Persistent Knee Pain after Arthroscopy
by Steve A. Mora, MD Orange County Knee Specialist
So you’ve had knee arthroscopy but your knee still hurts. This is something I frequently see in my office especially for second opinions. The usual scenario is one where a patient had arthroscopic knee surgery for a torn meniscus. The surgery went well but the patient still has pain even though it’s now 2-3 months later. These patients are usually quite frustrated because they were under the impression that they would bounce back fast after their “simple” surgery. Adding insult to injury is the fact that almost every patient has had a neighbor or co worker who had the “same” surgery and who was back doing everything in “2 weeks”.
I find these patients quite challenging but at the same time extremely thankful when I can make them better, educate them or allay their fears. I will start by saying that half of these patients are fine and just need more time to get better. What I see more often than not is that not enough therapy was done or perhaps the patient expectations were unrealistic. Therefore, the first thing that a patient with a “failed surgery” needs to understand is that no 2 surgeries are ever alike. In this manner inaccurate expectations can be addressed early. If a patient had surgery less than 3 months ago I usually find that they are incompletely healed and need more time or maybe more therapy. Those are the easy cases. The trick is to know when things are fine and moving a little slow or if indeed progress has stopped and a problem does exist.
In order to really understand what is happening I need information. I spend a lot of time trying to understand the current symptoms but I also ask about the symptoms before the surgery. It is also extremely helpful when a patient brings in their Op report, Pre-operative MRI and surgical pictures. Patients can usually borrow the surgical photographs or perhaps even get their own copy. These pictures allow me to see the state of the articular cartilage and the severity of the treated meniscus tear.
Patients can help their doctor by really understanding and making note of their pain and problem. Patients can help by marking their knee in the area that hurts or writing down their symptoms in detail. Also patients should know how much post-operative physical therapy they have had since their surgery. This information is actually very important. I can usually make a diagnosis just based on a good history.
*Is there pain with stair climbing (patellofemoral disease or tightness)?
*Is there pain and swelling with long walks (probably degenerative/arthritic problems)?
*Is there pain in an area that not related to the surgery (other diagnosis)?
*Is the problem going down stairs (weakness of quad muscle)?
*Is there a history of other joints with similar problems (rheumatoid disease)?
*Is there a history of morning stiffness of the hands (rheumatoid disease)?
*Does the spine or hip hurt (referred pain)?
I then spend just as much time doing a detailed physical exam. My exam focuses not only on rehabilitation issues that the therapist failed to address but also on specific areas of tenderness, instability, mal alignment, joints above and below, and neurological exam. It interesting how much information the tip of my finger can give me. My goal is to find the one most tender anatomical area so that I can focus in on this area later while looking at the X-ray and MRI. Is the bursa tender? Is the medial tibial condyle tender? Is the patella tender with crepitus? Is the bursa tender? Is there a palpable band? If I know what structure to look at the task goes from a shot in the dark to a highly accurate evaluation. In order to do a good exam I like to examine the whole leg from the hip to foot. Patients can help by wearing shorts or sweats that can be pulled up high to the evaluation. Key points that I look for in the exam:
*Is there a limp due to loss of knee extension or pain? Loss of knee extension can be a big problem. It is easily correctable with therapy.
*Is there a deformity such as bowing, effusion, and medial tenderness? Probably post meniscectomy degeneration/arthritis.
*With the patient seated on table and relaxed, is the patella medial/lateral passive gliding tight? This will cause anterior pain and effusion. It is easily correctable with therapy.
*With the patient in the prone position, is the Quadriceps tendon tight? If it is the heel of the foot will not reach as close to the buttock as the opposite side. This indicates incomplete rehabilitation and once again is easily corrected with good therapy.
*Can the patient do a single leg step down from a step stool? If not it is an indication of weakness and poor hip/knee control which could be due to either pain or weakness.
I like to see recent X-rays. I usually take standing weight bearing views of both knees, Lateral and Patellofemoral Sunrise view. These X-ray films are very important because they tell you information that the MRI does not.
I look at the Pre-operative MRI and sometime but not always order a new one. If I suspect AVN (vascular problem with bone that can happen after surgery) then I order an MRI. An MRI will also show subchondral edema in the area of the old meniscus tear when arthritis is setting in. It is not unusual for a new MRI to say “meniscus tear” in the area that was already treated with meniscectomy. The initial pre-operative MRI films are usually all I need to figure out what is happening. It is very hard if not impossible for an MRI to distinguish surgical changes from a persistent meniscus tear. A new MRI usually confuses the situation.
There are cases where severe swelling will occur due to overload following arthroscopy for degenerative meniscus tears. This is called subchondral edema. It is part of the progression of arthritis. It can be seen on a post op MRI. Some experts believe that the edema (fluid) is due to micro fractures of the bone in the area of the over load. Therefore in this case a post op MRI can be useful. A relatively new treatment is available for this in which a calcium like paste in injected into the affected bone. The paste will harden and provide support for the damaged bone.
Once I have all the above information I put together a differential diagnosis and present it to the patient. Like I mentioned at the top, sometimes the problem is simply being incompletely healed and more time is needed. Other possibilities include poor rehabilitation, cartilage defects, sub chondral edema from degeneration/arthritis (common), poor patella mechanics, poor range of motion, AVN (rare), IT band syndrome, pes bursitis, intra-articular ganglions, plica bands/synovitis, persistent tear that was incompletely treated (unusual).
Other problems that I also think about include rheumatoid disease, hip arthritis, and neurological disease such as a L4 radiculopathy.
I then spend a few minutes writing down my diagnostic plan and the treatment plan. Patients appreciate it when you write down the plan as well as “the next step”. For example I might say “lets try a steroid injection today, more therapy aimed at improving quad flexibility and 10 days of NSAIDs. If this does not work in 6 weeks I will recommend hyaluronate injections”. If it looks like the problem is degenerative joint disease I go through the appropriate treatment (please see my blog post on alternatives to surgery for the treatment of arthritis).
As you can see dealing with a patient that has already had surgery is more challenging than one who has not. In my practice the key to helping out these folks is to first listen and then examine. As I said above most of the time you can nail the diagnosis even before you touch the knee.
In most cases a good ear to listen and the tip of my finger are the best diagnostic tools.
I hope this information regarding meniscus tear treatment and the development of arthritis is helpful. Thank you for taking the time.
About Steve A. Mora MD:
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he earned top of his class honors with his induction into the Alpha Omega Alapha Medical Society honors. He completed his Orthopedic Surgery training USC. He then completed a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County. Dr. Mora’s practice focus on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy and partial knee replacement and ACL reconsctruction. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Some of the procedures he performs include Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, knee ligament reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, platelet rich plasma and adult stem cell injections. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
Steve A. Mora MD, Orange County ACL Surgeon. You can request an appointment with me by calling 714 639-3750 or going to my web page www.MyOrthoDoc.com
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