Common knee problems such as asymptomatic meniscus tears and most osteoarthritis will heal with non-operative treatment. Yet, patients with these problems are often told they need surgery based solely on an MRI or X-rays. When patients turn to Shelbourne Knee Center for a second opinion, they’re surprised when the orthopedic surgeon thoroughly examines both of their knees—the first step in making a definitive diagnosis and avoiding unnecessary surgery.1,2
“Patients don’t want surgery. They just want to get better,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.
Loss of the Art of the Knee Exam
Most orthopedic surgeons who perform a knee exam only examine the involved knee, sometimes without exposing the knee. A survey of 428 patients with a unilateral knee problem who saw another physician within six months of going to Shelbourne Knee Center3 found that 37% of orthopedic surgeons touched the non-involved knee and 63% exposed the knee for the exam.
Lack of training in performing proper knee exams and increasing dependence on MRI to diagnose knee problems leads to unnecessary surgery, especially for asymptomatic meniscus tears in patients over age 40 and patients with osteoarthritis, says Dr. Shelbourne. There is also a possibility that a symptomatic meniscus tear could calm down without surgery.
In patients age 40 and older or patients who have had knee surgery, MRI results will not be normal and are often read as a meniscus tear. Physical therapy (PT) is effective for asymptomatic meniscus tears and some types of symptomatic meniscus tears that don’t respond to surgery.
Nearly all patients with osteoarthritis who were told they need a total knee replacement have limited extension and flexion. “That’s a reversible problem,” says Dr. Shelbourne. “Through physical therapy, about 80% of our patients improve to the point that they don’t want surgery.”
Accurate Diagnosis of Knee Problems
To evaluate knee problems, orthopedic surgeons should obtain a good subjective history and examine the involved and uninvolved knees. The history includes a discussion of:
- Onset and circumstances of the knee problem
- Symptoms
- Previous treatments or self-care
- Limitations in daily functioning.
Shelbourne Knee Center gives patients shorts so that orthopedic surgeons can examine their thighs, knees and legs, looking for signs such as atrophy, swelling, tenderness and loss of extension in the involved knee. Usually, the orthopedic surgeons make the diagnosis based on the history and knee exam. Radiographs, or occasionally MRI, are sometimes used to confirm the diagnosis.
“We determine what’s different between the legs and how we can make them the same,” says Dr. Shelbourne.
Consistency and Continuity in Treatment
A physical therapist is always part of the initial patient visit at Shelbourne Knee Center. This ensures consistency and continuity in treatment. By being in the room with the orthopedic surgeon, the physical therapist hears the patient’s story and the discussion with the orthopedic surgeon.
“The patient doesn’t have to tell the story twice and the physical therapist gets the same story as the orthopedic surgeon,” says Laura Bray-Prescott, PT/LATC, Rehab Supervisor at Shelbourne Knee Center. That’s important because patients often remember things as the exam proceeds with the doctor. If patients go from the doctor’s office to the physical therapist’s office, they may not be able to recall or possibly didn’t understand everything the doctor told them about the knee to tell the therapist.
Even Surgical Candidates Improve Without Surgery
The COVID-19 pandemic highlighted how often surgery is unnecessary. While non-emergency surgery at Community Hospital East was shut down, patients at Shelbourne Knee Center continued to do their PT at home, with guidance from their physical therapists. When the hospital re-opened about three months later, about 50% of patients who were waiting for surgery had improved enough that they no longer needed surgery, says Dr. Shelbourne.
“Physicians need to get back to the basics of the accepted standard for a thorough knee examination and talk with their patients,” says Dr. Shelbourne. MRI scans should supplement, not substitute, for a knee examination. They should be used to confirm and correlate with the findings of the physical exam and the patient’s symptoms.
Case #1: PT Relieves Meniscus Pain
A 49-year-old female who had not been injured woke up with right knee pain and swelling. An orthopedic surgeon ordered X-rays, which were normal, and treated the patient with a cortisone injection. This relieved the patient’s pain for a few days. The orthopedic surgeon then ordered an MRI, and diagnosed the patient with a medial meniscus tear. He recommended an arthroscopy.
The patient sought a second opinion at Shelbourne Knee Center, where Dr. Shelbourne examined both of her knees and reviewed the MRI scan. Dr. Shelbourne diagnosed an extruded medial meniscus, which does not respond to surgery because it is the result of early osteoarthritis. He recommended PT, which is improving the patient’s symptoms and restoring meniscal function.
Case #2: Knee Rehabilitation Program Relieves Severe Osteoarthritis
Based on X-rays, a 66-year-old female with chronic bilateral knee pain was told she had bone-on-bone osteoarthritis and that total knee replacement (TKA) was her only option. The patient’s mother had a terrible experience with TKA and she didn’t want to go through this.
For seven years, the patient lived with pain and stiffness. When she went to Shelbourne Knee Center for a second opinion, Rodney Benner, MD, examined her knees and recommended Shelbourne Knee Center’s research-backed Knee Rehabilitation Program for Osteoarthritis. Dr. Benner gave her cortisone injections in both knees in order to manage the pain and facilitate PT.
The patient is currently participating in the Knee Rehabilitation Program. If she later decides to have surgery, the improvement in range of motion and strength that she’s achieving will lead to a better outcome and a faster, easier recovery.
References
- Shelbourne, KD. The art of the knee exam. Presentation at Andrews University, February 10, 2022.
- Shelbourne, KD. The Art of the Knee Examination: Where Has It Gone? The Journal of Bone & Joint Surgery. August 4, 2010 - Volume 92 - Issue 9 - p e9 doi: 10.2106/JBJS.I.01691
- Patient Survey on Knee Exams. Shelbourne Knee Center, 2009. Unpublished data.