Treatment of Meniscal Tears

For degenerative meniscal tears (patients >35 years), conservative management with structured physical therapy is the definitive first-line treatment, and arthroscopic surgery should be avoided entirely as it provides no clinically meaningful benefit over non-operative care. 1, 2

Primary approach: Conservative management only

Begin with structured physical therapy focusing on quadriceps and hamstring strengthening, combined with NSAIDs or topical analgesics 1, 2, 3
Continue conservative treatment for at least 3-6 months before considering any alternative 2
Add intra-articular corticosteroid injections if inadequate response after 3 months of therapy 2
Weight loss is essential for overweight patients and significantly reduces pain and improves function 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
Arthroscopic surgery provides no long-term improvement in pain or functional scores compared to conservative management 2, 3
Surgery exposes patients to 2-6 weeks recovery, 1-2 weeks off work, plus risks of anesthetic complications, infection, and thrombophlebitis 1, 2, 4

Surgical intervention is appropriate for:

Bucket-handle tears causing true mechanical locking (objective inability to fully extend the knee) in younger patients 2, 5
Acute onset after significant knee trauma with hemarthrosis 1
Reducible tears that are peripheral (near capsular attachment) and horizontal or longitudinal in nature 6

Meniscal repair is superior to partial meniscectomy:

Shows 80% success at 2 years with better functional outcomes and less severe degenerative changes over time 6, 7
Requires careful patient selection: younger patients, good compliance, peripheral tears in vascular zones 6, 8
Post-operative rehabilitation involves bracing and non-weight bearing for 4-6 weeks 6

Degenerative tears are characterized by:

Age >35 years with insidious symptom onset without specific traumatic event 2, 5
Complex tear patterns with fraying and imaging evidence of osteoarthritis 2
Clicking, catching, or intermittent "locking" sensations (these are NOT indications for surgery) 1, 2

Traumatic tears are characterized by:

Do not base surgical decisions on MRI findings alone:

Meniscal tears are common incidental findings in middle-aged and older adults that do not correlate with symptoms 2
The presence of a tear on imaging does not indicate need for surgery in degenerative disease 1

Do not interpret mechanical symptoms as surgical indications in degenerative tears:

Clicking, catching, or intermittent "locking" respond equally well to conservative treatment 1, 2
Only true mechanical locking (persistent objective inability to fully extend the knee) warrants surgical consideration 2

Do not rush to surgery without adequate conservative trial:

Even if patients later require meniscectomy after conservative management, they achieve similar functional outcomes as if initially treated surgically 6
Surgery should only be considered after failure of proper 3-6 month trial of conservative management 1, 2

For severe degenerative disease unresponsive to all non-operative measures:

Total knee replacement is the only definitive therapy, reserved for severe disease after non-operative management has been unsuccessful 1, 2
Arthroscopic debridement or lavage has no significant benefit for knee osteoarthritis and subjects patients to increased risks 2

Conservative management:

Arthroscopic surgery (if performed for traumatic tears):

Recovery typically 2-6 weeks with at least 1-2 weeks off work 1, 2, 4
Sedentary jobs allow return within 1-2 weeks; physical labor requires at least 6 weeks 4
Early mobilization and structured physical therapy focusing on quadriceps and hamstring strengthening is essential post-operatively 5