In many patients that come into our office, there is a complexity of symptoms and pain in multiple joints. In one patient, for instance, it could be that they suffer from back pain, hip pain, and knee pain. In the patient history, we ask that patient if they have been recommended to any surgeries? Sometimes they will respond, “yes, I have been recommended to back surgery,” or sometimes they will say, “my spinal surgeon is suggesting back surgery, my orthopedist is recommending hip surgery. The two of them agree that I should have the hip surgery first then the spinal surgery.” Sometimes a patient will say that their doctors are recommending a spinal surgery, hip surgery, and bi-lateral knee replacement, which surgeries first are dependent on which is thought to be the worst of their problems.
In this article I will discuss research that suggests that in some of these situations, where a patient has hip, back and knee pain, the rush to surgery may be sending many patients to an inappropriate or unnecessary surgery knee replacement.
A surgical recommendation for a problem that is not there. Twenty-one patients who were referred to knee surgery, but who in fact had a hip problem.
If you have an MRI of your knee and it shows degenerative arthritis and you tell your doctor that your knee hurts, there is a strong possibility that you will be recommended to knee replacement.
In a 2018 study, surgeons at the University of Florida publishing in the journal Arthroplasty today (1) suggested that patients could be getting unnecessary and unneeded knee surgery because their main problem was not what the knee MRI was revealing, but an unrecognized and misdiagnosed hip problem that was referring pain to the knee. Let’s read what happened to the 21 patients who were referred to knee pain treatment.
- Twelve of the 21 patients had undergone surgical knee interventions, including a total of 8 knee replacements with minimal to no relief of their pain.
- After unsuccessful knee pain relief, seventeen of 21 referred patients underwent total hip replacement.
- Fourteen patients had complete resolution of knee pain after total hip arthroplasty.
Conclusions of the study: “Although knee pain referred from hip disease may be considered a basic and common knowledge, it continues to be an overlooked phenomenon. Most of the cases were misdiagnosed by musculoskeletal providers including orthopaedic surgeons and this highlights the need for continued education and awareness of this clinical scenario.”
Knee pain complaints in women over 50. Is it really knee osteoarthritis or is it hip pain? Back pain? Weight?
Here is an interesting 2018 study (2) centered on women over the age of 50.
The researchers of this study investigated the factors associated with the level of knee pain in community-dwelling women aged 50 years or older. The radiographic grade of knee osteoarthritis, presence of low back pain, level of hip pain, Body Mass Index and presence of depressive symptoms were significant factors associated with the level of knee pain in the study group. For women without knee osteoarthritis, knee pain was found to increase according to increasing age, BMI, level of hip pain, and presence of low back pain. For women with knee osteoarthritis, knee pain was significantly associated with radiographic grade of knee osteoarthritis, BMI, level of hip pain, presence of low back pain, and presence of depressive symptoms.
Previous studies have indicated that patients with hip disease can go to the doctor with with knee pain. The sensory nerves of both the hip and knee joints originate from the femoral, sciatic, and obturator nerves (nerves at the L2-L4 lumbar region that impacts the mid-thigh). Hip joint pathology is known to be an important cause of pain referred to the knee joint. In addition, spinal problems can cause anterior knee pain through radiating pain or through the weakness of the quadriceps muscle. A previous study showed a high percentage of spinal symptoms in patients with knee pain, compared with controls. Although hip or back pain does not necessarily represent hip pathology or radiculopathy, our study results suggest that associated hip and spine disorders need to be evaluated in women with knee pain.
The question is. Women with knee pain without MRI evidence of osteoarthritis and women with knee pain with clear evidence of osteoarthritis. In this study the doctors warned to check the back, the hip, depressive episodes, and weight to determine the true cause of pain. This could prevent a recommendation to surgery that was not needed, worse, the wrong joint gets operated on.
Did depression cause a knee replacement surgery that was not needed?
Staying with this theme of women over 50, a July 2021 paper wrote (6): “An accurate diagnosis (for knee disorders) is necessary to guide toward a rapid and efficient management of knee disorders. However, the ability to make a valid diagnosis is often complex for clinicians and evidence is mainly focused on clinician cognitive biases or errors produced during clinical reasoning.” Errors can be made. One error may surround the depressive symptoms of the patient.
In this study of 279 participants, the average patient was about 50 years old and about 58% were female. The most common disorder was osteoarthritis (n = 117, 18.8% of cases were discordant). The key here is discordant, which means what the MRI image suggests may not be in agreement with the patient’s symptoms.
