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LOGINKeep Calm and Treat Meniscus Tears Without Surgery
Improveby Kieran Richardson
Meniscus tears continue to be at the centre of surgical vs. non-surgical management. Kieran Richardson discusses how conservative management can be as effective as surgery without the risks.
Seattle Sounders FC forward Osage De Rosario collides with Houston Dynamo FC midfielder Toyosi Olusanya in the second half at Shell Energy Stadium. Mandatory Credit: Thomas Shea-Imagn Images
It started with a simple twist. A casual walk through the bush, a misstep on uneven ground, and a sudden, sharp pain in the knee. Within 48 hours, sitting across from a surgeon being told that there is a torn meniscus and that it needs surgery, urgently. The escalation from a mild discomfort to invasive procedures is painted as the only choice. But something doesn’t sit right. Surely, there had to be a pause, a moment to breathe, gather information, and think slowly. That’s where this article begins: not in the operating room, but in the space between pain and decision-making, where evidence, reflection, and a different path await.
This all-too-common story takes place every day in Australia and around the world, with patients essentially confronted with a fork-in-the-road scenario. They are forced, as professor emeritus of psychology Daniel Kahneman coined, to either “think fast or think slow.” Thinking fast and superficially, this makes sense: there is a tear on the scan, you have pain, a healthcare professional is telling you that these are your options, and you don’t want the pain or your life to get worse.
However, when athletes are given the time and space to consider their options, they can think slowly and consider their options. This includes an analysis of their biopsychosocial contexts to determine their optimal solution. They can ask the following questions to guide their decision-making:
- Are there other options than surgery?
- Do I have to make the decision now?
- Could this get better in time with physiotherapy on its own, without surgery?
- Could I get a second opinion?
- What do the best clinical trials show?
- What are the risks, harms, and benefits of having surgery versus not having surgery and trying something less invasive?
- What happens if the surgery fails?
- What will this cost me?
In Westernized healthcare, there is a clash between many of the established systems and pathways to treat a meniscus tear and what the current highest-quality evidence is showing. Many current care models were established around 50 years ago, before the concept of ‘evidence-based medicine’ emerged, i.e., before a drug treatment can be given to human populations, it needs to be tested against a placebo control or a non-drug comparison in a randomised controlled clinical trial (RCT)(1).
“Physiotherapy can be just as effective as surgery without the risks.”
Since the 1970s, surgical techniques like meniscal repair (stitching the meniscus) and meniscectomy (cutting away part or all of the meniscus) have been funded and implemented across the globe without the same rigour of testing against placebo/pretend surgery or high-quality rehabilitation in clinical trials(2). This means that despite millions of patients undertaking them, clinicians simply did not know whether the procedures were necessary or whether patients could have been successfully treated with physiotherapy and exercise rehabilitation without surgery.
Mensicectomy is still performed on 100,000s of patients per year, despite calls to cease the procedure, with some research surgeons calling into question the credibility of the profession and rising public distrust for not doing so(3-8). From a surgical training, opinion, and real-world point of view, meniscus repair has overtaken meniscectomy as the ‘superior option’ for managing a meniscus tear. Recently, there has been a 258% increase in arthroscopic meniscal repairs within the Australian healthcare system(9).
Meniscus tears typically occur in one of three ways:
- As a process of aging over time without incident,
- After a specific incident, typically twisting,
- In combination with another injured part of the knee (e.g., ACL injury).
Treating Meniscal Tears
In the 2000s, when meniscectomy was first tested against sham surgery and physiotherapy for older patients, there were no significant or clinically important differences between the arthroscopic and nonoperative groups concerning functional improvement or pain relief over two years(10,11). Furthermore, the surgery may be harmful as shaving away the meniscus increases osteoarthritis (OA) and speeds up a patient’s trajectory towards a total knee replacement(12-15).
Researchers at the Erasmus MC University Medical Centre in the Netherlands have conducted the only RCT to compare meniscus repair surgery to physiotherapy for traumatic tears. Their results showed no differences between these treatment options, with only 26% of patients crossing over to surgery at long-term follow-up(16). Furthermore, they showed no effect of meniscus repair on OA rates, debunking the dogma that early surgery for meniscus tears prevents structural knee damage in young active patients(17,18).
As far back as 1994, Japanese researchers demonstrated that a bracing and exercise protocol has healing possibilities(19). Their study evaluated the natural healing of acute meniscus tears with concurrent cruciate ligament injuries in 32 patients treated nonoperatively. It included 30 lateral and 10 medial meniscus tears combined with 25 ACL and 7 PCL injuries, totaling 51 tear sites. The patients received protective mobilization and used a Kyuro knee brace to encourage healing. After three months, 69% of lateral menisci healed completely and 18% partially; 58% of medial menisci healed completely. Additionally, 20 of 25 ACLs and three of seven PCLs healed satisfactorily. The findings suggest that meniscal tears can heal without surgery, even with ligament injuries. Furthermore, treating ACL and meniscus tears conservatively with rehabilitation (three months) produces the best outcomes at five-year follow-up(20,21).
The Benefits of Conservative Treatment Include:
- Reducing joint effusion (swelling).
- Provision of pain-relieving strategies such as manual therapy, taping, and bracing.
- Restoring full joint range.
- Improves confidence in injured limb.
- Improving strength.
- Facilitating cellular tissue healing through physiological mechanical stress.
- Assessing whether the meniscus tear is symptomatic(22).
