Douchebag Doctor of the Week: Episode 4 – with Special Guest!!
Well, there’s a LOT to unravel and to ponder on with this one… and I’m honoured to have a very special guest at the end, who has kindly added their personal thoughts on this case and on some of the issues raised. This one’s a bit different, because the ‘Douchebag of the Week’ is actually a physio, not a doctor!
See what you make of it….
Case History
A 62-year-old lady started a Couch-to-5K program back in late 2021. With this, she developed pain in her right knee, and this pain persisted.
In February 2022, the patient went to see a physiotherapist, and she was simply given exercises to do.
In January 2024, the patient went to see a different physio. This physio injected the patient’s knee with hyaluronic acid plus steroid (without any imaging first).
In May 2024, the patient was suffering further pain in her knee. The physio therefore injected the patient’s knee again, this time with just hyaluronic acid.
In August 2024, the patient was again suffering ongoing pain. The patient therefore had her knee injected once again by the physio, again with hyaluronic acid.
In October 2024, the patient went back to the physio, and this time both of her knees were injected with hyaluronic acid.
In November 2024, the patient was still suffering ongoing pain, and she therefore went back to the physio. This time he injected her knee with steroid.
Towards the end of November 2024, the patient ended up coming to see me. At that point, the patient had medial joint line pain, with medial joint line tenderness. She had a fixed flexion deformity of 10o, and her flexion was limited to a maximum of about 110o, limited by pain. There was also a very slight varus in the knee, which was fixed, not correctable. The joint felt stable. A McMurray’s test was negative but a Clark’s test for patellofemoral irritability was positive.
I arranged for the patient to have some imaging of her knee. This imaging showed the following:-
1. There was an extensive degenerate tear of the medial meniscus.
2. There was fully-blown osteoarthritis in the medial compartment, with bone-on-bone contact.
3. There was just minor degeneration in the lateral compartment.
4. There was moderate patellofemoral arthritis at the front of the knee.
5. There were multiple loose bodies in the joint.
6. Finally, there was a small effusion in the knee, and a moderate Baker’s cyst posteriorly.
This patient has now undergone a left total knee replacement under my care, with a Conformis iTotal-CR prosthesis. This surgery was performed in mid-February. The patient has done very well. However, now that her left knee is feeling good, the patient is now more aware of similar pains in her other knee. Imaging has confirmed that the right knee is, similarly, also osteoarthritic, and the patient therefore now wants to go ahead with having her right knee replaced too, as soon as possible.
Questions.
- Is it appropriate for a patient to be ‘treated’ within the Independent Healthcare Sector without her first having had appropriate imaging (i.e. without a specific diagnosis first)?
- Is it appropriate to inject steroid into a patient’s knee as a form of ‘treatment’?
- Is it ever appropriate to inject hyaluronic acid into anyone’s knee (or any joint anywhere)?
- Was it appropriate for this patient’s physiotherapist to perform so many injections into her knee, repeatedly, or should she have been referred on much sooner?
- Do you think this patient was managed appropriately?
Footnotes:
- https://kneereplacements.co.uk/blog/latest-study-shows-steroid-injections-actually-increase-future-risk-knee-replacement-surgery/
- https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-knee/oak3cpg.pdf
- https://www.nice.org.uk/guidance/ipg637/chapter/1-Recommendations
Special Guest: Katie Knapton’s comments!
Katie Knapton is a Senior Physiotherapist in West Sussex, and she is the Chair of Physio First. Katie came across this series of case reports and she contacted me via LinkedIn. I’ve shared a couple of specific case reports with Katie, and we’ve had some fairly lengthy discussions about the general implications of some of the specific issues that these cases raise. Katie and I don’t agree on absolutely everything (let’s face it, it would be weird for two people to agree with each other on absolutely everything anyway!)… but we agree on most things, and we certainly agree on putting our patients first and on ensuring that each and every patient is managed properly and only offered appropriate treatments.
Katie has very kindly offered her thoughts on some of the issues raised in this particular episode of ‘Douchbag Doctor of the Week’ — which is particularly important, given that the ‘douchebag‘ is actually a physio this time, not a doctor!
So, I’ll like to thank Katie for getting involved, and for her specific comments:
“I welcome this discussion, though obviously disappointed in the case management presented.
The imaging question deserves clarification – I don’t agree that all knee presentations should be imaged at initial assessment, regardless of healthcare sector. Imaging is not required for most initial knee presentations. A full history and objective assessment should be performed to establish a working clinical diagnosis and decide on an appropriate treatment approach and timelines. This applies whether in NHS or independent practice.
Imaging becomes essential when patients aren’t progressing or when the results will alter the treatment approach. When patients are actually deteriorating – as clearly happened here with the development of a fixed flexion deformity – referring on becomes crucial.
We agree entirely on the core issue: the pattern of repeated ineffective interventions over nearly three years represents a breakdown in sound practice principles. Just doing the same thing because you can is not appropriate and not good practice. Importantly, this shouldn’t be just pointing the finger at injections – all our approaches should be reasoned and clearly communicated with patients.
As our profession evolves and we acquire new skills and treatment modalities, continuous reflection becomes essential. This case reminds us that technical ability to perform an intervention must always be balanced with thorough assessment and evaluation of the individual patient – these fundamentals should remain at the core of all we do.
The value in sharing these cases is to strengthen our collective practice through honest reflection, ultimately improving patient care.”
Katie Knapton, Chair, Physio First.