Traumatic Meniscal Tears Evidence that Physiotherapy is not inferior to Surgery

A traumatic meniscus injury is defined as a ‘meniscus tear’, which is associated with a significant knee inju ry and a sudden onset of knee pain, whereas a degenerative meniscus tear is marked pri marily by a slow progression of tissue degen eration without a history of an acute trauma. other 5% of the physiotherapy group elected surgery. By comparison, between months 12 and 24, 9% of the surgery group elected a second surgery. By these results, young pa tients with traumatic meniscal tears would elect to skip surgery more than two-thirds of the time, if they were prescribed a proper physio therapy program. All traumatic tears require urgent orthopae dic evaluation.

Some traumatic tears are suitable for repair, and in some cases urgent repair can result in a better outcome for the patient. For degenerative meniscal tears, physiotherapy was first shown to be non-inferior to surgery in 2007.2 Later, several high-quality studies, with follow-ups ranging from two years to five, have found the same conclusion. First-line phys iotherapy has even been associated with bet ter outcomes in terms of osteoarthritis progres sion.3 Consequently, recently updated guide lines recommend a period of non-surgical man agement for degenerative, non-locking, menis cal tears.4-6 However, in the absence of evi dence to the contrary, there has been a widely held belief that patients with traumatic menis cal tears would benefit more from surgery than from conservative management.7

Published in JOSPT in May, a randomised con trolled trial out of Aarhus University (Denmark) finds that first-line physiotherapy is also not inferior to surgery for traumatic meniscal tears. Eighty-nine patients aged 18 to 40 were com pared. The physiotherapy group received 12 weeks of supervised, therapeutic exercise. The surgery group received repair or resection at the surgeon’s discretion plus physiotherapy. At one year, 69% of the physiotherapy group reported mechanical symptoms, compared to only 35% of the surgical group.

However, in terms of function, pain, and quality of life, physiotherapy was not inferior. At two-year follow-up, there was no difference between treatment groups in terms of structural changes in the knee. The physiotherapy group retained the option to elect surgery, and 26% did so within the first year. By the end of the second year another ther 5% of the physiotherapy group elected surgery. By comparison, between months 12 and 24, 9% of the surgery group elected a second surgery. By these results, young pa tients with traumatic meniscal tears would elect to skip surgery more than two-thirds of the time, if they were prescribed a proper physio therapy program. 

To date, only two trials have compared early surgery to first-line physiotherapy for young patients with traumatic meniscal tears. The ear lier study found similar conclusions to the cur rent study.8 This data could be used in shared decision making between patients and their clinicians. In separate commentary, the authors of the current study suggest that symptom on set may not be a good factor for determining the course of treatment.6 Rather, they posit, this decision should be based on the patient’s pref erences, values, and goals.  

References

1. Kopf S, Beaufils P, Hirschmann MT, Rotigliano N, Ollivier M, Pereira H, Verdonk R, Darabos N, Ntagiopoulos P, Dejour D, Seil R. Management of traumatic meniscus tears: the 2019 ESSKA me niscus consensus. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Apr;28:1177-94.

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

3. Meng J, Tang H, Xiao Y, Liu W, Wu Y, Xiong Y, Gao S. Long-term effects of exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear: A meta-analysis of randomized controlled trials. Asian Journal of Surgery. 2024 Mar 25.

4. Abram SG, Beard DJ, Price AJ, BASK Meniscal Working Group. Arthroscopic meniscal surgery: a national society treatment guideline and consensus statement. The Bone & Joint Journal. 2019 Jun;101(6):652-9.

5. Van Arkel ER, Koëter S, Rijk PC, Van Tienen TG, Vincken PW, Segers MJ, Van Essen B, Van Mel ick N, Stegeman BH. Dutch Guideline on Knee Arthroscopy Part 1, the meniscus: a multidiscipli nary review by the Dutch Orthopaedic Association. Acta Orthopaedica. 2020 Nov 20;92(1):74 80.

6. Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L. Arthroscopic surgery for degenera tive knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017 May 10;357.

7. Thorlund JB, Damsted C, Hölmich P, Lind M, Skou ST. Should symptom onset guide treatment choice in young patients with meniscal tears? Insights from the DREAM-trial. JOSPT. Published online on April 17, 2024: https://doi.org/10.2519/jospt.blog.20240415.

8. van der Graaff SJ, Eijgenraam SM, Meuffels DE, van Es EM, Verhaar JA, Hofstee DJ, Yang KG, Noorduyn JC, van Arkel ER, van den Brand IC, Janssen RP. Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in a young study population: a randomised controlled trial. British Journal of Sports Medicine. 2022 Aug 1;56(15):870-6.