MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Meniscus-injuries are common and there is no consensus as to how best treat them. Physiotherapists tend to advocate exercise, while surgeons tend to advise surgery.

Of course, exercise is not a typical alternative therapy but, as many alternative practitioners might disagree with this statement because they regularly recommend it to their patients, it makes sense to cover it on this blog. So, is exercise better than surgery for meniscus-problems?

The aim of this recent Norwegian study aimed to shed some light on this question. Specifically wanted to determine whether  exercise therapy is superior to arthroscopic partial meniscectomy for knee function in  patients with degenerative meniscal tears.

A total of 140 adults with degenerative medial meniscal tear verified by magnetic resonance imaging were randomised to either receiving 12 week supervised exercise therapy alone, or arthroscopic partial meniscectomy alone. Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two-year follow-up and change in thigh muscle strength from baseline to three months.

The results showed no clinically relevant difference between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval −4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two-year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two-year follow-up, with no additional benefit.

The authors concluded that the observed difference in treatment effect was minute after two years of follow-up, and the trial’s inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short-term. Our results should encourage clinicians and middle-aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.

As I stated above, I mention this trial because exercise might be considered by some as an alternative therapy. The main reason for including it is, however, that it is in many ways an exemplary good study from which researchers in alternative medicine could learn.

Like so many alternative therapies, exercise is a treatment for which placebo-controlled studies are difficult, if not impossible. But that does not mean that rigorous tests of its value are impossible. The present study shows the way how it can be done.

Meaningful clinical research is no rocket science; it merely needs well-trained scientists who are willing to test the (rather than promote) their hypotheses. Sadly such individuals are as rare as gold dust in the realm of alternative medicine.

19 Responses to Is exercise better than surgery for meniscal tears?

  • As an orthopaedic surgeon I endorse Edzard’s opinion 100% – in so far as it goes.
    No study is perfect, but this is ‘good’ by all reasonable criteria.

    Please understand that patients referred to surgeons may be in a different sub-set to those referred for physio-alone.
    A partial menisectomy will remove tissue which might otherwise abrade and degrade the articular cartilage.
    Two year follow up is not really long enough to assess outcome.
    And patients who have had an arthroscopic partial menisectomy should be having physio as well.

    The outcome of this study should be expressed is “no difference – within two years”.
    Which is not to say there will not later be more rapidly developing OA in those patients who do not have the pesky damaged meniscal cartilage removed.
    So, as our camist friends are so fond of saying – more research needed!

    • I know next to nothing about knee injuries. But in my work as an Alexander Technique teacher I regularely meet people with knee issues and so would like to know more about it.
      Richard R says:
      “A partial menisectomy will remove tissue which might otherwise abrade and degrade the articular cartilage.”
      Is it a known fact that tissue from the meniscus might ‘abrade and degrade’ the cartilage or is it a hypothesis?

      Halvard Heggdal

    • you did not even bother to read as much as the title of the post you comment on!
      if you had, you would have noticed that your link is not even about the same condition.

      • “if you had, you would have noticed that your link is not even about the same condition.”

        Statement revised.

        Many simple alternative possibilities offer better results for medical conditions than crude drugs and useless surgeries.

    • “Most alternative possibilities offer better results.”

      Pilot studies do *not* provide clinically meaningful results.

      “A pilot study, pilot project or pilot experiment is a small scale preliminary study conducted in order to evaluate feasibility, time, cost, adverse events, and effect size (statistical variability) in an attempt to predict an appropriate sample size and improve upon the study design prior to performance of a full-scale research project.” — Wikipedia.

      • “Pilot studies do *not* provide clinically meaningful results.”

        This test was done on patients who did not respond to drugs.

        “It’s easy to learn and practice, say the researchers who tested it on a group of 25 people who had been diagnosed with major depressive disorder (MDD), and who hadn’t been helped by antidepressants.”

        Why was the practice picked up for test? Because it has been used for a few thousand years for similar condition minus the scientific jargon.

        Follow up studies with adjusted data will prove that there are no benefits and people will be put back on drugs with necessary side effects. And we bash Donald Trump for not believing in climate change.

  • “Exercises” for single joint complexes, e.g. knees are probably as good as anything. Whether you recommend the patient keep as busy and as active as possible, walking, cycling swimming etc. or do a specific set of “exercises” needs to be studied.
    For multi-joint complexes e.g. spine, I would suggest that exercises alone are ineffective as they do not address joint function error, nor associated neuro-physiological affects of the joint dysfunction. One ends up with temporary increased muscle strength until the patient ceases the activity and the muscle reverts back to the size and function needed to maintain the activities that the individual is participating in i.e. dis-use atrophy of the muscle. Joint function error with hyper and hypo mobile joints in adjacent areas in a multi-joint complex will just be exacerbated by exercises.

    • And chiropractic manipulation of the patient’s wallet is your proposed solution.

      Am I right?

      • @Simone

        Well…….Physiotherapy is a significant part of chiropractice, Simone. It would appear that this study countenances PT as equally effective at 2 years follow-up as surgery for the meniscal tears studied. One must wonder why you would suggest that SMT for spinal joint pain represents “manipulation of the patient’s wallet” when, by extension of your “logic,” orthopedic surgery for meniscal tear would rid one’s wallet of money much more readily than would PT. You failed to mention this. It appears you have an ax to grind.

