Should I have meniscus surgery? Reviews of Surgical and Nonsurgical Treatments for Meniscus Tears

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Many people who contact our office are in a decision-making process. The decision is to get a meniscus surgery, or, try to put off or avoid the meniscus surgery and find some type of non-surgical treatment for their knee pain. Many times, when we initially discuss meniscus surgery alternatives with people interested in non-surgical treatment options, we ask them if they know what type of surgery are they going to get, total meniscectomy? Partial meniscectomy? Meniscus suture repair? Many times these people do not know because the surgeon told them they themselves do not know what type of surgery they are going to have to do until they “get in there” and see what challenges their knee has.

If you are reading this article you may be likely waiting for an MRI to determine the extent of your knee damage. Depending on your MRI results you will be offered one of three choices:

  1. Do nothing.
  2. Do something non-surgically.
  3. Get surgery.

The reason you are probably reading this article is that you are exploring all these options and are probably leaning towards finding another way besides surgery. In this article you are going to see a lot of research, the orthopedists will speak up, the physical therapists are going to speak up, and health care providers offering regenerative medicine injections are going to speak up.

Article outline:

Part 1: The MRI examination and recommendation to surgery. The first half of this article is going to concentrate on a common patient concern. “My MRI says.” We sometimes find that a patient is led to believe that surgery is the only option for them because of what the “MRI said.”

Part 2: Arthroscopic meniscus surgery

Part 3: Pain after meniscus surgery 

Part 4: Non-Surgical and injection treatment options for the different types of Meniscus tears

 

Research: The rush to MRI is a rush to surgery. Is an MRI really necessary? Whatever your MRI says, you may get surgery anyway.

The question about meniscus tears and the subsequent MRI in emails we receive are numerous. These are paraphrased.

This is what my MRI says: Radial tear poster medial meniscus, degeneration fraying medial meniscus, moderate bone contusion medial tibial plateau with degenerative changes, moderate bakers cyst. My doctor says I should get a clean-up on my knee.

I had an MRI I have another tear

I had arthroscopic knee surgery for a torn meniscus. I just had an MRI and I have another tear in my meniscus. Now they tell me I am developing arthritis as well. I need more surgery. I am not sure I want or even need more surgery. Are non-surgical options available to me?

I had an MRI, I had surgery, and now I have more pain

I had a meniscus repair surgery about six months ago. Soon after the surgery, I started experiencing terrible pain. I cannot work like this. I had another MRI and I am being told to have more surgery. Are non-surgical options available to me?

I had an MRI, I had surgery, and now I have more pain, part 2

I had a meniscectomy in 2020 after suffering two previous meniscus tears. The surgeon shaved part of the torn meniscus and cleaned up any loose tissue. I followed up surgery with 12 months of physical therapy with a sports injury specialist. I am a very active person and play multiple sports. 

I have felt continuous pain since the surgery and have never really recovered. I have gained weight because of my inactivity. My knee pain recently increased dramatically causing me to have an MRI and X-ray scans. My doctor says that it is the meniscus, it is degenerating and I will need to stop my physical activity as it is straining my knee as well as lose weight and eventually have another surgery on my meniscus. For the time being, I was given a cortisone shot in my knee joint to reduce the pain.

Sometimes we simply get a cut-and paste of the person’s MRI report. MRI reports can be helpful but people with “terrible” MRIs have little knee pain. People with good MRIs have terrible pain. It is just as important to understand the person’s full situation, to know how someone feels today, what type of pain did they have when they woke up, and what makes it worse as it is to get an MRI report.

It is the patient’s belief that the surgical removal of the whole or part of the meniscus will restore function and lessen their pain.

It can be difficult to tell a patient to have patience when their knee hurts. Most of the time when someone comes into our clinic for the first time they will report the characteristic symptoms of meniscus-related knee problems:

It is also challenging to convince an athlete that meniscus surgery may prevent them from returning to sports altogether.

For most people, you cannot get a surgical recommendation for a meniscus tear without an MRI justifying a meniscus tear significant enough to get a surgical recommendation.

For most people, you cannot get a surgical recommendation for a meniscus tear without an MRI justifying a meniscus tear significant enough to get a surgical recommendation. It is often said that if you want surgery, get an MRI. What you are going to read below will take this idea one step further, if the MRI cannot tell if you need surgery, you may want to get surgery to see if you needed surgery. We will show you the studies.

(Lack of) “Diagnostic Accuracy of Magnetic Resonance Imaging in the Detection of Type and Location of Meniscus Tears”

That is the title of a February 2021 study published in the Journal of Clinical Medicine. (1) How the study ended was with a suggestion that if you really wanted to know how much damage there was to a patient’s meniscus or knee capsule, you should go in and see for yourself during an arthroscopic procedure because many times the MRI is not helpful. Let’s let the doctors of the study speak for themselves. First, this is why they did the study:

“Magnetic resonance imaging (MRI) has been widely used for the diagnosis of meniscal tears, but its diagnostic accuracy, depending on the type and location, has not been well investigated. We aimed to evaluate the diagnostic accuracy of MRI by comparing MRI and arthroscopic findings.”

Next, this is what they found out:

What the researchers here did was compare MRI findings with arthroscopic findings in the same patient to determine if the MRI detected the presence, type, and location of meniscus tears later revealed in an arthroscopic procedure. They also looked at a group of patients who had ACL injuries with meniscus tears to see if the meniscus tears showed up on MRI in the same manner that they were discovered during the ACL reconstruction surgery.

The researchers also excluded some patients from the study as not being good study candidates. This would include people who had degenerative arthritis. Degenerative arthritis makes it difficult through imaging, to understand the type and extent of the meniscus tear on MRI.

What the researchers revealed in the end was MRI is limited in understanding the scope of a meniscus injury. To quote: “MRI could be a diagnostic tool for meniscus tears, but has limited accuracy in their classification of the type and location.”

After the first surgery, MRI has a difficult time understanding where the new or same knee pain is coming from.

Many patients fall into a category of people who have an MRI that do not offer conclusive evidence for their continuing knee problems. Such is the MRI that cannot tell the difference between old or new knee damage causing old or new knee pain.

Doctors at the Mallinckrodt Institute of Radiology wrote in the November 2022 journal Magnetic resonance imaging clinics of North America (2) about the challenges an MRI may face is showing the true cause of a new or recurrent pain after the first meniscus surgery. The authors write: “Surgery to treat a torn meniscus is a common orthopedic procedure, and radiologists are frequently asked to image patients with new or recurrent knee pain after meniscus surgery. However, surgery alters the MR imaging appearance of the meniscus, making diagnosing recurrent tears a diagnostic challenge.”

Waiting until the arthroscopic procedure to figure out what type of surgery I am getting. My MRI was not helpful.

When there is uncertainty or confusion in the MRI image, surgery is then typically recommended. This is why your doctors want to “get in there” and see what is going on. There is a concern your MRI may be leading you down a poor treatment choice path.

An April 2021 paper in the Australian and New Zealand Journal of Surgery (3) suggested that “Magnetic Resonance Imaging (MRI) is commonly used for diagnosis and as a research tool, but its accuracy is questionable.” They further wrote that the goal of their study was to compare the accuracy of knee MRI with clinical (in surgery) assessment for diagnosing meniscal tears and to determine the accuracy of MRI for grading chondral lesions. What did they find? “MRI has relatively poor correlation with arthroscopic findings for grading the chondral damage and was less accurate than clinical assessment for the diagnosis of lateral meniscal tears.”

