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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (October 2022) New Findings for Degenerative Meniscal Tears: A’scopy vs Non-op…1st year joint space narrowing outcomes! by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 54 yr old male comes in for a 2nd opinion consult for his L knee. He’s had a h/o various knee injuries in the past with some periodic bouts of stiffness and swelling especially with impact activities if not careful of volume and intensity. Five weeks ago he was getting off the floor while playing with his grandchild and felt a small snap/click in his knee and suddenly had sharp pain with weight-bearing and difficulty extending his knee. His PCP referred him for an orthopedic consult. Mild DJD noted on plain films in the medial > lateral compartment. MRI was done on suspicion of a degenerative medial meniscus tear and found (+). Recommendations were to have Arthroscopic partial meniscectomy. He was assured it would have no bearing on arthritic progression since the torn meniscus was not functioning properly now. His lack of full extension was explained as part of the reason he needed A’scopy. He prefers non-op if possible but does not want to make his knee worse by avoiding surgery. He’s presently doing OTC NSAIDs and prn Tylenol. Findings showed AROM 5-1250 (vs 1350 on R) and extension PROM stiff/painful at 30, with the patient commenting that it had been 100 short just 2 wks ago. Medial joint line is very tender and there is a > 1+ effusion present. McMurrays is (+) with varus/ER especially, reproducing an asymmetric snap in the knee. Single leg squat is painful at 300 vs R 550 and Thessaly WB test is (+) for pain/snap also. My clinical thinking is: A’scopy will more quickly resolve his pain and restore extension for WB with generally very low risks. Recommend A’scopy. ROM has been steadily improving. He already has a mild DJD present on plain films. Leave the meniscus in if he can progress back to asymptomatic with near normal or normal function. Continue non-operative care - prescribe Physical Therapy including Class IV laser and customized biomechanical exercises for 4-6 wks and then reassess. Recommend a steroid injection to reduce inflammation first and reassess in 2-3 wks regarding continuing non-op care with PT vs doing A’scopy. Aspirate the fluid, begin prescription NSAIDs, advising general rest from activity and FU in 2 wks to reassess for surgery vs formal PT. CURRENT EVIDENCE Santana DC, Oak SR et al. Increased Joint Space Narrowing After Arthroscopic Partial Meniscectomy: Data From the Osteoarthritis Initiative. AJSM 50(8): 2075-2082. 2022 03635465221096790 SUMMARY: The question of how to appropriately treat degenerative meniscus tears of the knee remains a clinical challenge. On one hand, experience has shown many physicians and surgeons that immediately remove the damaged meniscus seems to provide earlier pain relief and restore normal motion and function more quickly. Leaving damaged tissue in a joint to potentially impact chondral stresses and even contribute to loose body development may be another rationale for some in addressing these surgically sooner than later. On the other hand numerous orthopedic organizations have recommended against routine degenerative meniscus arthroscopy based on outcome findings in comparison to non-operative rehab at 6 and 12 months. Karen last month shared a JAMA Network Open study from July 2022 showing a 5 year follow up in the ESCAPE RCT showing exercise based physical therapy non-inferior to Arthroscopic Partial Meniscectomy (APM). But another consideration not studied well is the joint space width (JSW) narrowing status comparing APM with non-operative treatment of meniscus tears vs normal knee. Santana et al, using the Osteoarthritis Initiative cohort (4796 adults 45-79 yr old from 4 centers in US who had or were high risk for tibiofemoral OA), looked at 144 patients undergoing APM and having > 12 months of follow ups vs 144 with meniscal tears not undergoing APM and also 144 knees without a meniscus tear - matched by age, sex, Kellgren-Lawrence (KL) arthritis grade and FU time. Minimum medial joint space width was calculated from radiographs taken annually or semiannually following all knees having an MRI at baseline. The authors found the rate of JSW decline over the first 12 months to be 27x greater than the non-operative group and 5x greater than the no tear group. From 12-72 months showed no differences between groups. JSW at baseline vs 72 months was significantly different for the APM group compared to others (P < 0.001) but not between the non-surgical and no-tear groups. Clinically speaking this is a challenging topic, in part because many times patients want a quicker answer for their pain and limitations