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Should you get surgery or consider physical therapy for a torn meniscus?



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So you are tired of dealing with your knee pain, popping, clicking, catching, or swelling. You may suspect you have a meniscal tear or you might have had imaging to confirm this. Maybe you saw an orthopedic specialist who offered you a partial meniscectomy or meniscal repair surgery to address this problem. When you mention your knee pain, everybody and their brother seems to have a different opinion or personal experience. Pretty confusing, huh?


Arthroscopic knee surgeries are some of the most commonly performed orthopedic surgeries. But does that mean it will give you the best chance to live without pain and get back to the activities you love?


Let’s briefly explain some common terms and look at what the research shows is best.

Meniscus: it is the c-shaped fibrocartilage tissue in the knee joint that provides cushion and stability to the knee.

Arthroscopic partial meniscectomy: a procedure that is to remove part of the meniscus, primarily the torn/loose fragments and also trim back the remaining meniscus. There are less restrictions after surgery and patients are typically allowed to be weight bearing as tolerated immediately after surgery. Complete meniscectomies used to be common, but now are quite rare as we understand the importance of maintaining the integrity of the meniscus as much as possible.

Meniscal repair: a surgery that repairs the tear and therefore typically requires some non-weight bearing time period (~6 weeks depending on surgeon) to allow the repair to heal.



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Arthroscopic partial meniscectomy vs physical therapy for degenerative meniscal tears



After 5 years, physical therapy remained equivalent to surgical treatment. The 2022 randomized controlled trial writes, “Physical therapy should therefore be the preferred treatment over surgery for degenerative meniscal tears. These results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear”.


Another study finds that the outcomes for those who had an arthroscopic partial meniscectomy were no better than those after a sham surgical procedure for those with degenerative medial meniscal tears.


Last study noted here. No significant difference in functional improvements at 6 and 12 months were found between surgical and physical therapy groups. However, 30% of patients who were assigned to the physical therapy group did elect to have surgery within 6 months. See below for why some types of meniscal tears will benefit from surgery more than physical therapy.


How about comparing outcomes between meniscal repairs and meniscectomies?


It is believed that removing part or all of the meniscus can lead to earlier onset of osteoarthritis. This 2019 study found that 40% of the partial meniscectomy group, 27% of the physical therapy group, and 0% of the meniscal repair group progressed to requiring a total knee replacement at 74 month follow-up.


A second 2018 study found the rate of osteoarthritis was 53% in the meniscal repair group, 99% in the meniscectomy group, and 95% in the conservative/non-operative group at a 10-year follow-up. The rate of total knee replacement was 34% in the meniscal repair group, 52% in the menisectomy group, and 46% in the non-operative group. Health care costs were 40% higher for meniscectomy group and 11% higher in non-operative group.


Maintaining the integrity of the meniscus is important and does decrease the rate of osteoarthritis and secondarily the need for a total knee replacement. In some cases, it is more important to seek surgical intervention than to push physical therapy first.

However, only 34.9% of meniscal tears were found to be repairable. Candidates for meniscal repair depend on a lot of factors. But younger patients with tears in the outer section of the meniscus where blood supply for healing is better are more likely to be good candidates.

Takeaways!

-Physical therapy first should be a common message in most issues, including meniscal tears (with some exceptions-see below).

-Physical therapy provides positive and comparable results to partial meniscectomies and with less risk and less financial investment.

-Maintaining the integrity of the meniscus is important for long-term health of the knee. If it is a large tear in certain areas of the meniscus that will allow for better healing, a meniscal repair may be the best option.

-Rates of osteoarthritis and in turn total knee replacements are higher in meniscectomy groups than meniscal repair groups.


For some case by case recommendations:

-If you have severe joint damage, then you need to skip the meniscectomy and try the physical therapy to potential knee replacement route.

-If your meniscal tear is not displaced and not symptomatic, go the physical therapy route and monitor.

-If your meniscal tear is displaced and symptomatic, it could be time to consider surgery.

-More specifically, if you are under 60 years of age and otherwise healthy with a tear in the area that gets good blood flow then you could be a candidate for a meniscal repair.

-If your tear is in the moderate blood supply region of the meniscus AND you are 40 or younger, then you might also be a candidate for a meniscal repair.

-If your tear is in the no blood supply region of the meniscus, then your option is to consider a meniscectomy or physical therapy in a case-by-case scenario.


Please be an advocate for your own health and don't be afraid to get multiple opinions prior to committing to a surgery. Reach out to us or a trusted performance physical therapist in your area for individualized care and recommendations.


-Dr. Sieara

828-808-3704

sieara@outshineptandfitness.com







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