There is significant controversy and debate within the medical community about the most effective treatment approaches for meniscus tears. And because of this, patients are often confused when they get conflicting opinions from healthcare providers. I’m going to help you understand what’s actually going on with a torn meniscus. I’ll clarify why treatments can be confusing and highlight how new advances in orthobiologics and regenerative medicine are transforming our approach to both surgical and non-surgical treatments for meniscus tears.
I’m also going to show you an easy at home rehabilitation program designed to treat both the acute injuries we often see in younger athletes as well as the degenerative conditions more typical in older adults. My goal is to provide you with all the necessary information to help you decide which treatments will enable you to restore your knee strength and improve your quality of life.
Meniscus Tears
Meniscus tears are common knee injuries affecting individuals at all levels of sports and recreational activities. The meniscus is a crescent-shaped, fibrocartilaginous structure within the knee, consisting of two parts: the medial meniscus and the lateral meniscus. Positioned between the femur (which is the thigh bone) and the tibia (which is the shin bone), these components serve as cushions that help improve knee functionality.
The meniscus plays a crucial role in shock absorption, weight distribution, and reducing friction, which collectively enhance mechanical stability during physical activities like walking, running, and jumping. Additionally, the meniscus contributes to the nutrition and lubrication of the knee by distributing synovial fluid. This distribution not only facilitates smoother knee movements but also helps reduce wear and tear on joint surfaces.
Meniscus tears are generally classified into two types: acute and degenerative. Acute tears often result from sports-related activities and occur during sudden twisting motions when the foot is planted and the knee is bent. This type of tear is frequent in sports requiring quick direction changes, such as soccer, basketball, and football, and is more common among younger individuals who are more active.
Degenerative meniscus tears are typically seen in older adults and occur due to the gradual wear and tear of the cartilage. Over time, this wear leads to weakening of the meniscus, making it susceptible to tears from even minor movements or stresses. Often, these tears happen without a specific memorable incident.
Meniscus Tear Symptoms
Meniscus tears can cause a range of symptoms depending on the tear's severity and location. Common symptoms include pain along the joint line, worsened by twisting or squatting, and swelling that usually occurs within the first 24 hours after the injury. The knee might also feel stiff with restricted range of motion.
Some individuals may notice a catching or locking sensation especially when trying to straighten the leg. In severe cases, the knee may feel unstable or may even give out during certain activities. What’s really confusing about meniscus tears is that symptoms can vary significantly from person to person. Some people have minimal discomfort whereas others will have severe debilitating pain.
It’s also important to point out that meniscus tears often do not heal on their own and there are several reasons for this. First, the blood supply to the meniscus varies significantly. The outer third of the meniscus is known as the “red zone” and has a robust blood supply. Tears in the red zone have some potential for healing. However, the inner two thirds of the meniscus is known as the “white zone” and has a very poor blood supply. Tears that occur in the white zone almost never heal on their own.
The type and severity of the tear also affects healing potential. For example, small longitudinal tears in the red zone are more likely to heal than complex or large radial tears in the white zone. Furthermore, the constant stress from daily activities and sports can prevent the torn edges of the meniscus from stabilizing, complicating the healing process.
Meniscus Tear Controversy
Now this next part is really important and explains why doctors give varying opinions when it comes to meniscus tears. We are coming to understand that not all meniscus tears are pathological. As we age, the meniscus naturally thins out and becomes more brittle. Just as we wouldn't recommend hair transplants for naturally graying hair, we are recognizing that meniscus tears can be a normal part of the aging process and don't always necessitate targeted treatments.
Research indicates that incidental meniscal findings on MRI scans of the knee are frequent across the general population and become even more common with age. For instance, this study found a 32% prevalence of meniscus tears in men aged 50 to 60 years old. This rate rose to 56% in men aged 70 to 90 years old. A similar trend is observed in women, where 19% of those aged 50 to 60 had meniscus tears, increasing to 51% among those aged 70 to 90 years old.
