I was sitting in my study this afternoon, fielding calls, writing emails and other correspondance and perusing the Google Alerts I have in place for interesting topics. I came across an interesting article from The New York Times Health Section, dated 12/09/08 (you see, there are some uses for the NYT other than lining bird cages and wrapping fish) that reminded me of the many times I faced similar diagnostic dilemmas in my years of practice. 
 
The gist of the article was that, in the quest for better and ever more sensitive noninvasive methods of diagnosis, like MRI Scans, more and more pathology is being revealed. But, the pathology observed may have nothing to do with the patient’s symptoms. 
 
This leads to a number of unnecessary surgical procedures, as doctors try to treat the pathology revealed by the scan, even if that was not the actual cause of the patient’s pain. This is the paradox of the nonsurgical study–it may result in MORE surgery, not less.
 
A good example is the common finding of a torn meniscus, inside the knee, revealed by an MRI Scan. It’s now well known that many middle aged and elderly people are walking around with torn menisci, without any resulting pain or other symptoms. So they really don’t need surgery, just because they have a torn meniscus, UNLESS they also have very specific mechanical findings or very specific pain, localized to the area where there is an identified torn meniscus. And yet, that is exactly what was happening, until recently.
 
I always got an MRI if my patient had persistent pain that failed to respond to conservative treatments, like those I describe in my newest healing program, HOW TO AVOID KNEE SURGERY, which you can see at  http://drbillsclinic.com/avoid_knee_surgery.html
But they only came to arthroscopic surgery if they had identified pathology AND specific symptoms and signs, consistent with the observed pathology.
 
I remember once, when I was much younger, I had a young man who had very specific joint line pain. He failed to get better with all the conservative treatments I prescribed–medications, local heat, physical therapy, the works. So, we got an MRI Scan. WOW! He apparently had an enormous tear of the posterior horn of his medial meniscus. Lit up like a Christmas tree! So obvious, even a lay person could see it from across the room.

Now, in a young person, job #1 is to preserve the articular cartilage at all costs: in other words, prevent arthritis, which is what happens if an untreated, unstable torn meniscus is allowed to remain, without treatment. So, with this as our goal, the patient, his parents and I were all of one mind: this kid needed surgery, pronto!
 
With all best intentions, I scoped the kid, expecting to see and repair or remove this enormous tear. Only…there WASN’T ANY TEAR. I looked and probed everywhere.  Nope.  Nada.  Well, I wasn’t about to fix what wasn’t broken, so I shaved away some inflamed synovium at the medial (inner) joint line, and got out.
 
He had what we call a “false positive” MRI Scan, a diagnostic image that appears for all the world to be a bona fide meniscus tear, only the tear doesn’t really exist. Imagine my embarrassment when I had to tell the family that I didn’t find the expected pathology, other than the inflamed synovitis (swollen, reddened lining membrane of the joint, which can get caught between the moving bones, just like a torn meniscus).  

The family was very grateful that he didn’t have a tear and all turned out well, because the patient’s preop pain was relieved, probably because I cut away that inflamed membranous tissue. But you could very easily argue that this was a completely unnecessary surgery–I was chasing the chimera of a false finding on a scan. It taught me a lesson, that’s for sure.
 
The fact is, MRI Scans are, at best, only 90-95% accurate on the medial (inner) compartment of the knee joint. This drops to only 60-70% accuracy on the outer or lateral compartment of the knee, because of the more complex anatomy of the lateral meniscus. Bottom line: MRI Scans and other diagnostic tests are NOT 100% accurate. They are just one part of the puzzle and have to be interpreted, based on the physical findings and a patient’s response to treatment. 
 
