Physiotherapy for meniscal tears in patients with osteoarthritis

New research suggests there is no difference in functional outcome when arthroscopic surgery is added to standardized physiotherapy for patients with both a meniscal tear and knee osteoarthritis.  

Meniscal tears are common in individuals with knee osteoarthritis (click here to learn more about knee osteoarthritis and its treatment). The Mayo Clinic estimates 300,000 arthroscopies are performed each year in the US on patients with osteoarthritis and a meniscal tear in the same knee (ref1). The most common surgical approach for treating a meniscus tear is arthroscopic partial meniscectomy.  In this procedure two small incisions are made and an arthroscope is inserted into the knee joint to help guide the surgeon in removing the damaged portion of the meniscus.

Even though arthroscopic surgery is often used to treat meniscal tears in patients with osteoarthritis, it is not clear if this is actually the best course of treatment.  This is in part due to the fact that it can be difficult to determine the true source of knee pain in these individuals.  Is it primarily the result of the torn meniscus, and thus a patient may benefit symptomatically from arthroscopic surgery? Or is the pain instead due to the pre-existing degenerative changes in the knee cartilage, and therefore arthroscopy may be largely ineffective?

The commonly used alternative to arthroscopic surgery for patients with both osteoarthritis and meniscal tear is treatment with physiotherapy alone.  Physiotherapy can successfully reduce pain arising from both of these conditions.  However, in some patients physiotherapy may not be as effective as arthroscopy in reducing pain arising from meniscal damage specifically.  So what should a patient in this situation do?

Physiotherapy or arthroscopic surgery?

Thankfully, new data sheds light on this debate.  Recent data presented in the prestigious New England Journal of Medicine (ref2) suggests that there may be no difference in outcomes between osteoarthritic patients who undergo surgery for their meniscal tear, and those who undergo physiotherapy alone.  The authors of this study randomly assigned 351 patients to either arthroscopy plus post-operative physiotherapy, or to physiotherapy alone, and assessed functional outcomes at 6 months and 12 months.  The researchers discovered that patients undergoing arthroscopy plus post-operative physiotherapy fared no better at 6 months or 12 months than patients who were treated solely with physiotherapy.

So does this mean that you should ignore your surgeon’s advice to undergo arthroscopy?  Although the above research is supportive of a physiotherapy-only treatment regimen, a definitive conclusion cannot be drawn from the data.  Since real people with real knee problems were the subject of the study, the treatment protocol allowed for patients to leave the study group they belonged to (say the physiotherapy-only group) at the 6 month mark to join the other study group (say the surgery group).  The number of patients who left the physiotherapy group for surgery at the 6 month mark was significant (30%), and may suggest poorer outcomes in this group.  This conceivably may have also masked a possible benefit of surgery over physiotherapy-alone at the 12 month mark.  Interestingly, this crossover between groups was much more pronounced at some of the centers participating in the study than at others (ranging from 0% crossover to a whopping 59%), suggesting that the root cause of patient transfer between study groups may in fact have been the bias of the treating physician rather than poorer outcomes.

This study was well designed and executed, and provides good data overall in support of using physiotherapy alone to treat meniscal tears in patients with osteoarthritis.  However, it seems likely that a subset of osteoarthritic patients would receive incremental benefit from adding arthroscopic partial meniscectomy to help treat their meniscal tear.  Your physiotherapist can help you get started with your rehabilitation and track your progress to help guide you in determining whether or not you could expect to see added benefit from surgical intervention.

References:

1. http://www.mayoclinic.org/medicalprofs/meteor-study.html
2. Katz, J.N. Brophy, R.H., et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2; 368(18):1675-84.