In 2002, I tore the meniscus in my knee while having a damn good time.
My orthopedist wanted to aggressively diagnosis and treat the injury with an MRI and then surgery but my out of pocket costs for that sequence probably would have been six months of my then limited as a grad student income. That was not going to happen. Instead, he gave me a PT regime that I could do at home and told me that my knee would probably be off for a year but eventually everything would be mostly all right.
And he was right and a recent study in JAMA shows that after a year, PT and surgery have about the same outcomes. Physical Therapy is also a whole lot cheaper than surgery.
TFW not having knee surgery in 2003 due to cost seems to have been a washhttps://t.co/t8dB8H38Jo
— David Anderson (@bjdickmayhew) October 3, 2018
If we are to move towards a system that prioritizes the combination of evidence based care and cost effectiveness, the number of people who get the expensive and non-superior treatment has to fall. In this case, that would mean far fewer meniscus repair surgeries when the injury is straightforward and the patient has no confounding complicating risk factors. And yes, the evidence shows that surgery has a faster return to low pain status than physical therapy but that is a matter of months and the level of pain and dysfunction at a year out are about the same.
From an insurance design perspective, benefits need to evolve. Try to fail which is a common benefit structure in the pharmacy benefit could expand to more physical health interventions where the non-inferior and cheaper alternative is mandated first and then the more expensive alternative is authorized only when the first attempt failed.
An alternative payment mechanism could also be set up where a simple knee meniscus tear triggers an episode based payment that is heavily weighed towards physical therapy. The surgeon would have a strong financial incentive to refer a patient with a simple injury to physical therapy.
Another alternative would be reference pricing where the bundle for meniscus repair is again heavily weighed towards physical therapy but if someone wants immediate knee surgery, they can pay most if not all of the incremental difference in costs.
If we actually want an evidence based medical system where cost is a major decision shaper, then we will need to change incentives to encourage treatment pathways that are less expensive and non-inferior.
Brad F
David
For readers, note the exclusion criteria. That’s probably 2/3 or more of the population who would face the choice of the two options:
Exclusion criteria were locking of the knee, prior knee surgery, instability caused by an anterior or posterior cruciate ligament rupture, severe osteoarthritis (Kellgren-Lawrence score of 4, indicating large osteophytes, marked joint-space narrowing, severe sclerosis, and definite bone ends deformity),14 and a body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) greater than 35.
Brad
Cheryl Rofer
Just started physical therapy yesterday for sciatica. Nobody was talking about surgery, but OMG the pain is gone and I have a way to deal with it if it returns. The stretches also help to fix what’s wrong. Nine sessions to go, maybe fewer.
Wag
I tore my right lateral meniscus in 1998. About twice each year, usually while sitting cross legged, the meniscus flips, and my knee locks. Takes me about 30 seconds of insane pain to unlock it, and I’m good for another 6-8 months. Never had surgery, and have run marathons, climbed innumerable mountains, skied more vertical feet than I can count, all without surgery.
I’m a believer.
dr. bloor
It would be interesting to know how many orthopedists would have recommended surgery as a first course of action for the stratified sample included in the study (see Brad F at #1). It’s not 2003 anymore, and my guess would be “not many.”
In addition to the conceptual problems I have with insurance companies engaging in the de facto practice of medicine through benefit shaping, there’s a cost risk in constructing complex payment schemes that target a utilization problem that looks worse on paper than it is in practice.
