The Knee Decision: Surgery or Rehab

Most people assume that when your MRI shows a meniscus tear, surgery is the only answer. But here’s the surprising truth: the most common surgery for meniscus tears can actually speed up arthritis.

In this episode, Dr. Fred Bagares unpacks the real decision point: not whether the meniscus is torn, but whether surgery is the right choice for you. Through two real patient stories, the latest research, and practical frameworks, he breaks down the long-term trade-offs between surgery, repair, and structured rehabilitation.

If you’ve ever stared at your MRI report and thought, “When’s my surgery?”—this conversation will change how you see your options.

🕰 Timestamps + Key Themes

[00:00] The Counterintuitive Truth
 Why the most common meniscus surgery may actually accelerate arthritis.

[02:00] The Patient Mindset
 How MRIs and fear drive people to assume surgery is inevitable.

[03:00] Two Case Studies: Mark & Sarah
 Same tear, different choices—how their paths diverged.

[05:00] The Numbers Behind Arthritis Progression
 What studies reveal about meniscectomy, repair, and non-operative care.

[07:00] Recovery Timelines Explained
 Surgery, repair, and rehab—what each path really looks like.

[08:00] Short Runway vs. Long Horizon
 How your goals, timeline, and risk tolerance shape the right choice.

[09:00] The Three Critical Questions
 Mechanical symptoms, real rehab, and your honest timeline.

[10:00] Metaphors That Make It Clear
 Your knee as a house foundation, or a shoe midsole—why mechanics matter.

[11:30] The Reframe: Surgery as a Tool, Not a Default
 When it makes sense—and when it doesn’t.

[13:00] Three Questions for You
 A self-reflection framework to guide your decision.

[14:00] Closing Takeaway
 Don’t let urgency or an MRI dictate your path—clarity comes from asking what outcome you value most.

👉 If this episode challenged the way you think about recovery, hit subscribe and share it with someone facing a knee decision. For same-day clarity on your own MRI or knee pain, visit fredbagares.com.

