Walk It Off: Exercise Therapy for Meniscal Tears Equivalent To Surgery

Exercise-based physical therapy remains in no way inferior to arthroscopic partial meniscectomy for treating degenerative meniscal tears, according to long-term data from the ESCAPE trial, suggesting physical therapy to be the preferred treatment over surgery.

At the 5-year mark, the patient’s reported knee function after 16 sessions of physical therapy was not lower than that observed after surgery, with a between-group difference of 3.5 points on the International Knee Documentation Committee Subjective Form 100 points (95% CI 0.7-6). ,3, P<0.001 for noninferiority) in the intention-to-treat analysis, according to movement scientist Julia Noorduyn, MSc, of OLVG Amsterdam, The Netherlands, and colleagues.

For the surgery and exercise therapy groups, respectively, the mean improvement from baseline was 29.6 and 25.1 points at 5 years. The progression of knee osteoarthritis, assessed radiographically, was equally low between the two groups, Noorduyn’s team reported in JAMA Network Open.

The main findings from the first 2 years of ESCAPE are retained in the long term. These results may inform future guideline recommendations for treating patients with degenerative meniscal tears, the researchers suggest.

In the trial, there was a crossover rate of 32% of people having delayed surgery after initial physical therapy — mostly within the first year. “These figures suggest that not all patients experience satisfactory outcomes after physical therapy,” Noorduyn and colleagues admit.

However, in the treated analyses, physical therapy was still not inferior to arthroscopic partial meniscectomy in terms of 5-year outcome.

“Surgery has been described as the primary placebo,” according to orthopedic surgeons Brian Hallstrom, MD, and Ramzy Meremicwu, MD, both of the University of Michigan in Ann Arbor.

“Although there have been several randomized clinical trials showing no efficacy of knee arthroscopy for knee osteoarthritis or degenerative partial meniscus debridement, we are still studying these treatments, perhaps looking for different results,” the two wrote in an accompanying editorial.

Hallstrom and Meremikwu also emphasize that knee surgery is “non-benign”, because the procedure is expensive and associated with accelerated progression of knee osteoarthritis.

Indeed, one study from 2014 showed that knee surgery was associated with an increased risk of osteoarthritis in the same knee, often developing within 1 year of surgery to repair a meniscus cartilage tear.

The ESCAPE randomized trial collected data from nine orthopedic departments across hospitals in the Netherlands from 2013 to 2020.

Eligible participants were individuals with degenerative meniscal tears. Those with locked knees, trauma requiring acute surgery, related injuries to the index knee, severe structural knee osteoarthritis, or a BMI of 35 or greater were excluded.

Of the 321 initial participants aged 45 to 70 years (mean age 58 years, 50.2% women), 278 completed a 5-year follow-up, with a median follow-up of 61.8 months.

The physical therapy and surgical groups share the same basic characteristics.

Noorduyn’s team cautions that ESCAPE does not list reasons why people do not participate in follow-up questionnaires or radiographs, and loss to follow-up could be linked to selection bias. Additional non-invasive treatments for knee pain were also not noted.

Even so, the findings from the trial are in line with the literature on knee surgery, suggest Hallstrom and Meremicwu.

“Several studies, including some with sham surgery as controls, have demonstrated repeatedly over the previous 2 decades that surgery is not superior to physical therapy, but the problems and uses of surgery persist,” they wrote. The current study shows “once again that arthroscopy is no better than nonsurgical management of meniscal tears.”

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  James Lopilato is a staff writer for Medpage Today. He covers a wide range of topics explored in current medical science research.

Disclosure

This study was funded by a grant from ReumaNederland, ZonMw, Zilveren Kruis Health Insurance, and the OLVG Medical Research Foundation, Amsterdam. The cost of the physical therapy sessions is covered by the Achmea Healthcare Foundation.

Noorduyn reports receiving grants from the Dutch Health Research and Development Organization, the Achmea Health Foundation, the OLVG Medical Research Foundation, the OLVG science committee and the Dutch Arthritis Society.

Hallstrom reports receiving partial salary support paid to the University of Michigan by the Blue Cross Blue Shield of Michigan for his work as co-director of the Michigan Arthroplasty Registry Collaborative Quality Initiative.

Meremikwu has no disclosures.

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