Meniscal Tear Knee Injury in a Younger Adult? Consider Physiotherapy

It is well established that physiotherapy is a good first-line treatment for certain meniscal tears in the knee, and that physiotherapy is not inferior to a common surgery. However, all this research was based on people age 50+. What about meniscal tear treatment in younger adults? Despite the differences in these populations, new, first-of-its-kind research finds physiotherapy also not inferior to certain surgeries for adults aged 18 to 40.¹  

About Menisci

Each knee has two menisci, crescent-shaped cartilage between the tibia and the femur. They work to disperse friction, impact, and pressure between the leg bones meeting at the knee joint. As such, tearing is common. Meniscal tears seem to occur as part of a degenerative process in the knee. In fact, more than half of people age 50+ have meniscal tears.¹ They are often asymptomatic, but for some, it can create pain and disability.

First-line Physiotherapy Treatment for Non-obstructive Meniscal Tears

Younger adults can also experience meniscal tears. A higher percentage of those tears would be from injury rather than degeneration.³ Nevertheless, this new study, published in the New England Journal of Medicine, finds that physiotherapy as the first-line treatment is not inferior to two common types of surgery: arthroscopic partial meniscectomy (APM) or meniscal repair. For non-obstructive meniscal tears, when physiotherapy is used first, seventy to seventy-five percent of patients using exercise treatment do not go on to surgery in one to two years.^1,4  

Considerations to Discuss with Your Surgeon

Some caution may be warranted with this advice. The new study used a 12-week physiotherapy program. If fast return to sport is the priority, this may warrant a specific conversation with the surgeon and physiotherapist. Also, Sood et al. show that patients with traumatic bucket-handle meniscal tears had a greater rate of successful repair when surgery was performed within six weeks of the injury.⁵ There may be some types of meniscal repair surgeries that work better when surgery is elected earlier. This is another issue that a patient would want to discuss with the surgeon.

Preventing Future Meniscus Degeneration

Among older patients, exercise-treated knees have fewer degenerative changes and lower risk of total knee replacement than APM-treated knees.^6,7 It has been theorised that exercise therapy reduces the progression of degenerative changes through improved biomechanics in terms of joint unloading and shock absorption.^18,19 Exercise therapy may offer similar benefits to younger patients. The authors of the new study are already planning a follow-up study to measure this.

Conclusion

The research offers considerable encouragement for people with knee injuries to receive a physiotherapy evaluation. For certain knee problems, exercise therapy may produce results not inferior to surgery while also protecting the knee against future degeneration.   

References:

1. Skou ST, Hölmich P, Lind M, Jensen HP, Jensen C, Garval M, Thorlund JB. Early Surgery or Exercise and Education for Meniscal Tears in Young Adults. NEJM Evidence. 2022 Jan 25;1(2):EVIDoa2100038.
2. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. New England Journal of Medicine. 2008 Sep 11;359(11):1108-15.
3. Wilson, PL, Wyatt, CW, Romero, J, Sabatino, MJ, Ellis, HB. Incidence, presentation, and treatment of pediatric and adolescent meniscal root injuries. Orthop J Sports Med. 2018;6(11):2325967118803888.
4. 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.
5. Sood, A, Gonzalez-Lomas, G, Gehrmann, R. Influence of health insurance status on the timing of surgery and treatment of bucket-handle meniscus tears. Orthop J Sports Med. 2015;3(5):2325967115584883.
6. 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.
7. 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.
8. 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.
9. 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.