Is "fixing" the meniscus the only goal?

Hey everyone, it’s Dr. Fred Bagares. In today’s episode, I’m diving into a common clinical situation that led to a bigger question: What are we really trying to accomplish with treatment? A patient with a classic meniscus tear asked me something simple but powerful—“Does any of this actually fix the meniscus?”

That one question opened up a whole conversation about how we frame injuries, treatments, and success. Is surgery always the fix? Or should we be thinking bigger—pain relief, improved motion, long-term function?

This episode isn’t just about knees. It’s about how we define problems, what counts as success, and how to shift from a “parts replacement” mindset to one that values movement and sustainability.

⏱️ Episode Highlights & Navigation

• [00:31] – Case study: Young patient with acute meniscus tear
• [01:57] – “Does this actually fix the meniscus?” and the problem vs. solution dilemma
• [03:00] – One-and-done conditions vs. musculoskeletal reality
• [04:49] – What are the real goals: pain, range of motion, stability
• [05:44] – Degenerative meniscus tears: common, normal, and not always symptomatic
• [06:00] – Why joint replacements aren’t a clean slate if lifestyle doesn’t change
• [07:52] – Pain relief ≠ long-term improvement: Don’t stop at symptom resolution
• [09:12] – I’m not anti-surgery—I’m pro-movement
• [10:03] – Respecting patient autonomy and informed decision-making
• [11:01] – Breaking free from the insurance model and reclaiming patient-centered care
• [12:04] – Regenerative medicine: exciting but misunderstood
• [12:29] – Why surgical and conservative failures often stem from the same issue
• [13:04] – Ask yourself: What is the real goal of treatment? What opportunity is it creating?

Thank you for spending your time with me on the Talking Rehab Podcast. My goal is to challenge how we all think about rehab—not just fixing problems, but truly empowering movement and health.

