Glenn Wellmann DPT

If an MRI shows a torn meniscus in a middle-aged knee, the natural question is whether skipping surgery means paying for it later. A group of Norwegian and Danish researchers followed 140 people for ten years to find out.

The study, briefly

This is the 10-year follow-up of the OMEX trial: Berg B, Roos EM, Englund M, Kise NJ, Engebretsen L, Eftang CN, Risberg MA. “Arthroscopic partial meniscectomy versus exercise therapy for degenerative meniscal tears: 10-year follow-up of the OMEX randomised controlled trial,” British Journal of Sports Medicine 2025;59(2):91 to 98 (doi:10.1136/bjsports-2024-108644, trial registration NCT01002794).

Researchers screened 341 people and randomised 140, splitting them evenly: 70 to arthroscopic partial meniscectomy (the keyhole surgery that trims the torn part of the meniscus) and 70 to exercise therapy. Everyone was between 35 and 60, had knee pain on one side lasting more than 2 months with no specific injury behind it, had an MRI confirmed degenerative tear of the medial meniscus, and had little to no arthritis on X-ray at the start (only 3% were at Kellgren-Lawrence grade 2 or higher). Critically, every participant had been judged eligible for surgery. These were not people talked out of an operation they did not qualify for.

The exercise arm was not vague advice to stay active. It was 12 weeks of progressive neuromuscular and strength training, 2 to 3 sessions a week, with one supervised session. Recruitment ran 2009 to 2012 and the 10-year assessments happened between June 2020 and October 2022. Seventy-eight percent of the original group showed up for the 10-year primary endpoint.

What they found

The headline number is the arthritis one, because that is the fear driving most surgical decisions. The adjusted mean difference in OARSI sum score change (a 0 to 18 X-ray scale combining joint space narrowing and bone spurs) was 0.39 (95% CI -0.19 to 0.97), and it leaned slightly toward the exercise group having less progression, not more.

• New arthritis on X-ray: 23% (13 of 57) in the surgery group versus 20% (10 of 49) in the exercise group. Adjusted risk difference 3% (95% CI -13% to 19%).
• Symptomatic arthritis (X-ray changes plus weekly knee pain): 14% (8 of 56) after surgery versus 10% (5 of 48) after exercise, adjusted risk difference 4% (95% CI -9% to 17%). Two thirds of each group, 66% versus 65%, had neither pain nor X-ray arthritis a decade later.
• How the knee actually felt: the KOOS score difference between groups was -2.4 points (95% CI -7.6 to 2.8), well under any threshold a person would notice. Both groups improved substantially, mostly in the first 2 years, and held those gains for a decade.
• Strength: quadriceps strength showed no meaningful between-group difference, and hamstring strength slightly favoured the exercise group (-0.07 Nm/kg, 95% CI -0.13 to -0.01).

Ten years, two very different treatment paths, and no separation worth talking about.

The catch

Three things temper this. First, dropout was uneven. About 28.6% of the exercise group missed the 10-year X-ray compared with 15.7% of the surgery group, and when the people who skip a follow-up are not random, the picture can shift.

Second, and more important for how you read this: 14 people in the exercise group, 20% of that arm, crossed over and had the surgery before the 2-year mark. Nobody crossed the other way. In an intention-to-treat analysis those crossovers stay in the exercise column, which tends to blur real differences between the two paths. So the honest framing is not “surgery is useless.” It is “starting with exercise, with surgery available if it fails, ended up in the same place as operating first.”

Third, the 10-year follow-up had no pre-planned sample size calculation and was underpowered for the yes or no arthritis outcomes. With 140 people you can rule out a large difference, not a small one. Those wide confidence intervals are telling you exactly that.

What this means for you

Two words carry most of the weight here: degenerative and middle-aged. A degenerative tear is wear and tear, the kind that shows up on MRI without a specific moment of injury. That is a different animal from a traumatic tear in a young athlete who felt a pop while cutting, and this evidence does not transfer to that scenario.

If your tear is the degenerative kind, here is how I would think about it:

1. Ask your clinician directly whether the tear is degenerative or traumatic. If nobody can point to an injury that caused it, you are probably in this study’s population.
2. Give exercise a real trial, not a token one. The OMEX program was 12 weeks, 2 to 3 sessions per week, progressive strength and neuromuscular work, with supervision. Four weeks of quad sets is not the same intervention and should not be judged as if it were.
3. Judge progress on function, not on the MRI. The tear is still on the film either way. What changes is what your knee lets you do.
4. Know that the door stays open. One in five people in the exercise arm chose surgery within 2 years and their long-term results still landed in the same range. Trying exercise first costs you very little optionality.
5. Do not expect either path to prevent arthritis. Roughly one in five knees developed X-ray arthritis over a decade regardless of the choice. Surgery is not an arthritis vaccine.

If a surgical recommendation is already on the table and you want to understand the alternative before you commit, that is exactly what a second opinion consult is for: an hour to review your imaging and your history, and a straight answer about what conservative care would actually involve for you. And if you are further along the arthritis path and a joint replacement is the real conversation, I covered the current evidence on that in what the latest research says about recovering well from knee replacement.

Where to go from here

My bias is toward the option that keeps your options open. For a wear-and-tear meniscus tear in a knee that still looks healthy on X-ray, a well built 12-week program is the low risk starting point, and this trial suggests you are not trading away your next decade to try it. If you want that program built and coached properly rather than handed to you on a printout, reach out and we will start with a real look at the knee.

References

• Berg B, Roos EM, Englund M, Kise NJ, Engebretsen L, Eftang CN, Risberg MA. Arthroscopic partial meniscectomy versus exercise therapy for degenerative meniscal tears: 10-year follow-up of the OMEX randomised controlled trial. British Journal of Sports Medicine 2025;59(2):91 to 98. doi:10.1136/bjsports-2024-108644 (PMID 39326908). https://bjsm.bmj.com/content/59/2/91