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Some physiotherapists say that expanding medical coverage to include exercise therapy would be more effective than surgery in treating age-related knee pain.

JOHN LEHMANN/The Globe and Mail

It starts with pain in the knee, followed by swelling so intense that a patient may have trouble bending or straightening the leg.

A torn meniscus – the cartilage that cushions the knee joint – is a common knee injury in Canadians aged 45 to 65. But patients may be better off without the most common treatment: surgery.

The benefits of knee meniscus surgery are meagre compared with the risks, according to an analysis published Tuesday in the medical journal BMJ. The review of 18 studies found that surgery-related complications, though rare, include deep vein thrombosis, infection or blockage of the main artery of the lung. Even in cases where surgery helps, the benefit is "markedly smaller than that seen from exercise therapy," the authors wrote.

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For middle-aged Canadians, this popular surgery has become a default solution to painful wear and tear on the meniscus. Over the past seven years, however, study after study has shown that arthroscopic surgery, which involves small incisions and a tiny camera that helps the surgeon trim any ragged cartilage, is no better than a placebo.

Physiotherapists note that surgery does not treat the underlying causes of a damaged meniscus, which may include excess body weight and weak musculature around the knee joint. Expanding medical coverage to include physiotherapy would be a more effective strategy to treat age-related knee pain, they argue.

Non-surgical treatments have potential to provide the same, if not better, outcomes for patients, with less risk, "and certainly with less cost," said Dr. Michael Hunt, an associate professor of physical therapy at the University of B.C.

Dr. Moin Khan, a research fellow in orthopedic surgery at McMaster University, agrees. He is the lead author of a 2014 study on arthroscopic surgery published in the Canadian Medical Association Journal. Khan and co-authors reviewed how a total of 805 participants in seven separate studies fared after receiving arthroscopic surgery, no surgery or a sham procedure, in which surgeons made an incision but did not trim any cartilage in the knee.

At the six-month and two-year mark the three patient groups showed no significant differences in their pain symptoms or ability to do everyday activities, such as walking or climbing stairs.

"Patients in non-operative groups did just as well, or better in some cases, as the operative group – and definitely at less risk," Khan said.

Asked why specialists continue to recommend arthroscopic surgery, Khan explained that studies casting doubt on the standard knee scope are relatively recent. "There is often a lag between research findings and changing widespread clinical practice."

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Knee arthroscopy is day surgery that usually takes an hour or two. The surgery is normally performed with local anesthetic around the knee, or regional anesthetic, which numbs the patient from the waist down. The recovery period is about one to two weeks, followed by three to six weeks of physiotherapy to help restore the full range of motion and strengthen the muscles around the knee.

Physiotherapy treatment without surgery typically involves weekly sessions with a physical therapist in addition to exercises at home. Depending on the patient, exercises may target the quadriceps, hamstrings, calves, hips and pelvis muscles, with the aim to improve kneecap alignment and range of motion of the joints. Many patients have less knee pain after six to eight weeks, but physiotherapy treatment may take longer for others, especially those who need to shed excess body weight.

The lack of benefit with arthroscopic surgery may be due to the fact that many patients suffer from osteoarthritis, a degeneration of joint cartilage and the underlying bone, as well as a thinning and weakening of the meniscus. Even if a meniscal tear shows up on an MRI scan, it may not be the source of the patient's pain, Khan said. "Orthopedic surgeons are often challenged to determine the true cause of patients' symptoms: the meniscal tear, osteoarthritis or a combination of both."

Treatments for osteoarthritis are the same as non-surgical interventions for a damaged meniscus. They include weight loss and physiotherapy, often combined with anti-inflammatory medications and cortisone injections to help reduce pain.

Keyhole surgery may help younger patients in their 20s and 30s with meniscal tears from acute sports injuries, according to a 2013 Finnish study. But older patients with knee pain should try alternative treatments for at least three months before considering surgery, Khan said.

Patients with time-worn knees may benefit from using custom orthotics in their footwear, Hunt said. Often, physiotherapists can help patients strengthen specific muscles to stabilize the knee joint, or adjust their movement patterns to reduce the load on the knee joint. "Exercise is the cornerstone treatment," he added.

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