The Bone Whisperers

Do All Meniscus Tears Need Surgery?

Episode Summary

Meniscus tears are common, but surgery isn't always the best option. Experts cover diagnostic methods, imaging, and treatment options.

Episode Notes

 Dr. Vinay Aggarwal & Dr. Mehul Shah of NYU Orthopedics discuss the anatomy and function of the meniscus, common causes of tears (such as sports injuries and age-related degeneration), and symptoms like pain and swelling. They cover diagnostic methods, including physical exams and imaging tests. Treatment options range from conservative approaches, like rest and physical therapy, to surgical interventions, depending on the severity of the tear. The podcast emphasizes the importance of early diagnosis and personalized treatment plans for optimal recovery.

Episode Transcription

Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis.  Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.

Dr. Vinay Aggarwal: Welcome to Bone Whisperer, brought to you by SiriusXM and presented by NYU Langone Health. Today's episode, I'm very privileged to have our guest speaker, Dr. Mehul Shah, who is our sports medicine specialist here in NYU Langone Orthopedics. And today's topic will be about meniscus tears. Do all meniscus tears need surgery? So welcome, Mehul. I am privileged to talk to you today about this topic. I think it's a very important one for people to get their heads around and for listeners to truly understand. Can you give us a little bit of background as to why you think that this diagnosis is so prevalent in your office, why it's important to talk about, and give us a little bit of important discussion points of why, you know, our listeners may need to talk about this today.

Dr. Mehul Shah: Yeah, Vinay, I'm very excited to talk about this topic that both, you know, it basically crosses both our practices. Like, we both take care of knees. And for our listeners, not just to orient you, the knee bone - sorry, the knee joint - what everyone's familiar with is basically consists of the end of our longest bone, our body, our femur, where it meets our shin bone, and there's also the patella or our kneecap. And those three bones basically form your articulation, which is the knee joint. And the surfaces are all covered in articular cartilage, a nice, smooth substance that allows our joints to freely move and almost like a frictionless surface. Along with the articular cartilage, there's other things in the knee joint, like the ACL, the PCL, or the ligaments in the knee. We have four of them. The MCL on the inside and also the lateral collateral on the outside. And then we have the things that we're talking about today - he meniscus, which are these cushions in our joints. I'm sure many people have heard of them, and many people have had friends and family members who have injured their meniscus. And some of them need surgery, some of them don't. And I guess that's what we're talking about here today. And it's quite common, I think you'd agree, too, right? You see people with knee pain, and some of them have meniscus tears, some of them have arthritis, and some of them don't. Right?

Dr. Vinay Aggarwal: Yeah, absolutely. I think so. You know, just to give a background on my practice, you see a lot of acute injuries, some related to athletics, some related, you know, just to everyday life. I see a lot of chronic injuries, chronic pain in knee joints, and it's very similar. The meniscus is a prevalent structure in all of these diagnoses that we're going to talk about today. And, yeah, giving a little bit of background as to the knee joint is important because there's a lot of things that are in the knee. And so breaking it down as to what may be causing that pain is super helpful. You talked about ligaments, you talked about the cartilage, which leads to arthritis. But today we are going to be focusing on those little cushion pads - the same way I described to patients the two menisci, um, one on the inside, one on the outside of the knee, uh, and how they may lead to pain or diagnosis. So let's talk about a patient that comes into your office with knee pain. What makes you think of a meniscus tear or a meniscus injury, rather than something else, like the cartilage, the ligaments? What are you thinking? How do you figure that out when you see a patient that says, doc, I got knee pain?

