International Orthopaedics (SICOT) (2015) 39:769775
DOI 10.1007/s00264-014-2539-z
ORIGINAL PAPER
Arthroscopic partial meniscectomy is superior to physical
rehabilitation in the management of symptomatic unstable
meniscal tears
Sherif A. El Ghazaly & Amr A. Abdul Rahman &
Ahmed H. Yusry & Mahmoud M. Fathalla
Received: 18 June 2014 / Accepted: 15 September 2014 / Published online: 10 October 2014
# SICOT aisbl 2014
Abstract
Purpose Meniscus injuries are the most commonly reported
in athletes. Meniscectomy is the most common treatment.
Stable peripheral tears may heal, while degenerative tears
do well with physical therapy. However, the exact role of
physical therapy in treating symptomatic unstable meniscal
tears is not known. We aimed to identify the role of physical
therapy in treating such patients and clarify the role of arthro-
scopic partial meniscectomy in treating unstable meniscal tears.
Methods Seventy patients with unstable meniscal tear met the
inclusion criteria according to Vande Berg and co-workers.
Clinical examination, McMurray test and magnetic resonance
imaging were done. Age ranged from 1867 years (average
39.87). Mild osteoarthritis was seen in 20 cases. Physical
therapy thrice a week for eight weeks was offered (faradic
quadriceps stimulation and neuromuscular strengthening
exercises). After physical therapy, patients still complaining
or unsatisfied were offered arthroscopic partial menisectomy
(APM). Outcomes were evaluated using the VAS pain score
and the Lysholm knee score.
Results Mean VAS before interventions was 7.4, significantly
improved to 5.16 after rehabilitation and to 1.9 after APM (p=
0.001). Mean Lysholm score before rehabilitation was 65.1
and improved to 69.6 after rehabilitation, the difference was
non-significant. However, Lysholm score difference before
and after APM showed a highly significant difference
(p=0.001).
S. A. El Ghazaly (*) : A. A. A. Rahman : A. H. Yusry
Orthopedic Surgery Department, Ain Shams University Hospital,
Ain Shams University, Cairo, Egypt
e-mail: sherifghazaly@hotmail.com
M. M. Fathalla
Physical Medicine and Rehabilitation, Ain Shams University, Cairo,
Egypt
Conclusions Pain and swelling improved after physical ther-
apy. However, patients were not satisfied as limited range of
knee motion persisted. APM was superior to physical therapy
in treating symptomatic unstable meniscal tears, with high
patient satisfaction and restored knee function.
Keywords Partial meniscectomy . Unstable tear . Meniscal
tear . Physical therapy . Meniscectomy
Introduction
Meniscal injuries are reported to be the most common injury
sustained by athletes, but sports injuries account for only 30 %
of all meniscal lesions. Meniscectomy is the most common
procedure performed by orthopedic surgeons for such injury.
However, the appropriate treatment of meniscal tears depends
on many factors. Tear type, location and tissue quality may
dictate treatment type and outcome. The presence or absence
of osteoarthritis and the degree of arthritis may allow or
obviate arthroscopic meniscectomy.
Unstable meniscal tears cause mechanical symptoms,
while synovial irritation can cause repeated effusion. Both
may prevent full knee flexion, which is sometimes incapaci-
tating in the Asian population. Symptomatic unstable
meniscal tears warrant excision, while stable peripheral tears
can heal without surgery. The goal of arthroscopic partial
meniscectomy (APM) is to preserve a stable meniscal rim,
removing only unstable, diseased tissue [1]. Yet, some authors
reported increase in radiographic evidence of arthritis years
later. Thus, arthroscopic menisectomy for meniscal tears is
still debated [13]. However, in patients with meniscal tear not
undergoing surgery, 30-month follow-up study showed
meniscal damage to be a potent risk factor for the development
of radiographic osteoarthritis [4].
