"Complex meniscus tear" -- doc said surgery is up to me. Thoughts?

The doc said I've got multiple tears in different directions, and that the "flapping" of the torn meniscus (pieces) is what's causing the pain. Currently, it's not painful throughout my normal day. But if I do a deep knee bend, it'll hurt. It's been about three weeks since the injury. I climbed yesterday and didn't push myself, and everything felt OK. But I didn't bend the leg any tighter than about a 25 degree angle. I asked the doc if things would improve if I just did PT and strengthened it. He said maybe. He said with 20-30 year olds, he'd recommend surgery. He said for 55 years old and older, he doesn't know if it would be worth it. I'm 45.  I also have little kids and I'm used to squatting quite a bit while playing with them. So I'm torn, no pun intended. My current thinking -- with Covid out there, I'm not in any rush to spend a day in a hospital getting surgery. So I may just do some PT for a few months and see how it feels. The doc said it would slowly get worse over the years, but that there was no big danger in waiting to do surgery.  Anybody else been in this situation? I know every case is unique, blah, blah, blah... just looking for more anecdotal info.  Thanks!

You have a ticking time bomb my friend.
I messed around with PT - it felt better.
Went on a climbing trip, and when Kris and I were 1/2 way up our New route- well that’s when the knee got bent and a big chunk of my meniscus got stuck in the knee hinge- effectively locking my leg/foot up around my ass!!! It stayed there!! I will not bore you with the rest of the details but let’s say it was a very long 12 mile hike to get back to the road.

Good luck with it. 

Can confirm what Guy said. I’ve torn both of mine. The first one I tried to wait and tough out a wrestling season. My knee ended up locking up halfway bent and I had to have most of my meniscus removed. I’m 22 and have arthritis in knee because I have no meniscus. Do the surgery

A while ago I had a meniscus tear, and I just lived with it. Luckily, it was rarely painful, but often when I moved into significant knee flexion, the flap would get out of place, which would feel weird and wrong. I could then straighten my leg to pop the flap back into place, accompanied by an audiable "pop" - loud enough that people around me would often give me a concerned look when they heard it.

Anyway, I lived with it for a couple years, popping it back in place whenever needed, until one day I was toproping in the gym, easy 5.7 warmup, when I felt the flap go out of place. "No problem. I'll just pop it back in and not even take" I thought. But.... it didn't. Ended up going home that night on some loaner crutches since I couldn't straighten my knee, and weighting it was painful. So that basically forced me to get surgery. All in all, I'm glad it happened there, instead of happening 20 miles into the backcountry on a runout slab pitch or something.

One thing to note is that, at least for me, the wait to get surgery was a bit longer than I expected. Spent 2 months on crutches before they got me in.

Before and after surgery, I did a fair amount of research on menisci, treatments, and outcomes. The relevant bits I found were these:

Small meniscus tears on the outer layer can often heal on their own over time, since the outer meniscus layer gets some blood flowing over it. Deeper tears never heal. If the outer meniscus layer is removed, you are exposing the non-healing inner tissue to greater forces, and you should expect this part of the tissue to degrade prematurely relative to the other parts of your knees. For this reason, the general recommendation is, if possible, get the surgeon to stitch the meniscus back together, rather then trim off pieces. The hope is that the stitches will hold the flap or tear in place long enough for the outer meniscus layer to heal. However, there is a non-neglible chance of the tear re-opening, so be aware that the problem is more likely to recur if you go the stitches route.

Additional medical interventions you might hear about to slow tissue degradation or decrease recovery times are stem cell or prp injections. Stem cells you've probably heard of. PRP is platelet rich plasma - basically a high density of red blood cells. In both cases, the idea is to shoot your knee joint full of some healing cells, and then the cells will heal the meniscus. However, the current scientific consensus (last I read, it was a few years ago) on these treatments is that they don't have any significant impact on healing or longevity. People who report success with them are basically experiencing a strong placebo effect, and the physical outcomes of the structures of their knee tissue matches the expected outcome of *not* performing the intervention.

