Surgery for my medial meniscal tear?

A 49-year-old woman was referred for treatment of her “medial meniscal tear”. Her primary complaint was of activity related medial knee pain - with no mechanical symptoms or instability symptoms. Her GP had arranged for her to have an MRI. The report outlined that she had a “medial meniscal tear” and she would need an arthroscopy. What had not been explained to her was that the MRI scan also documented that she had “full thickness articular cartilage loss” overlying most of the weight bearing surface of her medial femoral condyle (with corresponding changes over the medial tibial plateau).

The image shown here shows a large area of articular cartilage loss over the medial femoral condyle, with a small area of full thickness loss overlying the tibia. There is increased signal (a white appearance) in the adjacent bone. The arrow also shows a small area of increased signal in the posterior horn of the medial meniscus. Addressing the meniscal change in this situation would not be effective.

There is an increasing body of evidence that arthroscopies are not effective for many meniscal injuries. This is especially true when there is associated articular cartilage pathology. There is data to show that surgery is no more effective than rehabilitation for degenerative meniscal tears, even when there are mechanical symptoms. It is however important to emphasise that surgery can still be an important treatment for some patients. These patients are often younger, may have significant mechanical symptoms or have displaced or unstable meniscal tissue.

In almost all cases where a “meniscal tear” is suspected the best initial treatment is rehabilitation. Analgesia, avoidance of painful activity and an exercycle or pool-based programme is a very effective treatment. Targeted exercise to improve the patient’s range of motion and to prevent muscle wasting is also very important. Imaging (XR and MRI) can be useful when their symptoms have failed to settle, and additional treatment is being considered. For patients where an arthroscopy is not appropriate, there are a range of options available to manage their problem. It is essential that lifestyle factors are addressed This may include weight loss, facilitating exercise and stopping smoking. A range of medication and injection treatments may also be considered. One relatively novel treatment involves the injection of platelet rich plasma (PRP). This is something that may be considered when other treatment options have failed. There is a growing number of randomised controlled trials that have demonstrated the efficacy of this treatment.