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In spite of pain and mechanical symptoms, many patients try
to avoid undergoing surgery. Recently, physical therapy (PT)
has been advised to treat meniscal tears. This seems a sound
option for patients unwilling to be operated upon. Several
reports have proposed physical therapy to treat degenerative
meniscal tears [57]. Most surgeons use physical therapy after
arthroscopic surgery. However, the exact role of physical thera-
py in treating symptomatic unstable meniscal tears is not known.
sters et al. [6] postulated that exercise dosage given is
related to decrease in pain and swelling and improved neuro-
muscular function. We hypothesized that physical therapy,
through resolving knee swelling, improving pain and range
of motion, restoring muscle strength and improving quality of
movement performance, may be an effective alternative ther-
apy for patients with unstable symptomatic meniscal tears.
The aim of this work was to identify the role of physical
therapy when treating patients with unstable meniscal tears
and clarify the role of surgical arthroscopy.
Patients and methods
The methodology of this prospective study was approved by
the research ethical committee of Ain Shams faculty of med-
icine and all patients provided a written informed consent
prior to participation. This study included seventy patients
clinically diagnosed as having unstable meniscal tear which
was documented by magnetic resonance imaging (MRI) ac-
cording to the criteria of Vande Berg et al. [8], defined as
displaced meniscal fragment, visible on more than two sagittal
and three coronal images, having more than one orientation
plane, and showing intrameniscal high signal intensity on T2-
weighted images. All patients were recruited from the ortho-
pedic and physical medicine departments of Ain Shams Uni-
versity Hospitals during the period from 2009 until 2012.
Inclusion criteria were persistent knee pain despite
four weeks of rest, activity modification and medical treat-
ment, tenderness on the joint line, positive McMurray test, tear
documented on three consecutive sections of sagittal MRI
(Fig. 1) and absence of advanced osteoarthritis (a Kellgren-
Fig. 1 T2-weighted sagittal MRI showing a vertical tear of the medial meniscus on three sections
International Orthopaedics (SICOT) (2015) 39:769775
Lawrence grade 2 or less). Exclusion criteria were acute
locked knee, ligament injury, or knee surgery within the
previous two years. There were 30 women (42.8 %) and 40
men. Age ranged from 18 to 67 (average 39.87 years). All
cases were examined clinically and McMurray test was done.
The right side was involved in 70 % of the cases. There were
49 (73 %) medial meniscal tears and 21 lateral tears. Radio-
graphic evidence of osteoarthritis was seen in 20 cases
(28.5 %) (Kellgren-Lawrence grades 1 or 2) [9]. All cases
were offered physical therapy sessions thrice a week for
eight weeks, consisting of faradic stimulation to quadriceps
muscle (pulse duration=1 ms, pulse interval=500 ms) and
neuromuscular and strengthening exercise program [5, 6].
The exercise program was performed in the gym of the
physical medicine and rehabilitation department at Ain Shams
University hospital. The exercise program and exercise pro-
gression strategy were explained individually to the patients.
Subjects were informed that they could withdraw from the
study at any time. All patients were instructed and supervised
by the same physiatrist thrice a week throughout the program
to ensure the intended performance of exercises and progres-
sion for each individual.
The exercise program began with a warm-up on a station-
ary bike for ten minutes using the resistance level of choice
and concluded with another ten minutes at the end of the
session. The remaining exercises were initially performed with
low-dose, low repetitions, then gradually increased according to
the patients tolerance. The exercise program included: step-up;
knee stability to maintain balance; hamstring on fitball, where
both feet were placed on top of the ball then the back and pelvis
were lifted and the patient pulled the ball towards himself;
single-leg press,starting with 90 knee flexion; single-leg knee
extension, starting in 90 of knee flexion; single-leg leg curl,
where a weight was lifted quickly up and then slowly down. In
all exercises, knee flexion or extension was performed to the
range the patient can tolerate. After completion of this program,
patients still complaining or unsatisfied were offered arthro-
scopic partial menisectomy.
After pre-operative antibiotics and tourniquet control,
anteromedial and anterolateral portals were created, and both
International Orthopaedics (SICOT) (2015) 39:769775
menisci were examined. Limited synovectomy was done in
order to allow visualization in both knee compartments. Any
unstable meniscal tissue was excised and trimmed back to a
stable meniscal rim. Weight bearing was started as tolerated.
