any way to rehab with torn meniscus?

[pedsnurse8]

Hi everyone,
I tore my right medial meniscus right at the root sometime between the end of October and early November (had synovitis in right knee so it's a guess as to when the nature of the pain changed).

Anyway I am about 12-14 weeks out and have really been unable to restart my PT exercises without a lot of pain. I have not had a tkr yet as I am a military dependent and they refuse to consider surgery before I am 55. They also do not want to do an arthroscopic procedure unless the knee starts locking up. That the knee hurts and occasionally gives out is not an issue to them.

I was able to do some of the quad strengthening exercises (without ankle weights-I had been using 3 pound weights prior to synovitis) as long as I wore a brace on the right knee,which made it very awkward getting in position for some of the floor exercises as my other knee is also bad; but I tried a single set of 10 of the exercises without the brace the other night and am now back on tramadol for pain.

Called and tried to get back in to ortho for advice but cannot be seen until 1 March (good old military rationed care). Has anyone else tried to rehab with a torn meniscus? The MRI showed that the meniscus is evulsed. Any advice would be appreciated.

 

[calling_all_angels]

Ped,
Welcome it is so nice to meet you. Jo can tell you all about the knee she knows all about the knees. As far as being a military dependent "FrogFeathers" another member here is also a dependent and she too had to jump through hoops but she may be able to give you some advice.

 

[Jamie]

Hi, Pedsnurse....welcome to BoneSmart. I'm so sorry you are having so many problems!!

Are you working with a military hospital or through CHAMPUS? I think there may be some options for you, but you will probably have to push a little. Let me know some more details of who you are seeing that's telling you that you must wait to have relief from your pain.

 

[pedsnurse8]

I am being treated at a military facility through Tricare. My regular orthopedic doc (not a surgeon) saw my MRI results and said it was UGLY! :shk:She even took me to the guy that sets up the preliminary waiting lists for surgery as she was sure the orthopedic surgeon would want to do surgery. Unfortunately the surgeon I saw (he is head of the department) is the same one I saw for my original request for tkr. When he saw my first MRI results from 2008 he stated that he could not even see why the technician indicated I had OA.:sct:

I asked for a second opinion at that time and when I pulled copies of the MRI report read that there was :"bilateral tricompartmental osteoarthritis with posterior patellar spurring, a patellar enthesophyte at the quadriceps tendon insertion, squaring of the tibial plateau and femoropatellar and medial compartment narrowing. There is a small ossific density adjacent to the left medial spine which may be compatible with a loose body. There is a suspicion of a bilateral patellar chondromalacia. Small patellar subchondral cyst on left knee. A large degenerative cyst seen in the posterior lateral tibia close to the insertion of the cruciate ligament of left knee as well as a small joint effusion."

HOWEVER THIS DOCTOR COULD NOT SEE WHAT THE RADIOLOGIST WAS CALLING ARTHRITIS!!!

When I saw him for the second MRI results I don't think he knew that my ortho doc had shown my husband and I the meniscal tear because he told me there was only one angle that showed anything of the meniscus and that people had individual anomalies, implying that there was no tear.:skp:

I did get to have a second opinion (another surgeon who works under his authority) a week or so later who did confirm that there was a meniscus tear but since it was at the root it was unrepairable and that to go in and do arthroscopic surgery would accelerate my arthritis and I was too young for tkr.

I probably should have complained to the patient representative but am leery of making enemies in 'this good ole boy system' too far ahead of being a definite candidate for tkr. When I got a second (a civilian) opinion from the first MRI he also did not seem to think I needed a tkr yet. I think this is because I am not bone on bone, but my problems are due to knee instability and the locations of the spurs and cysts I have which cannot be clearly illustrated in black and white on a MRI or xrays.

 

[CG'sknees]

Hi Pedsnurse, and welcome.

I discovered I had severe "end stage" osteoarthritis as a result of a knee injury resulting in a torn right medial meniscus. I was referred to an OS, and had arthroscopic surgery. It was the worst decision I could have made!!

After suffering for almost a full year, never recovering from the surgery, I was referred to a second OS, who plainly stated that arthroscopic surgery should be reserved ONLY for a very healthy athletic knee. He described the surgery done to my knee as criminal. This OS is a highly regarded one in Los Angeles, who has worked on knees of star athletes, star performers, and lil ole me. I am blessed to have him as my surgeon.

The whole point of my dissertation is that you should absolutely forgo any thought of arthroscopic surgery. I can't advise about the insurance issue, but I desperately hope that you will seek the advice of an OS who is very experienced with TKAs (that's what my doc calls them..."arthroplasty" not "replacement"). It turned out that the first surgeon I suffered at the hands of never even did TKAs so he was in no position to advise me about my knees.

