Meniscal Injuries

Usually not. The FIDELITY trial (Sihvonen et al., NEJM 2013) randomly assigned 146 patients with wear-related (degenerative) tears of the inner meniscus and no osteoarthritis to keyhole surgery that trims the tear (arthroscopic partial meniscectomy) or to placebo (sham) surgery, and found no difference in any primary outcome at 12 months. The ESCAPE trial (van de Graaf et al., JAMA 2018) compared physical therapy with arthroscopic partial meniscectomy in 321 patients with degenerative tears. Its 5-year follow-up (Noorduyn et al., JAMA Network Open 2022) found physical therapy was still no worse than surgery (noninferior) for knee function as patients rated it. For degenerative tears, a structured rehabilitation program is a reasonable first step for many people.

Traumatic tears usually happen in a specific moment, often a loaded twist or cutting movement in a younger athletic knee, with immediate pain, swelling, and sometimes a true locking episode. Degenerative tears develop over years in middle-aged and older knees, often without a clear injury event, and commonly sit alongside early osteoarthritis. The rehabilitation pathway is quite different, which is why the history matters as much as the MRI.

The outer third has a blood supply and some capacity to heal, particularly in younger patients with tears near the outer edge (peripheral tears). Healing potential varies with the tear's location, pattern and treatment. The inner region has much less blood supply, so it has less ability to heal on its own. That does not mean symptoms cannot settle. Plenty of degenerative tears stop causing symptoms with strengthening, load management and time, even if the tear itself stays visible on imaging.

Possibly, but true locking and a vague sense of catching are different. True locking means something in the joint physically stops the knee straightening fully and you cannot unlock it yourself, often from a large tear that flips into the joint (a bucket-handle tear). That is an orthopaedic issue that needs prompt assessment. A feeling of clicking, catching, or the knee 'hesitating' is common in degenerative tears and osteoarthritis, and is usually managed without surgery.

The METEOR trial (Katz et al., NEJM 2013) randomly assigned 351 patients with a meniscus tear and osteoarthritis to keyhole surgery to trim the tear (arthroscopic partial meniscectomy) plus physical therapy, or to physical therapy alone, and found no meaningful difference in function at 6 months. Thorlund and colleagues' 2015 BMJ systematic review and meta-analysis of keyhole surgery for knees with wear-related (degenerative) problems concluded that any benefit over non-surgical care was small, short-lived, and gone by one to two years. Physiotherapy is a reasonable first choice for most degenerative tears, and plenty of injury-related tears that do not block the knee's movement also respond well to loading.

The clearer reasons for surgery are true locking that cannot be released, large tears that flip into the joint (bucket-handle tears), and torn flaps that have moved out of place (displaced flap tears) in younger patients whose symptoms genuinely limit what they can do. Some tears at the meniscus's anchor point (root tears) are also included, where early repair may help protect the joint. Younger patients with lengthwise tears near the outer edge, where the blood supply is good, may also be candidates for meniscus repair. That is a different operation from trimming the tear (partial meniscectomy) and has very different implications for long-term knee health. These are case-by-case decisions made with an orthopaedic surgeon.

Often yes, with modification, for a tear that has been assessed as stable or wear-related. Appropriately adjusted activity is often possible, and loading the front thigh and hip muscles is part of the treatment. Root tears, displaced tears, a new major injury and a repaired meniscus need different advice. Sharp twisting, deep squats with weight early on, and sudden large jumps in volume tend to flare symptoms. The usual approach is reducing aggravating activities for a few weeks while rebuilding strength, then adding load back in gradually.

Meniscus loss is a known risk factor for later knee osteoarthritis, and trimming the meniscus (partial meniscectomy) removes tissue that will not grow back. This is one of the reasons the evidence has pushed back against routine surgery for degenerative tears. Operating on a tear that would have settled with rehab can be counterproductive over decades. Keeping as much working meniscus as possible is generally the priority.