Posts tagged meniscal tear
Physical Therapy Supported As First Line Treatment For Meniscal Tears

Meniscal tears are a common knee diagnosis and can occur either traumatically or gradually over time. This latter type of meniscal tear, degenerative, was previously treated with arthroscopic surgery and post operative physical therapy but more recent research has changed our practice patterns with this patient population. Specifically, research shows no benefit of surgery over placebo surgery or surgery over conservative care including Physical Therapy. The equivalent outcomes of arthroscopic surgery and Physical Therapy has let many medical groups to advocate against the use of surgery for this condition.

A recent article in the Journal of the American Medical Association supports these previous findings on the management of patients with meniscal tears (van de Graaf et al. 2018). Three hundred twenty one (321) patients were randomized to either a knee arthroscopic menisectomy (meniscal tear removal) or Physical Therapy consisting of 16 sessions over 8 weeks. These sessions primarily consisted of strengthening exercises of the lower quarter. Authors found Physical Therapy was equivalent to surgery for improving knee function at 2 year follow up and stated Physical Therapy may be considered as an alternate to surgery for patients with meniscal tears. Although some patients may eventually require surgery the vast majority of patients will benefit from Physical Therapy first for their meniscal tears.

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Physical Therapy versus Surgery for Meniscal Tears

In our previous blog posts we have written on the inability of arthroscopic surgery to outperform Physical Therapy or placebo surgery for the treatment of degenerative meniscal tears.  A recent review and statement paper was released in the British Journal of Sports Medicine highlighting evidence regarding the management of meniscal tears (Thorlund et al. 2018). 

The authors highlighted the trials comparing surgery to Physical Therapy and reported exercise interventions improved pain and function to the same extent as surgery.  As expected, greater strength gains were found among the exercise therapy vs. surgical groups.  In addition, the authors found no clinically relevant effect of surgery in addition to exercise therapy on pain or functional outcomes for degenerative meniscal tears.  To date, no randomized trials have been performed including patients under 40 or including patients with traumatic meniscal tears.  

The authors concluded Physical Therapy should be recommend as the treatment of choice for middle aged and older patients with degenerative meniscal tears.  To schedule your first visit with the experts at MEND click here.

Evidence Does Not Support Knee Surgery for Meniscal Tears

Tears in the meniscus, cartilage within our knees, can occur due to injury or degeneration attributed to the aging process.  The latter is a much more frequent scenario and often these tears are found on MRIs of patients without knee pain.  These false positive results cast doubt on the direct correlation between a picture of your knee and the symptoms you are experiencing. Thus, meniscal tears are found in patients without pain and those with pain can have a negative image.  Unfortunately, arthroscopic surgery for these age related tears is on the rise with 700,000 procedures performed in the United States each year (Cullen et al. 2009).  Interestingly, a previous randomized controlled trial in the New England Journal of Medicine found no difference in patient outcomes between this meniscal surgery and a sham surgery (Sihvonen et al. 2013).  

In the study, 70 patients were randomized to a partial menisectomy (removal of the meniscus) and 76 were randomized to a sham surgery (Sihvonen et al. 2016).  In the article published in the Annals of Internal Medicine the authors reported close to half of the patients in either group reported mechanical symptoms such as locking or catching prior to surgery.  Surprisingly, no differences were noted between the surgery and sham surgery for relief of pain or mechanical symptoms.  The authors concluded, "resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking".

Patients with meniscal tears are advised to work with a local Physical Therapist on an cost and clinically effective treatment plan before considering any surgical procedure.