Wouldn’t it be amazing if you could simply surgically remove or ‘cut out’ the cause of your knee pain? I think everyone, from doctors to patients, would love it if things were so simple. Unfortunately, they’re not.

By far one of the most common questions Sport Medicine Physicians and Orthopedic Surgeons at Group23 get from patients suffering from knee pain of any type is “can’t I just have surgery for this?”.   Many of our patients are very active individuals and have likely had a friend, family member, teammate (or maybe even themselves) who has had a knee “scoped” or “cleaned out” with good success (return to activity, decreased pain). For this reason, it’s logical that they may think that arthroscopic knee surgery is exactly what they need to get back in the game so to speak. Unfortunately, the decision to proceed to surgery is not black and white. Many factors determine whether or not someone is a surgical candidate or whether their condition can be managed effectively using non-surgical treatments. Ultimately, the decision to proceed to surgery will be determined based on several considerations: 

1. Is surgery indicated for the diagnosis? In other words, is there a surgical procedure that can fix the problem at hand.

2. Has the patient weighed the risks of surgery (risk of anesthetic, infection, damage to nerves, blood clots, no change in pain despite the surgery etc.) against the potential benefits of surgery and determined that the potential benefits outweigh the risks?

3. What role does surgery play in your personal health journey to help you reach your goals? Are there other pathways to reach your goals besides surgery?

4. What are the timelines involved? Access to elective surgery in Canada is slow (very slow). Recovery times can vary from weeks to years depending on surgery performed.

Let’s examine some of the key factors that determine whether or not surgery can help for your knee pain: 

1.    What is the diagnosis and what does research say about the role for surgery? There are some conditions that are clearly surgical: displaced fractures, complete tears of multiple ligaments in the knee which would render the knee unstable, recurrent dislocations of the kneecap despite physiotherapy and bracing, “loose bodies” or tears of the meniscus (shock absorbing cushions between the bones) which if torn significantly can become flipped over and “lock” the knee (can’t move it — think a bunched up carpet stuck behind a door making if unable to open/close).   Research tends to support surgical management of these types of conditions.  Thankfully, these injuries are rare.  The far more common causes of knee pain which include diagnoses of degenerative meniscal tears/knee osteoarthritis, patellofemoral pain syndrome or “tendinopathy” are no longer managed with surgery as a 1st line treatment (see #4 below and links at end of blog) on surgery for knee osteoarthritis). 

2.    Although some of us hate to admit it, AGE is unfortunately a huge factor in determining whether you are a surgery candidate.  Tears of the meniscus or anterior cruciate ligament (ACL) are very often managed surgically if you are 20 years old but would be managed non-surgically if you are 50 years old.  This is because our choices of activities change as we get older.  Most older patients can get back to doing the things they love WITHOUT needing a surgery, while most younger patients would not.   

3.    Have you thoroughly exhausted non-surgical treatments?  Most of us like to take shortcuts whenever possible and naturally we conceptualize surgery as the quickest way to eliminating pain and getting back to the activities that we love.  The only problem with this approach is that surgery is not without some risk, therefore, most surgeons in public health care system will want to be sure you have done everything you can to have gotten better short of doing surgery.  At Group23 we teach our patients that one of the most important parts of your visit with the Orthopedic surgeon is when he or she asks you the question “What have you done to treat your knee pain so far?”  If you answer “Nothing…. I’ve just been waiting a year to see you” they will very likely send you away for 6-12 months to try non-surgical management i.e. prove that you can’t reach your goals with aggressive non-operative treatments (physiotherapy, injections, bracing, weight-management etc.) and then we’ll talk about whether surgery is appropriate.  We try to ensure that when a Group23 patient is asked this question by the surgeon, they blow them away with their answer.  Group23 patients demonstrate to the surgeon that they have undertaken a comprehensive, progressive and aggressive non-operative treatment course but, despite all this, they have not reached their goals.  Expect to hear the next words from the surgeon to be: “when would you like to come in for surgery?” 

4.    Understanding WHEN surgery is appropriate and WHAT KIND of surgery is required.  This applies most commonly to KNEE OSTEOARTHRITIS (OA) and degenerative meniscal tearing.  To keep it simple, there are 3 different types of surgeries which may be considered if you have knee OA. 1) Arthroscopic debridement (“Scoping the knee to clean it out”), 2) Arthroplasty (Joint replacement surgery – “knee replacement”) and 3) Osteotomies (“realignment of the bones”).  Based on all the research in the past 40 years where are we at in 2021 with respect to best evidence? 

1. Arthroscopy (scopes) are very rarely used in 2021 for knee OA or degenerative meniscal tears UNLESS you have a mechanical locking of the joint (see links to articles at end of blog for more information)

2. Arthroplasty (Knee replacements) are the “end-of-the line” treatment for knees with advanced osteoarthritis that have failed every non-operative treatment outlined in the G23 #RiseAbove Personal Health Journey – see www.group23.ca/riseabove )

These surgeries are typically very successful, but note that 1 in 5 patient will still have pain after getting a knee replacement.  

