Every dentist visit starts the same way: a cleaning, an X-ray, a look for small problems before they become big ones. No one waits until a tooth is unsalvageable to see a dentist for the first time.
Similarly, S. Ali Ghasemi, MD, clinical assistant professor of orthopedic surgery at Philadelphia-based Thomas Jefferson University, said knees deserve the same standard of care. He said closing that gap could meaningfully shrink the number of patients who ultimately need a knee replacement.
“We don’t have this structure for the knee,” Dr. Ghasemi said. “Why? Because our data and knowledge was not perfect 20 years ago. But in the past 15 years, we have gained a lot of knowledge. We found that knee osteoarthritis is not something unknown. It happens in front of us.”
He said treating meniscal extrusion as the root cause of pain — rather than treating pain as a symptom to manage until replacement becomes unavoidable — could shift a meaningful share of patients off the path toward joint replacement.
The ‘gray zone’ patient
Dr. Ghasemi’s work centers on what he calls the “gray zone”: patients whose knee pain does not fit neatly into either of orthopedics’ two standard buckets. They have tried physical therapy. They have had injections that helped for a few months and then stopped working. Their X-rays show joint space narrowing, but they are not bone on bone. So by the conventional playbook, they are not yet candidates for a knee replacement, and there is often little left to offer them beyond another round of steroids.
“The surgeon usually will consider joint replacement when it’s bone on bone. But right now, the patient is not bone on bone. The patient has pain,” he said.
For years, the honest answer for that population was to wait. Dr. Ghasemi argues that waiting has a cost, because the pain in these patients almost always has an identifiable, treatable source.
Over roughly two decades of research, a consistent finding has emerged in patients with knee pain and early-to-moderate osteoarthritis: the meniscus is often torn and displaced outside the joint space itself.
“The pain is correlated directly with the meniscal extrusion,” Dr. Ghasemi said.
Once the meniscus migrates out of position, the two bones lose their buffer.
“Over time, the cartilage completely drains away, and then we reach bone on bone, and at this point we do the replacement,” Dr. Ghasemi said. “Right now, orthopedic surgeons just wait, see what happens, and at the end they do the replacement. It’s the last shot, the end result — with complications.”
Making prevention routine
For patients who still have joint space, Dr. Ghasemi and his colleagues have spent five years refining an arthroscopic, outpatient procedure that pulls the extruded meniscus back into place — a centralization technique that had been used in younger patients but had not previously been applied to older patients in this “gray zone” stage of osteoarthritis, he said.
“If you just pass the sutures through the meniscus tissue, it never heals, because the meniscus is out, and every time the patient walks, the repair fails,” he said. Instead, his team removes the unsalvageable portion of the meniscus, advances the remaining tissue along with a portion of the posterior capsule back between the bones, and secures it with sutures — restoring its function as a shock absorber.
Dr. Ghasemi’s broader argument is that this is not just a technique but a case for restructuring how knee pain gets triaged in primary care and sports medicine. He described a simple screening test: pressing on the joint line to check for tenderness in a patient who has already had one injection and returned with recurring pain.
“It means there is a meniscal tear, and it means the meniscal extrusion has started,” he said. “What we do right now, the providers just repeat the injection — another steroid, three months, another steroid, three months. It is toxic to the cartilage. We lose more cartilage. The treatment is not repeating the injection. It’s to take one MRI, and then bring back the meniscus between the bones.”
As the population ages, Dr. Ghasemi expects demand for knee replacements to climb unless earlier intervention becomes standard practice — the same way dental cleanings became a routine, unremarkable part of healthcare decades ago.
“The dental cleaning and screening process is completely established,” he said. “But in the knee joint, we didn’t have this approach. We know what the pain generator is. We know when the pain generator [happens], why don’t we try to fix it?”
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