Current trends in meniscal tear management: guidelines and literature review, 2024–2026

Polish version: Aktualne trendy postępowania z uszkodzeniami łąkotek — przegląd wytycznych i najnowszego piśmiennictwa 2024–2026

Modern meniscal care increasingly moves beyond the assumption that a tear on MRI requires arthroscopy. The central direction is to preserve functional meniscal tissue whenever biologically and mechanically justified, while clearly distinguishing acute traumatic tears from degenerative lesions. Guidelines, an international rehabilitation consensus and systematic reviews published during 2024–2026 reinforce this approach.

This is a structured review of guidelines, randomized trials, meta-analyses and systematic reviews, rather than a formally registered PRISMA systematic review. It focuses on publications from 2024–2026 and key long-term studies that inform current practice.

The central change: preserving a functional meniscus

Arthroscopic partial meniscectomy (APM) was once a common response to a symptomatic tear. The emphasis has shifted towards meniscal preservation. The AAOS guideline on acute isolated meniscal pathology recommends retaining as much functional tissue as possible when surgery is necessary. This matters beyond short-term symptoms: meniscal loss alters load transmission and increases the risk of degenerative change.

A meta-analysis of nearly 4,000 repairs found an overall failure rate of approximately 15% at 2–5 years. Repair therefore has a meaningful risk of failure, but outcomes support broader preservation attempts in appropriately selected patients. Contemporary all-inside and inside-out techniques have broadly similar results. Choice should reflect tear pattern, location, stability and the ability to achieve an anatomical repair.

1. How an orthopaedic surgeon establishes the type of lesion

The most important distinction remains acute traumatic injury versus degeneration. MRI alone is insufficient. The same radiological description may have a different meaning in a 20-year-old athlete after a twisting injury and a 60-year-old with knee pain, chondropathy and no clear traumatic event.

• An acute displaced tear restricting extension or causing true locking may require urgent or early arthroscopy.
• A tear with good repair potential should prompt consideration of repair rather than resection.
• A degenerative lesion without locking or substantial trauma should initially be managed nonoperatively.
• Root, radial, horizontal and bucket-handle tears require distinct biomechanical assessment rather than being treated as one generic category.

2. Degenerative tears: exercise remains first-line treatment

Randomized evidence is consistent. At 5 years in ESCAPE, exercise-based physiotherapy remained noninferior to APM for knee function. At 10 years in OMEX, meniscectomy offered no clinically important pain or functional advantage over exercise therapy, and radiographic osteoarthritis incidence was similar.

Pain, clicking, catching or an MRI finding alone are insufficient indications for APM in a degenerative lesion. Care includes appropriate loading, strengthening, movement control, activity modification and treatment of coexisting osteoarthritis. Surgery may be considered in selected cases after unsuccessful nonoperative care when the clinical picture still supports a meniscal source of symptoms.

3. Acute traumatic tears: repair increasingly takes priority when surgery is needed

The 2024 AAOS guideline emphasises clinical examination, MRI when imaging is needed, and preservation during surgery. Prolonged delay in an acute tear that restricts motion, is unstable or is potentially repairable may reduce the opportunity to preserve tissue. Findings from trials of degenerative lesions in middle-aged adults should not be extrapolated to this group.

4. Age alone is no longer a contraindication to repair

Indications are extending beyond the traditional young patient with a fresh red–red zone tear. A meta-analysis of patients aged 40 and older reported failure of approximately 12%, without a significant difference from younger groups. Chronological age alone should therefore not determine resection. Tissue quality, tear pattern, vascularity, stability, cartilage status, limb alignment and functional expectations are more relevant.

5. Radial and horizontal tears: increasing opportunities for preservation

Radial tears disrupt circumferential fibres and hoop stress transmission, potentially approaching the functional consequences of substantial meniscal loss. A 2026 systematic review of 321 radial repairs reported complete or partial healing in approximately 82.5% of assessed lesions, with few complications. Certainty remains moderate or low because observational studies predominate.

