Meniscus tear: physical therapy or surgery? What the trials actually show

The menisci are two C-shaped pads of cartilage that cushion the knee. A tear can happen with a twist in sport, but in an older knee even an awkward twist getting up from a chair may be enough [2]. Common symptoms are pain, stiffness and swelling, catching or locking, and a feeling that the knee is giving way [2].

For years, an MRI showing a tear often led straight to arthroscopic surgery to trim the torn part (a partial meniscectomy). Large trials have changed that thinking, especially for people over about 35 whose tears came on gradually.

A tear on MRI does not always explain the pain

In a study of 991 adults aged 50 to 90 who were not selected for knee problems, an MRI showed a meniscus tear or damage in 19% of women in their 50s and up to 56% of men aged 70 to 90 [1]. Most of the people with a tear, 61%, had no knee pain, aching or stiffness in the previous month [1].

That is why guidelines call these tears common and usually incidental findings [4], and why the European knee society says an MRI is typically not needed as a first step [3].

Two kinds of tear

• Degenerative tears develop without a significant injury, usually in people over 35, as part of normal aging of the knee [3].
• Traumatic tears follow a clear injury, often a pivot or cut in sport [2].

The evidence is strongest for degenerative tears, but trials in younger people with injury-related tears point the same way.

What the trials found

Trial	Who	Compared	Result
FIDELITY, 2013 [6]	146 people aged 35 to 65, degenerative tear, no arthritis	Surgery vs. sham surgery	No difference in symptoms at 12 months; still none at 5 years [7]
METEOR, 2013 [5]	351 people 45 and older with a tear and arthritis	Surgery vs. physical therapy	Similar improvement in function at 6 and 12 months
Kise, 2016 [9]	140 people, average age about 50	Exercise vs. surgery	No meaningful difference at 2 years; better thigh strength with exercise at 3 months
ESCAPE, 2018 [10]	321 people aged 45 to 70, knee not locking	Surgery vs. physical therapy	Physical therapy was as good as surgery at 2 years, and still at 5 years [11]
DREAM, 2022 [13]	121 adults aged 18 to 40	Surgery vs. exercise and education	No significant difference at 12 months
STARR, 2022 [14]	100 adults aged 18 to 45, injury-related tear	Surgery vs. physical therapy	Identical knee scores at 24 months

The most striking result is the FIDELITY trial, where people did not know whether they had real surgery or a sham procedure. Both groups improved by about the same amount [6]. At 5 years, the surgery group had a slightly greater risk of arthritis getting worse on X-ray [7].

Not every trial agrees. In one Swedish trial of 150 middle-aged people that was not sham-controlled, adding surgery to exercise gave more pain relief at 12 months [12]. Most of the evidence, though, points to similar results with either approach.

Based on these trials, a BMJ guideline panel made a strong recommendation against arthroscopy in nearly all people with degenerative knee disease, whether or not they have arthritis on imaging, catching or locking symptoms, or a sudden start of symptoms [4]. The European knee society agrees that surgery should not be the first treatment for degenerative tears, and suggests it may be considered after about 3 months if pain or mechanical symptoms persist despite good non-surgical care [3].

What about catching and locking?

Many people assume that catching or clicking means the torn piece has to be removed. In the sham-controlled trial, surgery did not relieve catching or occasional locking any better than the sham procedure [8]. The important exception is a true locked knee: one you objectively cannot straighten fully. That was the one situation where the BMJ panel thought surgery might still be reasonable [4].

Will I end up having surgery anyway?

Some people do, and that is a reasonable path. In the trials, a share of the people who started with physical therapy later chose surgery:

• Kise, 2 years19%
• DREAM, 1 year26%
• ESCAPE, 2 years29%
• ESCAPE, 5 years32%
• STARR, 2 years41%

Sources: Kise et al., 2016 [9]; Skou et al., 2022 [13]; van de Graaf et al., 2018 [10]; Noorduyn et al., 2022 [11]; van der Graaff et al., 2022 [14].

In other words, most people who started with physical therapy never needed surgery, and trying it first did not stop anyone from having surgery later. In the Kise trial, those who crossed over to surgery gained no extra benefit [9].

When surgery does make sense

• A true locked knee that you cannot straighten [4] [17]
• Some injury-related tears in younger people that can be repaired. Tears in the outer third of the meniscus have a blood supply and may heal or be repairable, while the inner two thirds cannot heal on their own [2]. Repairing a tear has a higher reoperation rate than trimming it, but was linked to better long-term knee scores and less arthritis in limited data [15].
• Persistent pain or mechanical symptoms after a good trial of non-surgical care, after discussing the trade-offs with a surgeon [3]

Recovery times differ a lot: about 3 to 6 weeks after a partial meniscectomy, and about 3 to 6 months after a repair [2].

What you can do now

• Rest the knee in the first days, use ice for about 20 minutes at a time several times a day, and keep the leg raised [2] [17]
• Many tears do not need immediate surgery, especially if the knee is not locking or badly swollen [2]
• Start a structured exercise program; in the trials it typically ran for 8 to 12 weeks [9] [10]
• See a clinician if your knee pain does not improve within a few weeks [16]

Get prompt medical care if your knee locks and you cannot straighten it, becomes more unstable [17], is very painful, cannot bear weight, is badly swollen or has changed shape, or if you have a fever with a red, hot knee [16].

The takeaway

• Meniscus tears are very common on MRI, and many do not cause pain.
• For degenerative tears, surgery did no better than sham surgery or physical therapy in large trials.
• Physical therapy works as well as surgery for most people, and those who need surgery later can still have it.
• Catching and clicking are not, on their own, a reason for surgery. A knee that will not straighten is.
• Some injury-related tears in younger people may be worth repairing, so get a proper assessment.

You can start physical therapy in Utah without a referral. If you have been told you have a meniscus tear, an evaluation can check for warning signs, build a strengthening program and coordinate with a surgeon if you need one.