How orthopedic specialists go beyond imaging to diagnose and treat pre-arthritic knee pain
Sofía Stutz went bouldering for the first time in September of this year, when she suffered an injury that left her reeling with pain.
After Stutz, 22, climbed an indoor rock wall to the top and started slipping, she did what many climbers do: She jumped and dropped about 6 feet to the ground. Unfortunately, Stutz landed awkwardly on her feet and knew almost immediately that she had suffered an injury to her right knee. The pain was sharp and consistent.
“It was pretty bad,” she says. “I tried to put weight on my leg, and my knee immediately buckled.”
Stutz, who is studying philosophy at Northwestern University, went to the emergency department, where doctors gave her a brace and crutches. They weren’t able to diagnose the exact nature of her injury, though, until she had an MRI.
As Stutz now knows, many issues can cause significant pre-arthritic knee pain in an active person. Advanced imaging has increased awareness of these conditions, but orthopedic doctors still rely on their own judgement, along with the patient’s history and physical exam, to make a diagnosis and develop an appropriate treatment plan.
A few days after Stutz’s fall, she met with orthopedic surgeon Asheesh Bedi, MD, director of the NorthShore Orthopaedic & Spine Institute Sports Medicine and Joint Preservation Program.
With a history and physical exam, corroborated by an MRI, Bedi, who also is an orthopedic team physician for the Chicago Bears, was able to fully diagnose exactly what had happened to Stutz’s knee.
She had torn two ligaments and the meniscus in her right knee, which required two surgeries to repair. Given her young age, the surgeries were imperative to restore function and prevent future arthritis.
Knee ligaments, bands of aligned connective tissue, hold the knee together and allow for stable motion with activities. The meniscus is a c-shaped piece of tough, protective cartilage that acts as a shock absorber between the shinbone and the thighbone.
Bedi’s use of MRI reflects the increasing importance of advanced imaging in diagnosing and treating knee injuries and resolving patients’ pain. Technology enables physicians to see the human body in more detail than ever before, but images alone don’t tell the full story.
“Advanced imaging gives us incredibly greater insights on the diagnostic side,” Bedi says. “We are able to see cartilage, damage, swelling, and partial injury to ligament and muscle with a resolution that is orders of magnitude improved over what it was 10, 15, or 20 years ago.”
MRI also enables physicians “to identify the deeper injured structures like the meniscus and ligaments, but also the pattern and location of those injuries to guide the best approach and surgical treatment,” Bedi says. “The MRI is equally important to confirm what was not injured. The combination of history, exam, and imaging inform the best plan for a comprehensive yet precise [treatment].”
“These days, with advanced imaging, for any given patient, we can truly characterize the anatomy of their joint like a fingerprint.”
A 2020 study from the University of California echoes Bedi’s experience. The study concluded that advanced imaging, including CT scans, MRIs, and dynamic fluoroscopic imaging (imaging of internal structures’ movement), can help evaluate the biochemical properties of cartilage, meniscus, and ligaments.
Advances in image processing, shape modeling, and dynamic studies also offer a novel way to evaluate common conditions and to monitor patients after treatment, the study found.
Only part of the diagnosis
While advanced imaging is increasingly useful, diagnosing and treating knee pain is a multi-prong process that includes several steps. Physicians observe the person’s gait, how they stand, take the person’s medical history, and perform a physical exam.
John Miller, MD, assistant professor in the department of orthopedic surgery at Loyola University Medical Center, agrees with Bedi that finding the root cause of knee pain requires taking in all of those various data points.
“I like to look at the patient, to look at their alignment,” Miller says. “Are there limitations to range of motion? Is there tenderness to specific areas of the knee? Are the ligament and tendons functioning properly? We also perform certain provocative maneuvers to evaluate for particular abnormalities within the knee.”
Physicians want to know how the person is experiencing pain, too.
“Is it pain when it is weight-bearing, oris it radiating up and down the leg?” Millersays. “Is it a locking episode where the knee gets stuck in a bent or straight position? Are there any feelings of instability?”
The physicians agree that advanced imaging also helps when people undergo a knee or other joint replacement.
“These days, with advanced imaging, for any given patient, we can truly characterize the anatomy of their joint like a fingerprint,” Bedi says. “What is the size of their knee? What is the shape of their knee? What are the angles that make their knee unique for them?”
Then, during surgery, Bedi says, “We use the advanced imaging data to position a graft or an implant with accuracy customized for that individual. Advanced imaging has allowed us to deliver individualized medicine and a personalized approach to surgery in a way that we could not in the past.”
About a week after each surgery, Stutz’s postoperative pain was gone. As of early December, she was still using crutches, and was even planning a two-week trip home to Argentina later in the month.
“I’m feeling much better,” she says. She planned to bring her crutches on the trip but was hoping she wouldn’t need them.
And she didn’t. Stutz brought one crutch with her, and never used it. She walked 10,000 to 20,000 steps per day without pain — a far cry from where she found herself just a few months before.