What is the best treatment approach for a medial meniscus injury?

Treatment Approach for Medial Meniscus Injury

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

Initial Assessment and Treatment Algorithm

Step 1: Diagnosis and Classification

• Evaluate type of tear: traumatic vs. degenerative
• Assess location: peripheral (vascular) vs. central (avascular)
• Determine pattern: bucket handle, vertical, horizontal, radial, complex
• Check for mechanical symptoms (locking, catching)
• Obtain appropriate imaging:
  • Radiographs are appropriate for initial imaging 2
  • MRI without contrast is indicated when radiographs are normal or show joint effusion 2

Step 2: First-Line Treatment (Conservative Management)

For all medial meniscus injuries, begin with:

1. Structured Exercise Therapy/Physical Therapy 1

   • Range of motion exercises
   • Weight-bearing exercises
   • Low-impact aerobic activities
   • Quadriceps and hip girdle strengthening 2

2. Pain Management 1

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

3. RICE Protocol 3

   • Rest
   • Ice
   • Compression
   • Elevation

4. Adjunctive Therapies

   • Therapeutic ultrasound (shown to decrease pain and increase ROM) 3
   • Intra-articular corticosteroid injections for acute pain relief 1

Step 3: Evaluation of Conservative Treatment (after 6-8 weeks)

If symptoms persist after 6-8 weeks of conservative management, evaluate for:

• Persistent pain
• Functional limitations
• True mechanical symptoms (especially locked knee)
• Impact on quality of life

Step 4: Surgical Intervention (if conservative management fails)

1. Meniscal Repair (preferred when possible) 1

   • Best for:
     • Younger patients
     • Peripheral tears (vascular zone)
     • Horizontal or longitudinal tears
     • Reducible tears
   • Has 80% success rate at 2 years

2. Arthroscopic Partial Meniscectomy 1, 4

   • Consider for:
     • Non-repairable tears
     • Central (avascular) tears
     • Complex, degenerative tears that failed conservative management
     • Bucket handle tears causing mechanical symptoms 4

Evidence-Based Considerations

Efficacy of Conservative vs. Surgical Treatment

• Evidence from BMJ review shows that meniscal repairs have better long-term outcomes, better activity levels, and lower failure rates than meniscectomy 2
• For degenerative meniscal tears, particularly in middle-aged patients, arthroscopic partial meniscectomy provided no clinically relevant difference in outcomes compared to supervised exercise programs 2
• Surgical treatment should not be considered the first-line intervention for patients with knee pain and meniscal tear 2

Special Considerations

• The medial meniscus is more vulnerable to injury due to its attachment to the medial collateral ligament 5
• Older patients may present without a specific mechanism of injury as their meniscal injuries are often degenerative 5
• Peripheral, well-vascularized tears may be more prone to healing with nonsurgical management 5

Post-Surgical Rehabilitation

• Crucial for optimal outcomes, particularly following meniscal repair 1
• May include bracing and non-weight bearing for 4-6 weeks after repair 1
• Focus on functional retraining and sport-specific activities in later phases 5

Pitfalls and Caveats

1. Avoid premature surgical intervention before adequate trial of conservative management (minimum 6-8 weeks)
2. Don't overlook the importance of addressing underlying biomechanical issues and muscle imbalances
3. Consider the patient's age and activity level when deciding between repair and meniscectomy
4. Be aware that meniscectomy may lead to premature osteoarthritis if not properly indicated 5
5. Recognize that degenerative meniscal tears in older patients with osteoarthritis respond differently to treatment than traumatic tears in younger patients

By following this evidence-based approach, most patients with medial meniscus injuries can achieve significant improvement in pain and function while minimizing the risk of long-term complications.