Meniscus tear: symptoms, surgery or physiotherapy?

A torn meniscus sounds like it needs surgery, but for many tears exercise works just as well. Which tears need a surgeon, and how physio helps the rest.

Your knee has been aching on the inside or outside of the joint. It swelled after a twist, or maybe it crept up without any injury at all. Squatting hurts, there is an occasional click, and an MRI comes back: "Tear of the posterior horn of the medial meniscus."

For decades, a meniscus tear on a scan often led straight to keyhole surgery. Then a series of high-quality trials — including one comparing surgery with a placebo operation — changed the picture. For many people, especially those over about 35 to 40 with tears that developed gradually, a structured exercise programme gives results as good as surgery, without the risks. This guide explains what the meniscus is, the different kinds of tears, which ones need a surgeon, and what physiotherapy involves.

What is the meniscus?

Each knee has two menisci — the medial meniscus on the inside and the lateral meniscus on the outside. They are C-shaped pads of tough, rubbery cartilage that sit between the thigh bone and the shin bone. They spread load across the joint, absorb shock, help the knee stay stable and help nourish the joint cartilage.

Only the outer edge of the meniscus has a good blood supply. That is one reason why some tears can be stitched and heal, while many others cannot heal in the usual sense — but that does not mean they cannot become pain-free.

Two very different kinds of tear

Traumatic tears

These happen with a specific injury, typically a twist on a bent, weight-bearing knee — landing awkwardly, changing direction in sport, or getting up from a deep squat. They are more common in younger, active people, and often occur alongside an ACL injury. The knee usually swells within hours.

Degenerative tears

These develop gradually as the meniscus ages, often with no clear injury, or after something as minor as getting out of a car. They are very common from middle age onwards and often go hand in hand with early knee osteoarthritis. A study in the New England Journal of Medicine using MRI found that meniscal tears were common in middle-aged and older people, and that most people with a tear had no knee symptoms. In other words, a tear on a scan may be part of normal ageing rather than the cause of your pain.

Symptoms

• Pain along the joint line on the inside or outside of the knee
• Swelling, sometimes developing over a day after an injury
• Pain with twisting, squatting or kneeling
• Clicking or catching
• Stiffness
• True locking — the knee gets stuck and cannot straighten fully, often from a displaced "bucket-handle" fragment

Catching and clicking are common and not necessarily a reason for surgery. True mechanical locking, where the knee cannot be straightened, is different and needs prompt assessment.

“A meniscus tear on an MRI report is very common, especially after 40. What matters is how the knee behaves — and most knees that do not lock improve with a well-structured exercise programme.”

— UpPlus Physiotherapy team

Surgery or physiotherapy? What the trials show

• Surgery versus placebo surgery: a Finnish trial in the New England Journal of Medicine compared keyhole partial meniscectomy (trimming the torn meniscus) with a sham operation in people with degenerative tears and no arthritis. Both groups improved similarly.
• Surgery versus physiotherapy with mild arthritis: the METEOR trial found people with a meniscal tear and mild osteoarthritis improved similarly at six months with surgery or physiotherapy. Some in the physiotherapy group later chose surgery, and they did well.
• Exercise versus surgery in middle age: a Norwegian trial in the BMJ found a 12-week supervised exercise programme gave results similar to surgery at two years in middle-aged people with degenerative tears, with better thigh muscle strength in the exercise group.
• Non-locking tears in 45 to 70 year olds: the Dutch ESCAPE trial in JAMA found physiotherapy was not inferior to surgery over two years.
• Benefits and harms: a systematic review in the BMJ found arthroscopic surgery for the degenerative knee gave only a small, short-lived benefit, with rare but real harms such as blood clots and infection.

Based on this evidence, an international panel publishing a clinical practice guideline made a strong recommendation against arthroscopic surgery for nearly all people with degenerative knee disease, including degenerative meniscal tears.

This does not mean surgery is never helpful. It means that for the most common type of tear — the gradual, age-related one — a good exercise programme should come first, and that surgery should be reserved for the specific situations below, where it clearly has a role.

When surgery is still the right call

• A locked knee that cannot straighten, often from a bucket-handle tear
• A traumatic tear in a younger person, especially near the outer edge, that a surgeon may be able to repair rather than trim — preserving the meniscus protects the knee long-term
• A tear with an ACL injury, where both may be addressed together
• Persistent mechanical symptoms that do not improve with a good rehab programme

Physiotherapy for a meniscus tear

Programmes in the trials above typically ran for about 12 weeks, two or three sessions a week, combining:

1. Settle the knee

• Reduce activities that flare it — deep squatting, twisting, kneeling — for a few weeks
• Manage swelling with ice, compression and elevation
• Keep moving with walking, cycling or swimming within comfort

2. Restore movement and strength

• Full straightening and bending
• Thigh strengthening: straight leg raises, leg press, sit-to-stand, step-ups, wall squats
• Hip and calf strengthening

3. Control and function

• Balance and single-leg control
• Neuromuscular exercises: controlling the knee over the foot during squats, lunges and step-downs
• Gradual return to twisting, running and sport-specific movements as needed

Exercises to start with

• Static quads: tighten the thigh with the knee straight, hold 5 seconds, 10 times.
• Straight leg raise: tighten the thigh and lift the straight leg a short way, 3 sets of 10.
• Sit to stand: from a chair, 3 sets of 10.
• Bridges: 3 sets of 10.
• Step-ups: onto a low step, keeping the knee in line with the foot, 3 sets of 8–10.
• Stationary bike: 10–20 minutes at an easy resistance.

Mild discomfort during exercise that settles within a day is acceptable. Increased swelling or pain that lasts into the next day means you should ease back.

Getting back to running and sport

Most people can return to running and sport after a meniscus tear once the knee is settled and strong. A typical progression:

1. Pain-free daily activity, little or no swelling, and full knee straightening.
2. Strength: single-leg squats and step-downs with good control, and thigh strength close to the other side.
3. Running: start with short, flat run-walk intervals every second day, and build distance gradually.
4. Agility: side-steps, figure-eights, then cutting and pivoting at increasing speed.
5. Sport-specific training, then full training, then games.

Swelling after a session is the knee's way of saying the step was too big. Drop back for a few days and build again.

Kneeling and squatting at work

Tradespeople, cleaners, carers, childcare workers and anyone whose job involves kneeling, squatting or crawling put a lot of load through the menisci. While a tear is settling, knee pads or a kneeling mat, half-kneeling instead of full squatting, and sitting on a low stool for floor-level work all reduce the strain. As strength improves, these positions are gradually reintroduced rather than avoided forever. If your knee problem is related to work, a physio can help plan a graded return to full duties with your employer.

If you do have surgery

Rehab differs depending on what the surgeon does:

• Meniscus repair (stitching the tear): the repair needs protecting while it heals, so surgeons often limit deep bending and sometimes weight-bearing for several weeks, and return to sport usually takes four to six months.
• Partial meniscectomy (trimming the torn part): recovery is quicker, often walking normally within days and returning to sport over several weeks, guided by swelling and strength.

In both cases, rebuilding thigh and hip strength is the main focus of rehab, and following your surgeon's restrictions protects the result.

Myths about meniscus tears

• "A tear on the MRI needs fixing." Many tears are found in people with no pain; scans need to be read alongside symptoms.
• "Clicking means I need surgery." Clicking and catching are common and usually not a reason for surgery on their own.
• "Keyhole surgery is minor, so why not?" For degenerative tears it is no better than placebo surgery and carries small risks.
• "Exercise will make the tear worse." Structured exercise is an evidence-based treatment.
• "Once torn, the knee is ruined." Many people return to full activity, including sport.

When to see a physio or doctor

• Knee pain on the joint line that is not settling after a couple of weeks
• Swelling after a twisting injury
• An MRI report mentioning a meniscal tear that you want explained
• You have been offered keyhole surgery and want to understand the alternatives

Seek prompt medical review if the knee locks and will not straighten, if you cannot bear weight after an injury, or if the knee becomes hot, red and very swollen with fever.

How UpPlus Physiotherapy helps

• A thorough knee assessment, including checking for locking, ligament injury and arthritis
• Help understanding your MRI report
• A structured, progressive exercise programme modelled on the approaches used in the research
• Return-to-sport and return-to-work planning
• Referral to a knee surgeon when a repair or locked knee needs it, and rehab afterwards

Read more about meniscus injuries, our knee osteoarthritis guide and our sports injury physiotherapy.

Finding a physio near me for a meniscus tear

When searching for the best physio for a meniscus tear, look for someone who checks whether your knee truly locks, explains your scan in context, follows an evidence-based exercise programme for about 12 weeks, and refers you to a surgeon when it is genuinely needed.

Our clinic is at 177 Trimmer Parade, Seaton, a short drive from Henley Beach, Grange, West Lakes, Woodville and Findon. No referral is needed, and you can claim on the spot with private health cover.

If knee pain or a scan result is worrying you, our physiotherapists can assess your knee and explain your options. Book online or call 0403 907 587.

This article is general information, not a diagnosis or a substitute for an individual assessment. If you are unsure about your symptoms, see a health professional.