Few MRI results alarm people like “meniscus tear.” It sounds mechanical and final, something is torn, surely someone should go in and fix it. Sometimes that is right. But the meniscus story split in two over the last decade, and which half you are in changes everything.
Two kinds of tears
The menisci are two C-shaped cartilage pads that cushion and stabilise the knee. Traumatic tears happen with an injury, a twist under load, often in younger athletes, sometimes alongside an ACL tear. Degenerative tears develop gradually in middle-aged and older knees as the tissue wears, frequently with no injury anyone can remember. They are extremely common, often coexist with early osteoarthritis, and, this matters, they also show up on the MRIs of people whose knees feel fine.
What the trials found
The FIDELITY trial (New England Journal of Medicine, 2013) randomised patients with degenerative meniscus tears to arthroscopic partial meniscectomy, trimming the tear, or to sham surgery, where patients went through the full theatre experience but nothing was trimmed. At one year, outcomes were the same. The same year, Katz and colleagues compared surgery plus physiotherapy with physiotherapy alone for meniscus tear with osteoarthritis: again, no meaningful difference at six and twelve months.
Read those results carefully. They do not say surgery never helps. They say that for degenerative tears, an operation should not be the first move when a structured course of physiotherapy achieves the same for most people, without surgical risk, and while preserving meniscus tissue that protects the joint from arthritis long-term.
Where surgery is still the right call
- A knee that locks, genuinely stuck, cannot straighten, from a displaced tear
- Traumatic tears in younger patients, especially repairable patterns (repair, which preserves the meniscus, is preferred over trimming where possible)
- Symptoms that persist despite a real, completed course of rehabilitation
What physio for a meniscus tear looks like
It is not generic knee exercises. First, calm the joint: manage swelling, trim the aggravating loads (deep squats, pivoting under load, hills) without stopping movement altogether. Then build: quadriceps and hip strength is the foundation, stronger muscles reduce the load the meniscus absorbs each step, plus balance and movement retraining, and graded return to the activities that were provoking it. Most people feel the trend within four to six weeks; a fair trial runs about three months.
A word on “bone on bone” and clicking
Clicking without pain is common and, on its own, not a surgical indication. And a degenerative tear plus arthritis on an X-ray does not doom you to a knee replacement, knees like that often settle and function well for years with good strength and load management. The pain and the picture are related, but they are not the same thing.
References
- Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear (FIDELITY). New England Journal of Medicine. 2013;369:2515–2524. doi:10.1056/NEJMoa1305189
- Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. New England Journal of Medicine. 2013;368:1675–1684. doi:10.1056/NEJMoa1301408
General information only, not medical advice. A locked knee, or a tear from a significant injury, should be assessed promptly in person.