Your doctors went in there to see what the MRI could not.

MRI recommendation for arthroscopic surgery should be questioned.

In the above study, researchers looked to see if an MRI was as accurate as direct observation in an arthroscopic procedure. The answer was no. Doctors should consider arthroscopic surgery as the best diagnostic tool in some cases of knee pain from a suspected meniscus injury.

A group of physical therapists, based on responses from the patients they see suggest that doctors can be a little too enthusiastic in promoting an arthroscopic surgery to “see what is going on.” Especially when the surgery may not be needed in most cases. This is what the physical therapists wrote in the peer-reviewed journal Musculoskeletal Science & Practice (4) February 2021.

“Current clinical practice guidelines for degenerative meniscal tears recommend conservative management yet patients are frequently referred to the consultant orthopedic surgeon despite a lack of evidence for the use of arthroscopy.”

The controversy over the value of knee MRI in meniscus diagnosis has been ongoing. Taking the other side of the argument a 2018 (5) study suggested that “MRI could effectively demonstrate imaging features of medial and lateral meniscal root tear and its accompanying signs. It could provide the basis for preoperative diagnosis of clinicians, and be worthy to be popularized.” These arguments have not taken hold over the past five years.

A January 2023 study in the American Journal of Sports Medicine (6) wrote: “The diagnostic accuracy of MRI for multiple ligament knee injuries largely varied among knee structures, with many of them at risk of a misdiagnosis, especially PLC, meniscal, and chondral lesions. The severity of multiple ligament knee injuries lowered the diagnostic accuracy of MRI for peripheral structures.”

The problem of meniscus pseudo tears

A February 2021 study in the medical journal Arthroscopy (7) examined why MRI readings were often inaccurate when it came to interpreting whether there was an actual tear or not of the anterior horn of the lateral and medial meniscus. What these researchers examined was the phenomena of pseudotear, the appearance of a meniscus tear that is not there.

Peter R. Kurzweil, M.D. is an orthopedic surgeon. He is an editorial reviewer for the journal Arthroscopy. This is what he wrote in response to this study’s observations: (8)

Editorial Commentary: False-Positive Meniscus Pseudotear on Magnetic Resonance Imaging: A False Sign That Rings True

“The false-positive finding of anterior horn meniscus (pseudo)tear on magnetic resonance imaging (MRI) is an important finding of which to be aware. We have recently seen awareness similarly raised regarding root tears of the meniscus, which, if overlooked, could have detrimental consequences. Manifestations of the MRI finding of meniscus pseudotear arise from the variability of the insertion of the transverse geniculate ligament into the anterior horn of the lateral meniscus. Bearing in mind that anterior knee pain is a common reason that patients present for an orthopaedic and sports medicine evaluation, the understanding that this MRI finding does not represent a true meniscus tear may save patients from unnecessary arthroscopic surgery.”

In August 2022, a paper in the journal Scanning (9) proposed a different way to interpret MRI imaging of the knee, “In order to solve the problem of observing and analyzing the clinical value of MRI diagnosis in patients with knee sports injury and guiding clinical targeted treatment.” In other words, rule out pseudo tears masquerading as meniscus tears. The author proposed that small ligaments in the knee are causing “pseudo-tear sign” MRIs in the meniscus of patients. The paper notes that in 101 knee MRIs:

Experimental results show that the incidence of transverse geniculate ligament (the ligament showed up on an MRI) was about 67.3% (68/101), and the incidence of “pseudo-tear sign” in the anterior horn of the lateral meniscus caused by the transverse geniculate ligament (fooling the MRI into thinking it was a meniscus tears) was 2.9% (2/68).

The overall appearance rate of the meniscofemoral ligament on MRI was 91.1% (92/101), the appearance rate of the plate anterior ligament was 13.9% (14/101), and the occurrence rate of “pseudo-tear sign” in the posterior horn of the lateral meniscus caused by the plate anterior ligament (fooling the MRI into thinking it was a meniscus tears) was 7.1% (1/14).

The occurrence rate of the posterior ligament was 77.2% (78/101), and the incidence of “pseudo-tear sign” in the posterior horn was 20.5% (16/78).

The author concluded that identifying the shape and location of transverse geniculate ligament and meniscofemoral ligament on MRI, and the direction and position of the lateral meniscus pseudo-tear, combined with MRI sagittal plane and coronal plane observation, “it can effectively identify the true and false attributes of lateral meniscus anterior and posterior horn tears, thereby reducing unnecessary surgical treatment.”

The hard to find Meniscus Ramp Lesion in an ACL deficient knee

For those of you reading this article, and you had an acute ACL tear or you had previous ACL surgical repair and were diagnosed with a “ramp lesion” you should understand that ramp lesions are vertical or longitudinal tears of the peripheral capsular attachment (the meniscus’ outer edge attachment) of the posterior horn of the medial meniscus at the meniscocapsular junction. (Simply an anchor that keeps the meniscus from floating around in the knee). It is often considered a minor injury and is especially suspected in ACL-deficient or compromised knees.

This injury is often difficult to detect on MRI. 

A July 2021 study in the journal Skeletal Radiology (10) suggests MRIs can only offer “moderate accuracy.” Here are the summary learning points:

This next part sounds like an MRI report. If you had a suspected meniscus tear it may sound like your MRI report.

Here is a point. This MRI report-sounding description appears detailed and in-depth. It is giving a picture of what is happening in the knee. Or is it?

An August 2022 paper in the journal Knee surgery, sports traumatology, arthroscopy (11) writes: “The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). . . Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries.

Another study: A physical examination is just as good as an MRI. So is it important to have an MRI report relating the different types of meniscus tears you may have? No, not if you are trying to avoid surgery.

If you have decided to try to avoid surgery, an MRI may not be needed. In a May 2020 study in the journal Advances in Orthopedics,(12)  the doctors were looking for ways to best diagnose a meniscus tear. To find this answer the researchers of this study looked at patients who were already deemed surgical candidates because of meniscal or cruciate ligament tears. Just before these patients had knee surgery the patients had an MRI and a physical examination. The researchers then wanted to compare the MRI reading interpretation and the results of the physical examination to what they saw during the surgery.

The problem of MRI misdiagnosis in adolescent soccer players.

The problem of MRI misdiagnosis in adolescent soccer players

You have a superstar soccer player. He or she has been complaining about knee pain. You go to the doctor who orders and MRI that suggests a meniscus tear. You may not want to lose any more of the soccer season so you may decide on a quick arthroscopic surgery for your player. Now let’s look at a recent paper. An August 2022 case history in The Journal of the Canadian Chiropractic Association (13) opens the question of accuracy in diagnosis in adolescent soccer players. Here, Antonio Petrolo, a Sports Sciences Resident, at the Canadian Memorial Chiropractic College writes:

“Injuries to the meniscus are particularly prevalent in soccer players . . .However, in the adolescent soccer player population, it has been reported that up to 63% of asymptomatic knees may demonstrate horizontal or oblique tears on MRI. These results may negatively influence clinical decision-making and plan of management for adolescent soccer players with knee problems.

A case of a 15-year-old soccer player is presented after having been diagnosed by his family physician with a left lateral meniscus tear as per MRI, following a 10-week period of anterior knee pain. He presented to a chiropractor for a second opinion before consulting with the orthopedic surgeon. . . Recommendations for progressive rehabilitation owing to the lack of clinical evidence for meniscal abnormality were made. A primary diagnosis of left patellar tendinopathy was determined and after a 6-week comprehensive rehabilitation program, the patient made a complete recovery.”

