Shelbourne Knee Center: Fall 2022 Newsletter

KNEE TREATMENT NEWS

RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES

a possibility that a symptomatic meniscus tear could calm down without surgery. In patients age 40 and older and patients who have had knee surgery, MRI results will not be normal and are often read as a meniscus tear. Physical therapy (PT) is effective for asymptomatic meniscus tears and some types of symptomatic meniscus tears that don’t respond to surgery.

Nearly all patients with osteoarthritis who were told they need a total knee replacement have limited extension and flexion.

“That’s a reversible problem,” says Dr. Shelbourne. “Through physical therapy, about 80% of our patients improve to the point that they don’t want surgery.”

AVOIDING UNNECESSARY SURGERY WITH A KNEE EXAM

Common knee problems such as asymptomatic meniscus tears and most osteoarthritis will heal with nonoperative treatment. Yet, patients with these problems are often told they need surgery based solely on an MRI or X-rays. When patients turn to Shelbourne Knee Center for a second opinion, they’re surprised when the orthopedic surgeon thoroughly examines both of their knees—the first step in making a definitive diagnosis and avoiding unnecessary surgery.1, 2

“Patients don’t want surgery,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. “They just want to get better.”

Most orthopedic surgeons who perform a knee exam only examine the involved knee, sometimes without exposing the knee. A survey of 428 patients with a unilateral knee problem who saw another physician within six months of going to Shelbourne Knee Center3 found that 37% of orthopedic surgeons touched the noninvolved knee and 63% exposed the knee for the exam. Lack of training in performing proper knee exams and increasing dependence on MRI to diagnose knee problems leads to unnecessary surgery, especially for asymptomatic meniscus tears in patients over age 40 and patients with osteoarthritis, says Dr. Shelbourne. There is also

Improving Diagnosis

To evaluate knee problems, orthopedic surgeons should obtain a good subjective history and examine the involved and noninvolved knees. The history includes a discussion of:

• Onset and circumstances of the knee problem

• Symptoms

• Previous treatments or self-care

• Limitations in daily functioning.

Shelbourne Knee Center gives patients shorts so that orthopedic surgeons can examine their thighs, knees and legs, looking for signs such as atrophy, swelling, tenderness and loss of extension in the involved knee. Usually, the orthopedic surgeons make the diagnosis based on the history and knee exam. Radiographs, or occasionally MRI, are sometimes used to confirm the diagnosis.

K. DONALD SHELBOURNE, MD, PERFORMS A KNEE EXAM.

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AVOIDING

UNNECESSARY

SURGERY WITH A KNEE EXAM PT Helps Meniscus Pain

“We determine what’s different between the legs and how we can make them the same,” says Dr. Shelbourne.

Continuity and Consistency

A physical therapist is always part of the initial patient visit at Shelbourne Knee Center. This ensures continuity and consistency in treatment. By being in the room with the orthopedic surgeon, the physical therapist hears the patient’s story and the discussion with the surgeon.

“The patient doesn’t have to tell the story twice and the physical therapist gets the same story as the orthopedic surgeon,” says Laura Bray-Prescott, PT/LATC, Rehab Supervisor at Shelbourne Knee Center. That’s important because patients often remember things as the exam proceeds with the doctor. If patients go from the doctor’s office to the PT’s office, they may not be able to recall, or possibly didn’t understand, everything the doctor told them about the knee to tell the therapist.

A 49-year-old female who had not been injured woke up with right knee pain and swelling. An orthopedic surgeon ordered X-rays, which were normal, and treated the patient with a cortisone injection. This relieved the patient’s pain for a few days. The surgeon then ordered an MRI and diagnosed a medial meniscus tear. He recommended an arthroscopy. The patient sought a second opinion at Shelbourne Knee Center, where K. Donald Shelbourne, MD, examined both knees and reviewed the MRI scan. He diagnosed an extruded medial meniscus, which doesn’t respond to surgery because it’s the result of early osteoarthritis. He recommended PT, which is improving the patient’s symptoms and restoring meniscal function.