Outcomes were assessed using the 10-cm visual analogue
scale (VAS) and Lysholm knee score [10]. The VAS for pain
was recorded before and after physical therapy and six weeks
after arthroscopy. The Lysholm knee score demonstrated ac-
ceptable psychometric performances as outcome measure for
patients with meniscal injury [11], and was recorded before
physical therapy, before and after arthroscopy and at final
follow-up. Range of motion, McMurray test and patient sat-
isfaction were recorded. A minimum follow-up of six months
was ensured (range, six to 24 months). Average follow-up was
12.5 months.
Statistical analysis
The data was revised, encoded and tabulated then entered into
a personal computer using the Statistical Package for Social
Sciences software (SPSS) version 18 (Chicago, IL). Numeric
data were described as meanstandard deviation (SD). Non-
numeric data are shown as frequencies and percentages.
Paired t-test was used to analyze differences of mean VAS
before and after interventions. Differences of the mean
Lysholm score were analyzed using the F-test. Significance
Fig. 2 VAS for the study cohort
pre-physiotherapy versus post
physiotherapy and pre-scope
versus post scope. Values are
presented as median (interquartile
range)
771
was set at p value<0.05, while p value <0.01 was highly
significant.
Results
Mean VAS before interventions was 7.41.1, and improved to
5.161.75 after the rehabilitation program (p=0.001) and 1.9
0.93 after APM (p=0.001), (Fig. 2). Mean Lysholm score
showed a non-significant improvement from 65.1 to 69.6 after
rehabilitation. This value improved to 87.9 after APM, and to
90.5 at final follow-up (p=0.001) (Fig. 3). Multivariate re-
gression analysis between various parameters and the final
Lysholm score showed a significant difference only for pres-
ence of osteoarthritis (p=0.001), whereas follow-up period,
age and sex showed no significant difference. Further, com-
paring arthritic versus non-arthritic patients, outcome scores
were consistently better for non-arthritic cases (Table 1). Com-
paring medial versus lateral meniscal tears using the paired t-
test, statistically significant differences were detected only in
mean VAS score and mean Lysholm knee score after PT. Also
results showed improvement of both scores for medial and
lateral menisci after APM but without statistical significance
(Table 2).
Patients undergoing physical therapy noticed improved
pain and swelling. Pain recurred seven to ten days after
completing the program, especially with deep knee bends.
Full knee flexion or extension was not possible. After APM,
772 International Orthopaedics (SICOT) (2015) 39:769775

Fig. 3 Lysholm score before

APM, after and at final follow-up.
All values are presented as
median (interquartile range)

knee range improved and burning pain within the knee was
reported with gradual daily improvement, as well as pain at
the portals which also subsided gradually after surgery. Pain
subsided completely within two to four weeks. Patient satis-
faction following APM and physical rehabilitation was 85 %
vs 57 % respectively regarding pain, 88 % vs 92 % respec-
tively regarding swelling and 90 % vs 35 % respectively
regarding function, with 60 % overall patient satisfaction after
PT. At final follow-up, overall patient satisfaction following
APM was 87 % (61/70). Six months after surgery, 80 %
had returned to their previous activity levels. Complications
included transient knee swelling (three cases), superficial
infection needing antibiotics (one case) and mild vastus
medialis weakness (three cases).
Table 1 Differences of VAS score and Lysholm knee score before and
after interventions for patients with and without osteoarthritis using the
paired t-test
Discussion
To our knowledge, this is the first report studying the role of a
standardized physical therapy program versus APM in the
management of symptomatic unstable meniscal tears. Pain
and swelling improved after physical rehabilitation but pa-
tients were not fully satisfied because pain recurred and lim-
ited range of motion of the knee persisted. APM was superior
to physical rehabilitation with high patient satisfaction and
restored knee function.
