Physiotherapy vs surgery for a meniscal tear

The menisci are two C-shaped pads of cartilage that cushion the knee and help spread load. They can tear suddenly in a twisting injury, typically in younger people, or gradually through wear, often in people over 40 who notice pain after a minor twist or even without a clear event.

Pain, swelling and catching are common. Because the outer part of the meniscus has a blood supply while the inner part does not, where the tear lies and what shape it takes strongly affect whether it can heal or be repaired.

A structured programme usually runs over several weeks and focuses on strengthening the thigh muscles, hip and calf, improving balance and control, and gradually restoring movement and activity. It also addresses load management, for example reducing activities that provoke pain while keeping the knee moving. Pain relief and, in some cases, a corticosteroid injection may support the programme.

Research comparing exercise therapy with arthroscopic partial meniscectomy in people with degenerative tears has found similar improvements in knee function and pain at follow-up, with a proportion of the exercise group going on to have surgery later. Exercise has no operative risk, though it asks for commitment.

Arthroscopic surgery uses a camera and instruments through small cuts to either trim (partial meniscectomy) or stitch (repair) the torn meniscus. Trimming removes the damaged fragment and is quicker to recover from but removes cushioning tissue, which is linked with earlier arthritis in some knees. Repair preserves the meniscus but requires a longer period of protected movement.

Risks include infection, blood clots, stiffness and a chance that symptoms persist, particularly if arthritis is the real source of pain. Surgery can relieve mechanical catching and locking that exercise cannot.

The British Association for Surgery of the Knee and other bodies advise that arthroscopic surgery is not recommended for degenerative meniscal tears as a first step in people with osteoarthritis. NICE osteoarthritis guidance (NG226) similarly advises against arthroscopic procedures in osteoarthritis unless the person has a clear history of mechanical locking.

For younger patients with acute injuries, surgeons look at tear pattern and location on MRI, along with locking and instability, to decide whether repair is feasible. Timing matters for repairs, which generally do better when done relatively soon after injury.

• Over 40, gradual pain, no true locking, some arthritis on X-ray: start with physiotherapy and review after a trial of exercise.

• The knee gets stuck and will not straighten: seek prompt orthopaedic review, since a displaced fragment may need surgery.

• Young, active, injury during twisting sport, outer-rim tear on MRI: ask whether a repair is possible.

• Swelling and giving way with a suspected ligament injury: needs assessment of the ligament as well as the meniscus.

• Severe pain after a fall with inability to bear weight: urgent assessment to exclude fracture.

A tear on an MRI does not always mean surgery is needed; many such tears cause no symptoms. And surgery is not a way to make the knee "as good as new"; removing meniscus tissue can alter load on the joint.

It is also a misconception that rest alone will fix it. Active rehabilitation matters more than avoiding movement.