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Don't rush into knee surgery, therapy can be just as good

Teresa Tanoos's picture
Therapy can work as good as knee surgery

Physical therapy is can be just as good for a common injury as surgery, according to the most rigorous study yet, and it is a lot less expensive and risky than surgery.

By the same token, physical therapy didn't always help those with certain injuries, such as a torn meniscus, which is one of the crescent-shaped cartilage discs that cushion the knee and one of the most common knee injuries. About one-third of people over 50 have a torn meniscus, and arthritis makes it more likely. The tear usually doesn't cause symptoms other than pain.

When that happens, it's tough to tell if the pain is from the tear or the arthritis – or whether surgery is needed or will help. Knee surgery for a torn meniscus is performed approximately 500,000 times each year in the United States alone.

While conservative treatment – including rest, ice and medication – can sometimes be enough to relieve the pain of a torn meniscus and allow it time to heal on its own, surgical repair may be required for other patients.

However, researchers found that those patients who stuck with physical therapy had improved as much six months to one year later, compared to those who had arthroscopic surgery right away. Knee arthroscopy is surgery that uses a tiny camera to look inside your knee.

"Both are very good choices. It would be quite reasonable to try physical therapy first because the chances are quite good that you'll do quite well," said study leader, Dr. Jeffrey Katz, a joint specialist at Brigham and Women's Hospital and Harvard Medical School.

Dr. Katz discussed the study Tuesday at a conference for the American Academy of Orthopaedic Surgeons in Chicago, with the results published online in the New England Journal of Medicine.

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The new, federally funded study compared surgery with a less drastic option. Researchers at seven major universities and orthopedic surgery centers across the country assigned 351 people who had arthritis and meniscus tears to one of two options: 1) surgery; or 2) physical therapy, which consisted of nine sessions on average plus exercises to do at home, which experts say are the key to success.

At the end of six months, both groups had similar rates of functional improvement, as well as similar pain scores.

Meanwhile, thirty percent of patients assigned to physical therapy wound up having surgery before the end of six months – usually because they didn’t feel therapy was helping. Nevertheless, such patients ended up the same as those who got surgery right away, as well as those who got physical therapy only and stuck with it; thus, avoiding surgery.

"There are patients who would like to get better in a 'fix me' approach," said another study leader, Elena Losina, of Brigham and Women's Hospital. She said surgery may be best for those patients.

But a preventive medicine expert from Australia contends that the study's results should change practice. Rachelle Buchbinder of Monash University in Melbourne wrote in a commentary in the medical journal that therapy "is a reasonable first strategy, with surgery reserved for the minority who don't have improvement."

As it is now "millions of people are being exposed to potential risks associated with a treatment that may or may not offer specific benefit, and the costs are substantial," she added.

Indeed, costs for surgery are approximately $5,000, whereas physical therapy is around $1,000 to $2,000 total for a series of sessions.

SOURCE: New England Journal of Medicine, March 19, 2013. DOI: 10.1056/NEJMoa1301408