What is the recommended treatment for injecting meniscal tears in a patient with a meniscal tear?

Treatment of Meniscal Tears with Injections

Direct Recommendation

For degenerative meniscal tears, intra- and perimeniscal corticosteroid injections combined with structured physiotherapy provide excellent surgery-free survivorship (83% at 5 years) and should be considered as first-line treatment before any surgical intervention. 1

Treatment Algorithm Based on Tear Type

For Degenerative Meniscal Tears (Age >35, No Major Trauma)

Primary approach: Combined injection therapy with structured physiotherapy

• Ultrasound-guided injection protocol consists of: 1.5 ml intra-meniscal triamcinolone, 1.5 ml in the meniscal wall, and 2 ml in the peri-meniscal space 1
• This approach achieves 83% surgery-free survivorship at 5 years and 52% second injection-free survivorship 1
• Significant improvements occur in pain (5.2 points), stiffness (2 points), and function (7.3 points) on WOMAC scores 1
• Average duration of pain relief from meniscus-targeted corticosteroid injections is 5.68 weeks, with substantial pain reduction (2.14 points on VAS) 2

Critical patient selection factors:

• Knee effusion before injection is an independent risk factor for treatment failure 1
• Advanced osteoarthritis (Kellgren-Lawrence >III) is associated with significantly poorer outcomes 1
• These patients should be counseled about potentially needing repeat injections or alternative treatments

When Injections Are NOT Appropriate

Arthroscopic surgery is strongly recommended AGAINST for degenerative meniscal tears 3, 4

• Less than 15% of patients experience small, temporary improvements at 3 months that completely disappear by 1 year 3, 4
• The BMJ guideline provides a strong recommendation against arthroscopy even when mechanical symptoms like clicking, catching, or "locking" are present 3
• Recovery burden includes 2-6 weeks of limited function, inability to bear full weight for up to 7 days, and minimum 1-2 weeks off work 3

For Traumatic Meniscal Tears (Acute Injury, Younger Patients)

Injections are NOT the primary treatment

• Traumatic tears, particularly bucket-handle tears causing true mechanical locking (objective inability to fully extend the knee), require arthroscopic surgery as first-line treatment 5, 6
• These tears risk cartilage damage if treatment is delayed 5
• Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time 7
• Repair shows 80% success at 2 years for peripheral, reducible tears that are horizontal or longitudinal in nature 8

Key Clinical Distinctions

Differentiating degenerative from traumatic tears:

• Degenerative: Age >35 years, insidious onset without major trauma, imaging evidence of osteoarthritis 5
• Traumatic: Acute onset after significant knee trauma, bucket-handle tear pattern, younger patient age, true mechanical locking 5

Physical examination findings to assess:

• Joint line tenderness, knee effusion, McMurray test, Apley test, and "bounce home" maneuver 6
• Limited range of motion, particularly objective inability to fully extend the knee (true locked knee) 3, 6
• Presence of effusion is particularly important as it predicts poorer outcomes with injection therapy 1

Common Pitfalls to Avoid

Do not rush to surgery based on MRI findings alone 4, 5

• Meniscal tears are common incidental findings in 60% of middle-aged and older patients that do not correlate with symptoms 3
• Degenerative tears are unlikely to be the actual cause of knee pain, aching, or stiffness 3

Do not interpret clicking, catching, or intermittent "locking" as surgical indications 4, 6

• These mechanical symptoms respond equally well to conservative treatment including injections 4
• Only objective inability to fully extend the knee (true locked knee) represents a clear indication for arthroscopy 6

Do not use standard intra-articular injections instead of meniscus-targeted injections 2

• Standard intra-articular corticosteroid injections produce short-lasting results (average 4 weeks) 2
• Meniscus-targeted injections provide longer duration of relief (5.68 weeks average) 2

Expected Outcomes and Patient Counseling

For injection therapy:

• Patients should expect average pain relief duration of 5-6 weeks 2
• Approximately half of patients will require a second injection within 5 years 1
• 83% of patients avoid surgery at 5 years with this approach 1
• Patients with knee effusion or advanced osteoarthritis should be counseled about potentially less favorable outcomes 1

Natural history of degenerative knee disease:

• Degenerative knee disease is a chronic condition where symptoms fluctuate 3
• Pain tends to improve over time after seeing a physician, even without intervention 3, 4