The researchers speculated that the most probable reason for diagnostic discordance included having depressive symptoms, which was associated with an increased probability of diagnostic discordance. The study concludes: “Our results suggest that depressive symptoms may increase the risk of knee diagnostic discordance. Clinicians may be more likely to make diagnostic errors and should be more cautious when evaluating patients with knee disorders suffering from psychological distress.”
Having the wrong joint replaced is not a new problem, it happens quite often, especially when the hip is involved.
In a study published in the medical journal Modern Rheumatology,(3) surgeons discussed the complexity of hip disease and how it impacts other joints and areas of the body.
Here the surgeons found that:
- Hip disease was the cause of knee pain in 29% of patients.
- Hip disease was the cause of low back pain in 17% of patients.
Their warning to their fellow surgeons?
- “be aware of hip disease masquerading as knee pain or low back pain” That is how wrong surgeries may be performed.
The dilemma of diagnosis the knee or the spine as a primary pain source
A May 2022 paper (7) suggested guidelines to help clinicians understand the older patient who has knee and spine osteoarthritis symptoms. Here is what these researchers wrote: “Whether to operate on the knee or spine first, the preference of surgery needs clinical correlation, and it continues to puzzle even seasoned clinicians and surgeons. No sufficient evidence is available to guide the choice of treatment order for the symptomatic patient group. An astute clinical judgment following a thorough physical examination and radiological assessment remains the guiding factor for managing concurrent knee-spine degeneration. The dilemma of decision-making remains unanswered mainly, and challenges persist. Further studies are required to understand the management of concurrent knee and degenerative spine disorders in the elderly.”
“Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis.”
Here is study from surgeons in the United Kingdom. Published in the medical journal International Orthopaedics, (4) the surgical team of this study wanted to answer the question as to why up to 20% of total knee replacement patients complain of persisting pain after the knee replacement. Here was there answer:
- The investigators examined 45 consecutive patients with pain after total knee replacement. Of the 45 patients, one-third, 15 patients had degenerative hip and lumbar spine disease. Nine patients had unexplained pain.
- The study concluded: “Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”
The patients still had knee pain after knee replacement because it was not their knee generating the knee pain, it was the hip and spine.
A 2017 study published in the journal Clinical Orthopedic Surgery, (4) doctors found that in the patients they examined with pain after knee replacement
- 25.6% of the patients in the study were found to have nerve entrapment in the spine,
- 15.4% were found to have hip osteoarthritis or femoral head avascular necrosis.
Knee pain persisted after knee replacement because the problem was not the knee but the hip and spine.
Physical examination can help rule out “wrong joint surgery”
I have written extensively on this website about the problems of MRIs sending people to surgery that they do not need. W\hat an MRI cannot do is gently press on the hip joint. If we can press on the hip joint and you get a shooting pain in your knee, we can have a realistic expectation that knee replacement may not be the answer. If we can gently press on your spine, and this creates a knee pain, we may come to the same conclusion. Knee replacement may not be the answer.
1. Dibra FF, Prieto HA, Gray CF, Parvataneni HK. Don’t forget the hip! Hip arthritis masquerading as knee pain. Arthroplasty today. 2018 Mar 1;4(1):118-24.
2 Lee KM, Kang SB, Chung CY, Park MS, Kang DW, Chang CB. Factors associated with knee pain in 5148 women aged 50 years and older: A population-based study. PLoS One. 2018 Mar 8;13(3):e0192478. doi: 10.1371/journal.pone.0192478. PMID: 29518078; PMCID: PMC5843201.
3 Nakamura J, Oinuma K, Ohtori S, Watanabe A, Shigemura T, Sasho T, Saito M, Suzuki M, Takahashi K, Kishida S. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Modern rheumatology. 2013 Jan 1;23(1):119-24.
4. Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11.
5. Lim, H.-A., Song, E.-K., Seon, J.-K., Park, K.-S., Shin, Y.-J., & Yang, H.-Y. (2017). Causes of Aseptic Persistent Pain after Total Knee Arthroplasty. Clinics in Orthopedic Surgery, 9(1), 50–56. http://doi.org/10.4055/cios.2017.9.1.50 —
6 Lowry V, Bass A, Vukobrat T, Décary S, Bélisle P, Sylvestre MP, Desmeules F. Higher psychological distress in patients seeking care for a knee disorder is associated with diagnostic discordance between health care providers: a secondary analysis of a diagnostic concordance study. BMC musculoskeletal disorders. 2021 Dec;22(1):1-2.
7 Govil G, Tomar L, Dhawan P. Knee-Spine Syndrome: Management Dilemma When Knee Osteoarthritis Coexists With Spine Degeneration. Cureus. 2022 May 12;14(5).