Sometimes supplements are pitched for this sort of thing. The most common ones are fish oil, glucosamine, and chondroitin. However, again, medical consensus last I heard was that these have minimal if any effects, and are mostly placebos. You can use Examine.com to assess the possible effectiveness of most supplements you hear about, and Labdoor.com to check the veracity of supplements you buy.

Sometimes dietary changes are recommended. Turmeric and ginger are supposed to decrease inflammation. Drinking bone broth or eating tendons have been trendy sometimes. AFAIK, the scientific consensus here is basically the same as the supplements - maybe some things help a little, but overnight successes are probably mostly due to placebo. The exception here being if you are chronically deficient in some basic nutrient and start getting some (unlikely with a modern diet) or if you are allergic to something and stop eating it (maybe more likely).

So, science says all that stuff is garbage (what a buzzkill). What does science say *is* effective?

Basically, surgery and PT. And PT is clearly cheaper and lower risk, so you should go with that before and/or after surgery.

Unfortunately, my personal experience after going to a number of PTs for various ailments is that physical therapists know a lot about the science of the human body, but not that much about actually... accomplishing anything. I've had better results through traditional strength work and yoga. If you try yoga, make sure to find an instructor who pays a lot of attention to alignment, and who doesn't value extreme flexibility. It's a good sign if the median age of the class is over 50.

I've also recently found (for other injuries) some value in meditation. Sit down, focus on your breath. Eventually, your injury will start niggling. Now, instead of focusing on your breath focus on how the injury feels. Relax and accept it. Often, the pain recedes and you can return your focus to your breath. You are basically habituating your brain to the pain sensation, and telling it that the pain is not worth noticing, eventually leading to less pain in your daily life.

Hope this helps!

Brice C wrote:

A while ago I had a meniscus tear, and I just lived with it. Luckily, it was rarely painful, but often when I moved into significant knee flexion, the flap would get out of place, which would feel weird and wrong. I could then straighten my leg to pop the flap back into place, accompanied by an audiable "pop" - loud enough that people around me would often give me a concerned look when they heard it.

Anyway, I lived with it for a couple years, popping it back in place whenever needed, until one day I was toproping in the gym, easy 5.7 warmup, when I felt the flap go out of place. "No problem. I'll just pop it back in and not even take" I thought. But.... it didn't. Ended up going home that night on some loaner crutches since I couldn't straighten my knee, and weighting it was painful. So that basically forced me to get surgery. All in all, I'm glad it happened there, instead of happening 20 miles into the backcountry on a runout slab pitch or something.

One thing to note is that, at least for me, the wait to get surgery was a bit longer than I expected. Spent 2 months on crutches before they got me in.

Before and after surgery, I did a fair amount of research on menisci, treatments, and outcomes. The relevant bits I found were these:

Small meniscus tears on the outer layer can often heal on their own over time, since the outer meniscus layer gets some blood flowing over it. Deeper tears never heal. If the outer meniscus layer is removed, you are exposing the non-healing inner tissue to greater forces, and you should expect this part of the tissue to degrade prematurely relative to the other parts of your knees. For this reason, the general recommendation is, if possible, get the surgeon to stitch the meniscus back together, rather then trim off pieces. The hope is that the stitches will hold the flap or tear in place long enough for the outer meniscus layer to heal. However, there is a non-neglible chance of the tear re-opening, so be aware that the problem is more likely to recur if you go the stitches route.

Additional medical interventions you might hear about to slow tissue degradation or decrease recovery times are stem cell or prp injections. Stem cells you've probably heard of. PRP is platelet rich plasma - basically a high density of red blood cells. In both cases, the idea is to shoot your knee joint full of some healing cells, and then the cells will heal the meniscus. However, the current scientific consensus (last I read, it was a few years ago) on these treatments is that they don't have any significant impact on healing or longevity. People who report success with them are basically experiencing a strong placebo effect, and the physical outcomes of the structures of their knee tissue matches the expected outcome of *not* performing the intervention.

Sometimes supplements are pitched for this sort of thing. The most common ones are fish oil, glucosamine, and chondroitin. However, again, medical consensus last I heard was that these have minimal if any effects, and are mostly placebos. You can use Examine.com to assess the possible effectiveness of most supplements you hear about, and Labdoor.com to check the veracity of supplements you buy.

