Employment-related meniscus tears are among the more common worker’s compensation claims.  The reasons are myriad but are influenced by the fact that most people develop degenerative meniscus tears as they age and the mechanism of injury for an acute tear merely involves twisting the knee, which can occur in even the lightest and most sedentary occupations because all workers who are not wheelchair-bound walk which means all workers are at risk of twisting their knee in a slip, trip, or fall at the workplace.  Setting aside the possibility that such an event is idiopathic, if a worker seeks medical treatment for knee pain following an industrial event and a meniscus tear is discovered on an MRI the treating physician usually relates the tear to the event.  Standard treatment in most such cases is usually surgical excision of the loose or torn meniscal tissue, more commonly known as a meniscectomy.  The assumption driving the surgery is that the meniscus tear is causing the knee pain and resecting the tear will eliminate the pain.  The problem with this scenario is that most meniscus tears are degenerative and there is no high quality research demonstrating that meniscectomy is an effective treatment for degenerative meniscus tears.  In fact, when researchers recently studied the question they found that exercise was equally effective as meniscectomy to treat knee pain in the presence of a degenerative meniscus tear, according to results published in the British Medical Journal (“BMJ”).

In the worker’s compensation setting, the argument is often made that an industrial event extended a preexisting degenerative meniscus tear in order to justify the surgical intervention (and coverage of the procedure under a worker’s compensation insurance policy).  The cost of meniscectomies to the worker’s compensation system is substantial.  The medical expenses alone are significantly higher for surgery than for conservative care.  In addition, meniscectomies often result in some permanent partial disability.  For example, a meniscectomy in Wisconsin carries with it a 5% minimum PPD rating to the lower extremity at the level of the knee and under the AMA Guides a meniscectomy typically results in at least a 1% impairment rating.  Surgery also typically necessitates a period of temporary total disability in non-sedentary workers.  The findings of the BMJ study should give every employer and worker’s compensation insurer pause and an editorial advocating systemic prohibition of using arthroscopy to treat knee pain that appears in the same issue should spur change.

First, a few things about the study itself.  The BMJ study is a level 1, properly designed randomized controlled trial.  This is the highest category of medical studies and is considered to produce the best and most reliable evidence available.  The BMJ study was conducted in Norway and was a randomized control trial with two parallel intervention groups of 70 patients per group.  One group received exercise alone and the other group received partial meniscectomy alone.  The participants were 35-60 year old persons of both sexes with a 2+ month history of unilateral knee pain without a major trauma but with a verified medial meniscus tear verified on MRI and no worse than grade 2 arthritic changes on x-ray.  The study found that there was no difference in outcomes between the two groups at 3 months and 24 months post-intervention.  The meniscectomy group reported better function and greater participation in sports and recreation at 12 months post-intervention, but the effect was gone by 24 months.  The authors could “not exclude the possibility that the greater placebo effect from surgery on patient outcomes” may have “mask[ed] the ‘real’ difference in treatment between the groups,” which they postulated could explain the temporary effects observed in the meniscectomy group.

More striking even than the study findings is the accompanying editorial.  The authors of the editorial call for a systemic level rule to prevent unnecessary knee arthroscopies from being performed to treat knee pain.  As they note, in the last decade:

A series of rigorous trials, summarized in two recent reviews and meta-analyses, provide compelling evidence that arthroscopic knee surgery offers little benefit for most patients with knee pain.  The latest nail into what should be a sealing coffin appears in a linked paper by Kise and colleagues (doi:10.1136/bmj.i3740):  a rigorous comparison between exercise alone and arthroscopic partial meniscectomy alone (without any postoperative rehabilitation) in adults with degenerative meniscus tear.  The authors found no between group difference in patient reported function at the two year follow-up…

The editorial authors note there has never been high quality research supporting meniscectomy in an older population with degenerative meniscus tears, but that the procedure was extended to this population based on unverified assumptions:

With no support aside from biological rationale, the indication crept from locked knees in young patients to all patients of all ages with knee pain and meniscus tears of any sort; tears which, on magnetic resonance imaging, have proved poorly associated with symptoms. 

