Review
Effectiveness of exercise therapy for meniscal lesions in adults: A systematic review and meta-analysis

https://doi.org/10.1016/j.jsams.2016.04.003Get rights and content

Abstract

Objectives

This study evaluated the effectiveness of exercise therapy in patients with meniscal lesions.

Design

Systematic review and meta-analysis.

Methods

Nine databases were searched up to July 2015, including EMBASE and Medline OvidSP. Randomized and controlled clinical trials in adults with traumatic or degenerative meniscal lesions were considered for inclusion. Interventions had to consist of exercise therapy in non-surgical patients or after meniscectomy, and had to be compared with meniscectomy, no exercise therapy, or to a different type of exercise therapy. Primary outcomes were pain and function on short term (≤3 months) and long term (>3 months). Two researchers independently selected the studies, assessed the risk of bias, and extracted data.

Results

Of the 1415 identified articles 14 articles describing 12 studies were included; all had some concerns about the risk of bias. There was no significant difference between exercise therapy and meniscectomy for pain (MD 0.27 [−4.30,4.83]) and function (SMD −0.32 [−0.68,0.03]). After meniscectomy, there was conflicting evidence for the effectiveness of exercise therapy when compared to no exercise therapy for pain and function. There was no significant difference between various types of exercise therapy for pain (MD 19.30 [−6.60,45.20]) and function (SMD 0.01 [−0.27,0.28]).

Conclusions

Exercise therapy and meniscectomy yielded comparable results on pain and function. Exercise therapy compared to no exercise therapy after meniscectomy showed conflicting evidence at short term, but was more effective on function at long term. The preferable type/frequency/intensity of exercise therapy remains unclear. The strength of the evidence was low to very low.

Introduction

Knee injuries are very common in general practice: in the Netherlands, the incidence of traumatic and non-traumatic knee injuries is 5.3 and 17 per 1000 persons per year, respectively.1 The annual incidence estimate of a meniscus tear for primary and secondary care in Sweden was 79 [95% CI: 63,94] per 100,000 patients with an observed peak age of 15–19 years old.2 The cause of a meniscal lesion can be either traumatic or degenerative. Most patients with a traumatic meniscal lesion are younger and have a longitudinal meniscal lesion, whereas most patients with a degenerative meniscal lesion are older and have concomitant joint cartilage damage.3

In the Netherlands, patients with a meniscal lesion who have knee pain or difficulty with activities of daily living and sports can consult their general practitioner (GP) or contact a physiotherapist. In primary care, it is difficult to diagnosis a meniscal tear based on history taking plus physical examination.4 With the exception of patients presenting with a locked knee, GPs generally treat meniscal lesions by applying a wait-and-see policy, consisting of advice to rest for a few days and using pain medication on demand. Patients who consult their GP with persistent or recurrent knee complaints are referred to an orthopedic surgeon.5 After radiographic imaging or magnetic resonance imaging of the knee, the surgeon may decide to continue the wait-and-see policy. Alternatively, depending on the state and/or duration of symptoms, arthroscopic surgery may be performed: either treating the lesion by meniscectomy or by suturing a torn meniscal lesion in younger patients.6

As part of the wait-and-see policy, or after meniscectomy, GPs or orthopedic surgeons can refer patients to a physiotherapist, whose treatment consists of exercise therapy to reduce limitations in knee function, reduce knee pain, and restore normal muscle strength.7

However, because the effectiveness of exercise therapy for the treatment of patients with meniscal lesions remains unclear, this review assesses the effectiveness of exercise therapy in patients with a meniscal lesion compared with: (1) no exercise therapy in non-surgical patients, (2) meniscectomy, and (3) no exercise therapy or a different type of exercise therapy after meniscectomy.

Section snippets

Search strategy

The following databases were searched up to July 2014: EMBASE, Medline OvidSP, Web of Science, Scopus, SportDiscus, the Cochrane Central Register of Controlled Trials (CENTRAL), Cinahl, PubMed and Google Scholar. Existing highly sensitive search strategies (filters) to identify randomized trials were used. See Appendix 1 for the search strategy. The protocol of the review is registered in the International Prospective register of systematic reviews [CRD42014014892].

Selection of studies

Assessment of the eligibility

Results

Appendix 2 is a flow chart of the included and excluded articles. The interobserver reliability of the eligibility assessment of the articles was good (κ 0.71). Of the 14 articles originally included,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 the results of one study were described in three separate articles15, 16, 18 leading to 12 unique studies.

Discussion

No studies evaluated the effectiveness of exercise therapy compared to no exercise therapy in non-surgical patients with a meniscal lesion. Although the effectiveness of exercise therapy in patients with osteoarthritis has been established in systematic reviews and meta-analyses,23, 24 the effectiveness of exercise therapy in non-surgical patients with a meniscal lesion and no osteoarthritis remains unclear. The Dutch guidelines for GPs and physiotherapists state that exercise therapy might

Conclusion

No studies were found that assessed the effectiveness of exercise therapy compared to no exercise therapy in non-surgical patients with a meniscal lesion. Exercise therapy and meniscectomy yielded comparable results for patients with degenerative meniscal lesions on knee pain, function and performance, but exercise therapy was more effective on muscle strength at short term. The evidence for exercise therapy compared to no exercise therapy after meniscectomy on knee pain and function was

Practical implications

  • Health professionals should take into consideration that no studies have investigated the effectiveness of exercise therapy in non-surgical patients with a meniscal lesion.

  • Included studies showed methodological limitations (for example: no blinding of either participant or investigator), and most results are based on 2 or 3 studies only.

  • In patients with a degenerative meniscal lesion, exercise therapy is preferable when compared to meniscectomy to improve muscle strength of the knee, but only

Acknowledgements

This review is partly funded by a program grant of the Dutch Arthritis Foundation. The funder had no involvement in the study design; in the collection of the data, their analysis and the interpretation; in the writing of the report; and in the decision to submit the paper for publication.

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