Meniscal Lesions

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Definition/Description

A meniscus rupture is an injury that occurs when pieces of the meniscal cartilage are ruptured and when those pieces were injured by specific movements that rotate the knee with a lot of force, while the foot doesn’t rotate and is firmly planted on the floor. Meniscus injuries are often seen in athletes as a result of a sports injury and represent approximately 15 % of all cases sports injuries. There are partial or total ruptures of a lateral or medial meniscus. Medial tears are reported more commonly than lateral tears. In addition to tears occurring in sports, osteoarthritis can also lead to a spontaneous meniscal tear through breakdown and weakening of the meniscal structure. Possible risk factors for meniscal tears are sports, older age, male sex, and pre-existing pathologies such as osteoarthritis.

Clinically Relevant Anatomy

The clinical relevant anatomy is already described in Arthroscopic Meniscectomy and meniscus lesions.

Epidemiology /Etiology

A meniscus injury is generally caused by a torsional movement between the femur and the tibia under load without contact, or making an abrupt movement like a squat. Anything which allows the femur to slip too much forward or backward in relation to the tibia may cause some of the forces to be transmitted to the meniscus and result in a meniscus rupture.

Characteristics/Clinical Presentation

• Joint line tenderness, Mc Murray test, Thessaly test and squat test
• Symptoms are popping sound and intermittent residual pain.
• Occurs mostly in aged population. The age of onset is mostly over 50 years of age.
• Hyper-flexion of the knee for a long period of time under weight-bearing lead to excessive pressure.
• Medial meniscus resists more pressure during weight bearing than the lateral meniscus and therefore it is more likely that tears occurs on the     medial menisci. 

Differential Diagnosis

An examination of the knee and possible arthroscopy provides a clear classification of meniscus injuries. The size and severity of the meniscus rupture are often indicative for the recovery after surgery and for eventual later degenerative phenomena in the knee joint.
Different kinds of meniscus ruptures:
- Radial rupture
- Oblique rupture
- Longitudinal rupture
- Bucket handle
- Horizontal rupture
- Complex rupture

Medial tears are reported more commonly than lateral tears and are classified according to the ISAKOS (International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine) Meniscal Documentation Committee as longitudinal-vertical, horizontal, radial, vertical flap, horizontal flap, or complex. Vertical tears may result in locked and detached fragments, while horizontal tears result in superior and inferior flaps.Horizontal tears can produce fragments that become inverted and subsequently “trapped” between the medial aspect of the tibial plateau and the deep fibers of the medial collateral ligament (MCL). This particular type of medial meniscal tear may be more difficult to recognize during arthroscopy, and if missed, results in ongoing knee pain postsurgery.

Diagnostic Procedures

Routine tests during physical examination can be used to detect meniscal injury, including joint line tenderness, Apley compression test, Thessaly test and the McMurray test.
When a meniscus rupture is suspected, a magnetic resonance imaging (MRI) is considered as the best medical imaging modality to confirm a meniscus rupture. This is necessary when the clinical trial and the anamnese aren’t specific enough.
The clinical diagnosis of meniscal tears has been found to be more accurate when combinations of tests are used. Some test have low diagnostic accuracy when preformed in isolation. By combining these test ware able to lift sensitivity and specificity.

During clinical trials, it’s important to pay attention to some specific data:
- Swelling, hydrops at the level of the knee
- Muscle atrophy
- Painful palpation zones, especially at the level of the joint space
- Limited mobility
- Positive McMurray – test

In the clinical setting, provocative maneuvers that cause compression of meniscal fragments between the tibia and femur will often lead to pain. Thus, pain with varus stress may suggest medial meniscal injury. This concept is supported by maneuvers such as the Payr and Bohler tests, in the former maneuver, the patient sits cross-legged placing a stress on the medial meniscus, and in the latter, a simple varus and valgus stress elicits pain with compression of the meniscus. It is further suggested through more modern tests in which weightbearing is incorporated into rotatory movements, such as in the Thessaly test. However, when the meniscal fragment is flipped and interposed between the deep fibers of the MCL and the tibia, valgus stress will lead to compression of the fragment between these structures and medial pain.