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Transcript

0:00

What is rehab or rehabilitation? My name is Fred Begaris, a board-certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge dogma, and share my experiences in musculoskeletal medicine. Welcome to the Talking Rehab Podcast. I had a patient recently that presented with knee pain related to a meniscus tear. This was a kind of a slip and fall situation. They injured their knee. They came in with a very classic meniscus tear presentation. MRI supports the diagnosis, but their main symptoms are pain and also instability of the knee. This is their first kind of major injury. Fairly young person. Sounds like it was like a freak accident. This is their first real injury. And I started to discuss the treatment options when it comes to acute meniscus tears. Meniscus tears are fairly common. They can happen related to something in particular, like a slip or a fall or trauma, but they can also just happen with time. And a large majority of meniscus tears are managed non-surgically. That means rest, physical therapy, sometimes an over-the-counter medication, injections, and time, plus even surgery. So these are all the basic treatment options. And a majority of meniscus tears or injuries, whether acute or degenerative, are managed non-surgically. So in this particular case, as I'm going through the treatment options, the patient at the very end says, well, does any of these options actually, quote unquote, fix the meniscus? And the answer for the conservative treatment options is no. It doesn't actually fix the meniscus. The only way to really fix the meniscus is with a surgery. I think the follow-up question to this is, which part of the problem is surgery actually managing? I could tell that this particular person was essentially looking at this problem as a parts problem. There's a tear in the meniscus, so obviously this needs to be repaired in order for the treatment goals to be achieved. So this sparked the topic of today's episode about what is the actual problem and what is the goal and point of treatment? Naturally, no one likes a problem. And if someone was to have a problem, they'd like the easy one. So in medicine, there are what I consider one-and-done conditions, things like endopendicitis, you get an appendectomy. You have cholecystitis or a gallbladder disease, you have a cholecystectomy. You can have your uterus removed, you can have a tubal ligation, and for the most part, the condition is no longer a problem. It's not like you can have appendicitis after the appendix has been removed. So these are the more straightforward, one-and-done conditions that can be treated with a surgery. Now the question I have, is meniscus one of those types of problems? Again, maybe, it might be, but it does lead me to think about, well, what is the goal of a treatment option, whether it's a non-surgical option or a surgical option? From a knee standpoint, the main factors include pain or pain relief, improved range of motion, stability of the knee, those are probably the three factors that are measured when talking about the success of a treatment. Again, this is with time, rest, physical therapy, injections, or surgery. These are the three probably most common measures that anyone would monitor. Those are the main goals. So I take this approach when I think about physical therapy, when I think about injections, because, as I said, there are different ways that meniscus tears can present. Meniscus tears can present acutely or sometimes with time. So the thing that we have to take into account is that degenerative meniscus tears naturally happen with time but don't always develop symptoms. So you can go online, read all over the place that people over the age of 40 who are fairly physically active or even sedentary will have evidence of a meniscus tear. So it is normal for the meniscus to break down. It is also possible for people to have meniscus tears and have no symptoms and have very productive lives, be physically active. It's just one of these things that happens with general wear and tear. So that brings me to the question, if a meniscus is supposed to tear with time, like it's very rare to see an 80-year-old with a completely intact meniscus. If it is supposed to tear, then is fixing the meniscus necessarily the only way that these treatment goals can be achieved? Again, pain relief, improved range of motion, improved stability of the knee. Now, when it comes to chronic pain or musculoskeletal disorders, there's not really a ton of these one-and-done conditions. Now, I know what everyone is going to say is, well, what about a hip replacement? You can't have hip arthritis again. What about knee replacement? You can't have knee arthritis again. And it doesn't work that way because when it comes to the joint replacement, no matter what body part it is, even though the condition, the arthritis is gone, if you don't treat the underlying issues that led to that point, you're going to end up with the same problem. So what are the problems after a joint replacement or potential problems? You can have pain, decreased range of motion, you can have instability. And again, there's no joint to have arthritis, but you can have these features with hardware loosening, but also joint prostheses can break down with just general use and of course, excessive use. So unless you're treating the primary problem, which isn't necessarily a parts problem, you end up in the same place. So if you are someone who has underlying joint arthritis, you're relatively sedentary, you could lose a couple extra pounds, you could go to the gym, you could do something, you develop arthritis, you get an injection into the knee, it gets better just pain-wise, but then the symptoms come back with time. What have you actually accomplished? Same thing goes with, let's say this person has a, goes on to fail all of the conservative treatment options, ends up with a knee replacement and they continue to be sedentary, not be physically active, so on and so forth. The knee replacement is probably, it has a good chance of either having a complication or failing. And even if it doesn't fail, if you, what was the whole purpose of the actual surgery? It was it, for some people it's purely just to decrease the pain. And I guess that's okay, but I think we all have to acknowledge that the goal of any treatment is not just the pain. It's to allow you the opportunity to, to improve overall the quality of your movement. And I think that's where a lot of people fall short is that we tend, we like, we like the quick fix. We like immediate results. And if the knee injection makes the knee pain go away, we tend to essentially just stop there. We don't really see any value or a lot of people don't really see any value in doing more if there's no pain, but the work isn't necessarily done just because the pain has actually improved. Your range of motion still might not be normal. You might still have moments of instability, but more importantly, if you don't take this time to learn how to take care of your knee joint, you've really missed a major opportunity. So it has shifted the way they think of any treatment option that is offered. And again, I've said this on prior episodes, I'm not anti-surgery. I am pro-movement. The goal of surgery is to improve the general quality of life. That's probably the first acute goal, but it should improve the quality of life past the year. Same thing with any injection that I offer or any modality that I offer. If it helps you only for a week or two, that's not really massively changing someone's quality of life. I quickly pivot to look for other treatment options. And so again, it is something that I wrestle with patients about. In the beginning of my career, I really spent a lot of time saying like, hey, you don't necessarily need a meniscus surgery because we have all these other tools to get you there. And at some point I started questioning, well, who am I to say that this isn't what needs to happen next? If I present all the facts and the person wants to do surgery, they are doing a calculated risk. I've done my part. Why not? I started really questioning like, what makes me the end-all be-all to say that this is the next best step for them? It's a different type of thinking. It's hard for me to say because for essentially greater than 90% of my clinical practice, I've been involved in the insurance world, the traditional practice. And a lot of times I've seen patients where I thought that surgery is the next best step, but I knew at the back of my mind that if I didn't go through the conservative treatment stuff, even though that is what is recommended, that the surgery was not going to be approved. Sometimes even just to get a basic MRI, you have to do a certain conservative treatment options, which again, from a book standpoint is the correct answer. But from a clinician and human standpoint, there are just some times that you have to treat what's in front of you, not read off of a page. And I am glad that I pulled away from the insurance model completely because now I started to see the blinders that I had on, the short-sightedness of some of my initial recommendations as a young clinician, but it is a big reason why I am doing this podcast is to be the other voice. I talk with plenty of colleagues and a lot of them say the same stuff that I said 10 years ago, which isn't wrong. But at the same time, it's sad that a lot of people are still saying the same thing or have the same approach. Right now, the hot thing is regenerative medicine, which of course is very exciting. But again, if the person doesn't understand the treatment goals or they fail to seize upon the opportunity that the treatment offers them, it's going to fail. It's a tough thing to say, but it's true. The surgical failures and conservative failures, they fail for the same exact reason a lot of the time, not all the time, but a lot of the time. Even the folks that have a great surgical outcome in terms of they went through without any infections, they finished physical therapy, I end up seeing a lot of them where they continue to have pain or they continue to have symptoms and we're doing the whole song and dance all over again. But again, for this episode, I really wanted to drill down and ask you guys, the listeners, the patients, like what is the goal of the treatment? Is it purely just pain? If it is alleviating your pain symptoms, can we agree that it's giving you an opportunity? And if so, what's the purpose of that opportunity? You have to seize the opportunity in order to achieve the true benefit and the true value of modern day medicine. Thanks again for your time. I hope you enjoyed this one. Thank you for listening to the Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement-filled day. Take care.