Summary: “A thorough history, physical examination, and understanding of the patient’s injury mechanism are suggested before confirming/refuting suspicions of meniscal abnormalities via MRI. This will help to inform better clinical decision-making as well as decrease the occurrence of unnecessary imaging.”

So what is it that a doctor should look for in a physical examination of knee pain with a suspected meniscus tear?

If you decide to forego the MRI because you want to avoid a surgical recommendation, then what is it that your doctor should be looking for in a physical examination?

We are going to present a brief video that explains the concept of knee instability and how it impacts your pain and function in a meniscus-damaged knee.

A brief video on knee instability and a bulging meniscus – the many types of meniscus tears may have ligament damage as a common factor

Part 2: A review of arthroscopic meniscus surgery

In this article, we will focus on meniscus surgery and for those who already had the surgery, post-meniscus recovery. We will explore why some patients may have continued or worsening knee problems after meniscus surgery and subsequent treatment recommendations. Many people have successful meniscus surgeries. These are typically not the people we hear from. We hear from the people whose surgery did not meet hoped-for results.

Getting in there, the arthroscopic meniscus and knee clean-up surgery.

Many times we will hear from people that when the doctor gets into his/her knee, they will “clean things up” and get these people back on their way. The clean-up procedure is usually recommended to someone who in the past has “fought through” knee pain, had past injuries without standardized treatments including surgery, and has recently done something to aggravate their knee. Many of these people will likely require some type of surgical procedure if they can no longer bend their knees or walk without significant pain. However, many people are not recommended for surgery because their knee is already in a wear and tear degenerative state and the surgical procedure may accelerate the person’s knee osteoarthritis. The patient can in some instances be stuck in the “rock and a hard place scenario.” Get the surgery and accelerate the knee osteoarthritis, don’t get the surgery, and figure out some other types of treatments. All during this time the person figures out clever ways to get in and out of chairs, beds, and cars without significant pain while doing so. At some point, for many people, something needs to be done and that something is surgery.

If you have been given the meniscus injury surgical recommendation, you have been told that you will get one of these three procedures.

One of the primary reasons for a meniscal operation is to improve joint stability, yet meniscectomy often appears to have the opposite effect, as it elicits even more instability, crepitation, and degeneration than the meniscus injury produced prior to operation. This is why reoperation rates after meniscectomy can be as high as documented in the research below.

Meniscus repair surgery

Recently doctors have been debating the types of meniscus surgery. More recently, as opposed to removing the meniscus, suture repair is being recommended in cases where it can be performed. It cannot be performed in all cases.

Dr. Kavyansh Bhan of the Department of Trauma and Orthopaedics, Whipps Cross University Hospital, London published this June 2020 review of surgical treatment in the medical journal Cureus. (14)  “Arthroscopic partial meniscectomy (APM) is currently the most performed orthopedic procedure around the globe. However,  recent studies have conclusively shown that outcomes after an Arthroscopic partial meniscectomy are no better than the outcomes after a sham/placebo surgery. Meniscal repair is now being touted as a viable and effective alternative. Meniscal repair aims to achieve meniscal healing while completely avoiding the adverse effects of partial meniscectomy.  It is now increasingly recommended to attempt a meniscal repair in all repairable tears, especially in young and physically active patients. Partial Meniscal implants have also shown excellent outcomes in long-term studies, but their efficacy in acute settings still requires further research. Research performed on various techniques of meniscal regeneration looks promising, and regenerative medicine appears to be the way forward.”

When is it that suture repair can be recommended? Mostly when the tear falls within the well blood supplied meniscus red-red zone.

Red zone tear, white zone tear. When non-surgical options can work and when surgery will be the maybe the only choice.

This illustration demonstrates the reasoning often given to patients that meniscus surgery is the only way.  Menisci have two zones. The red zone is the meniscus’ outside zone the white zone is the inside zone. A red zone tear lies within the blood-rich portion of the meniscus. Where there is a blood supply to the meniscus, there is the opportunity to stimulate healing or repair. The white zone meniscal tear is thought to be non-healing because there is no direct blood supply.  Many doctors do not believe the white zone meniscus tear can be repaired because of this. This is typically the part of the meniscus removed in meniscus surgery.

This illustration demonstrates the reasoning often given to patients that meniscus surgery is the only way.  Menisci have two zones. The red zone is the meniscus’ outside zone the white zone is inside zone. A red zone tear lies within the blood-rich portion of the meniscus. Where there is a blood supply there is healing as blood brings the healing and growth factors needed for wound repair.  The white zone meniscal tear is thought to be non-healing because there is no direct blood supply.  Many doctors do not believe the white zone meniscus tear can be repaired because of this. This is typically the part of the meniscus removed in meniscus surgery.

Partial-thickness tears or full-thickness tears: The other classification of the meniscus tear is related to the depth of the tear.

What are we seeing in this image?

Meniscus tears can be considered to either be partial-thickness tears or full-thickness tears. Partial-thickness tears are tears that only extend partway across the meniscus, while full-thickness tears extend fully across. So, if you have a full-thickness flap tear, then it is a tear that cuts across the meniscus completely.

Tears are considered to either be partial thickness tears or full thickness tears. Partial thickness tears are tears that only extend part way across the meniscus, while full thickness tears extend fully across. So, if you have a full thickness flap tear, then it is a tear that cuts across the meniscus completely.

Arthroscopic surgery with partial meniscectomy

In the research below you will see that this surgery is fraught with many long-term problems including an increased risk of disabling osteoarthritis. However, many people do have successful procedures. The image below shows arthroscopic surgery with partial meniscectomy.

Arthroscopic surgery with partial meniscectomy

Athletes can return to sport faster with a partial meniscectomy. But at what cost?

Let’s start talking surgery and let’s start with athletes as they represent a group of patients who are most aggressive in getting treatment to get them back to their sport. For many athletes, surgery is a strong consideration. However which surgery is best at getting them back to sport fastest?

In November 2022, a multi-national team of doctors writing in the journal Knee surgery, sports traumatology, arthroscopy (15) evaluated outcomes and compared:

The doctors hypothesized that both procedures would return similar, high rates of return to sports, with lateral (outside knee) meniscus procedures exhibiting higher potential healing compared to the medial (inside) meniscus.

Learning points:

Is it a meniscus problem or osteoarthritis? A look at patients over 50

Much of the controversies surrounding meniscus surgery revolve around middle age patients and as to whether or not this surgery is helpful or harmful.

An October 2022 paper in the journal Current reviews in musculoskeletal medicine (16) summarizes the controversies surrounding surgical treatment of meniscus tears. “In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for arthroscopic partial meniscus surgery or non-surgical intervention depending on the tear pattern and symptoms. . . There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of arthroscopic partial meniscus compared to physical therapy or sham surgery in symptomatic degenerative meniscal tears.  . . Despite an abundance of literature exploring outcomes of arthroscopic partial meniscus  for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following arthroscopic partial meniscus. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant osteoarthritis.

The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Research Results: Surgeons making a prediction on who would have a successful meniscus surgery was equal to predicting a coin toss.

A March 2020 study in the British Journal of Sports Medicine (17) questioned whether experienced orthopedic surgeons could predict who would benefit from surgery for degenerative meniscus tears and who would not.

The researchers set up an experiment. Surgeons participating in this study were given 20 cases to examine. In each case, the surgeon was asked to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients. The surgeons were also asked to predict the beneficial change in knee function in those patients they would recommend surgery and those patients they would send to physical therapy or an exercise program.

