The Art of the Knee Exam

Our office meets twice a month for research meetings to discuss various topics that relate to treatment of the knee joint, or other topics that may affect our orthopedic practice of treating knee problems/injuries. Last month we discussed chapter 30 out of the book: BareBones by A. Sarmiento.

The chapter discusses how the “industry today has changed the essential nature of medicine and redirected its focus. Modern medicine centers not on the patient but on the insurers, hospitals, rehabilitation centers, and industry.” Because of the industry, there are more unnecessary arthroscopy procedures for meniscus tears performed because industry is convincing orthopedic surgeons that there is a “product” that can “fix” the meniscus. If orthopedic surgeons took time to properly examine the knee, get appropriate X-rays, and listen to the patient’s history, I think we would find that most of these meniscus tears found on MRI scans do not require a surgery to make the patient better. Then the question becomes, are we doing surgery because we can? On the other hand, are we doing surgery because it is the best “right” choice for the patient? Having a good understanding of the types of meniscus tears, what has caused the tear, does the MRI scan align with the patient’s symptoms and physical exam, and if a surgery is chosen, will it make the patient better? No arthroscopic procedure is going to return a patient’s knee to normal. However, if the arthroscopy is going to be done it should eliminate the pain that brought the patient to the office to begin with. Most surgeons do not follow up with their patients post operatively to collect enough information to know if what they are doing in surgery is actually making a difference in the patient’s outcomes.

While at the American Academy of Orthopaedic Surgeons in 2009, Dr. Shelbourne had a discussion with other orthopedists around the country regarding concerns of what was happening in the profession. He was also recognizing that many patients who come into the office for a second opinion were given their original diagnosis with either just an X-ray, just an MRI scan or both, but the patient’s knee had never been properly examined with the patient in shorts. Some had an MRI scan prior to even seeing the doctor. Many other orthopedists were also commenting that they felt they were becoming more dependent on technology and losing the ability to reason.

Patient History Is Key

It is our opinion that a good subjective history should be the first thing a physician does. The physician should find out how the knee pain started, what are the symptoms, and how functionally limiting is the patient’s knee to their lifestyle, and build trust and rapport with the patient. Secondly, do a proper physical exam of both knees and determine what is different about the two. All of this information combined should be enough for a physician to be able to give good thought/critical thinking to the problem and if technology is utilized than it should be to confirm and correlate with the symptoms and the physical exam. There have been several past studies that show how common it is to find abnormal signals in the meniscus or meniscal tears on MRI scans of individuals who are asymptomatic, and these abnormalities become more common in the older population. Just because there are abnormal findings on the MRI does not make it a surgical problem.

Sarmiento discussed how technology and the industry as a whole has been a major factor in the decline of respect for the discipline of orthopaedics. Physicians need to get back to the basics of the accepted standard for a thorough knee examination and talk with our patients and not be “lulled into a slumber that has prevented us from realizing the degree to which we have become subservient to the industry.”