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Get Knee Scoped?

post #1 of 26
Thread Starter 
Need advice. I'll distill the facts:

1. I had some pain in my right knee a few weeks back, so went to an orthopaedic surgeon. He did an X-ray and MRI, said I had a torn/ragged meniscus (sp?) and that I should get arthoscopic surgery.

2. I then consulted with my regular doc, and internist who I've been going to for 15 years, and she said I should put off the surgery until I "really hurt". The past couple weeks I've gone on a couple of three-mile runs and several times on an elliptical and have had no increase in pain.

3. I had my left knee scoped twenty year ago and have had no problems with it since then, but the idea of taking away non-regenerating cartilage gives me pause. Also, I was 20 years younger then and the doc let me watch it on TV while he was doing it.

4. My wife, not in the medical profession, says if you go to Midas they tell you that you need a muffler.

5. I spoke again with the surgeon and asked him if there was a downside to waiting on the surgery. He replied, essentially, that the risk was like "sand in the gears" -- that if my cartilage flopped around it could screw up the joint.

6. I'm 54, just started skiing in 2007 and want to get in at least 30 more years before switching to something easier on the knees (maybe snowboarding?). My other sports include running, tennis, and mountain biking.

Any thoughts or advice? Thanks.
post #2 of 26
I am with you on avoiding surgery until you cant handle it. If you have not already done so might I suggest you consult with a knee joint specialist that deals with athletes not just a "common" orthpaedic surgeon. Good luck.
post #3 of 26
Scoping your knee should be based on symptoms, not MRI results. There are an awful lot of 50+ year old knees with "ragged menisci". Most of these are age-related degenerative changes.

Just because one can scope a knee doesn't mean one should.

You should clarify what type of meniscal tear you likely have (? degenerative, radial, bucket handle, parrot beak, etc.). Understand that MRI is not the best test to visualize complex meniscal tears - scoping is.

The uncertainty with all mensical tears (degenerative or traumatic, symptomatic or asymptomatic) is the difficulty in predicting if they will extend into a bigger/significant tear. This can result in further damaging the meniscus (turning a trim job into a removal job) and/or locking the joint.

There's no absolute right or wrong approach here, but if you're able to run, you probably have a common sense answer right there .

ps. You might want to consider giving up running if you still want to be skiing in 20 years.
post #4 of 26
Definitely give up the running. Esp. if you want to keep up the tennis (although maybe that's not so good right now) I've seen the effects on relatives.
Does anyone ever scope just to look? I'd think if they were doing that they'd be too tempted to remove.

JdI, how's the view on biking? Not bad right? Although mt. biking may have a lot more shock to it than road biking.
Good god, reading Hermann Maier's book he does a lot of biking!
post #5 of 26
I had an exploratory scope whereby the doctor (highly reputed knee specialist) told me that they would do what they had to do if they found a correctable problem. In my case I had some floaters and a roughened surface behind the knee cap, he smoothed it and aspirated it....no more problems.
post #6 of 26
Tog,

Yes, scoping is still the diagnostic gold standard. It's not unusual to scope for a look-see and do a little buff, trim, and washout while you're there. Removing the meniscus is something completely different.

Biking = good.
post #7 of 26
Thread Starter 
Thanks to you all for your replies. I have an appointment next week with a third doc (also an orthopaedic specialist) to get a second opinion. The first doc (the surgeon) said he thought my problem is long-term wear and tear, rather than a specific event. Also, I get the sense that he doesn't see this as major cartilage removal job -- although, JDI, from your message I take it that he won't know for sure until he puts the camera in.

Also, JDI, it sounds like you agree with his "sand in the gears" thought on downside risk.

JDI and Tog, I appreciate your advice re running. I've been running regularly, including occasional races, for 33 years. It would be hard to give up: good aerobic exercise in a short time period, can be done almost anywhere, minimal investment in equipment (although I splurge on running shoes), the endorphins, etc. But life is full of trade-offs -- I can do more biking.

Thanks again.
post #8 of 26
Quote:
I've been running regularly, including occasional races, for 33 years. It would be hard to give up: good aerobic exercise in a short time period, can be done almost anywhere, minimal investment in equipment (although I splurge on running shoes), the endorphins, etc. Jimski
I have only anecdotal evidence on the ill effects of running but I don't believe there's much controversy about it. Bicycle is the way to go even if it's stationary inside. Works for Hermann Maier.

Also, have you considered Chondroitin/Glucosamine? There's a bit of a controversey on that though!
Any longtime users of chondroitin/glucos/msm?
post #9 of 26
Thread Starter 
I haven't tried c/g/m. Generally, I only do drugs that are derived from grapes or hops. Very occasionally I take Advil. Also, I keep fish oil capsules at my desk and pop one a day.