        • .

          L-B

          One must wonder why you would suggest that SMT for spinal joint pain represents “manipulation of the patient’s wallet” when, by extension of your “logic,” orthopedic surgery for meniscal tear would rid one’s wallet of money much more readily than would PT. You failed to mention this. It appears you have an ax to grind.

          It seems you have not read my comment at the bottom of the page that covers this issue.

          Chropractic can offer no objective evidence for use in anything other than back pain and for that it shows no evidence better than other therapies. The topic here is knee problems. I didn’t bring up the subject of chiropractic, GG appeared to allude to it, hence my comment.

          To be clear, if we have good evidence that surgery is worthless, it should not be performed. Medicine has many other treatments to offer and surgeons have many other tasks to perform. We’d all want more evidence collected more quickly, but as it emerges, conventional medics can accommodate evidence-based changes to treatment recommendations. Chiropractors cannot. The appropriate response of chiropractors to this situation would be to pack up shop and get more useful jobs. There is little to no evidence for their main treatment and their ancillary services would be better supplied by other people without the added nonsense and outright quackery.

      • Simon.

        Who mentioned chiropractors?

        • I asked a question, promoted by this circumlocution “Joint function error with hyper and hypo mobile joints in adjacent areas in a multi-joint complex will just be exacerbated by exercises.”

          If that’s not a proxy for invoking chiropractic manipulation then please be clearer what treatment you are actually advocating.

  • @ GibleyGibley

    In light of the recent update to the NICE guidelines for low back pain and a number of Cochrane reviews, I would say that exercise alone for spinal pain is better than manual therapy (spinal manipulative therapy, massage, mobilisation) alone.

  • As vets we have a limited evidence-base for our knee surgeries, which is a source of great frustration to me.

    In dogs, meniscus injury is invariably part of a cruciate ligament problem. Cruciate surgery is a huge industry. What I find interesting is that the process is usually bilateral, but the second side is operated on in only a minority of cases. That suggests to me that we are non-surgically managing a large fraction of our caseload without formally acknowledging the fact. That accords with the outcome of this trial in an experimental animal (humans).

    Having said that, and granted in a different species, a canine joint with a big bucket-handle tear of the meniscus looks like a very ‘angry’ joint at surgery and pre-op manipulation of these joints reveals most pain when the torn portion fixes then clicks. My impression is that these cases do less well long-term than those without meniscal injury. My suspicion is that they do poorly with surgery but terribly without at least in the medium-term. I suspect arthritis catches up with all cases long-term. Unfortunately, this complex situation (variety of pathology and timescale over which outcomes are assessed) has not been well captured in the veterinary literature and the people doing the largest numbers of surgeries are too busy operating to run the trials we need and they and their clients are not motivated to participate in them so we are left with a thin evidence-base and a lot of anecdotalising.

    As an aside, and consonant with my observations about inadvertent non-surgical management of ACL damage, I think I’m right in saying that cruciate injury was regarded as an acute injury in people but about 1/4 of knees that come for replacement turn out to have no ACL yet ACL deficiency was not recognised. Perhaps Richard could comment.

  • It is a great shame that they didn’t include a no-treatment group.
    The problem with this sort of study is that it doesn’t preclude the possibility that neither treatment has the slightest effect.

    • Indeed, true, but even as it was, the numbers of subjects were small. Another group would have reduced group sizes (or prolonged recruitment and demanded more funding) and increased the number of comparisons being required. And if you have just a waiting list control you’ve still got the problem that the subjects aren’t blinded, which is a problem that riddles even the most plausible physical therapies.

      For me, I still think there is value in a study like this if an invasive and risky intervention like surgery can be shown to offer no benefit over something innocuous like physio. I think the follow-on questions implied by your comment would then be addressable by a follow-up study of physio vs control/s.

      This study is actually (by chance?) already one step down that road. It lacked a sham-surgery arm, but the question that would be addressed by a sham arm is addressed adequately if verum surgery can be rejected.

      All that said, to infer that surgery should never be done flies in the face of strong clinical impression that some knees need surgery. I’d happily quit operating on knees and send them all for physical rehabilitation but I’d need to see more lines of consistent reinforcing evidence. In my little vet world, I’ll be waiting a long time.

      Overall, bearing all these arguments in mind, I probably manage more knees conservatively than I used to. But it can’t be 100% and I have two cases as examples. Grossly fat spaniels who had both been hospitalised for bacterial pneumonia. Not helped that their owners smoked like chimneys. We were very keen to avoid anaesthesia with them. So we did all the physio we could. In both cases the joints became so unstable that the ends of the femurs actually slid off the top of their tibias making use of the limb impossible. We operated and they did fine.

      I think that example highlights a real problem. Findings that are true across the population on average may not be true for each individual and every subgroup. This is an excuse used feebly by homeopaths but it is actually a valid point.

Leave a Reply

Your email address will not be published. Required fields are marked *

Please answer the following: *

Recent Comments

Note that comments can now be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories