How is a torn meniscus treated?

After an acute meniscus injury, your knee may be painful and swell. If that happens, it’s recommended to first

• rest your knee, lie down and elevate your leg, and
• ice it by placing a cold pack on your knee for about 15 minutes every 2 to 4 hours. Icing the knee on the same day is especially important to prevent swelling.

It is recommended to rest your knee until the pain and swelling have improved. Any movements that place a lot of strain on the meniscus, like squatting or kneeling, should be especially avoided. The same is true for activities where the knee is turned or repeatedly bent, like climbing stairs, bicycling, or driving a car (operating pedals).

If you’re in a lot of pain, anti-inflammatory painkillers like ibuprofen and crutches are sometimes considered.

A few days after the injury, when the swelling has gone down and the diagnosis of torn meniscus has been confirmed, treatment can start.

Some acute meniscus tears can be treated conservatively, others need surgery. This depends in part on the size of the tear, its starting point, its shape, and your symptoms.

In Germany, acute torn meniscus is usually treated with surgery. In other countries, conservative treatment is often used for smaller tears that don’t block knee motion.

It is not yet clear how the two treatment methods compare in terms of their success. There are no studies comparing conservative and surgical treatment so far. The first study of this type has now been started in Denmark.

Well-trained muscles generally protect the knee. Structured training is recommended after surgery. A physical therapist can teach you these kinds of exercises, which you can then do on your own later on.

The table below summarizes the pros and cons of surgery versus conservative treatment. The table doesn’t cover every aspect, and shouldn’t be interpreted as giving recommendations. But it may help you to discuss the various options with your doctor.

A torn meniscus can be treated with the following conservative methods:

• Exercise therapy
• Anti-inflammatory painkillers, like diclofenac or ibuprofen
• Knee braces or orthoses
• Weight loss (if very overweight)

But the effectiveness of these treatment methods for injury-related meniscus tears has not been well studied. For wear-related meniscus tears, osteoarthritis of the knee and other knee disorders, there are many studies that show exercise therapy to be especially effective.

Helpful exercise therapy includes exercises to strengthen muscles and improve stability, range of motion, and coordination. It is important to do the exercises properly. This means, for example, avoiding jerky movements and stabilizing yourself by holding onto a chair or table when doing certain exercises while standing. Wearing sturdy, shock-absorbing sneakers with good traction is also recommended.

Physical therapists and doctors who specialize in knee problems can show you suitable exercises and guide you through them. But it's important to do the exercises on your own and regularly for them to be successful. You can do that at home or in a group exercise class like a functional exercise course.

Anti-inflammatory painkillers and knee braces can help support your exercise therapy, but they can't replace it.

Surgery is almost always done as part of knee arthroscopy (keyhole surgery). Two or three small cuts (incisions) are necessary to do this procedure. A special endoscope called an arthroscope is inserted through one of the incisions. It contains a small camera, a light source, and a cannula to rinse the knee for a better view. Doctors can use the arthroscope to look at the inside of the joint, including the meniscus. Through the other cuts, small surgical instruments for grasping, cutting, and suturing can be introduced.

The damaged parts of the torn meniscus can be removed or sutured:

• If they are removed, ragged parts of the torn meniscus are shaved off. This makes the rough surface of the torn meniscus smoother. This procedure is also known as meniscus smoothing or partial resection.
• In meniscus repair, the tear is sutured using small instruments. This procedure is also called meniscus suture.

Which procedure is chosen will depend on various factors. The location of the tear plays an important role:

• In the outer third (“red zones”), the meniscus has a good blood supply and heals better. That’s why it can sometimes be sutured there, especially in young people.
• The middle third is known as the red-white zone. Experts don't agree on whether suturing the meniscus in this area is a good idea.
• The inner third of the meniscus – the white zone – has no blood supply. The chances of a tear healing in this zone are very slim. That’s why tears in the white zone are not usually sutured.

Whether the meniscus is sutured or partially removed also depends on the stability of your knee joint and the size of the tear. Sometimes the decision about whether it is possible to suture the tear can only be made during the procedure.

So far, few studies have examined the advantages and disadvantages of meniscus suture in comparison with partial removal. The same is true for the advantages and disadvantages of different surgical techniques and materials. The studies done had very few participants, and some of their results were contradictory.

Advantages of meniscus repair over removal include

• better preservation of meniscus function and
• a lower risk of developing osteoarthritis of the knee compared to partial removal.

Disadvantages include

• a longer recovery period after the procedure and
• a higher risk of revision surgery after a few years compared to partial removal.