The surgeons combined to examine and predict outcomes in 3880 knees. The results?

Typically when patients decide whether to have surgery or not they typically do not toss a coin. Probably some do because they do not have enough information to make a more educated assessment of their chances of having a successful surgery or having equal success with non-surgical options.

So here are the results of this study. Remember a surgeon was asked to look at 20 patient profiles and make a recommendation for surgery or no surgery. The 20 patients had already had surgery or exercise therapy and the successful results of their treatment had already been recorded. How did the surgeons do? They may as well have flipped a coin.

Here is what the study said:

Conclusions: Surgeons’ criteria for deciding that surgery was indicated did not pass the statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.

Meniscus surgery that resulted years later in the patient’s need for further surgical treatment in the form of knee replacement or were considered failures

Surgeons at the Glasgow Royal Infirmary, University Hospital Llandough, and the University Hospital Wishaw in the United Kingdom published a February 2020 paper (18) recommending to their fellow surgeons which patients with meniscus damage and osteoarthritis would be considered as good candidates for surgery. Here is what they said:

“Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis unless there are mechanical symptoms. (Knee function is significantly compromised) This study assessed the risk of needing further surgery for osteoarthritis in the five years following partial meniscectomy in different age groups and different grades of knee osteoarthritis.”

What these doctors did was look at partial meniscectomies that were performed by the paper’s senior author during a 31-month period.  The range of follow-up was 3 to 5 years.

Results:

Conclusion: “(This) study shows that patients with no/mild osteoarthritis should be considered for  Arthroscopic Partial Meniscectomy. Patients with meniscal tears and severe osteoarthritis should be counseled on the outcomes and risks of further surgery after an Arthroscopic Partial Meniscectomy.

Arthroscopic partial meniscectomy or physical therapy in the middle-aged patient?

Arthroscopic partial meniscectomy or physical therapy in the middle aged patient?

Given the choice, most patients would rather see if physical therapy can alleviate their knee pain and improve function. However, as research points out, when physical therapy fails, the next step is usually surgery. Yet, the evidence suggests that the surgery will work just as well or not work just as well as the physical therapy. When then are people going to surgery?

A July 2022 paper writes (19): “It is unclear whether the results of arthroscopic partial meniscectomy are comparable to a structured physical therapy.” The researchers of this review study then investigated the efficacy of arthroscopic partial meniscectomy in the management of symptomatic meniscal damage in middle-aged patients. Using current available randomized controlled trials  which compared arthroscopic partial meniscectomy performed in isolation or combined with physical therapy versus sham arthroscopy or isolated physical therapy, the researchers found: “The benefits of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms are limited.” Further, they could not determine if arthroscopic partial meniscectomy or physical therapy offered superior results.

A June 2022 paper in the journal Osteoarthritis and cartilage open (20) from doctors at Brigham and Women’s Hospital, Harvard Medical School and Boston University School of Public Health suggests that physical therapy can be a “reasonable initial treatment.” But it is unclear what the best treatment would be for those for whom physical therapy did not offer substantial benefit. “The evidence also demonstrates that arthroscopic partial meniscectomy may be associated with greater risk of radiographic osteoarthritic changes, though more research and the addition of enhanced quantitative MRI-assessments are needed to further detail any compositional changes in the knee.” Simply, arthroscopic partial meniscectomy may be associated with a more rapidly developing osteoarthritis which should be explored further. Researchers have explored this further and we will discuss this below.

In six reviews of randomized controlled trials, arthroscopic partial meniscectomy did not show clinically important benefit over conservative treatment for knee function and pain.

A July 2021 paper (21) published in the British Medical Journal (BMJ) by the United Kingdom’s National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, and the University of Bristol examined the clinical effectiveness of common elective orthopedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines. Among these elective procedures was arthroscopic partial meniscectomy.

In this examination of effectiveness, the doctors explored previously published research including review articles. A review article is a study where previous research is accumulated into one set of findings. Here is what these doctors found.

Researchers in Spain writing in the Archives of orthopedic and trauma surgery (22) compared the effectiveness of exercise versus arthroscopic partial meniscectomy in August 2022 research. They also explored exercise alone for degenerative meniscal tears in the knee function of patients at a 5-year follow-up. In examining the data from previously published studies, the researchers suggested no significant between-group differences existed. Exercise vs exercise and arthroscopic partial meniscectomy resulted in similar outcomes in activities of daily living and quality of life.

Meniscus surgery recovery times: Patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time

Meniscus surgery recovery times

We will now see why people get meniscus surgery. For many there is an over expectation of what the surgery will do for them. This is why there is the lure to surgery. We see it every day in our offices. The long-standing belief is that surgery will fix everything. A recent paper from the University of Southern Denmark (23) wrote:

Patients are too optimistic about the success of a meniscus repair – Failure of meniscal repair occurs in up to 25% of patients.

A January 2020 paper published in The Archives of Bone and Joint Surgery (24) offers this assessment of meniscus repair:

“Meniscus repair is not a small surgery without complication. It is technically challenging and has a steep learning curve. General complications of arthroscopy such as venous thromboembolism, infection, and vascular injury could occur. Specific complications including nerve injuries, ligamentous injury, iatrogenic cartilage lesions, and poor suture techniques can happen during the meniscal repair. The surgeon should depict and accept the eventual complications and address them as rapidly as possible. It is also important to form patients about potential complications. Failure of meniscal repair occurs in up to 25 % of patients.”

Surgeons suggest the reason people come in for meniscus surgery is over expectation of what the surgery can really do for their knee problem.

Doctors writing in The Journal of the American Academy of Orthopaedic Surgeons (25) offer a very good rationale for why people still have meniscus surgery. Here are some talking points of the research:

Evaluating this data, one could imply that:

The surgical realities of meniscus tear surgery – the research

Between 2013 and 2016 – research began appearing to question not only the value of meniscus surgery but whether or not the surgery caused more harm than good. Let’s start with a New York Times piece in 2016. The summary is below.

What is the recovery time after arthroscopic meniscus surgery?

Some of the questions patients want to be answered when they compare non-surgical to surgical treatment of meniscus tears are:

While these numbers sound reasonable they are not for the patients in the long run. Non-surgical treatments such as comprehensive Prolotherapy typically and for a realistic expectation of treatment success are offered at about 6-week intervals and on average see results at the third treatment – anywhere from 12 – 18 weeks after the first treatment.

The difference is: While meniscus surgery can offer short-term goals the knee is in a downward spiral of joint instability from osteoarthritis to degenerative joint disease.

Short-term follow-up of meniscectomy has generated some positive results

Short-term follow-up of meniscectomy has generated some positive results; for example, a meniscectomy can provide temporary pain relief in the early stages following the operation, especially when an acute tear had caused excessive pain or popping preoperatively. Another immediate result may be a greater feeling of stability if the tear had previously been a source of instability or knee locking by catching between the tibia and femur. On long-term follow-up, however, these initial improvements have rarely been shown to last. Complete pain relief from meniscectomy is nearly unheard of after more than ten years and, at that point, more complex issues including a limited range of motion, radiographic degeneration, crepitation, and severe functional impairment have usually begun to surface. In many cases, a simple meniscus tear, if operated on, can become a career-ending injury.

