Meniscus Injury – Rehabilitation or Surgery?

Few diagnoses create more uncertainty than a meniscus tear. Many people assume that a meniscus finding on MRI automatically means surgery – but research over the past decades has turned that assumption around. For most people, targeted exercise is the first choice, and surgery is the exception rather than the rule.

Two very different types of meniscus injury

The meniscus consists of two crescent-shaped cartilage pads that distribute load and provide stability in the knee. Injuries fall broadly into two categories requiring entirely different approaches.

Traumatic tears typically occur in younger, active people following a specific twisting movement with the knee under load – often in sport. Degenerative tears develop gradually over years as part of normal ageing in the tissue, and often appear without any triggering incident.

This distinction is crucial, because it's where most misunderstandings arise. Degenerative changes are very common in people with no pain at all, and increase steadily with age. Such a finding is therefore not automatically the cause of your symptoms.

What the research actually shows

The Norwegian OMEX trial, published in the BMJ in 2016, randomised middle-aged patients with degenerative meniscus tears to either keyhole surgery or three months of supervised exercise therapy. After two years there was no difference between the groups in pain and function – and the exercise group additionally had better muscle strength.

Ten years later the researchers followed up the same patients, published in the British Journal of Sports Medicine in 2025. The conclusion held: equally good improvement in pain and function in both groups, and no difference in the development of osteoarthritis on X-ray. In other words, surgery offered no long-term advantage.

This doesn't mean surgery is never appropriate. In cases of true locking, where a meniscus flap mechanically blocks movement, or with larger traumatic tears in younger patients, surgery can be both correct and necessary. The point is that surgery should be a deliberate choice based on precise assessment – not an automatic consequence of an imaging finding.

Why thorough assessment matters

The knee has many structures that can produce similar symptoms: ligaments, cartilage, tendon insertions, bursae, and referred pain from the hip or back. A clinical examination with specific tests for the meniscus, ligaments and cartilage surfaces provides information about what actually provokes your symptoms.

Ultrasound is a useful supplement because it shows tissue in real time while you move. It gives a good overview of joint fluid, tendon insertions, bursae, cartilage along the joint line and any cysts – and lets me assess the structures during active movement, not just at rest. Ultrasound doesn't replace MRI for viewing the entire meniscus in depth, but it often clarifies whether the symptoms come from the meniscus at all, and it gives answers immediately during the consultation.

The combination of history, clinical examination and ultrasound usually determines whether further imaging or referral to an orthopaedic surgeon is necessary – or whether we can start rehabilitation straight away.

Phase and timeline shape the plan

The phase you're in determines what rehabilitation should look like. Jumping straight to heavy loading in an irritated phase causes setbacks, while staying too long in the protective phase causes unnecessary loss of strength and function. A typical progression looks like this:

• Early phase: reduce swelling and irritation, restore full range of motion and activate the thigh muscles with low load
• Middle phase: gradually increasing strength training for thigh, glutes and calf, monitoring how the knee responds from session to session
• Late phase: heavier strength, balance and change of direction tailored to what you're actually returning to
• Return to sport: jumping, landing and sport-specific demands with objective criteria before full return

When is surgery still relevant?

Surgery should be considered in cases of true mechanical locking that doesn't resolve, larger traumatic tears in younger active people where meniscus repair is possible, and cases where structured rehabilitation over sufficient time doesn't produce progress.

Note the difference between repairing the meniscus and removing part of it. Where it's possible to preserve meniscal tissue, that's usually preferable, because the meniscus plays an important role in distributing load over time.

Sources

1. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. "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.
2. Berg B, Roos EM, Englund M, Kise NJ, Engebretsen L, Eftang CN, Risberg MA. "Arthroscopic partial meniscectomy versus exercise therapy for degenerative meniscal tears: 10-year follow-up of the OMEX randomised controlled trial." British Journal of Sports Medicine 2025;59(2):91–98.
3. Brinjikji W, Luetmer PH, Comstock B, et al. "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations." AJNR Am J Neuroradiol 2015;36(4):811–816.