What is the best course of action for a 32-year-old female with chronic right knee pain, weakness, locking, and a history of left knee meniscus tear and other internal derangements, who has not responded to conservative management?

Management of Right Knee Pain with Mechanical Symptoms

This patient requires immediate initiation of structured physical therapy for 3-6 months before considering any surgical intervention, as high-quality evidence demonstrates no benefit of arthroscopic surgery over conservative management for degenerative meniscal tears, even in the presence of mechanical symptoms like locking. 1

Critical Context: Discrepancy Between Clinical Documentation

There is a significant documentation inconsistency that must be addressed:

• The patient presents with right knee pain [@clinical info]
• All imaging and surgical procedures were performed on the left knee [@clinical info]
• This represents either a documentation error or the patient has bilateral knee pathology

Assuming the question addresses the symptomatic right knee (not the previously operated left knee), the following management algorithm applies:

Initial Diagnostic Workup

Imaging Protocol

• Start with plain radiographs (standing AP, lateral, and Merchant views) to rule out fractures, assess for degenerative changes, and evaluate joint space 1
• Proceed to MRI without contrast if pain persists after initial conservative treatment or if radiographs show joint effusion, as MRI has 96% sensitivity and 97% specificity for meniscal tears 1
• MRI is the gold standard for evaluating bone marrow contusions, meniscal tears (sensitivity 85-96%, specificity 89-97%), and ligamentous injuries (sensitivity 91-93%, specificity 88-96%) 2
• Either 1.5T or 3T MRI provides equivalent diagnostic accuracy for meniscal and ligament evaluation 2

First-Line Treatment: Conservative Management

Mandatory Conservative Trial (3-6 Months)

• Structured physical therapy and exercise therapy must be attempted for at least 3-6 months as the initial approach 1
• Patient education about the degenerative nature of meniscal pathology in the absence of acute trauma 1
• Activity modification to reduce mechanical stress 1
• NSAIDs and topical treatments 3
• Weight loss if overweight, as this decreases pain and improves function 3

Second-Line Conservative Options

• If inadequate response after 3 months, consider intra-articular corticosteroid injection 1
• Viscosupplementation and orthobiologics can be considered if osteoarthritis is present 3

When Surgery Should NOT Be Performed

Critical Evidence Against Arthroscopic Surgery:

• Do not perform arthroscopic partial meniscectomy for degenerative meniscal tears, even with mechanical symptoms such as catching or locking 1
• Multiple high-quality randomized controlled trials show no significant functional improvement between arthroscopic partial meniscectomy and physical therapy in middle-aged patients with degenerative tears 1
• The BMJ explicitly recommends against arthroscopic surgery for degenerative meniscal tears 1

Common Pitfalls to Avoid

• Do not rush to surgery based on MRI findings alone, as degenerative meniscal tears are common age-related findings that do not benefit from arthroscopic intervention 1
• Do not interpret clicking, catching, or "locking" sensations as surgical indications, as these mechanical symptoms respond equally well to conservative treatment 1
• When MRI shows grade 2/3 signal (equivocal findings) in the posterior horn of the medial meniscus that does not unequivocally extend to the joint surface, a meniscal tear is unlikely (only 10% arthroscopic confirmation rate), and conservative treatment is recommended 4

Rare Indications for Surgical Consideration

Surgery may be considered only after failed conservative management (minimum 3-6 months) AND one of the following:

• True mechanical locking (not pseudo-locking or catching sensations) with failure of nonoperative treatment 3
• Acute traumatic tear with clear evidence of trauma 3
• Persistent pain with documented failure of comprehensive nonoperative treatment 3

Special Considerations for This Patient

At age 32, this patient is relatively young, but the 8-month duration without acute injury suggests a degenerative rather than traumatic etiology 3. The fact that she has taken no medications and rates pain 8/10 indicates inadequate conservative management has been attempted [@clinical info]. She must complete a full trial of structured physical therapy, NSAIDs, and activity modification before any surgical intervention is considered [@4