Ten years of research 2013-2023 Arthroscopic Partial Meniscectomy versus Sham Surgery

We are going to take a ten year journey through the medical research calling into question meniscus surgery. We are going to start with a January 2023 paper published in the journal Osteoarthritis Cartilage (27). In this paper, researchers examined comparison studies between arthroscopic partial meniscectomy versus non-surgical or sham treatment in patients with MRI-confirmed degenerative meniscus tears. This was a systematic review and meta-analysis with individual participant data from 605 randomized patients performed by a team of Dutch, Norwegian, and Danish medical researchers.

In this study, the researchers combined data from four previously published studies. The patients in these studies averaged about 55 years old and about evenly split between men and women. A data comparison was made between the patients that had an actual arthroscopic partial meniscectomy against those that had a sham or fake knee surgery.

Primary outcomes were knee pain, overall knee function, and health-related quality of life, at 24 months follow-up.

Results: The arthroscopic partial meniscectomy group showed a small improvement over the non-surgical or sham group on knee pain at 24 months follow-up. Overall knee function and health-related quality of life did not differ between the two groups. Across all outcomes, no relevant subgroup of patients who benefitted more so from the arthroscopic partial meniscectomy vs. the sham surgery was detected. The researchers recommend “a restrained policy regarding meniscectomy in patients with degenerative meniscus tears.”

Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscus Tear – Surgery does not alleviate knee catching or knee locking after surgery.

The research mentioned above and reported by the New York Times was not the first time the meniscus surgery controversy was reported in the international media. On December 24, 2013, the New England Journal of Medicine published an article entitled “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear.”(28)

Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. Then a scoring system was designed to measure pain, symptom severity, and knee pain after exercise at 12 months after the procedure.

What they found was “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.”

In other words, avoid the rush to surgery that may not fix the patient’s reported problems.

Continuing forward, the lead researcher of this study Raine Sihvonen, MD published more papers on the problems of meniscus surgery.

In February 2018, in the Annals of the Rheumatic Diseases (29) Dr. Sihvoven and his fellow researchers noted that degenerative meniscus tear can be the result of knee osteoarthritis and not vice-versa: “(Our) results support the evolving consensus that degenerative meniscus tear represents an (early) sign of knee osteoarthritis, rather than a clinical entity on its own, and accordingly, caution should be exercised in referring patients with knee pain and suspicion of a degenerative meniscal tear to MRI examination or Arthroscopic partial meniscectomy, even after a failed attempt of conservative treatment.“

In other words, the meniscus tear is the result of knee osteoarthritis development. If you remove the meniscus you accelerate knee osteoarthritis. We will discuss this further below.

In April 2016, Dr. Sihvonen and colleagues wrote in the Annals of Internal Medicine (30) that removing parts of the meniscus did not appear to relieve the symptoms of knee pain and knee locking in surgical patients. “Resection of a torn meniscus (cutting away tissue that cannot be sutured) has no added benefit over sham surgery to relieve knee catching or occasional locking. These findings question whether (these) mechanical symptoms are caused by a degenerative meniscus tear and prompt caution in using patients’ self-report of these symptoms as an indication for Arthroscopic Partial Meniscectomy.” In other words, avoid the rush to surgery that may not fix the patient’s reported problems.

Many orthopedic surgeries in my opinion have a far worse outcome than patients anticipate primarily because they cannot return to the activities they love, such as running. When people have arthroscopy surgery I try to go over their surgical reports with them because often what they perceived as what was done with the surgery was not done and other things were done that were detrimental and they had no idea they were done.  I have never as far as know saw an orthopedic operative report that showed a real meniscus repair, where the meniscus was sewn together and that was it.  The typical report shows partial meniscectomy and no repair yet the patient believes it was a repair. Every arthroscopy report I have ever seen has findings that reveal osteochondral lesions, chondromalacia, meniscus degeneration, articular cartilage lesions ligament injury, and many others. Remember anyone can have decreased pain by doing less, and unfortunately, many people who receive orthopedic surgeries end up doing less.

Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.

Earlier in 2013 research published in the American Journal of Sports Medicine showed what little value meniscectomy has. Researchers compared meniscectomy to nonoperative treatment for meniscus tears. (31)

At the two-year follow-up, there was no difference in pain relief, improved knee function, or patient satisfaction. Results also showed that meniscectomy did not provide better functional improvement than the nonoperative group.

But what was the difference between these two groups? One group of patients underwent invasive surgery, had tissue removed, and will likely experience long-term meniscus degeneration.

In fact, most surgical meniscus treatments have, “have a high long-term failure rate with the recurrence of symptoms including pain, instability, locking, and re-injury. The most serious of the long-term consequences is an acceleration of joint degeneration.”

In research from May 2016, (32) doctors warned that the role of arthroscopic partial meniscectomy in reducing pain and improving function in patients with meniscal tears continues to remain controversial and that studies show no difference between arthroscopic partial meniscectomy and non-surgical treatment. 

Meniscus surgery outcomes in American soldiers

Army physicians from the William Beaumont Army Medical Center and doctors from Rush University Medical Center published a March 2018 study in the Journal of Knee Surgery. (27)

It reports on how military surgeons dealt with meniscal injuries. The report reveals findings on nearly 30,000 meniscus surgeries.

What are we to make of this?

Surgeons strongly argue that there is validity to meniscectomy

Doctors in Germany (33) say that many of the studies critical of arthroscopic meniscus surgery are not 100% reflective of the patients they see. Medical research is broken up into levels of evidence. Level 1 is based on evidence which means a researcher took existing research and combined it into a review of the literature. Doctors and researchers grade this at the lowest level of accredited research.

The German doctors say too much level 1 evidence is being offered as a generalization of meniscus surgery. The complaint is some surgeries will help some patients and that every meniscus surgery is not a bad surgery and this research is not reflective of that.

“The treatment of degenerative meniscal lesions should start with conservative management.”

The ESSKA guidelines also say the treatment of degenerative meniscal lesions should start with conservative management. In the case of persistent symptoms, surgery should be considered after 3 months. In the case of mechanical symptoms, arthroscopy might be indicated earlier.

They do say arthroscopy in advanced osteoarthritic knees is not indicated due to inferior clinical outcomes.

The complaint surgeons have is that some surgeries will help some patients and that every meniscus surgery is not a bad surgery and research is not reflective of this benefit.

In March 2020, (34) researchers announced a new study to answer this question. They write of their study:

“Arthroscopic partial meniscectomy after degenerative meniscus tears is one of the most frequently performed surgeries in orthopedics. Although several randomized controlled trials have been published that showed no clear benefit compared with sham treatment or non-surgical treatment, the incidence (numbers performed) of Arthroscopic partial meniscectomy remains high. The common perception by most orthopedic surgeons is that there are subgroups of patients that do need Arthroscopic partial meniscectomy to improve, and they argue that each study sample of the existing trials is not representative of the day-to-day patients in the clinic.”

The researchers of this study announced that they will seek to find “whether there are subgroups of patients with degenerative meniscus lesions who benefit from Arthroscopic partial meniscectomy in comparison with non-surgical or sham treatment.”

Another procedure – knee microfracture surgery and cartilage implant surgery

The notion that replacing dead meniscus tissue, with a dead person’s meniscus (human allograft) or with synthetic meniscus (really meniscus replacement) is going to prevent osteoarthritis, as discussed in our article Alternatives to knee microfracture surgery and cartilage implant surgery is not realistic. By the time a person has a damaged meniscus, many other tissues in their joints are also affected including ligaments and tendons that provide stability when strong or provide instability when compromised. The whole knee joint needs to be treated not just the meniscus tear. The human meniscus is mobile, movable, stretchable, and made up of fibrocartilage, and has many functions including joint stabilization and the manufacturing of specific mediators of healing that go into the synovial fluid. None of these functions can truly be reproduced by any other type of meniscus besides the person’s own meniscus.