than non-operative care can bring. A consideration is certainly, however, to do no harm. While further evidence would be needed to confirm these findings, there is some other published evidence that APM leads to an increased rate of TKA. We find non-operative care most often, though not always, effective at resolving symptoms and restoring function in these cases. Two factors that should be considered and require further study but we see regularly on an anecdotal basis is the efficacy of our Class IV 25W laser and customizing especially squat based strengthening exercises to unload the specific meniscus tear side. That is not part of traditional physical therapy approaches. This greater attention to utilizing biomechanics to alter medial and lateral joint forces can literally allow an otherwise painful knee to perform valuable step down or split squat etc. strengthening through effective ranges when traditional technique causes pain that prevents continuing. We find that simply using otherwise deemed “functional” strengthening methods with simple step ups or downs (...etc.) contributes to the appearance for patients and physicians of “failed conservative care” and may lead prematurely to APM and the accelerated degenerative changes noted by Santana et al. Careful consideration by referring physicians of how customized and detailed rehab is for even just a “routine degenerative meniscus tear” case can significantly influence patient outcomes. Background: APM is a widely performed treatment option for patients with degenerative meniscus tears. Recent evidence has produced debate whether APM accelerates progression of OA. Purpose: To compare tibiofemoral joint space width (JSW) across three groups - patients undergoing APM, those with meniscus tears treated non-operatively, and those without a tear. The hypothesis was JSW would be least in those undergoing APM and greatest in those without a tear. Methods: Cohort design using the Osteoarthritis Initiative cohort, inclusion and exclusion criteria identified 144 patients having undergone APM having at least 12 months follow up and no prior knee surgery along with matched (by age, sex, Kellgren-Lawrence grade and follow-up time) 144 each in the meniscus tear without APM and the no meniscus tear groups. Baseline MRI used and then annual or biannual radiographs used to calculate the minimum medial compartment JSW. Linear regressions done. Findings: All groups had comparable 4.33 - 4.38mm JSW at baseline. The rate of JSW decline for the APM group was 27x greater during the first 12 months than the non-surgical tear group and 5x greater than the no tear group. No differences present in the rate of JSW decline between 12 and 72 month follow ups between groups. There was a significant difference in JSW from baseline to 72 months for the APM group vs the other groups (P < 0.001). Author's Conclusion: APM results in a faster rate of joint space narrowing during the first 12 months postoperatively than nonsurgical management of meniscal tears. Comparable rates of OA progression occur between 12 and 72 months regardless of treatment approach. Untreated meniscus tears do not hasten radiographic progression of OA as measured by JSW narrowing. THE PEAK PERFORMANCE PERSPECTIVE Orthopedists, whether non-operative specialists or surgeons, and family practice physicians alike often see patients in the 40+ age range with complaints of sudden onset knee pain and swelling. This is oftentimes accompanied by a lack of motion, catching/snapping symptoms and sometimes frank or pseudo-locking symptoms. With no frank trauma implicating ligament injury, along with joint line tenderness and a (+) McMurray’s, Appley’s or Thessaly sign this is typically considered a degenerative meniscus tear until proven otherwise. MRI is most often utilized to confirm the diagnosis if needed. The question then becomes “what is the next right step for care?” Oftentimes it’s patients themselves who are looking for the “quick fix” of arthroscopy also. Historically, a decade or more ago, these cases were moved to arthroscopic partial meniscectomy (APM). Typically patients have a fairly short recovery and their pain/mechanical symptoms are effectively treated - a seemingly good outcome. The costs and albeit infrequent adverse events related to even a “minor” arthroscopic procedure, among other considerations, led the responsible orthopedic community to study efficacy and alternatives further. I was a lead on the PT care side while at University Sports Medicine in the 90’s of a study done by the Sports Medicine Dept by several surgeons on non-operative care for MRI diagnosed degenerative meniscus tears that began as a 6 wk treatment program. The majority of participants did so well the study was extended. During that time and following, numerous other studies