Meniscus Tear: Do You Really Need Surgery?

Each knee has two menisci — C-shaped pads of tough, rubbery cartilage that sit between the thigh bone and the shin bone. They spread the load across the joint and help keep it stable. When patients say “cartilage tear”, this is usually what they mean.

The most useful thing I can tell you is that meniscus tears come in two broad kinds, and they behave quite differently.

• Injury tears. These happen in a younger, healthy meniscus with a sudden twist — turning on a planted foot in football or cricket, a fall on a wet road, or a slip getting off a moving train. There is usually a clear moment, often with swelling over the next day.
• Wear-related (degenerative) tears. After the late thirties, the meniscus slowly becomes more brittle. It can tear with something as ordinary as getting up from squatting, using an Indian toilet, or sitting cross-legged on the floor. Many people cannot remember any injury at all.

Wear-related tears are far more common, and they often come alongside early arthritis in the same knee. That is why the treatment for a forty-five-year-old with a niggling knee is usually very different from that for a twenty-two-year-old who twisted it on the field.

For a wear-related tear in a knee that is not locking, physiotherapy is the right first treatment — and for many people it is the only treatment they ever need.

Good research over the past several years has consistently shown that, for this group, keyhole surgery to trim the meniscus generally does not give better long-term results than a proper exercise programme. Trimming also removes part of a cushion the knee needs, which may speed up arthritis later. I would rather protect what you have.

What does a proper programme look like?

• Strengthening the thigh and hip muscles, especially the quadriceps. A strong thigh takes load off the joint.
• Restoring full straightening of the knee and good balance.
• Modifying the worst activities for a while — deep squatting, floor sitting and twisting — rather than stopping all movement.
• Simple pain relief and ice in the first few weeks if needed.

Give it a fair trial: roughly six to twelve weeks of regular, guided exercise, done at home most days, not only at the physiotherapist’s clinic. Many patients notice the clicking and catching settle well before that. A steroid injection is occasionally useful for a flare in a knee that also has arthritis. If you are being offered PRP or stem cell injections for a torn meniscus, read my article on knee injections first.

Surgery has a clear place. These are the situations where I recommend it.

• A locked knee. If a flap of torn meniscus flips into the joint — often called a bucket-handle tear — the knee gets stuck and cannot straighten fully. Exercises cannot move it back. This needs keyhole surgery, ideally soon.
• A fresh injury tear in a younger person. Some tears, particularly near the outer edge where the meniscus has a blood supply, can be repaired with stitches rather than trimmed. Repair keeps the cushion and protects the knee for decades, but it works best when done early.
• A tear with an ACL injury. Twisting injuries often tear the anterior cruciate ligament too. In that case the meniscus is usually dealt with during ACL reconstruction, and repairing it is a priority.
• Root tears. A tear where the meniscus attaches to the bone can let the knee collapse quickly into arthritis. Selected patients benefit from having it reattached.
• Mechanical symptoms that persist — repeated catching or giving way — despite a proper course of physiotherapy.

The operation is done through two or three small cuts, usually as a day-care or one-night stay. Recovery depends on what is done: after trimming, most people walk the same day; after a repair, the knee is protected for several weeks so the stitches can heal, and return to sport takes months rather than weeks.

A common story in my clinic: a patient in their fifties or sixties with knee pain, an MRI showing a meniscus tear, and a recommendation for keyhole surgery. When I look at the X-ray, the knee also has arthritis — the joint space is narrowing and the cartilage is wearing.

In that knee, the tear is usually part of the arthritis, not a separate problem. Trimming the meniscus does not treat the worn cartilage, and in a knee with established arthritis it rarely gives lasting relief. Some people feel worse afterwards.

For these knees the honest plan is the arthritis plan: strengthening, weight management where relevant, activity changes, pain relief, and an injection when it helps. If the arthritis is advanced and life has shrunk around it — you are avoiding the stairs in a building without a lift, or cannot walk to the market — then the conversation is about whether it is time for a replacement, which I have written about in Do I need a knee replacement yet?

This is why I ask for a standing X-ray as well as the MRI. An MRI is excellent at showing soft tissue, but the standing X-ray shows how much cartilage is truly left, and that often changes the advice completely.

Most meniscus problems can be assessed at a normal appointment. But some signs mean you should not wait to see if physiotherapy helps:

• The knee is locked and you cannot straighten it fully, even with gentle effort.
• Rapid, large swelling within a few hours of a twisting injury. This often means bleeding inside the joint and can signal an ACL tear or a fracture.
• The knee keeps giving way on stairs or uneven ground, or you heard a pop at the time of injury.
• You cannot put weight on the leg after a fall or accident.
• A hot, red, swollen knee with fever, especially without any injury. Infection must be ruled out the same day.
• Calf pain and swelling after a knee injury or surgery. This can be a clot and needs urgent attention.

If you have had a twisting injury and are not sure how serious it is, an examination at the Mira Road clinic usually makes the picture clear, and tells us whether an MRI is needed at all.