Exercise May Work as Well as Surgery for Knee Injuries by Dr. Mercola
Exercise May Work as Well as Surgery for Knee Injuries
August 12, 2016|25,537views
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By Dr. Mercola
The knee is the mostly commonly injured joint by athletes,
accounting for 2.5 million sports-related injuries seen in the
emergency department annually.1 Meniscal tears occur in 35 percent of people over the age of 50.2
Ruptures of the anterior cruciate ligament (ACL), important to
stabilizing your knee, occur in 100,000 to 200,000 people each year.3
Knee injuries may be treated by a wide range of clinicians, from
orthopedic surgeons to internal medicine physicians or Physical
Medicine and Rehabilitation Specialists.
Your knee may suffer from an acute or traumatic injury or, through
overuse, you may experience degenerative changes to your meniscus. How
you treat these injuries may have an impact on your ability to return
to your normal activities, and whether you experience degenerative
arthritis in the future.
A recent randomized control trial demonstrated the effectiveness of using a structured exercise program to rehabilitate your knee either prior to surgical repair, or in many cases, instead of a surgical repair.
To take full advantage of rehabilitation it's important to
understand how the knee works and what key factors are evaluated to
determine which option is best for your unique situation.
Anatomy of Your Knee and Meniscal Tears
Three bones meet at your knee to form the joint that is the largest and considered the most complicated joint in your body.4 Although your knee is a hinge joint, it must not only bend and be flexible to allow walking but also stable to allow you to stand stationary.
Between your thigh bone (femur) and shin bone (tibia) are two wedge
shaped pieces of cartilage. The function of these tough and rubbery
pieces are to cushion the two bones and keep them from rubbing against
each other.5 These pieces are called your meniscus.
The menisci have blood supply to the outer edges but this supply
rapidly declines as you move further toward the center of the cartilage
located directly between the two large bones. Your menisci can tear in
a number of different ways from either an acute injury or from
degenerative changes over time.
The number of surgeries done each year to repair a meniscus tear has
been on the rise. Recent findings in the American Journal of Sports
Medicine demonstrated that meniscus repairs increased 100 percent
between 2005 and 2011.6
Additionally the research demonstrated that patient pain may not have been related to the meniscal tear in the first place.7
The researchers found patients experienced pain relief despite the
fact that the tear did not heal after surgery. The lack of healing was
discovered during a follow-up arthroscopy. What did appear to relieve
pain and improve function was immobilization and physical therapy.
Study Demonstrates Effect of Exercise Versus Surgery
Two studies demonstrated the effectiveness of using a structured physical therapy program to either eliminate the need for surgical repair or to improve outcomes when therapy was done prior to surgery.
In the first study, researchers followed participants for five years
with minimal follow up loss. The study participants had suffered an
ACL injury. The researchers found that results between those who had
surgical repair and those who were treated with rehabilitation alone
were near identical.8
Another study released in 2016 followed participants for two years who had suffered a meniscal tear in their knee.9
Again researchers found exercise and rehabilitation in middle-aged
patients with knee damage was as effective as a meniscal surgical
repair, which is an outpatient procedure.
Researchers estimate that 2 million people worldwide undergo
arthroscopic surgery every year. But in their review of the literature,
researchers did not discover benefits to the patient. This prompted
scientists from Denmark and Norway to undertake this two-year study.
In this study, researchers identified 140 patients who had a
meniscal tear, the majority of whom were without any osteoarthritic
changes to the knee. Half underwent an intensive 12-week exercise
program and the other half had arthroscopic surgery and given a home
rehabilitation program.
No clinical difference between the two groups was found as it
related to their ability to do daily activities, participate in sports
or pain
levels. Thirteen of the participants who were in the exercise-only
group opted to have arthroscopic surgery during the study, but didn't
experience any additional benefits.10
Additional Benefits of Exercise Versus Surgery
Arthroscopic surgery is considered a low risk procedure. The most
common serious side effects are deep vein thrombosis, infection and
pulmonary embolism, occurring only 0.4 percent of the time.11
However low risk this procedure may be, surgical repair increases
medical costs, insurance costs and doesn't appear to produce superior
results. On the other hand, a strong rehabilitation exercise program
does produce increased strength in the large muscles supporting the
knee joint.
