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Meniscus Injuries

Meniscus injuries are one of the most common pathologies of the knee. There are two types of meniscal injuries; traumatic and degenerative, meaning that people young and old can get them.

What is the meniscus?

The main knee joint has two articulating surfaces; the femur and the tibia. The tibia is flat whereas the femur has pronounced curves meaning that they do not articulate too well on their own. As a result, the stability relies on two wedge shaped menisci and two cruciate ligaments. The menisci increase surface areas and are useful in distributing the loads transmitted evenly through the knee.

The menisci are fibrocartilagenous structures that have strong fibres running circumferentially to provide strength and prevent longitudinal splitting.

The blood supply is relevant when considering the healing of a meniscal injury- only the peripheral parts of the meniscus receives a blood supply.

Consequently, there has been termed two distinct zones in the meniscus; the red-red zone that is vascularised (with a blood supply) and the white-white zone that is avascular (without a blood supply). Tears located in the white-white zone are unlikely to have any significant healing response (Mordecai et al, 2014).

In the younger population, meniscal injuries are generally related to sports, with injuries commonly sustained while landing and twisting on a slightly bent knee. Small minor tears in the vascularised red zone are able to heal over a short period of time (less than 3 months) (Mordacai 2014).

In the older population, tears can be the result of degeneration and forces placed through the knees.

Presentation

A history of a painful twist on a slightly bent knee is usually a tell-tale sign when considering the likelihood of traumatic meniscal injury and subsequent clunking, popping or locking of the knee joint may be observed. These signs in conjunction with a pain around the joint line of the knee and swelling would warrant further investigation by a physiotherapist.

How do we treat meniscal tears?

Firstly, we need to establish if the tear is stable or unstable. If the knee locks into place or has any painful catching or clunking, then we would classify the knee as unstable and generally referral to an orthopaedic consultant may be recommended.

Historically, there has been some debate over how to treat stable meniscal injuries. There are two options; Surgical intervention or conservative treatment. The best way to solve this debate is through conducting good research.

A study conducted in 2012 compared outcomes of surgical vs conservative over 6 months, 2 years, 5 years (Herrlin et al 2013) and they found that both groups do well and there is no difference between the two groups on their measures. These findings are also backed up by Katz et al (2013) when their study showed no difference in outcomes of their two groups at 6 months.

Another study concluded that degenerative meniscal tears in the medial meniscus responds equally as well to non-operative strengthening compared to a menisectomy (cartilage removal surgery) when responding to a questionnaire 2 years after the input (Yim et al 2013).

Ultimately, there are many variable factors involved with each study, but the message is quite clear- try to rehab the meniscus first.

As discussed, the tears in the perimeter of the meniscus can heal and physiotherapy can optimise the healing process by strengthening and monitoring activity through the different stages of healing, and this should usually take less than 3 months.

Those in the red-white or the white-white areas are potentially not going to heal as well. The structural change to the meniscus will also have an effect on the meniscus ability to absorb shock and distribute forces.

Surgical options

In the recent past surgeons have been quick to take away the parts of the torn meniscus in a procedure called a partial menisectomy. It had been a quick way of resolving the meniscal injury symptoms, but as time has gone on, it appears that the removal of part of the meniscus removes an important part of the knee.

As we have seen in the anatomy section, the menisci serve an important role in the function of the knee. They are load bearing, shock absorbing and stabilising structures. They may also have a role in joint lubrication, nutrition and proprioception (awareness of where your body is). Studies have shown that in many cases, the more of the meniscus that is removed, the chance of developing knee arthritis is increased.

However, this isn’t always the case and there have been studies to find out what predictors are associated with certain outcomes. For example pre-existing degenerative changes to the articular surfaces means that outcomes are likely to be less favourable after a menisectomy…

Generally speaking, good predictors are being aged younger than 40 years, symptoms present for less than 1 year, no patella symptoms and no other structural defects.

(Mordacai, 2014)

Scans

Another interesting point is that meniscal tears can be pain free and if it is shown on a scan it is not necessarily the source of the pain. In 2003 a study was conducted where 100 patients suspected of having a meniscal tear had MRI scans. 57 patients has meniscal tears related to the same symptomatic knee and 36 meniscal tears were found in non-symptomatic knees. Their conclusion was that horizontal and oblique tears are often found in symptomatic and asymptomatic knees so they may not be related to the knee pain.

Knee pain can be from a combination of abnormalities of the collateral ligaments and so soft tissue structures around the knee joint, which are rarely seen in asymptomatic knees. (Zanetti et al, 2003). Incidental findings are more often seen as we age (Englund et al, 2008).

In conclusion, if you find you have a suspected meniscal tear, get it checked by a physio or another trained healthcare professional. We can help to diagnose if the tear is stable or unstable and provide specific recommendations on the best way to manage your issues based upon your presentation.

Conservative management (including physiotherapeutic exercises) are generally recommended for up to three months with stable menisucus injuries, with good results expected in most cases.

If expected improvements are not obtained within that period, your physiotherapist will assist with a referral for additional opinions or input as deemed necessary.

If you are suffering from a knee injury and would like a professional opinion, please contact us on 0330 088 7800 to arrange an assessment with one of our therapists.

 

References:

Englund, M., Ali Guermazi, M.D., Daniel Gale, M.D., David J. Hunter, M.B.,B.S., Ph.D., Piran Aliabadi, M.D., Margaret Clancy, M.P.H., and David T. Felson, M.D., M.P.H. (2008) Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. N Engl J Med 2008; 359:1108-1115

Herrlin, S.V., Wange, P.O., Lapidus, G. et al. Knee Surg Sports Traumatol Arthrosc (2013) 21: 358.

Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368:1675-1684

Mordecai, S. C., Al-Hadithy, N., Ware, H. E., & Gupte, C. M. (2014). Treatment of meniscal tears: An evidence based approach. World Journal of Orthopedics, 5(3), 233–241.

Yim JH, Seon JK, Song EK, Choi JI, Kim MC, Lee KB, Seo HY. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus. Am J Sports Med. 2013;41:1565-1570

Zanetti M, Pfirrmann CW, Schmid MR, Romero J, Seifert B, Hodler J. Patients with suspected meniscal tears: prevalence of abnormalities seen on MRI of 100 symptomatic and 100 contralateral asymptomatic knees. AJR Am J Roentgenol 2003;181:635-641

 

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