To have opted for conservative treatment not surgery?

[growingsidewaysnotup]

I’m just looking for some opinions here as between this, a potential new job, and day to day life, my head is a scrambled mess.

I have recently been diagnosed with a painful but not critical knee injury. This injury is very hard to treat via physio, it has a poor outcome.

I really do not want surgery. I don’t particularly have the time for it this year, nor do I have the energy for the (intense) rehab after.

The physio said she understands this, in my shoes she’d be hearing for surgery but she can see why I’d want to opt for conservative treatment.

My partner, family and colleagues all think I’m being silly. They think that given the long term impact on my life and the pain I’m in, I should have opted for surgery. I do have to admit that after a couple of weeks of physio and being back to normal exercise levels, it does seem to be getting worse and not better.

Am I being silly? Should I just bite the bullet and get my name on the list? As this is a soft tissue injury the waiting list for surgery isn’t actually that long at my hospital (the consultants take on extra lists to do these - confirmed by a family member who works in the team), so id be looking at a 12-16 week wait.

I just need some clarity because my life is incredibly hectic at the moment and I can’t see the wood from the trees.

What does the surgeon advise?

I had arthroscopy for meniscal tear, unfortunately I did develop arthritis but that was because I left it for years and scar tissue developed in the knee joint which then wore away the cartilage. They removed a lot of the scar tissue when they fixed the tear but the damage had been done.

The recovery from surgery was 48hr minimal weightbearing, then I was off the crutches by day 4 and driving/back at work after a week. It’s only if you’re having ligament reconstruction or similar that the recovery takes a long time.

Most knee injuries can led to arthritis unfortunately- regardless of the treatment. I've gone the conservative route but mine is ACL and my surgeon agrees its the best way forward.

I opted to avoid surgery - one of the stupidest decisions of my life. You will regret it if you don’t do it.

I think that you are assuming the surgeries always work though. Friend of mine has now had 3 surgeries after her acl rupture as the replacements failed and she wishes she didn't have the first.

I think it depends on lots of things including the injury, your age, the stage you’re at in the process. Physios can have vastly different approaches and some will likely encourage a more conservative approach than others as even with surgery there are likely to be trade offs. Perhaps get a second opinion from a physio in a different field. Personally as someone who has navigated and still navigating various injuries with a conservative approach I think it’s reasonable to do that but it’s not the easy option. The pain, the physical limitations, the time it takes to recover naturally can feel pretty relentless and affect your mental health so only you will know if you have the mental capability to deal with it without intervention but good luck. I tore my hamstring tendon 8 years ago and opted for a conservative approach, it took years to recover but even now still get flare ups.

You need to tell your insurance company about any changes to your health before you go as otherwise you won't be insured.

I don't think the conservative treatment option is necessarily the wrong one, even if your reasons for choosing it might be more about fear and the inconvenience. There's a book called Surgery: the Great Placebo by an orthopaedic surgeon called Ian Harris which you might find interesting/useful. He argues that a lot of surgeries have been introduced too quickly without being fully evaluated and says the gold standard is to test them against sham surgery in a placebo trial. I had a search of the book and this is some of what the book says about arthroscopy for meniscus tears, for example: "In 2013, a placebo-controlled trial was published comparing surgical excision (via arthroscopy) to sham surgery for patients with signs and symptoms of a medial meniscus tear, with a proven meniscus tear on MRI, and without any significant arthritis in the knee.

This study was high quality. Not only did the researchers follow the usual steps in reducing bias by not letting anyone know in advance which group they would be in and keeping nearly all the patients right to the end of the study, they also made sure that not only were the patients and researchers blinded, the statisticians were blinded. They even went to the extreme of writing the paper before revealing (to themselves) which group was the sham. They also checked that the blinding was successful (it was) by asking patients whether they thought they got the sham treatment.

The results showed that there was no statistically significant or clinically important difference between the real surgery and the sham surgery for any of the primary outcomes (like knee scores, knee pain after exercise, and general health) at any of the time points.And, of course, most patients showed considerable improvement after the treatment – it just didn’t matter whether or not the torn meniscus was removed. [...] It should be noted, though, that most people over forty have a meniscus tear, nearly everyone with osteoarthritis has a meniscus tear, and of all the people in the community that have a meniscus tear, most do not have knee pain. The link between the presence of a meniscus tear and knee pain is not strong, and the link between taking it out and relieving pain is even more tenuous, but we continue to do this procedure in record numbers. "

The book is from 2016, so there could well be newer evidence in favour of surgery, but my understanding is that what doctors recommend can really vary and isn't always based on the most up to date research anyway. I know someone with a meniscus tear right now who was advised by the doctors to try physio first for 3 months, at the moment she seems unlikely to need the surgery. I also know someone else who had a similar if not the same injury (she thinks it was but isn't sure) who similarly wasn't even offered surgery. She still has twinges but I've know her for nearly a decade and it only came up when the first person had her meniscus tear so it hasn't affected her much. Both those people were injured in their late twenties though so that might make a difference or maybe your injury is more severe.

Anyway, I found the book helpful when I was thinking about wrist surgery for nerve/joint pain, obviously it is just one person's view of the evidence though. I think if I remember rightly he talks about regression to the mean and how most people will improve regardless of intervention, which gave me hope, I think I initially felt I needed to rush into treatment or my pain would get worse but it's actually pretty ok most of the time now. Doesn't sound like it was ever as painful as yours though!

Edited after OP updated

Well done, good choice. You can’t think your way out of this type of injury.

Hi @growingsidewaysnotup I’ve had the meniscus shave thing. Did you not have an MRI? It showed a sticky up flap on mine! That said, I’m pretty sure it would eventually have got better. Recovery (because I had a great physio and religiously did the work) was actually very quick, as was the surgery.

DH's NHS consultant (different part of the leg) said it would be normal for him to let his injury heal which would take more than a year. Surgery apparently wasn't needed and would also take a long time to heal. He still has problems up to this day. Another doctor let it slip that the reason he didn't heal properly was because he should have been offered surgery but upon further questioning he tried to say that that was not what he meant. Although DH's issue was not the same as yours I would opt for surgery after what happened to him!!

Make sure that you follow the doctor's guidance and take it easy after the surgery. I hope you have a good network to help you with cooking, shopping etc.

Good luck

How on earth are you going to go on an intense walking holiday if you are still in pain? If you have the surgery in April there is a chance that you might still be in pain by August. If you don't have any surgery, there is no chance that you'll be in a fit state to go on this holiday! Your family are correct, you aren't approaching this rationally at all.

I don't see how you wouldn't make it far worse by putting your leg through that much pressure, that just makes no sense whatsoever.

You'll be lucky to get it this year if you're just going on the list now.
And surely if there are times you know you won't be in the country or whatever they won't book it for then?