What is the recommended management for a meniscal tear causing knee pain?

Management of Meniscal Tears

For patients with degenerative meniscal tears (age >35 years), conservative management with structured physical therapy and exercise is the definitive first-line treatment, and arthroscopic surgery should be avoided entirely as it provides no clinically meaningful benefit over non-operative treatment. 1

Treatment Algorithm Based on Tear Type

Degenerative Meniscal Tears (Age >35 Years)

The BMJ clinical practice guideline explicitly recommends AGAINST arthroscopic knee surgery in patients with degenerative knee disease, even when mechanical symptoms like clicking, catching, or "locking" are present. 1

First-Line Conservative Management:

• Structured physical therapy focusing on quadriceps and hamstring strengthening is the cornerstone of treatment 2
• NSAIDs (oral or topical) for pain relief, with topical formulations preferred to avoid gastrointestinal side effects 3
• Weight loss for overweight patients, which significantly reduces knee pain and improves function 2
• Activity modification to reduce mechanical stress on the knee 2
• Continue conservative management for at least 3-6 months before considering any alternative 2

Additional Options if Inadequate Response:

• Intra-articular corticosteroid injections may be considered after 3 months of failed conservative management 2

Why Surgery Fails in Degenerative Tears:

• Less than 15% of patients experience small, temporary improvements at 3 months that completely disappear by 1 year 2
• No meaningful long-term benefit for pain or function compared to conservative treatment 1
• Surgery subjects patients to 2-6 weeks recovery, 1-2 weeks off work, plus risks of anesthetic complications, infection, and thrombophlebitis 1

Traumatic Meniscal Tears (Younger Patients, Acute Injury)

For acute traumatic tears, particularly bucket-handle tears causing true mechanical locking (inability to fully extend the knee), arthroscopic surgery is first-line treatment. 4

Indications for Surgery in Traumatic Tears:

• Acute onset after significant knee trauma with bucket-handle tear pattern 4
• True mechanical locking (persistent objective inability to fully extend the knee, not just clicking or catching sensations) 2, 4
• Younger patient age without degenerative changes 4
• Associated ACL injuries 4

Surgical Approach:

• Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time 5, 6
• Recovery typically requires 2-6 weeks with at least 1-2 weeks off work depending on job demands 4
• Post-surgical rehabilitation includes early mobilization and structured physical therapy 4

Critical Distinctions to Guide Treatment

What Qualifies as "Degenerative" vs "Traumatic":

Degenerative tears include patients with: 1

• Age >35 years
• Insidious onset without major trauma
• Imaging evidence of osteoarthritis
• Complex tear patterns with fraying
• Clicking, catching, or intermittent "locking" sensations (these are NOT indications for surgery)

Traumatic tears include: 4

• Acute onset after significant knee trauma with acute joint swelling
• Bucket-handle tear pattern
• True mechanical locking (objective inability to fully extend)
• Younger patients without degenerative changes

Common Pitfalls to Avoid

• Do NOT rush to surgery based on MRI findings alone - meniscal tears are common incidental findings in middle-aged and older patients that do not correlate with symptoms 2, 4
• Do NOT interpret clicking, catching, or intermittent "locking" sensations as indications for surgery - these mechanical symptoms respond equally well to conservative treatment in degenerative tears 1, 2
• Do NOT assume all meniscal tears require the same treatment - the distinction between degenerative and traumatic tears is critical 4
• Do NOT overlook associated conditions like quadriceps tendinosis, which requires specific eccentric strengthening exercises 3
• Do NOT delay treatment for true locked knees (traumatic tears with objective mechanical locking), as this can lead to cartilage damage 4

Special Considerations

Peripheral Stable Tears During ACL Reconstruction:

• Conservative approach (leaving tear in situ) is more effective for lateral menisci (55-74% complete healing) 7
• For medial meniscus peripheral tears, repair may be indicated to decrease risk of postoperative pain or subsequent meniscectomy 7

When Conservative Management Fails:

• Only consider surgery after comprehensive conservative treatment lasting at least 3-6 months 2, 3
• Even then, surgery is only appropriate for younger patients with truly traumatic tears, not degenerative disease 2, 4
• Knee replacement is the only definitive therapy for severe degenerative disease after non-operative management has been unsuccessful 1