Follow Dr Huang’s Clinical Reasoning (24): Finding What Can Change Within Irreversible Changes

By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)

Recently, I treated a patient with approximately five years of right lateral knee pain. He had undergone MRI, X-rays, ultrasound and specialist assessment. His reports described marked lateral compartment degeneration, full-thickness cartilage damage, a meniscal tear, synovitis, joint effusion, a Baker’s cyst, iliotibial band thickening and other degenerative changes. He also had a history of right hip structural abnormalities and an L5/S1 disc bulge.

Honestly, my first reaction was: my head was spinning. If every finding on those reports was something I had to “fix”, there would be very little I could do.

Structural Abnormalities Remained, but Pain Could Change

The patient had undergone two meniscal operations and received local injections, acupuncture, physiotherapy and chiropractic treatment. After the second operation, he had been almost pain-free for more than six months. Previous injections had also substantially reduced his pain. Treatment had clearly been able to change his symptoms.

His cartilage damage, joint degeneration and synovial changes had not all disappeared after an operation or injection. Yet his pain had changed considerably. Pain can improve without every structural abnormality being repaired.

Some structural changes were real and potentially irreversible. Acupuncture cannot regrow severely damaged cartilage within a few sessions or return a degenerative joint to its younger state.

But if our thinking stops there, little room remains for conservative care. My question was: within these irreversible changes, was there anything we could still change?

The Pain Pattern Made Me Think Again

The patient worked as a chef, spending long periods standing and walking. On a difficult day, his right lateral knee pain could reach 5–6/10.

However, something made me question the picture. He enjoyed cycling and regularly attended the gym, yet these activities rarely provoked his familiar knee pain. Prolonged standing, driving, remaining in one position and sometimes resting at night were more troublesome.

This made me question whether the structural findings alone explained his symptoms. If meniscal or cartilage damage were the main determinant, why did cycling and exercise not consistently provoke pain, while sustained positions and static loading were more troublesome?

This did not exclude joint degeneration or other structures within the knee as contributors. Nor did it mean the imaging findings were irrelevant. It suggested that the imaging did not fully explain his current pain pattern.

Which Clinical Clues Were Worth Following?

I returned to the physical examination. Knee movement, squatting and single-leg loading did not clearly reproduce his usual lateral knee pain. However, pressure over the right lateral popliteal groove produced pain close to 10/10.

He also described longstanding tightness, aching and discomfort extending down from the upper outer calf, sometimes involving the foot. He had always called this “nerve pain”.

I compared knee flexion with the patient lying prone. The heel-to-buttock distance was approximately 5 cm on the left and 22 cm on the right—a substantial difference.

Several findings now stood out: functional movements did not reproduce his typical pain; the lateral popliteal groove was markedly tender; there were radiating nerve-like symptoms; and right knee flexion was clearly restricted.

My treatment focus shifted from the fixed structural findings on MRI towards the posterolateral knee, particularly the lateral popliteal groove and surrounding soft tissues. I wondered whether increased soft-tissue tension and some degree of neural mechanical sensitivity were contributing to his pain and restricted movement.

This remained a working hypothesis. What mattered next was the response to treatment.

Following the Changes, One Finding at a Time

After the first treatment, the patient said his leg felt noticeably easier. With further treatment, the pain that previously reached 5–6/10 after a working day gradually decreased. By around the fourth session, pain following prolonged standing or sitting was usually only 1–2/10, and night pain had largely resolved.

Meanwhile, tenderness over the lateral popliteal groove gradually decreased, and right knee flexion continued to improve.

By the tenth treatment, lateral knee pain had almost disappeared, local tenderness had largely resolved, and right knee flexion was close to the left. Interestingly, the “nerve pain” he had considered largely unrelated to his knee pain had also resolved.

What Had We Actually Changed?

This made me ask: what had we actually changed?

Was there evidence that the meniscal tear had healed? No. Had the full-thickness cartilage damage repaired itself? There was no evidence of that either. Could we say the degeneration had disappeared? Certainly not. Yet pain, tenderness, nerve-like symptoms and movement had all changed during treatment.

These changes suggested that, alongside the established and potentially irreversible structural abnormalities, there were important factors that could improve. This was consistent with my suspicions about local soft-tissue tension and neural mechanical sensitivity. However, improvement alone could not establish exactly which tissue or mechanism had changed.

What I could confirm was that the patient’s symptoms and examination findings were changing.

My Clinical Reflection

This case strengthened my belief in a clinical principle:

First acknowledge what may be irreversible, then look for what may change. Use the history to narrow the possibilities, the pain pattern to raise questions, examination to find clues, and reassessment after treatment to keep testing the reasoning.

Imaging is important, but an imaging report is not the whole patient. The presence of a structural abnormality does not automatically make it the main source of pain at that moment.

We should not dismiss MRI findings because a patient improves after treatment. Equally, a report containing several serious abnormalities should not stop us looking for other factors we might change.

Next time I face a complicated MRI report, instead of immediately asking, “How can I treat all these problems?”, I can ask: “Within these irreversible changes, is there something we can still change?”

Find it, examine it, treat it, and return to reassess it.

Following Dr Huang’s clinical reasoning is not simply about where a needle goes. It is about how a clinician works, step by step, towards understanding the real problem in a complex patient.

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 Disclaimer

This article shares observations and clinical reasoning from an individual case. It provides general information and does not replace personalised medical assessment, diagnosis or treatment advice. The response described relates to this patient during the reported period and does not guarantee similar outcomes for others. It is not evidence of meniscal or cartilage repair, reversal of joint degeneration, or confirmation of a specific nerve disorder.