Although there is some short-term improvement after these surgeries in aspects such as pain control, the long-term effects of meniscectomy, meniscal repair, and meniscal allograft transplantation reveal that symptoms, such as pain and instability, will persist for years afterward.

A November 2022 paper (35) in The American Journal of Sports Medicine  looked at meniscal allograft transplant (MAT), following a previous meniscectomy. In this study of 324 consecutive patients, the survivorship of arthroscopic Meniscal allograft transplant (MAT) using the soft tissue technique (the transplant is held in place by soft tissue as opposed to screwing it into the bone) was examined. Further, factors that could potentially influence failures and outcomes were investigated.

Study highlights:

Summary of this section: Why do we still perform meniscectomy?

Knee Arthroscopy

The goal of meniscectomy was to reduce pain, restore knee function, and prevent the development of osteoarthritis. As surgeons had long believed that the meniscus was a “remnant” tissue and that it was not needed, it could be removed if damaged without a negative effect.

However, as medical research studied the long-term effects of this procedure, it became apparent in the medical community that meniscectomy was a primary cause of the sudden onset of knee osteoarthritis. The meniscus was, in fact, an important component of the knee.

The meniscus provides several vital functions including mechanical support, localized pressure distribution, and lubrication to the knee joint. They are made of thick fibrous cartilage that allows them to function as a shock absorber between the upper and the lower leg bones.

Doctors in France writing in the medical journal Orthopaedics & Traumatology, Surgery & Research, (36) joined the growing list of doctors rallying under the banner “Save the Meniscus!”

This research asks the same question we do, Why do we still perform meniscectomy?

Why do we ignore a mountain of clinical and scientific evidence against meniscectomy?

They, like us, agree that it is high time that the paradigm shifted, in favor of meniscal preservation.

Part 3: Pain after meniscus surgery and rapidly developing osteoarthritis

What happens when all or part of the meniscus is removed? Joint instability is a common result of meniscectomy and so is pain after meniscectomy

Doctors at the Departments of Orthopedic Surgery and Biomedical Engineering at the University of California, Irvine teamed with the doctors at the Sports Medicine Institute, Hospital for Special Surgery, New York to assess what to do with the patient who had all or part of their meniscus removed. This is what they wrote in their November 2021 paper in the medical journal Cartilage. (37)

“Meniscus tissue deficiency resulting from primary meniscectomy or meniscectomy after the failed repair is a clinical challenge because the meniscus has little to no capacity for regeneration. Loss of meniscus tissue has been associated with early-onset knee osteoarthritis due to an increase in joint contact pressures in meniscectomized knees. Clinically available replacement strategies range from allograft transplantation to synthetic implants, including the collagen meniscus implant, ACTIfit (scaffold that is implanted in patients who have an intact meniscus rim), and NUSurface (an artificial meniscus). Although short-term efficacy has been demonstrated with some of these treatments, factors such as long-term durability, chondroprotective efficacy, and return to sports activities in young patients remain unpredictable. Investigations of cell-based and tissue-engineered strategies to treat meniscus tissue deficiency are ongoing.”

It has been suggested that the “quickest way for a person to get osteoarthritis is to have arthroscopic removal of their meniscus. There are many ways meniscectomy accelerates the osteoarthritis process through the structural wear of the articular cartilage.

Doctors at the Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, and The George Washington University School of Medicine and Health Sciences, Washington, DC., described the problem of degenerative joint disease after meniscectomy in a September 2021 paper published in the Sports Medicine and Arthroscopy Review. (38)

“The meniscus has an important role in stabilizing the knee joint and protecting the articular cartilage from shear forces. Meniscus tears are common injuries and can disrupt these protective properties, leading to an increased risk of articular cartilage damage and eventual osteoarthritis. Certain tear patterns are often treated with arthroscopic partial meniscectomy, which can effectively relieve symptoms. However, removal of meniscal tissue can also diminish the ability of the meniscus to dissipate hoop stresses, resulting in altered biomechanics of the knee joint including increased contact pressures.”

What are we seeing in this image? Even the radiologist cannot determine whether the image he/she is seeing represents a recurrent meniscus tear or is just post-surgical changes.

As mentioned above, the patient will be told that they will eventually develop knee problems. The long-term side effect of meniscus surgery is that meniscectomies can worsen knee joint instability by negatively influencing other supporting knee structures by increasing contact stress on the cartilage. The knee’s house of cards will crumble thereafter as increasing contact stress on the cartilage, increases the risk and occurrences of chronic knee inflammation and accelerates the degenerative knee conditions that lead to knee joint erosion or irreversible joint damage to the knee.

Joint instability is a common result of meniscectomy, which is not surprising when considering that the meniscus is a primary stabilizing component of the knee. The knee meniscus provides maximum joint contact protection and thus, reduces the contact stresses on the load-bearing surface of the joint, much like a washer does to distribute the pressure of the nut or bolt evenly and to provide a smooth surface or a double rear wheel (four-wheel) truck distributes less pressure on each tire than a normal two rear wheeled truck.

Common physical symptoms of instability after meniscectomy are crepitation, such as cracking or popping and locking in the joint. On radiographic examination, this postoperative deterioration of the knee is evidenced by a narrowing of the joint space between the thigh and shin bones or a flattening of the tibiofemoral surfaces.

Biomechanically, the development of osteoarthritis can in part be explained by the increased stress placed on the tibia and femur post-meniscectomy. It is a known fact that reducing the size of the contact area on a surface increases pressure in the remaining area. Therefore, by removing part of or the entire meniscus from the knee, the area through which weight is transmitted in the joint is reduced, thus increasing the pressure on both the tibia and the femur and their articular cartilage.

Accelerated breakdown of the articular cartilage between the femur and tibia and the patella and femur bones

How does this happen? Meniscectomy increases friction dramatically during motion by depriving the joint of the ability to lubricate the articular cartilage properly. This accelerates the breakdown of the articular cartilage between the femur and tibia and the patella and femur bones.  When these metabolically active articular cartilage cells degenerate faster than they can regenerate, the result is accelerated breakdown (degeneration) within the joint. This is not a recently discovered phenomenon.

Hyaluronic Acid Intra‐articular Injection after Arthroscopic Knee Surgery

In an effort to prevent rapid knee breakdown following meniscectomy surgery, many doctors offered their patients hyaluronic Acid intra-articular injections. The thinking is that the “gel” shots would provide some cushion and help prevent the grinding of a “bone-on-bone situation.”

A November 2022 study in the journal Orthopaedic Surgery (39) assessed the effectiveness of Hyaluronic Acid intra-articular injection in helping patients with their recovery following arthroscopic knee surgery. The researchers acknowledge that while accepted hyaluronic acid injections after arthroscopic knee surgery have been widely offered, the injection’s effectiveness and safety remain controversial.

In reviewing previously published data, the researchers focused on fifteen studies involving 951 knees. The results showed no significant difference between the hyaluronic acid group and the control group in the reduction of pain or improvement of function. The researchers concluded: “Although hyaluronic acid injection after arthroscopic knee surgery is safe, the available evidence does not support its (effectiveness) in pain relief and functional recovery. Therefore, the application of hyaluronic acid injection after arthroscopic knee surgery is not recommended.”

