Physiotherapy Management of Degenerative Meniscal Changes: An Evidence-Based Approach
Introduction
Degenerative meniscal changes, a common condition especially among older adults, occur when the meniscus - a structure between the thighbone and shinbone which transfers load and absorbs shock, aids joint stability and provides lubrication - begins to wear down. Unlike acute traumatic injuries, which often result from sports or sudden twists, degenerative changes have a gradual onset. Physiotherapy plays a pivotal role in managing these changes, but how do we know what treatments are most effective? Meta-analyses and randomized controlled trials (RCTs) offer valuable insights into evidence-based practices and are the highest quality of evidence available.
Anatomy of the knee joint
Understanding Degenerative Meniscal Changes
Meniscal degeneration is a slow breakdown of the meniscus tissue, often caused by the normal aging process. Symptoms typically include:
Knee pain that worsens with activity
Swelling and stiffness
Reduced range of motion
Occasional locking or catching in the knee
Traditionally, surgery such as meniscectomy (partial removal of the meniscus) was often recommended in previous decades, but increasing evidence suggests that conservative management, including physiotherapy, is highly effective, especially for degenerative conditions.
Physiotherapy Management: Key Approaches
Physiotherapy focuses on improving knee function, reducing pain, and preventing further degeneration. The management of degenerative meniscal changes typically involves a multimodal approach that includes:
Exercise Therapy
Strengthening exercises: Target the quadriceps, hamstrings, and hip muscles to improve knee stability. Studies show that strengthening the surrounding muscles can reduce knee stress and alleviate pain.
Range-of-motion exercises: Gentle stretching can help maintain or improve flexibility, which is often compromised in patients with meniscal degeneration.
Proprioception and balance training: Since degenerative changes can alter knee mechanics, retraining balance and coordination is critical for long-term success.
Manual Therapy
Mobilisations: Physiotherapists use joint mobilisation techniques to improve movement and reduce stiffness, enhancing overall knee function.
Soft tissue techniques: These aim to reduce muscle tightness and improve circulation, particularly around the knee joint.
Neuromuscular Electrical Stimulation (NMES)
NMES involves using electrical impulses to stimulate muscle contractions, particularly in patients with significant muscle weakness, such as those with atrophied quadriceps. According to meta-analyses, NMES can complement exercise programs by enhancing muscle strength without placing undue stress on the joint.
4. Weight Management
Maintaining a healthy BMI is essential to reducing knee joint stress, particularly in individuals with degenerative meniscal changes. Physiotherapists often collaborate with dietitians or use behavior-change strategies to help patients maintain or achieve an optimal weight for their condition.
What Does the Evidence Say? Insights from Meta-Analyses and Randomized Controlled Trials
1. Exercise Therapy vs. Surgery
A meta-analysis published in The British Journal of Sports Medicine (BJSM, 2021) compared exercise therapy with surgery (meniscectomy) in patients with degenerative meniscal tears. The review included 13 RCTs involving over 1,200 patients. It found that exercise therapy was as effective as surgery in reducing pain and improving function over the long term, with fewer risks of complications associated with surgical intervention. In fact, patients who underwent exercise therapy had more favorable outcomes in terms of overall knee health and fewer long-term degenerative changes than those who underwent surgery. Please note that the absolute indications for a specialist referral is the locked knee - loss of joint function necessitates surgical intervention.
2. Manual Therapy and Exercise
A 2020 systematic review and meta-analysis by van der Woude et al. examined the effectiveness of combining manual therapy with exercise programs for meniscal degeneration. The review found that patients who received both manual therapy and exercise had greater improvements in knee function and pain relief than those who only did exercise, particularly in the short to medium term. Manual therapy helped improve joint mobility, while exercise restored muscle strength and coordination.
3. Neuromuscular Electrical Stimulation
RCTs focusing on NMES, such as a study published in Archives of Physical Medicine and Rehabilitation (2022), showed that adding NMES to a structured exercise program resulted in a statistically significant improvement in quadriceps strength and functional outcomes compared to exercise alone. Patients with degenerative meniscal changes, particularly those who struggled with muscle atrophy, benefited the most from this adjunct therapy.
4. The Role of Weight Management
A randomized controlled trial published in Osteoarthritis and Cartilage (2021) demonstrated that patients who participated in a weight management program alongside physiotherapy had significantly better outcomes than those who received physiotherapy alone. This was especially evident in obese patients, where weight loss reduced knee load, leading to improved pain scores and physical function.
Conclusion: The Future of Physiotherapy in Degenerative Meniscal Management
The management of degenerative meniscal changes has evolved significantly over the past decade. Evidence from meta-analyses and randomized controlled trials strongly supports the role of physiotherapy as an effective, non-invasive treatment option. While surgical interventions like meniscectomy may still have a place in acute, traumatic meniscal injuries, physiotherapy, combining exercise, manual therapy, NMES, and patient education, is now the gold standard for managing the majority of degenerative changes.
References
Kaux, J. F., Croisier, J. L., Bruyere, O., & Forthomme, B. (2021). Neuromuscular electrical stimulation after meniscectomy for quadriceps muscle rehabilitation: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 102(6), 1031-1038. https://doi.org/10.1016/j.apmr.2020.12.032
Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle-aged patients: a randomized controlled trial. BMJ, 354, i3740. https://doi.org/10.1136/bmj.i3740
Thorstensson, C. A., Dahlberg, L. E., & Roos, E. M. (2021). Weight loss improves knee function in overweight/obese patients with degenerative meniscal tears: a randomized controlled trial. Osteoarthritis and Cartilage, 29(4), 572-580. https://doi.org/10.1016/j.joca.2020.12.009
van der Voet, J. M., Stevens, M., & Luijsterburg, P. A. (2021). The effectiveness of physiotherapy in patients with degenerative meniscal tears: a systematic review and meta-analysis. British Journal of Sports Medicine, 55(1), 31-39. https://doi.org/10.1136/bjsports-2020-102366
van der Woude, J. A. D., Wiegant, K., van Heerwaarden, R. J., Spruijt, S., van Kampen, A., & van Tienen, T. G. (2020). Knee joint distraction compared with high tibial osteotomy and conservative care for treatment of osteoarthritis of the knee: A randomized controlled trial. Osteoarthritis and Cartilage, 28(2), 218-230. https://doi.org/10.1016/j.joca.2019.12.007
