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Editorial
Degenerative meniscus tears should be looked upon as wrinkles with age— and should be treated accordingly
who is also an orthopaedic surgeon, degenerative tears should be looked upon as wrinkles with age. Although some may try, we all know that one cannot cut away age with surgery. The best antiage medicine is physical activity.
May Arna Risberg
Competing interests None.
We know that menisci play an important role in the knee. They contribute significantly to load bearing, load transmission and shock absorption across the joint and should, therefore, be preserved whenever possible. Furthermore, we have known for many years that meniscectomised knees develop osteoarthritis. We are also learning that not all meniscus injuries are the same. Acute tears, often occurring in adolescence and early adulthood, should be treated differently to degenerative tears in middle-aged patients. In fact, evidence suggests that, in the latter case, meniscus lesions are often merely an early sign of cartilage degeneration and osteoarthritis development.1 We have had a long history of treating meniscus tears with surgery without really having had any evidence if that was the best alternative treatment. There are at least three knowledge gaps within this field. The first is that we lack sensitive and valid measures of impairments, activity limitations and health-related quality of life for patients with early osteoarthritis. These are difficult constructs to measure, but this gap is closing with the development of valid questionnaires and performance-based measures of physical function.2–4 In order to fully close this knowledge gap, we need to take our inspiration from Galileo; ‘Measure what is measurable, and make measurable what is not’. Our second knowledge gap within this field is type and severity of dysfunctions in patients with degenerative meniscus tears; Stensrud et al5 tackle this issue. Not only does this study establish age-matched and gender-matched normative values, but also reports clinically relevant differences in several important outcome measures. We have known for long time that patients have reduced self-reported function, muscle strength and performance following meniscectomy, but Stensrud et al5 is Correspondence to Professor May Arna Risberg, Department of Sport Medicine, Norwegian School of Sport Sciences, PB 4014 Ullevaal Stadion, Oslo 0806, Norway; [email protected]
Risberg MA. Br J Sports Med May 2014 Vol 48 No 9
Provenance and peer review Not commissioned; internally peer reviewed.
among the first to report patients’ muscle strength and physical performance prior to surgery. The study showed that the quadriceps muscle strength deficits found preoperatively were similar to those found up to 4 years after partial meniscectomy in other studies.6 Considering our knowledge on the significance of quadriceps muscle strength in patients with osteoarthritis, these impairments should be addressed as early as possible and not be overlooked. Furthermore, studies have shown that quadriceps muscle strength impairments similar to those found in Stensrud et al have been found to be associated with worse outcome after meniscectomy.6 Improved knowledge of patients’ dysfunctions should lead to the development of new treatment strategies for degenerative meniscus tears. This is our third knowledge gap; more studies are needed on the effect of exercise interventions and treatment guidelines need to be established. A recent randomised controlled trial,7 summarised on page 797 of this issue, evaluated outcomes of patients receiving partial meniscectomy and those only receiving a physiotherapist-guided training programme. The result, no significant differences in knee function after 6–12 months, adds to a growing body of literature which casts a shadow over the value of surgery among these patients. Another great example is the most recent Finnish study which showed that patients receiving arthroscopic meniscectomy did not fare better than those treated with sham surgery.8 However, these types of studies need to be followed up for at least 5 or 10 years, and the development and progression of osteoarthritis should be their endpoint. Nevertheless, recent studies indicate a paradigm shift in the management of degenerative meniscus tears; first-line treatment should be a well-described and evaluated exercise programme.9 First-line treatment of degenerative meniscus tears should not be surgery. To paraphrase one of my PhD students,
To cite Risberg MA. Br J Sports Med 2014;48:741. Accepted 13 February 2014 Br J Sports Med 2014;48:741. doi:10.1136/bjsports-2014-093568
REFERENCES 1
2
3
4
5
6
7
8
9
Englund M, Roemer FW, Hayashi D, et al. Meniscus pathology, osteoarthritis and the treatment controversy. Nat Rev Rheumatol 2012;8:412–19. Collins NJ, Misra D, Felson DT, et al. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken) 2011;63(Suppl 11):S208–28. Kroman SL, Roos EM, Bennell KL, et al. Measurement properties of performance-based outcome measures to assess physical function in young and middle-aged people known to be at high risk of hip and/or knee osteoarthritis: a systematic review. Osteoarthritis Cartilage 2014;22:26–39. Dobson F, Hinman RS, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage 2013;21:1042–52. Stensrud S, Risberg MA, Roos EM. Knee function and knee muscle strength in middle-aged patients with degenerative meniscal tears eligible for arthroscopic partial meniscectomy. Br J Sports Med 2014;48: 784–8. Ericsson YB, Roos EM, Dahlberg L. Muscle strength, functional performance, and self-reported outcomes four years after arthroscopic partial meniscectomy in middle-aged patients. Arthritis Rheum 2006;55:946–52. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675–84. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013;369:2515–24. Stensrud S, Roos EM, Risberg MA. A 12-week exercise therapy program in middle-aged patients with degenerative meniscus tears: a case series with 1-year follow-up. J Orthop Sports Phys Ther 2012;42: 919–31.
741
Downloaded from http://bjsm.bmj.com/ on March 9, 2015 - Published by group.bmj.com
Degenerative meniscus tears should be looked upon as wrinkles with age−−and should be treated accordingly May Arna Risberg Br J Sports Med 2014 48: 741
doi: 10.1136/bjsports-2014-093568 Updated information and services can be found at: http://bjsm.bmj.com/content/48/9/741
These include:
References Email alerting service
This article cites 8 articles, 0 of which you can access for free at: http://bjsm.bmj.com/content/48/9/741#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Degenerative meniscus tears should be looked upon as wrinkles with age— and should be treated accordingly
who is also an orthopaedic surgeon, degenerative tears should be looked upon as wrinkles with age. Although some may try, we all know that one cannot cut away age with surgery. The best antiage medicine is physical activity.