Skepticat
Had a mostly broken neck (one broken, four displaced vertebrae) after a fall, and twice-monthly steroid injections controlled the pain only briefly. However, daily at-home traction saved me from a spinal fusion.
raven
I have been experiencing what I first thought was vertigo. I did the exercises that usually help but they didn’t. I went to my GP and we determined that I have peripheral double vision. I got into a neuro the next day and had a brain MRI. They found no evidence of stroke or tumor so she sent me on my merry way with no restrictions. It got no better and I was at meeting with a neuroscience prof and she urged me to go to an ophthalmologist so I got there tomorrow. I hope we fond some cause I can work on solving.
raven
@Skepticat: I had a fractured t-6 43 years ago and they put harrington rods on my spine along with the fusion. Glad you dodged that,
Balconesfault
I haven’t looked at the study, but does it conclude that PT versus arthroscopic for a torn meniscus for someone who’s not grad school age would have similar outcomes? Because from what I know once you get up into your 50s you’re not going to have natural healing from PT and a torn meniscus is going to keep causing pain until it’s operated on.
Wag
@Balconesfault:
Here are the inclusion and exclusion criteria from the study.
raven
@Balconesfault: I couldn’t drive any distance in my 50’s till I had mine repaired.
BroD
Yep, my reverse shoulder replacement earlier this year was a mistake. In hindsight, the contra-indications are now pretty clear to me (and, I think, should have been clear to the surgeon in advance of the procedure.) My bad for not getting a 2nd opinion.
p.a.
So this is saying after 12 mos outcomes are ~=. What if job/life requirements don’t allow for the extra lag time for the less aggressive, less expensive treatments to have the desired effect, but insurers deny the aggressive measures? Not everyone can afford the extra time at < 100%. I'm speaking generally, not just about the meniscus.
Example eleventy-thousand that this stuff is complicated.
Buford
@Skepticat: Ahhh…broken necks are a pain…I broke my neck three times…twice, I didn’t know it, and just added the pain into the rest of my body’s index of pain…the last time I broke my neck was because my knee collapsed, and I fell on my shoulder, causing the c3/c4 disc to herniate, and it broke loose many bone spurs, creating a large blood clot and restriction in the spinal column…I went to Physical therapy, which ended up aggravating the neck injury, and it almost caused me the loss of the use of my left arm…and weakening my right side….then the MRI and CT scans were performed, and I was scheduled for surgery that day…My neck had naturally fused with several large bone spurs bridging most of my cervical area…but now, it looks as though I have reached another milestone in the sad saga of my cervical region…it looks like I may have more surgery upcoming…and I am not a happy camper….
Art
Back in the late 90s I used to sometimes eat lunch in the cafeteria with an orthopedic surgeon. He was one of the relatively rare professionals who liked slumming it with the little people. He had a fine sense of humor. He also was one of the few vocal voices strongly in favor of PT, often several courses of PT, before surgery. Outside of a need to correct severe trauma he wouldn’t touch a case if they hadn’t gone through PT. He said more than half the cases would get to an acceptable level of health with PT alone and, in cases where PT would get them there, a few months of PT gave him more and healthier tissue to work with in surgery and it did it all at very little risk.
He also pointed out that people who worked hard in initial PT were also those likely to work hard through the pain of post-surgical PT and to get the best possible results from surgery. People unwilling to work hard and comply with directions generally had poorer outcomes from both initial PT and surgery.
My short conversations with this surgeon convinced me that there are indeed medical professionals who put what is really good for patients first. For a time I thought that that sort of person was as rare as unicorns.
I’m glad to see the medical profession officially catching up to what was known twenty years ago. Large wheels grinding very slowly.
Racer X
There is no such thing as “meniscus repair”. They cut the torn and frayed stuff out. It is straight mutilation. Of course they are going to call it “repair” no one will sign up for “meniscus mutilation”. If it is done right it and depending on the tear it can contain the problem – but it is not and never will be repaired. When its done wrong you end up with a full knee replacement like me. I am happy with my new knee. The 4 “repairs” I suffered through gave me a decade of pain. Kudos for avoiding surgery!
Dev Null
@Wag: @Balconesfault:
I tore an ACL in the 1960s [1], which was repaired with an innovative technique that is now known not to work (spoiler: it didn’t). Multiple arthroscopies and a tendon graft in the past 20 years.
