Knee problems, Meniscal Repair

Questions About Meniscus Injury, Surgery, Rehab

Dr. O'Hea's Comments:

 This is an excellent  response  to a  question about knee injuries; specifically about injury to the cartilage pad on the outer sides of the  knee  called the meniscus.  It explains how you can  recover on your own and on  what you can  expect if your injury is too far gone and you need surgery.

 I'm a big believer in letting these injuries heal on their own whenever possible. You will need some guidance from a chiropractor or therapist to assist in your recovery.   This post is from the blog of  Doug Kelsey PT, a great therapist/author in Austin, Tejas.

Hi Doug,

I recently came across your blog while searching for answers on a ACL and meniscus injury. I’m fairly new to this as my wife recently had an injury in her gym where her left knee popped. After the instructed popped it back in, and couple of x-rays, few weeks of physiotherapy, and an MRI, 6 weeks later the orthopedic surgeon told us that she has a torn ACL and tear of medial cartilage (meniscus). He also mentioned that he couldn’t see any ACL fragments so it could be from an earlier injury which happened 18 years ago and we have no record of it as to what happened other than that left knee has been weak.

I have quite a few questions for which I received different responses from different people so will try to compile them here so that others can benefit too.

1)    I’ve read that meniscus can repair/heal itself. To what extent is this true? It seems like outer shell of meniscus has blood flow so there might be a chance of healing a tear on the outside.

2)    In case of a meniscus tear or a fold-in, does it need to be cut in a curved fashion? And if can heal, then can the cut now heal itself?

3)    I’ve heard that if you don’t cut the meniscus away then it might result in degeneration. What would happen if it just degenerates itself without actually cutting it thru a surgery? How long does a cut meniscus take to degenerate?

4)    The ortho advised that the meniscus surgery needs to happen within 6 weeks of the injury… I haven’t been able to find any such reference although people say sooner the better. What’s sooner here and what if it’s not too soon but still sooner than later?

5)    I’ve also read a lot about the rehabilitation programs and trying those first (even one of your blog entry from 2006) so in what cases this is helpful? Can physiotherapy help with my wife’s case?

6)    The full recovery period after an ACL and meniscus surgery has been told to be 3 months to 6 months? Can one fully recover to 100% in six months (playing soccer, doing gym etc).. assuming they are within 80-90% of the cases who recover fully. Even though they recover, I’d assume that they have more chances of subsequent injury as compared to a other people. Right?

7)     How long to absorbable bioscrews take to dissolve? There are people with partially dissolved screws after 2 years.

I really appreciate your knowledge and time to respond to this and I’d be willing to add more information to the blog so others might find it informative and useful.

Best Regards,

-H

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Thanks for reading and for the questions. I'll do my best.

Ok, first off H, the best answers come following an interview and exam. Everything else is guesswork really. There's just no substitute for the process. The internet is the great democratizer of information. What it lacks however is judgment; wisdom. We all have the same bones, muscles, cartilage, etc. yet we're different people with different needs. Clinicians use the data from the history and exam and run that through an "experience filter" to arrive at an answer for you (or your wife). So, my advice is meet with several clinicians and ask the same questions you listed above.

Meniscus tears that are in the more vascular part of the tissue, generally the outer 1/3, have a better chance for healing. If a surgeon can repair the tissue, he or she will usually try. Whenever you remove part or certainly all of the meniscus, you increase the chance for early onset of osteoarthritis due to a change in contact pressures in the knee. The meniscus gets some of its nutrients via the synovial fluid and responds to mechanical pressure in a similar way to articular cartilage so movement and controlled loading usually help.

As far as a surgery time line, I have noticed, and the literature tends to support this, that surgeries go better when the knee is not swollen at the time of surgery. So, if you tear the ACL and your knee swells, which it usually does, most surgeons will wait for the swelling to go down. If you don't, the risk of arthrofibrosis or scarring in the joint, goes up.

We've had clients with partial meniscal tears, some operated on and some not, who have done quite well in rehab as well as folks with meniscal repairs. But, as I mentioned earlier, this is very case dependent. The rehab programs are all custom built based on the person's unique mix of needs, problems, and goals.

Your question about full recovery is a good one and I think what you're asking about is the physical recovery.  But, there's recovery and then there's restoration. The difference is that recovery is a physical process. Tissues heal. Motion returns. Strength increases. But restoration is a mental-emotional-physical process and for some this takes a long time. When you have an injury that sends you to surgery, disrupts your life, perhaps even your livelihood, you have to make some adjustments; accept reality and do things you basically don't want to do. And you usually need a coach or someone to help you through it. Some people are restored to a place of wholeness in months; some years; some I suspect never really make it (for example, their leg is strong but they don't totally trust it).

But, back to your question about physical recovery, the record holder at Sports Center returned to sport level activity in 61 days. But, most people reach athletic capability in 6 to 9 months. However, if you've had articular surface damage, it usually takes longer - 12 to 18 months or more. There are a number of factors that come into play - the type of procedure used, the extent of damage to your knee, how your body responds to surgery or how rapidly you form scar tissue, how adherent you are to post-op instructions (and how thorough the instructions are), your pain tolerance, how your knee responds to load and the type of rehab you go through as well. Tiger Woods was out for 8 months and more than one surgeon believed at the time of surgery that it would take him 24 months to get back into his pre-surgery condition (of course, that's been interrupted due to his personal problems).

