What are the treatment options for a medial meniscus tear?

Treatment Options for Medial Meniscus Tear

Conservative management with physical therapy and NSAIDs should be the first-line treatment for most medial meniscus tears, particularly degenerative tears in patients over 35 years old, with surgery reserved only for cases that fail at least 3 months of conservative treatment or for young patients with acute traumatic tears causing true mechanical locking. 1

Initial Treatment Decision Algorithm

Patient Age and Tear Type Assessment

• Patients over 35 years with degenerative tears: Start with conservative management as recommended by the American Academy of Orthopaedic Surgeons 1
• Young patients with acute traumatic tears: Consider earlier surgical intervention, particularly if mechanical symptoms are present 2, 3
• Degenerative tears are common and often asymptomatic in patients over 35, frequently associated with early-stage knee osteoarthritis 4

Mechanical Symptoms Evaluation

• True mechanical locking (objective locked knee): May warrant surgical consideration even with conservative treatment 3
• Catching or clicking without true locking: Does NOT require surgery and should be managed conservatively 1
• A common pitfall is assuming all mechanical symptoms require surgical intervention, which is incorrect 1, 3

Conservative Management Protocol

Core Treatment Components

• Structured physical therapy program focusing on quadriceps and hamstring strengthening exercises 2, 3
• NSAIDs (oral or topical) for pain management, with topical formulations preferred to avoid gastrointestinal side effects 3
• Cryotherapy applied through a wet towel for 10-minute periods to reduce pain and swelling 2, 3
• Activity modification as needed 1
• Weight loss for overweight patients, which can significantly reduce knee pain and improve function 1

Critical Management Principles

• Avoid complete immobilization to prevent muscular atrophy and deconditioning 2, 3
• Continue conservative treatment for at least 3 months before considering surgical options 3
• Early mobilization is recommended to reduce pain and improve function 2

Advanced Conservative Options

• Intra-articular corticosteroid injections may be considered if inadequate response after 3 months of conservative management 1
• Combined intra- and perimeniscal corticosteroid injections with structured physiotherapy show 83% surgery-free survivorship at 5 years for degenerative medial meniscus tears 5
• Knee effusion and advanced osteoarthritis (Kellgren-Lawrence > III) are associated with poorer outcomes from injection therapy 5

Surgical Management

Indications for Surgery

• Failure of comprehensive conservative treatment lasting at least 3 months 3
• Persistent objective locked knee (true mechanical locking) 3
• Young patients with acute traumatic tears rather than degenerative tears 3
• The British Medical Journal explicitly states that arthroscopic surgery is NOT recommended for degenerative meniscal tears, even with mechanical symptoms like catching or locking 1

Surgical Options

• Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time 6
• Partial meniscectomy involves removal of the damaged portion, ranging from minor trimming to removal from the meniscocapsular junction 2, 7
• Surgical decision-making requires thorough understanding of vascular zones and biomechanical classifications of meniscal tears 6

Recovery Timeline

• Recovery from arthroscopic procedures typically takes 2-6 weeks 2, 1, 3
• At least 1-2 weeks off work is usually required, depending on job demands 2, 1, 3

Common Pitfalls to Avoid

• Rushing to surgery without adequate trial of conservative management is the most common error 1, 3
• Treating all meniscal tears the same way regardless of tear pattern or patient characteristics 2
• Assuming guidelines for degenerative meniscal tears apply to traumatic tears 2
• Delaying treatment for truly locked knees can lead to cartilage damage 2
• Overlooking concurrent pathology such as quadriceps tendinosis, which requires specific eccentric strengthening exercises 3

Special Populations

Degenerative Tears in Older Patients

• Conservative management is highly effective, with most patients experiencing symptomatic relief and functional improvements 8
• Non-operative treatment provides pain reduction within 3 months for most patients 8
• When surgery is contraindicated due to medical comorbidities, conservative management is appropriate 2

Younger Patients with Traumatic Tears

• More likely to benefit from surgical repair, especially with good blood supply to the meniscus 2
• Bucket handle tears typically require surgical intervention due to mechanical symptoms 2