When can exercise supplant surgery for degenerative meniscal tears?
Patients with a medial, degenerative meniscal tear and a minimal history of osteoarthritis make good candidates for physical therapy—and there is an added benefit, too.
PRACTICE CHANGER
Recommend supervised exercise therapy to your patients with a medial, degenerative meniscal tear and a minimal history of osteoarthritis because it is as effective as partial meniscectomy, entails little risk, and has the added benefit of increasing muscle strength.1
STRENGTH OF RECOMMENDATION
B: Based on a single, good quality, randomized controlled trial.
Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016;354:i3740.
WHAT'S NEW
Head-to-head comparison adds evidence to previous findings
This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a 2-year follow-up period and was superior in the short term for thigh muscle strength.1 The results of this study build on those from the smaller study conducted in Finland mentioned earlier.8 In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.
CAVEATS
Results may not translate to those with more severe osteoarthritis
This trial included patients with only mild to no osteoarthritis in addition to their meniscal tear.1 It is unclear if the results would be maintained in patients with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.
CHALLENGES TO IMPLEMENTATION
The cost and effort of physical therapy may be a deterrent
The cost of PT can be a barrier for some patients who have adequate insurance coverage for surgery, but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing amounts of time and effort, which may be a deterrent for patients with busy lifestyles. Patients and physicians may view surgery as an “easier” fix.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