More importantly, when patients reported catching, popping, or clicking in the knee, doctors commonly attributed these issues to meniscus tears. It was believed that fragments from a torn meniscus could interfere with the joint's smooth movement, leading to what were termed "mechanical symptoms." Previously, the prevailing belief was that surgery to remove these fragments was the only way to alleviate these mechanical symptoms.
However, recent insights suggest that these mechanical symptoms may not be directly caused by meniscus issues. Instead, research indicates that symptoms traditionally associated with meniscal tears, such as catching, clicking, and popping, are more closely linked to broader joint issues like inflammation and osteoarthritis. The authors report that “contrary to current dogma, traditionally defined ‘meniscal’ and ‘mechanical’ knee symptoms are strongly associated with the burden and severity of underlying cartilage damage rather than with specific meniscal pathology.”
This shift in understanding is crucial for guiding treatment strategies. It highlights the importance of avoiding unnecessary surgeries, which may not alleviate pain if the meniscal tear is degenerative or asymptomatic, or if the symptoms are incorrectly attributed to the meniscus. Instead, the focus can shift toward non-surgical options such as physical therapy, injections, and lifestyle changes, which may be more effective in managing the underlying joint issues.
Meniscus Repair Surgery
So now let’s transition the discussion to talking about treatment options for meniscus tears and how to choose between surgical and nonsurgical options. Let’s first discuss the two most common surgical interventions which include meniscus repair surgery as well as arthroscopic partial meniscectomy. Determining whether a patient is suitable for surgical meniscus repair largely depends on the characteristic of the tear as well as the healing potential of the meniscus.
An ideal candidate for meniscus repair surgery is typically a younger person who has recently sustained a small tear in the red-red zone of the meniscus. As a reminder, this area has a rich blood supply, which is crucial for effective healing. The likelihood of a successful recovery is further increased if the patient has no other knee issues, such as ligament injuries or osteoarthritis. Additionally, an active lifestyle and a strong commitment to adhering to a structured rehabilitation protocol after surgery are essential for optimizing the healing process and restoring full joint function.
Age also plays a significant factor in predicting the success of meniscus repair surgery. Patients under 35 usually have high healing potential and are often considered ideal candidates for this procedure. Although being over 50 does not automatically rule out the possibility of meniscus repair, it is rarely performed in this age group due to poorer tissue quality, the presence of arthritis, and higher rates of repair failure. For patients between these age ranges, the benefits of meniscus repair are more contentious and widely debated.
This debate is fueled by the variable success rates of meniscus repair surgeries. One study reported that meniscus repair remains a procedure with a high failure rate. They analyzed nearly 4000 patients with meniscus repairs and reported close to 15% failure rate at follow-up between 2 to 5 years. Another study reported that at a minimum of 5 years after surgery, the failure rate of meniscus repairs was nearly 25%.
To make matters worse, failed meniscus repairs often require additional surgery. Typically, this next step is an arthroscopic partial meniscectomy, which we will soon learn has been linked to increased cartilage loss and worse progression of arthritis. That’s on top of all the extra pain and extended rehabilitation associated with an additional surgical procedure.
So given the significant risk of failure and subsequent need for additional surgery associated with meniscus repairs, it becomes even more crucial to consider activity level and risk factors for knee osteoarthritis. The presence of cartilage loss, particularly in patients with high body mass index, diabetes, hypertension, and high cholesterol, significantly reduces the likelihood of a successful repair.
Ultimately, the decision to proceed with a meniscus repair must consider not only the chance of initial success but also the long-term health implications should the repair fail. This brings us to the option of arthroscopic partial meniscectomy, also known as cleanup surgery or debridement. This procedure, which involves the removal of meniscus tissue, is often recommended for meniscus tears where repair is either not possible or is likely to fail.
Arthroscopic Partial Meniscectomy
Over the last decade, arthroscopic partial meniscectomy has become one of the most commonly performed orthopedic surgeries in the United States for the treatment of degenerative meniscus tears. But recent clinical trial evidence has shown that arthroscopic surgery should only be performed after an extensive trial of non surgical management has failed, and even then, surgery may not result in better outcomes.
For example, there are now numerous clinical trials that compare arthroscopic surgery to physical therapy and, after 5 years, there are no differences in outcomes whether patients undergo surgery or continue with exercise therapy. Systematic reviews and meta-analyses of these trials have concluded that exercise therapy not only poses a lower risk of progressing knee osteoarthritis but also provides comparable benefits in terms of pain relief and knee function.
More alarmingly, studies comparing arthroscopic surgery to sham placebo surgery show concerning results. At 1 year, 2 years, and 5 years post-surgery, there was no difference in patient outcomes, indicating that arthroscopic surgery provided no clinical benefit compared to placebo surgery. Additionally, these studies found that arthroscopic surgery was associated with an increased risk of progressive arthritis when compared to placebo surgery.
And this makes sense. We are learning that a torn and frayed meniscus is still a functional meniscus. Recall that the job of the meniscus is to help in shock absorption, weight distribution, and reducing friction. By cutting out the meniscus, you have cut out the cushion between your bones and that will result in worse arthritis. Consequently, there is a growing trend in clinical research to “save the meniscus” and not cut it out.
What’s really interesting is that after all these studies started to come out with negative outcomes of the surgery, surgeons started to find other reasons to take people to the operating room. These reasons included the type, location, or specific characteristics of the meniscus tear, or the presence of mechanical symptoms such as clicking or catching.
But recent trials consistently challenge these justifications. This study says it best: “there is no evidence to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative management are more likely to benefit from arthroscopic partial meniscectomy.”
The one exception to this may be a specific type of meniscus tear called a bucket handle tear. This is because a bucket handle tear involves a large, longitudinal tear of the meniscus, which can cause a segment of the meniscus to displace into the joint. This can physically block the normal motion of the knee and prevent the knee from fully extending or bending, effectively locking the knee in a particular position. This is a direct mechanical problem caused by the displaced meniscal fragment itself, not just by inflammation or degenerative changes.
Unlike other scenarios where non-surgical treatments might be preferable due to the underlying cause being more related to degenerative changes, bucket handle tears usually require surgery. The locked knee condition is not only painful but also limits mobility and function, making surgical treatment necessary to physically remove the obstruction and prevent further damage to the joint.
So for all the above reasons, I generally do not recommend arthroscopic partial meniscectomy for the treatment of degenerative meniscus tears and encourage my patients to explore non surgical management options.
Exercise and Physical Therapy
Now let’s transition to talking about what options we have to treat meniscus tears instead of surgery. We’ll start by discussing the critical role of exercise and physical therapy. This approach is considered the first line and foundation for treatment for most patients.
Physical therapy serves multiple purposes in treating meniscus tears. Its primary goal is to restore knee mobility and to strengthen key muscles around the knee to support and stabilize the joint. Exercises also help enhance proprioception, which is the ability to sense the position of the joint, as this can be impaired following an injury. Better proprioception improves balance and coordination, thus reducing the risk of future injuries. By improving knee biomechanics through targeted strengthening and conditioning, physical therapy helps reduce stress on the meniscus, creating a better environment for recovery. This strategic approach is essential for effective treatment and long-term knee health.
In fact, clinical trials continue to support the recommendation that exercise therapy should be considered first line treatment, even for young adults. This study looked to test the hypothesis that early meniscus surgery including repair or partial meniscectomy would result in better outcomes when compared to exercise with the option of surgery later if needed.
The results showed that both groups experienced clinically relevant improvements in pain, function, and quality of life at 12 months and that there was no difference in outcome measures between both groups. Only 1 in 4 people from the exercise group eventually had surgery. These findings reinforce the effectiveness of conservative treatment approaches and suggest that exercise therapy not only serves as a viable first line treatment but also may reduce the need for surgical intervention in managing meniscus injuries.
Corticosteroid Injections
Now let’s discuss how injection therapy can play an important role in the management of degenerative meniscus tears and knee osteoarthritis. The most common offered injections are corticosteroids and hyaluronic acid but newer research has also been examining the effectiveness of orthobiologics, including the use of platelet rich plasma.
