What is the appropriate initial treatment for a 51‑year‑old man with a 5‑day history of right‑knee pain, swelling, sharp pain on rotation and a positive McMurray test?

Initial Treatment for Suspected Meniscal Tear

Begin conservative management immediately with structured physical therapy, activity modification, and acetaminophen for pain control—surgery is not indicated as first-line treatment for this presentation. 1, 2, 3

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with appropriate imaging:

• Obtain plain radiographs first (anteroposterior, lateral, sunrise/Merchant, and tunnel views) to exclude fracture, loose bodies, or other bony pathology that would change management 4
• Order MRI if radiographs are normal and symptoms persist, as MRI is necessary to characterize the meniscal tear type, location, and associated injuries 4, 1
• The combination of joint line tenderness (83% sensitivity, 83% specificity) and positive McMurray test (61% sensitivity, 84% specificity) strongly suggests meniscal injury, but imaging confirmation guides treatment decisions 1, 5

First-Line Conservative Management (4-6 Weeks Minimum)

Non-operative treatment should be the initial approach for all meniscal tears except severe traumatic bucket-handle tears with displaced tissue: 1, 2, 3

Pain Management

• Start with acetaminophen up to 4 grams daily as the safest first-line analgesic 6, 7
• Oral NSAIDs are appropriate if acetaminophen is insufficient and not contraindicated 7, 1
• Avoid opioids entirely—they are not indicated for meniscal injury management 4, 6

Physical Therapy Protocol

• Initiate structured, supervised physical therapy immediately focusing on quadriceps strengthening, range of motion restoration, and functional retraining 8, 1, 3
• Include tri-planar functional exercises progressing to sport-specific or work-specific activities 8, 3
• Non-weight bearing or bracing is NOT required for most meniscal tears unless there is a locked knee or inability to bear weight 3

Activity Modification

• Relative rest with controlled movement—complete immobilization is counterproductive 6, 1
• Ice application after activity for symptom control 6
• Gradual return to activities as symptoms improve 1, 3

When Surgery May Be Considered

Surgical referral is appropriate only after 4-6 weeks of failed conservative management OR in specific acute scenarios: 1, 2, 3

Immediate Surgical Indications (Rare)

• Bucket-handle tears with displaced meniscal tissue causing true mechanical locking (inability to fully extend the knee) 1, 2
• Traumatic tears in young patients (<40 years) in vascularized zones amenable to repair 8, 2, 3

Delayed Surgical Consideration

• Persistent symptoms after 4-6 weeks of structured physical therapy 1, 3
• Important caveat: "Mechanical symptoms" (clicking, catching, popping) are NOT indications for surgery in degenerative tears—these symptoms often resolve with conservative treatment 1, 2

Critical Pitfalls to Avoid

• Do not rush to surgery based on MRI findings alone—degenerative meniscal lesions are present in 12% of adults and are often asymptomatic 1, 2
• Do not assume mechanical symptoms require surgery—8 recent randomized trials showed arthroscopic meniscectomy was non-superior to conservative treatment for degenerative tears 2
• Do not skip the 4-6 week conservative trial—patients who initially receive physical therapy achieve similar functional outcomes even if they later require surgery 3
• At age 51, this patient's tear is likely degenerative rather than acute traumatic, making conservative management even more appropriate 1, 2

Expected Outcomes

• Most patients achieve significant functional improvement with conservative management alone 1, 2, 3
• Meniscal repair (when indicated) shows 80% success at 2 years, but requires careful patient selection and 4-6 weeks of protected rehabilitation 3
• Meniscectomy should be avoided when possible, as it leads to premature osteoarthritis even when the peripheral rim is preserved 8, 2