There are lots of reasons for knee pain. You can learn more about them, in layman’s English, in my best selling LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN (see here at http://drbillsclinic.com/eliminate_knee_pain.html )
 
Many, if not most of them, can be treated with effective nonsurgical treatments, including alternative and complementary methods. The trick is knowing when surgery is really warranted–and when it’s NOT. That’s why I wrote HOW TO AVOID KNEE SURGERY, which you can see here http://drbillsclinic.com/avoid_knee_surgery.html
 
Remember, the very best surgery is the one you avoid. Til next time, my friend, be well. 
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION

Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

When I switched on the compouter this morning in my study, I clicked on my email, as I usually do, to see what, beside spam and junk, was in the inbox. As you might imagine, I get lots of emails and referrals and requests for advice about knee pain, hip and back pain, arthritis and all the rest of it. Whenever possible, I try to help, if I can.
 
Oftentimes, that means referring the enquirer to one of my healing programs or books. Sometimes, I can give them some short term advice that may help. Of course, I’m limited by the fact that I can’t see, much less examine them, and I’m further limited by their description of their problems. 
 
Lay people know what they mean, but they often can’t express it well enough for me to understand what the problem is. We don’t share the same vocabulary when it comes to medical problems. That’s one of the most important contributions of my LITTLE GREEN BOOK (see it  at http://drbillsclinic.com/eliminate_knee_pain.html ), which translates a number of medical problems from “medicalese” into everyday plain English, so the average person can understand what we’re talking about.
 
Anyway, recently, I’ve had a number of questions from people who have already HAD surgery, usually arthroscopic surgery, but STILL have pain. As is typical in my experience, many tend to blame the doctor for screwing up the surgery. But in fact, persistent pain may be from residual arthritic changes inside the joint. And it’s now well accepted, backed up by two large studies, that arthroscopic  surgery for arthritis is pretty ineffective. So, it’s not uncommon to have persistent pain after that procedure.
 
Let me give you an example of what I mean. This is the most recent email from someone in this very situation:
 
“I have had arthroscopic surgery on both knees. My right knee is in really bad shape after surgery. I think the surgeon really must have botched it because I am in constant knee pain after being on my feet for a few hours. How will your exercises help with no meniscus left in my knee? By the way, I am 57 and the surgeon says I am too young for knee replacement. Can you help me strengthen my knees through exercising?  Thanks…”
 
And here was my reply:
 
“…Your problem is not uncommon. You may have had a torn meniscus, which the surgeon probably removed PARTIALLY (you generally try to leave some of it as a cushion, unless it is already completely shredded from degeneration).  However, most likely, he did NOT “botch it.” It’s just that you undoubtedly have ARTHRITIS in that joint, which arthroscopy CANNOT CURE. That’s the most likely source of your pain. 

“57 is NOT too young to have a total knee. But, there are a number of proven, very effective non-surgical methods that can help to relieve your pain, and restore your function, at least for a while. You may wish to get my newest healing program, HOW TO AVOID KNEE SURGERY   at http://drbillsclinic.com/avoid_knee_surgery.html
 
“Exercises help by increasing the stability and the support of the arthritic joint by increasing the mass and strength of the surrounding muscles. But they are only one method, among many others, that can delay surgery. If you have end stage arthritis, eventually you WILL come to a total knee. 
 
” But that day can be delayed in many cases–I had one patient I carried in this way for TEN YEARS,before he finally got it done. But remember, everyone is different, so you can’t predict how well these methods will work for you. Still, isn’t it worth a shot? 
 
” BTW, be sure you have your Total Knee done by a specialist in joint replacement, when the time comes. It’s a very technique dependent procedure, so a guy who’s doing a LOT of them will have better results and fewer problems and complications. Hope these  tips help. Good luck to you!…”
 
Hopefully, he’ll take my advice and click on   http://drbillsclinic.com/avoid_knee_surgery.html  He’s likely to find a highly effective combination of conventional and alternative measures and exercises that will give him FAST RELIEF from his knee pain and help him AVOID SURGERY, if that’s possible. How about you?
 
Til next time, my friend, be well. 
 
Yours for a pain-free tomorrow, 
 
Dr. Bill
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved