Everyone’s life is not the same and everyone’s needs are not the same so one of the things we have to keep in mind is that the answer is not that same for everyone.
In my last post I discussed the symptoms caused by a torn meniscus in the knee. Today we are going to cover the options for dealing with this problem.
One of the most difficult things in medicine is helping patients decide the best treatment for their individual situation. Everyone’s life is not the same and everyone’s needs are not the same so one of the things we have to keep in mind is that the answer is not that same for everyone.
Unless the knee is stuck and will not bend or straighten at all, a torn meniscus is not an emergency. You can take your time deciding what you want to do about it and not rush into making a decision. The initial treatment consists of activity restrictions, ice, and oral anti-inflammatory medication. Some activities may cause more pain and swelling and these activities are best avoided initially. This may be more intense activities like running, jumping, or playing sports. Sometimes simple things like climbing stairs or walking on uneven surface (gravel or grass) is enough to cause problems. After the initial pain is managed, there are basically 5 options for dealing with a torn meniscus:
Activity Restrictions - if pain is only caused by certain movements or activities, one option is to simply limit that type of activity. If this is an acceptable solution for a patient (not playing tennis anymore) there may not be any further treatment required.
Cortisone Injection - a cortisone injection in the knee can help reduce pain and swelling in the knee. Sometimes this allows a return to function that more acceptable than quitting a desired sport or activity. Cortisone does not cause the meniscus to heal but can help manage the symptoms quite well. Repeat cortisone injections may be necessary if the symptoms return.
Physical Therapy - Therapy to restore the normal motion and strength around the knee can also improve pain and allow a return to function. If therapy is too painful, sometimes a combination of a cortisone injection and therapy is easier to manage. Therapy usually requires twice a week visits for a few weeks.
Meniscus Repair (Surgery) - if the symptoms are not well managed with simpler methods, sometimes surgery is necessary. If the meniscus is torn in an area that may heal, a repair of the meniscus may be the best option. This is done arthroscopically (a small camera is inserted into the knee through small incisions) and the meniscus is stitched back together. Recovery from a meniscus repair usually requires use of a brace and sometimes requires limited weight bearing on the injured knee for several weeks to allow the meniscus to heal properly
Meniscus Removal (Surgery) - most meniscus tears are in a part of the meniscus that is not likely to heal. In this case, simple removal of the meniscus is the most successful surgery. Only the damaged portion of the meniscus is removed, not the entire meniscus. This surgery is performed arthroscopically and typically does not require any significant restrictions or limitations after surgery. The recovery varies depending on the individual patient but most patients are able to fully weight bear on the injured leg within a few days and can return to sedentary work within a few days. More physical work may take longer to resume.
Taking care of younger patients is different than taking care of older patients. In children we have to consider that their bodies are still developing and we don’t want to do anything that is going to cause any problems with development or future growth. We also have to consider the long term consequences of not fixing a problem that exists. In patient younger than 25, most meniscus tears are best treated with surgery. The irregular surface of a torn meniscus can cause abrasion and wear of the cartilage nearby and that is not something we want for someone that needs to use that knee for another 40+ years. Children also have a greater ability to heal, making a repair of the meniscus a better option.
No one like to be considered old but we must recognize that things change over time. Normal wear and tear changes develop over time and studies have shown that meniscus tears can be seen on MRI in 20-50% of patients over the age of 50 without any knee pain or swelling. This is considered an incidental finding - it does not require any treatment if it is not causing any symptoms. Knowing that some meniscus tears are present without causing any symptoms creates a challenging dilemma in a 60 year old patient with a month of knee pain and a torn meniscus on MRI.
In this population I usually advise a more conservative approach. Try a cortisone injection, do a few weeks of physical therapy, and see how much things improve. If the pain continues at a significant level, then surgery is worth discussing. If the symptoms are mechanical (locking, catching, knee giving out, popping) then the surgery is more likely to be successful. If aching pain is the major issue, surgery is less reliable and may not eliminate the pain.
Most of the meniscus tears I see are in people aged 30-60. They range from sedentary - working at a desk all day and not very active, to the very active - working in a manual labor job or exercising several times a week. The best treatment in this varied group depends on their expectations and overall health. People that are more active, with better strength, balance, and coordination, are better able to handle minor problems in the knee and may be able to simply modify how they do things and do not require surgery. On the other hand, their expectation may be higher and even minor knee pain can cause problems at work or an unacceptable restriction in their ability to exercise. This may push them toward having surgery to fix the problem so they can resume the lifestyle they desire.
The best way to make this decision is to have a discussion with your doctor about your lifestyle - your job, your exercise, your overall health - and your expectations and together you can decide which option is best for you.