My second OS said that if he had seen me first he would have advised that I lose weight and do strengthening exercises (cycling) until I was ready to consider replacement.

I hope this is of some help to you.

 

[pedsnurse8]

Thanks for the info. I too had come to the opinion that arthroscopy would do more exaccerbation than relief in my situation, but as it stands now I am essentially unable to do the physical tharapy that was recommended to strengthen the quadriceps. Even before the meniscus tear I was limited in what I could do because of problems with my other joints. I believe that the only option I will be given once I get back in to see my ortho doc is cortisone injections but I don't feel the sharp tearing/grating type of pain (like I had in my shoulder) that would indicate cortisone might help.

 

[Josephine]

Well, honey, you're never going to be able to effectively 'rehab' your knee with a torn meniscus. This is not only because of the instability caused by the meniscal tear but the consequence of the arthritis.

When a joint becomes arthritic, the articular hyaline cartilage begins to fragment. It's much like a concrete door step that begins to crumble when feet are continually walking on it. The debris created on the step happens just the same in the joint. When bits of this debris get between the joint surfaces, it's very much like getting a sharp stone in your shoe. Pain!! And because of it you can't walk properly. But then the debris moves out of the way and you're okay for a bit - or better, anyway. The meniscus is getting fragmented in the same way and contributing to the mass of debris.

Added to this, as you know, a torn meniscus is actually very painful in itself! So these guys are totally wrong, even cruel - you need an arthroscopic menisectomy and washout because it will actually relieve a lot of your pain, hopefully almost all of it, and buy you a lot more time. It's totally unacceptable for them to hold you off this way.

Attempting to 'rehab' your leg is not going to do anything because the strength of your muscles is not going to make matters better or worse. The problem is in your knee joint. And injections are not going to help either, not until the debris and torn cartilage is removed. It will be a waste of time and money, little more than a band-aid.

I speak on this not only as a nurse but as one who has had just this scenario treated only last September. I too had a posterior horn tear with some wear and tear. My surgeon trimmed the cartilage and did a good washout. My knee is now fine though I am seeing signs of continued deterioration. Can't walk easily down slopes, for instance. But I doubt I shall serious need to consider another replacement until late summer (well, I'm hoping so!).

You really need to fight this with everything you have. It is, in my opinion, an untenable attitude for them to adopt.

 

[pedsnurse8]

Thanks for the info. What about the beliefs that arthroscopic surgery would accelerate the progression of the arthritis? I am not sure but I think their "line of reasoning" is that until there is enough debris to cause the knee to lock, they do not want to mess with it. I will be seeing my regular ortho doc 1 March. She can do injections, and might be able to put in a referral for an opinion by an approved civilian orthopedic surgeon. Whether or not Tricare (west coast equivalent of CHAMPUS) will approve it is questionable since I was seen by two different military orthopedic surgeons and therefore technically have had two opinions already.

Any help from someone who has dealt with Tricare would be most appreciated!!!

 

[Josephine]

Yes, many have that belief but it's founded on faulty thinking. So long as the surgeon does only what is necessary, there shouldn't be a problem. Issues arise when the surgeon gets carried away with his tools and starts debriding the joint surfaces. At the end of the operation, the surface looks all smooth and shiny but, in effect, all he is doing is what the arthritis is doing!

I've observed lots of arthroscopies and the amount of debris that ends up in the lavage bottle afterwards is amazing! Fact is, any debris in the joint is too much and a locking can occur with a multitude of bits or just one. It's purely a matter of luck - or bad luck, depending upon your point of view!

I knew a man who put off his TKR for several years by insisting on an arthroscopy every 6 months or so! Happily his surgeon was willing to go along with him and just do a washout and nothing more. If you succeed in getting this done, be sure you stipulate 'menisectomy and washout only with debridement only where absolutely necessary'.

 

[1jt@atime]

Ped,

My husband is a retired Marine and I know all too well when you talk about the Tricare good ole boys network. I'm guessing you are on Tricare Prime which is very similar to an HMO in the civilian world. I stayed with the standard form of Tricare for just this reason; I wanted to be able to select what doctor or surgeon I saw.

I also got additional insurance through my employer when I knew that I needed multiple joint replacements. This made Tricare my secondary insurance which picks up all my deductibles. Do you have an opportunity to get a second insurance or move to the standard Tricare which offers more flexibility?

For the immediate, I would definitely push for an outside referral from your regular doc. Tell her what you were told. You don't have to wait until you are 55. We are the same age and I have had three joint replacements. This surgeon must not realize that arthritic pain has no age.

