What are the management options for a meniscus tear?

Management of Meniscus Tears

Conservative management with structured physical therapy is the first-line treatment for degenerative meniscus tears in patients over 35, while traumatic tears (especially bucket-handle tears) in younger patients require surgical intervention. 1, 2

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Treatment Algorithm Based on Tear Type and Patient Characteristics

For Degenerative Meniscus Tears (Age >35, Atraumatic Onset)

Do NOT perform arthroscopic surgery as first-line treatment - the BMJ clinical practice guideline provides a strong recommendation against arthroscopy for degenerative knee disease, even when mechanical symptoms like clicking, catching, or "locking" are present. 3, 1

Initial Conservative Management (3-6 months minimum):

• Structured physical therapy focusing on quadriceps and hamstring strengthening exercises 1, 4
• NSAIDs (oral or topical) for pain management 2, 4
• Weight loss for overweight patients - this significantly reduces knee pain and improves function 1
• Activity modification to reduce mechanical stress on the knee 1
• Cryotherapy applied through wet towel for 10-minute periods to reduce pain and swelling 2, 4

Why Surgery Fails in Degenerative Tears:

• Less than 15% of patients experience small, temporary improvements at 3 months that completely disappear by 1 year 3, 1
• No meaningful long-term benefit over conservative treatment for pain or function 1
• Recovery burden includes 2-6 weeks of limited function, inability to bear full weight for up to 7 days, and 1-2 weeks minimum off work 3, 1

If Conservative Management Fails After 3 Months:

• Consider intra-articular corticosteroid injections before proceeding to surgery 1
• Surgery may be considered only after documented failure of adequate conservative trial 1

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For Traumatic Meniscus Tears (Younger Patients, Acute Injury)

Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time. 5

Indications for Surgical Repair:

• Bucket-handle tears - these typically require surgical intervention as they cause true mechanical locking of the knee 2, 4
• Acute traumatic tears with clear evidence of sufficient trauma 6
• Reducible tears that are peripheral (near capsular attachment) and horizontal or longitudinal in nature 7
• True mechanical locking (not clicking or catching) where the knee cannot fully extend 3, 2

Surgical Decision-Making:

• Patient age matters - younger patients are more likely to benefit from repair 2, 5
• Tear location matters - peripheral tears in vascular zones have 80% success rates at 2 years 7
• Lateral meniscus tears show better prognosis than medial tears when left in situ if stable 8
• Timing matters - surgery should be performed as early as possible when repair is required 8

Surgical Options:

• Meniscal repair is preferred when feasible - preserves meniscal function and prevents early osteoarthritis 5, 8
• Partial meniscectomy only for symptomatic tears not amenable to repair, preserving the peripheral rim when possible 7, 6

Post-Surgical Rehabilitation:

• Early mobilization to reduce pain and improve function 2, 4
• Structured physical therapy with quadriceps and hamstring strengthening 2, 4
• Avoid complete immobilization to prevent muscular atrophy 2, 4
• Bracing and non-weight bearing for 4-6 weeks may be required depending on repair technique 7
• Recovery typically takes 2-6 weeks with at least 1-2 weeks off work 2, 4

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Critical Pitfalls to Avoid

• Do not rush to surgery based on MRI findings alone - degenerative meniscal tears are common incidental findings in middle-aged and older patients that do not correlate with symptoms 3, 1
• Do not assume clicking, catching, or intermittent "locking" sensations require surgery - these mechanical symptoms respond equally well to conservative treatment in degenerative tears 1
• Do not treat all meniscal tears the same way - traumatic bucket-handle tears in young patients require completely different management than degenerative tears in older patients 2, 4
• Do not delay treatment for truly locked knees - this can lead to cartilage damage 2
• Do not apply guidelines for degenerative tears to traumatic tears - the strong recommendation against arthroscopy for degenerative disease does not apply to young patients with acute traumatic bucket-handle tears 2, 4

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Special Considerations

When MRI is Indicated:

• MRI should be performed when arthroscopy is being considered to identify concomitant pathologies like ACL injuries 8
• The indication should be determined by a musculoskeletal specialist 8

Failed Repair Consequences:

• Failed meniscal repair can negatively impact patient outcomes 5
• Surgeons must thoroughly understand vascular zones and biomechanical classifications to determine appropriate treatment 5

Biological Enhancement:

• No evidence supports that needling or platelet-rich plasma application improves healing rates 8