In the JournalsPerspective

Physical therapy may be alternative to surgery for patients with nonobstructive meniscal tears

Victor van de Graaf headshot
Victor A. van de Graaf

Patients with nonobstructive meniscal tears may benefit from physical therapy as an alternative to surgery, according to recently published results.

Victor A. van de Graaf, MD, and colleagues randomly assigned 321 patients with nonobstructive meniscal tears to undergo either arthroscopic partial meniscectomy or a physical therapy protocol which consisted of 16 sessions of exercise therapy for 8 weeks focused on coordination and closed, kinetic chain strength exercises. Change in patient-reported knee function on the IKDC subjective knee form scores from baseline during a 24-month follow-up period was identified as the primary outcome measure.

Results showed 90% of 321 patients completed the trial. During the 24-month follow-up period, researchers found 29% of patients in the physical therapy group underwent arthroscopic partial meniscectomy and 5% of patients in the arthroscopic partial meniscectomy group did not undergo surgery. Patients in the arthroscopic partial meniscectomy group and the physical therapy group experienced improvements in knee function by 26.2 points and 20.4 points, respectively. Researchers noted an overall between-group difference of 3.6 points, which van de Graaf told Healio.com/Orthopedics “was smaller than the predefined non-inferiority margin of eight points, indicating non-inferiority of [physical therapy] PT as compared to [arthroscopic partial meniscectomy] APM.”

Overall, results showed 18 patients in the arthroscopic partial meniscectomy group and 12 patients in the physical therapy group experienced adverse events. The most frequent were repeat surgery and additional outpatient visits for knee pain.

Physicians performing physical therapy on older women for knee injury
Physical therapy may be an alternative treatment to surgery for patients with nonobstructive meniscal tears.
Adobe Stock

“We found physical therapy to be non-inferior to surgery for the outcome [of] patient-reported knee function,” van de Graaf said. “Our results confirm the findings from previous studies and justify an initial conservative approach with physical therapy in patients older than 45 years with a nonobstructive meniscal tear.” – by Casey Tingle

Disclosures: van de Graaf reports that he receives grants from the Netherlands Organization for Health Research and Development, Achmea Healthcare Foundation and the Foundation of Medical Research OLVG, Amsterdam, the Netherlands. Please see the full study for a list of all other authors’ relevant financial disclosures.

Victor van de Graaf headshot
Victor A. van de Graaf

Patients with nonobstructive meniscal tears may benefit from physical therapy as an alternative to surgery, according to recently published results.

Victor A. van de Graaf, MD, and colleagues randomly assigned 321 patients with nonobstructive meniscal tears to undergo either arthroscopic partial meniscectomy or a physical therapy protocol which consisted of 16 sessions of exercise therapy for 8 weeks focused on coordination and closed, kinetic chain strength exercises. Change in patient-reported knee function on the IKDC subjective knee form scores from baseline during a 24-month follow-up period was identified as the primary outcome measure.

Results showed 90% of 321 patients completed the trial. During the 24-month follow-up period, researchers found 29% of patients in the physical therapy group underwent arthroscopic partial meniscectomy and 5% of patients in the arthroscopic partial meniscectomy group did not undergo surgery. Patients in the arthroscopic partial meniscectomy group and the physical therapy group experienced improvements in knee function by 26.2 points and 20.4 points, respectively. Researchers noted an overall between-group difference of 3.6 points, which van de Graaf told Healio.com/Orthopedics “was smaller than the predefined non-inferiority margin of eight points, indicating non-inferiority of [physical therapy] PT as compared to [arthroscopic partial meniscectomy] APM.”

Overall, results showed 18 patients in the arthroscopic partial meniscectomy group and 12 patients in the physical therapy group experienced adverse events. The most frequent were repeat surgery and additional outpatient visits for knee pain.

Physicians performing physical therapy on older women for knee injury
Physical therapy may be an alternative treatment to surgery for patients with nonobstructive meniscal tears.
Adobe Stock

“We found physical therapy to be non-inferior to surgery for the outcome [of] patient-reported knee function,” van de Graaf said. “Our results confirm the findings from previous studies and justify an initial conservative approach with physical therapy in patients older than 45 years with a nonobstructive meniscal tear.” – by Casey Tingle

Disclosures: van de Graaf reports that he receives grants from the Netherlands Organization for Health Research and Development, Achmea Healthcare Foundation and the Foundation of Medical Research OLVG, Amsterdam, the Netherlands. Please see the full study for a list of all other authors’ relevant financial disclosures.

    Perspective

    The ESCAPE trial is well-conducted; however, careful analysis of its design raises questions about unreported eligibility screening, lack of subject and clinician blinding, lack of distinction or reporting of any traumatic etiology, and unclear Kellgren-Lawrence grade 2 or 3 interpretation that was limited to one radiologist without inter-interpreter reliability calculations. In addition, the minimal clinically important difference (MCID) using the IKDC for assessing treatment of meniscal tears has not been defined and so the noninferiority margin was calculated at 8.8 and rounded down. Furthermore, the authors did not report on the arthroscopic correlation of surgically observed degenerative changes noted at surgery.

    Does this study change the way I practice? I think not.

    My patients who present with symptomatic meniscal pathology and associated radiographic degenerative changes (Kellgren-Lawrence 2 or 3) and corroborative MRI findings are initially treated nonoperatively for 6 to 8 weeks. They are advised on inflammation reduction measures, frequently prescribed PT and in some cases recommended a corticosteroid injection. What is important is to consider the level of inflammation, magnitude of symptoms, presence of recurrent effusions and patient goals. I agree with other authors that conservative treatment with therapy before surgery should precede cohort randomization. A compelling finding is 29% of the study patients treated with PT went on to require operative arthroscopy during the 24 month follow-up. Our goal should be to identify that select group to understand what the optimal indications for surgery are and to determine the treatment value for those who will benefit rather than to simply recommend against arthroscopy.

    In summary, this study tells us that in patients with degenerative meniscal tears without mechanical symptoms, PT has an important and effective role in the initial treatment regimen. In other patients with mechanical symptoms or who may fail 8 weeks of PT, operative arthroscopy remains an effective clinical option.

    References:

    Liebs TR, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2017.12.016.

    Webster KE, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2018.02.021.

    • Nicholas A. Sgaglione, MD
    • Orthopedics Today Editorial Board Member

    Disclosures: Sgaglione reports he is chair of the Arthroscopy Journal Board of Trustees and receives royalties from Wolters Kluwer

    Perspective
    Robert F. LaPrade

    Robert F. LaPrade

    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
      Vail, Colorado

    Disclosures: LaPrade reports he is a consultant and receives royalties from Arthrex, Ossur and Smith & Nephew.