Dr. Mehul Shah: Right. The one thing about the knees, when we talk about all those various structures, all or any of them, or some of them in combination, can be the source of the pain. And meniscus tears are very, very, very prevalent, especially over the age of 50. We estimate about 30% of the people are walking around with meniscus tears. And especially in the setting of osteoarthritis, sometimes, we estimate almost 60% of people with osteoarthritis are going to have some sort of meniscus pathology. So it's obviously a very common diagnosis. And the whole art of what we do is trying to correlate whether these people who come into your office with knee pain have the meniscus that's causing their pain or it's something else. So that's the whole art. And what we do is trying to figure out is the pain that the person's coming in with due to a meniscus tear or not. Everyone always asks about getting an MRI, right? Always asks about getting mrI. And I tell people, especially over the age of 50, I know that just sending you for an MRI right now, 30% chance you're going to have a meniscus tear. So what are some keys in discerning whether I think a meniscus tear is causing the pain? Normally, it's point tenderness. So in contrast to osteoarthritis and stuff that you mostly deal with, people come with generalized type of knee pain, swelling, they can't localize it. When someone comes in with a meniscus tear, typically they can point to the spot in the knee that's hurting them the most, and typically, that's at the joint line. A lot of times, there's associated mechanical symptoms and swelling. Now, mechanical symptoms may or may not be associated with meniscus tears. Sometimes things like osteoarthritis or roughening of the articular cartilage that can cause mechanical symptoms. So it doesn't always correlate. But typically, what discerns people is point tenderness over the joint line is what makes me mostly suspect. And there's certain things on exam, like what's called a, uh, McMurray's test or a Steinman test, where we twist the knee in certain areas or in certain ways, and that reproduces the pain. Again, point tenderness, those are also something that make me believe that their pain is coming from meniscus tear. But otherwise also can come from most common other conditions, like patellofemoral pain, which is pain related to the kneecap. So sometimes that can be the source of pain, and that's also a quite common condition. So, again, it's all about correlating the patient's symptoms and eventual imaging studies to see if the meniscus is the source of the symptoms.

Dr. Vinay Aggarwal: You mentioned MRI, and we're definitely going to get all into the whole debate of MRI and the question of what that brings in terms of advanced imaging. But before we get there, I think you pointed out, you know, one thing I want to go a little bit further into, and that's mechanical symptoms. So we talk about that a lot - mechanical symptoms - in the orthopedic world. What do you think that may mean in a patient's words? What does that manifest as? What might they complain to you specifically about.

Dr. Mehul Shah: Right. I mean, people don't come into you, obviously, and say I have mechanical symptoms in my knee, right? They say “I have clicking”, “I have catching”. “When I twist my knee, I feel a pop”. Sometimes the most severe circumstances, mechanical symptoms may mean locking of their knee when their knee gets stuck in a position. In fact, there's a certain type of meniscus tear, what we call a bucket handle tear of the meniscus that notoriously can get stuck in someone's knee and then they can't fully straighten it. And they'll come to you with the inability to straighten their knee. Typically locks somewhere between 15-20 degrees and inability to bear weight. So those are what we call mechanical symptoms.

Dr. Vinay Aggarwal: That makes a lot of sense, and we're going to get into the certain types of tears, that is a great segue you just provided there. I had a patient yesterday just exactly as you said. Twisting at night hurts me, doc, it's in this one spot right at the joint line. At night, it really bothers me when I turn and move and I get this pinching type sensation right in that knee. And it's nowhere else, it's just in this area. 50 year old guy, laborer, he really works hard, and when he's twisting on the job, he really feels it grinding in there. So pretty pathognomonic, um, pretty diagnostic just on history alone for a meniscus tear, in contrast to some things else, like you mentioned, like osteoarthritis of the whole knee. So let's go into certain types of tears here. Are there certain age groups that we need to categorize or focus on that get the differing types of meniscus tears? And what might those differing types of meniscus tears be?

