Meniscus injuries of the knee are common. There are lots of treatment options, including meniscus tear surgery or injections. But which one is the best to address your meniscus tear pain? The data surprises almost everyone.
History of meniscus tear treatments
Orthopedic surgeons used to perform a total meniscectomy for patients with meniscus tears. This procedure involved taking out the entire meniscus. If you have a tear that causes you pain, why not remove it? This made theoretical sense. In practice, this proved to be a mistake. After the surgeons removed the padding between the bones, the bones rubbed against each other more. This led to increased degeneration and arthritis. This comes as no surprise. But back then, it seemed a viable treatment option.
The surgeons then tried taking out only the torn part of the meniscus. This is a partial meniscectomy. Arthroscopic partial meniscectomies are one of the most common procedures performed in the United States. But should they be?
Meniscus tear surgery randomized controlled trials
The New England Journal of Medicine published an eye-opening study looking at arthroscopic partial meniscectomy versus sham surgery for degenerative meniscus tears. They had a total of 146 patients who had a meniscus tear confirmed during arthroscopy. They were then randomized in the operating room. 70 ended up with the actual surgery. 76 ended up with a sham surgery. During the sham surgery, the surgeons mimicked the process of the actual surgery. They asked for all the instruments, manipulated the knee, used suction, applied instruments against the knee, and kept the patient in the operating room for the same amount of time required to perform the actual surgery. This trial is important as a sham surgery is the best placebo for a surgical procedure.
Researchers administered questionnaires at 2, 6, and 12 months after surgery. They found that the surgical group significantly improved at 12 months. What’s shocking is that the sham group also significantly improved at 12 months. There was no statistical difference in any of the outcomes between the two groups. The surgical group was no better than the sham surgery group.
The authors continued to follow these patients. They published their results from 2 years of follow up. Here are the authors’ conclusions: “The outcomes after arthroscopic partial meniscectomy were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with the presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from an arthroscopic partial meniscectomy.”
Mechanical symptoms from meniscus tears and arthritis
The researchers mention the presence of mechanical symptoms and meniscus tear characteristics. They do this because surgeons started using those as reasons to operate. If you have catching or locking, you will benefit from surgery.
This was actually investigated by the British Journal of Sports Medicine. They conducted an observational study examining how often a meniscus tear was present during surgery when a patient-reported mechanical symptoms. They found that “preoperative mechanical symptoms were equally prevalent in patients with and without a meniscal tear.”
The authors go on to conclude that “patient-reported mechanical symptoms were equally common irrespective of presence or absence of a meniscal tear in patients undergoing arthroscopy for suspicion of a meniscal tear. Our findings suggest that mechanical knee symptoms have a limited value when considering indication for meniscal surgery.”
Meniscus tear pain and meniscus tear MRI
Things get even more interesting. Just because you have a meniscus tear, doesn’t mean the tear is the cause of your knee pain. In fact, just because you have a meniscus tear, doesn’t mean you have knee pain at all. The British Journal of Sports Medicine also published a systematic review and meta-analysis looking at the prevalence of meniscus tears on MRI. These patients had no knee pain and no history of knee injuries. They included 63 studies with a total of 5,397 knees. They found that 19 percent of patients over 40 years old had meniscus tears. The older you are, the more likely you are to have a meniscus tear. A meniscus tear on an MRI could be an incidental finding.
Meniscus tear treatment: sham surgery
This study actually followed their surgery vs. sham patients out to 5 years. They concluded: “Arthroscopic partial meniscectomy was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at five years after surgery.”
Long term data shows removing part of the meniscus has no benefit in patient outcomes. But the surgery leads to arthritis. Is that something you want to consider?
Nonsurgical meniscus tear treatment options
So what are the nonsurgical options to treat meniscus tears? Physical therapy or home exercise programs, as well as injections, are great options.
Systematic review and meta-analyses continue to arrive at the same conclusions. A systematic review and meta-analysis of randomized controlled trials comparing arthroscopic partial meniscectomy to physical therapy in patients with degenerative meniscus tears. They concluded that the literature “provides relatively strong evidence that [surgery] did not improve functional activity or reduce pain compared with the results with conservative treatment or sham operation in knees with mild or no osteoarthritis.”
Intra-articular knee injections can significantly decrease pain
Cortisone injections have been around forever and can reduce pain. But their use is starting to fade away due to concerns for tissue toxicity.
Orthobiologics such as platelet-rich plasma are an excellent option. Many clinical trials, systematic reviews, and meta-analysis support the use of orthobiologics, especially if there is underlying mild to moderate knee osteoarthritis.
Don’t jump straight to surgery for degenerative meniscus tears. Read through the evidence and make an informed decision about your health and your knee.
Image credit: Shutterstock.com