What is the treatment for a torn meniscus?

Treatment of Torn Meniscus

For torn meniscus, conservative management should be the first-line treatment, with arthroscopic surgery reserved only for specific cases where conservative measures fail and there are clear mechanical symptoms. 1

Initial Assessment and Classification

When evaluating a torn meniscus, it's important to distinguish between:

1. Degenerative meniscus tears:

   • Typically atraumatic
   • Common in middle-aged/older patients (>35 years)
   • Often associated with osteoarthritis
   • Usually complex tear patterns with fraying

2. Traumatic meniscus tears:

   • Clear injury mechanism
   • More common in younger patients
   • May present with locking or catching
   • Often repairable

First-Line Treatment: Conservative Management

For most meniscus tears, especially degenerative tears, conservative management should be tried first:

• Physical therapy and exercise:

  • Supervised exercise programs
  • Quadriceps and hamstring strengthening
  • Range of motion exercises

• Medications:

  • NSAIDs for pain and inflammation
  • Topical analgesics

• Weight management for overweight patients

• Activity modification to avoid aggravating activities

Conservative management should be attempted for at least 6-12 weeks before considering surgical options 1, 2.

Surgical Management

Surgery should not be the first-line treatment for most meniscus tears, particularly degenerative tears. The 2017 BMJ clinical practice guideline makes a strong recommendation against arthroscopic surgery for degenerative knee disease, which includes meniscus tears 1.

Indications for Surgery

Surgery may be considered only in specific circumstances:

1. Persistent mechanical symptoms - true locking (not just catching or giving way)
2. Failed conservative management - persistent pain despite adequate trial of non-surgical treatment
3. Acute traumatic tears in younger patients
4. Primary signs and symptoms of torn meniscus with secondary osteoarthritis 1

Surgical Options

When surgery is indicated:

1. Meniscal repair:

   • Preferred for younger patients (<40 years)
   • Better long-term outcomes
   • Appropriate for peripheral tears with good blood supply
   • Higher initial reoperation rate but better long-term function 3

2. Partial meniscectomy:

   • Reserved for irreparable tears
   • Removes only damaged tissue
   • Higher risk of future osteoarthritis
   • May be appropriate for older, lower-demand patients 4

3. Meniscal allograft transplantation:

   • Salvage procedure for younger patients with prior complete meniscectomy
   • Used for persistent pain and functional limitations 4

Important Caveats and Pitfalls

• Avoid arthroscopy for degenerative disease: Arthroscopic surgery has not shown significant benefit for degenerative knee disease and may expose patients to unnecessary risks 1

• Mechanical symptoms alone are not sufficient justification for surgery in degenerative disease

• Presence of osteoarthritis should generally lead toward conservative management rather than surgery

• Post-surgical rehabilitation is crucial for optimal outcomes regardless of surgical approach

Treatment Algorithm

1. Initial presentation of meniscus tear:

   • Begin conservative management (PT, NSAIDs, activity modification)
   • Continue for 6-12 weeks

2. If symptoms persist:

   • Reassess for true mechanical symptoms
   • Consider MRI if not already performed

3. Decision for surgery:

   • For young patients with traumatic tears: Consider repair
   • For older patients with degenerative tears: Continue conservative management
   • For persistent true locking: Consider appropriate surgical intervention

4. Post-treatment:

   • Rehabilitation regardless of treatment path
   • Regular follow-up to monitor symptoms and function

The evidence strongly suggests that conservative management should be the mainstay of treatment for most meniscus tears, with surgery reserved for specific indications where the benefits clearly outweigh the risks 1, 2.