Nonoperative Treatment of Meniscus Tears
Non-operative treatment of a meniscus tear means managing the tear with exercise, activity changes, and treatment of any arthritis in the knee, without surgery. The meniscus is a C-shaped cushion of tough cartilage that sits between the thigh bone (femur) and the shin bone (tibia) on the inner (medial) and outer (lateral) sides of the knee. It spreads the load across the joint and protects the cartilage.
The reality is that most meniscus tears do not need surgery. Some tears are small and are not causing symptoms. Some are found in a knee with arthritis, where the treatment revolves around the arthritis and not the tear. And many are simply incidental findings on an MRI. In a large MRI study of adults over 50, about 60% of people with knee arthritis had a meniscus tear whether or not they had knee pain. I often talk patients out of surgery, because the meniscus is only to blame for symptoms in certain types of tears, usually a torn flap that has moved out of place.
I often have to unwind an MRI report in clinic. I go over the X-rays, the cartilage, and every other possible reason for the pain, and I share the studies showing that people whose knees do not hurt also have meniscus tears on MRI. What I tell patients is that I treat the patient, not the MRI. The goal is to find out why you are having symptoms, not to react to the word “tear” on a report. It is also why I often do not order an MRI when I already know the problem is arthritis: the report will come back showing a tear, and that only confuses the picture.
Video Education
Dr. Merritt has filmed an in-depth video on meniscus injuries and surgery. It explains the types of tears, which ones need surgery, and what to expect.
Which Meniscus Tears Do Not Need Surgery
Arthritic meniscus tears
The most common tear I see that does not need surgery is an arthritic meniscus tear, meaning a tear that shows up in a knee with arthritis. The meniscus lives in a space created by the cartilage. On a normal MRI, the meniscus is a wedge that fits into the gap between the rounded end of the thigh bone and the flat top of the shin bone, and on a normal X-ray you can see that space, where the meniscus lives.
With arthritis, the cartilage wears away and that space disappears, so there is no more room for the meniscus to live. The meniscus has to tear to get out of the way. A meniscus tear in this situation is not what is causing the symptoms. The problem is the arthritis, and treatment has to revolve around the arthritis.
Trimming out the torn meniscus in an arthritic knee does not treat the arthritis. In a large trial of patients with a meniscus tear and arthritis, people treated with physical therapy improved about as much as people who had arthroscopic surgery, and in a follow-up of the same patients, the knees that had surgery showed more worsening of their cartilage on MRI.
Radial and root tears
The other large group of tears I treat without surgery is radial tears. A radial tear runs straight across the meniscus and splits it into two halves, so the meniscus is separated and can no longer hold load like a hoop. In young patients these can sometimes be repaired, but in older patients they are often not repairable because the tissue does not generally heal even if sutured together. If a repair is not possible, removing more of the meniscus does not help either, because that only takes away the padding the knee has left. For this reason I do not recommend trimming (meniscectomy) for radial tears or root tears. A root tear, where the meniscus tears off its attachment at the back of the knee, can often be fixed, but if it is not fixed, I do not trim it out for the same reason. Taking more tissue out, when the issue is a lack of functional tissue, does not make sense and research clearly backs this up.
“Meniscal positive” versus “meniscal negative” symptoms
I often explain this to patients as “meniscal positive” versus “meniscal negative” symptoms.
Meniscal positive symptoms come from a torn piece of meniscus that is getting in the way. The meniscus itself has no pain fibers, so the tear does not cause pain directly. A tear causes pain only when a flap gets in the way of the knee’s normal motion or pushes against a part of the knee that does have nerves. These are the symptoms of catching, locking, or a sharp pain in one spot when the knee twists. The term meniscal positive comes from the fact that the tear is causing the pain.
Meniscal negative symptoms come from having too little working or functional meniscus. That can be because the meniscus was removed in an earlier surgery, or because a radial tear has disrupted how the meniscus works. Without enough meniscus, the cartilage takes more load, and the knee aches, swells, and wears out faster. The term meniscal negative comes from the fact that the pain and swelling is the result of having too little functional meniscus.
This difference guides treatment. Meniscal positive symptoms often respond well to surgery, because removing or repairing the flap removes the cause. Meniscal negative symptoms do not get better when more meniscus is trimmed out, because the problem is already that there is too little meniscus in the knee.
Treatment Options
For most meniscus tears, the first treatment is a focused exercise program. Strong thigh and hip muscles protect the knee and calm the pain, and for most wear-and-tear tears, exercise works as well as surgery. My meniscus tear home exercise program and physical therapy protocol focus on the stationary bike, getting the knee fully straight, and strengthening the quadriceps and hips.
In the meantime, cut back on deep squatting, twisting on a bent knee, and kneeling if they hurt. Walking, biking, and swimming are good for the knee.
The plan depends on the reason for your pain. If you have a meniscus tear in an otherwise good-looking knee and we are treating it without surgery, I usually start with about 6 weeks of physical therapy and the home exercise program. If the knee is still irritated after therapy and time, I sometimes calm it down with an injection, either PRP or cortisone.