Sometimes dietary changes are recommended. Turmeric and ginger are supposed to decrease inflammation. Drinking bone broth or eating tendons have been trendy sometimes. AFAIK, the scientific consensus here is basically the same as the supplements - maybe some things help a little, but overnight successes are probably mostly due to placebo. The exception here being if you are chronically deficient in some basic nutrient and start getting some (unlikely with a modern diet) or if you are allergic to something and stop eating it (maybe more likely).

So, science says all that stuff is garbage (what a buzzkill). What does science say *is* effective?

Basically, surgery and PT. And PT is clearly cheaper and lower risk, so you should go with that before and/or after surgery.

Unfortunately, my personal experience after going to a number of PTs for various ailments is that physical therapists know a lot about the science of the human body, but not that much about actually... accomplishing anything. I've had better results through traditional strength work and yoga. If you try yoga, make sure to find an instructor who pays a lot of attention to alignment, and who doesn't value extreme flexibility. It's a good sign if the median age of the class is over 50.

I've also recently found (for other injuries) some value in meditation. Sit down, focus on your breath. Eventually, your injury will start niggling. Now, instead of focusing on your breath focus on how the injury feels. Relax and accept it. Often, the pain recedes and you can return your focus to your breath. You are basically habituating your brain to the pain sensation, and telling it that the pain is not worth noticing, eventually leading to less pain in your daily life.

Hope this helps!

Thanks for all that. So how was your recovery after surgery?

My recovery was pretty uneventful, but I am still in my 20s (just barely!) so YMMV.

My surgeon said pre-surgery that my flap may or may not be re-attachable, and asked my permission to make the judgement call once he actually had a camera in there. I agreed. During surgery, the call they made was that reattachment was not a good bet, and so they snipped it.

Post surgery, I obviously had some pain and swelling, which went down after a few weeks. Pain was really not that bad, so I think I ended up saving most of the opiates for my med kit. I was on crutches for maybe a week or two, then started hobbling as my leg was able to bear more weight. Post op PT (the most useful PT I ever had) consisted of simply getting the joint moving and making sure I got full extension and flexion back, plus some controlled resistance training (one legged leg press and leg extension).

About 2 months post surgery I was out climbing and hiking more or less normally. I think I treated the knee pretty gingerly for about a year post-op, and these days it is a non-issue.

My advice for post-op looking back would be this -

Do all the PT, even if you think it's worthless. Punch the clock and never miss an exercise. Once you get cleared for general activity and you're feeling pretty ok, you'll see diminishing returns on PT exercises, so stop doing the ones that you think aren't helpful.

In the gym, I thought the leg press and extension were quite helpful early on, for making sure the knee regained full extension. However, they do a poor job of tying the hip into the motion, so they will also yield diminishing returns. I think doing very light goblet squats and kettlebell deadlifts could be really good. Also farmer walks, which would be a good exercise to add weight to early on.

For yoga, I think focusing on the standing poses, with long, strong holds, would be really good. Tadasana, trigonasana, and the warrior series. Plus child's pose for flexion.

Not the same situation but had a meniscal repair in my teens and am climbing now in my 30s.  I had a hybrid repair with darts (resorbable) and permanent sutures due to the extent of the tear.  Like some of the other folks above mine was locked at about 30 degrees from straight.  I likely still have some tearing but it's been surprisingly robust, although I have definitely gone through some PT from time to time for it.  I did take glucosamine after but... The science behind that isn't crystal clear.  

Sounds like they'd likely remove most of the damaged parts of the meniscus... Which might have short term benefits, but will likely cause arthritis over time.  The benefits/drawbacks seem pretty situation dependent from what literature says (pubmed searches).

That being said I'd definitely try PT first if it were me.  I'd make sure to go to a PT that focuses on active people (kinda like what Brice said with yoga look for mostly younger active folks at the PT place).  These might take some shopping around but I've found a few in the PNW.

