Eve is here. I hope that most of my readers are either not candidates for, or have managed to escape, the bad orthopedic fad of cleaning knee cartilage in symptomatic patients.
By pure coincidence, I learned early on that orthopedic surgeons only have four treatment modalities: rest, ice, compression, and elevation. Physical therapy; steroids; surgery; too many people are willing to recommend surgery when none of the first three are all that effective.
Sorry if you’ve read this story before. In the early 1990s, after paying off a trainer who injured my knee, I was referred to one of the two best knee specialists in New York City. I knew a few people in his class, so we talked a little about Harvard, but we didn’t have anything in common.
The symptoms did not improve even after 10 days. I ordered an MRI.
When I came in for my next visit, he threw me the radiologist’s report and said, “You went to Radcliffe. Tell me what you think this means.”
The report consisted of five paragraphs per page. The diagnosis was made in one paragraph.
I said, “It says it could be a medial meniscus tear, or it could be a false positive. It could be a false positive.” I knew that medial meniscal tear = surgery.
The doctor said, “They all say that to cover their butts. I’ll go in on Friday and clean up what I see. I’ll be walking on Monday.”
I went out thinking, “I’m not going to kneel down and let you go fishing.”
This is one of the cases that led me to specify that “looking unlucky is lucky.”
If the orthopedic surgeon had not made me read the radiology report, I would have sought a second orthopedic opinion. I realized that I needed a second radiological opinion.
One of my college friends was married to a radiologist. I called her. She called Frank.
Frank said, “Read the report,” and I did.
He said, “Who signed it?” I gave it a name.
Frank said, “I know him. He doesn’t write ‘possible false positive’ unless he’s very suspicious. Send me the film.”
The entire team at Cedars Sinai reviewed the image. Frank called me and said, “Your knee looks perfectly normal.”
The second part of this anecdote is that the orthopedic surgeon said he would just “clean it up,” including trimming the rough-looking cartilage. I didn’t understand that part until I came across a man in his 50s at another gym in New York City doing what appeared to be knee rehabilitation exercises. I said sympathetically, hoping it would make him feel better.
He is feeling better and tells me that he sees an orthopedic surgeon every 18 months to have his knee “examined” and the rough cartilage “cleaned out.”
I was surprised. I asked a friend of mine, a physical therapist who rehabilitates elite athletes, if it was a good idea to gradually chip away at the cartilage in the knee, and he joined me.
Written by Elizabeth Rosenthal. The original article was published on KFFHealth News
The thousands of Americans who undergo common knee surgeries may be making the problem worse, not better.
Researchers who followed patients for 10 years who had either real surgery to trim degenerative cartilage tears, or just a “sham surgery” (skin incision), found that the procedure had little effect and was actually associated with accelerated osteoarthritis and higher reoperation rates. This generally means a total knee replacement.
“I have no idea how to defend this surgery,” said Teppo Jarvinen, one of the study’s authors, an orthopedic surgeon and director of the Finnish Center for Evidence-Based Orthopedics. “What became dramatically clear was that patients who had this surgery had more pain. The pain was getting worse. All the scores were pointing in the same direction.”
Javinen said a Finnish study published in April in the New England Journal of Medicine was the first to show that surgery made many patients’ symptoms worse. Although the study was small, he said the results were convincing because the team selected patients “most likely to benefit.”
This study does not apply to cartilage tears caused by acute, painful injuries. The study included middle-aged and older subjects who experienced knee pain and had cartilage tears seen on MRI scans.
Evidence has been steadily accumulating for more than a decade that arthroscopic knee surgery, which removes torn and degenerated cartilage, is no more effective than physical therapy. Jarvinen said arthroscopy rates in Finland have fallen by 90%. It is also declining in the United States, but at a much slower rate.
One study of U.S. commercial insurance claims that counted more than 2 million meniscal surgeries from 2010 to 2020 found that number decreased by about 4% each year. Most surgeries were performed on women and patients in their 50s.
