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Dr. Phil, MD
Dr. Phil, MD, Medical Doctor
Category: Medical
Satisfied Customers: 43634
Experience:  Medical Doctor Trained at a Top Academic Institution
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In February 2009 I tore my medial meniscus in my right knee.

Customer Question

In February 2009 I tore my medial meniscus in my right knee. Despite being 53, I still had good speed being a college sprinter (400 meters) and was doing interval work (sprinting followed by slow jog and then repeat), and in retrospect sometimes pushing myself on long, slow runs (not that long - 2.5 miles) by altering my stride. I first noticed a problem just getting up from an office chair at work.

An MRI showed "an indistinct, small complex tear of the posterior inferior corner of the posterior horn of the medial meniscus, and Grade I/II chondromalacia of the posterior weight-bearing portion of the medial compartment, which is greater on the condylar side laterally over the posterior horn of the medial meniscus."

After the tear I was limping for some time, but then I started to get better to the point I was walking normally and the only pain I felt was if doing a complete squat, and very minor pain when declining stairs. However, the surgeon stated that the tear was present and that the "improvement" was due to the "flap falling back into place" and that delaying surgery could make the injury worse.

I had the surgery on May 23, 2009, and went to physical therapy one week later and continued therapy for almost three months. I couldn't bend my knee fully for several weeks. In early September my knee still did not feel recovered, and my orthopedic surgeon ordered a new MRI. The surgeon stated that my recovery was taking so long because besides doing a meniscopy, he also did a chondroplasty.

I obtained the hospital report and it stated, ""Through an inferolateral portal the knee had a grade II chondromalacia, which was debrided. Medially there was a complex tear of the posterior horn of the medial meniscus, which was resected using upbiting shaver to a stable rim. Chondroplasty of the medial femoral condyle was carried out. It had a Grade II lesion which had significant delamination of the weightbearing dome."

A new MRI was taken on September 20, 2010, which stated: "Postop change of the posterior horn medial meniscus. The signal in the posterior horn extends to the fibial articular surface maybe slightly more prominent, but is probably due to postop status; Findings suggestive of a small new tear at the apex of the body segment medial meniscus. A new tear in the posterior horn lateral meniscus also; Chondromalacia of the posterior articular surface of the medial femoral condyle may be slightly more prominent. Chondromalacia of the patella stable." My surgeon dismissed the tears as MRI artifacts as he said he did not see them when he did the surgery, and I had no pain on the outside of my knee.

Questions:

1. Did the small, complex tear of the medial meniscus definitely require surgery, or could it have healed with physical therapy? Can delaying surgery cause a tear of the medial meniscus to worsen?

2. Was a chondroplasty warranted? Is it standard procedure to perform a chondroplasty when doing a meniscopy when Grade II chondroplasty is seen? I raise the question because usually the recommended treatment (from what I have read) for Grade II chondromalacia is physical therapy. Should the doctor have asked permission before performing a chondroplasty?

3. The new MRI indicates postop changes. Is this normal, or indicative of a worsening of the condition due to the surgery?

4. Is the clicking upon extending my knee normal? The doctor said that this is due to a "hole" resulting from surgery and that it takes time to build up fibrocartilage. Your opinion?

It has know been 16 months from the surgery and I still feel the knee is stiff at times, slight pain when descending stairs, some pain after cycling on recumbent bike for thirty minutes, and when I extend me knee a slight clicking sound is heard (less clicking than four months after surgery; however, I had no clicking upon extending leg prior to the surgery. I am concerned that the clicking may result in arthritis). I have yet to try running on the leg, or playing basketball or tennis, but want to resume the activity I had prior to the surgery. The doctor told me it was alright to start running in February 2011 with the caveat that is would be wise to run on a soft surface. Is this possible without reinjuring my knee? I see where many if not most patients come back from meniscus surgery in a matter of weeks, but, again, I was told my lengthy recovery was due to the chondroplasty.

Answers to these questions and any observations much appreciated. I have an upcoming appointment with the surgeon so welcome questions to ask the doctor and whether a new MRI is warranted.

Positive feedback and maximum bonus upon detailed answering of questions. Thank you!!
Submitted: 3 years ago.
Category: Medical
Expert:  Dr. R. Bora replied 3 years ago.
Did you undergo menisectomy or removal of the torn meniscus?

Did you have any ligament tear?

Besides, do you have osteoarthritis of the knee joint prior to injury?
Customer: replied 3 years ago.