However, most surgeons are trained that “repairable” meniscus tears must be repaired, and will not repair them without reconstruction. However, when performed early, ACL surgery increases inflammatory markers, elevates the knee joint temperature, and causes additional post-traumatic OA due to the knee bone and joint drilling(23-25).
What makes this topic even more challenging is the realization that a similar tension exists between traditional orthopedic beliefs about how meniscus tears should behave and what the research evidence suggests, such as:
- Humans can have large meniscus tears without symptoms as we age(26,27),
- Mechanical symptoms like locking and catching shouldn’t be blamed on meniscus tears and may be related to knee problems like stiffness, tightness, and weakness instead(28),
- Orthopedic tests such as McMurray’s have been shown to have a poor correlation with meniscus tears(29),
- Exercise can treat symptoms like pain, clicking, and pseudo-locking(30).
“Clinicians must arm patients with the latest science on managing their meniscus tears…”
Where to now?
In the initial consultation, clinicians must include the third option of waiting, watching, and rehabilitating a meniscus. This would enable the majority of degenerative and acute traumatic tears to be managed by physiotherapy first, before considering anything invasive and costly.
For example, in Australia, if a patient injures their knee or develops pain over a few months without incident, Medicare will fund a GP consultation and an MRI scan, which increases surgery rates(31-33). However, no treatment codes support conservative initial management of acute knee pain.
However, forward-looking research is shifting to investigate biologic and material-based approaches that promote healing through enhanced cell activity, vascularization, matrix support, and inflammation control(34).
Clinical Implications
Surgical versus non-surgical discussions often become circular. Surgical proponents argue that certain meniscus tear types need surgery. At the same time, non-surgical advocates appeal to the lack of decent efficacy of any arthroscopic procedure compared to mock surgeries or high-quality rehabilitation.
A practical middle ground can be achieved through classic medical and healthcare management based on signs and symptoms. For example, if patients undergo physiotherapy and exercise and achieve full function without pain, they should continue without surgery. If they don’t achieve positive results after three months, they may consider surgery. Clinicians must take a patient-centric approach with simple questions like “How is your knee feeling?” demonstrating that the patients’ symptoms should dictate their management approach instead of their MRI findings.
Clinicians must arm patients with the latest science on managing their meniscus tears, unifying with like-minded clinicians without loaded conflicts of interest who prioritize the best studies, and communicate the options in balance. Hopefully, in the future, there will be better-quality evidence to predict which types of meniscus tears need which specific type of treatment in each age and activity-level cohort. Clinicians and patients must think slowly to thoroughly consider and analyze all the options to ensure an optimal solution that meets their needs.
Clinical Takeaways
- MRI findings don’t always equal symptoms.
- Physiotherapy can be just as effective as surgery without the risks.
- Meniscectomy may increase osteoarthritis risk.
- Thinking slow allows time for swelling to settle and strength to build.
- Evidence supports waiting and rehab first, especially for degenerative and isolated tears.
- Surgery is still an option, but not the only one.
References
- Manera M, Ceffalo N, Harris I. 2020 New World Podcast: Episode 7: Surgery…We have a problem…with Dr. Ian Harris. February 2020
- BMJ 2021; 374:n1511
- J Bone Joint Surg Am 2011;93:994-1000
- Knee Surg Sports Traumatol Arthrosc. 2022 Apr;30(4):1430-1435.
- Acta Orthop. 2016;87(1):2-4.
- Br J Sports Med. 2017;51(6):490-491.
- Osteo and Cartilage, vol. 31, no.5, pp. 554-556
- Hunter D, Järvinen T. Joint Action: Arthroscopy, past time to stop the harm with Prof Teppo Järvinen. Season 4, Ep.4 Monday, February 20, 2023
- MacKee, N. Knee arthroscopy: changing practice. Medical Journal Australia Issue 1/13 January 2020
- N Engl J Med 2002;347:81-88
- N Engl J Med 2008;359:1097-1107
- BMC Musculoskelet Disord. 2022 Jul 25;23(1):709
- Br J Sports Med. 2020;54(22):1332-1339.
- Am J Sports Med. 2013;41(10):2333-2339.
- Br J of Sports Med. 2022;56:870-876.
- NEJM Evid. 2022;1(2):EVIDoa2100038.
- Am J Sports Med. 2018;46(9):NP43-NP44.
- Br J Sports Med. 2023;57(24):1566-1572.
- Clin Orthop Relat Res. 1994;(307):146-154.
- BMJ. 2013;346:f232. Published 2013 Jan 24.
- Br J Sports Med. 2017;51(22):1622-1629.
- J Orthop Sports Phys Ther. 2010;40(11):705-721.
- J Exp Orthop. 2024 Sep 9;11(3):e70012.
- Osteoarthritis Cartilage. 2017;25(9):1443-1451.
- Osteoarthr Cartil Open. 2023;5(3):100366.
- Skeletal Radiol. 2020;49(7):1099-1107.
- Br J Sports Med. 2022;56(24):1393-1405.
- Br J Sports Med. 2018;52(9):557-565.
- J Orthop Sports Phys Ther. 2007;37(9):541-550.
- British Journal of Sports Medicine 2019;53:315-316.
- Br J Gen Pract 2007;57:622–9.
- Br J Sports Med. 2019;53(20):1285-1292.
- BMJ Open Quality 2021;10:e001287.
- Arthroscopy. 2019;35(12):3287-3288.
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