Mr. Richardson is a 55-year-old man who comes into your clinic complaining of knee pain. He used to enjoy going on long jogs, but as the years have gone by the pain in his joint has increased and he’s lost a lot of mobility. He’s frustrated by the weight that he’s put on due to lack of mobility, and ibuprofen is no longer working to lessen his ever increasing pain. You order an MRI, which shows radiographic evidence of a meniscal tear and osteoarthritis (OA). Now, you have to decide how to treat Mr. Richardson. Should you immediately send Mr. Richardson to surgery, or will he benefit from PT? If you send him to PT first, will the delay to surgery impair his outcome? For the most part, in the world of mechanical joint diseases, surgery reigns supreme. But until now, it has not been clear if surgery provides a benefit to patients with a meniscal tear and osteoarthritis (OA) in comparison to standard physical therapy.
In this week’s NEJM, Katz and colleagues report the results of a randomized controlled trial addressing this uncertainty. Across seven U.S. centers, 351 symptomatic patients over the age of 45 who have radiographic evidence of OA and a meniscal tear were assigned to either surgery or physical therapy. At both 6 months and 12 months after randomization, there were no statistically significant differences in pain or improvement in function between the two groups. Notably, 30% of patients assigned to the physical therapy group had chosen to have surgery by 6 months. However, by 12 months, these patients’ functional improvement was not significantly different from those of the other two groups, implying that the delay to surgery did not affect their final outcome.
The findings of this article are important reminders that surgery may not always be the best first treatment option. In an accompanying editorial, Rachelle Buchbinder, PhD, stresses that these results should change practice. She suggests that a change in the approach to caring for these patients can occur, and that it is reasonable, in light of these results, to use PT as a first therapy. She also points out that, although the article reported no difference in adverse effects, further follow up will need to be performed to assess any long-term risks associated with these therapies.
This article suggests that there should be a change in the treatment strategy for patients like Mr. Richardson: we can safely try PT first and, if he doesn’t respond, he can get surgery later.