Episode 1525 - Offensive meniscal care: another call to stop the scope

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the significance of addressing the underlying ecosystem challenge to achieve better outcomes for patients. She specifically highlights the prevalence of poor diet and obesity as contributing factors to this challenge. Lindsey points out that there is evidence suggesting a link between these factors and knee pain, as overweight and obesity are often observed in individuals experiencing knee pain.

Lindsey emphasizes that focusing solely on physical therapy interventions, such as knee range of motion and strength exercises, is insufficient. Instead, she argues that healthcare professionals, including physical therapists, need to consider the broader ecosystem in which patients exist. This includes addressing mindset, mindfulness, exercise, diet, and sleep.

To guide patients along this path, Lindsey suggests that physical therapists can play a role by providing support and education. She compares physical therapists to shepherds, who can assist patients in navigating and making positive changes in their overall lifestyle. By addressing the underlying ecosystem challenge, Lindsey believes that better outcomes can be achieved for patients.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How's it going? Welcome to Clinical Tuesday. I'm Dr. Lindsay Hughey coming to you live from Edgerton, Wisconsin. So good to see you all today. I am going to chat with you about playing offensive medicine in our folks with degenerative meniscal injury. Before I dive in to what that looks like, I'd love to share with you a little bit about courses Mark and I have coming up in extremity management. So we have a couple options in August and actually one of them, well we did have a couple options, we only have one now because all the tickets in Fremont, Nebraska August 19th and 20th are actually sold out. So our last ticket went I think yesterday. So the only option in August to check us out and learn all things best dosage and tendinopathy care of the upper and lower quarter is Rochester Hills. So August 12th and 13th I will be teaching there and so join me if you can. And then in September Mark has two options for you on September 9th and 10th out of Amarillo, Texas and then September 16th, 17th out of Ohio. So Cincinnati will be coming your way. And then some fall and winter courses but again opportunities are dwindling. We hope if we don't see you this summer to see you in the fall or winter. 01:48 STOP THE SCOPE But let's chat about how do we play offense for degenerative meniscal injury because today is really a call, another call to stop the scope. I've hopped on here before over a year ago, I'm kind of charging us with those folks that have that gradual onset of symptoms of pain in their knee, maybe a little bit of swelling but have no specific injury or twisting event that happened that's more related to a degenerative process or like or I would like to refer to as a living life process. They don't need arthroscopic meniscectomy. And so we had more literature just come out this year to really bolster that argument of why physical therapy is really the number one choice, exercise medicine is the way to go. But I would like to first highlight that new literature that came out in January of why it's not appropriate to have surgery for these folks and then to also take a moment to reflect on why are we still seeing the arthroscopic partial meniscectomies being done if we keep finding literature that says let's not do this. And then also reflect on how can we do better as a profession to stop this continued over medicalization. So I first just want to briefly review in January 2023 we had a systematic review and meta-analysis come out from the Osteoarthritis and Cartilage Journal and we actually did share that on hump day hustling a while back. But this systematic review and meta-analysis again let us know that degenerative meniscal injury, the scope is not the way. And so let me unpack a little bit about this study because it was pretty inclusive this systematic review and meta-analysis. They looked at tons of RCTs so that the pool data of all patients was 605 patients. The study populations in each of the RCTs ranged somewhere between 44 and 319 so decent size overall in each study. The mean age of these folks was about 55 with the standard deviation of 7.5 so kind of that middle age and then majority were female about 52.4 percent. So you also see an even distribution almost of males and females in this study and then mean BMI was 26.5 standard deviation 3.7 you know below or above that. And what they investigated was the effectiveness of using arthroscopic partial manisectomy and they compared that via non-surgical so either sham which was exercise treatment or some form of exercise program so every RCT they looked at had to have the comparator of exercise. And degenerative meniscal findings were confirmed on MRI in all of the studies. The primary outcomes were knee pain, overall knee function, and then health-related quality of life and they looked at outcomes for up to two years so we see again a long-term follow-up in these RCTs this collection of RCTs that they looked at. And so the conclusions January 2023 so we're you know over six months out over half a year through and the conclusion was for insidious onset of knee pain so non-traumatic with MRI confirming degenerative meniscal tear in adults arthroscopic partial manisectomy is not the answer. 05:15 "NO CLINICALLY RELEVANT EFFECTS OF PARTIAL ARTHOSCOPIC MENISECTOMY" Literally if I'm going to quote verbatim no clinically relevant effect of arthroscopic partial meniscectomy was detected for overall knee function health-related quality of life or mental health. They did find one small marginal difference in pain levels a couple points but there was no evidence that there was superiority in having surgery. In fact they even took a look to see are there subgroups of patients right that might have a greater benefit from APM that were just not recognizing and when they looked and compared again the non-surgical to sham exercise therapy they did not see a subgroup that existed. They made other conclusions to say most degenerative meniscal tears are going to improve over time without the need for that arthroscopic partial menisectomy. Other findings that I think are really important to point out before we kind of reflect on why if we have this evidence do we keep seeing surgeries being done is that when they looked at the individuals in the studies those with BMI over 30 so obese individuals compared to the healthy BMIs less than 25 they had a 4.7 fold increased risk of progressing to knee osteoarthritis whether they had surgery or not. It was really a call to action when they found this in this pool data of all these folks is that body weight reduction strategies need to be on board for pain and function effects. 07:28 "...NO SIGNIFICANT ADVANTAGE OVER NON-SURGICAL TREATMENT" So just to send it home about this study and what they said one of the final things that they wrote in their conclusion was and I'm going to read it verbatim we recommend that physicians minimize the use of arthroscopic partial mastectomy to treat patients with degenerative meniscal tears because there is no significant advantage over non-surgical treatment. This is the osteoarthritis journal right this is a pretty high tier journal osteoarthritis and cartilage journal making this statement. So why are we still seeing a ton of them? Why does this keep happening where we see patients I have one of my caseload right now right why is this happening? Well we're obviously not reading the literature as a health care team and as physicians right because patients still think this is a primary defense. I'd love to reflect on that even 10 years ago in 2013 we had a study from Yim et al where they compared meniscectomy versus non-operative strength care and this was in 103 patients them and the same exact message was there there are no significant difference between arthroscopic meniscectomy and non-operative management with strengthening exercises again when we look at knee pain function and satisfaction at the two-year mark. So even 10 years ago we had this evidence but yet it's not translating to practice that's a lot of surgeries a lot of over-medicalization so I we need to really step it up here in our not only in ingesting this information but advocating that this is not a new message. In this article they point out that in 2017 so the systematic review and meta-analysis that we just reviewed that in 2017 an expert panel that regarding the degenerative meniscal injury said that the use of arthroscopic partial meniscectomy in nearly all patients with degenerative knee disease that several guidelines do not support this procedu