Meniscus Tears: Surgery or No Surgery?

As the sporting season commences for another year, we can be sure that as clinicians we will stumble across a number of various knee injuries; including meniscal tears. While the importance of the meniscus as a shock absorber in the knee and for overall knee health is understood, what is less understood is what path patients should take should they experience this type of injury. The question still remains: Surgery or No Surgery? Having dealt with this injury in all its different forms and presentations and similarly struggled with this burning question, I may have found the answer. Lets take a deeper look!

What is a Meniscal Tear?

The menisci are two c-shaped structures made of tough fibrocartilage that sit on top of our shin bone (tibia) and act to absorb forces placed on the knee and preserve the joint as much as possible. Typically, tears to these structures can be chronic and related to repetitive stress over time or acute where they can occur with acute twisting or high forces placed on the knee, most commonly seen in but not limited to, sporting scenarios. A meniscal tear will typically present with pain walking or weight-bearing, swelling around the knee and tenderness to touch on the joint line, depending on which side of the knee is affected. It can be accompanied by clicking and/or locking, depending on the severity of injury.

Types of Meniscal Tears:

Longitudinal (vertical) tear: Runs along the length of the meniscus. If it worsens, it can turn into a “bucket-handle” tear.

Bucket-handle tear: A large longitudinal tear where a piece flips into the joint, often causing the knee to lock.

Radial tear: Starts at the inner edge and extends outward. These are common and can disrupt how the meniscus distributes weight.

Horizontal tearSplits the meniscus into top and bottom layers. Often linked with wear and tear over time.

Flap (parrot-beak) tear: Creates a loose fragment that can catch in the joint, causing sharp pain.

Complex tear: A combination of different tear patterns, usually seen in more severe or degenerative cases.

As well as the type/severity of the tear, it is also important to consider its blood supply:

Blood Supply:

The meniscus has different blood supply zones, which affect healing:

Red-red zone (outer third) Good blood supply → better chance of healing on its own or after repair.

Red-white zone (middle)Moderate blood supply → healing potential varies.

White-white zone (inner third)

Poor blood supply → tears here usually don’t heal well and may require surgery.

Now that we have established a little bit about the meniscus itself, the question still remains; what management strategy is best?

And unfortunately, the answer isn’t exactly one size fits all.

Factors to consider:

There are many factors we need to consider when planning our treatment for a meniscal tear. These include personal factors, the degree of injury/healing potential and functional limitations. Here are two examples below:

1. A 16 year-old Basketballer sustains a radial tear to the medial meniscus following a twist in a game. Initially, she struggles to put weight through the leg but after 5 days is back walking comfortably. Her swelling has settled a lot, and has regained full movement in her knee. She is due to start some physio.

2. A 65 year-old male begins to develop severe knee pain upon waking after a busy weekend on his feet while on holidays. The knee is quite swollen and walking is painful. When he attempts to bend his knee, his knee locks up and the pain becomes very sharp. He is struggling to perform his normal daily tasks. An MRI confirms a degenerative flap tear with a loose body present.

These are two very different scenarios. In case A, this is a young athletic person with good healing potential and a significant improvement in symptoms in a short period. In this case, it may be more appropriate to begin physio once the acute inflammation is settled and begin a progressive strengthening programme before incorporating into return to play. In case B, there is a mechanical issue and it is having an affect on activities of daily living. Quality of life is reduced and MRI has confirmed that there is a loose body that may be responsible for the dysfunction that is displayed. A bout of physiotherapy can always be beneficial and can help reduce symptoms, but in this case, surgery may be appropriate to remove the loose body and restore normal function.

What Do the Best Recent Reviews Actually Show?

Meniscal Tears: Surgery or Rehab?

The latest high-quality reviews (2024–2025) all point in the same direction: for most degenerative meniscal tears, surgery doesn’t outperform rehab.

• van de Graaf et al. (2025): no meaningful difference in pain or function vs non-op care, with a signal toward more OA after surgery

• Brignardello-Petersen et al. (2024) and Thorlund et al. (2024): same story—no clinically important benefit for surgery

A couple of other things to consider:

• For root tears, evidence is still unclear (LaPrade et al., 2024)

• If you do operate, repair > meniscectomy for long-term outcomes (Abrams et al., 2024)

  
  

Takeaway

• For most people, rehab first is the way to go. Surgery still has a role—but mainly for specific cases (e.g. traumatic tears, locking, or failed rehab).

• It is important to always listen to your patient and monitor symptoms and dysfunction during rehabilitation- it can take time, but improvements should be noted throughout

• Recognise when something isn’t working- and don’t be afraid to get help or a second opinion, or just simply change things up!

  
  

If you are struggling with a meniscus injury, get onto us in Physio K and we can get started!