out with his son training for a marathon when he felt knee pain. He suspected 26 miles was too much but he really wanted to do this with his son. After a few weeks of training his medial knee was painful to stand on. Subjective: It began with a small ache, and after a week more of running, he could barely walk. Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 Full extension Single leg squat knee angle L 650/ Unable ** L 750/R 650 Calf raise L 240/R 20 L 260 / R 240 3” quad dom step down (eccentric ) Unable * 15 # front racked L 24x / R 15x Single leg hop 10 sec L 14x / R unable ** L 16x / R 5x ** Knee Flexion R 700 R 1250 Single leg balance rotation 15 sec Unable L 12x R 9x IKDC 32% 64% Treatment: Nicolas presented with limited ROM due to pain. He had limited calcaneal eversion R >L. R forefoot valgus was 50, while L is 30. His PT began with restoring ROM as able. Once he could fully extend his knee, he was able to do weight bearing activities beginning with B at 50% WB on the leg and progressing to SL weight bearing as able. He received mobilization to his calcaneus to increase available eversion and reduce his varus knee force on each step. To decrease WB forces on the medial meniscus, Nicolas used a 4 degree lateral forefoot and 2 degree lateral rearfoot wedge in his R shoe. He had limited hip IR to 15 degrees B. Hip IR stretching NWB was added in, as well as hip extension. His exercise program progressed to upright hip ext and IR stretches and then small range strengthening of the ER’s and hip extensors. As symptoms allowed he also began quad dominant step downs, ant medial lunges to facilitate a valgus force at the knee, and calf raises. After 3 weeks: Pt ambulating at 2.5 mph with no pain. Outcome: By controlling the knee varus through his shoe posting, and allowing him freer calcaneus, hip, and knee frontal plane motion, Nicolas was able to return slowly to prior activities. It took him 3 months to return to walking on even surfaces, and almost 6 months before uneven surface and small hiking, (specially downhill) felt good. I interviewed him last week, and after five years he is hiking, portaging (carrying) his canoe/kayak, climbing mountains, and getting on and off the ground with no pain. Jumping and landing on the R leg alone will bring on some discomfort (1-2/10), as will planting R and cutting L if he isn’t careful. He has returned to his full activities with no complaints. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs.