Do you know not all standard medical procedures and surgeries are supported by research data? Take for example arthroscopic knee surgery, the number-one most common orthopaedic operation. More than two million are done annually and yet sham operative studies and other research have demonstrated it offers no advantage for most knee pain patients (Scientific American, 2018). Other surgeries, including those for low back pain have come under fire for being harmful and useless (The Sydney Morning Herald, 2018) and is a significant contributor to increasing health care costs (The Conversation, 2018)!
There has been a lot of media coverage questioning common, standard medical procedures. The issue in concern is that these procedures’ effectiveness are not supported by research data.
Tendon pathology is a widely researched and discussed topic, and a quick google search can end up taking you down a deep dark rabbit hole of conflicting research, opinion, and debate.
Musculoskeletal pain affects up to 44 per cent of Singaporeans (The Straits times, 2015) and the number of people with knee pain has doubled since World War II (Science, 2017). But is surgery the solution to your problem?
What are common knee problems?
There are many possible reasons why your knee may be hurting. Be it from traumatic injuries, sports, maybe you have no idea why it is hurting. That is okay. This is where I come in to help. The common knee injuries and reasons for knee pain are:
- Runner’s Knee
- Patellofemoral Pain Syndrome (PFPS)
- Iliotibial band syndrome (ITB syndrome)
- Knee Osteoarthritis (Knee Degeneration)
- Rheumatoid Arthritis (RA)
- Anterior Cruciate Ligament Injury (ACL sprains or tears)
- Patella or Quadriceps Tendinopathy
Surgery Is Not The Ultimate Solution
When it comes to knee pain, most people think of knee surgery as both the last resort and ultimate solution. This is not true. Knee surgeries have recently come under scrutiny for being ineffective at treating pain. A study by prestigious journal Pain Medicine in 2017 found that fake orthopaedic surgeries (including knee surgeries) were as effective as real surgeries in reducing pain swelling and improving disability! Given the case, how do we know real surgery actually work? Placebo perhaps?
If you have been referred for surgery and you haven’t tried any conservative care, you should consider carefully. Always ask the doctor in charge of your care for references/research to support his or her claim. In our opinion, surgery is the last resort but doesn’t deliver better results than conservative care.
Do you know knee replacement has a limited lifespan? Most knee replacements need to be replaced every ~15 years or so.
ACL Tears DO NOT NEED surgery
Most ACL knee injury patients assume they would need surgery to achieve full recovery because they have torn their ACL. Guess what? This is not true.
A study published last year followed patients who had ACL surgery vs. no-surgery for TWENTY years found that while surgical patients did have more knee stability, there is no difference in both subjective or objective outcomes (i.e. they have the same function). If you know some one or if you yourself are considering going under for a ACL reconstruction. Maybe try exercise therapy first.
Return To Sports After Surgery is Poor
We strongly suggest patients with ACL injuries to seek conservative care BEFORE considering surgery.
Only 80% of ACL reconstruction patients return to some form of sports. 65% will return to a sporting level comparable to pre-injury, and a mere 55% return to play at a competitive level.
You might think those numbers are not too bad but let’s look at it from a different perspective. If you are currently participating in sports now in spite of your chronic knee pain, there is a 20% chance that you might end up not returning to the sport you love after surgery. We think it’s not worth the risk. Furthermore, as mentioned in point #2, surgery is not superior to non-operative care.
Exercise is the Secret to Recovery Success
You probably saw social media posts promoting the use of some type of manual therapy (i.e. hands on therapy like IASTM, dry needling, cupping) for knee joint pain.
Do you know that that is NOT the best clinical recommendation? A paper published this year recommended that manual therapy should be used only as an adjunct. This is what the latest research says.
Their recommendations are to provide education and to utilise management that addresses physical activity and/or exercise.
The days of rubbing a “tight muscle”, breaking up “scar tissue”, or even apply ice and physical therapy is over. Exercise is the gold standard treatment for musculoskeletal pain.
Most Knee Pain Solutions Are Lies
Everyone makes claim that they have the solution for your knee problems but how many of them actually provided the references to support their claim? We do – because we don’t expect you to “just trust us”. We take your time seriously and we also are committed to getting you better.
- If you are a runner, you’d probably have heard of people telling you that the wrong footwear causes injuries. That is FALSE. Reference: A 2-Year Prospective Cohort Study of Overuse Running Injuries: The Runners and Injury Longitudinal Study (TRAILS).
- What about alignment? Surely it matters right? No, it doesn’t. A different study found Q-angle and short-leg to be not associated with running injuries and flat foot (yes, even that) also isn’t a risk for running injuries! We talked about this study extensively at How To Prevent Running Injuries: From a Sports Chiropractor’s Perspective.
- You might have also seen people undergoing IASTM therapy for knee pain. It’s supposed to “breakdown scar tissue” by means of scrapping the skin with a metal tool. The therapy is also known by other names such as Graston, HawkGrips, etc. One, it is physiologically impossible for that to breakdown scar tissue. Two, research already tells us they don’t relieve pain. I’ve blogged about it here (references included).
FAQ ON KNEE PAIN
Yes, it’s an absolute yes!
Surgery comes with its own set of risks and challenges you can avoid by choosing rehabilitation. In a 2018 study, meniscectomy was found to be strongly associated with the progression of articular cartilage damage. In a second 2018 study, 80% of patients who had undergone knee surgery suffered from knee arthritis compared to 68% in the group who did not have surgery.
Risks aside, surgery is not superior to rehabilitation. Patients who had ACL (anterior cruciate ligament) reconstruction did not yield better results than rehab alone at 5-year follow up. Sure, you tore your ACL but do you need it reconstructed? Most likely not.
Rehabilitative exercise is a safe treatment option for knee pain and it suits people of all ages.
If you have tried home exercises by yourself and didn’t get any results, that is normal. To understand why you need professional supervision for successful rehabilitation outcomes, check out Why Instagram Rehab Doesn’t Work.
- Risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament reconstruction in The Bone & Joint Journal
- Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes in American Journal of Sports Medicine
- Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial in British Medical Journal
At least nine months after your surgery.
39% of patients who underwent surgery and returned to sport earlier than nine months re-injured their ACL. That study concluded that for every one month delay in returning to sport, the injury rate was reduced by 51%.
While ACL surgery remains a legitimate option for patients with ACL injuries, rehabilitation remains the safer choice. In patients who have had undergone ACL repairs, extra effort must be taken to prevent further injury.
Reference: Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction in British Journal of Sports Medicine
Why are we telling you this?
There are a lot of knee pain solutions in the market that are trying to get your attention. The truth is most of these treatments do not come with scientific research to support their claims. Maybe they will work for you in the short-term and you feel less pain as a result. That, in our opinion, doesn’t constitute a pain solution.
At Square One, we are about helping you navigate your knee pain experience and walking you through this journey to pain-free living. We are not about trying to alleviate your pain but rather to bring you back to your pre-pain lifestyle so you can continue doing what you love.