Corticosteroids, while effective in reducing pain and inflammation, have been shown to damage cartilage and contribute to joint degeneration. While there is still controversy over the degree to which this is clinically relevant, studies suggest corticosteroid injections can induce rapidly destructive joint disease and even accelerate the need for a total knee arthroplasty.
Hyaluronic Acid Injections
Another injection option is hyaluronic acid, also called gel shots or viscosupplementation injections. There continues to be controversy over the effectiveness of hyaluronic acid for the treatment of a degenerative knee. Many studies challenge its efficacy, while others show clear benefit. A critical factor influencing outcomes is the technique in which hyaluronic acid injections are performed. Patients treated with ultrasound guided hyaluronic acid injections are significantly less likely to undergo knee arthroplasty surgery when compared to patients getting landmark guided injections. This is why professional organizations such as the American Medical Society for Sports Medicine have consensus statements that continue to recommend hyaluronic acid injections as an effective treatment for knee osteoarthritis.
Platelet Rich Plasma Injections
Regenerative treatments and orthobiologics are emerging as promising therapeutic options for meniscus tears and the degenerative knee. Platelet rich plasma injections also known as PRP are a cutting edge treatment that utilizes the healing properties of your own cells. The procedure involves a simple blood draw and then separating the blood into various components using a centrifuge. We then take the layer that has all the platelets and growth factors and then inject that into an injured area. PRP treatments have been shown to be incredibly effective in treating a variety of conditions including tendons, muscles, and joints.
Recent systematic reviews and meta-analyses suggest that platelet rich plasma injections outperform corticosteroids, viscosupplementation, and placebo when it comes to treating a degenerative knee including osteoarthritis and meniscus tears. But it gets even better because PRP does more than just improve symptoms. One of the most compelling reasons to pursue PRP is that it may also slow down the progression of arthritis. This was demonstrated in a randomized controlled trial involving 610 patients which compared the effects of PRP injections to saline placebo injections in treating symptomatic knee osteoarthritis.
The study performed MRI scans at baseline and then again at 5 years post treatment. And the results showed that PRP injections led to an almost 50% reduction in the progression of arthritis when compared to the saline placebo.
What’s more exciting is that platelet rich plasma can even be used in meniscus repair surgery to improve the healing process. Studies suggest that meniscus repairs augmented with PRP injections led to significantly lower failure rates and better postoperative pain control compared to controls.
All of this compelling evidence from clinical trials is further reinforced by leading medical organizations. Both the American Academy of Orthopedic Surgeons and the American Medical Society for Sports Medicine have acknowledged the effectiveness of PRP. They’ve released summaries and consensus statements highlighting PRP’s significant benefits in reducing pain and enhancing joint function in knee osteoarthritis.
Dietary Supplements
Lastly, I want to quickly discuss dietary supplements. There has been a recent resurgence in the interest of using dietary supplements in reducing pain and symptoms related to a degenerative knee. Most people think of glucosamine and chondroitin when it comes to knee pain. And while clinical trials show that glucosamine chondroitin can help reduce symptoms, the effect size is small. More importantly, clinical trials suggest that there are two even better options.
The first is called Boswellia serrata. It is an herb extracted from the Indian frankincense tree. The active compound, called boswellic acids, inhibits the 5-lipoxygenase enzyme which results in potent anti-inflammatory effects. Many studies have shown that boswellia serrata can help reduce pain, decrease stiffness, and improve joint function in those with symptomatic knee osteoarthritis. The typical recommended dose of boswellia extract is between 100 mg and 250 mg daily.
The second supplement is turmeric. Turmeric is a spice derived from the Curcuma longa plant. Its active component is curcumin which has anti-inflammatory effects through several biomolecular pathways including inhibition of the NF-kB pathway as well as inhibiting the COX-2 enzyme. Systematic reviews and meta-analyses have found that curcumin supplementation was significantly more effective than placebo in the improvements of pain, stiffness, and functional scores.
Interestingly, studies directly comparing turmeric extract to NSAIDs such as ibuprofen and naproxen have shown similar reductions to knee pain and improvements to physical function. Notably, turmeric extracts had much fewer adverse events compared to NSAIDs. This is particularly important as chronic NSAID use increases the risk for cardiovascular complications, kidney impairment, and gastrointestinal complications. The typical recommended dose of turmeric is 1000 mg daily. I’ve included links to sample boswellia and turmeric supplements in the video descriptions.
The most important thing to keep in mind with regards to knee injections as well as supplements, is that they are meant to help improve pain and symptoms so that you can work on exercise therapy. Remember that the foundation of treatment for everyone with meniscus tears is to help support and stabilize the knee. This is best done through a targeted rehabilitation program that can restore knee mobility, strengthen supporting muscles, and improve joint proprioception.
Knee Braces & Supportive Devices
Now I’d like to give a quick overview of bracing options for those with meniscus tears. There are three main types of braces available: neoprene knee sleeves, hinged knee braces, and unloader braces. Unloader braces are specifically designed to relieve pressure on a particular area of the knee joint, which can effectively reduce pain. However, due to their bulky size and the difficulty in managing them, I generally do not recommend unloader braces.
Hinged knee braces have metal or plastic hinges on the sides of the brace that help to limit side to side movement of the knee. These can provide support to the knee and can be very effective after acute injuries or during flare ups. Hinged knee braces can potentially help correct alignment issues as well as reduce pain and improve function. I want to point out that hinged knee braces should not be worn 24/7 unless specifically instructed by a healthcare provider. Prolonged immobilization can be counterproductive and result in significant muscle atrophy.
Neoprene knee sleeves are among the most versatile aids for knee support. They offer gentle compression, which can help reduce swelling and inflammation in the knee joint. Additionally, knee sleeves enhance proprioception and provide a sense of stability, especially during exercise and other physical activities. They are also affordable and easy to use, making them a practical choice. Compared to other bracing options, knee sleeves are less intrusive and highly adaptable, suitable for a range of activities including walking, running, cycling, weightlifting, and more. For those interested in exploring these products, I’ve included links to sample knee braces in the video description to help you start your research.
Meniscus Tear Rehabilitation Stretches and Exercises
Now let’s shift our focus to a rehabilitation program. Remember, exercise and physical therapy is arguably the single most important thing you can do to get better after a meniscus tear. The following is a sample meniscus tear rehabilitation program designed to be done 3 times a week for at least 6 weeks. Commit to the program and you will see significant improvements to strength, range of motion, balance, coordination, and functional abilities.
Ok so, one of the first problems we need to address is muscle tightness, which can limit both range of motion and mobility. This tightness leads to repetitive friction, resulting in local inflammation and potential cartilage wear over time. Therefore, we will begin with four simple stretches aimed at increasing mobility and reducing knee tension.
Quadriceps stretch
The first stretch targets the quadriceps muscle which plays an important role in patellar tracking. Stretching out the quads can help improve alignment. Start by standing on your unaffected leg. Bend the knee of your other leg bringing the heel towards your buttocks. Gently grasp the ankle with your hand. Aim to keep your knees close together and aligned to effectively stretch the quadriceps. You can stand next to a wall or a sturdy object to help with balance. Hold this stretch for 30 seconds, then repeat on the other side.
Calf stretch
The next stretch targets the calves. Tight calf muscles can restrict range of motion which then increases tension in the knee joint. Start by facing a wall and then step your unaffected foot forward. Keep your back leg straight. Lean towards the wall until you feel a stretch in the calf. Hold this stretch for 30 seconds, then repeat on the other side.
IT band stretch
The next exercise is a standing IT band stretch. Stretching out the IT band can relieve any tension pulling the patella laterally. Begin by standing on the affected leg and then cross your other leg in front of it. Gently allow the hip of the affected leg to drop outwards away from your body. Lean your upper body slightly towards the opposite side to increase the stretch. You should feel an extending sensation along the hip and side of the affected leg. Maintain this position for 30 seconds and then repeat on the other side.
Hamstring stretch
The last stretch is a seated hamstring stretch. Just like with the calves, tight hamstrings can restrict range of motion which then increases pressure in the knee joint. Straighten out the affected leg in front of you and bend your other leg inwards so that the foot rests against the inner thigh of the straight leg. Hinge forward at the hips and reach towards the toes. Try to keep the leg as straight as possible. If you have tight hamstrings, a slight bend in the knee is okay, as long as you are feeling the stretch. Hold this position for 30 seconds and then repeat on the other side.
Next, we’re going to focus on strengthening exercises. Weakness and imbalances in the hip and knee muscles can lead to improper tracking of the patella. By strengthening these areas, we can improve patellar alignment and reduce stress on the knee joint. In addition, stronger muscles serve as shock absorbers which can diminish the impact on the knee during physical activities.
Bodyweight squat
The first exercise is the bodyweight squat. This is excellent for targeting the lower body particularly the quadriceps, hamstrings, glutes, and calves. Stand with your feet shoulder width apart. Extend your arms straight out in front of you to help with balance. Slowly bend your knees to lower your body, keeping your back straight and your core engaged. Aim to lower until your thighs are parallel to the floor. If you experience pain, you can start off doing half squats by stopping midway, and then gradually progressing to a full squat as your pain and mobility improves. Complete 2 sets of 15 repetitions. You can make this exercise more challenging by holding weights.
Straight leg raise
The next exercise is the straight leg raise. This is designed to strengthen the quadriceps, hip flexors, and abdominal muscles. It can also improve stability and flexibility in the lower back and hips. Start by lying flat on your back and bend both your knees with your feet flat on the floor. Then, straighten out the affected leg and lift it upwards to an angle of about 45 degrees from the ground. Hold the leg at the top of the movement for a few seconds and then slowly lower the leg back down. Perform 2 sets of 15 repetitions on each side.
Glute Hip bridge
The next exercise is the glute hip bridge which will help strengthen the glutes and provide stability to the leg. Begin by lying on your back with your knees bent and feet flat on the ground, positioned about hip-width apart. Keep your arms flat at your sides. Lift your hips, aiming to form a straight line from your shoulders to your knees. At the top of the movement, squeeze your glutes and hold briefly before gently lowering back down. To increase the challenge, consider adding resistance by using a band wrapped around your waist. Perform 2 sets of 15 repetitions.
Side lying Clamshells
Next we have the side lying clamshell. This will target the hip and pelvic muscles. Begin by lying on your side with both your hips and knees bent. Keep your feet together. Then, raise the top knee as high as possible without moving your hips or pelvis. Pause for a moment at the top, where you feel maximum engagement in your glutes, and then slowly lower the knee back down. To increase the difficulty, consider using resistance bands around your thighs, just above the knees. Perform 2 sets of 15 repetitions on each side.
Side lying leg raise
The next exercise is a side lying leg raise. This focuses on hip abduction which is great for enhancing hip stability and balance. Lie on your side with your legs straight. Raise the upper leg while maintaining a straight line with your body. Aim to lift it to about 45 degrees, hold it briefly at the top, and then gently lower it back down. Perform 2 sets of 15 repetitions on each side.
Step ups
Next, we have the step up. This exercise helps strengthen the lower extremity muscles, improves balance and stability, and addresses strength imbalances between the two legs. Stand in front of a sturdy platform. Step up onto the platform with your injured foot first and then follow with the other leg. Step back down, again with the injured foot first. Perform 2 sets of 15 repetitions on each side. To further challenge yourself, increase the step height or perform the exercise while holding weights.
Single leg balance exercise
The last exercise is the single leg balance. This helps improve stability, coordination, and lower body strength. Begin by standing on the affected leg on a stable surface. Put your hands on your hips and slowly shift your weight onto one foot. Carefully lift your other foot and raise the leg so that your thigh is as close as parallel to the ground. Hold this position for 1 minute and then repeat on the other side. As you build more stability, you can make this exercise more challenging by holding weights.
Remember, the goal of this rehabilitation program is to eliminate pain and restore function. Commit to this exercise regimen 3 times a week for at least 6 weeks and you will see tremendous improvements.