I underwent a menisectomy; I still have 75% of my meniscus (confirmed by MRI). No ligament tear. I had little to no osteoarthritis of the knee joint prior to surgery; the x-ray taken after the injury had the following findings: AP, lateral and sunrise views o fhte right knee received on 2/11/10. Mild medial compartment narrowing. Minimal superior patellar spurring. Minimally prominent prefemoral soft tissues.. No acute fracture. Mild lateral patellar spurring. Impressions: Early arthrosis in the patellofemoral joint; mild medial compartment narrowing; minimal joint effusion. Thank you for your efforts!

Expert:  Dr. R. Bora replied 3 years ago.
Complex tears have to be removed by surgery for fear of future infection and knee problems.

Chondroplasty can be done while doing meniscopy as you had chondromalacia and a second operation is not advisable as cartilage repair can be performed as a single procedure.
You had osteoarthrosis prior to the surgery mostly between the small knee bone (patella) and the long bone of the thigh (femur).

We can not change the natural outcome or arthritis, nor can we cure arthritis. What we hope to do by performing with the chondroplasty is to delay progression of arthritis significantly so that the time before you develop profound arthritis is much longer. The way that you can grow fibrocartilage best is to create as much new synovial fluid with new nutrition as possible and present it to the surface of the scar tissue that is growing from the operation that you have.

In order for new synovial fluid to manufactured there has to be an exit of the old synovial fluid. Synovial fluid leaves the knee throughout the mechanical motion of the knee moving. Using a stationary bicycle and riding it slowly at 15 minute intervals for at least 2 hours daily is one way to "squish out" the old knee fluid and allow the new knee fluid to present itself to the scar tissue. Joint motion following injury is extremely important in the healing and rehabilitation of the injured extremity. One reason that this is so important is that the joints must move in order to remain healthy and have good nutrition to the end of the cartilage. Good nutrition to the end of the fibrous tissue is also important and new synovial fluid must be remanufactured. This is why you must ride a stationary bike for 2 hours daily at 15 or 20-minute intervals.


I hope my answer is helpful to you.

If you would like to give credit for my answer, please press the GREEN ACCEPT BUTTON. Feedback and Bonus would be highly regarded.

With Regards,
Dr. Bora.




Customer: replied 3 years ago.

Thanks for the informative reply. So apparently it is standard procedure in a case like mine to perform a chondroplasty rather than try phsycial therapy? And to do so without my consent? Although you cite its preventative effect, it appears that the chondroplasty is the reason that the recovery is taking so long. Without further medical knowledge, I don't know if it had a detreimental effect on the current status of my knee.

 

Are the post op changes in the second MRI normal, or indicative of a worsening of the condition due to the surgery?

 

What is your view of the clicking when I extend my knee? This is often cited as a reason for surgery; yet, I never had this prior to the surgery. Is this a normal outcome of a meniscopy?

 

I heard recommendations for continued bike therapy, but not to the extent mentioned in your response. Is it too late at this point (16 months from surgery) to still fully benefit from this program of cycling?

 

Thank you for time on complex question. If you have additiona questions questions I should ask my doctor, let me know, and I will accept this answer and ask a new quetion following my upcoming visit. Thank you!

Expert:  Dr. R. Bora replied 3 years ago.
Chondroplasty treatment is individualiszed meaning that while performing arthroscopy or meniscopy, if wa weak cartilage is detected, cartilage repair should be performed in the same sitting.

Secondly, Yes, there are chances that the post op MRI changes could be due to motion artifacts during the MRI scan which is very common with meniscal tears.


Popping and snapping are common symptoms found in patients with knee pain. Often popping and snapping are associated with damaged meniscus or cartilage.

Yes, you can still do cycling to regenerate new fibrocartilage, but the results may not be as good just prior to surgery.

I hope my answer is helpful to you. Please try it under the care of the physical therapist.

If you would like to give credit for my answer, please press the GREEN ACCEPT BUTTON. Feedback and Bonus would be highly regarded.

With Regards,
Dr. Bora.

Customer: replied 3 years ago.
Thank you for your patience. With regard to the clicking/popping noise, this did not occur after I tore my meniscus; rather, it only appeared after surgery.......why do I have it post surgery? Seems slightly better than a year ago, with popping heard only intermittently. Could it go away with the buildup of fibro cartilage?

When you say the results from cycling may not be good as just prior to surgery, did you mean to say the results may not be as good as just after surgery?

