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Exercise therapy recommended as initial treatment for non-traumatic meniscal tears
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The results of this level 1 study comparing arthroscopic surgery after exercise therapy to exercise therapy alone for patients with non-traumatic, degenerative meniscal tears found significant clinical improvements from baseline to 2-year and 5-year follow-ups in both groups, and showed no significant differences in outcomes between treatment groups.
“The findings indicate that arthroscopic surgery followed by exercise therapy was not superior to the same exercise therapy alone for this type of patients,” the authors wrote in their study abstract. “Consequently, exercise therapy can be recommended as initial treatment. However, one third of the patients from the exercise group still had disabling knee symptoms after exercise therapy but improved to the same level as the rest of the patients after arthroscopic surgery with partial meniscectomy.”
The investigators studied 96 patients with Ahlbäck osteoarthritis (OA) grade 1 or lower and MRI-verified medial meniscus tears who were assigned to receive either exercise therapy alone or arthroscopic treatment followed by 2 months of the same exercise program.
Follow-up at 24 months and 60 months revealed significant improvements in both groups compared to baseline measures using the KOOS, Tegner Activity Scale, Lysholm Knee Score and Visual Analog Scale for pain. At 5-year follow-up the investigators also found that two patients in each group showed progression of their OA.
Perspective
Back to TopFreddie H. Fu, MD, DSc(Hon), DPs(Hon)
Modern orthopaedics has been criticized for relying heavily on imaging studies to diagnose and treat musculoskeletal conditions. This article demonstrates that the overall results of a simple exercise program for middle aged patients with symptomatic knee pain and MRI evidence of a degenerative meniscus tear were equivalent to patients treated with arthroscopy and a similar exercise program. Interestingly, 1/3 of the patients randomized to the non-operative arm of the study ultimately underwent arthroscopy due to persistent symptoms that limited their activities of daily living. When the results of these patients were analyzed with an intention-to-treat model, the outcomes of each group were not significantly different.
Perhaps the most important conclusion from this study is that not all patients with atraumatic knee pain and suspected meniscal pathology need to be immediately evaluated with an MRI. A simple physical therapy exercise program will be sufficient to successfully manage most of these patients, with advanced imaging and arthroscopy reserved for those with persistent symptoms for longer than 6 weeks. We must always remember to treat the patient, not the imaging studies!
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