Table 2 Differences of mean VAS score and mean Lysholm knee score
before and after interventions when comparing medial versus lateral
meniscal tears using the paired t-test
Parameter Medial Lateral p value
meniscus meniscus

Parameter: Osteoarthritic Non-arthritic p value Follow-up time 11.26 12.22 0.52

(n=20) (n=50)
VAS before PT 7.61 6.84 0.01a
VAS before physiotherapy (PT) 8.2 7.08 0.001 VAS after PT/Before APM 5.51 4.21 0.005b
VAS after PT/Before scope 6.2 4.74 0.001 VAS after APM 1.96 1.74 0.37
VAS after APM 2.2 1.78 0.09 Lysholm knee score before APM 68.43 72.74 0.03a
Lysholm knee score before PT 60.1 67.3 0.001 Lysholm knee score after APM 87.27 89.74 0.09
Lysholm knee score before APM 63.7 71.96 0.001 Final Lysholm knee score 89.96 92.21 0.1
Lysholm knee score after APM 83 89.92 0.001
a
Final Lysholm knee score 84.8 92.88 0.001 Statistically significant
b
Highly significant
International Orthopaedics (SICOT) (2015) 39:769775
Meniscectomy is the most common procedure performed
by orthopedic surgeons, [12] with an incidence of 61 per
100,000 per year. [13]. While it is still debated if a degener-
ative horizontal tear should be treated surgically [2], unstable
tears, like flap tears, usually need surgical intervention. Some
studies reported use of physical therapy to treat degenerative
tears, while others used physical therapy only after
meniscectomy. However, the efficacy of physical therapy in
patients with symptomatic meniscal tears is unproved [7].
While some authors consider horizontal tears unstable, Yim
et al. [2] consider them stable. In a study of meniscectomy
versus non-operative treatment for degenerative horizontal me-
dial meniscal tear, no differences were found in terms of knee
pain relief, improved knee function, or increased satisfaction
after two years of follow-up [2]. Although the work by Yim
et al. [2] implies only a limited role for menisectomy, our results
showed statistically significant improved knee pain after both
physical therapy and APM. However, significant patient satis-
faction and improved knee function were evident after APM, as
evidenced from the sustained improvement of the Lysholm
score, which improved to 87.9 after APM and to 90.5 at final
follow-up (p=0.001).
Dervin et al. [14] found mechanical symptoms unreliable
predictors of unstable meniscal tear. The only positive predic-
tor was a positive McMurray test, thus we relied on a positive
McMurray test to clinically detect unstable meniscal tears.
Meniscal tear may cause pain, effusion, muscle weakness,
and limited range of motion. The goals of physical therapy are to
obtain painless full range of motion, improve muscle strength,
balance and function [15]. While knee pain may cause quadri-
ceps weakness, [16] physical training and neuromuscular exer-
cises play an important role in reducing symptoms, improving
muscle strength, physical ability and quality of life in patients
with medial meniscus tears [17]. In this study, all patients
underwent a standardized physical therapy protocol, consisting
of faradic quadriceps stimulation and neuromuscular
Fig. 4 Treatment algorithm for
patients with unstable meniscal
tears
No improvement
OA < /= grade 2
APM
773
strengthening exercises. This protocol reduced swelling and
pain, and improved range of motion, but full knee flexion was
not restored. Sessions were attended three times weekly, in
contrast to once weekly sessions in the study of Katz et al. [18].
Several studies reported non-operative treatment to be a
reasonable first strategy [7, 18, 19], with surgery reserved for
patients not showing improvement [7]. The current study
contradicts this, since patients were not satisfied with physical
therapy alone and underwent APM.
Arthroscopic debridement was compared to non-operative
treatment among osteoarthritic patients in two randomized
controlled trials [1821]. After two years, neither trial showed
any significant or clinically important difference between
arthroscopic and non-operative groups regarding functional
improvement or pain relief [20, 21], emphasizing that arthro-
scopic treatment was not superior to other interventions in
treating knee osteoarthritis. However, they did not focus on
management of a symptomatic meniscal tear, which is a
frequent indication for knee arthroscopy in patients with os-
teoarthritis of the knee. The efficacy of APM in symptomatic
patients with a meniscal tear and osteoarthritis was evaluated
in a randomized, controlled, single-center study involving 90
patients. This showed no significant difference in pain relief or
functional status between APM plus physical therapy versus
physical therapy alone [17]. However, patients in this cohort
were osteoarthritic. Herrlin et al. [19] reported 33 % of pa-
tients treated using exercise therapy alone felt no better after
treatment and still had disabling knee symptoms that im-
proved after arthroscopic surgery.
Most articles studied the effect of APM on arthritic knees
[7, 18, 21]. Katz et al. [18] studied patients with osteoarthritis,
while in the current study, only 28.5 % had mild arthritis,
possibly explaining our better results.