This past weekend I: (a) played tennis on Sunday with my wife for two hours (I won 6-3 9-7), and (b) went on a three-hour bike ride on Monday with my daughter. Had to ice my knee after both events, and am hobbling a bit today along with some swelling. Tomorrow I will see ortho doc #2 for the second opinion. However, based on what the knee feels like right now, my gut instinct on what to do has changed since last week.
post #10 of 26
I also would avoid surgery. If there is a loose body (piece of meniscus) floating around in your knee it will lock up. You should slow your activity down. Reduce the inflammation. Activities with weight bearing cutting, and pivoting like tennis, play hell on your knee.

I would (strongly) consider going to PT. Continually increasing the inflammation in your knee, will create a chronic condition (The harbinger of surgery).

http://health.msn.com/health-topics/...3906&GT1=31036
post #11 of 26
Thread Starter 
Thanks very much. Good article -- now I'm more conflicted than ever. I played tennis again last Saturday morning and have been hobbling around since then. When you say "slow your activity down", you mean in the short run, I hope, until I get the inflammation down? Slowing down is hard, especially now that we're on the cusp of summer (yes, yes, I know, that's just what smokers say too).

I did get a copy of my MRI report. It says I have a "horizontal tear of the inferior surface of the posterior horn of the medial meniscus", "mild subluxation of the medial meniscus", "small joint effusion", and a "small popliteal cyst with mild extravasation of fluid". OK....

Maybe I will go for a consult with a physical therapist, as you suggested.

Thanks again. I appreciate your help.
post #12 of 26
If you like playing tennis, and you're hobbling around, and that happens most times you play, then I'd try a little PT first. If that doesn't help, then have 'em go in and Zamboni the damn thing and then you can play again. This is coming from someone who's had two arthroscopies for meniscal tears, and finally ACL reconstruction.
post #13 of 26
Jim,

Your MRI report confirms the impression of degenerative mensical tear - this is age related/wear & tear.

MRI is useful for answering a focused question, but it is not the basis on which a scope/no scope decision should be made. That should be based on your symptoms. MRI often gives too much information - as we say in the business, it is very sensitive, but often not particularly specific. Every middle aged guy is going to have a bunch of this 'n that on his MRI report .

Now - your knee is talking to you, and you're not listening. Remember, you only have one of these (well, two) and there are no magical surgical solutions to a worn out knee. Scoping for definitive diagnosis, or a specific mechanical problem (chondral flap, torn meniscus) is a very useful endeavour, but for wear & tear, a scope has limited long-term (>1yr) effects. There are many good studies that bear this out.

So, the best initial management of your problem is activity modification. Patients hate hearing this, but it's the truth. I would minimize cutting/pivoting activities and absolutely give up running. Unless you're built like a gazelle and have perfect alignment and flawless technique, your knee is not going to be happy with continued pounding. Get on the bike and in the swimming pool.

Short-term PT for assessment and teaching is worthwhile, but the bottom line is that you need to give your knee an [active] rest.

In our ortho/sportsmed/fracture clinic, the indications for scoping are very straightforward:

- Locking
- Joint line pain
- Persistent/recurrent swelling
- Can't squat/cut
- For definitive diagnosis
- When all else fails (the patient wants it )

Hope that helps.

Regards,
Matt
post #14 of 26

Knees

Jimski, After hammering a bike across some rolling terrain while training for a road race, I rammed my femur into the knee and dislodged some cartilege. Did therapy, rehab, ice, advil etc. etc. for about 10 months and didn't help at all. Went to reg. doc and he recommended the above. Finally went to Orthopedic surgeon in Lake Tahoe, a Dr. Browning that was/is an avid backcountry skier - so he understood my delimena.

Scoped knee and cleaned out loose junk. It took about 4 years for 100% recovery under stress. Wore a neoprene brace for skiing for those 4 years (basically just to keep warm). It has been about 15 yrs since scope and I am fine and have been for 10 yrs.

Doctor said I could rehab skiing since I did it biking. He always told his ski knee surgeries to bike and spin for rehab so.......

Just general info. no recommendations other than your wife is right. Ask around, ask everyone you can. Good luck.
post #15 of 26
Pete,

My advice is based on the nature of Jim's problem. You had a loose body in your knee, which of course requires a scope .