The conclusion they reach is both astonishing and harsh:

We are at the point where any careful scrutiny, by, for instance, public health administrators or officials of an insurance company, would conclude that the estimated two million arthroscopic partial meniscectomies undertaken globally each year at a cost of several billion US dollars is potentially nothing but medical waste. Because frontline practitioners and local commissioners have not responded appropriately to the evidence, it follows that system level measures that result in more appropriate use of scarce medical resources are necessary—and perhaps urgently required.

In short, the authors believe the evidence against arthroscopy to treat knee pain is so strong and the evidence for it is so weak that health systems as a whole should stop paying for these procedures.  Such a rule would have a significant impact on worker’s compensation claims where meniscectomies are routinely performed to treat degenerative meniscus tears.

Choosing the right IME doctor can be challenging, especially in complex claims or those with unusual injuries.  Numerous factors influence the decision-making process.  However, two of the most important factors include familiarity with the injury or condition at issue and knowing the precise claims at issue.  These factors are particularly important because many injuries or conditions can be treated by different specialists and it can be difficult in these cases to figure out which specialist is truly the most qualified and credible for the claim at hand.   In simple terms, merely knowing the diagnosis is not enough.

For example, an orthopedic surgeon may amputate toes in a diabetic foot infection claim, but if the cause of the infection is themain issue an endocrinologist, infectious disease specialist, or podiatrist may be better able to write a detailed, credible report as to what caused the infection.  The reason is simple:  orthopedic surgeons do not treat diabetic foot problems unless amputation is required.  The treatment of diabetes, infection risk, and diabetic foot infection management are handled by other specialists.  On the other hand, if permanent impairment is the main issue then an orthopedic surgeon may well be the best expert to use because they are uniquely qualified to evaluate the effects of surgeries they perform.

A similar situation arises in the context of moderate to severe traumatic brain injury.  A neurosurgeon will typically treat the initial injury, but once the condition has stabilized and requires no further surgical management care is usually transferred to a rehabilitation specialist (or more than one).  Once rehabilitation and recovery are complete, care is transferred again, often to a neurologist and a psychiatrist.  In addition, neuropsychologists are often involved in the rehabilitation and recovery process to assess mental functioning.  If the main issue in the claim is the extent of permanency and the type and nature of future care, a neurosurgeon would be of limited value.  However, if the issue is the appropriateness of care in the critical post-traumatic period, a neurosurgeon would obviously be the most qualified expert.  Yet another iteration may involve questions over the extent of mental impairment, in which case a neuropsychologist would be the most qualified expert. 

Facial injuries involving the eye can be difficult also.  The initial treatment may involve an ophthalmologist and a plastic surgeon.  Once the emergency treatment is completed, care may be transferred to a different ophthalmologist for treatment and management of long term vision issues.  Severe ocular injuries can precipitate neurological issues as well, especially headaches.  Sinus and nasal problems can also be present.  In such complicated cases, the actual issues must be examined to assess which experts to use.  For example, in a penetrating eye injury where the patient claims he cannot return to work an ophthalmologist may not be the best choice where the failure to return to work is unrelated to vision loss.  In penetrating eye injuries, the loss of intraocular pressure can precipitate headaches with position changes.  If the claimant was a laborer who routinely has to bend over or look up, a neurologist may very well be the best expert to assess whether the work conditions would in fact precipitate headaches that would prevent the claimant from returning to his employment.  Again, knowledge of both the injury and the actual claim being made are necessary to make the best doctor choice.

Choosing the right doctor is often vexing.  Making the most informed doctor choice not only requires knowledge of the type of injury or condition, but also the precise issues or claims being made in relation to the injury or condition.  To make an informed doctor choice, it is important to recognize that the seemingly obvious specialist might not actually be the best choice depending on what exactly is at issue.  Hence, being familiar with both the injury or condition and the precise issues involved in the claim are necessary to make the best doctor choice.