A 2025 systematic review of horizontal cleavage tears found similar clinical outcomes after repair and partial meniscectomy, but greater progression of degeneration after resection. This does not mean every horizontal tear should be repaired. It means tear configuration alone should not automatically determine meniscectomy.

6. Root tears require a separate biomechanical assessment

Root tears, particularly of the medial meniscus posterior root, can cause substantial extrusion and loss of hoop function. A systematic review comparing root repair, partial meniscectomy and nonoperative care favoured repair for clinical and radiographic outcomes. Decisions must still account for osteoarthritis severity, alignment, cartilage quality, BMI and biological age. With substantial varus, root repair alone may not address medial compartment overload.

7. Partial meniscectomy retains a selective role

APM remains an option for an unstable, irreparable fragment that explains symptoms and cannot safely be preserved, and for selected persistent symptoms after appropriate nonoperative treatment. The aim is to remove the minimum tissue needed to obtain a stable rim while preserving functional meniscus, rather than extending resection simply to create a uniformly smooth appearance.

8. Biological augmentation: promising but not routine

PRP, marrow stimulation, fibrin clot, scaffolds and cell-based therapies are under active investigation. A 2025 scoping review found highly varied techniques and predominantly low-level evidence. A 2026 meta-analysis suggests that PRP added to repair may reduce retear or failure, but does not consistently improve patient-reported outcomes or justify routine use for everyone.

A biological signal should be distinguished from an established clinical standard. Further research needs to identify which tear patterns and vascular zones may benefit from augmentation.

9. Rehabilitation must reflect the tear and repair

The 2024 ESSKA–AOSSM–AASPT consensus, published in 2025, provides a framework. After partial meniscectomy, progression should primarily be criterion-based, reflecting swelling, pain, range of motion, strength and function rather than a fixed calendar. After repair, functional criteria must be combined with time for biological healing.

Root and radial repairs, or other tears disrupting circumferential continuity, may require different weight-bearing and flexion restrictions from a stable longitudinal repair. Return to sport should consider time, symptoms, strength, movement control and functional testing together.

10. Meniscal allograft transplantation: a salvage option after meniscal loss

Meniscal allograft transplantation (MAT) may be considered for younger active patients with symptomatic deficiency after subtotal or total meniscectomy. A 2026 meta-analysis with follow-up beyond 10 years found sustained function and activity in some patients, alongside a moderate graft-failure rate. MAT should not be regarded as a way to reverse advanced osteoarthritis. Selection requires assessment of cartilage, alignment and knee stability.

A practical assessment pathway

• Establish context: recent trauma or a degenerative lesion?
• Assess function: true locking, loss of extension, instability, effusion and loading limitations.
• Match imaging to the question: MRI for suspected significant intra-articular injury; radiographs for degeneration, alignment and bony pathology.
• For degenerative lesions: begin with nonoperative treatment and progressive exercise.
• For an acute repairable tear: consider preservation and repair rather than resection.
• For radial, horizontal or root tears: assess their biomechanics, tissue quality and compartment condition separately.
• If resection is necessary: remove as little tissue as possible and retain a stable functional portion.
• After surgery: tailor rehabilitation to tear type and repair rather than applying one programme to every patient.

Remaining uncertainties

Key uncertainties concern the limits of repair in degenerative tissue, optimal treatment of selected horizontal and radial tears, biological augmentation and individualised rehabilitation after different repairs. In many emerging areas the direction is persuasive, but evidence still relies mainly on observational studies and heterogeneous reviews.

Conclusions

Clinical decisions should address the patient and functional problem, not the image alone. When surgery is required, preserve as much functional meniscus as possible. Degenerative lesions generally warrant initial nonoperative care. Repair is increasingly important for acute repairable tears and selected older patients and radial or horizontal patterns. Root tears need separate biomechanical assessment, while partial meniscectomy remains a selective procedure.

