Understanding Joint Problems and Common Treatments

Joint issues can arise from various causes, such as osteoarthritis, injury, or inflammation. Symptoms often include pain, swelling, and difficulty moving the affected joint. Traditionally, when conservative treatments fail, surgery is considered to repair or replace damaged joints.

Common surgical procedures include:

• Arthroscopy to clean or repair joint tissues

• Meniscectomy: meniscus tear repair in the knee

• Joint replacement, especially in hips and knees

• Ligament reconstruction

  
  

While surgery can be effective in some cases, it carries risks such as infection, blood clots, and long recovery times.

Why Surgery May Not Always Be the Best Choice

The British Journal of Sports Science published an article on a randomised control trial of 140 participants with meniscus tears. The study aimed to see whether the progression of osteoarthritis, evaluated using knee function, strength, pain, and radiographs, revealed any difference either post-op or 10 years later. Their findings reveal several important points:

• Non-surgical treatments often provide similar pain relief and functional improvement as surgery.

• Surgery does not guarantee better long-term outcomes (10 years).

• Many patients improve with physical therapy, medication, and lifestyle changes without needing invasive procedures.

  
  

In this study, patients with no arthritis but pain due to a torn meniscus either underwent surgery or did physical therapy exercises. Ten years later, 23% of the surgery group had developed osteoarthritis, compared to 20% in the strengthening group. This difference is considered not clinically significant. All participants had comparable improvements in pain and mobility to those who had surgery. This suggests that surgery may be avoidable for many individuals.

Paul Biegler is a medical doctor who explores the reasons for chronic pain in his book Why Does it Still Hurt? Chronic pain is defined as pain lasting more than three months. He cites Christian Burton, a physio and researcher at La Trobe University in Melbourne. Burton initiated the GLA:D program in Australia. This program aims to provide education and exercise to people with knee osteoarthritis. In 2020, of the 7,641 participants who completed the course, there was a 31% reduction in pain, even a year later. Before attending the strengthening program, one-quarter wanted surgery; after it, two-thirds had not undergone the procedure.

Most health professionals believe that the structure of the joint drives pain. This is why we do scans and x-rays. However, this is only one piece of information, not the whole story. Even bone-on-bone contact does not guarantee pain. Why? Because the smooth cartilage surfaces of the knee joint have no nerves.

Scott Dye, an orthopedic surgeon and professor at the University of California, chose to undergo surgery without anaesthetic on his own knee in the late 90s. His colleague Geoffrey Vaupel pressed a probe on his meniscus, under the kneecap on his tibia and femur. Surprisingly, this caused very little pain. So, where is the pain in an arthritic knee coming from? Possibilities include inflammation of the super-sensitive synovium or pressure built by excess fluid under the knee (called a Baker’s cyst), which causes pain mostly when bending and straightening the leg. It could also come from the ligament attachments, but we suspect it arises from low-grade inflammation of the knee that accompanies osteoarthritis. This inflammation brings heat and fluid, which do not create pain but make the nerves more active, potentially leading to allodynia (extreme sensitivity to touch). What if we could desensitise these nerves by gradually introducing movement and load that doesn’t hurt, thereby building resilience?

Effective Non-Surgical Alternatives

Patients experiencing joint pain should consider these evidence-based alternatives before opting for surgery:

Physical Therapy and Exercise

Targeted exercises strengthen muscles around the joint, improve strength and flexibility, and reduce pain. Physical therapists and sports therapists tailor programs to individual needs, such as swimming, cycling, or strength training.

Weight Management

Excess weight increases stress on weight-bearing joints like knees and hips. Losing even a small amount of weight can significantly reduce joint pain and slow disease progression.

Lifestyle Modifications

Avoiding activities that strain joints, adopting ergonomic practices, and maintaining a balanced diet rich in anti-inflammatory foods contribute to joint health.

When Surgery Becomes Necessary

Surgery remains a valuable option for severe joint damage or when non-surgical treatments fail to provide relief. Signs that surgery might be appropriate include:

• Persistent, severe pain limiting daily activities

• Significant joint deformity or instability

• Loss of joint function despite conservative care

  
  

In these cases, consulting an orthopaedic specialist is essential to evaluate risks and benefits.

Patient Stories Highlighting Non-Surgical Success

We often believe that bone-on-bone knee joints will be painful due to the lack of cartilage. However, we are increasingly finding instances where this isn’t the case. Paul Biegler writes about an 82-year-old man with severe osteoarthritis of the knee, whose knee joint was reduced to only a crack on an X-ray. This man runs a weekly ParkRun and participates in a fortnightly 15km run with no knee pain. Why? Because he strengthens it.

Rays Donna, a 30-year-old man with a history of surgery to correct a dislocated kneecap, underwent several arthroscopies and finally a partial knee replacement. He was nearly immobile and in crippling pain. By using gradual step-ups onto one book and then two, he became pain-free and was able to walk the Inca Trail in Peru.

Exercise Post Surgery Should Include Loading

It is outdated to suggest caution with exercise after surgery. When a surgeon recommends lifting nothing heavier than 2kg for 12 weeks post-surgery after putting a metal plate around a broken ulna, they aren’t considering that bones need loading to remodel. A gradual and consistent rehab plan could get you safely lifting 15kg within a matter of weeks. This actually happened to physiotherapist Christian Barton at age 30.

These examples illustrate how many patients can regain function and reduce pain without invasive procedures.

What This Means for Patients and Healthcare Providers

The British Medical Journal’s findings encourage a more cautious approach to joint surgery. Patients should:

• Discuss all treatment options with their healthcare providers.

• Seek second opinions if surgery is recommended from places like GLA:D and informed physiotherapists.

• Explore non-surgical therapies as first-line treatments.

  
  

Healthcare providers should prioritise conservative care and reserve surgery for cases where it clearly offers superior benefits.

In conclusion, understanding the complexities of joint pain can lead to better treatment decisions. Non-surgical options often provide significant relief and improved function. By exploring these alternatives, we can enhance our quality of life without the need for invasive procedures.

References:

Article in Journal of Sports Science: Arthroscopic partial meniscectomy versus exercise therapy for degenerative meniscal tears: 10 year follow-up of the OMEX randomised controlled trial. Bjornar Berg & co. Sept 2024

Paul Biegler, Why Does it Still Hurt? 2023