Meniscal Tear Physiotherapy Patients Have Half the Risk of Knee Replacement

Meniscal tears seem to occur as part of a degenerative process in the knee. More than half of people age 50+ have meniscal tears without pain.1 In previous decades, arthroscopic partial meniscectomy (APM) has been considered the gold standard of treatment, but, more recently, physiotherapy has emerged as the recommended first-line treatment.2,3

The preponderance of studies comparing APM with physiotherapy as the first-line treatment for non-obstructive meniscal tears find that physiotherapy is not inferior to surgery.4-11 Therefore, the lower-cost and non-invasive nature of physiotherapy make it a preferred first-line treatment. Both physiotherapy and APM prove highly effective in treating knee pain related to non-obstructive meniscal tearing. Within two years, thirty percent of patients randomised to physiotherapy elect APM, suggesting a 70% success rate with physiotherapy.

Most studies on the subject followed patients for two years. Recently, lead researcher Jeffrey Katz, MD, of Harvard’s Brigham and Women’s Hospital, published a study with a five-year follow-up period for 351 patients.12 Their work provides new insight that can assist with patient conversations. Both physiotherapy and APM prove effective at reducing pain in the short and long term.

Pain scores tend to improve substantially in the first three months, continue a less rapid improvement through month 24, and then stabilize through month 60. As in a previous study,11 APM trends toward slightly better pain scores than physiotherapy, but those differences do not reach statistical significance. In the current study, about eight percent of patients undergo a total knee replacement (TKR).

Patients randomized to physiotherapy have half the risk of a TKR. There are two possible theories for the much lower risk of TKR in the physiotherapy group. One is that having experienced a previous surgery, patients randomised to APM might have a lower resistance to surgery in the future.

The other theory is that groups relying primarily on physiotherapy may do a better job of reducing the progression of their osteoarthritis (OA). Less quadriceps strength has been identified as a risk factor for initiation and progression of knee OA.13 Physiotherapy ameliorates osteoarthritis progression.14-16 For instance, in a study published recently in Arthritis Care and Research, meniscal tear patients were randomised to APM or physiotherapy, and MRI findings were examined eighteen months later.17

While both groups experienced advancement in osteoarthritis indicators, the APM group had greater advancement in osteophytes, effusion-synovitis, and cartilage surface damage. For example, damage to cartilage surface areas advanced in multiple regions for one third of the physiotherapy group compared to nearly two thirds of the APM group.

It has been widely theorised that the reduced progression of OA stems from improved biomechanics in terms of joint unloading and shock absorption.18,19 This new data continues to support the consensus that physiotherapy makes a good first-line treatment choice for non-obstructive meniscal tears. APM proves largely successful among the percentage of cases that do not succeed with physiotherapy,1 and delaying surgery for physiotherapy does not reduce the effectiveness of surgery.11 

References 1

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2. Beaufils P, Becker R, Kopf S, Englund M, Verdonk R, Ollivier M, Seil R. Surgical management of degenerative meniscus lesions. Arthroskopie. 2017 Jun 1;30(2):128-37.

3. Stone JA, Salzler MJ, Parker DA, Becker R, Harner CD. Degenerative meniscus tears-assimilation of evidence and consensus statements across three continents: state of the art. Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine. 2017 Mar 1;2(2):108-19.

4. Katz JN, Brophy RH, Chaisson CE, De Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA. Surgery versus physical therapy for a meniscal tear and osteoarthritis. New England Journal of Medicine. 2013 May 2;368(18):1675-84.

5. Herrlin S, Hållander M, Wange P, Weidenhielm L, Werner S. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2007 Apr;15(4):393-401.

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7. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016 Jul 20;354.

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10. Gauffin H, Tagesson S, Meunier A, Magnusson H, Kvist J. Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study. Osteoarthritis and Cartilage. 2014 Nov 1;22(11):1808-16.

11. van de Graaf VA, Noorduyn JC, Willigenburg NW, Butter IK, de Gast A, Mol BW, Saris DB, Twisk JW, Poolman RW. Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: the ESCAPE randomized clinical trial. JAMA. 2018 Oct 2;320(13):1328-37.

12. Katz JN, Shrestha S, Losina E, Jones MH, Marx RG, Mandl LA, Levy BA, MacFarlane LA, Spindler KP, Silva GS, MeTeOR Investigators. Five‐Year Outcome of Operative and Nonoperative Management of Meniscal Tear in Persons Older Than Forty‐Five Years. Arthritis & Rheumatology. 2020 Feb;72(2):273-81.

13. Øiestad BE, Juhl CB, Eitzen I, Thorlund JB. Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis. Osteoarthritis and Cartilage. 2015 Feb 1;23(2):171-7.

14. Katz J, Brophy R, Chaisson C, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. NEJM. Mar 19 2013; DOI: 10.1056/NEJMoa1301408.

15. Pinto D, Robertson M, Abbott J, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial. Osteoarthritis and Cartilage. 2013; joca.2013.06.014.

16. Fransen M, McConnell S, Harmer A, et al. Exercise for osteoarthritis of the knee. Br J Sports Med. 2015; 49 (24): 1554-1557.

17. Collins JE, Losina E, Marx RG, Guermazi A, Jarraya M, Jones MH, Levy BA, Mandl LA, Martin SD, Wright RW, Spindler KP. 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 & Research. 2020 May;72(5):630-40.

18. Segal NA, Glass NA, Felson DT, Hurley M, Yang M, Nevitt M, Lewis CE, Torner JC. The effect of quadriceps strength and proprioception on risk for knee osteoarthritis. Medicine and Science in Sports and Exercise. 2010 Nov;42(11):2081.

19. Anwer S, Alghadir A. Effect of isometric quadriceps exercise on muscle strength, pain, and function in patients with knee osteoarthritis: a randomized controlled study. Journal of Physical Therapy Science. 2014;26(5):745-8.