What are the treatment options for a posterior horn meniscus tear?

Treatment Options for Posterior Horn Meniscus Tears

Conservative management should be the first-line treatment for posterior horn meniscus tears, with surgical intervention reserved only for specific circumstances where conservative treatment has failed and true mechanical symptoms persist. 1, 2

Conservative Treatment Options (First-Line)

Physical Therapy and Exercise

• Structured exercise therapy/physical therapy programs
• Range of motion exercises
• Weight-bearing exercises
• Low-impact aerobic activities
• Activity modification

Pharmacological Management

• Acetaminophen (up to 4,000 mg/day) with caution regarding total daily dose
• Oral NSAIDs (consider patient's comorbidities and risk factors)
• Topical NSAIDs (particularly recommended for patients ≥75 years)
• Intra-articular corticosteroid injections for acute pain relief
  • Studies show 82% of patients with degenerative posterior horn medial meniscus tears experience improvement with steroid/bupivacaine injections 3
  • Complete resolution occurs in 72% of patients with isolated tears 3

Surgical Options (Second-Line)

Surgical intervention should only be considered when:

1. Conservative management has failed after 6-8 weeks
2. Symptoms significantly impact quality of life
3. Patient has true mechanical symptoms (especially locked knee)

Surgical Procedures

1. Arthroscopic Partial Meniscectomy

   • Appropriate for degenerative tears that have failed conservative management
   • BMJ guidelines (2017) indicate limited benefit for most degenerative tears 1
   • May be considered for specific meniscal tear patterns not responsive to conservative care 2

2. Meniscal Repair

   • Success rate of approximately 80% at 2 years 2
   • Best candidates:
     • Younger patients
     • Peripheral tears
     • Horizontal or longitudinal tears
     • Reducible tears
   • Post-repair rehabilitation requires bracing and non-weight bearing for 4-6 weeks 2

3. Subtotal Meniscectomy

   • Reserved for unsalvageable tears (e.g., large posterolateral corner loss) 4
   • Associated with high prevalence of early degenerative changes 4

Clinical Decision Algorithm

1. Initial Assessment

   • Evaluate pain characteristics, mechanical symptoms, and functional limitations
   • Obtain appropriate imaging (radiography initially, MRI if needed)

2. First 6-8 Weeks: Conservative Management

   • Implement structured physical therapy program
   • Prescribe appropriate pain medications
   • Consider intra-articular corticosteroid injection

3. Re-evaluation at 6-8 Weeks

   • If improved: Continue conservative management
   • If not improved: Consider the following criteria for surgical intervention

4. Surgical Consideration Criteria

   • Persistent pain despite adequate conservative management
   • True mechanical symptoms (especially locked knee)
   • Significant impact on quality of life
   • MRI confirmation of repairable tear pattern

Important Caveats

• High-quality evidence shows that arthroscopic surgery offers no significant benefit over conservative treatment for most degenerative meniscal tears 1
• Patients with isolated tears are more likely to have favorable outcomes with conservative treatment 3
• Long-term results of subtotal or total meniscectomy show high prevalence of early degenerative changes 4
• Post-surgical rehabilitation is crucial for optimal outcomes, particularly following meniscal repair

The evidence strongly supports starting with a comprehensive conservative approach before considering surgical options for posterior horn meniscus tears, as this provides the best balance of benefits and risks for most patients.