There are several solutions to reduce pain in case of meniscus injury, osteoarthritis or even torn ligaments in the knee. Contrary to what one might think, knee surgery is a very delicate operation that can only be considered in certain cases.

Knee, pain:, when, to, operate?

At the end of 2019, the orthopedic surgeons of the Société francophone d'arthroscopie called for "saving the menisci," which are too systematically removed. Meniscus removal is a common procedure (about 150,000 each year), the most frequent at knee level, ahead of prosthetic or cruciate ligament surgery. However, this operation is not always indispensable, nor is it always beneficial in the long term.

When is meniscus removal necessary?

If you feel something abnormal when you bend your knee, with difficulty in re-tensioning the leg, it surely means that the injury is unstable, with a mobile meniscus fragment that causes blockages or protrusions in the knee. This is often the case after a sports trauma, when the knee spins, or when you hurt yourself by rising too abruptly from a long crouching or kneeling position, for example after doing work.

Depending on the type of lesion, visible on MRI, the surgeon will consider a suture: he brings the edges of the fissure together with a thread in the hope that it will heal. This procedure preserves the meniscus but is delicate and reserved for lesions on the peripheral areas, which are more vascularized and have a better chance of healing. Otherwise, the ablation will be as partial as possible, removing the piece of cartilage that is causing discomfort. But sometimes the meniscus must be completely removed: this is the case of "bucket-handle" lesions, when a tear cuts it in half.

How is the meniscus operation going?

The meniscus removal is an outpatient operation, via an arthroscopy (the surgeon passes a pair of forceps and a minicamera through two incisions).

Recovery is quick: you can walk immediately, with crutches for a few days. The work stoppage is one week for a sedentary job, 3 weeks for a physical job.

Menisci, small fragile cartilage

These are two small, moon-shaped, fibrous cartilage pads on either side of the knee that fill the empty spaces between the femur and tibia.

Their function? They act as shock absorbers to ensure knee stability and facilitate sliding between the bones for good mobility. Over time, the menisci wear out or may crack or even tear, generally causing pain on one side of the knee. 

In which case is the operation avoidable?

"Around the age of 50 or 60, when meniscus pain is related to natural wear and tear due to age and not to trauma, it is generally avoidable," says Dr. Romain Letartre, president of the IRBMS (Research Institute for Well-being, Medicine and Sport Health).

It is also not mandatory if the injury does not cause mechanical discomfort in movement. In these cases, the pain can most often be treated medically. 

Is it necessary to operate if the pain is related to osteoarthritis?

Surgery is only a last resort, when analgesics, infiltrations (corticosteroids or hyaluronic acid) and physical activity are not enough to alleviate the pain and it becomes disabling, reducing our activities and walking range.

"We prefer to delay the installation of a knee prosthesis as long as possible and avoid it before the age of 60. Its lifespan is limited to 15 to 20 years, we can change it once, but from the second time on, the results are really less good. What's more, you can feel the prosthesis and rarely forget it," says Dr. Letartre.

For the other pains, we bet on muscular reinforcement.

Whether it is a patella problem (pain in the front of the knee, when going down stairs or sitting for a long time) or a rupture of the cruciate ligaments, remuscle the area with physiotherapy sessions and exercises at home should be the first reflex. Strengthening the quadriceps but also the buttocks helps to stabilize the knee and limit the stress on the joint.

This can be done through sports without jumps such as swimming (crawl without fins), cycling (without too much resistance), elliptical, Nordic walking, possibly tennis... preferably avoiding lunges, squats and steps. To be completed by stretching the muscles of the back of the leg.

Why is it better not to have surgery (when possible)?

In the short term, the operation reduces pain. But in the long term, since there is no longer a "shock absorber" between the bones of the joint, the cartilage wears out faster and the risk of osteoarthritis increases. It is best to initially treat the pain with painkillers or anti-inflammatory drugs and rest for 6 weeks. You can then resume sports activities such as cycling, swimming (rather crawl than breaststroke) and if the pain has disappeared, try running again, at least 3 months later.

If the pain persists, the doctor suggests corticosteroid infiltrations to reduce the inflammation around the meniscus, as it is responsible for the pain. "Combined with rest, one or two infiltrations most often help to calm the pain because the body 'accepts' the fissure over time," says Dr. Letartre.

Wearing orthopedic insoles can also provide relief, especially if it is the arched shape of the legs (genu varum) that damages the internal meniscus. If, after 4 to 6 months, these solutions have not been sufficient, an MRI will be required to observe the lesions and consider surgery.