Arthroscopic Surgery vs. Physical Therapy for Degenerative Meniscal Tears

Is arthroscopic surgery superior to physical therapy (PT) for degenerative meniscal tears?

Arthroscopic surgery, PT, and exercise can be offered to patients with degenerative meniscal tears; none of these is considered superior. Compared with PT, arthroscopic surgery does not result in any clinically significant differences in pain, symptoms, function, activities of daily living, knee-specific quality of life, or generic quality of life. (Strength of Recommendation [SOR]: A, multiple meta-analyses.) Arthroscopic surgery may worsen range of motion in the knee and cartilage surface area compared with PT. (SOR: C, randomized controlled trials [RCTs].)

A 2022 Cochrane review compared arthroscopic surgery for degenerative knee disease with several nonsurgical treatments.¹ A subset of the review included five trials comparing arthroscopic surgery plus exercise with exercise alone and three trials comparing arthroscopic surgery with exercise. Seven of the trials included patients with degenerative meniscal tears and excluded patients with severe osteoarthritis (OA).

For pain, arthroscopic surgery showed little or no benefit at any point in time compared with exercise. A 0- to 100-point scale was used to assess pain, with a threshold for clinical significance of 15 points. Although there was statistical improvement in pain at the “up to 3 months” and “3 to 6 months” time points, these translated to clinically unimportant mean differences on the pain scale of −4.2 points (95% CI, −6.6 to −1.6) at up to 3 months and −4.0 points (95% CI, −6.6 to −1.6) between 3 and 6 months. Arthroscopic surgery minimally affected function, knee-specific quality of life, and generic quality of life compared with exercise.

A 2023 systematic review and meta-analysis of four RCTs (N = 713) compared the effectiveness of PT with arthroscopic partial meniscectomy in patients 18 years and older with degenerative meniscal tears.² All studies included a 5-year follow-up to assess pain or physical function as an outcome measure. The analysis found no significant differences on the Knee Injury and Osteoarthritis Outcome Score for pain, symptoms, activities of daily living, or quality of life.

A 2020 RCT (N = 286) compared arthroscopic partial meniscectomy with PT in patients with a degenerative meniscal tear, focusing on the patients' most significant functional limitations.³ This study was part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial. The Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS) was the main outcome measure. Exclusion criteria included severe OA, body mass index greater than 35 kg per m², and previous knee surgery.

In the RCT, 139 patients underwent arthroscopic partial meniscectomy, whereas 147 patients participated in 16 PT sessions over 8 weeks. After their respective interventions, patients completed the PSFS, which assesses subjective functional status by measuring perceived difficulty in performing activities valued most in daily life and at which patients would like to improve. At 24-month follow-up, the PSFS scores of the surgery group improved by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 at baseline to 2.0 ± 2.2 after intervention), and the scores of the PT group improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 at baseline to 2.7 ± 2.5 after intervention). The between-group difference was −0.6 points (95% CI, −1.0 to −0.2; P = .004) in favor of the surgery group, which was statistically significant but less than the clinically meaningful threshold (2.5 points on an 11-point scale).