Under the traditional Medicare fee-for-service program, the number of procedures has steadily declined in recent years, from about 169,000 in 2014 to 91,000 in 2024, according to federal data. These numbers do not include beneficiaries of Medicare Advantage, the private insurance plan that covers more than half of Medicare enrollees.
Previous studies on the scan have found that such tears are common in people over 50, are the result of wear and tear, and are often painless.
“There is nothing to support the idea that the patient’s pain is caused by the meniscus,” Jarvinen says.
“There is growing evidence that this procedure can be used judiciously in this population,” said Robert Brophy, director of the Orthopedic Clinical Research Center at Washington University in St. Louis. But, he noted, “many patients are benefiting.”
Still, he acknowledged that current practice among his colleagues is “across the board.” For example, data shows that meniscal tear surgery among Medicare enrollees is much more common in the South than in the Northeast.
A large research committee from the European and American Orthopedic Societies issued a consensus statement last June stating that “degenerative meniscal lesions can be treated with either nonsurgical (including physical therapy) or surgical approaches with comparable results.” Although he recommended trying physical therapy before surgery, he still supported surgery.
A joint campaign by orthopedic specialty societies called “Save the Meniscus Society” has been ongoing for many years. The group advocates protecting and maintaining long-term knee health through non-surgical treatment, surgical repair, and other treatments.
One of the problems inherent in all medical specialties is that appropriate treatment is often in the hands of physicians. This means that experts will create guidelines for when treatment is appropriate. And economic considerations could influence that decision, Jarvinen said.
In the United States, physician payments are determined by the Relative Value Scale Update Committee (RUC), a committee of the American Medical Association comprised primarily of experts. Health and Human Services Secretary Robert F. Kennedy Jr. and his advisers are reportedly considering taking control of the commission away from the association, although it’s unclear how that could be done, since the AMA owns the billing codes used to calculate patient charges.
Arthroscopic knee surgery takes 30 to 60 minutes in the operating room, and patients spend several hours recovering at a surgery center or hospital outpatient clinic. Medicare allocates an average of $2,159 to $3,875 for surgery, depending on where the surgery is performed. Patients pay 20% of the fee as coinsurance. For example, if more than one doctor is involved in a procedure, there may be additional costs. The average for private insurers is well over twice that, said Marcus Dostel, senior vice president at data analytics firm Turquoise Health, adding that the amount insurers charge for procedures varies widely. These fees do not include surgeon and anesthetist fees.
Treatment of chronic knee pain has a mixed history.
Fifty years ago, the treatment for cartilage tears caused by acute trauma or abrasion was to remove the entire cartilage. At the time, doctors thought it was a useless vestige of tissue, like an appendix, rather than a shock absorber.
Currently, the first-line treatment for painful knees with degenerative tears is physical therapy and, for some, weight loss. Then there is arthroscopic surgery, depending on the surgeon’s opinion of its usefulness.
There is also a menu for injections. Steroids have been scientifically proven to be valuable in the short term. And while stem cell and plasma-enriched protein injections are widely available, their effectiveness is controversial, with research inconclusive at best, and most insurance policies don’t cover them.
And as orthopedic surgeons retreat from shaving away torn meniscuses, they are turning to a newer procedure that involves sewing the torn cartilage back together. However, this is usually an option for patients younger than 50 with acute trauma and clean tears, and it is unclear exactly which patients will benefit.
If all else fails, there is another surgery that can be of great benefit to hospitals and doctors as well. It’s a knee replacement.
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1 A few years later, a trainer named John showed up at my gym. I said to one of his staff members, “That guy broke my knee.”
What’s your reaction? “Oh, you mean Johnny Kevorkian? His other nickname is 007, License to Kill.”
This entry was posted by Yves Smith on July 14, 2026 in Questionable Statistics, Guest Post, Healthcare, Ridiculously Obvious Scams, Science and the Scientific Method.
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