May Arna Risberg
Competing interests None.
We know that menisci play an important role in the knee. They contribute significantly to load bearing, load transmission and shock absorption across the joint and should, therefore, be preserved whenever possible. Furthermore, we have known for many years that meniscectomised knees develop osteoarthritis. We are also learning that not all meniscus injuries are the same. Acute tears, often occurring in adolescence and early adulthood, should be treated differently to degenerative tears in middle-aged patients. In fact, evidence suggests that, in the latter case, meniscus lesions are often merely an early sign of cartilage degeneration and osteoarthritis development.1 We have had a long history of treating meniscus tears with surgery without really having had any evidence if that was the best alternative treatment. There are at least three knowledge gaps within this field. The first is that we lack sensitive and valid measures of impairments, activity limitations and health-related quality of life for patients with early osteoarthritis. These are difficult constructs to measure, but this gap is closing with the development of valid questionnaires and performance-based measures of physical function.2–4 In order to fully close this knowledge gap, we need to take our inspiration from Galileo; ‘Measure what is measurable, and make measurable what is not’. Our second knowledge gap within this field is type and severity of dysfunctions in patients with degenerative meniscus tears; Stensrud et al5 tackle this issue. Not only does this study establish age-matched and gender-matched normative values, but also reports clinically relevant differences in several important outcome measures. We have known for long time that patients have reduced self-reported function, muscle strength and performance following meniscectomy, but Stensrud et al5 is Correspondence to Professor May Arna Risberg, Department of Sport Medicine, Norwegian School of Sport Sciences, PB 4014 Ullevaal Stadion, Oslo 0806, Norway; [email protected]
Risberg MA. Br J Sports Med May 2014 Vol 48 No 9
Provenance and peer review Not commissioned; internally peer reviewed.
among the first to report patients’ muscle strength and physical performance prior to surgery. The study showed that the quadriceps muscle strength deficits found preoperatively were similar to those found up to 4 years after partial meniscectomy in other studies.6 Considering our knowledge on the significance of quadriceps muscle strength in patients with osteoarthritis, these impairments should be addressed as early as possible and not be overlooked. Furthermore, studies have shown that quadriceps muscle strength impairments similar to those found in Stensrud et al have been found to be associated with worse outcome after meniscectomy.6 Improved knowledge of patients’ dysfunctions should lead to the development of new treatment strategies for degenerative meniscus tears. This is our third knowledge gap; more studies are needed on the effect of exercise interventions and treatment guidelines need to be established. A recent randomised controlled trial,7 summarised on page 797 of this issue, evaluated outcomes of patients receiving partial meniscectomy and those only receiving a physiotherapist-guided training programme. The result, no significant differences in knee function after 6–12 months, adds to a growing body of literature which casts a shadow over the value of surgery among these patients. Another great example is the most recent Finnish study which showed that patients receiving arthroscopic meniscectomy did not fare better than those treated with sham surgery.8 However, these types of studies need to be followed up for at least 5 or 10 years, and the development and progression of osteoarthritis should be their endpoint. Nevertheless, recent studies indicate a paradigm shift in the management of degenerative meniscus tears; first-line treatment should be a well-described and evaluated exercise programme.9 First-line treatment of degenerative meniscus tears should not be surgery. To paraphrase one of my PhD students,
To cite Risberg MA. Br J Sports Med 2014;48:741. Accepted 13 February 2014 Br J Sports Med 2014;48:741. doi:10.1136/bjsports-2014-093568
REFERENCES 1
2
3
4
5
6
7
8
9
Englund M, Roemer FW, Hayashi D, et al. Meniscus pathology, osteoarthritis and the treatment controversy. Nat Rev Rheumatol 2012;8:412–19. Collins NJ, Misra D, Felson DT, et al. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken) 2011;63(Suppl 11):S208–28. Kroman SL, Roos EM, Bennell KL, et al. Measurement properties of performance-based outcome measures to assess physical function in young and middle-aged people known to be at high risk of hip and/or knee osteoarthritis: a systematic review. Osteoarthritis Cartilage 2014;22:26–39. Dobson F, Hinman RS, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage 2013;21:1042–52. Stensrud S, Risberg MA, Roos EM. Knee function and knee muscle strength in middle-aged patients with degenerative meniscal tears eligible for arthroscopic partial meniscectomy. Br J Sports Med 2014;48: 784–8. Ericsson YB, Roos EM, Dahlberg L. Muscle strength, functional performance, and self-reported outcomes four years after arthroscopic partial meniscectomy in middle-aged patients. Arthritis Rheum 2006;55:946–52. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675–84. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013;369:2515–24. Stensrud S, Roos EM, Risberg MA. A 12-week exercise therapy program in middle-aged patients with degenerative meniscus tears: a case series with 1-year follow-up. J Orthop Sports Phys Ther 2012;42: 919–31.
741
Downloaded from http://bjsm.bmj.com/ on March 9, 2015 - Published by group.bmj.com
Degenerative meniscus tears should be looked upon as wrinkles with age−−and should be treated accordingly May Arna Risberg Br J Sports Med 2014 48: 741
doi: 10.1136/bjsports-2014-093568 Updated information and services can be found at: http://bjsm.bmj.com/content/48/9/741
These include:
References Email alerting service
This article cites 8 articles, 0 of which you can access for free at: http://bjsm.bmj.com/content/48/9/741#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