Dr. Mehul Shah: Right, so meniscus tears do come in all age groups. They span the width of young kids, eight, seven years old, into the elderly, for us, above the age of 65 or so. So there's different types of meniscus tears. But again, old people, elderly people, they can also get dramatic types of tears. Younger people sometimes can have early onset of osteoarthritis. You can’t broadly categorize this or define that only young people get certain types of tears and older people get other types of tears. So age is one of the ways we classify it. The other way we classify it is whether it's traumatic or degenerative. So traumatic tears and everyone's definition of trauma can be a little bit different, but typically happens after a certain type of injury. And the meniscus is torn, typically in a very sort of clean, sort of simple type of tear in one direction. Classically, we call this peripheral or vertical tears, where the meniscus almost tears off the capsule. Other types of traumatic tears can be radial tears in which the meniscus basically is almost like cut in half. So those types of tears, what we would classify as traumatic tears. And sometimes we're more aggressive in treating those tears, especially in the young people, where those might be in a certain configuration that may be amenable to repairs. Um, and we can get into that. Then there's other types of tears we call degenerative types of tears. They're commonly associated with arthritis. It's more of a wear and tear of the meniscus. As that knee joint is wearing down and the cartilage is getting rough, that meniscus is becoming fibrillated, frayed, torn, sometimes there can even be a flap of tissue that's coming off the meniscus. But typically, with these degenerative types of tears, they're commonly associated with arthritis. So the meniscus is just one piece of the reason why this person is having pain. I commonly say to people where their arthritis is significant, and they're worrying about the meniscus. I say it's like worrying about your paint chipping on your wall when your sheetrock's falling down. There's a much bigger problem behind that paint chipping. There's a much bigger problem behind that meniscus tear. And one other thing I want to talk to you about is what makes a meniscus repairable, and what makes meniscus not repairable. Because that goes through my mind, and when I'm trying to discuss whether a meniscus should be treated operatively or not operably. So the meniscus doesn't have a great blood supply. Only really on the periphery of the meniscus, or where the meniscus attaches to the capsule, are blood vessels penetrating the meniscus. The majority of the meniscus is what we call avascular, where it's just cartilage or fibrocartilage. And it doesn't have a great healing potential. So some meniscus tears happen in an area, or, um, a lot of meniscus tears happen in an area where even if we stitch it together, if there's no blood circulating through the tear, it's not gonna heal. And that would also make it irreparable and not amenable to repair. But a select few where it's off the capsule, those are more amenable towards repairs.

Dr. Vinay Aggarwal: So I definitely wanna dive deeper into the repair and tear words. Cause I think that drives a lot of fear in our listeners minds. But before we get to that, because I do wanna spend some ample time on that, you're exactly right - I see the osteoarthritis, and when I equate to them the meniscus tears that we classify as degenerative. Those are the ones that. I like your analogy - I'm going to take another analogy, just because food is one good thing people all can kind of rally around. I tell them when you tear your meniscus because of arthritis, it's almost like the meat between two deli grinders that are getting closer and closer together. And that's because of the arthritis, the cartilage is no longer nice and smooth on the ends of the bones, and you have these sharp, jagged edges. The bones are getting closer together, and the collateral damage between the bones is just going to be the meniscus, because it's the soft structure. And so that's a degenerative chair, where, again, you said it right, the paint is the least of their worries, the paint chips. It's really the arthritis, the underlying jagged edges of bone, the sharp, exposed, rough bone that needs to be replaced. And the meniscus, just addressing that will not lead to any kind of solution or resolution of their symptoms. But, yet, you know, the acute ones - let's talk a little bit about diagnosis, imaging perspective. Um, in the era of patients having up to the second access of their medical tests, their notes, their imaging, their reports, getting an MRI and getting the reports before the doctor is becoming more and more common. So have you seen any increase in anxiety regarding meniscus, tears in general, in your office? MRI reports? Doctor, what does this mean?

