Conservative Care Often Isn't What It Seems

Traditionally, conservative care meant non-operative care. You injured your shoulder, knee, or ankle and the doctor said, "Let's try conservative care first and see if you get better." 

The problem today is that you, the patient, don’t know if “conservative care” means that your insurance company has only authorized a couple of physical therapy sessions, or a few tablets of anti-inflammatory medications, with the aim of delaying a full workup or surgical repair as long as possible. If so, this level of conservative care may not be in your best interest. How do you know if this is the case?

Let’s start at the shoulder. Many shoulder injuries, unfortunately, create pain that can last for months or even years. A number of these injuries, such as a torn rotator cuff,  have a wide range of initial presentations. While physical therapy is often helpful, some rotator cuff tears can now be reliably cured with targeted injections of growth factors and lubricants. Some tears, though, are best treated with early surgical repair. The only way to be sure is to image the tissue with high-quality MRI or sometimes ultrasound. A “wait-and-see” approach forfeits the early healing response that can be obtained if the diagnosis is made accurately and the therapy applied quickly and correctly.

For knee injuries, the data shows that if a person twists their knee, hears a pop, and the knee swells, there is a 90 percent chance that a significant injury to the meniscus, articular cartilage, or ligaments has occurred. Our current understanding of these tissues is that they are crucial to knee function, rarely heal on their own, and are best treated with surgical repair as soon as is practical.

In the case of the meniscus cartilage, a tear that results in the patient hearing a pop and the knee swelling means a significant portion of the tissue has been torn. This won't heal on its own. Non-operative care (such as physical therapy) means that the torn tissues are exposed to repetitive motion, which can further damage the tissue—often beyond the ability of the surgeon to repair it. Unrepaired meniscus tears lead to arthritis. Not very conservative! Early repair or replacement of the meniscus with donor tissue, on the other hand, can effectively treat and prevent the progression.  

In the case of ligaments (such as the ACL), the longer the knee is left unstable the more the secondary restraints—i.e., the ligaments on the side of the knee— become stretched. This raises the chance of a secondary injury to the knee’s supporting structures, such as the meniscus. It can also lead to a worse result when surgery is eventually performed; even more so if the patient is young.

The same is true for the articular cartilage, the bearing surface of the joint. Acute damage that leads to knee swelling never heals on its own. Articular cartilage has no nerve supply (it is aneural), and so the injury may not be initially painful. But if left unrepaired the lesions expand, inviting early arthritis and persistent pain. 

Today, though, articular cartilage is often completely repairable. Our articular cartilage paste graft technique has shown success in athletes for up to 30 years following the procedure. And with the use of growth factors and stromal cell recruitment, cartilage regeneration will continue to improve.

In this 21st century, the ability to make extremely accurate diagnoses of joint injuries depends upon the combination of careful history (i.e. talking to the patient about exactly how the damage occurred), an experienced examiner, accurate X-rays, and high-field, high-quality MRIs. It is pennywise and pound-foolish to forego these assessments after significant joint injuries since it is far cheaper and much more efficient to fix injuries sooner rather than later.

We hope that the cost of an MRI will be driven down so low that, in the near future, most acute joint injuries will be scanned without hesitation. We also hope for an increase in the knowledge that early repair is far better for the patient than false conservative care. In the meantime, after suffering a significant injury, don’t hesitate: Get thee to an expert. And get accurate, image-supported data.
 

Article originally published April 22, 2014. Updated & republished June 11, 2023 by Kevin R. Stone, MD with content updates.