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Knee osteoarthritis with degenerative medial meniscal tear — MSRA MCQ

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HardKnee InjuriesKnee osteoarthritis with degenerative medial meniscal tearMSRA

A 59-year-old warehouse supervisor presents 6 weeks after twisting his right knee while turning at work. He had no immediate swelling and continued weight-bearing. For 18 months before this event he had activity-related medial knee pain and stiffness lasting about 10 minutes each morning. Since the twist, he reports intermittent clicking and brief catching when squatting, but no persistent block; he can fully extend the knee and flex it beyond 100 degrees. Examination shows medial joint-line tenderness and crepitus, with no effusion or ligamentous laxity. BMI is 33 kg/m². Weight-bearing radiographs show moderate medial-compartment osteoarthritis. An MRI requested before this review reports a complex degenerative medial meniscal tear. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Provide exercise-led osteoarthritis care, weight-management support and topical NSAID treatment; do not refer for arthroscopy

Explanation lettering: E = shown as A · A = shown as B · B = shown as D · D = shown as E

This is symptomatic knee osteoarthritis with an associated degenerative meniscal tear, rather than an acute displaced meniscal injury requiring arthroscopy. The long history of activity-related pain and brief morning stiffness, obesity and medial-compartment radiographic osteoarthritis establish the dominant diagnosis. Intermittent clicking or catching does not equal a true locked knee: he has full extension and no persistent mechanical block. Therefore, the MRI finding should not drive operative referral. NICE recommends tailored therapeutic exercise, weight management where appropriate, information and support as core osteoarthritis treatment, and topical NSAIDs for knee osteoarthritis. Arthroscopic lavage or debridement should not be offered for osteoarthritis. Evidence-based guidance against arthroscopy for degenerative knee disease also applies where meniscal tears and mechanical symptoms are present; persistent objective locking is the relevant exception. A is inappropriate because there is no true locked knee. B wrongly treats a common degenerative MRI finding as an indication for meniscectomy. D may be considered for short-term relief when other pharmacological treatments are ineffective or unsuitable, or to facilitate exercise, but is not first-line here. E bypasses core treatment and oral NSAIDs require individual renal, gastrointestinal, cardiovascular and drug-interaction risk assessment.

Reference: NICE NG226: Osteoarthritis in over 16s: diagnosis and management — Recommendations (Published 19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline (2017) — https://www.bmj.com/content/357/bmj.j1982