A knee replacement nightmare; one doctors experience with one size fits all medicine.
We are all alike, aren’t we? This is of course a ridiculous suggestion however, the health care system constantly uses a one size fits all model to make our problems fit the way they are taught to see them, but not necessarily the way they are. In my opinion, it is one of the largest cost drivers of health care resulting in many useless tests and interventions due to a lack of understanding that often begins with primary care. Is your blood pressure low, high or right for you? Does everyone really need an aspirin per day to reduce heart attack risk? All people with plantar fasciitis have a foot problem or do they? Neck and back pain is just a back problem that often resolves or does it? Do all people with higher than the desired cholesterol numbers really require statins, which requires constant medical oversight, or do many people who are overweight with high cholesterol live well into their 90’s without any medical intervention?
These statements are the result of perceptions people have of medical problems they may experience, and often, the approaches the healthcare system takes towards people who suffer from many health conditions are institutionalized, rather than individualized, with sometimes disastrous outcomes. Remember when the FDA said saturated fats were bad, and we all ate low fat this and low fat that, only to find out that fats are now health for us and that more people than ever now have diabetes as we consumed products laden with sugar which was used to make the low fat foods?
Eric Topol MD, the author of “The Patient Will See You Now: The Future of Medicine Is in Your Hands” is a cardiologist who was the former chief of cardiology at the Cleveland clinic and now edits for Medscape has been a critic of healthcare for many years, and often questions what he sees as problems in how the medical profession handles many health conditions the profession takes care of.
Dr. Topol, who had problems in his knees (osteoarthritis dessicans) when he was a child. Recently, he decided to have his left knee replaced at the recommendation of an orthopedist. Over the years he was very careful in the way he did activities because his knees would be painful, and he used anti inflammatory medication to reduce the pain, which also inhibits healing, something most medical providers believe is appropriate management. Based on years of helping people with knee problems, it is quite likely that he was experiencing the problem many medically managed patients experience when their problem is ignored or poorly understood, but the symptoms are relieved by OTC medication. When his left knee became sufficiently problematic, he opted for the surgery and went into rehab for the problem. Since he was a physician, he was well aware of the risks of the surgery and risks of infection which happen to 1-2 percent of those who have the procedure.
The rehab was expected to be painful, but it was more painful than he ever imagined with pushing, pulling and stretching which after 6 weeks inflamed the knee. After seeing the orthopedic for a follow-up visit, he was told to have more physical therapy which consisted of the same painful treatments that left him unable to sleep due to the pain.
Finally, he decided to visit a different therapist who used a different approach which eliminated most of the active rehab and did not incite pain or inflammation, which helped him recover. He believed the reaction to the rehab was due to Arthofibrosis, or perhaps, the people who did the original rehab, which consisted of canned exercises did not fully understand his body mechanics. Did he just get unlucky and have Osteochondritis Dessicans as a child or was there a mechanical basis for all of this that was just misunderstood by all the health care providers who evaluated him.
Ironically, his other history included a frozen shoulder which occurred five years prior to his knee replacement, something that is quite common. A restricted hip capsule will restrict shoulder motion and it is common for frozen shoulders to improve just by loosening the hip alone. Based on this small fact in the article, I am assuming that the frozen shoulder was on his left side as well, since it is a typical presentation. He also seems to believe that he has a propensity for scarring based on his frozen shoulder, or is he seeing the problem through a very limiting medical lens?
Most recently I saw this on a patient who did the NY Marathon who complained of shoulder pain and restriction that resolved when we stretched out his left hip. One of the most common reasons for knee pain is a restricted hip capsule and while I do not know Dr. Topol personally, it is likely that the problems with his knee rehab may have been due to a restricted hip, rather than an arthritic knee.
The truth is, the lack of a patient centered approach which recognizes that we are all unique, a concept pioneered by British psychoanalyst Enid Balint. During a lecture, he introduced the term “œpatient-centered medicine,” the idea that “œthe patient, in fact, has to be understood as a unique human-being.”
We are indeed the sum of our parts, and in the case of Dr. Topol’s knee, we cannot walk without the ankle and the hip, so why does it make sense for an orthopedic doctor to just look at the knee and assume that the knee itself is the only part that should be evaluated when a patient has knee pain. The truth is that movement is more like a slinky and when it is not, the body develops problems mechanically, and knee replacement is a huge business probably because we evaluate patients by the part, assuming we are all the same.
Of course, we are not and in the case of Dr. Topol’s knee, the right approach used for years may have prevented his knees from becoming bad enough to even entertain a knee replacement. Better patient centered protocols for evaluating gait and problems in the extremities by their doctors would likely help. Seeing a practitioner that does a thorough workup of mechanical function could have definitely helped here however, even Dr. Topol probably lacks the training in musculoskeletal evaluation, as do many of his medical colleagues to adequately evaluate his pre surgical knee pain, which apparently have been present for years.
Currently, chiropractic sports physicians are one of the few groups who can adequately do the types of functional evaluation and treatment that many aging American’s would require to keep their aging knees functional even into their golden years.
You can read more about his journey here.
A doctor with a bad knee runs into one-size-fits-all medicine
It took me three months of physical torture before I diagnosed my problem: I was suffering from one-size-fits-all medicine.
I am one of more than 750,000 Americans who this year will have a total knee replacement, the most common orthopedic operation. Most people do well with the standard physical therapy protocol, but there are many who have a rough rehab.
My knees went bad as a teenager because of OCD “” not obsessive-compulsive disorder, but a rare condition known as osteochondritis dissecans. It wreaked havoc on both knees with plenty of pain and frequent dislocations, ultimately leading to extensive surgery just before I started medical school at age 20.
[Knee surgery for pain may not be worthwhile]
Over the next four decades, I progressively curtailed activities including running, hiking, tennis and even elliptical exercise, while increasing my reliance on anti-inflammatory medications to deal with the pain. After injections of steroids and synovial fluid directly into the joint failed, it was time to consider getting a new knee. My orthopedist told me I was a “œperfect candidate” being relatively young (I was 62), thin and fit; he said the only concern would be a risk “” 1 to 2 percent “” of infection. Nothing else.