When you remove the meniscus you remove vital knee lubrication

One of the most vital but lesser-known roles of the meniscus is to provide lubrication to the knee, which it accomplishes by diffusing (spreading out) synovial fluid across the joint. Synovial fluid provides nutrition and acts as a protective measure for articular cartilage in the knee. The femoral condyle of the thigh bone in the knee is covered in a thin layer of articular cartilage, which serves to reduce emotional friction and to withstand weight-bearing. This cartilage is very susceptible to injury both because of its lack of proximity to the blood supply and the high level of stress placed on it by excessive motion. The meniscus, therefore, is able to provide a much-needed source of nutrition to the femoral and tibial articular cartilage by spreading fluid to that avascular area.

Arthroscopic meniscus surgery leads to a three-fold increase in the need for knee replacement and supper accelerated osteoarthritis.

Here we present a brief review of many of the papers published in recent years suggesting that meniscus surgery causes more harm than good in many patients.

These are not new controversies. In November 2016: Research in the medical journal Orthopedics (40) examined the rate of patients needing knee replacement after an arthroscopic procedure. 

The study’s doctors suggested that this information can help surgeons to counsel patients on the incidence of total knee replacement after knee arthroscopy and identify preoperative risk factors that increase risk.

In 2017, doctors in the Netherlands published their findings in the medical journal Osteoarthritis Cartilage: (41) “In patients with knee osteoarthritis, arthroscopic knee surgery with meniscectomy is associated with a three-fold increase in the risk for future knee replacement surgery.”

Citing this 2017 research is an August 2022 study lead by doctors at Brigham and Women’s Hospital and Harvard Medical School and published in the journal Arthritis & rheumatology (42) examined the risk of the development of MRI documented structural changes in knee osteoarthritis among individuals with meniscal tear and knee at baseline and 18 and 60 months after arthroscopic partial meniscectomy versus physical therapy.

The researchers found that for both treatment groups, arthroscopic partial meniscectomy and physical therapy, knee osteoarthritis changes were seen during the early observation intervals than during the later intervals.  Analysis revealed that, between baseline and the 18th month assessment arthroscopic partial meniscectomy was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint sub regions (contact areas of the knee), and the number of sub regions damaged, having a worsening effusion-synovitis score (more swelling), and having  more than an additional sub region with develop boney overgrowth or bone spurs. Significant associations were detected between months 18 and 60 only for having any sub region with a worsening osteophyte score (the bone spurs got worse).

Conclusion: “These findings suggest that the association between arthroscopic partial meniscectomy and MRI-based structural changes in knee osteoarthritis is most apparent during the initial 18 months after surgery.” In other words the osteoarthritis develops quickly.

Meniscus surgery causes super-accelerated knee arthritis

Do these findings present anything really new? No, research has been ongoing telling patients and doctors of the risks associated with arthroscopic meniscus repair.

It is remarkable that studies more than a decade and a half old have issued the same warnings. In 2005, doctors in Canada audited the effectiveness of certain medical procedures and found very poor quality evidence on the efficacy of arthroscopic debridement of the knee with partial meniscectomy. (43)

The summary of these studies is? If you have a meniscus surgery, chances are you will be disappointed in the outcome and then move on to an eventual knee replacement.

In research appearing in the medical journal Clinical Anatomy, doctors issued their report on a phenomenon of super-accelerated osteoarthritis in knees with meniscus tear damage and a history of surgical meniscus removal.

Coming out of Tufts Medical Center in Boston, the researchers noted that knee osteoarthritis is typically a slow, progressive problem; however, in some patients knees progressed to osteoarthritis with dramatic rapidity. However, clinicians cannot determine which patients may be at risk for accelerated knee osteoarthritis without knowing the incident structural damage that predisposes a knee to accelerated osteoarthritis. The Tuft researchers found that structural damage that is associated with accelerated knee osteoarthritis destabilizes and compromises the function of the meniscus or compromises the subchondral bone. (44) 

In an early study researchers from the Department of Orthopaedic Surgery at Carolinas Medical Center found that a damaged meniscus is an active participant in the development of knee osteoarthritis. In the study above, the relationship to bone damage is discussed, in this cited study the Carolinas Medical team found a strong association between meniscus damage and cartilage loss. (45) The two combined studies help confirm missing meniscal tissue contributes to bone and cartilage degeneration.

Meniscus removal throws the whole knee out of balance and damages other structures – the best way to prevent cartilage breakdown and knee osteoarthritis caused by meniscal surgery is to AVOID the surgery.

Doctors at the Hospital of Special Surgery found that meniscus removal, not only impacts the knee at the point of the surgery but throws the whole knee out of balance and leads to several points of cartilage deterioration. (46)

What is really remarkable is that researchers write paper after paper saying that the removal of meniscal tissue in surgery causes advanced osteoarthritis and the procedures continue.

Clearly, the best way to prevent cartilage breakdown and knee osteoarthritis caused by meniscus surgery is to AVOID the surgery.

Here is a positive study on the benefits of meniscus surgery (47) in middle-aged patients: In this study, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For the best success, you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after the operation.” 

In other words, even if a patient received “a proper diagnosis and excellent surgical technique,” problems with motion restrictions in the knee developed early. Motion restrictions are probably not what a middle-aged patient is expecting as a result of their meniscus surgery.

In the above research we cited from Raine Sihvonen, MD in February 2018, in the Annals of the Rheumatic Diseases, it is noted that:

Part 4: Non-Surgical and injection treatment options for the different types of Meniscus tears

A December 2021 paper published in the medical journal Cartilage (48) describes the challenges of treatment for a symptomatic painful knee with or without loss of function. About surgery, the paper notes: “arthroscopic surgery provides unpredictable results: recent evidence has shown that partial meniscectomy is not better than conservative management up to two years of follow-up, and the removal of meniscal tissue may accelerate osteoarthritis progression. . . ”

About injections, the paper describes: “Intra-articular injection of corticosteroids or hyaluronic acid may help in providing temporary symptomatic relief, but no influence should be expected on the quality of the meniscal tissue.” In other words, these injections will not help repair a damaged meniscus. Then the authors describe. the use of platelet-derived growth factors. “Preclinical studies have documented that platelet-derived growth factors may play a beneficial role in stimulating meniscal repair and regeneration by triggering anabolic pathways and stimulating local mesenchymal stem cells from synovium (the fluid of the knee). Furthermore, also mechanical stimulation (e.g., arthroscopic trephination (punching holes in the meniscus to try to stimulate healing) or percutaneous needling) in the red-red or red-white zone may further promote tissue healing.”

A December 2021 paper published in the Journal of Experimental Orthopaedics (49) revealed the thoughts of the attending members of the 2021 5th International Conference on Meniscus Science and Surgery in “for furthering the state of meniscus science in 2021.”

The most important findings of this survey were that the highest ranked future research and development focus areas should include meniscus repair, biologics, osteotomy procedures, addressing meniscus extrusion (your meniscus is sticking out beyond the shin bone and has its causes in root tear), and the development of new therapies for the prevention of Post-traumatic osteoarthritis. Currently, the reported most ‘valuable’ type of biologic for meniscus treatment was PRP injections, while amniotic fluid was reported as least ‘valuable’.

So what are we reading here? The doctors thought that the feature of meniscus tear treatment should be:

Are there risks of using cortisone before meniscus surgery?

Are there risks of using cortisone before meniscus surgery?

Most people that contact us already have a good understanding that frequent or long-term cortisone use has its challenges and risks.

In March 2021, research led by Rush University Medical Center and published in the journal Arthroscopy (50) found that patients who received knee injections within one month prior to knee arthroscopic surgery developed postoperative infections at twice the rate of those who did not receive an injection.

