What is the plan of care for a patient with a possible acute meniscal tear?

Plan of Care for Possible Acute Meniscal Tear

Conservative management should be the first-line treatment for a possible acute meniscal tear, with surgical intervention reserved only for specific circumstances where conservative treatment has failed and true mechanical symptoms persist. 1

Initial Assessment and Diagnosis

• Clinical Evaluation:

  • Look for pain, swelling, joint line tenderness, and mechanical symptoms (catching, locking)
  • Special tests: McMurray test, Apley test, Thessaly test
  • Assess for mechanical symptoms, especially locked knee (crucial for surgical decision-making)

• Imaging:

  • Plain radiographs to rule out fractures or degenerative changes
  • MRI indicated to confirm diagnosis when clinical findings are inconclusive
  • Look for specific MRI signs: meniscal extrusion, signal changes at meniscal root, "ghost sign" 2

Conservative Management (First-Line Approach)

1. Structured Exercise Therapy/Physical Therapy (6-8 weeks):

   • Range of motion exercises
   • Weight-bearing exercises
   • Low-impact aerobic activities
   • Progressive strengthening

2. Pain Management:

   • Acetaminophen (up to 4,000 mg/day)
   • Oral NSAIDs (considering patient's comorbidities)
   • Topical NSAIDs (particularly recommended for patients ≥75 years) 1

3. Special Pain Management Considerations:

   • For patients with history of symptomatic/complicated upper GI ulcer: COX-2 selective inhibitor or nonselective NSAID with proton-pump inhibitor
   • For patients with history of upper GI bleed within past year: COX-2 selective inhibitor with proton-pump inhibitor 1

4. Adjunctive Treatments:

   • Intra-articular corticosteroid injections for acute pain relief
   • Tramadol may be considered if first-line treatments fail 1

Surgical Intervention Criteria

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 1

Surgical Options (When Indicated)

1. Meniscal Repair:

   • Preferred for younger patients
   • Best for peripheral tears, horizontal or longitudinal tears, and reducible tears
   • Superior outcomes with 80% success rate at 2 years
   • Better functional outcomes and less severe degenerative changes over time 1, 3

2. Arthroscopic Partial Meniscectomy:

   • May be considered for degenerative tears that have failed conservative management
   • Limited benefit for most degenerative tears
   • Option for patients with mild-to-moderate knee osteoarthritis where meniscal tears contribute to predominantly mechanical symptoms 1

Post-Surgical Rehabilitation

• For Meniscal Repair:

  • Bracing and non-weight bearing for 4-6 weeks
  • Progressive rehabilitation protocol

• For Partial Meniscectomy:

  • Earlier weight-bearing and return to activities
  • Focus on strengthening and range of motion

Follow-Up and Monitoring

• Regular assessment of pain levels and functional improvement
• Progression of physical therapy as tolerated
• Repeat imaging only if symptoms significantly worsen or change in character 1

Important Considerations

• High-quality evidence shows that arthroscopic surgery offers no significant benefit over conservative treatment for most degenerative meniscal tears 1
• Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time 3
• Failure to properly rehabilitate after meniscal repair can lead to poor outcomes and increased risk of re-tear
• Patient age, activity level, and tear characteristics significantly influence treatment decisions and outcomes

Special Cases: Meniscal Root Tears

• Require special attention as they can lead to significant biomechanical changes
• Often present with posterior knee pain, joint line tenderness, and popping sound
• Active patients, regardless of age, should be considered for meniscal root repair
• Transosseous repair technique most commonly used for medial meniscus root tears 2