Dr. Mehul Shah: Yeah, you know, when you read some of these MRI reports, they can certainly sound scary. People have, again, sometimes even before I look at the MRI report, the patient has the MRI report in hand, and those are from the tests that I order. A lot of times people come into the office for a second opinion, or after they saw their primary care doctor who ordered an MRI and had many, many questions. And the MRI is a very detailed test which looks at all the structures about your knee. It's magnetic resonant imaging. It uses magnetic fields and sound waves to recreate images in your knee. They're really cool tests. But certainly most people who I see, at least initially, don't even need an MRI. But yes, to get to answer your question, a lot of these reports do cause anxiety and I think we, as physicians, our job is to simplify things and put things into language that the patients can understand. Um, but surprisingly, like I said, that's not where, unfortunately, right now, that's a lot of times what people demand and what people want right away. But that's probably not where the imaging should start, right? I mean, simple things like x-rays that I can get at the initial visit before I send the patient to an MRI, a lot of times shows me a lot more information and get to the point than an MRI. And certainly, I've had people come in with MRIs of their knee and their meniscus sounds like, oh, my God, this needs to be fixed tomorrow. And I got an x-ray, and they have bone on bone arthritis. Right? So, x-rays, what we get in the office, mostly standing x-rays in which the joint is loaded, tells me a lot about the, one, the degree of arthritis the patient has, and two, sometimes the alignment. Um, it's quick, easy, and cheap. It's very low risk. I mean, there's minimal amount of radiation. So typically, for me, imaging starts with a simple x-ray that I explained to the patient right in the office.

Dr. Vinay Aggarwal: Yeah, you're exactly right. I think that the low cost available nature of x-ray, put that together with the history and physical exam that you've done in the office, you've answered almost 90% of the patient's question right there. But yet, keep in mind, there's going to be patients that come in and want everything done diagnostically and from a treatment perspective. Sometimes people can't fathom, well, how can you know, just based on the x-ray alone? What if I have a meniscus tear? Or I've gotten the MRI from an outside physician, a family practitioner, internal medicine doctor, another orthopedic surgeon - and the MRI is already done, and the report already says meniscus tear. Why aren't you doing anything about it, doctor? Why may an MRI not have been necessary in the first place? And as you were getting to, why does tear not necessarily equate to must be repaired?

Dr. Mehul Shah: Right. So, two things. One, a lot of times a patient comes into the office with an MRI of a meniscus tear. And the meniscus, like we talked about earlier, uh, meniscus tears are very prevalent thing. One, many times, their pain has nothing to do with their meniscus tear. They have a meniscus tear, but their pain is coming from around their kneecap. So I think a lot of it is reassurance to the patient, especially in the people over the age of 50, I use the analogy all the time that if I, right now, called up everyone in your high school class and got them an MRI, whether or not they had pain, 30% of them would be walking around with meniscus tears. And the vast majority of them are completely pain free. So that sort of opens their eyes to things. The other thing is on the person who comes in without any prior imaging, who wants an MRI, and I think they may have a meniscus tear that's causing their pain, I said, okay, so we already know just by your age, you have a 30% chance of having a meniscus tear. So put that aside. Let's assume you have a meniscus tear. What are we gonna do? I would suggest trying some non operative treatment first before we start talking about surgery. So that may include some physical therapy. So corticosteroid injection, anti inflammatory medication, something to calm this down. And I sort of try to look at an MRI as a preoperative test. So once you fail those conservative measures, then we should start thinking about surgery. And I think one of the things about people not getting so anxious and not getting so worked up about their knee is trying to talk to them about how common these meniscus tears are and how the vast majority of people are fine with meniscus tears.

Dr. Vinay Aggarwal: Yeah, putting it into context, I think that's definitely a good thing to do. I gotta be careful about my patients in the 90 plus age group. If I ask them about high school graduating class, you know, I'm not sure it would equate as well as your patient. Possibly, but definitely pointing.

Dr. Mehul Shah: Definitely be a lot smaller.

Dr. Vinay Aggarwal: A lot smaller. Meniscus is probably the least of their worries at that point. That being said, I think putting it into context is everything, and really giving reassurance that there are things other than surgery, which is the question at hand, right? That's what we're talking about this episode. The whole point of this - do all meniscus tears need surgery? And you alluded to, the answer is no. Get into a little bit more detail, if you don't mind going back to blood supply. And really, just how commonly are you repairing these? And talk to us about what that's like. What's the recovery? How do you do the repair, and what does it look like for the patient on the back end?