Why do I still have some pain and stiffness after 16 months? Do I pretty much have to accept that after 16 months this is as good as it gets or can further cycling (e.g., 2 hours per day at 15 minute intervals) result in further improvement? A lot of effort but will do if improvement likely.

I am concerned that the second MRI said that some areas were more prominent than before; e.g., "area of cartilaginous hyperintensity and irregularity to the posterior articular surface in the medial femoral condyle condyle appears to be slightly more prominent than before with possible slight subchondral edema", and, "there is interval blunting of the apex of the posterior horn medial meniscus most likely postsurgical in nature", and "the lateral meniscus reveals a hyperintense signal at the tibial articular surface of the posterior horn which is more prominent than before and also seen as an oblique image on image 7, series 4. This is concern for a new tear". Why would these areas be more prominent than before surgery? Is this normal?
I will accept and pay bonus after answering of above. I will have a separate question for any follow-up. Future questions will be broken up and not this extended. Thank you so much for your assistance.

Expert:  Dr. Phil, MD replied 3 years ago.

Hello. I would like to help you find an answer.

 

The other expert opted out. What would you like to know further?

Customer: replied 3 years ago.

Yes, thanks. The question is quite complex, and if the physician does not have knowledge of orthopedics it could be difficult to answer. (Prior doctor just cut and pasted answer regarding riding a bike two hours a day in 15-minute intervals for recovery; I have never been told to do therapy this extensive.) Further, the same web site where the preceding doctor obtained his information

 

http://draubreysmith.com/knee_chondroplasty.htm

 

also states that the patient should stay non-weight bearing on crutches for a period of at least 4 weeks. I was on crutches for about three days, and started physical therapy 10 days after the surgery; it must have take at least three weeks before I could straighten my leg; yet, the medical assistants at the doctors office said most patients are pretty much back to normal after three weeks (again, the chondroplasty; I never asked for that!)

 

It's been 17 months since the surgery, and I still have a dull pain when walk. Knee just doesn't feel the same, but maybe that's normal after the surgery I had? What concerns me is the follow-up MRI which states in a few places postoperative changes that were not present prior to surgery, and the clicking when I extend my leg that was not present before surgery. And all that for just a nondistinct complex tear (albeit for a few weeks I was limping).

 

The lengthy recovery time was attributed to the chondroplasty, which from understanding is basically a preventative procedure to stall arthritis. Yet, I was having little problem the last couple weeks prior to surgery, and wonder if the surgeon was too aggressive in performing a chondroplasty for Grade I/II chondromalacia (in hospital report surgeon stated Grade II)? My thought process is that what good is a preventative procedure if it caused the knee problems I have now? I bet me left knee has similar chondromalica; yet, it is not giving me any problems. So I've been told I can start running again, but little hesitant. Surgeon said if still giving me problems in the spring to come back, and he will reevaluate for another MRI.

 

Do you think me knee is as good as its going to get, but either through time, or, as the prior doctor mentioned, riding an exercise bike for a couple hours a day, I can fill in the gaps with fibrocartilage and improve?

 

So I'm kind of ranting here, but if you could look back over my info and try to address my concerns and give advice for future care (e.g., running/non-running; tennis; basketball - I would hate to give these up due to a indistinct small complex tear of the meniscus!; physical therapy again; another MRI; get a second opinion from another orthopedic surgeon).

 

Thank you!

Expert:  Dr. Phil, MD replied 3 years ago.
Have you seen any other doctors like a physical medicine doc or anything about this?
Customer: replied 3 years ago.

No; I just had physical therapy for approximately three months following surgery. I've been riding a stationary recumbent bike for about thirty minutes a day three times a week, and taking Glucosmine/Condrotin supplements daily.

Expert:  Dr. Phil, MD replied 3 years ago.
At this point you need to see a physical medicine doctor.

This is not normal.

Physiatrists specialize in post op pain like this.
Customer: replied 3 years ago.

Specifically, what is not normal: the pain, the clicking when extending my leg, or the MRI showing post op changes that were not present before surgery, or all of the above?

 

Do you believe the chondroplasty was warranted, and should I have been informed ahead of time of the procedure?

 

I will look into making an appointment.

 

Thank you!

Expert:  Dr. Phil, MD replied 3 years ago.
You're welcome. :)

All of the above.

No I don't think it was really warranted and yes you should have been informed.
Dr. Phil, MD, Medical Doctor
Category: Medical
Satisfied Customers: 43634
Experience: Medical Doctor Trained at a Top Academic Institution
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