Improving Without Surgery

The COVID-19 pandemic highlighted how often surgery is unnecessary. While nonemergency surgery at Community Hospital East was shut down, patients at Shelbourne Knee Center continued to do their

Survey to Determine Knee Examination Practices3

Shelbourne Knee Center surveyed 428 patients (average age of 42.4 + 18.7 years) with a unilateral knee problem who saw at least one other physician within six months of getting a second opinion at Shelbourne Knee Center. The patients saw orthopedic surgeons (202), primary care providers (154), chiropractors (44) and emergency physicians (28).

CASE #2

Nonsurgical Relief for Severe OA

Based on X-rays, a 66-year-old female with chronic bilateral knee pain was told she had bone-on-bone osteoarthritis (OA) and that total knee replacement (TKA) was her only option. The patient’s mother had a terrible experience with TKA, and the patient didn’t want to go through this. For seven years, she lived with pain and stiffness. When she went to Shelbourne Knee Center for a second opinion, orthopedic surgeon Rodney Benner, MD, examined her knees and recommended the Center’s research-backed Knee Rehabilitation Program for OA. Dr. Benner gave her cortisone injections in both knees to manage the pain and facilitate PT. If she later decides to have surgery, the improvement in range of motion and strength she’s achieving in the program will lead to a better outcome and a faster, easier recovery.

PT at home, with guidance from their physical therapists. When the hospital reopened about three months later, about 50% of patients who were waiting for surgery had improved enough that they no longer needed surgery, says Dr. Shelbourne.

“Physicians need to get back to the basics of the accepted standard for a thorough knee examination and talk with their patients,” says Dr. Shelbourne. MRI scans should supplement, not substitute, for a knee examination. They should be used to confirm and correlate with the findings of the physical exam and the patient’s symptoms.

REFERENCES

1. Shelbourne, KD. The art of the knee exam. Presentation at Andrews University, February 10, 2022.

2. Shelbourne, KD. The Art of the Knee Examination: Where Has It Gone? The Journal of Bone & Joint Surgery. August 4, 2010 - Volume 92 - Issue 9 - p e9 doi: 10.2106/ JBJS.I.01691

3. Patient Survey on Knee Exams. Shelbourne Knee Center, 2009. Unpublished data.

THE BEST CONSERVATIVE TREATMENTS FOR KNEE OA

A Convenient Rehabilitation Program

After the physical therapist teaches the patient how to do the exercises during the first visit in the Knee Rehabilitation Program for OA, patients do their exercises at home, 3–5 times a day. Most patients also use the IdealKnee, a stretching device for knee extension.

Patients complete most of their physical therapy at home, with guidance from their physical therapist and periodic visits at Shelbourne Knee Center. This maximizes results by enabling patients to continue therapy for longer.

CONSERVATIVE TREATMENTS for symptomatic knee osteoarthritis (OA), especially physical therapy (PT), are more effective than many physicians think in relieving pain and improving function. The American Academy of Orthopedic Surgeons (AAOS) strongly recommended the use of self-management, exercise and oral NSAIDs, when not contraindicated, in its 2021 update to the Clinical Practice Guideline for Management of Osteoarthritis of the Knee (Non-Arthroplasty).1 The AAOS also moderately recommended intraarticular corticosteroids to provide patients with short-term relief.1

Research-Backed PT

The Shelbourne Knee Center Knee Rehabilitation Program for OA exceeds the AAOS’s recommendations for selfmanagement and exercise by providing research-backed PT under the guidance of a physical therapist who specializes in knees.

“Many physicians tell patients that physical therapy won’t make the arthritis go away and shouldn’t help with symptoms. Our data shows that physical therapy does help arthritic knees get better,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.