Dr. Mehul Shah: Okay, so let's go back a little bit, and let's just say that whenever I'm examining a patient, I'm evaluating a patient, I'm trying to categorize them in several different ways. So, one, I'm looking at the degree of arthritis they have, what their age level is, what their activity level is, are they having mechanical symptoms or not, and how much arthritis is in their knee. Those are all those things that factor in to what are we going to do for this meniscus? So someone who has a traumatic injury, who has no significant arthritis, has mechanical symptoms, and they have an MRI in a simple sort of configuration where it's a nice, clean cut in an area in which there is perceived blood supply. So on the MRI, we can look at the tear pattern. We can sort of get an idea of where this meniscus tear goes. If it's all, like, at the periphery, on the outside of the meniscus, where the vascularity is, we start talking about meniscus repair. So, again, we are a little bit fighting Mother Nature in trying to do meniscus repairs, right? So, typically what an arthroscopy is, the surgery we do is we first make two small holes in the knee, and we insert a fiber optic camera inside the knee, and we look all the way around and we examine the tear of the meniscus. Sometimes these meniscus tears are displaced where they're moved into a spot, like that bucket handle tear, where we have to try to push it back into its normal spot. And number one, in order for a tear to be repairable, we have to reduce the tear. We have to be able to put it back into its normal anatomic position. Then I look at, is it in this vascular area? Sometimes you can see there's some blood vessels in that area or really how far off the capsule it is. So if it's in that outer one third of the meniscus and there's no significant arthritis, then we start again thinking about a meniscus repair. Now, basically what we do is we basically use sutures to stitch back the meniscus back into place. Sometimes we make an incision on the inside of the knee, or the outside of the knee, and pass sutures from inside the knee to outside the knee, and tie those sutures, you know, over the capsule through another incision. That's called an inside out repair. We do that quite commonly. There's also these really cool sort of devices in which we call it an all inside repair, where they have sort of like suture anchors that we pass through the meniscus, and we sort of stitch the meniscus back into place without putting any extra incisions. But, you know, sometimes we use a combination of both. We do different techniques to suture that meniscus back into place. And then the recovery's a little bit more simple, sorry, more involved than just your simple knee scope. We have to protect the repair. There may be a period of time when people are walking on crutches. There may be a period of time when the people are in a brace, limiting the range of motion, and we allow that meniscus to heal. That doesn't always work out. Sometimes the meniscus, even though we do a great job and we repair the meniscus again, we're fighting mother nature, and the meniscus doesn't heal. And sometimes it re-tears, and sometimes then we have to go back in and clean that, either ride or re-repair it or sometimes clean out that tear. And then there's the more sort of other types of that other category of patient, the older patient, the one with arthritic conditions in their knee. And, uh, that kind of patient is something that we really try to treat them conservatively before we start thinking about surgical options.

Dr. Vinay Aggarwal: Before we get to that patient population, because that's definitely up my alley, I want to know, you've mentioned some great aspects of recovery and actually technical aspects of the surgery itself that listeners can understand better what's happening to them when a repair is done. The use of sutures to first putting back the meniscus to where it should be, and the use of sutures to arrange the tissue back and allow it to heal. Going into recovery a little bit more, should patients understand what exactly they're getting into when they sign up for a meniscus repair? You mentioned things like not weight bearing or crutches or braces. If you don't mind just being a little more specific, just let us know - what is your preferential algorithm for how long you're kind of rehabbing a patient and how? 

