What is the best approach for conservative management of a meniscus tear in a patient seeking non-surgical treatment?

Conservative Management of Meniscus Tears

Critical First Distinction: Degenerative vs. Traumatic Tears

For degenerative meniscus tears (patients >35 years with insidious onset), conservative management with structured physical therapy and exercise is the definitive first-line treatment and arthroscopic surgery should be avoided entirely, as high-quality evidence demonstrates no clinically meaningful benefit over conservative treatment. 1

The 2017 BMJ clinical practice guideline provides a strong recommendation against arthroscopic knee surgery for degenerative knee disease, even when mechanical symptoms like clicking, catching, or "locking" are present. 1 This applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset. 1

Key Evidence Against Surgery for Degenerative Tears

• Less than 15% of patients experience small, temporary improvements at 3 months after arthroscopic surgery that completely disappear by 1 year, with no meaningful long-term benefit for pain or function compared to conservative treatment. 2
• Surgery requires 2-6 weeks recovery, at least 1-2 weeks off work, and carries risks including anesthetic complications, infection, and thrombophlebitis. 1, 2
• Meniscal tears on MRI are common incidental findings in middle-aged and older patients that do not correlate with symptoms. 2

Conservative Treatment Protocol for Degenerative Tears

Core Components

Structured physical therapy and exercise therapy should be implemented for at least 3-6 months as the primary treatment. 3, 2

• Quadriceps and hamstring strengthening exercises are the foundation of the rehabilitation program. 4, 3
• Tri-planar functional retraining addressing range of motion, musculotendinous length, muscle strength, and neuromotor control in major muscle groups. 5, 6
• Early mobilization to reduce pain and improve function, avoiding complete immobilization to prevent muscular atrophy. 4, 3

Adjunctive Treatments

• NSAIDs (oral or topical) for pain management. 1, 4
• Weight loss for overweight patients, which can significantly reduce knee pain and improve function. 2
• Cryotherapy (ice) applied through a wet towel for 10-minute periods to reduce pain and swelling. 4
• Activity modification to reduce mechanical stress on the knee. 3, 2
• Intra-articular corticosteroid injections may be considered if inadequate response after 3 months of conservative management. 2

Special Consideration: Traumatic Tears in Younger Patients

For traumatic meniscus tears (particularly bucket-handle tears in younger patients with acute onset after significant knee trauma), arthroscopic surgery is first-line treatment because these differ fundamentally from degenerative tears. 4, 3

Distinguishing Features of Traumatic Tears

• Acute onset after significant knee trauma with joint swelling (hemarthrosis). 1, 3
• Bucket-handle tear pattern causing true mechanical locking (inability to fully extend the knee). 4, 3
• Younger patient age (typically <35 years). 3
• Often associated with ACL injuries. 4, 5

Why Surgery for Traumatic Tears

• Delaying treatment for true locked knees can lead to cartilage damage. 4, 3
• Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time. 7
• Peripheral, well-vascularized tears in the red zone have better healing potential with surgical repair. 5, 7

Critical Pitfalls to Avoid

• Do not treat all meniscal tears the same way regardless of tear pattern or patient characteristics. 4, 3
• Do not rush to surgery based on MRI findings alone in patients >35 years, as degenerative changes are common age-related findings that do not benefit from surgery. 3, 2
• Do not assume clicking, catching, or intermittent "locking" sensations require surgery for degenerative tears, as these mechanical symptoms respond equally well to conservative treatment. 2
• Do not assume guidelines for degenerative meniscal tears apply to traumatic bucket-handle tears. 4, 3

Expected Outcomes with Conservative Management

• Pain tends to improve over time in degenerative knee disease, as symptoms naturally fluctuate in this chronic condition. 2
• Conservative management provides no recovery time and allows continuation of work with only time off for appointments. 1
• The minimally important difference scores for meaningful improvement are 12 points for pain and 8 points for function. 1