Good luck and let me know if you have any questions from a fellow military dependent.

 

[pedsnurse8]

Yes, we are Tricare Prime, which we chose to minimize out of pocket expenses. We have no other insurance. My husband is retired army, and as I am sure you know, dependents of retirees are at the bottom of the list for any kind of care. I have already looked at the list of approved docs in the area and have one picked out if I can get a referral. Thanks for the suggestions and support!

 

[1jt@atime]

You're right Pedsnurse about being bottom of the list as a retiree dependent. I forgot that was another reason I had searched out other insurance. When we moved to Virginia in 2003, we couldn't get in to use the local military hospitals as retirees and had to go civilian so that's when I pretty much broke my connection with them other then using Tricare as a secondary insurance. My husband usually goes to the doctors once a year for physicals and that's it. He's lucky. I make up for everyone else in the family with my ortho problems.

Let us know how your appointment works with your doctor. Keep us posted!

btw, my husband is a retired Marine but is currently working in Afghanstan.

 

[pedsnurse8]

Went to 1March appointment with my regular ortho doc and her jaw literally dropped when I told her about my appointment with the ortho surgeon. She said I would get no further relief from pain in my right knee unless something was done. She could not refer me out as it would put her in a very awkward position (as I said before, the surgeon I saw is head of the department )but she told me how to get in touch with patient advocacy. Patient advocacy said my PCM would be the one that could refer me out (fortunately I anticipated this and already had an appointment for 4March:D) Patient advocate sent my PCM an e-mail just in case he hesitates about the referral. Saw PCM yesterday and he put the referral request into the system. I have to wait until Tuesday and call to see if it gets approved but patient advocate said it would be no problem and to call her if it doesn't get approved. So, hopefully I can call the civilian doc Tuesday and get an appointment with him. He will only be allowed to give an opinion at this stage then I will have to find out what the steps are from there.

 

[Jamie]

Slow steps, but you're moving forward. Good for you!! Sometimes you must really be pushing all the way.

 

[1jt@atime]

It's good to hear that you may be making some progress. I'm saying may because I know the system you are working with. Please keep us posted on how it goes this week. Good luck.

 

[ginawhitmarsh]

Also go easy on the injections. I have gone through series of 5 Euflexxa and Hyalgan injections. Also tried cortisone in between. They can become very expensive and insurance does not like to pay for them. They are also only a temporary pain helper. They help for a few months then the pain comes back. My left knee also has a deformity from too many cortisone shots. I was told it was from being given the shot incorrectly. My knee has some tissue loss and the skin has color change. It is really ugly.

 

[pedsnurse8]

Thanks for sharing your experience with me. My regular ortho doc agreed with the second OS that cortisone would not help the pain I was having from the torn meniscus, and I am hesitant to even consider a third round of synvisc after having the synovitis following the second series. I am getting some relief of pain in the left knee following the synvisc-it just is not as effective as previous-or it could just be that the left knee is overworking to compensate for the right knee even though I am using a cane. I'm still waiting for the referral to a civilian OS, I have been told that it is being approved, I just have not received the official notice with the confirmation number yet.

 

[Jamie]

Sorry this is taking so long for you, but hang in there....it will get done. I'm saying a prayer that it is soon.

 

[ginawhitmarsh]

Hopefully you will get that appointment. When injections stop helping, medication does not seem to be helping, you have had enough surgeries, your saying no to things you would like to do but know it would hurt............it is time to take the next step!!! Your not much older than me so I'm sure there are things you want to get out and do. I'm only 40 and so tired of sitting in a chair because my knees keep me from walking, hiking, riding my new bike that sits parked. HOPEFULLY SOON!!!!!!!!!!!:thmb: 23 days!!!!!! :amen:Then on to the other knee.:D

 

[pedsnurse8]

Tricare Red Tape Reigns Supreme Received a message last week that I had a referral to a specialty clinic at my TMC-meaning the military orthopedic clinic whose treatment(should I say lack thereof)I am protesting. Went back to patient advocacy today after two days of trying to get through by phone. Found out my PCM put the referral in correctly but the orthopedic clinic refused to refer me:rant: All is not bad though, the arrogant OS that likes to ignore MRI reports has been replaced. This slows things down as the new OS has the right to personally review cases before allowing them referrals out. Unfortunately there do not seem to be any appointments available before May that I can go to. :shk: Patient Advocate is trying to get me a referral out on the grounds that there is not access within a reasonable timeframe from (March 4) the original request. So I continue in a holding pattern and surviving on TENS unit and tramadol