I’d probably have been excluded from the study by “knee instability” prior to the tendon graft but not excluded post-graft. However my last (so far) arthro / meniscus tear was after the tendon graft (I jumped down off the cab of a (non-moving) moving van and landed wrong).
I remember always-present discomfort in the knee, and having to take a couple of minutes to warm up the knee to get it working again once I’d been sitting for more than, oh, I dunno … ten minutes, say. Something in the joint (torn meniscus? calcium sand?) was obstructing movement.
Not pretending to insight here, but (never one to hesitate to express an opinion despite my ignorance) I am skeptical that PT would have helped much in my case.
[1] Come to about it, the ACL was torn for me.
Felanius Kootea
OT: Nikki Haley resigned? Just saw a headline. I wonder why.
Eric U.
I had a knee problem earlier this year, and a physician friend urged me to go see an orthopod about it. I decided to start swimming again instead, because that’s what fixed the other knee when I had similar issues. For the other knee, I went to the orthopod, they prescribed PT, and that wasn’t helpful. In the grand scheme of things, I don’t think it was that serious of an injury. But when it’s limiting your activities, that’s hard to stomach.
Dev Null
@Racer X:
Yep.
My first arthro was 25 years after the ACL tear, and did exactly zippo for the instability in the knee, but then that’s not what a meniscus clean-out is for. That said, the instability was way more noticeable, post arthro. bad enough that I went back for the tendon graft four or five years later…
… with a different (“50 best in state”) surgeon.
The graft stabilized the knee, and y’know? The bum knee is as good as the good knee, modulo (I presume) less cushioning in the bum knee.
No particular message here, other than “get a good surgeon when you need surgery”, just providing anecdata.
rk
@Balconesfault:
My personal experience as an over 50.
I had severe knee pain,went to an orthopedic doctor who ordered an MRI and diagnosed it as a torn meniscus. He gave me a shot of cortisone (I did not want it, and he did not ask my permission before he jabbed me), His nurse showed me exactly two exercises to do (diagram on a piece of paper). Told me to come back in a month. The shot did not help with the pain at all. I was told that physical therapy helps. I did some online research and looked at the study which showed that physical therapy and surgery have the exact same results after one year. I insisted that the doctor write me a script for physical therapy. I did the therapy and it was a slow and painful journey (especially as I had a job which involved standing on my feet a lot). I was pain free in a few months (you have to give it at least three months and some days you’ll feel it’s useless). I went to the doctor for two more months, but stopped because all he did was twist my knee to check range of motion, mumble into his dictaphone and otherwise ignore me. I paid $100 for each visit.
I would highly recommend physical therapy for most types of pain (I’m not talking cancer or similar types of pain). I had a year or two of a whole host of issues (tennis elbow, back pain, shoulder pain) each of which was resolved by stretching and targeted exercise.
I did a free online course on pain which helped understand what’s going on. It’s very helpful if you have the time. Strangely enough it starts today.
https://www.coursera.org/learn/chronic-pain
These guys are also very good for exercises
https://www.youtube.com/channel/UCmTe0LsfEbpkDpgrxKAWbRA
This exercise for tennis elbow was 100% effective for me. It took less than three weeks for the pain to go away.
https://www.nytimes.com/video/health/100000001768943/a-fix-for-tennis-elbow.html
cmorenc
@Racer X:
BUT: is the relation between meniscus surgeries and later knee replacement (on the same knee) one of causation (by degree or lack thereof of surgical skill in the meniscus surgeries) or else correlation (luck of the genetic draw, you drew failure-prone cartilage, coupled with an active knee-stressing lifestyle) ? I had two meniscus “repair” surgeries on my R knee, one @ age 27, the other @age 37, and then had full R knee replacement at age 67, all three done by highly competent orthopedic surgeons (I had some knowledgeable help in selecting them from my physician father and also physician wife, seconded by general community reputation). I doubt that my later knee replacement was due to any surgical hackery or unwise advice from my earlier two orthopedic surgeons, but YMMV with who you earlier used.