 In an alternative sense, stem cell therapies have been and will continue to advance for repairs.  I know there are some active trials but not sure if anything is fully vetted yet.  I'm crossing my fingers for this as I'm sure I'll be in a similar situation to you sometime in the future.

Stem cell therapy is also my retirement plan for my knee. C'mooooooon future!

Last time I looked into it, the issue with stem cells repairing bodily structures like the meniscus was that the cells need something to work with. If you just plop them in there, they'll just float around for the most part until the body's immune system cleans them up. So a big part of the research is about creating appropriate artificial structures on the damaged tissue for the stem cells to latch onto. We can hope. 

Whatever direction you choose- I swear by hydrolyzed collagen powder and vitamin c. I also take fish oil and glucosamine/condroiten, but definitely try the hydrolyzed collagen 

have it fixed.  You’ll regret not doing it years down the road when you need a knee replacement.  First hand experience 

Had medial meniscus resection 2x when younger. PT after is super important.  Cycling made things loads better. Second time happened during lax season and ortho told me I could keep playing (which I did) but tear could go into joint and lock up (which it didn’t).  Procedure is relatively quick and straight forward (if arthroscopic) but totally get wanting to avoid hospital right now 

Had minor issues - flapper removed from one knee, beak tear (?) cleaned up on the other.  Well worth it.  Sounds like not your case though.

A climbing friend sometimes had knee-locking while climbing.  Went into surgery thinking it'd be two weeks on crutches and a little PT.  Came out with a plan of many more weeks on crutches (etc.), a knee infection soon started up, second surgery to install a manual pump to remove fluid, third surgery to remove pump when no longer needed, loss significant range of motion due to scar tissue, lots of PT.  Had to work hard in PT to get back to where he was pre-surgery.  Not happy.  But this isn't a bid to dissuade you.  Just another risk besides COVID.

Any 50 year olds face this same decision?  I have what appears to be a small meniscus tear - probably degenerative in nature vs acute - and so far my research indicates results are mixed.

My two cents would be wait til January and have the surgery.  I tend to agree with the above comments around that knee being a ticking time bomb.

I had a 90% torn bucket handle meniscal tear last November.  Like many of the above stories, my knee was also locked about 30 degrees from straight.  I gave the Dr. permission to make the call on repair vs remove when he was in there as long as he suspected it to be greater than a 50% chance of healing.  At 29 years old, having damn near the entire meniscus wasn't ideal and he thought it looked repairable, so he went for it.

It was ~6 months before I even thought about climbing and ended up getting on some 5.easy routes.  I've been doing some PT at home (it's hard to be consistent with PT at home and avoiding gyms due to covid) but mostly just stay very active. I'm 11 months post surgery now and the repaired knee still swells up and feels like it's about 50 years older than my other knee.  I am back to a mostly normal life and my climbing is starting to get closer to where I used to be, albeit I have to modify my climbing significantly.  I'm afraid to / don't have the range of motion to bend my knee much, so I had to cut high steps out, mantles have turned into beached whale moves and I haven't had the opportunity yet, but will likely cut most kneebars and knee drops from climbing.   Not sure if I regret the repair or not, because I don't think the long term effects of losing nearly your entire meniscus at 29 years old would be very nice either.

At 45 years old and faced with the 'leave it, repair it, or clean it up' options I'd for sure take the clean it up option.  You don't want a flap floating around in there because eventually it's gonna flip and lock your knee.  Being a long way from help with a knee that doesn't work is not a situation you want to be in.

Brice C wrote:

Stem cell therapy is also my retirement plan for my knee. C'mooooooon future!

Last time I looked into it, the issue with stem cells repairing bodily structures like the meniscus was that the cells need something to work with. If you just plop them in there, they'll just float around for the most part until the body's immune system cleans them up. So a big part of the research is about creating appropriate artificial structures on the damaged tissue for the stem cells to latch onto. We can hope. 

Yup... It'll get there... Someday...  There are a few companies actively working on it and several open clinical trials.  The scaffolding piece has some challenges though.  Matching bone... Kinda easy.  Matching softish tissue...a bit harder.  Some of the woven scaffolds looked promising.

There are places you can get an injection of your own cells but not sure how much clinical evidence exists for those types of treatments.