At Group23, our purpose is to deliver positive healthcare experiences and empower individuals to #RiseAbove injury and get back to movement. Understanding your diagnosis (what we call “becoming an EXPERT in your condition”) is a critical part of every Group23 #RiseAbove health journey. Hopefully this article helps answer some of the questions many patients with knee pain have when it comes to deciding if surgery is appropriate for their condition. If you are suffering from pain and would like access to the sport medicine physicians, you can do so by SELF-REFERRAL click here.

Sources

https://www.health.harvard.edu/blog/knee-arthroscopy-should-this-common-knee-surgery-be-performed-less-often-2020042019507 

 http://blog.arthritis.org/news/doctors-patients-say-no-arthroscopy-arthritis/ 

This stretch is important for those who sit for the majority of their day.

The goal is to feel it in the front of the hip. If needed, place a soft cushion under the knee. If you need a deeper stretch, lift the back leg up onto a step.

How To: Hip Flexor Stretch

1) With the leg you want to stretch, start with one knee on the ground.

2) Pull your pelvis up and back.

3) Push your hips forward until a stretch in the front of the leg is felt.

4) Hold for 30 seconds, then switch sides.

See the photo below to see a Group 23 physiotherapist performing the exercise.

The offering of telehealth appointments allows for Group23 to be flexible with our patient population and their needs, especially during a time of uncertainty. Read an interview with Lisa, one of our physiotherapists, so see how we can help you reach your goals virtually.

What is telehealth? Telehealth is a visit between you and your healthcare provider. Telehealth uses video conferencing or just audio conferencing to provide a connection between patients and their doctors, physical therapists, psychologists, or other health care providers.

Do you need special equipment? It is suitable for anyone who has access to a landline phone, a cell phone, or tablet or a computer and a reasonable internet connection.

Who would want to use telehealth? There are lots of people who love the opportunity to talk to their provider without coming into the clinic. These reasons could include:

• You don’t WANT to leave your home (you are isolating due to health concerns or poor weather).

• You are UNABLE or not supposed to leave your home (caregiving or quarantine)

• You may not have time to come into the clinic for an update with your practitioner

• You don’t need hands on assessment or care

Many people are waiting for the COVID crisis to end before they take care of themselves. Health professionals concerned that they are suffering unnecessarily. We have no idea of when the COVID crisis might end.

How does someone get a telehealth appointment? Ask at your clinic if they offer telehealth (most do). Book a telehealth appointment. If you are doing a phone call visit, the doctor or therapist will call you at the appointed time. If you are doing a video telehealth visit, the clinic will send you an email with a link to click at your telehealth time. Click the link at the appointment time and your therapist, if not present already, will appear shortly.

Is there anything special about telehealth that you don’t get in clinic? As a therapist you get to see people in their natural habitat. You design home exercises using what people have at home and you trouble shoot the little things that can prevent people from doing the exercises that will make them better.

Does every therapist or doctor do telehealth? Some people like it more so than others. I personally enjoy telehealth. It is satisfying to reach people who otherwise would be waiting in pain and get them started on their recovery. I like that it relies on people to help themselves. Many people are concerned that they will be reliant on the healthcare provider and not be able to help themselves. Sometimes they are frustrated because they aren’t sure HOW to help themselves. A little bit of solid information about what they are experiencing and how they can get better can go a long way to help someone feel less anxiety, use less medication, sleep better, and be more active on a daily basis.

What if you start telehealth but it isn’t what’s best for you? While you are talking to your healthcare provider, it will become clear to one or both of you that it would be best if you came to the clinic. You shouldn’t need to repeat all of history of assessment so your first in clinic visit can be shorter. Telehealth is not meant for those who would best be served with hands on assessment or hands on care.

I don’t know about you, but when I first started coaching lifestyle and behaviour change, my perception of what it looked like was far different than what I know now.

We tend to think the trajectory of lifestyle change looks like a straight line from A to B. Often, the only truth to that is that the journey starts at A. How we get there looks more like a cat chasing a laser pointer than a straight line and the more accepting we are of that fact, the more we can learn about ourselves along the way.

Behaviour change is hard. A lot of us have been practicing old behaviours that no longer serve us for decades, so it makes sense that changing these behaviours will take time. One of the things we know about changing behaviour is that we will get it wrong- a lot! This is not failure but rather learning, or failing forward. The only true failure is the refusal to move from the starting line because we no longer believe we can change. Change is possible – our clients have shown us this more times than we can count – but sustainable change is slow. I say sustainable change because when we want behaviour change to last, it must be built upon a new foundation of lifestyle skills that take time to implement. When we try to change everything at once we end up overwhelmed and onto the next plan. That’s a failure of process- not our ability to change.

So what exactly is failing forward when it comes to lifestyle change? It’s realizing your why and holding it tight regardless of how many times you “fall off the wagon.” Falling only requires a course correction not a complete abandonment of the plan. I tell my clients the most important concept in lifestyle change is consistency. Weight loss can look many different ways to different people but the one constant is that we just keep going. When we hold onto the idea of improving our health and the reasons why it is important to us, the “falling off” is just learning. We then continue to tweak (over and over again) until our new lifestyle feels clear and simple. Simple; but never easy. If it was easy, everyone would be doing it!

Tracy Fisher, Health Coach