And for your last question, bioabsorbable screws are not something we have much to do with but from what I've read, those usually take 18 to 24 months to be absorbed.

"Food Rules": A Completely Different Way To Fix The Health Care Crisis

 By Michael Pollan

The idea for this book came from a doctor--a couple of them, as a matter of fact. They had read my last book, "In Defense of Food", which ended with a handful of tips for eating well: simple ways to navigate the treacherous landscape of modern food and the often-confusing science of nutrition. "What I would love is a pamphlet I could hand to my patients with some rules for eating wisely," they would say. "I don't have time for the big nutrition lecture and, anyway, they really don't need to know what an antioxidant is in order to eat wisely." Another doctor, a transplant cardiologist, wrote to say "you can't imagine what I see on the insides of people these days wrecked by eating food products instead of food." So rather than leaving his heart patients with yet another prescription or lecture on cholesterol, he gives them a simple recipe for roasting a chicken, and getting three wholesome meals out of it -- a very different way of thinking about health.
Make no mistake: our health care crisis is in large part a crisis of the American diet -- roughly three quarters of the two-trillion plus we spend on health care in this country goes to treat chronic diseases, most of which can be prevented by a change in lifestyle, especially diet. And a healthy diet is a whole lot simpler than the food industry and many nutritional scientists -- what I call the Nutritional Industrial Complex -- would have us believe. After spending several years trying to answer the supposedly incredibly complicated question of how we should eat in order to be maximally healthy, I discovered the answer was shockingly simple: eat real food, not too much of it, and more plants than meat. Or, put another way, get off the modern western diet, with its abundance of processed food, refined grains and sugars, and its sore lack of vegetables, whole grains and fruit.
So I decided to take the doctors up on the challenge. I set out to collect and formulate some straightforward, memorable, everyday rules for eating, a set of personal policies that would, taken together or even separately, nudge people onto a healthier and happier path. I solicited rules from doctors, scientist, chefs, and readers, and then wrote a bunch myself, trying to boil down into everyday language what we really know about healthy eating. And while most of the rules are backed by science, they are not framed in the vocabulary of science but rather culture -- a source of wisdom about eating that turns out to have as much, if not more, to teach us than nutritional science does.
What follows is a small sample of "Food Rules", a half dozen policies that will give you a taste of what you'll find in the book: sixty-four food rules, each with a paragraph of explanation. I think you'll see from this little appetizer that "Food Rules" is a most unconventional diet book. You can read it in an hour and it just might change your eating life. I hope you'll take away something you can put to good use, and maybe get a chuckle or two along the way. And do let me know if have any food rules I should know about. I'm still collecting them, at pollanfoodrules@gmail.com.
#11 Avoid foods you see advertised on television.

Food marketers are ingenious at turning criticisms of their products -- and rules like these -- into new ways to sell slightly different versions of the same processed foods: They simply reformulate (to be low-fat, have no HFCS or transfats, or to contain fewer ingredients) and then boast about their implied healthfulness, whether the boast is meaningful or not. The best way to escape these marketing ploys is to tune out the marketing itself, by refusing to buy heavily promoted foods. Only the biggest food manufacturers can afford to advertise their products on television: More than two thirds of food advertising is spent promoting processed foods (and alcohol), so if you avoid products with big ad budgets, you'll automatically be avoiding edible foodlike substances. As for the 5 percent of food ads that promote whole foods (the prune or walnut growers or the beef ranchers), common sense will, one hopes, keep you from tarring them with the same brush -- these are the exceptions that prove the rule.
From "Food Rules":
#19 If it came from a plant, eat it; if it was made in a plant, don't.
#36 Don't eat breakfast cereals that change the color of the milk.
This should go without saying. Such cereals are highly processed and full of refined carbohydrates as well as chemical additives.

#39 Eat all the junk food you want as long as you cook it yourself.
There is nothing wrong with eating sweets, fried foods, pastries, even drinking soda every now and then, but food manufacturers have made eating these formerly expensive and hard-to-make treats so cheap and easy that we're eating them every day. The french fry did not become America's most popular vegetable until industry took over the jobs of washing, peeling, cutting, and frying the potatoes -- and cleaning up the mess. If you made all the french fries you ate, you would eat them much less often, if only because they're so much work. The same holds true for fried chicken, chips, cakes, pies, and ice cream. Enjoy these treats as often as you're willing to prepare them -- chances are good it won't be every day.


#47 Eat when you are hungry, not when you are bored.
For many of us, eating has surprisingly little to do with hunger. We eat out of boredom, for entertainment, to comfort or reward ourselves. Try to be aware of why you're eating, and ask yourself if you're really hungry -- before you eat and then again along the way. (One old wive's test: If you're not hungry enough to eat an apple, then you're not hungry.) Food is a costly antidepressant.
#58 Do all your eating at a table.
No, a desk is not a table. If we eat while we're working, or while watching TV or driving, we eat mindlessly -- and as a result eat a lot more than we would if we were eating at a table, paying attention to what we're doing. This phenomenon can be tested (and put to good use): Place a child in front of a television set and place a bowl of fresh vegetables in front of him or her. The child will eat everything in the bowl, often even vegetables that he or she doesn't ordinarily touch, without noticing what's going on. Which suggests an exception to the rule: When eating somewhere other than at a table, stick to fruits and vegetables.