Thursday, April 7, 2016

Knee Imaging is Not An Examination or Absolute by Itself

Many times we see patients that have had imaging done (sometimes costly) after having a minimal examination by their doctor.   Then they are told they have a...insert your diagnosis.... based on the imaging results, a very brief exam or a combination of both.   The knee is one of the most commonly imaged areas of the body. The infamous diagnosis of the knee is a meniscal tear.  However, there has been shown to be a high incidence of meniscal tears in non-symptomatic knees as well as symptomatic knees.  Additionally,  lateral or medial joint line tenderness and end range of motion joint pain seem to be the best indicators of meniscal issues.  There are other tests such a McMurray’s and Thessaly’s test that has some usefulness as well.  

One of the biggest problems we see is that people come to me with pain in the front part of the knee yet they are told they have a meniscal tear and that is why they have pain.   However, if you look at the anatomy of the knee the menisci do not go all the way to the front of the knee and there is actually joint capsule and a fat pad that take up much of the anterior knee.  So if the pain is felt toward the front of the knee it is almost impossible to palpate meniscus there.
Meniscal tears actual occur for two main reasons: trauma or overuse.   The trauma kind is usually caused by a loading of the knee vertical with a twisting motion with the knee extended or flexed.  A pop is usually felt but swelling may not occur hours after the injury.  If the swelling occurs immediately, then more likely some ligament injury or anterior knee structure irritation has occurred.  The overuse kind is degenerative and occurs over time.  Overuse meniscal degeneration is usually seen after the third decade of life but can be seen early in individuals that perform high impact activities to the lower extremities (lots of jumping or constant twisting).  However, degeneration is common in people without any pain or issues.   Remember there are many soft tissue structures on the front of the knee and if they are compressed by the knee cap, they can cause debilitating pain and swelling.
The problems that should concern you with a meniscal tear is if the knee is locked in a position or unable to move through the full range of motion with help.   This would require a visit to an orthopedic surgeon.  Surgery is not always thebest course and complications do arise from surgery.   If you just have pain with certain activities and the motion is full, then an individualized thorough examination and rehabilitation is the best course.  If you are barely touched or someone tries to tell you what to do based on imaging alone, I would be wary of this.  It is your body and you have to live with it. 

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