Regards,
Matt
post #16 of 26
Thread Starter 
Thanks very much to all who replied. Matt, your long e-mail was particularly helpful. I feel like you should send me a bill for medical consultative services. You conclusion that this is age-related tracks with what ortho doc #1 told me. I had asked him if the MRI results gave him any clue as to what had caused the problem and he said (with a straight face) that it was probably related to the color of my hair -- the silver and grey.

I will cancel my tennis match for this weekend and get on the bike. I'll lay off the running for a while. As to swimming, our town pool is only a block from my house so I have no excuse (I find swimming to be mind-numbing -- but, as I said before, life has trade-offs). Can I go back to tennis in 2-3 weeks? Would it help if I wore a knee brace?

Regarding your checklist, here's how it applies to me:

- Locking -- occasionally, but only for a moment, and then I hear (and feel) a loud snap and it is unlocked;
- Joint line pain -- low level pain most of the time (of course, most people my age have low level pain somewhere most of the time; we just ignore it). Occasional shots of more intense pain, but I can't tell if it is coming from the joint line;
- Persistent/recurrent swelling -- yes; usually after a sport activity, but also, generally the right leg feels tighter (more internal pressure).
- Can't squat/cut -- no. I do squats as part of my morning exercise routine. There is typically some stiffness and pain, but not enough to make it impossible. Cutting: in tennis, I start slowly and then, after my opponent scores the first 2-3 times, my competitive juices kick in and I cut like a jackrabbit.
- For definitive diagnosis -- I don't know how to rate this. Is there anything in my summary of the MRI report that sounds suspiscious, such that a surgeon would need to go in just to check it out?
- Patient wants it -- The patient is of two minds. If I thought it would give me the knee of a 22-year-old I would go to the hospital this afternoon and get it done (heck, I would settle for a 42-year-old knee!). But, Matt, you've noted there are studies showing that I would get not much more than a year of relief (can you send me some cites? -- thanks!) I had mentioned in my first message that I had my left knee scoped 20 years ago, but that injury had specific origins: a very competitive racketball game (I tore it half way through the game but didn't want to concede). My left knee has been fine since the scoping. That's not inconsistent with what you've said, since that was not a degenerative, age-related injury. Short answer: I just want to do what's right for the long-term health of my knee, without having to make shuffleboard my only sport. And ski season is only about five months away....

Again, thanks to all for your thoughtful and helpful responses.

Jim
post #17 of 26
Quote:
Originally Posted by Jimski View Post
I just want to do what's right for the long-term health of my knee, without having to make shuffleboard my only sport. And ski season is only about five months away....
Jim
I've noticed that runners often feel that if they give up running they can't do anything else. I think the answer is more like if you give up running you'll be able to do a lot of other things. You're at least saving the bad part for the good part.

For pain - ice too. I always hated ice till I discovered the CryoCuff after surgery. Ahhh...so good. Do a search for it.
Weird note: for me immediate recovery, like 1st five days, after arthroscopic surgery was far worse than after acl reconstruction. I know many people walk home etc. after arthroscopic, but not me. Of course the rehab was far worse for acl surgery.

Biking- I don't think I'd recommend Hermann Maier's book in general, but if you want some reinforcement of how much biking he does, well it's in there. My favorite part of the book is when he talks about how he prefers Super-G to Downhill saying SuperG has "no boring gliding sections".
Huh, gliding at 70mph is boring!

here's an article:
http://www.skiworldcup.org/load/repo...aier_news.html
quote:
Hermann said he had always been a cycling fan and riding a Tour
stage was a dream come true. “I ride thousands of miles in training on Austrian and Italian roads and I spend many afternoons in the summer watching the Tour during some indoor training sessions on my homebike in the “Olympia training” centre in Obertauern,” Maier explained.
“I will have near 15’000 kms in my legs at the start of the season. It’s a great sport”.
l
-------------------------------------------------
from cyclingnews.com:
2003 TDF Forerunner H. Maier:
525x525px-LL-vbattach3436.jpg
post #18 of 26
Quote:
Originally Posted by Jimski View Post
Thanks very much to all who replied. Matt, your long e-mail was particularly helpful. I feel like you should send me a bill for medical consultative services. You conclusion that this is age-related tracks with what ortho doc #1 told me. I had asked him if the MRI results gave him any clue as to what had caused the problem and he said (with a straight face) that it was probably related to the color of my hair -- the silver and grey. LOL, bang on.

I will cancel my tennis match for this weekend and get on the bike. I'll lay off the running for a while. As to swimming, our town pool is only a block from my house so I have no excuse (I find swimming to be mind-numbing -- but, as I said before, life has trade-offs). Can I go back to tennis in 2-3 weeks? Would it help if I wore a knee brace? I'll have to get my crystal ball warmed up.... Seriously, you just need to see how it goes and be guided by your symptoms.

Regarding your checklist, here's how it applies to me:

- Locking -- occasionally, but only for a moment, and then I hear (and feel) a loud snap and it is unlocked; Impression: probably your kneecap, although if this gets worse, you have to consider an internal source.
- Joint line pain -- low level pain most of the time (of course, most people my age have low level pain somewhere most of the time; we just ignore it). Occasional shots of more intense pain, but I can't tell if it is coming from the joint line; Impression: non-specific.
- Persistent/recurrent swelling -- yes; usually after a sport activity, but also, generally the right leg feels tighter (more internal pressure). Ah ha.
- Can't squat/cut -- no. I do squats as part of my morning exercise routine. There is typically some stiffness and pain, but not enough to make it impossible. Cutting: in tennis, I start slowly and then, after my opponent scores the first 2-3 times, my competitive juices kick in and I cut like a jackrabbit. This is a good sign, but don't overdo it.
- For definitive diagnosis -- I don't know how to rate this. Is there anything in my summary of the MRI report that sounds suspiscious, such that a surgeon would need to go in just to check it out? No. Again, MRI is generally not the basis for making yes/no surgical decisions - symptoms are. MRI can help re. surgical planning.
- Patient wants it -- The patient is of two minds. If I thought it would give me the knee of a 22-year-old I would go to the hospital this afternoon and get it done (heck, I would settle for a 42-year-old knee!). But, Matt, you've noted there are studies showing that I would get not much more than a year of relief (can you send me some cites? -- thanks!)
http://www.ncbi.nlm.nih.gov/pubmed/18254069?ordinalpos=3&itool=EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
I had mentioned in my first message that I had my left knee scoped 20 years ago, but that injury had specific origins: a very competitive racketball game (I tore it half way through the game but didn't want to concede). My left knee has been fine since the scoping. That's not inconsistent with what you've said, since that was not a degenerative, age-related injury. Short answer: I just want to do what's right for the long-term health of my knee, without having to make shuffleboard my only sport. And ski season is only about five months away....

Again, thanks to all for your thoughtful and helpful responses.

Jim
See comments above in bold.

Your MRI report also suggests the beginning of a popliteal cyst, aka Baker's cyst. You may want to look it up. It's simply an indication of an aging knee. Although these cysts can exist on their own, their presence is usually an indication of arthritis and/or degenerative mensical tears that cause recurrent swelling - and therefore exert pressure on the back of the knee capsule.
post #19 of 26
Thread Starter 
Tog and Matt, thanks!!

Tog, you've inspired me to switch to biking as my week-day aerobic exercise. I've got a good dual-suspension mountain bike and a trail near my house, so why not? I'd read a while back that biking is only about half as aerobically efficient as running but, as Matt pointed out before, I only have two knees. And I will search for Cry-cuff. Interesting what you said about pain and recovery from arthroscopy. My regular doc said that ortho docs always under-estimate the p&r from scoping. The only time I've ever fainted in my entire life was about 8 hours after I had my left knee scoped. But the doc who did the surgery told me he wanted me back running within two weeks, to prevent scar formation. I did it. It was 20 years ago.

Matt, thanks very much again. From your message, I take it that my responses to the checklist give no reason to change your previous diagnosis. I read the abstract of the article you cited. Do I have knee "osteoarthritis"? And is my OA "undiscriminated ... (mechanical or inflammatory causes)"? I will look up Baker's cyst. Arthritis is one of my family diseases, although in the past it hasn't hit members of my extended family until they were in their 80s.

Thanks again!
post #20 of 26
Quote:
Originally Posted by Jimski View Post
Matt, thanks very much again. From your message, I take it that my responses to the checklist give no reason to change your previous diagnosis. I read the abstract of the article you cited. Do I have knee "osteoarthritis"? And is my OA "undiscriminated ... (mechanical or inflammatory causes)"? I will look up Baker's cyst. Arthritis is one of my family diseases, although in the past it hasn't hit members of my extended family until they were in their 80s.
Mechanical arthritis = degenerative breakdown of articular cartilage, aka "wear & tear" with genetic predisposition.

Inflammatory arthritis = inflammation from multiple potential causes (gout, psoriasis, rheumatoid, etc) that injures the cartilage.

That article I cited took all comers re. the definitions above.

It is rare to have a Baker's cyst and degenerative meniscal tear without also having some degree of osteoarthritis. All these conditions usually co-exist to some degree. Hence the cited study is relevant to your condition.