Transcript

0:00

Did you know that surgery most people get for a torn meniscus is also the one most likely to speed up arthritis? Let me say that again. The fix can actually accelerate the very problem you're trying to avoid. What if the real fork in the road after a meniscus tear isn't whether the tissue is torn or not, but whether you decide to have surgery? Think about it. Two people can have nearly identical MRIs, the same tear, same location, and one ends up in an operating room while the other one gets back to running from a non-surgical approach. So why is the decision so complicated and more importantly, why? What do we really know about the long-term trade-offs? That's what we're here exploring today. I'm Dr. Fred Biris, and this is The Talking Rehab Podcast. Quick favor, before we dive in. If this podcast has changed how you think about your body or your recovery, hit that subscribe button. It's free. It takes two seconds, and it's how we keep bringing you these conversations every week. No fluff. Just real talk about what actually works. Thanks for being here. Now let's get into it. Here's the story. Most people tell themselves, my meniscus is torn. Surgery will fix it. It feels logical. Something is broken. We go in, we fix it. That belief is so ingrained that when patients sit across from me, they'll often ask, so when do we schedule the surgery As if it's a foregone conclusion. They walk in with their MRI report. Point to the word meniscus tear and assume that's the end of the conversation. But here's what they don't realize. The meniscus isn't a car part that you simply replace when it wears down. It's living tissue. It absorbs shock, it stabilizes, it distributes load across your knee joint which is what most meniscus surgeries do, you fundamentally change the mechanics of the entire joint. And here's the kicker. The fix can sometimes accelerate. The very problem you're trying to avoid arthritis, but most people never hear that part of the story. Let me introduce you to two patients. Mark and Sarah both came to me with nearly identical meniscus tears. Both are very active and anxious to get back to their sports, but their stories ended very differently. Mark is 46 and plays pickup basketball on the weekends. Still pretty quick on his feet, but one wrong step and he hears a pop. The knee swells up, it locks for a moment, and eventually he had an MRI, which shows he has a lateral meniscus tear. Mark walks in with one question, how soon can we fix this? And can I get back on the court? He assumes that surgery is the only way back, but when we look deeper, things get a little complicated. His tear isn't a clean bucket handle tear. It's actually a degenerative tear, which is mixed in with some early cartilage thinning surgery could help his short term pain, but long term, the numbers tell a different story. Sarah is a 52-year-old runner she does five milers on the weekend, local 5K throughout the year, felt a pop, swollen knee, and diagnosed with a meniscus tear. But Sarah asked a different question, what are my options and what happens in five years? This changes the way we approached everything so here's what happened. Mark chose surgery and Sarah chose a structured rehabilitation program. Both of them are doing very, very well. Mark felt better faster and was able to get back to the court in about six to eight weeks. Sarah's recovery took four months of consistent physical therapy, strength training, and also patience. But two years later, Mark's dealing with a little bit of stiffness in the knee. Sarah just finished her third marathon Pain-free, same problem, two different decisions, both very happy So why do most people default to surgery? Part of it is the MRI. When you see the word tear on an MRI report, your brain screams something's broken. And when something's broken, the natural instinct is to fix it. Another part is fear. Fear of missing out on work, being benched from sports, fear of living with a that just doesn't feel right. Surgery offers the illusion of certainty, even though it is very effective, it feels like action. After a lateral menisectomy, that's when they remove part of the tor meniscus. The progression of arthritis accelerates dramatically. One study found that the rate of joint space narrowing was 27 times faster in the first 12 months after menisectomy compared to non-operative care. That's not a small number. That means that Mark could feel better in the short term, but the cost might be accelerated arthritis and a higher risk of knee replacement down the line. Now compare that to a meniscus repair where they actually stitch the torn tissue back together. Repairs have a much lower arthritis risk than menisectomy at eight to nine years follow up, about 80% of patients had no arthritis progression after repair compared to only 40% after menisectomy. So the risk still isn't zero. Repairs carry about a 10 to 15% arthritis rate long-term versus two to 3% in people who had never had surgery at all. So the spectrum looks like non-operative care carries the lowest arthritis risk meniscus. Repair is the middle ground, and then Menisectomy carries the fastest arthritis risk of progression. And yet, here's the complex part, menisectomy is still the most common procedure. Why? Because the psychology of pain is very powerful. When your knee hurts today, it's hard to worry about arthritis in 10 years when you're told surgery will get you back to normal in six weeks. It's hard to choose four months of rehab instead. But here's what I want you to understand. This isn't just about your knee today. It's about your knee for the next 20 years. Let's talk about what these paths actually mean for your life, because this is another layer. Patients rarely hear in the consult room. With weightbearing is usually immediate. Most patients are walking without crutches in a couple days back to work in a week or two. It's great. It feels quick and reassuring. You're driving within days climbing stairs within week with a meniscus repair. This is where patience is your friend. Depending on the tear, you might be on crutches or restricted weight bearing for two to four weeks. If the tear is simple and peripheral, you might walk sooner. But repairs demand patients, you're looking at three to four months before you're really back to full activity. With non-operative management, meaning anti-inflammatories, and sometimes an injection, there's no surgery at all. Just structured rehabilitation. You're moving right away. But improvement takes consistency over weeks to months. You might feel worse before you feel better, but the trajectory, if you stick with it, can be quite remarkable. So the question becomes. Do you want the short runway or a long horizon? And here's where your goals matter. This is why just reading an MRI report isn't enough. We need to see your knee in real time, understand how you move, what you value, and where you wanna be in five years. Ask yourself, am I willing to trade two weeks on crutches for a healthier knee in 10 years? What do I value more right now? Speed or longevity? If I could guarantee the same outcome with rehab as surgery, but rehab took twice as long, what would I choose your answers to? Those questions matter more than what the MRI shows. When I sit with patients, I don't frame the decision as surgery or not. I frame it as, what tradeoffs are you willing to accept? Because every path does have a cost. Surgery has immediate relief, but carries a long-term risk. Rehabilitation has delayed gratification, but better joint preservation and doing nothing. That definitely has consequences as well. So this is how I work through some of these tough questions. Do you have true mechanical symptoms? I mean real locking where your knee gets stuck and won't straighten. This is where a piece of tissue is mechanically or physically blocking your knee from moving. If you have true mechanical symptoms, surgery often makes sense, but soreness after a basketball stiffness in the morning, these are not true mechanical symptoms. The next question is, have you tried a true course of rehabilitation? Not two weeks of ice and rest, but a dedicated six to 12 weeks of progressive strength training, proprioception, load management, and essentially learning how to use your leg. Again, if you haven't given your body a real chance to adapt and heal, how can you know if surgery is necessary? The third question is, what's your real timeline? If your livelihood depends on getting back in weeks, not months, that changes everything. If you're a professional athlete or your job requires specific physical demands, the risk to benefit ratio shifts. But if you're a weekend warrior playing basketball or occasional tennis. Time might actually be your best ally. This is where a personalized protocol becomes everything. Your choice depends on your goals, your timeline, and your risk tolerance, and that's not something that gets figured out in a rushed seven minute visit. Think of your knee like a house. The meniscus is part of the foundation. It distributes weight, absorbs shock, and keeps everything stable. If a crack forms in your foundation, you don't always call the demolition crew. Sometimes you patch it, sometimes you reinforce it, and additional support beams. Sometimes you work around it and sometimes you do have to call the demolition crew. The point is you don't make the decision just by steering at the crack. You decide based on how you want to live in that house for the next 20 years, or think of it this way. Removing part of your meniscus is like cutting a piece out of your shoes, midsole. The shoe still works. You can still walk, but the cushioning changes forever. Every step hits a little bit harder and the wear pattern does shift, and that change compounds over thousands and thousands of steps. Sometimes that trade off does make sense, but sometimes it doesn't. Here's the reframe I want you to take away. Meniscus surgery is not a default. It's a tool. And like any tool, it works best when used for the right job. For degenerative tears in older patients, data is clear. Physical therapy first, surgery only If mechanical symptoms persist for acute traumatic tears, especially in younger or athletic patients, repair if possible, and resection only if necessary. And for everyone. Remember that arthritis is part of the equation, not just the immediate pain relief. The hardest part isn't the technical decision. It's stepping back from the urgency and fear and asking what outcome do I actually value the most? Because in one visit, you can walk out with a diagnosis of plan and peace of mind, but that requires time, questions, and a real partner in the process, not a rushed consultation where the decision feels predetermined. Before we close, I want to try something. If you're dealing with a meniscus tear or know someone who is, here are three questions to work through. First, write down what getting better actually means to you. Is it no pain? Is it getting back to your sport? Is it climbing stairs without worry? Be specific, not just fix my knee. That's not specific enough. Second, what's your honest timeline? Not what you wish it could be, but what you can realistically commit to. If the answer is four months of consistent rehab, can you actually do that? Or do you think that you're gonna quit after three weeks? The third question, the third framework is what scares you more living with uncertainty about your knee or potentially accelerating arthritis for quicker relief today? There are no wrong answers to these questions. There are honest ones and dishonest ones. There are no wrong answers to these questions if you're standing at the crossroads in hand Question swirling in your head. Don't let the scan make the decision for you. Don't let urgency dictate your path. Instead, ask, what outcome do I value most? What risk am I willing to accept, and how do I make sure this knee carries me? Not just through the next season, but through the next chapter of my life? Ultimately, the choice is yours, but make sure it is an informed one. Thanks again for listening. Have a great day. 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.