Of 396 patients who participated in the Knee Rehabilitation Program for OA between 2013 and 2017, 76% avoided total knee arthroplasty. These patients maintained their improvements through the study’s one-year follow-up period.2

The Knee Rehabilitation Program for OA focuses on normalizing knee extension first, followed by improving flexion and then strength. Most other nonsurgical rehabilitation programs for knee OA focus on increasing strength, which is difficult to achieve in patients with even a few degrees of loss of extension and flexion.

Enabling PT with Corticosteroids

Despite the potential risk of accelerating osteoarthritis from intra-articular corticosteroids, the surgeons at Shelbourne Knee Center find them to be useful in some circumstances. “A corticosteroid injection is a way for us to provide a patient with short-term relief of significant symptoms, enabling us to then get to the root of the problem with physical therapy,” says Dr. Shelbourne. “We never recommend repeated injections every three months as the sole mode of treatment.” Patients who can’t

Most patients are discharged from the Knee Rehabilitation Program for OA after 2–4 months. Then they self-manage their knee OA through the maintenance program.

tolerate an injection receive oral steroids.

NSAIDs are the best type of medication for relieving knee pain, says Dr. Shelbourne. While some data may show that a particular NSAID is most effective, what’s best in clinical practice varies among patients.

“Some people like naproxen because you only have to take it twice a day. Some people say naproxen doesn’t help but ibuprofen works,” says Dr. Shelbourne. Prescription NSAIDs are an option for patients who have GI problems from OTC NSAIDs or need longer relief.

REFERENCES

1. American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline (3rd Edition). https:// www.aaos.org/oak3cpg. August 31, 2021.

Accessed July 13, 2022.

2. Benner RW, Shelbourne KD, Bauman SN, et al. Knee Osteoarthritis: Alternative Range of Motion Treatment. Orthop Clin North Am. 2019 Oct;50(4):425-432. doi: 10.1016/j. ocl.2019.05.001. Epub 2019 Aug 5.

Rare Knee Injuries: Research-Backed Treatment

TREATMENTS AT SHELBOURNE KNEE

CENTER are based on nearly 40 years of research and follow-up with more than 13,000 patients. The practice’s two surgeons, K. Donald Shelbourne, MD, and Rodney Benner, MD, have had their research published in more than 160 medical journals and over 100 book chapters. Because we specialize only in knees, we

see more rare knee injuries than most orthopedic practices, and we welcome the opportunity to discuss these cases with our colleagues.

Through our Rare Knee Injury Research Program, we’ve begun to identify outcomes and factors related to those outcomes for the following injuries:

• Arthrofibrosis

• Chronic patellar tendinosis

• Failed ACL surgery

• Knee dislocations

• Patellar tendon rupture

• Patellofemoral instability

• Quadriceps tendon rupture.

Whether you would like to discuss a case or make a referral, patients will benefit from our research-backed treatment protocols. Referrals enable us to expand our research to further improve treatment for rare knee injuries.

To discuss a rare knee injury or other case with one of our orthopedic surgeons, email skckneecare@ecommunity.com or call 888-FIX-KNEE (317-924-8636)

ORTHOPEDIC SURGEONS

n K. Donald Shelbourne, MD

n Rodney Benner, MD

CLINICAL TEAM

n Jean Fouts, RN, BSN

n Lee Linenberg, CA

n Emily Guy, PA

PHYSICAL THERAPISTS AND ATHLETIC TRAINERS

n Bill Claussen, MPT

n Emma Sterrett, LAT, ATC

n Laura Bray-Prescott, PT/LATC

n Darla Baker, PT, DPT ATC/L

n Sarah Eaton, PT, DPT, ATC, LAT

n Jennifer Christy, PT

n Alana Gillenwater, PT, DPT

n Bryanna McKinstry, PT

RESEARCH TEAM

n Scot Bauman, PT, DPT

n Adam Norris

n Heather Garrison

n Diane Davidson, BS, MBA, CCRC

Our orthopedic surgeons, K. Donald Shelbourne, MD, founder of Shelbourne Knee Center, and Rodney Benner, MD.