At 48 I torn my meniscus, tried to avoid surgery with Pt but every time I stressed the knee it would swell up.

For me the most important thing was to avoid knee replacement in the future.

Surgeon said if you don’t fix the meniscus now, I guarantee you will need a knee replacement.

So I fixed the meniscus and cleaned up some arthritis, did some rehab.
And back at 100 %.

Able to ski hike bike and climb pain free!

Eric Metzgar wrote:

He said with 20-30 year olds, he'd recommend surgery. He said for 55 years old and older, he doesn't know if it would be worth it. 

Why would your age make a difference?  

Here’s a specific story since you asked for one:  my husband is 64. He’s on the road bike 5000 miles a year. In the past he’s had two arthroscopic surgeries on his left knee. His right knee started bothering him and it felt to him like a meniscus tear. As we moved 400 miles since the last surgeries, he needed to find a new surgeon. The first one - a more “general population kind of orthopedist”- looked at the MRI and said he didn’t see any tears and just prescribed PT. After 2 months of no functional improvement, I found him a new doc - a sports medicine specialist orthopedist - who looked at the same MRI, saw two small tears and said arthoscopic surgery was a no brainer. It’s now been six months post surgery and he’s back to as good as new. 

Get a second opinion and find someone who works with athletes. 

Eric, I just saw you are based in San Francisco. There are fantastic orthopedists there. Our surgeon up there did my left knee, and both my shoulders, 20 years apart. Gary Fanton, runs the sports medicine dept at Stanford University. SOAR (Sports Orthopedic and Rehab) in Redwood City also typically has fantastic docs. 

I have a torn meniscus that I have been dealing with for almost two years now. I am 30 years old. Decided to tough it out and see how things went. Inevitably it kept flapping / getting stuck, and has gradually worsened over time. Mine has never locked but has fucked me multiple times and probably cost me more climbing time than just getting Surgery right away; now I am having to go ahead with the surgery anyways.

One time I was unroped on fourth class, and the meniscus 'flapped' while I was shuffling through a section with a few hundred feet of air below me. I straightened my leg out and it popped back into place painfully. Not sure how that would have unfolded if it truly locked.

Get the surgery, whether it be repair or removal.

51 yo, 18 days out from a repair of a bucket tear in my left medial meniscus. Four "darts" to make the repair. On crutches until November 6. Don't have much else to add yet...

It's a ticking time bomb indeed. I've spent my 20's beating on my knees HARD and brushing off injuries. I'm 40 now and the surprise jolts of pain were more frequent, but I still ignored them because the alpine season had been so good. The last trip of the year, I hauled my 50 lb 8 miles into the Winds, and the horse brought another 150lb for the week for the group. We did a small climb next day, and on day 3 I woke up with a watermelon where my knee was and pain when I looked at it. I spent the next 3 days in a hammock popping ibuprofen unable to even get water for the camp...

Once back, my first ever MRI showed medial tear on the right and slight lateral tear in the left. I actually just had the scope on the right last week to remove the flapper. I think I lost less that 20% of meniscus or so. I've spent two days on the couch, crutch-sliding to the bathroom, walked to the kitchen on day 3, finished some home improvement on day 4, walked to the store on day 5, and here on day 6 I'm moving around almost without a limp. Pain was manageable without narcotics. Day one I had kind of dull pain like you hit that soft spot under your patella really hard. Day 3 and on the holes hurt a bit, or if moved to the point where the swelling is compressed. It's still swollen a bit, and it hurts a bit to extend and bend all the way, but overall it's going well. I can already tell that certain pivoting motions are clean compared to before. 

My advice is to do your research and don't put faith into snake oil. Supplements won't do much without blood flow to the site (about half of meniscus gets blood). Stem cells are still a bunch of hype and something worth being VERY careful with despite having a stem cell clinic on every corner ("Bad Batch" podcast might open some eyes to some of the fuckery that goes on there). Also, PT can get you stronger but broken structure won't mend without blood flow.

For me it was a simple decision. I felt like I've gotten away with it for long enough, and it felt it was either getting scooped or selling all my skis (instead bought new skis