started being published lauding the merits of non-surgical care for degenerative meniscus tears. Various orthopedic societies and organizations have published position statements suggesting routine APM is no longer recommended. Other authors have cited that despite all these recommendations the rate of APM has not significantly dropped (Rongen 2018). There are certainly some percentage of patients with meniscus tears who are good candidates for APM for numerous reasons that may be unique to their situation and life demands, timing needs etc. Clearly this is true for frank locking of the knee due to the tear. Less clear is the “slow to recover non-operatively” knee case. We don’t know how long is “too long” before the benefits outweigh the risks and costs of APM versus waiting longer for the hoped benefits of non-operative care to manifest. One consideration some have indicated is whether leaving the torn, and less effective, meniscus in the joint would impact OA progression or produce risk of further injury. The ESCAPE Trial that Karen’s last newsletter reported on from JAMA Open Network reviewed 5 year follow up results vs APM and noted non-operative care to be non-inferior to APM long term. Obviously these non-op approaches inherently cost less and carry less risk of adverse event than APM. In this study, by Santana et al, joint space narrowing (JSN) was specifically assessed. APM having produced a 27x greater rate of decline in joint space vs non-operative meniscus tear approach weighs significantly into the basis for deciding on APM as an option. While not the standard, and yet to be well studied or an algorithm determined for identifying at-risk patients, we have personally seen numerous times patients with reported “mild to moderate, but not bone-on-bone” plain film radiographic findings who undergo APM for meniscus tear having a very negative post-op course of recovery and eventually have a much earlier than expected TKA done. The question remains, how much pre-existing OA can be tolerated by a joint undergoing APM and not have degradation accelerated to a point more further procedures are needed compared to having left the degenerative meniscus alone? While non-operative physical therapy care will, of course, not “heal” the tear or smooth over rough edges of torn meniscus this study by Santana et al supports the findings of many studies before it that physical therapy care for these cases produces good results very often, allowing patients to forego otherwise anticipated necessity for APM and the associated costs and risks of having a procedure. It also established that leaving a torn degenerative meniscus tear in the joint did not contribute to significant further abnormal narrowing in the first 12 months, and that comparable progression of OA still does occur over ensuing years comparable to that of an intact meniscus knee with OA. The JAMA Open paper did, of course, as expected, reveal that some percentage of non-operative care cases will eventually move on to surgery. Certainly not all meniscus tear cases begun in physical therapy alone will be fully successful in resolving symptoms and restoring full function. The key to recovery from a degenerative meniscus appears though not to be dependent on removal of the tear or rough margins. It often means reduction of pain and inflammation, and recovery of ROM and strength - common pursuits of typical physical therapy care. And now there is mounting evidence suggesting that “fixing” the torn meniscus may bring with it unwanted accelerated adverse effects. What is not typical in non-op care of these cases, however, is the unique demand for biomechanical “respect” for the painful tear side of the joint. Traditional PT does not teach or espouse a keen focus on “unloading techniques” for the painful tear side during typical WB strength or balance exercises. Yes…squats and leg presses, lunges and step downs or step ups, these all can be part of a functional strengthening regime of PT exercises. But done in standard “PT fashion” they oftentimes will requires unnecessary reductions in training ROM and/or loading due to pain issues (without advanced biomechanical approaches being used). The problem is that most degenerative meniscus patients have pain, sometimes very sharp debilitating pain, during these exercises. If one were to employ only NWB quad bench strengthening, even if it were pain-free (which it often is not in these cases), I’d submit we wouldn’t remotely see the effectiveness that studies show for non-op care. We see even better results utilizing biomechanical considerations to unload the painful knee side via frontal and/or transverse plane pre-positioning or reaching techniques that allow needed stimulus of the Quads, for example, but reduce the compressive pain over the meniscus