What is the recommended treatment for meniscal pain?

Recommended Treatment for Meniscal Pain

Conservative management with exercise therapy is the first-line treatment for meniscal pain in most patients, particularly those over 35 years old with degenerative tears, and arthroscopic surgery should be avoided as it provides no meaningful long-term benefit over conservative treatment. 1

Treatment Algorithm Based on Patient Characteristics

For Degenerative Meniscal Tears (Age >35 years)

Conservative management is strongly recommended and should NOT proceed to surgery even if mechanical symptoms like clicking or locking are present. 1, 2

Initial Conservative Treatment (First 3-6 months):

• Exercise therapy focusing on quadriceps and hamstring strengthening 3, 4
• Weight loss if patient is overweight (can significantly reduce pain and improve function) 2, 4
• NSAIDs (oral or topical) for pain management 3, 4
• Patient education and self-management programs 4
• Physical therapy for 4-6 weeks minimum 4

If Inadequate Response After 3 Months:

• Consider intra-articular corticosteroid injections 2
• Continue exercise therapy and activity modification 3

Surgery is NOT Recommended:

• Arthroscopic partial meniscectomy provides no clinically meaningful improvement in long-term pain or function compared to conservative treatment 1
• Even the presence of mechanical symptoms (catching, locking, clicking) does NOT justify surgery for degenerative tears 1, 2
• Small improvements at 3 months post-surgery are not sustained at 1 year 5

For Traumatic Meniscal Tears (Age <40 years)

The treatment approach differs significantly from degenerative tears and depends on the specific tear pattern. 3

Bucket-Handle Tears or Displaced Tears Causing True Mechanical Locking:

• Arthroscopic surgery is recommended as first-line treatment 3, 4
• These tears typically require surgical intervention because they cause genuine mechanical obstruction 3
• Meniscal repair is superior to partial meniscectomy when feasible (better functional outcomes and less degenerative changes over time) 6
• Recovery typically takes 2-6 weeks with 1-2 weeks off work 1, 3

Post-Surgical Rehabilitation:

• Early mobilization to reduce pain and improve function 3
• Structured physical therapy with quadriceps and hamstring strengthening 3
• Avoid complete immobilization to prevent muscular atrophy 3
• Cryotherapy (ice through wet towel for 10-minute periods) for pain and swelling 3

Non-Displaced Traumatic Tears Without True Locking:

• Trial of conservative management with exercise therapy for 4-6 weeks 4
• Surgery only if conservative treatment fails 2

Key Distinguishing Features

Degenerative vs. Traumatic Tears:

• Degenerative tears occur in patients >35 years, often without specific trauma, and are associated with early osteoarthritis 4, 7
• Traumatic tears occur in younger patients (<40 years) following acute injury with twisting mechanism 4, 8
• This distinction is critical as treatment recommendations are completely different 3

True Mechanical Locking vs. Pseudo-Locking:

• True locking means persistent objective inability to fully extend the knee due to displaced meniscal tissue blocking motion 3
• Pseudo-locking (catching, clicking, intermittent symptoms) does NOT require surgery even in degenerative tears 1, 2

Common Pitfalls to Avoid

• Do not treat all meniscal tears the same way regardless of patient age and tear pattern 3, 2
• Do not assume guidelines for degenerative tears apply to traumatic bucket-handle tears 3
• Do not rush to surgery without adequate trial of conservative management (minimum 4-6 weeks) 2, 4
• Do not assume mechanical symptoms automatically require surgical intervention in degenerative tears 1, 2
• Delaying treatment for true locked knees can lead to cartilage damage 3

Evidence Quality and Strength

The recommendation against arthroscopic surgery for degenerative meniscal tears is based on high-quality evidence from multiple randomized controlled trials showing no clinically meaningful difference between surgery and exercise therapy 1. The BMJ clinical practice guideline panel was confident that arthroscopic knee surgery does not result in improvement in long-term pain or function for degenerative disease 1. This represents a strong recommendation supported by the American Academy of Orthopaedic Surgeons and British Medical Journal guidelines 1, 2, 5.

For traumatic tears, particularly bucket-handle tears, the evidence supporting surgical intervention is based on the mechanical nature of the obstruction and the risk of cartilage damage from delayed treatment, though direct comparative trials are limited 3, 4.