There is no convincing evidence that surgical management is likely to be better than use of conservative measures as first-line treatment for acute knee pain in middle-aged or older individuals.12,15,30-34
- Not all meniscal and ACL tears require surgery (low-grade injuries respond well to conservative therapies).9
- At least one group of study investigators has recommended that clinicians adopt a 'wait-and-see' approach when managing traumatic knee disorders, after finding that the vast majority of patients report clinically relevant recovery, regardless of whether MRI reveals a meniscal tear, ligament lesion or no identifiable damage at all.35
In addition, recently published data do not support the use of arthroscopic surgery as a treatment for middle-aged or older patients with knee pain and degenerative joint disease (± radiographic signs of OA).12,36
When seeking to treat symptoms of degenerative joint disease in middle-aged patients, GPs are advised always to initiate conservative, non-surgical interventions as first-line therapy (eg, weight loss interventions, appropriate exercise regimens, physiotherapy, use of simple analgesics,b,3,8,30 In each case, the effectiveness of prescribed or recommended interventions should be periodically reviewed, over several weeks, or even months, to determine whether the patient's treatment plan needs to be adjusted.
b Unless arthroscopy/surgical interventions definitely indicated, for example, evidence of loose bodies or mechanical symptoms, such as locking, giving way or catching, or some other serious underlying disorder.
Advice for patients and clinicians
The 4 Ms for patients 3,37
- Modify lifestyle (eg, reduce weight, increase or change exercise).
- Minimise loads on the knee.
- Maintain strength of muscles that move and support the knee joint (by performing simple, appropriate exercises).
- Medicate with simple over-the-counter analgesics (eg, paracetamol).
Advice for clinicians
- Manage the patient's expectations – explain the likely cause(s) of pain, the rationale for performing specific investigations (eg, MRI) and the aims of specific treatments or interventions.
- Favour simple conservative interventions whenever possible, ensuring that sufficient time is allowed for them to work.
- Recognise that surgical procedures (eg, arthroscopy) have a limited role in the management of acute knee pain in middle-aged or older patients and may cause irreversible side effects. Only recommend when definitely indicated.
- Periodically review the effectiveness of interventions and reconsider management strategy, or refer, if symptoms persist.