After a year of pain and his right knee ‘locking’, keen club runner Tom Hooper, 43, happily agreed to surgery thinking it would mean an end to the problem.
Nine months after the operation, however, he was still in pain and needed steroid injections and intensive physiotherapy.
Three months after that, the pain thankfully has gone, but his knee remains inflexible – he can’t straighten it or move it easily. Yet he remains optimistic he will get back to full fitness.
But is Tom’s confidence misplaced?
Controversial new research from Finland recently published in the New England Journal of Medicine suggested that the knee procedure Tom underwent might do more harm than good in some patients.
Tom had a meniscus tear, a common knee injury which affects the wedge of cartilage between the bones in the knee joint.
Meniscus tears can happen at any age but are most common in 15 to 30-year-olds due to sports injuries, and 45 to 70-year-olds as a result of age-related degeneration that can mean even everyday movements result in a tear.
Symptoms include a popping sensation at the time of injury, knee pain and tenderness, especially when rotating the knee, swelling or stiffness, difficulty fully straightening or bending the joint, and a sensation of it giving way or locking in place.
Tom Hooper suffered a meniscus tear and had surgery to fix it. However, months after the operation he was still in pain and needed steroid injections and intensive physiotherapy
Meniscus tears can happen at any age but are most common in 15 to 30-year-olds due to sports injuries
Tom first developed knee pain after training 60 miles a week and running the London Marathon in 2024 – the pain, which was focused in the middle of his knee joint, didn’t stop him running completely ‘but it severely restricted what I could do’, recalls video games design director Tom, who lives in Brighton with his wife Anna, 44, and their five-year-old son.
‘I used to run every single day and do a long run at the weekend, but I had to cut back and couldn’t go as far or as fast. It wasn’t just running that hurt. I felt the pain when I woke up in the morning and walked my son to school.’
He tried physiotherapy, but after a year this hadn’t helped. He then had an MRI scan, which revealed he had a ‘bucket handle’ meniscus tear – a large rip in the central part of the C-shaped cartilage, where the torn bit flaps like a handle towards the centre of the knee joint.
These can occur due to a combination of wear and tear and sudden twisting movements (such as getting out of a car). The cartilage flap can restrict movement and cause pain if it becomes wedged inside the knee joint. It can also irritate the knee lining, causing swelling, stiffness and throbbing.
Meniscus tears are linked to a four-fold increased risk of developing knee osteoarthritis, as they reduce the protective effect of the meniscus on the bones in the joint. Treatment often involves rest and painkillers in the early stages, sometimes followed by physiotherapy to strengthen the muscles and stabilise the joint.
But in more severe cases surgery may be offered. This can involve either stitching the tear back together or trimming and removing the damaged tissue – usually performed via keyhole or in the worst cases, open surgery.
Around 75,000 such operations are performed in the NHS each year, with an estimated 24,000 more in the private sector. The consultant Tom saw said he’d either need surgery to repair the meniscus – or to trim and remove some of the damaged tissue, known as a partial arthroscopic meniscectomy (APM).
As he was told the scan showed the beginnings of osteoarthritis Tom ‘didn’t think there was any other option’.
Professor Teppo Jarvinen, principal investigator of the study at Helsinki University, Finland, said the findings showed APMs were an example of how a broadly used therapy can be ‘ineffective or even harmful’
A year on from his surgery and, as well as having restricted movement in his affected knee, Tom can’t run as far as he used to.
‘I went back a few months ago and had another MRI, and have been told it shows the meniscus surgery has been successful in that there is no further damage to the area. But I needed steroid injections to calm the inflammation from osteoarthritis down, which has helped a lot.’
But a recent study, involving 146 patients aged 35 to 65, suggests that, for some, the APM surgery Tom had may do more harm than good.
The findings, published in a letter to the New England Journal of Medicine, showed that after ten years patients treated with APMs to remove damaged or loose bits of meniscus were no better off in terms of health-related quality of life, knee function or pain after exercise than patients given sham surgery.
What’s more, one in five (22 per cent) of the surgery group had developed knee osteoarthritis compared with 19 per cent in the sham group; they also had a higher rate of total knee replacements and high tibial osteotomy (a procedure to realign the knee joint by cutting the shinbone).
Professor Teppo Jarvinen, principal investigator of the study at Helsinki University, Finland, said the findings showed APMs were an example of how a broadly used therapy can be ‘ineffective or even harmful’.
He added: ‘For nearly a decade, many independent, non-orthopaedic organisations providing clinical guidelines have recommended the procedure should be discontinued. Still, for example, the American Academy of Orthopaedic Surgeons and the British Association for Surgery of the Knee (BASK) have continued to endorse the surgery.’
It’s not the first study raising questions about meniscus surgery – another review, by researchers from Denmark, Norway and the Netherlands, published in 2023 in Osteoarthritis and Cartilage, found that none of the 605 patients benefited from APM compared to non-surgical or sham treatments.
Philip Conaghan, a professor of musculoskeletal medicine at Leeds University, says knee arthroscopies – keyhole procedures to inspect, repair and wash out joints, of which meniscus trimming and repair is just one type – have previously been overperformed.
‘We’ve known for some years that much arthroscopic surgery and debridement [trimming the meniscus] is done because of people’s symptoms.
‘But if you were to scan a whole lot of people over the age of 40, you’d find asymptomatic [symptom-less] tears.’
In other words, it’s not necessarily the tear causing the pain.
Professor Conaghan, who is also director of the National Institute for Health and Care Research Biomedical Research Centre in Leeds, said national guidelines including those of BASK, published in 2019, advised APM should be reserved for cases where there is locking of the joint.
But he says ‘there is confusion between ‘gelling’ of a joint, where it is temporarily hard to straighten and stiff after inactivity and it frees up as you move, and locking, where the knee becomes mechanically blocked and gives way and you fall over’.
‘Locking suggests there might be a meniscus fragment that’s moving and stopping the knee fully extending.
‘We think for meniscal tears causing locking, surgery is a useful procedure, but for meniscus that is just a bit damaged or worn down, it’s not,’ he adds.
BASK agrees that a lot of middle-aged people with meniscus problems do not need surgery, but the fear is the new Finnish findings may scare off patients who genuinely need surgery – particularly younger patients with sport-related injuries, who were not included in the study.
‘A young person who tears their meniscus playing sport is in a completely different situation from a 55-year-old with a degenerative tear,’ says BASK president Alasdair Santini, a consultant orthopaedic surgeon in trauma and orthopaedics at Liverpool University Hospitals.
He warned that if younger people are scared off having meniscus surgery, they may damage their knee even more. The body’s president elect, Chinmay Gupte, a consultant trauma and knee surgeon at Imperial College Healthcare NHS Trust, adds: ‘Underdiagnosis and undermanagement of knee problems is a big issue in this country in younger people.’
He says APM may also benefit middle-aged people with a flap tear that’s moving inside the knee causing pain and knee lock: ‘These patients need surgery that gets them back to work.’
Tom is optimistic he’ll ‘get back to where he was’ with physio’. ‘I don’t think there was an alternative to surgery given how serious the tear was,’ he says.
‘Surgery was the right decision for someone like me with a sports injury. I’d advise others in the same boat not to be put off having it.’