Arthritis is graded arthroscopically from 1-4 (minor to potholes).
post #21 of 26
Thread Starter 
Matt,

Thanks. Of course, I don't like the "genetic predisposition" part -- why can't medical science solve this one: e.g., regrow cartilage from stem cells? Did I mention that my mother (82) has had both her knees replaced?

Re the article you cited, I can't figure out how to get the entire text. When I click on the link you provided I get only the abstract. Do I need to be a doc to get in? This looks like an NIH site -- I have a contact there if needed.

BTW, this past weekend I skipped tennis and running, and went on a two-hour bike ride. I iced the knee afterwards and it was/is fine: a little pain and tightness today, but nothing debilitating.

Thanks again!
post #22 of 26
I have been scoped three times. I go when I feel loose bodies getting caught in the knee joint,

Skip the pounding exercises and take advantage of ones that have much less of an impact. Swimming is the best and biking is very good also. Hiking up is good but down is not. Stairs the same. Down is very bad .

They do repair cartridge arthoscopically . Small tears or frayed ones. Also a polishing of the surfaces that rub can lessen joint pain. Kneecap. Spurs.

My knees took a beating playing high school football but still serve me well when I take care of them properly. They tell me when I don't

My mom had both of her knees replaced . I don't feel doomed because of that. We may be predisposed to certain ailments but we can alter that path by taking care of ourselves.
post #23 of 26
Quote:
Originally Posted by Jimski View Post
Matt,

Thanks. Of course, I don't like the "genetic predisposition" part -- why can't medical science solve this one: e.g., regrow cartilage from stem cells? Did I mention that my mother (82) has had both her knees replaced?

Re the article you cited, I can't figure out how to get the entire text. When I click on the link you provided I get only the abstract. Do I need to be a doc to get in? This looks like an NIH site -- I have a contact there if needed.

BTW, this past weekend I skipped tennis and running, and went on a two-hour bike ride. I iced the knee afterwards and it was/is fine: a little pain and tightness today, but nothing debilitating.

Thanks again!
Jim,

The PubMed/NIH database allows you to pull abstracts easily. You will have to either pay for the article online from the original journal or simply go to your local university library and have it pulled or ordered. IMO, it's not worth reading - you already got the gist of it .

There's a lot of work going on in the field of articular cartilage regrowth/regeneration, but nothing is even close to ready for clinical application. There's a company called Carticel that will grow harvested cartilage cells for re-implantation (results mixed at best), and there are various harvest/transplant techniques (exactly like doing hairplugs) that have had some success. However, the quality of cartilage (and it's attachment to underlying bone) is highly variable in the population, so all current "repair" approaches are limited by the nature of native tissue.

Re. Garry's post above about meniscal cartilage (not articular cartilage) repair - it's a pretty rare thing to do, and you have to be young and have a peripheral tear (within 3-5mm from the capsular attachment - this is where the blood supply is) to make a worthwhile attempt. Otherwise, the "repair" is simply cutting out the shredded parts .

Good luck with things, sounds like you're on track....
post #24 of 26
Thread Starter 
Garry and Matt,

Thanks. Biking and swimming for me this weekend, instead of running and tennis.

And, to everyone who responded: have a great summer, and take care of your knees!

Jim
post #25 of 26
Thread Starter 
Further conformation of what Matt ("jdistefa") was saying back in June:
http://www.washingtonpost.com/wp-dyn...091002981.html

I did not have the surgery. My knee is fine; the swelling and pain went down a week or so after my last post on this thread. I very occasionally have twinges of minor pain in that knee, which usually tells me to apply ice and stop/switch my exercise routine for a day. I splurged on new running shoes (and bought them at a place that was able to evaluate my type of gait). Although I still do run, I've cut the frequency in half and have switched to biking and eliptical to fill in for the aerobic part of my exercise routine.

So, Matt, thanks again. I had a full, fun summer without having to hobble around post-operation. And, I probably saved some bucks -- I had to hassle the insurance company just to get reimbursement for the MRI. They eventually paid, but only after I told them that I wasn't having the surgery.
post #26 of 26
Analysis of your gate is also an extension of considering the action of running on hard surface does to damaged cartilage or the knee of a 54 yr old. The pounding ,repeating movement is very damaging to your knee but you can mitigate your affect by running on softer surfaces. Tartan tracks, grass or running on the beach will soften the impact. Get to love your bike and if you can handle swimming it is the best therapy for those knees.

Good luck to you. I have the same aged knees as you do and I still have many years I expect to ski on them with . Try to find replacement excercise for the running.
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