If the real problem is arthritis, I aim the treatment at the arthritis instead of the meniscus tear: exercise, weight management, and injections with gel (hyaluronic acid), PRP, or cortisone. My non-operative knee arthritis guide goes through each option, including cortisone, gel, and PRP injections. For many patients, losing weight takes a meaningful load off the knee, and I wrote about the newer weight-loss medicines in this article on GLP-1 medicines and knee arthritis.
Meniscal negative knees are tricky. These knees hurt because there is not enough working meniscus left, and there are not always good options. I usually start by unloading the knee with a brace and calming it down with injections. In younger patients, a meniscus transplant or an alignment surgery that shifts weight off the worn side, a high tibial osteotomy (HTO) or distal femoral osteotomy (DFO), can be options. In older patients, we often manage the knee with injections, while recognizing that it is developing arthritis, and a knee replacement may eventually be the answer.
When surgery does help
Surgery makes sense when the meniscus itself is the problem. That usually means a meniscal positive tear: a flap or a bucket-handle tear that has flipped out of place and is catching or locking the knee.
If the meniscus is repairable, I generally aim to repair it, to save the tissue and the support it gives the cartilage in your knee. If it cannot be repaired but a large flap is causing mechanical symptoms, this is often an excellent situation for trimming out the loose piece (a meniscectomy). A degenerative tear without an unstable flap or mechanical symptoms is the one I usually try to treat without surgery. You can read more about why I save the meniscus whenever I can in this article on root and ramp tears.
Recovery and Results
Most people with a wear-and-tear meniscus tear improve with 6 to 12 weeks of a consistent exercise program. Do the exercises once a day, 5 days a week. Mild discomfort up to 3 out of 10 is okay during exercise, as long as it settles back to your usual level by the next morning.
In the trial of patients with a meniscus tear and arthritis, about 30% of those who started with physical therapy went on to have surgery within 6 months. Physical therapy first does not close the door on surgery if the knee does not improve. In a separate trial, patients with a degenerative meniscus tear who had a partial meniscectomy did no better at one year than patients who had a placebo (sham) surgery.
Of course, your symptoms can change and that can therefore change our plan of action. Call us if your knee locks and will not straighten, or if it keeps catching or giving way despite the exercises, since that can mean a flap is out of place.
Surgery & Physical Therapy Resources
Discover detailed instructions and protocols to guide patients through Pre-Op, Post-Op and Physical Therapy from Dr. Merritt.
Related Articles
Read more from Dr. Merritt about meniscus tears and when surgery helps.
Common Nonoperative Meniscus Tear Questions
FAQs
A: Usually not. Meniscus tears are very common on MRI, especially after age 50, and many people with a tear have no symptoms at all. The question is whether the tear is causing your symptoms. If you have catching or locking from a displaced flap, surgery can help. If the tear is part of arthritis, or it is a radial or root tear in an older knee, surgery usually does not help.
A: The inner part of the meniscus has very little blood supply, so most tears do not heal back together. That does not mean they keep hurting. Many tears settle down and stop causing symptoms as the swelling calms and the muscles get stronger.
A: A traumatic tear happens with a specific injury, often a twist, usually in a younger person, and may be repairable. A degenerative tear develops over time as the meniscus wears, often in a knee with early arthritis, and is usually treated without surgery.
A: The meniscus is the knee’s cushion. If the problem is too little working meniscus, as with a radial tear or after an earlier meniscectomy, removing more takes away the padding that is left and puts more load on the cartilage.
A: Mechanical symptoms are catching, locking, or a block to straightening the knee, caused by a piece of meniscus getting in the way. They are the best sign that a tear is causing symptoms and may benefit from surgery.
A: A tear that takes away meniscus function, such as a radial or root tear, can speed up wear of the cartilage over time. Strengthening, keeping a healthy weight, and repairing tears that can be repaired help protect the knee.
A: The stationary bike, the heel prop to get the knee fully straight, sit-to-stands, step-ups, side-lying hip raises, single-leg balance, and bridges are all part of my meniscus home exercise program. Avoid deep squats and twisting on a bent knee while the knee is sore.
A: A simple hinged knee brace does not do much for a meniscus tear. An unloader brace, though, can be very effective at calming down a knee with meniscal deficiency. It works best for meniscal negative symptoms when the pain is in one compartment (one side) of the knee, whether or not there is arthritis.
A: If the knee is still painful after 6 to 12 weeks of a consistent program, we take another look. That may mean a PRP or cortisone injection to calm the knee, injections aimed at the arthritis if that is the main problem, or surgery if there is a displaced flap causing mechanical symptoms.
Studies Cited
- Englund M, Guermazi A, Gale D, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. N Engl J Med. 2008. PubMed
- Katz JN, Brophy RH, Chaisson CE, et al. Surgery Versus Physical Therapy for a Meniscal Tear and Osteoarthritis. N Engl J Med. 2013. PubMed
- Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic Partial Meniscectomy Versus Sham Surgery for a Degenerative Meniscal Tear. N Engl J Med. 2013. PubMed
- Collins JE, Losina E, Marx RG, et al. Early Magnetic Resonance Imaging-Based Changes in Patients With Meniscal Tear and Osteoarthritis: Eighteen-Month Data From a Randomized Controlled Trial of Arthroscopic Partial Meniscectomy Versus Physical Therapy. Arthritis Care Res (Hoboken). 2020. PubMed
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