tear. Consider this example - a posterior horn medial meniscus tear on the R knee may be especially loaded in WB by varus (knee adduction) and tibial ER (compression of posterior horn). While not exclusive we often find that patients unable to squat at all for effective strengthening exercise can suddenly perform (happily) through pre-positioning with the R hand reaching down or out to the R (tipping R, creating gapping on the medial knee) or by IR the foot slightly. The use of customized frontal and transverse plane adjustments allows us to identify unique positions for effective strengthening. Another key consideration is the kinetic chain biomechanics. For example, a varus knee with a MM tear must have the ability to internally rotate the hip, pronate the subtalar joint, and adduct the hip (limited by ITB tightness) addressed if there is any chance to reduce the magnified loading of the medial joint biomechanically. These are parts of our Applied Functional Science (AFS ©) training that are not part of traditional PT approaches. Our Class IV 25W laser has also been a key tool in reducing pain and inflammation. Last year I had a typical degenerative meniscus event…simply picking up my leg to dry off in the shower, felt a click. Within an hour the knee was swollen, I was unable to fully extend, ambulation was limited and painful, and flexion was reduced probably 15-200 also. These episodes typically would take me 2-4 wks to recover from. With only 3 laser treatments I was feeling 75% better in just three days! In less than a week I was fully recovered as if nothing had happened, able to do stairs, workout w wts, and golf. The case below illustrates a patient who had plain film confirmed DJD but sharp pain with clunking on McMurrays suggestive of also having a degenerative LM tear. MRI was never done to confirm findings but clinically speaking he presented with findings beyond typical knee OA alone or an ITB syndrome. THE PEAK PERFORMANCE EXPERIENCE Ken said: “Now my knee feels like it’s 95% of normal! I walked 18 holes of golf 3x in one week without trouble.” HX: 68 yr old male retired engineer and recreational golfer developed R knee pain laterally over the prior month especially with descending stairs, sit-stand ADL, and getting out of the car. He was referred by his PCP with plain films apparently showing DJD changes. He had just finished a 5 day steroid dose pack which helped. Subjective: Max sx 3/10 and self-rating function at 70%. WOMAC 28%. CC is pain w stairs (desc > asc), getting out of car, twisting activities, had to change to taking a golf cart to avoid walking hills with reduced golf. Objective: 1+ joint effusion, tender lateral joint line + ITB @ LFC, (+) McMurrays all four combinations w sharp pain and clunk noted @ lateral knee. (*=pain) Eval 6wk DC ReEval Knee ext AROM (L/R) 0/2.00 0/2-30 Knee ext PROM R 20 1-20 hyperext Knee flex AROM (L/R) 135/1320 NT/1430 Isometric Quads @ 300 89% w * 98% Isometric Hams @ 200 87% w * > 100% Single squat 74/650 * NT/750 SLB rotations <5sec/>10sec 7sec/NT FWB hip flexion (glutes/hams fxn) 30/300 45/540 WB hip IR 26/300 40/400 Quads Anterior (toes off) Stepdown 4” w 12# wts NT 35x/35x (100%) Key Findings: (+) McMurrays w lateral sharp pain and clunk consistent w R/O degenerative LM tear. Pt had weakness in Quads/Hams NWB w pain at lat/posterolateral knee, limitation and sx w squat function. WB hip IR restricted (B) - an issue for golf demands (ie, if hip unable to adequately rotate then forces at knee increased) , and poor function of hip extensors as assist w squat function. Treatment: Manual therapy joint mob’s for knee extension + sustained stretch after. Flexibility/ROM work to improve R TFL/ITB and hip IR WB (B) along w knee flex PROM. US utilized at lateral knee/ITB. Class IV laser demo done but pt chose to not purchase package for treatment (was already improving significantly). SLB work done to improve rotational control and tolerance - especially due to being a CC, despite actually better performance at RLE on IE testing than LLE. Functional squat based strengthening for quads/thigh utilized frontal plane unloading during Ant stepdowns initially (tipping trunk L to unload lateral joint - ie, reducing compression forces at LM…attempt to unload potential ITB as primary source via tipping to R worsened sx), tipping L via LUE reach table also utilized during split squats to allow deeper and heavier training. Outcome: Pt progressively reported increasing stairs/squat function and ability to tolerate rotation. Eventually he resumed walking golf, playing even 3x in one week w/o sx prior to his ReEval. WOMAC reduced to 5% and self-report score 95% at DC. 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. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 ext (585) 218-0240 www.PeakPTRochester.com