In the most recent study, researchers tested the quadriceps (thigh)
muscles of the participants at baseline, three months and 12 months.
They found the individuals who underwent rehabilitation not only
experienced similar results to those who had arthroscopic surgery, but
also exhibited increased strength.12 The authors, quoted in Science Daily, said:13
"Supervised exercise therapy showed positive effects over
surgery in improving thigh muscle strength, at least in the short term.
Our results should encourage clinicians and middle aged patients
with degenerative meniscal tear and no radiographic evidence of
osteoarthritis to consider supervised structured exercise therapy as a
treatment option."
Strength improvements were demonstrated in the first 12 months of
the study, but were not evaluated during the remainder of the study.
Improved strength in the knee joint may reduce your potential for
further injury and may also improve your ability to perform daily
activities.
Sham Surgery or Placebo as Effective as Arthroscopic Surgery in Older Individuals
A placebo effect happens when you think you're being treated with
something, but the medication you're given doesn't have any
physiological effect. This video
describes what may be happening in your brain when you take a placebo.
To gain approval by the U.S. Food and Drug Administration (FDA) a
medication must prove it is more effective than a fake drug or placebo.14 However, when approving medical devices or surgical procedures for treatments, this proof is not required.
In 2002, research published in the New England Journal of Medicine
proved the results people experienced from arthroscopic surgery for osteoarthritis were no better than those results you would expect from a placebo.15
In another trial, conducted with 146 patients who experienced a
meniscal tear without osteoarthritis, researchers found that a sham
surgical procedure had the same results as those who underwent a
meniscal repair.16 The study evaluated the participants over a 12-month period and found no significant difference between the groups.
The study proving the placebo effect in arthroscopic surgeries for
osteoarthritis occurred in 2002. Unfortunately, to date this
information has not changed the number of arthroscopies performed,
costing insurance companies and individuals over $3 billion each year
for a procedure that produces results individuals may experience with physical therapy and rehabilitation alone.17
Consider These Important Factors Before Surgery
If you would like to consider a surgical option for your injury
there are several factors that may improve or reduce the likelihood of a
successful outcome.
• Functional Changes
While you may have changes to your meniscus on an MRI, if you
don't exhibit pain or functional changes to your gait, surgical repair
is likely not necessary. Sports medicine physicians use a "duck walk" to
evaluate the impact knee injuries have on your stability and strength.18 Squat and walk like a duck. If you aren't able because of knee pain or weakness, consider a rehabilitation program to improve your joint strength and reduce pain. • Weight
Your weight is a significant factor in determining the potential
success of a surgical repair. For instance, research has found
significant changes in the curvature of your knee joint within the first
three months after injury with an increased body mass. The results
found those who underwent surgery experienced greater flattening of the
knee joint than those who used rehabilitation without surgical
intervention when their body mass index was higher.19 • Size and Placement of the Tear
The reduced blood supply to the meniscus in the center of the knee
increases the likelihood any surgical repair will not heal or will
fail. The size of the tear and the placement — whether in the center of
the meniscus or along the outer edges with greater blood supply —
impacts the decision about surgery.
Repair of the meniscus has a greater success rate in younger
patients with peripheral tears near the capsular attachment that are
either horizontal or longitudinal. Even in these cases, success depends
on compliance with post-operative exercise and rehabilitation,
including non-weight bearing and bracing.20
Before Surgery, Seriously Consider Ozone Therapy
I've previously interviewed Dr. Robert Rowen
about ozone therapy for a variety of painful conditions. He is one of
the leading ozone physicians in the U.S. and has successfully treated
many patients with ozone therapy as an alternative to surgical
intervention. If the ozone treatment fails, there is no harm and one
can always have surgery, but if you have surgery and it fails, the
surgery may cause irreversible damage. Infrared laser treatment
(K-Laser) is another option. It's a relatively new type of therapy
that speeds healing by increasing tissue oxygenation and allowing
injured cells to absorb photons of light. This special type of laser
has positive effects on muscles, ligaments and even bones, so it can be
used to speed the healing of traumatic injuries, as well as chronic
problems like arthritis of the knee.
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