Studies show that about 20% of people who had meniscus repair needed revision surgery within 5 years, usually because the suture didn't hold. About 4% of patients who had partial removal needed revision surgery within 5 years.

Complications from knee arthroscopy are very rare. A large study analyzed the results of 700,000 knee arthroscopies for partial meniscus removal. They showed that

• infection occurred in about 1 in 1,000 procedures, and
• lung embolism occurred in less than 1 in 1,000 procedures.

These numbers are averages across all age groups. The risks are slightly lower for people under age 40 and slightly higher for people over age 40.

To prevent blood clots and the possibly resulting vein thrombosis and lung embolism, anti-thrombotic injections and anti-embolism stockings are often prescribed. But studies show that they are not necessary after partial removal of the meniscus: The risk of thrombosis or lung embolism is very low anyway – in part because you start walking again soon after surgery. The anti-thrombotic injections increase the risk of bleeding, too.

How long it takes to recover from surgery depends very much on whether the meniscus was partially removed or repaired. A repaired meniscus can tear again if too much strain is put on it too early. That’s why it’s important for the rehabilitation to be planned together with doctors and physical therapists and for you to get instructions on how to do the exercises.

In the first few days after surgery, it’s recommended to rest the knee, regularly elevate it, and ice it to reduce pain and swelling.

Rehabilitation after partial removal of the meniscus has three general phases:

• Up to week 3: Theoretically, you can put your full weight on the leg directly after partial removal of the meniscus. But that can be painful, so crutches are often recommended for the first few days. After about one week, you can walk normally on flat ground. When climbing stairs, you shouldn’t yet put your full weight on the leg, though. In the first few weeks, different physical therapy exercises help restore the range of motion, strengthen muscles, and improve stability.
• Weeks 4 to 6: You can start light exercise on a bicycle or stationary bike. Once your muscles are strong again and your knee is stable enough, you can do movements that strain the knee, like climbing stairs normally.
• After 6 weeks, you can do most activities and sports again – if possible after talking with your doctors or physical therapists.

After meniscus repair, longer rehabilitation treatment is necessary. The speed of your recovery will depend on your physical condition and size of the meniscus injury. So, the total length of rehabilitation treatment can vary quite a bit. To give you a general idea, there are roughly three phases of rehabilitation:

• Up to week 6: In the first few weeks, crutches are used to reduce the weight put on the leg, and more weight is put on it gradually. As part of physical therapy, the knee is first moved passively with the goal of fully extending the leg and bending it to 90 degrees. Light strengthening exercises can strengthen the front of the thigh – for example, by repeatedly lifting and lowering the straight leg while lying on your back. Strains like actively bending the knee are avoided.
• Weeks 7 to 14: Usually, the knee can now bear your full body weight. In this phase, the goal is for the knee to gradually regain full range of motion and for you to be able to walk normally again. Endurance for everyday tasks gradually returns. But the knee needs to be stable enough before starting to do activities that put a strain on it.
• After week 14: Specific exercises and light sports activities are done to get the your leg to be as strong as the other healthy leg and have the same range of motion. You can ride a bicycle and use a stationary bike after about three months (sometimes earlier), run after about four months, and play ball sports or ski after about six months.

You are advised to avoid painful movements during rehabilitation: Pain or swelling is a sign that you are trying to do too much with your knee.

Many people assume that all the symptoms will go away after meniscus surgery. That isn't always true: Studies show that about half of the people who had partial resection of the meniscus are still satisfied with the results one year later. About 15% of people who had surgery said it was not successful.

The amount of time it takes to heal also varies a lot. For example, a young professional soccer player who’s back on the field within a few weeks is in very different physical shape than a less athletic or older person.

Many changes in the meniscus are the result of normal wear. This is known as "degenerative" meniscus damage. People usually don’t notice that they have it.

Degenerative meniscus tears and changes are most common in people over age 40 and in people with osteoarthritis of the knee. If these people do have knee symptoms, they are usually not caused by the meniscus damage.

Studies show that for wear-related meniscus tears, arthroscopy doesn't relieve the pain, nor does it improve the functioning of the knee.

Many experts now advise against surgery for people with degenerative meniscus injury – especially if they also have osteoarthritis of the knee. Because of this, the treatment of degenerative meniscus injury is no longer covered by the statutory health insurance in Germany. Exceptions may be made if part of the meniscus has torn off and is blocking knee motion to the point where the knee can no longer be fully straightened. For people with symptoms due to wear and/or osteoarthritis of the knee, the most important thing is to regularly exercise the knee and get good osteoarthritis treatment.