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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Knee Injury--The PT Alternative

Published March 19, 2013 1:00 PM by Lisa Lombardo

Last month, my mom, who is 67, had surgery on a torn meniscus in her right knee. She's not even sure how she tore her meniscus, and it was a very light tear; could have been something as simple as planting her foot wrong or her foot coming lose from her shoe, causing the twist. I wouldn't consider her particularly "active;" she has a full-time desk job but does walk for about 20 minutes a day at lunch when weather permits.

Before her surgery, I did some investigating on whether surgery was necessary, and what she could expect to be able to do once her treatment was complete. I asked her if her doctor had suggested physical therapy as an option, rather than the surgery. She was told the surgery, done in an outpatient office, was very non-invasive and with some rest and proper pampering of her knee, she'd be fine in a few weeks. And she now is, having recently returned to work. Other than the exercises she was told to do every day after she got home, she was told post-op physical therapy would not be needed.

It turned out that her surgeon removed some arthritic cartilage too, so perhaps the surgical intervention was the best option, in her case. But it did make me wonder if physical therapy was even put forth as a viable alternative to having the surgery. Perhaps the doctor took a look at the tear and decided surgery would be minimal enough to go right to the source. And when my mother first experienced the tear, she was in a great deal of pain; at the outset the combination of the tear and arthritis formed in the knee made walking near to impossible.

New research from Brigham and Women's Hospital (BWH), suggests that physical therapy may prove just as effective as surgery for some patients. These findings were presented this month at the annual meeting of the American Academy of Orthopedic Surgeons and simultaneously published online in the New England Journal of Medicine.

Researchers at seven major universities and orthopedic surgery centers around the U.S. assigned 351 people with arthritis and meniscus tears to get either surgery or physical therapy. The therapy was nine sessions on average plus exercises to do at home, which experts say is key to success.

After six months, both groups had similar rates of functional improvement. Pain scores also were similar.

Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn't helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and averted an operation. The research was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health.

Should my mom have been encouraged to opt for physical therapy rather than the surgery? It might have saved her time off from work, but would it have prolonged her pain when walking? Can patients assume doctors do consider PT as an option, but decide on a patient-by-patient basis who needs surgery and who can heal just as well without it? I'd be interested to know what readers think.



Great discussion all the way around.

I just did some quick math. I'm having CMC reconstruction surgery (bone-on-bone thanks to some phenomenal genetics at work) next month. My out-of-pocket cost is the equivalent to my cost for 12 PT visits. I know this to be true thanks to my daughter's out-patient PT last year - which, by the way, was a smashing success.

PT won't cost insurance nearly as much as the surgery would, but because of the payment/co-payment structure, it's costing me the same. So while it may be a win for insurance, it's a wash for me - financially.

Depending on the patient's philosophy will depend on how they'd rather go. Unfortunately, in our microwave society that wants results now and would prefer not to have to work for them, surgery is the no-brain winner in this scenario. From a PR perspective, we have our work cut out for us convincing them that good old fashioned hard work is the more sensible choice.

Janey Goude March 22, 2013 12:43 AM
Lexington SC

I agree with Ian, Surgeons are also business people. If they can do surgery, why wouldn't they? Especially when PT isn't reimbursed unless seen and referred by a doctor first? Until insurers will pay for treatment provided through direct access, the surgeons will do procedures that may or may not be necessary.

I'm curious, how can surgery be "non-invasive"? Once the skin is broken, it is invasive. "Selling points" like this only make me question the surgeon's motives all the more.

Dean Metz March 19, 2013 4:26 PM

I always tell my patients you don't go to a car salesman if you don't expect to be sold a car.  A surgeon is going to recommend surgery 9/10 just like a PT is going to recommend PT.  When it comes to your mothers case specifically its hard to tell if the initial pain was coming from the OA or the meniscus.  When you have surgery to clean out the knee you inevitably rest your knee which will allow an OA flare up to heal as well.  Therefore, you never really can know where the true source of the pain came from.  In my opinion you should always try PT first (I may be a little bias).  It is cost preventative for the health care companies.  The patient will get better or stay the same.  If their pain and function do not improve then its time to go under the knife.  In some cases though you can definitely avoid surgical intervention (sorry surgeons).

Ian, , Physical Therapist March 19, 2013 3:57 PM
North Kingstown RI

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