Origuy
I tore my right medial meniscus in May while dancing.I’m 61. I told my doctor that I had a trip to the Yukon planned for August which I didn’t want to cancel. I told him about my activities (orienteering, Scottish country dancing). He referred me to an orthopedic surgeon, to whom I told the same thing. I got an MRI and arthroscopic surgery. I had 12 sessions of PT. Had I not had surgery, insurance would only have paid for 6 sessions. My portion of the costs was about $2100. I’m glad I did it.
Brachiator
@dr. bloor:
But wouldn’t we be shifting “de facto practice of medicine” from insurance companies to the government?
Who is the “we” being described here if there was a health insurance system not based on insurance companies?
I agree with the benefits of an evidence based system, but no matter how you slice it, someone will be acting as referee and enforcer.
ETA: I really found this discussion of surgery vs therapy illuminating. It is obviously useful to detail what injuries can be most effectively be treated by therapy.
But what about people who might be able to better deal with surgery and a relatively short recovery period than a lengthier physical therapy regimen?
StringOnAStick
I could have used a referee to save me from an ENT that convinced me that having my ear drum replaced would solve my inability to equilibrate ear pressure with altitude changes. I asked if there was any risk that I would lose any hearing ability because of it, and he told me “no, that never happens” (his glib use of “never” should have been a hint). Had the surgery, and permanently lost a huge amount of hearing in that ear, and of course he wanted to do the other one. I decided to get a second opinion, and that doctor flat out told me that the surgery I’d undergone had “nothing whatsoever to do with” the problem it was sold to me to resolve. Later I worked with an audiologist who was quite frank that the surgeon I had used had a horrible reputation. Funny how nothing I could find about him online indicated any of that.
The final word is that what was caused the “plugged ear” sensation and trouble changing altitude was an allergy to wheat. Once I quit eating that, the problem vanished, but of course the severe hearing loss remains. Doctors aren’t gods, though some of them think they are.
dr. bloor
@Brachiator: Well, government–and, justifiably, insurance companies–already establish standards of care and place parameters on what will be paid for. No one should have to reimburse Dr. Quack for treating melanomas with IV drips of WD-40.
But it’s easy for payors to get out over their skis when it comes to applying emerging science to cost structures, and there’s a risk of creating micromanaging payment models where you’re dealing with “exceptions” so often that it becomes costlier and more burdensome than its worth. I remember a time when the Cognitive-Behavioral Therapy revolution fueled capping of outpatient psychotherapy benefits because No One should need more than X sessions per year, and having to go through mindless, intrusive utilization reviews every few months to access those sessions.
So–without really knowing how much unnecessary knee surgery is being done–you could use the study above create a payment structure that steers patients to PT before resorting to surgery. But if the patients who qualified for the study weren’t going to be referred for surgery anyways, and the excluded patients will frequently fail a course of PT before getting surgery and a second course of PT, is it worth implementing the policy?
It almost always happens too slowly and with regional biases, but medicine really does catch up with science most of the time. I’m so old I remember when everyone had back surgery and CABG for issues that are now routinely addressed with PT and PCI.
satby
My injuries were in my shoulders, not my knees (and happened one at time), but after one surgeon suggested surgery I went home and did the research. For my particular tendon damage the outcome from surgery vs. physical therapy were about equal, so I opted for the therapy too. It took quite a while because I injured the second shoulder while still recovering from the first one, but I got almost all the range of motion back in both arms. Better than some friends my age who never had shoulder injuries in the first place. I’m a PT believer.
Tehanu
@Cheryl Rofer: I had the same thing, terrible sciatica, and when I was supposed to have surgery my insurance insisted on a second opinion. The second doctor sent me to a physical therapist and she worked wonders. Hope your experience is as good or better!