Meniscal Tears

WHAT IT IS ?

The medial meniscus is a fibrocartilage semicircular band that spans the knee joint medially, located between the medial condyle of the femur and the medial condyle of the tibia. It is also referred to as the internal semilunar fibrocartilage. The medial meniscus has more of a crescent shape while the lateral meniscus is more circular. The anterior aspects of both menisci are connected by the transverse ligament. It is a common site of injury, especially if the knee is twisted.

Menisci can be torn during innocuous activities such as walking or squatting. They can also be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged ‘wear and tear’ called a degenerative tear.

Tears can lead to pain and/or swelling of the knee joint. Especially acute injuries (typically in younger, more active patients) can lead to displaced tears which can cause mechanical symptoms such as clicking, catching, or locking during motion of the knee joint. The joint will be in pain when in use, but when there is no load, the pain goes away.

A tear of the lateral meniscus can occur as part of the unhappy triad, together with a tear of the anterior cruciate ligament and medial collateral ligament.

SIGNS AND SYMPTOMS :

The common signs and symptoms of a torn meniscus are knee pain and swelling. These are worse when the knee bears more weight (for example, when running). Another typical complaint is joint locking, when the affected person is unable to straighten the leg fully. This can be accompanied by a clicking feeling. Sometimes, a meniscal tear also causes a sensation that the knee gives way.

A person with a torn meniscus can sometimes remember a specific activity during which the injury was sustained. A tear of the meniscus commonly follows a trauma which involves rotation of the knee while it was slightly bent. These maneuvers also exacerbate the pain after the injury; for example, getting out of a car is often reported as painful.

After noting symptoms, a physician can perform clinical tests to determine if the pain is caused by compression and impingement of a torn meniscus. The knee is examined for swelling. In meniscal tears, pressing on the joint line on the affected side typically produces tenderness. The McMurray test involves pressing on the joint line while stressing the meniscus (using flexion–extension movements and varus or valgus stress). Similar tests are the Steinmann test (with the patient sitting) and the Apley grind test (a grinding maneuver while the person lies prone and the knee is bent 90°). Bending the knee (into hyperflexion if tolerable), and especially squatting, is typically a painful maneuver if the meniscus is torn. The range of motion of the joint is often restricted.
The Cooper’s sign is present in over 92% of tears. It is a subjective symptom of pain in the affected knee when turning over in bed at night. Osteoarthritic pain is present with weightbearing, but the meniscal tear causes pain with a twisting motion of the knee as the meniscal fragment gets pinched, and the capsular attachment gets stretched causing the complaint of pain.

INVESTIGATIONS REQUIRED :

X-ray images (normally during weightbearing) can be obtained to rule out other conditions or to see if the patient also has osteoarthritis. The menisci themselves cannot be visualised with plain radiographs. If the diagnosis is not clear from the history and examination, the menisci can be imaged with magnetic resonance imaging (an MRI scan). This technique has replaced previous arthrography, which involved injecting contrast medium into the joint space. In straightforward cases, knee arthroscopy allows quick diagnosis and simultaneous treatment. Recent clinical data shows that MRI and clinical testing are comparable in sensitivity and specificity when looking for a meniscal tear.

Classification

Normal meniscus (a) and several types of meniscus tears (b-e)

A meniscal tear can be classified in various ways: by anatomic location, by proximity to blood supply, etc. Various tear patterns and configurations have been described. These include:

  • Radial tears;
  • Flap or
  • Parrot-beak tears;
  • Peripheral, longitudinal tears;
  • Bucket-handle tears;
  • Horizontal cleavage tears; and
  • Complex, degenerative tears.

These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.

The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:

  • Age/strength
  • Activity level
  • Tear pattern
  • Chronicity of the tear
  • Associated injuries (anterior cruciate ligament injury)
  • Healing potential
TREATMENT POSSIBLE :

Presently, treatments make it possible for quicker recovery. If the tear is not serious, physical therapy, compression, elevation and icing the knee can heal the meniscus. More serious tears may require surgical procedures.

Depending on the location of the tear, a repair may be possible. In the outer third of the meniscus, an adequate blood supply exists and a repair will likely heal. Usually younger patients are more resilient and respond well to this treatment, while older, more sedentary patients do not have a favorable outcome after a repair. “There’s potential harm of the operation, and there’s some data to suggest it might increase progression of the disease and lead to earlier joint replacement.”

REHABILITATION AND RECOVERY :

If the destroyed part of the meniscus was removed, patients can usually start walking using a crutch a day or two after surgery. Although each case is different, patients return to their normal activities on average after a few weeks (2 or 3). Still, completely normal walk will resume gradually and it’s not unusual to take 2–3 months for the recovery to reach a level where a patient will walk totally smoothly.

If the meniscus was repaired the rehabilitation program that follows is a lot more intensive. After the surgery a hinged knee brace is sometimes placed on the patient. This brace allows controlled movement of the knee. The patient is encouraged to walk using crutches from the first day, and most of the times can put partial weight on the knee.
Improving symptoms, restoring function, and preventing further injuries are the main goals when rehabilitating. By the end of rehabilitation, normal range of motion, function of muscles and coordination of the body are restored. Personalized rehabilitation programs are designed considering the patient’s surgery type, location repaired (medial or lateral), simultaneous knee injuries, type of meniscal tear, age of patient, condition of the knee, loss of strength and ROM, and the expectations and motivations of the patient.