This was an interesting and well-performed study from colleagues in the Netherlands. The authors should be commended because any prospective studies like this are difficult to perform.
It is important to read the “devil in the details” to assess what the patient population was comprised of and the overall assessment tools to determine its relevance to our practices. Patients overall had a mean age of 58 years, had Kellgren-Lawrence grade 1 to 2 changes, primarily had non-displaced medial meniscus tears, with most tears overall being horizontal or degenerative. Overall, 29% of patients failed PT and required a partial meniscectomy.
My impression is the guidelines followed in one arm of this study (a trial of PT for older patients with potentially stable meniscus tears) is what most of us follow presently in clinical practice, however I obtain an anteroposterior flexion standing radiograph on all of these patients to better objectively assess their degree of osteoarthritis. Many or most of these patients have some degree of OA so it can be difficult to determine if it is the OA or the meniscus tear causing their functional limitations and pain, so a trial of PT, a possible viscosupplementation, corticosteroid or biologic injection, and possibly the use of an unloader brace may be our first step, or a series of steps of treatment for many of these patients. After this potential nonoperative program, this study shows, and we find it in clinical practice, most patients with these findings get better, but some may still require and benefit from a partial meniscectomy.
Once again, one should rely on the physical exam and pertinent radiographic studies to determine which patients have “obstructive” meniscal tears (direct mechanical irritation such as from a radial or radial flap tear) to ensure these patients are brought to surgery in a timely fashion and not needlessly sent to PT. In addition, ensuring a patient does not have a meniscus root tear, with its known deleterious effect on knee loading, is an essential part of a patient’s workup in this age group because these patients usually benefit from early surgical repair.
Robert F. LaPrade, Md, PhD
The Steadman Clinic
Chief medical officer, Steadman Philippon Research Institute,
Co-director, Sports Medicine Fellowship Program
Director, International Scholar Program
Disclosures: LaPrade reports he is a consultant and receives royalties from Arthrex, Ossur and Smith & Nephew.