Physical therapy noninferior to arthroscopic partial meniscectomy for partial nonobstructive meniscal tears

1. In this randomized controlled trial, patient-reported knee function did not significantly differ between those randomized to physical therapy compared to arthroscopic partial meniscectomy (APM).

2. While there was no significant difference in activity level between the two groups, the APM group had improved knee pain while weight-bearing.

Evidence Rating Level: 1 (Excellent)     

Study Rundown: For patients 45 to 70 years old, the etiology of knee injuries can be secondary to degenerative disease, trauma, or both. The beneficial role of physical therapy in partial nonobstructive meniscal tears has not led to a decline in surgical options for this condition. In this randomized, controlled, non-inferiority trial, patient-reported knee function did not differ after 24-months following randomization to either physical therapy (PT) or arthroscopic partial meniscectomy (APM). As a secondary outcome, pain during weight-bearing significantly improved in the APM group compared to the PT group. However, there was no significant difference between the groups in activity level at 24-months.

Overall, the results from this study demonstrate that PT is an acceptable alternative to surgery for patients with partial nonobstructive meniscal tears. As patients in this age cohort often have significant comorbidities making surgery a risky option, having effective non-surgical treatments such as PT are ideal. However, over 80% of the tears were of the medial meniscus in both the control group, and it’s not clear that these results would be well-generalized to those with lateral tears.

Click to read the study in JAMA

Relevant Reading: Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up

In-Depth [randomized controlled trial]: In the ESCAPE trial, 321 patients aged 45-70 years with partial, nonobstructive meniscal tears were enrolled between July 17, 2013 and November 4, 2015. to receive physical therapy (PT) (n= 162) or arthroscopic partial meniscectomy (APM) (n= 159). After randomization, patients were followed for 24 months. Patients with a BMI greater than 35 and severe osteoarthritis were excluded. Knee function improved by 26.2 points in the APM group and by 20.4 points in the PT group. The overall between-group difference was 3.6 points (P for noninferiority = 0.001). Knee pain during weight-bearing significantly improved in the APM group as compared to the PT group (5.9 mm between-group difference; CI₉₅ 1.4-10.3). There was no significant difference in activity level between the two groups (0.04 points between-group difference, CI₉₅ -0.3 to 0.2). For patients randomized to PT, 47 (29%) ended up undergoing APM during the follow up period. Two participants in the APM group ended up having a total knee arthroplasty within 2 years of APM.

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