Initial Management of Posterior Horn Medial Meniscus Tear
Conservative management with structured physical therapy and exercise therapy is the recommended first-line treatment for posterior horn medial meniscus tears, and arthroscopic surgery should be avoided as it provides no meaningful long-term benefit over non-operative treatment. 1, 2
Treatment Algorithm
Step 1: Determine Tear Type and Patient Characteristics
Age and mechanism of injury are critical decision points:
- Patients >35 years old with degenerative tears (most common presentation for posterior horn tears): Begin conservative management immediately 1, 2
- Younger patients with acute traumatic tears causing true mechanical locking (displaced bucket-handle pattern): Consider surgical consultation, though this is rare for isolated posterior horn tears 3, 4
Step 2: Initial Conservative Management (First-Line for Most Patients)
Implement the following protocol for 3-6 months before considering any surgical intervention: 2
- Structured physical therapy focusing on quadriceps and hamstring strengthening exercises 2, 4
- NSAIDs (oral or topical) for pain management 3
- Activity modification to reduce mechanical stress 2
- Cryotherapy applied through wet towel for 10-minute periods to reduce pain and swelling 3
- Weight loss for overweight patients, which significantly reduces knee pain and improves function 2
Expected timeline: Most patients experience decreased pain severity and frequency within 3 months, with symptomatic relief and functional improvements sustained in the short-to-medium term 5
Step 3: If Inadequate Response After 3 Months
Consider intra-articular corticosteroid injection if conservative management fails to provide adequate relief 2, 6
- 82% of patients with degenerative posterior horn tears report symptom improvement following guided intra-articular steroid/bupivacaine injection 6
- 53% maintain sustained improvement at follow-up 6
- Patients with isolated tears (without additional degenerative changes) have 72% complete resolution rate 6
Critical Evidence Against Surgery
The BMJ clinical practice guideline explicitly recommends against arthroscopic knee surgery for degenerative meniscus tears, even when mechanical symptoms are present: 1
- Less than 15% of patients experience small, temporary improvements at 3 months that disappear by 1 year 1
- Arthroscopic surgery does not result in improvement in long-term pain or function compared to exercise therapy 1, 4
- Partial meniscectomy significantly increases stress in both medial and lateral compartments during dynamic activities, potentially aggravating joint degeneration 7
Common Pitfalls to Avoid
Do not rush to surgery based on MRI findings alone - posterior horn tears are common age-related findings that do not benefit from arthroscopic intervention 2
Do not interpret clicking, catching, or "locking" sensations as surgical indications - these mechanical symptoms respond equally well to conservative treatment and do not predict surgical benefit 2, 4
Do not assume all mechanical symptoms require surgery - true persistent objective locked knee (rare) differs from intermittent catching or pseudo-locking 1, 2
Special Considerations for Posterior Horn Tears
Clinical presentation typically includes: 8
- Discrete precipitating event (85% recall a click or shock sensation) 8
- Severe pain or giving way immediately after the event 8
- Hydrarthrosis >5ml present in 81% of cases 8
- Nearly normal radiographs in 92% of cases 8
Recovery expectations if surgery were performed (not recommended): 1, 2