Between six to12 months, 34.9 % of 169 patients crossed
over from physical therapy to APM, [18] indicating the degree
of patient dissatisfaction with physical therapy alone. This is
Unstable meniscal tear
Physical therapy (8 weeks)
Improved
Un-satisfied Satisfied
and/or
OA > grade 2
Symptoms
recurred
OTHER TTT
774
explicitly mentioned by the authors and is in agreement with
our findings that patients in this study were not fully satisfied
with physical therapy alone. Also, comparing the average
Lysholm scores before and after surgery for arthritic versus
non-arthritic patients, better results were found in non-arthritic
cases (p=0.001) (Table 1).
At 6 months, WOMAC score improved in 67.1 % of
patients assigned to APM versus 43.8 % of patients assigned
to physical therapy as reported by Katz et al. [18]. We report
significant improvement of the Lysholm score after APM,
which was sustained up to the final follow-up. A small num-
ber of patients showed limited improvement of the Lysholm
score, possibly attributed to osteoarthritis, poor quality of
meniscal tissue and associated chondral damage. Katz and
co-workers report 59.5 % cross-over from physical therapy
to APM across study centres. These patients showed no sub-
stantial functional improvement until cross-over [18].
A study on effects of surgery versus non-operative treat-
ment in patients with osteoarthritis concluded that arthroscop-
ic surgery was not more effective than non-operative treat-
ment, which included physical therapy (one session per week
for 12 weeks), patient education, and stepwise use of acet-
aminophen, anti-inflammatory drugs, glucosamine, and local
hyaluronic acid [21]. In their study, it was not possible to
isolate the effects of the various non-operative modalities. In
fact, the use of several drugs that may have improved pain and
other symptoms may be a reason why surgery appeared no
better than non-operative therapy.
In patients with concomitant osteoarthritis, disease-related
pain can persist after arthroscopic surgery [22]. Osteoarthritis
patients having chondral or osteochondral lesions may not be
treated during the course of APM. This may explain why in
some previous studies no significant differences were found
between APM and physical therapy.
We agree with Marx [23] that although the work of Kirkley
et al. [21] showed lack of efficacy of arthroscopic surgery, it
should not imply that it has no role in the treatment of patients
who may have osteoarthritis and a symptomatic meniscal tear.
Kirkley and co-workers concluded that osteoarthritis of the
knee, in the absence of a meniscal tear, is not an indication for
arthroscopic surgery. However, osteoarthritis is not a contra-
indication to arthroscopic surgery. Arthroscopic surgery is
appropriate in patients with arthritis in whom osteoarthritis is
not the primary cause of pain [21]. This is in agreement with
our findings that there is a substantial role for arthroscopic
menisectomy in treating symptomatic meniscal tears, even in
patients with arthritis.
Although there was a statistically significant better out-
come for patients with lateral meniscus tears after physical
therapy sessions, we do not have an explanation for this
finding. This is also coinciding with the findings by Pujol
and Beaufils [24], who have also reported better results for
conservative treatment in the lateral compartment.
International Orthopaedics (SICOT) (2015) 39:769775
Sihvonen et al. [25], comparing APM to sham surgery for
degenerative medial meniscus tears, found no difference be-
tween the two interventions, contradicting with findings in the
current study. However, this may be explained by the placebo
effect of surgery for the sham group. Also, when comparing
patients before and after APM, this study showed improve-
ment in the Lysholm knee score in this group [25].
While it is generally believed that meniscal tissue loss may
lead to osteoarthritis and poor knee function, many variables
influence meniscectomy outcome [12]. Although Petty and
Lubowitz report favorable short-term results of APM [1], we
need to review our patients after five years, to identify any
progression to osteoarthritis. Also, an algorithm for treatment
decision in cases with unstable meniscal tear is proposed
(Fig. 4).
Conclusions
Physical therapy alone was not sufficient to treat unstable
meniscal tears. Arthroscopic partial menisectomy provided
effective treatment, with high patient satisfaction and restored
knee function, even in the presence of grade 2 osteoarthritis.
Conflict of interest The authors declare that no funding or grant was
received for the study, and that they have no conflict of interest, nor
financial or personal relationship related to the study.
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