Meniscal Tear Treatment: Why Surgery Is Usually Not Needed

By Maxence Legout, MSc · Advanced Practice MSK Physiotherapist & Sonographer · Published June 2026

Meniscal problems are remarkably common, and as a physiotherapist they're often one of the first things people ask me about, especially anyone who plays sport. Look around your own friends and family and there's almost always someone who has had a meniscus problem, and very often they've had surgery, or at least they assume that a meniscus problem automatically means an operation. Being told that an MRI shows a torn meniscus can sound worrying, and it's understandable to think that something has torn inside the knee and therefore needs to be surgically repaired or removed. For most adults with a degenerative meniscal tear, though, that's no longer what the best evidence tells us. Large randomised trials have shown that removing the torn part of the meniscus usually offers no meaningful advantage over exercise-based rehabilitation, and the latest evidence now follows patients for as long as 10 years.

So the aim of treatment is usually not to "remove the tear". It's to reduce pain, restore movement, rebuild strength, and get you back to exercise and normal activity. For some patients an injection can help along the way, not because it makes the tear disappear, but because reducing pain and joint irritation can make it easier to exercise and rehabilitate the knee effectively.

What is the meniscus?

Each knee contains two menisci, a medial meniscus on the inside of the knee and a lateral meniscus on the outside. They're crescent-shaped pieces of fibrocartilage that help spread load across the knee, add stability and protect the joint surfaces. This matters, because the meniscus is useful tissue. Removing part of it is very different from clearing away a useless fragment of damaged cartilage, and modern treatment increasingly aims to preserve the meniscus whenever possible.

Degenerative versus traumatic meniscal tears

Not all meniscal tears are the same, and the difference changes the treatment.

Degenerative tears

These usually develop gradually, particularly from middle age onwards. They often sit alongside early osteoarthritis and can be thought of as part of the natural ageing of the knee rather than a distinct injury. Meniscal changes are also commonly found on the scans of people who have no knee pain at all. In other words, a tear on an MRI does not automatically mean the tear is the cause of your pain.

Pain may instead come from several structures and processes within the knee, including:

• synovitis, or inflammation of the joint lining;
• early knee osteoarthritis;
• a joint effusion (swelling);
• the bone just under the cartilage;
• reduced muscle capacity;
• a sudden increase in activity or loading.

This distinction is fundamental when deciding what to do next.

This is also why a proper clinical assessment matters more than simply treating an MRI report. A meniscal tear may be present on imaging, but that doesn't prove it's the main source of your pain. In practice, a skilled MSK clinician combines the history, physical examination, imaging findings and, where useful, ultrasound assessment to look for other possible pain generators such as osteoarthritis, synovitis, a joint effusion, patellofemoral pain, tendon pathology, ligament irritation or a Baker's cyst. Sometimes the tear on the MRI is only part of the picture, or may be an incidental finding altogether. That matters, because the right treatment may be rehabilitation, activity modification or simple reassurance rather than an injection. The aim of the assessment is therefore not just to decide which injection to give, but first to work out whether an injection is needed at all, and what is actually causing your symptoms.

Traumatic tears

A traumatic tear happens after an injury, commonly a twist or rotation, and is more frequent in younger or athletic people. Some traumatic tears settle well without surgery. Others, particularly displaced or repairable tears, need a different approach. So the strong evidence against routine surgery for degenerative tears does not mean that every meniscal injury should avoid surgery.

Why isn't surgery usually necessary?

Historically, people with knee pain and an MRI showing a degenerative meniscal tear often had an arthroscopic partial meniscectomy, a keyhole operation to trim away the torn portion of the meniscus. It sounds mechanically logical: if something is torn, remove the damaged part. The difficulty is that high-quality trials have repeatedly shown this does not usually improve the outcome.

Physiotherapy performs as well as surgery

The ESCAPE randomised trial included 321 patients aged 45 to 70 with degenerative meniscal tears, who received either arthroscopic partial meniscectomy or an exercise-based physiotherapy programme. After five years there was no clinically important difference in knee function between the groups, and the researchers concluded that exercise-based physiotherapy should be the preferred treatment for degenerative meniscal tears (Noorduyn et al., 2022).

What happens when surgery is compared with placebo surgery?

This is where the evidence becomes especially compelling. The Finnish FIDELITY trial did not simply compare surgery with physiotherapy. Patients with degenerative medial meniscal tears were randomised to either a real arthroscopic partial meniscectomy, or placebo surgery, where they went through the whole surgical experience but the meniscus was not actually trimmed. That design lets us see whether removing the meniscal tissue itself really provides any benefit. Earlier follow-up showed no meaningful symptomatic advantage, and we now have the 10-year results.

