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Physical Therapy or Surgery for a Meniscus Tear?

Today’s article is a guest post from Lenny Macrina, my co-owner of Champion and co-author of my online knee course.  Meniscal tears are common, and some interesting new studies are coming out showing that surgery may not be the best option, at least for some people.  Social media is quick to shun meniscus tear surgery, however there are likely still some people that will benefit from this more than physical therapy alone.  Lenny discusses more in the article below. But I also wanted to make sure you knew that Lenny and I’s online course on the Evaluation and Treatment of the Knee is on sale this week for 50% off.  More info below!

 

Meniscus tears are very commonly diagnosed by physical therapists and doctors. The question remains, what is the best treatment for someone with a meniscus tear…surgery or physical therapy?

I may be a bit biased because I am a physical therapist. Let me get that out there right now. I’d almost always advocate for physical therapy over surgery for most of the cases that I deal with. But I do believe we are trying to be too black and white at times and need to keep an open mind.

There are many factors that need to be considered when deciding between physical therapy or surgery for a meniscus tear.  Some people may do better with physical therapy, while others may do better with meniscal tear surgery.

It depends.

With that, I decided to do a literature to see what the latest research is telling us. There’s lots out there and it seems as if the recent studies push for physical therapy as the first line of defense for someone with a mensical tear.

Intuitively, that makes sense but I wanted to dig deeper and see if this was true for everyone, or are there certain people that may benefit more from surgery.

 

Do You Need Surgery After a Meniscus Tear?

Of course, I went to PubMed because that’s my go to website for the latest in research topics. My search for knee meniscus physical therapy pulled up hundreds of papers, so of course I read them all…ok, maybe not.

I did my best so here goes…

In summary, it seems like there’s pretty good evidence to support that physical therapy should be used early after a meniscus tear in most of the common cases that we see.

There’s a growing body of evidence to try physical therapy first, especially for chronic degenerative meniscus tears. When I say a degenerative meniscus tear, I mean a tear that is probably a bit older and has been chewed up, well beyond repair.

Mensicus Tear Surgery or Physical Therapy

 

These degenerative meniscus tears are also often associated with knee arthritis, to some extent. Because of this, surgery to help with the associated pain is often limited due to the arthritis, and may not help the patient as much.

A period of active rest to calm the knee down and determine the course of treatment (surgery or more physical therapy) is often employed.

Very rarely is there a case where we should rush in to a surgery unless there’s a gross loss of motion, as in a bucket-handle meniscus tear that is obvious and leading to a disability.

I also think there’s a population of people who will benefit from surgery because they MAY be expecting to have surgery. I know, it’s complicated but that’s why we practice this stuff daily.

It’s not always cut and dry. People are human, and have emotions and opinions.

We can do all of the educating that we want but if they expect to have surgery and WANT surgery then just maybe they may benefit from having surgery. And that group of people may just do well.

Part of my treatment plan early on would be to educate them regarding the surgery, potential complications, some of the research and the post-op course.

All too often people are told that they’ll be back in 4-6 weeks after meniscus tear surgery and we all know that is NOT true. I usually tell people that it will take 4-6 months and even then, they still may not feel right until a year later. Sure, they may be doing some of their activities in 4-6 weeks, but that doesn’t mean they are completely back to normal.

The key is to recognize and find that person during your examination. I previously wrote a blog post on meniscus examination that goes over this in more detail.

Once diagnosed, can you separate out the meniscus tears that truly could benefit surgery from the ones that would do just as good without surgery?

Unfortunately, that’s the complicated part!

In a recent study from 2016, this group found that shorter symptom duration and greater baseline pain may be a predictor of who would qualify for earlier surgical intervention rather than physical therapy. They also suggested that an initial course of rigorous treatment prior to a knee scope may not compromise surgical outcome.

When in doubt, take it to Twitter.

In a recent Twitter discussion with some doctor colleagues of mine, we talked about this same and it was refreshing to hear that many are recognizing the fact that physical therapy may be the better option for most meniscal injuries.

Mensicus Tear Surgery or Physical Therapy

What is the Best Treatment Option for a Meniscus Tear?

Like I said earlier, there’s a bunch of research, so I tried to pick out some that I thought were the best and from highly reputable journals.

This study from the Journal of the American Medical Association showed that among patients with non-obstructive meniscal tears, physical therapy was equal to arthroscopy for improving patient-reported knee function over a 24-month follow-up period. ⠀⠀

They went on to say that “Based on these results, physical therapy may be considered an alternative to surgery for patients with non-obstructive meniscal tears.”

So, basically if there is not a bucket handle meniscus tear present that may be blocking joint range of motion, then it is highly encouraged that the treatment and exercise, and not undergo surgery.

Without going out on a limb, I’d say this is a much cheaper treatment option as well and would greatly reduce health care costs associated with the surgery and lost time from work.

This study from the British Medical Journal looked at the cost-effectiveness of meniscus tear surgery versus nonoperative treatment and showed that surgery was not economically effective and should be reconsidered.

I did note a couple limitations: the surgical group did not get treatment after surgery if they did ‘as expected’ but they could get treatment to help improve their symptoms.

The physical therapy group did pretty basic exercises although leg press, lunges and balance type exercises were included. I would’ve liked to have seen a more robust attempt at treatment that involved more strength training and true progressions for the quads, hip and complete lower body.

Another study that I wanted to discuss was a systematic review that looked at the best treatment options for someone greater than 40 years of age diagnosed with a degenerative meniscus tear.

They showed that ‘the results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy for a meniscus tear.’

There was an issue with the quality of the studies involved in the study, including a high risk of bias, weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics.

Furthermore, they said that no conclusion could be drawn as to which treatment was the best option for this patient population. Which I tend to agree, right?

Intuitively, one would say that physical therapy, as the cheaper option, would be the best but I think it goes to my above statements that “it depends” on the person, type of mensicus tear, chronicity of the tear, their symptoms, AND their beliefs.

I think this study from The New England Journal of Medicine basically says the same thing. A course of physical therapy may be good for some but often times surgery may be needed for a select group of people.

This study from the British Medical Journal looked at exercise versus surgery for degenerative meniscal tears in Norway. The mean age was 49.5 years, which is pretty typical, right?

This study also controlled for degenerative tears only and most everyone had no signs of radiographic knee osteoarthritis (96% of the cohort had no definitive radiographic evidence of osteoarthritis).

They showed that middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis should consider supervised meniscus tear physical therapy as a treatment option over surgery.

 

What to Recommend to Your Patient, Physical Therapy or Surgery for a Meniscus Tear?

Remember, about 1/3 of the meniscus has blood supply that can help it to potentially heal on its own. We got that information from a paper way back in 1982 and it still seems to apply today.

I don’t think there’s any doubt that physical therapy (swelling control, range of motion, strengthening, education) should be one of the first treatment options in someone that has been recently diagnosed with a meniscus tear.

This seems to definitely be true in the groups of people with a degenerative meniscus tear. They seem to do just as well with early treatment than a more expensive surgical option.

For someone with an acute meniscus tear that is blocking range of motion, such as with a bucket handle tear, then surgery may be indicated right away.

For the younger athlete with an acute meniscus tear, I would potentially consider a surgery a bit earlier but still gives them a course of treatment for 4-6 weeks to see if the symptoms subside and the person can resume their normal function.

So, try meniscus tear physical therapy and hope to see significant changes in the patient’s symptoms and function in the first 4-6 weeks. If no true changes or if they are getting worse (and frustrated), then consider surgery.

After meniscus tear surgery, pick up the therapy where you left off and hopefully get them back to their ultimate goals.

 

Learn How We Evaluate and Treat the Knee

For those interested in learning more about how Lenny and I evaluate and treat the knee, we have an amazingly comprehensive course that covers everything you need to know to master the knee.  Our detailed examination process, all our treatment progressions, and detailed information on nonoperative and postoperative treatment of ACL, patellofemoral, meniscus, articular cartilage, osteoarthritis injuries, and so much more.

 

 

 

Meniscus Repair Rehabilitation: Why Are We Still Stuck in the 90’s?

Today’s article is from my co-owner of Champion PT and Performance and co-author of OnlineKneeSeminar.com, Lenny Macrina.  Lenny does a great job discussing some of the controversies surrounding postoperative progressions, specifically weight-bearing and range of motion, follow meniscus repair surgery.

 

Meniscus injuries within the knee are a common occurrence.  In fact, the National Center for Health Statistics reports that meniscus surgery is the most frequent surgical procedure performed by orthopedic surgeons in the United States, with more than 50% of the procedures performed in patients 45 years of age or older.

Despite this high occurrence, many inconsistencies continue to exist in the rehabilitation of a patient following meniscus repair surgery, particularly involving the rate of weightbearing and range of motion.

I’m still shocked by this and wanted to discuss the recent research that is lending to a more progressive approach to return people safely back to their prior level of function.

Rehabilitation Follow Meniscus Repair

meniscus repair surgery weightbearingRehabilitation after surgical debridement of the meniscus is pretty straightforward. We return the patient’s range of motion, strength and function per their symptoms and let pain and swelling guide the rehab process (a very general guide but one often employed by many rehabilitation specialists).

However, when the meniscus is actually repaired and not just debrided, there are other factors to consider.  When a meniscus is repaired, the tear is approximated using stitches to allow the tear to heal.  

Rehabilitation following a meniscus repair has to be more conservative, however, despite research saying otherwise, there are still many rehabilitation protocols floating around the orthopaedic and sports medicine world that recommend limiting weight-bearing and range of motion after a meniscal repair.  We continue to ignore the literature because of fear that the ‘stress’ on the meniscus with walking and range of motion may be too high.

Unfortunately, many of these commonly used protocols are from the 1990’s. (The current protocols we use can be found at RehabilitationProtocols.com)

So if we’re going to talk 90’s protocols, take a look at these studies from way back when from Shelbourne  and Barber  that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction.

Recent studies from VanderHave and Lind on isolated meniscus repairs have shown similar results using an “aggressive” program of immediate weightbearing compared to a more conservative approach.

I certainly wouldn’t consider these “aggressive” programs, they simply used immediate weightbearing and range of motion.

Again, these studies show meniscal repair outcomes are no different while using restricted weightbearing and range of motion versus an “aggressive” protocol of immediate weight-bearing and unlimited range of motion.

Early Weightbearing After Meniscus Repair

meniscus repair surgery range of motionBut what about the exact mechanisms that many are still fearful of allowing early in the process, like early walking and range of motion? Won’t that put the repair in a position to fail?

We typically immobilize people in full extension during weightbearing, locked in a brace for 4-6 weeks after meniscal repair surgery.

So, if immobilized in extension, why do we limit weightbearing?

During weightbearing, compressive forces are loaded across the menisci. These tensile forces create ‘hoop stresses’, which expand the menisci in extension. These hoop stresses are thought to be helping the healing process in many tears by approximating the tissue.

Furthermore, the compressive loads applied while weightbearing in full extension following a vertical, longitudinal repair or bucket-handle repair have been shown to reduce the meniscus and stabilize the tear, as noted by Rodeo  and more recently by McCulloch.

Early Range of Motion After Meniscus Repair

What about early range of motion?

There is very limited literature on the influences of range of motion on meniscal movement. Thompson showed that during flexion, the posterior excursion of the medial meniscus was 5.1 mm, while that of the lateral meniscus was 11.2 mm.

Looking at meniscal movement as the knee flexes in weightbearing and non-weightbearing you can see there’s less motion, although I really don’t think we know how much motion is detrimental. The motion has been shown to help improve blood flow to the area. This is huge and may aid in the healing process!meniscus biomechanics

What Do We Recommend?

Anecdotally, I can say we have handled meniscal repairs to allow weightbearing and range of motion to tolerance for many years.  Some of the top orthopedic surgeons in the world that I have worked with currently handle a meniscal repair the same as an ACL reconstruction with a meniscal repair .

For an isolated meniscal repair, I prefer the knee continue to be immobilized in full extension for 4-6 weeks but allowed full weightbearing immediately (if a longitudinal repair). For complex repairs, I would recommend limiting weightbearing to partial but understand that the hoop stresses could aid in healing and are arguably helpful and necessary.  For both cases, I would recommend passive range of motion to tolerance.

Trust me, I respect the healing meniscus and continually monitor patients as I progress their range of motion and weight-bearing activities. Things like new joint line pain along the site of the repair, new swelling or a change in pain patterns, and even clicking (although most people have this) are all signs that I may want to further assess and modify my progression.

Based off of this, I continue to stand by my rehab guidelines of full, pain free passive range of motion and immediate weightbearing after a vertical longitudinal meniscal repair. The literature is screaming this same thing at us but we continue to ignore their calls and revert to the 90’s!

What do the surgeons that you work with recommend?  Are any of them still recommending rehab guidelines based on outdated research?  Comment below and let me know, I want to hear what the rest of the country is seeing!

 

Learn How We Evaluate and Treat the Knee

For those interested in learning more about how Lenny and I evaluate and treat the knee, we have an amazingly comprehensive course that covers everything you need to know to master the knee.  Our detailed examination process, all our treatment progressions, and detailed information on nonoperative and postoperative treatment of ACL, patellofemoral, meniscus, articular cartilage, osteoarthritis injuries, and so much more.

 

 

 

Meniscus Repair or Meniscectomy? Comparison of Long Term Outcomes

image There is an interesting study about to come out in an upcoming article in the American Journal of Sports Medicine comparing the outcomes of arthroscopic meniscus repair and partial meniscectomy. 

The authors compared 42 patients undergoing meniscal repair to 39 patients undergoing partial meniscectomy at a mean of 8.8 years after surgery.  The authors specifically evaluated osteoarthritic progress, loss of knee function, and influence on sports activities.  The authors did a good job controlling the study by excluding knees with instability and only including medial meniscus tears.  However, the study was no completely randomized, the decision to perform a repair versus meniscectomy was based on the type of meniscus tear present.

 

Arthroscopic Meniscus Repair Surgery Video

There are some pretty neat videos on YouTube of meniscus repairs, thought this would be a good place and time to include one here:

 

Results

Results of the study were interesting:

  • 81% of patients having a meniscus repair did not show any significant osteoarthritis at the time of follow up, while 60% of meniscectomy patients did show osteoarthritic changes.
  • Functional scores showed no difference between the two procedures, however 94% of meniscal repair patients returned to their previous level of sport activity compared to only 44% of the meniscectomy group.
  • There was a significant drop in sport activity in the meniscectomy group only.

 

Clinical Implications

Personally, I wasn’t very surprised at the large difference between groups.  It is obvious that the mensical repair procedures are fair superior to partial meniscectomy.  It is well established that preserving as much as the meniscus as possible will yield greater results over time.  The menisci play a very important role in shock absorption and the normal biomechanics of the knee. 

There are many pros and cons to both procedures, and the postoperative recovering is certainly longer following meniscal repair, however the results of this study certainly show that pros should outweigh the cons.  It should be noted that sometimes a repair is not always feasible and meniscal damage of this nature will likely result in osteoarthritic changes over time, potentially explaining the results of this study.

What I take away from this study is more educational that clinical.  I am not sure that there is anything we can do differently to enhance outcomes in meniscectomy patients based on this study, but the results do underscore the dramatic importance of the meniscus on knee function.

Imagine that it was fairly common to perform a COMPLETE meniscectomy only a few decades ago!

Clinical Examination for Meniscus

Today’s post is a review of a recent meta-analysis looking at the accuracy of clinical tests for meniscal lesions from our friend Dan Lorenz, MS, PT, ATC/L, CSCS.

RESEARCH UPDATE: Clinical Tests for Meniscal Lesions

Dan Lorenz, MS, PT, ATC/L, CSCS

It has been estimated that approximately 27% of all outpatient physical therapy visits are for knee pain.1 Of the many possible lesions causing pain, one common source is from a meniscal lesion. Recently, Meserve et al2 did a meta-analysis summarizing the accuracy of clinical tests for assessing meniscal lesions of the knee. Previous researchers have performed meta-analyses on clinical tests for meniscus tear, but failed to account for the variability and in test sensitivity and specificity due to differences in methodological quality among the studies.3-5 Because of that, diagnostic accuracy could be skewed. Clinicians should select tests with the highest sensitivity or negative likelihood ratio to rule out meniscal injury, or conversely, rule in meniscal injury with tests having high specificity or positive likelihood ratios.1 The purpose of this update is to provide a synopsis of what was found in their review.

Eleven studies satisfied the authors criteria of sixty-four total considered for potential review. Joint line tenderness, Apley’s, and McMurray’s were reviewed based on them being the most common tests utilized. Ege’s and Thessaly tests were also evaluated, but the quality of the studies was not good based on small sample sizes. Of note, diagnostic tests findings were interpreted without considering whether the lateral or medial meniscus was torn.

The researchers ultimately found that:

  • Joint line tenderness was found to be the superior test in terms of sensitivity, followed by the McMurray’s and then Apley’s.
  • Specificity values were larger with Apley’s compared to joint line tenderness and McMurray’s.
  • Ege’s Test and the Thessaly Test,6-7 tests that have either compression with weight bearing or clinician-applied axial rotation, were found to have the strongest diagnostic accuracy, but with smaller samples in the studies.

image

Based on this review, like any other special test used clinically, a combination of a thorough history along with a physical exam will help the clinician differentially diagnose conditions that are presented to them. As with many other tests used for other pathologies, it appears that using several tests to detect meniscal lesions is supported by the literature.

 

EDITOR’S NOTE: The results are interesting and clinically applicable. Anecdotally, I have always observed that joint line pain and pain with deep knee flexion, either with weightbearing or passively, where the most indicative of meniscal pathology in my hands. Conversely, passively extending the knee into hyperextension seems to be uncomfortable in patients with anterior horn tears. One test that just doesn’t seem to work well for me is the Apley’s test. Sounds like the test may still useful as the specificity is high. What has your experience been? What other tests you feel are helpful in detecting a meniscal lesion? Thanks for the review Dan.

References

  1. Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997; 77: 145-54.
  2. Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clinical Rehabilitation. 2008; 22: 143-161.
  3. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003; 139: 575-88.
  4. Scholten RJ, Deville WL, Opstelten W, et al. Accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract. 2001; 50: 938-44.
  5. Solomon DH, Simel DL, Bates DW, et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA. 2001; 286: 1610-20.
  6. Akseki D, Ozcan O, Boya H, et al. A new weight bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. Arthroscopy. 2004; 20: 951-58.
  7. Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005; 87: 955-62.

 

Meserve BB, Cleland JA, & Boucher TR (2008). A meta-analysis examining clinical test utilities for assessing meniscal injury. Clinical rehabilitation, 22 (2), 143-61 PMID: 18212035