What is the initial treatment for a patient with a tear of the lateral meniscus?

Initial Treatment for Lateral Meniscus Tear

Conservative management with structured physical therapy and exercise therapy should be the first-line treatment for most lateral meniscus tears, particularly degenerative tears in patients over 35 years old, with surgery reserved only for truly obstructing displaced tears causing objective mechanical locking after failed conservative treatment. 1

Treatment Algorithm Based on Patient and Tear Characteristics

For Degenerative Tears (Age >35 years)

• Begin with conservative management for at least 3-6 months before considering any surgical intervention 1
• Structured physical therapy focusing on quadriceps and hamstring strengthening exercises 2
• Activity modification to reduce mechanical stress on the knee 1
• Weight loss for overweight patients, which can significantly reduce knee pain and improve function 1
• NSAIDs and cryotherapy (ice through wet towel for 10-minute periods) for pain and swelling control 2

Critical distinction: Do NOT rush to arthroscopic surgery based on MRI findings alone, as degenerative meniscal tears are common incidental findings in middle-aged and older patients that do not correlate with symptoms 1. The British Medical Journal explicitly recommends against arthroscopic knee surgery in patients with degenerative knee disease, even when mechanical symptoms like clicking, catching, or "locking" are present 1.

For Traumatic Tears in Young/Active Patients

• Always evaluate for concurrent ACL injury first, as meniscal tears are typically a consequence rather than cause of knee instability 2
• MRI is the gold standard with 96% sensitivity and 97% specificity for diagnosing meniscal tears and concurrent ligamentous injuries 3, 2
• If ACL deficiency is present, address the ligamentous instability first or concurrently, as ACL-deficient knees have significantly elevated risk of subsequent meniscal damage 2

For acute traumatic lateral meniscus tears in active adults without degenerative changes, surgical repair may be considered earlier, particularly for lateral meniscus oblique radial tears (LMORT) associated with ACL injuries 4.

When Surgery Should Be Considered

Surgery is only appropriate for a small subset of patients with truly obstructing displaced meniscus tears causing objective mechanical locking (inability to fully extend the knee) 1. This means:

• True mechanical obstruction preventing full knee extension, NOT clicking, catching, or intermittent "locking" sensations 1
• Failure of adequate conservative treatment trial (3-6 months minimum) 1
• Younger, active patients with acute traumatic tears in the vascular zone where repair is technically feasible 5

Common Pitfalls to Avoid

• Do NOT interpret clicking, catching, or intermittent "locking" sensations as indication for surgery—these mechanical symptoms respond equally well to conservative treatment 1
• Do NOT assume all MRI-documented tears require surgical intervention—less than 15% of patients experience small, temporary improvements at 3 months that completely disappear by 1 year after arthroscopic surgery 1
• Do NOT proceed with isolated meniscal surgery without evaluating for ACL injury, as this represents the underlying instability pattern 2

Expected Outcomes with Conservative Management

• Pain tends to improve over time after initiating conservative treatment, as symptoms naturally fluctuate 1
• Physical therapy and exercise programs are effective for managing symptoms and improving function 1
• If intra-articular corticosteroid injections are needed, consider them only after inadequate response following 3 months of conservative management 1

Recovery Timeline if Surgery Performed

• Initial recovery from arthroscopic procedures takes 2-6 weeks 1
• At least 1-2 weeks off work is required, depending on job demands 1
• Weight-bearing restrictions for 2-7 days, return to sedentary work within 1-2 weeks, and return to physical labor/sports at minimum 6 weeks 2
• Early mobilization to reduce pain and improve function—avoid complete immobilization to prevent muscular atrophy 2