As a physical therapist, I often treat physical impairments which I have no personal experience with. That’s not only okay, but it’s expected and necessary in many cases. I have treated patients with >90% burns, after a stroke, suffering from rare and fatal diseases as well as multiple traumas. Healthcare professionals often need to treat patients without having direct personal experience with what they’re going through. However, I have had my fair share of personal and professional experience with meniscus tears. In high school I was a competitive volleyball player and I’ve always been a fitness enthusiast. At 16, during the height of my varsity volleyball career, I tore my right medial meniscus. It was painful and at times I could barely walk. After examination from an orthopedic surgeon and MRI, I was told surgery was the only option. I had an arthroscopic partial meniscectomy. Back in the early 2000s, that was standard protocol for all traumatic meniscus tears. MRI = meniscus tear = surgery. However, as science so often does, protocol is (or should be) much different now. As the great Maya Angelou said, “when you know better, do better”.
What is a meniscus?
Meniscus in the knees are C-shaped cartilage discs (2 in each knee - medial and lateral) which act as shock absorbers and stabilizers. They also reduce friction between your femur and tibia bones.
What do you do if you think you have a tear?
Signs which may indicate a tear include pain with walking, twisting, end-range bending or straightening the knee, tenderness along the joint line, and swelling. There are 2 types of tears:
Acute tears. These often occur in younger (<40), active people with sudden twisting motions in weight bearing. Surgery is indicated with failed conservative care, a large tear located in an area of less blood flow and results in an unstable knee.
Chronic tears. Degenerative tears often occur without trauma in the 4th or 5th decade of life. Surgery is rarely indicated in these cases.
As mentioned above, you used to be sent in for an MRI then surgery then physical therapy. However, now the first line of defense for (most) acute and chronic meniscus tears is conservative care including physical therapy.
Why not surgery as first line of defense?
A randomized control trial was published in 2022 by the British Journal of Sports Medicine comparing arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in younger (18-45) populations. They found “early arthroscopic partial meniscectomy was not superior to a strategy of physical therapy” at 24-months follow-up.1
And what about for degenerative tears? A huge systematic review and meta-analysis with >600 patients compared arthroscopic partial meniscectomy vs a sham treatment at 24 months follow-up resulting in no difference between the groups. The authors “recommend a restrained policy regarding meniscectomy in patients with degenerative meniscus tears”.2
So what’s the harm in just going with the “easy” route and having the surgery?
Well, a lot. For one, any surgery has inherent risks including infection and blood clots. Particularly for knees, the risk of symptomatic knee osteoarthritis is increased 2x for arthroscopic meniscus repairs (~15% of cases can be repaired according to the literature) and 6x for arthroscopic meniscectomy vs the general population!3 There’s a greater chance of a knee replacement down the road with symptomatic early osteoarthritis. And you’ll be doing PT after surgery anyway - why not just skip the surgery altogether if you can.
Take-away:
Knee meniscus tears are common and painful. Research has evolved and now indicate physical therapy as the first line of defense, not surgery. In fact, knee surgery…
1) is no more effective than physical therapy alone according to the literature,
2) has inherent risks,
3) will increase your odds of having osteoarthritis down the road.
Do yourself a favor and get 12 weeks of physical therapy before even considering surgery.
Soon after my knee surgery, my meniscus re-tore like so many other people experience (check out "When knee pain is worse after meniscus surgery" here). This time I decided to take it into my own hands instead of going into surgery again. I wish someone would have told me to try conservative care and physical therapy before surgery. However, I'm happy to say my 1RM squat is heavier than its ever been and I plan on running a 5k for Thanksgiving with minimal to no pain. If you’ve already had arthroscopic knee surgery (or any knee surgery for that matter), don’t worry - there are things you can do to get and keep your knees as healthy as possible to keep living your best life. I’m happy to sit down and discuss your individual situation and goals in more detail. Reach out!
Resources:
Comentarios