The new 10-year evidence

Published in the New England Journal of Medicine in 2026, the 10-year FIDELITY follow-up found that arthroscopic partial meniscectomy gave no long-term benefit over placebo surgery. The results also raised concern about possible long-term harm, including greater progression of osteoarthritis in the group whose meniscal tissue had been removed. The authors concluded that, over 10 years, the outcomes suggested no benefit and possible harm from arthroscopic partial meniscectomy for degenerative meniscal tears (Kalske et al., 2026). This is important. It suggests that routinely removing meniscal tissue is not just an unnecessary operation, it may also take away tissue that helps protect the knee and spread load.

What about clicking, catching or giving way?

These symptoms are often blamed on the meniscus. But clicking or occasional catching is not the same as a genuinely locked knee. Studies from the placebo-controlled FIDELITY programme have not shown that people reporting intermittent catching or locking get a particular benefit from partial meniscectomy.

This is very different from the common clicking or catching. From my own experience working in emergency departments, I have seen a small number of genuinely locked knees that could not be unlocked even after the knee had been completely numbed, which shows just how mechanical a true block can be, and why it needs urgent orthopaedic assessment rather than an injection.

The goal of treatment: get the knee moving again

The purpose of conservative treatment is not to make the meniscus look normal again on a scan. It's to restore what the knee can actually do. A good rehabilitation programme gradually rebuilds:

• knee movement;
• quadriceps, hamstring, calf and hip strength;
• balance and control;
• tolerance to squatting and stairs;
• walking capacity;
• and running or sport where appropriate.

Many people return to excellent function even though the meniscal change is still visible on imaging. The question is not "how do we heal the MRI?", it's "how do we help this knee tolerate normal loading again?"

But what if the knee is too painful to exercise?

This is where injections can have a useful role. An injection is not an alternative to rehabilitation. For the right patient, it creates a window of opportunity: pain settles, movement becomes easier, exercise progresses, strength returns and activity increases. This is particularly relevant when a degenerative tear sits alongside synovitis, an effusion or early osteoarthritis, because the MRI may describe a meniscal tear while much of the pain actually comes from the irritated joint around it.

Corticosteroid injection: useful when the knee is inflamed

Corticosteroid is particularly helpful when there's an inflammatory component to the pain, for example a swollen knee, a joint effusion, synovitis, a recent painful flare, associated osteoarthritis, or pain severe enough to prevent meaningful rehabilitation. It's a powerful anti-inflammatory and can settle pain relatively quickly. Importantly, a corticosteroid injection does not stitch or regenerate the torn meniscus. Its role is different: if inflammation and pain are stopping someone from walking comfortably, strengthening the quadriceps or progressing through physiotherapy, calming that inflammation can make rehabilitation far more achievable.

A typical example is someone with a degenerative tear who has developed pain, swelling, reduced movement and difficulty exercising. Rather than jumping to arthroscopy, we might:

1. assess the knee clinically and with ultrasound;
2. identify an effusion or synovitis;
3. drain excess fluid when appropriate;
4. perform an ultrasound-guided corticosteroid injection;
5. and progressively restart rehabilitation once symptoms settle.

The injection is a facilitator of rehabilitation, not the end point, and repeated corticosteroid injections should not become the long-term strategy for a degenerative knee.

Hyaluronic acid: an option when degeneration or OA contributes

Hyaluronic acid, or HA, is another option, particularly when the tear sits in a knee that already shows degenerative or osteoarthritic change. HA is naturally present in joint fluid and contributes to its lubricating, shock-absorbing properties. Like corticosteroid, an HA injection does not mechanically repair a tear. Its purpose is to reduce pain, improve movement, improve tolerance to loading and make activity and rehabilitation easier.

Is there evidence specifically for meniscal tears? There's some, though much less than for knee osteoarthritis. A small randomised trial of 50 patients with degenerative meniscal tears found that those given an intra-articular HA derivative improved more in pain and function than controls in the short term, and MRI even suggested reductions in tear length and depth (Zorzi et al., 2015). That's an interesting biological signal, but the study was small, short-term and involved the manufacturer, so it's not enough to claim HA reliably heals tears. A separate observational cohort also reported improvement after HA, but its design means we should read it cautiously. For most middle-aged patients, the stronger reason to consider HA is the frequent overlap of degenerative meniscal change, early osteoarthritis and an irritable joint. If reducing that pain lets someone return to strengthening, walking, cycling or sport, HA can be part of a broader conservative plan.

Cortisone or hyaluronic acid, which is more appropriate?

They have different roles. Corticosteroid may be preferable when the knee is swollen, there's a significant effusion, ultrasound shows synovitis, symptoms have recently flared, rapid pain relief is needed, or pain is currently preventing rehabilitation, its main advantage being fast anti-inflammatory action. Hyaluronic acid may be preferable when symptoms are more chronic, degenerative change or osteoarthritis is present, stiffness and activity-related pain predominate, there's no major inflammatory flare, longer-duration relief is the goal, or repeated corticosteroid is undesirable. Neither should be chosen simply because an MRI report contains the words "meniscal tear". The treatment has to match how the knee actually presents.

Why use ultrasound guidance?

Ultrasound gives useful information that an MRI report alone cannot provide at the time of treatment. We can assess the knee dynamically for a joint effusion, thickened synovium, active inflammation, a Baker's cyst, peripheral meniscal changes and any associated tendon or ligament problem. If there's a large effusion, it can be drained before treatment when appropriate. During an injection, ultrasound lets us watch the needle enter the joint in real time and confirm the medication is delivered accurately, which matters especially with treatments such as HA where we want the full dose in the right place. So the scan is not simply about finding the tear, it helps us understand what else in the knee is driving the symptoms and whether an injection is likely to help.

What about PRP?

Platelet-rich plasma (PRP) is an emerging option for meniscal problems. Unlike corticosteroid and HA, some researchers have looked at whether PRP might have a more direct biological effect on meniscal tissue. One interesting 2023 study treated 392 meniscal lesions with a combination of ultrasound-guided intrameniscal and intra-articular PRP. Only 38 went on to have meniscal surgery, a reported 90.3% surgery-free rate, and around two-thirds of patients with follow-up had clinically meaningful improvement, with horizontal tears responding particularly well and existing cartilage damage predicting poorer results (Sánchez et al., 2023). That's encouraging, but there's an important limitation: there was no control group, and we already know many patients improve without surgery, so we can't tell how much of the benefit was specifically due to PRP. For now this is an emerging treatment rather than an established first-line option.

I should also be clear that I don't currently offer PRP at Insight MSK. I've included it here so you have the full picture of where the research is heading.

Do younger patients with traumatic tears always need surgery?

No. There's also randomised evidence that many younger patients with traumatic tears can start with rehabilitation. That said, the threshold for seeking a surgical opinion is lower when the injury is acute and the meniscus may be repairable, because repairing and preserving functional meniscal tissue is very different from routinely trimming away a degenerative tear.

When is surgery actually appropriate?

There are still important situations where surgical assessment is the right step:

• A genuinely locked knee, where the knee physically cannot straighten because a displaced fragment is blocking movement, needs urgent assessment.
• A displaced bucket-handle tear may need arthroscopic reduction and repair.
• A repairable traumatic tear, particularly in younger active patients, may be worth repairing to preserve meniscal function.
• A significant radial tear can disrupt the fibres that let the meniscus spread load and may warrant repair.
• A meniscal root tear deserves particular attention, because it can seriously compromise the meniscus's ability to distribute load. Selected patients, particularly those without advanced osteoarthritis, may benefit from root repair, though age, alignment, cartilage condition and existing arthritis all influence the decision.

What if physiotherapy has already failed?

"Physiotherapy didn't work" can mean very different things. There's a big difference between being handed a few generic exercises, stopping because exercise was initially uncomfortable, completing a progressive three-month strengthening programme, and actually building back towards the activities that matter to you. Pain can create a vicious circle: pain leads to reduced activity, which leads to muscle weakness, lower knee capacity and then more pain with activity. This is one reason injections can be useful. If a corticosteroid or HA injection reduces symptoms enough to break that cycle and allow effective exercise, it has achieved an important goal, even though it hasn't physically repaired the meniscus.

Our approach to degenerative meniscal tears

Rather than treating the MRI, we assess the whole knee.

1. Work out what's causing the symptoms. A meniscal tear may be relevant, but we also look for osteoarthritis, synovitis, an effusion, a Baker's cyst, reduced strength, loss of movement and other problems.
2. Keep the knee moving. Exercise is not something to leave until everything has "healed", it's usually central to recovery.
3. Reduce pain if it's preventing exercise. Corticosteroid is particularly useful with significant inflammation, synovitis or effusion; hyaluronic acid can be considered when degenerative or OA-related symptoms predominate and longer-term control is the aim.
4. Progressively strengthen the knee, building through walking, cycling, functional loading and running or sport when appropriate.
5. Reserve surgery for the situations where it genuinely adds value. The goal isn't to avoid surgery at all costs, it's to avoid unnecessary surgery while recognising the smaller group who truly benefit from meniscal repair or other surgical management.

The key message

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