Dr. Mehul Shah: Yeah, not as cookie cutter as you think, because it has to do with some different types of repairs or how stable the repair is. You know, sometimes you get out there, you get a nice, firm repair, and you're really confident you may progress that person a little bit, a little bit faster. And sometimes the repair or the tissue isn't as strong, and you may want to slow it down. But, yes, you know, having looked at thousands upon thousands of MRIs and treated thousands upon thousands of patients, before I take them to the operating room, I sort of have an idea whether a meniscus repair is on the table or indicated. So I educate them that, say, hey, listen, there's a x percentage of chance, I sort of, sort of ballpark it with them, that there's a 20% chance, 50% chance, or 70% chance that you're going to end up with a meniscus repair here. And that's not going to be just a sort of walk in the park. There's going to be a period of time in a brace, and typically for me, vast majority of times, patients are in a knee brace for about five to six weeks. The first two weeks or four weeks or so, two to four weeks, I'm allowing them to weight bear in a knee brace, so putting full weight on it, not even with crutches, but their knee brace is locked in extension. And then somewhere around, typically four weeks, I start allowing them to bend their knee when they walk and then get rid of the brace around six weeks. And in physical therapy, we sometimes limit their range of motion. Classically for me, vast majority, I limit their range of motion to 70 degrees for the first two weeks, then 90 degrees to week six, and after week six, progressing their flexion to about 120 degrees. The reason for that? The more flexion your knee does have, especially when weight bearing, the more force gets transmitted to the meniscus, and particularly the posterior horn, where commonly most of these meniscus tears are. And the more deep flexion you get, you don't want to disturb or rip up the repair. So that's why we sort of limit their flexion for a certain period of time. And then again, in terms of returning to sport, particularly pivoting and cutting activities, that's somewhere between six to nine months.

Dr. Vinay Aggarwal: That makes a lot of sense. I think that's very helpful for the listeners to hear, understanding that some variability exists between surgeons that they go to, or between injury types, between repair patterns. But that gives a general sense of what we're talking about in terms of recovery and what people may or may not be able to handle. In addition to the fact that the structure of the meniscus serves a purpose which provides inherent stability to the knee, and so you don't want to disrupt that repair when that was the whole purpose of repairing it. You want a nice, stable knee at the end of it once it's healed. So let's get into some of the older groups. Just very briefly talk to us about what a partial meniscectomy means for a patient rather than a repair.

Dr. Mehul Shah: Right, so, during arthroscopy, for these degenerative meniscus tears, we use instruments like what we call biters, which are basically like scissors to trim away the meniscus tear. We also use these other devices, which is like a little bit of a suction on the end with a sharp blade that trims away the meniscus back to a stable rim of tissue. So the flapping tissue is removed, and the meniscus has in its periphery some pain fibers. And when the thought process is this flapping tissue that gets pinched in between the two bones causes pain as it gets pulled and twisted in the knee.

Dr. Vinay Aggarwal: Yeah, I do some partial meniscectomies, obviously, just giving some historical context on this. In the 1970s, 80s, early 90s even, a lot of meniscectomies were being performed in this country. And some of them what we call total meniscectomies or subtotal meniscectomies, where almost the entire meniscus, because of a tear or because of a small amount of arthritis, was being cut out of the patient. And when you do that, just to give the listeners some idea, there was a significant progression of their underlying arthritis. The cartilage would wear away earlier. This is why it's no longer considered a large meniscectomy operation. We say partial meniscectomy because at the end of the day, we want to leave some healthy, viable meniscus tissue, even if you have what we call a degenerative tear, so that the progression of arthritis does not rapidly occur. And a lot of my patients that have this surgery still get great pain relief. It may be temporary, but it is excellent pain relief for a lot of them. But I want to pivot and talk a little bit about this - a lot of national media attention, large name medical journals, newspaper articles, online sources, patients are reading about this. Can you talk to us a little bit about the big name trials of nonoperative versus operative treatment of what we would call, I guess, degenerative meniscus tears.

Dr. Mehul Shah: Yeah, I mean, certainly this dates back to 2003 and 2013. There was something called The MeTeOR Trial  published in the New England Journal. There was something called a FIDELITY trial, which was a very interesting study out of Finland, in which they basically randomized patients with arthritis to either having an arthroscopic meniscectomy, that degenerative type of meniscus tear where we remove it, or, and this could never be done in this country, but in Finland, they can do it, where they did sham surgery, where they basically made two incisions, inserted a camera, evaluated the knee, and then they either randomized the patient to either having that meniscus tear trimmed, or they just basically closed up shop and didn't do anything. And though there were some differences in the early stages, I think it was like one year, and then even five years later, they reported no long term benefits to arthroscopic meniscectomy. Now, again, it does show you that there is a very good role for non operative treatment for meniscus tears. However, there were some flaws in the study selection of the patients, whether they were truly, like we said, meniscus tears are quite common - were the patient's pain truly related to their meniscus or not? So how discerning were they in selecting the patients that had undergone surgery? That’s one of the things. It's a national database that may not be, their results may not be transferred to us here in the United States. But what all these major articles, landmark articles have shown is that, yes, we should not be thinking about arthroscopic meniscectomies as our primary treatment in patients with osteoarthritis. That should be something that's delayed and possibly considered if we fail a lengthy, conservative course. That would include physical therapy, plus minus corticosteroid injection, activity modification, and time. I typically, when patients are coming in with these MRIs and arthritis of their knee, I'm really hesitant to do surgery right away. I don't really think that's in their patient's best interest. My goal is to make the patient better with or without surgery. And if you get the patient better without surgery, you're a win. That's a win win for everybody.

Dr. Vinay Aggarwal: Yeah, 100% agree. I think you're right on with those trials. It really, aside from not talking about so much dissuading surgery, it more validated non operative treatment, as you said. And so I think that's a good take home for listeners here is that - to answer our question, do all meniscus tears need surgery? Patients are going to be scared. Doctor - I get this question a lot - doctor, if you don't do surgery and repair it, is it going to heal itself? It's torn right? So the answer to that question is no, it may not heal itself, but it will stop hurting. And that's really the bottom line of why the patient's there in the office in the first place. It's the pain. So if you do those non operative things like in those trials, like physical therapy, anti inflammatory medications, plus minus injections, as you mentioned, it's a win win if you can treat that non operatively. I think that patients would go for no surgery a large majority of the time. Um, and really understand that their pain may actually just, quote unquote, burn out eventually and the meniscus will stop hurting.

Dr. Mehul Shah: I definitely want to bring home a point, though, is that some people misconstrue this, is that there's no role for arthroscopic meniscectomy. And I certainly wouldn't say that, because certainly, I know in my patient population that I treat, there's certainly patients who show up to my office, who have been referred to me by my primary care sports medicine colleagues, rehab doctors, other orthopedic surgeons who have been treating them conservatively, done all those things. Sometimes I've been treating them conservatively, and ultimately, after months and months and months, sometimes even over a year, they have continued pain. And then we take them to the operating room, and we do the surgery, and they do get better. So there's not zero role, but the take home message is our initial treatment should be conservative, and there's no emergency in these degenerative meniscus tears.

Dr. Vinay Aggarwal: Perfect. You know, we're going to close with just giving some hope for our patients here. What's the long term prognosis? Give us some positive spin, positive outlook. Do these patients with meniscus tears get back to their normal life, normal sports? Is that an expectation we can actually deliver?

Dr. Mehul Shah: Yeah, I mean, for the vast majority. I mean, though, it's gotten a lot of bad knocks, again, in the right patient, not significant arthritis. One of the main things also is we really try to preserve as much meniscus as possible. So in the right patient, minimal arthritis - is a very successful operation. Meniscus surgery, repairs, and meniscectomies are very successful, in which people, 80% to 90%, are getting back to their activities. The bad knock comes from the patients who have arthritis who probably didn't need the meniscectomy in the first place.

Dr. Vinay Aggarwal: Yep. And those patients who, like you said, didn't have surgery to begin with and treated it with physical therapy, they have hope, too, that, you know, surgery may not be necessary, and they can still get back to a healthy, active lifestyle. Regardless, I want to thank you for your time Mehul, We've covered a lot of stuff on meniscus and the knee and surgery in general. I think we've come to a good conclusion here. Do all meniscus tears need surgery? The answer is no, but with a caveat that they can do well when properly indicated, as with all of our orthopedic surgeries. So, once again, thank you for joining us. This was another episode of Bone Whisperer, brought to you by SiriusXM as well as NYU Langone Health. My name is Vinay Aggarwal. It's been a pleasure.

Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing. Sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen, and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world-renowned doctors at NYU Langone Health, tune in to Doctor Radio on SiriusXM on channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.