References

1. American Academy of Orthopaedic Surgeons. Clinical Practice Guideline for the Management of Acute Isolated Meniscal Pathology. 2024. AAOS.
2. Pujol N, Giordano AO, Wong SE, et al. The formal EU-US Meniscus Rehabilitation 2024 Consensus: Part I—Rehabilitation management after meniscus surgery. Knee Surg Sports Traumatol Arthrosc. 2025;33:3002-3013. DOI: 10.1002/ksa.12674. PMID: 40353298.
3. Prill R, Ma CB, Wong SE, et al. The formal EU-US Meniscus Rehabilitation 2024 Consensus: Part II—Prevention, non-operative treatment and return to sport. Knee Surg Sports Traumatol Arthrosc. 2025;33:3014-3024. DOI: 10.1002/ksa.12689. PMID: 40501314.
4. Berg B, Roos EM, Englund M, et al. Arthroscopic partial meniscectomy versus exercise therapy for degenerative meniscal tears: 10-year follow-up of the OMEX randomised controlled trial. Br J Sports Med. 2025;59:91-98. DOI: 10.1136/bjsports-2024-108644. PMID: 39326908.
5. Noorduyn JCA, van de Graaf VA, Mokkink LB, et al. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022;5:e2220394. PMID: 35802374.
6. Schweizer C, Hanreich C, Tscholl PM, et al. Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure. Am J Sports Med. 2024;52:822-831. DOI: 10.1177/03635465231158385. PMID: 37022676.
7. Sedgwick MJ, Saunders C, Getgood AMJ. Systematic Review and Meta-analysis of Clinical Outcomes Following Meniscus Repair in Patients 40 Years and Older. Orthop J Sports Med. 2024;12:23259671241258974. DOI: 10.1177/23259671241258974. PMID: 39131093.
8. Lee DR, Lu Y, Reinholz AK, et al. Root Repair Has Superior Radiological and Clinical Outcomes Than Partial Meniscectomy and Nonoperative Treatment in the Management of Meniscus Root Tears: A Systematic Review. Arthroscopy. 2025;41:390-417. DOI: 10.1016/j.arthro.2024.02.017. PMID: 38401664.
9. Allende F, Dzidzishvili L, Garcia JR, et al. Partial Meniscectomy Yields Comparable Outcomes and Failure Rates to Meniscal Repair for Horizontal Cleavage Tears, With Fewer Complication Rates but Greater Progression of Degenerative Changes. Arthroscopy. 2025;41:2680-2694. DOI: 10.1016/j.arthro.2024.10.009. PMID: 39426762.
10. Borim FM, Zeng C, Rechsteiner J, Lording T. Surgical repair of radial meniscus tears yields favorable healing rates: a systematic review. J Orthop Surg Res. 2026. DOI: 10.1186/s13018-026-07080-z. PMID: 42432690.
11. Dave U, Rubin J, Chang N, et al. Platelet rich plasma augmentation for meniscus repair reduces failure but not complication rates or outcomes: A systematic review and meta-analysis. J Orthop. 2026;73:62-71. DOI: 10.1016/j.jor.2025.12.015. PMID: 41487690.
12. Yu V, Meglino N, Cohen D, et al. Meniscal allograft transplantation maintains function and activity beyond 10 years with moderate graft failure: a systematic review and meta-analysis. J ISAKOS. 2026;19:101147. DOI: 10.1016/j.jisako.2026.101147. PMID: 42208660.
13. Mazy D, Wang J, Dodin P, et al. Emerging biologic augmentation strategies for meniscal repair: a systematic review. BMC Musculoskelet Disord. 2024;25:541. DOI: 10.1186/s12891-024-07644-2. PMID: 39003467.
14. Super JT, LaPrade RF, Robinson J, et al. Biologic augmentation of meniscus repair: A scoping review. Knee Surg Sports Traumatol Arthrosc. 2025;33:4176-4188. DOI: 10.1002/ksa.12634. PMID: 40145235.

Related resources

For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.