This of course relates to an injection increases the risk of surgical infection. But what about the overall impact of corticosteroids on the meniscus?

A November 2022 paper, also from Rush University Medical Center (51) and published in the journal Knee surgery, sports traumatology, arthroscopy offers a different perspective: “(while) consensus guidelines recommend administering a corticosteroid injection for patients with a symptomatic degenerative meniscus lesion prior to arthroscopic partial meniscectomy, (the study cited above) found that corticosteroid injection administered within one month prior to meniscectomy is associated with an increased risk of postoperative infection.”

Not all infections are the same: The authors continued: “However, infections may range in severity from superficial infections to serious infections requiring surgical interventions. Serious infections requiring surgical intervention are rare after a meniscectomy, occurring in 0.1% (1 in 1000) of arthroscopic partial meniscectomies. . . Patients were five times more likely to return to the operating room for infection after arthroscopic partial meniscectomy if they had a corticosteroid injection the month before or had multiple corticosteroid injections in the year before surgery. The risk of infection was no longer significant if there was at least a 2-month interval between preoperative corticosteroid injection and arthroscopic partial meniscectomy.”

Corticosteroid short-term success and long-term problems in meniscus injuries.

It is well understood by most medical professionals and their patients that prolonged and long-term corticosteroid injections for knee pain can break down cartilage including the meniscus. In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?”

Writing in the Journal of the American Medical Association, (JAMA) (52) they published their answer:

“Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”

In February of 2020 a review study with the title “Medical Reversals in Family Practice: A Review,” (53) published in the journal Current Therapeutic Research, Clinical and Experimental offered these points:

Cortisone can thin out the meniscus.

In August of 2020 in the journal Scientific Reports (54) doctors expressed concerns about damaging the meniscus tissue with cortisone injections. It should be noted that this research’s main findings were that it was okay to get one cortisone injection. For many people, one injection would be considered safe. Here are the learning points of that research:

Cortisone during the surgery

Doctors at The Ohio State University Wexner Medical Center offered a May 2022 report (55) that evaluated the risk of post-operative infection after intra-articular steroid injection at the time of knee arthroscopy in 2416 patients who were given intra-articular steroid at the time of knee arthroscopy. The authors noted: “Knee infection following arthroscopic surgery is rare. Intra-operative steroid injection during arthroscopic knee surgery is associated with a 4.3-fold increased risk of a subsequent knee infection. While the overall risk remains low, the use of intra-operative steroids is expected to result in one additional knee infection for every 448 arthroscopic procedures performed.”

In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue

We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below is an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C of Caring Medical Florida.

Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, have many advantages over arthroscopy, which include:

Research on stem cell therapy for treating a meniscus

Here is a summary view of the current state of stem cell repair of a meniscus tear published in December 2021 in the journal Orthopaedic Surgery. (56) According to the authors: “Due to the special anatomical features of the meniscus, conservative or surgical treatment can hardly achieve the complete physiological and histological repair. As a new method, stem cells promote meniscus regeneration in preclinical research and human preliminary research. We expect that, in the near future, in vivo injection of stem cells to promote meniscus repair can be used as a new treatment model in clinical treatment. The treatment of animal meniscus injury and the clinical trial of human meniscus injury has begun preliminary exploration. As for the animal experiments, most models of meniscus injury are too simple, which can hardly simulate the complexity of actual meniscal tears, and since the follow-up often lasts for only 4-12 weeks, long-term results could not be observed. Lastly, animal models failed to simulate the actual stress environment faced by the meniscus, so it needs to be further studied if regenerated meniscus has similar anti-stress or anti-twist features.”

Still a great potential to repair

Despite these limitations, repair of the meniscus by MSCs has great potential in clinics. MSCs can differentiate into fibrous chondrocytes, which can possibly repair the meniscus and provide a new strategy for repairing meniscus injury.

The reality of stem cell therapy

We don’t treat everyone with stem cell therapy

If you do not have a meniscus, stem cell therapy as an injection will not make a new one

Expectations of what stem cell therapy can do may lead to patient disappointment

Should I have another meniscus surgery?

We offer a non-surgical option for meniscus repair and that is why people reach out to us. It is probably the reason you arrived at this article now. To see if our non-surgical option may be an option for your meniscus surgery recommendation. We do understand that there are instances where someone will consider that they have no choice but to have surgery. They are active people whose knees lock up and are acutely painful on movements. The meniscus problem is interfering with their ability to work, participate in sports or simply have a decent quality of life. For some people, meniscus surgery will be successful. The point of this article however is what is the long-term cost of meniscus surgery in terms of knee function and pain? Secondly, if non-surgical options can deliver success equal to or better than surgical intervention.

Another of the most common calls our office receives involves patients who have had part or all of their meniscus removed and are now suffering from continued pain or arthritis as a consequence of the meniscus or multiple meniscus surgeries they had.

This is reflected in the types of emails that we get from people looking for help. They go something like this:

I have severe osteoarthritis in both knees. I have had meniscus surgery on both knees. Every day I live with severe pain and swelling in both of my knees. I am told only knee replacements will help me now. I do not want any more surgery. I feel that it is the meniscus surgeries that put me in this position.

I have had meniscus surgery on each knee. X-rays and MRIs show major arthritis in each knee. I can’t walk for longer than an hour without my knees swelling and being so painful I can’t walk anymore. I just turned 50, I do not want to even consider knee replacement without trying everything first

Again, some people do benefit from meniscus surgery in the short-term and near future. It is these recent surgical success patients that we do not see in our clinic. Who we see are the people, who already had meniscus surgery and their knee is causing them problems, or people who do not want a meniscus surgery at this time because of upcoming sports seasons, competitions, or simply because they need to work and there is a waiting list to get the surgery.

The meniscus can have a 90% tear and it will still figure out how to function

The meniscus has a very difficult time healing its own injuries because of a lack of vascularization to the entire meniscus. That is the blood that carries healing elements do not reach the entire meniscus. Because of this, the meniscus is a composite of different types of cells, superficially, those that can heal, and those that can’t.

However, researchers at the University of Pennsylvania examining the meniscus’ complex mesh of fibers that run criss-cross to each other discovered that the two types of meniscus fibers, whose jobs are to absorb knee impact, the circumferential fibers and the radial tie fibers have a unique understanding of maintaining knee integrity in the event of meniscus injury.

They write: The meniscus is comprised of circumferentially aligned fibers (basically a mesh) that resist the tensile forces within the meniscus that develop during loading of the knee. Although these circumferential fibers are severed by radial meniscal tears, tibial contact stresses (the impact on the shin bone) do not increase until the tear reaches about 90% of the meniscus width, suggesting that the severed circumferential fibers still bear the load and maintain the mechanical functionality of the meniscus.

Note: The meniscus can have a 90% tear and it will still figure out how to function.

How it does this, is that the radial tie fibers, the perpendicular mesh network of the meniscus are helping to redistribute the knee load back to the severed but still functioning circumferential fibers.

Note: What does all this mean?

The study conclusion spells it out. “This finding supports the notion that radial tie fibers may similarly promote tear tolerance in the knee meniscus, and will direct changes in clinical practice and provide guidance for tissue engineering strategies.”(40)

If you are exploring stem cell therapy for a meniscus tear, the great likelihood that you are doing this research is that you are looking for an option for surgery. Please see our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work?

Do you have a question about meniscus surgery or need help?
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References
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This article was updated January 20, 2023

 

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