Outcome Measures

WOMET – Western Ontario Meniscal Evaluation Tool 
NRS – Numeric Rating Scale for pain
VAS pain – Visual Analogue Scale for pain
KOS – Knee outcome survey
KOOS – Knee injury and osteoarthritis outcome score 
IKDC – Internation Knee Documentation Committee

See Outcome Measures Database

Examination

For the medial meniscus: provocative maneuvers that cause compression of meniscal fragments between the tibia and femur will often lead to pain. Thus, pain with varus stress may suggest medial meniscal injury.
This can be tested , on the basis of various tests , such as the
the Payr test where the patient sits cross-legged placing a stress on the medial meniscus and the Bohler test where a simple varus and valgus stress elicits pain with compression of the meniscus. More modern tests, such as in the Thessaly test, where weightbearing is incorporated into rotatory movements, are also used for finding this injury. A positive sign of a trapped medial meniscus tear, is when the pain is localized to the point where the fragment is interposed just inferior to the joint line.
Magnetic resonance imaging (MRI) and subsequent arthroscopy can also be used for early detection of a meniscus rupture.
For the lateral meniscus: the patient can be tender over the posterolateral joint line. A McMurray will be positive for lateral pain, but with no “pop”. Although MRI is considered the gold standard for diagnosing meniscal pathology, but ultrasonography was two times more likely than MRI to correctly determine the presence or absence of meniscal pathology. 

Medical Management

Nonoperative treatment is rarely recommended for meniscal injuries. Sometimes it’s possible when there is a peripheral tear in the red-red junction. Then is healing possible without surgery because of the adequate vascularisation.
The nonoperative treatment consist of rest, ice, compression, elevation, nonsteroidal anti –inflammatory drugs, stretching and strengthening and various physical therapy modalities.

Operative:

Arthroscopy is a small surgery. They look through a thin tube into the knee joint. The procedure can be performed to obtain information of the knee joint. In many cases, there can during the arthroscopy immediate a treatment be given. It’s possible that a larger operation is necessary. You can find more information about arthroscopy at the page Arthroscopic Meniscectomy.

Certain meniscal tears like the bucket –handle rupture require operative treatment to prevent worsening of the rupture, to minimize additional damage to the torn portion of the meniscus and to optimize healing.
There are different kinds of operative treatment for meniscal tears as repair and partial resection.
If a rupture can’t be treated and it involves a large portion of the meniscus, or when repair failed, a significant portion of the meniscus must sometimes be removed. To avoid secondary osteoarthritis and reducing pain, meniscal transplantation may be the best solution. 
Meniscal allograft transplantation (MAT) is now considered an effective method of biologically reconstructing symptomatic, meniscectomized knees. 

Physical Therapy Management

The physical therapy consists mainly of RICE (Rest, Ice, Compression, Elevation) when surgery isn’t necessary.
RICE is very important in the first 24 hours after an acute soft tissue injury. Especially when there are damaged blood vessels. It helps to reduce pain and swelling.

Cryotherapy, also known as ice application, is a method in which the body is contacted with a medium with a lower temperature. Applying a cold source would decrease the temperature of the tissues. It causes superficial vasoconstriction and a decrease of the local blood flow. How long, how often? This is the point where few people agree. The most common recommendation is to apply ice for 20 minutes every 2 hours for the first 48 to 72 hours. You must take into account that some people are more sensitive to cold than others are.

Strengthening and stretch exercises for quadriceps and hamstrings are also important when surgery isn’t necessary. 
If surgery is necessary there are two options: a meniscus repair; or a meniscectomy.
After surgery, expect to be on crutches for at least three weeks. Full recovery, using a comprehensive rehabilitation program will generally take about three to four months and athletes involved in high demand sports can be back on the field in about six to eight months.

The rehabilitation of a meniscus rupture after surgery depends on the size of the operation.
Each operation and each person are different.
Therefore it’s so important that the physiotherapist makes every time a complete new rehabilitation program. It is proven that free rehabilitation after meniscus repair is safe and does entail increased failure rates compared with restricted rehabilitation.

1. The method of advancing strength depends on the timing of the rehabilitation program but also on the patient response, availability of equipment and the rehabilitation clinician’s preference.  
     - Strength exercises:

Isometric exercises for strengthening the quadriceps:
             • Quad set: With patient supine, uninvolved knee flexed and involved knee straight. The patient tries to push the knee down on the table

             • Straight-leg raise

Isometric exercises for strengthening the hamstrings:
             • Hamstrings sets: The patient supine, uninvolved knee straight and involved knee in partial flexion. The patient

               tries to push the heel into the table.

Non-weight-bearing isotonic exercises:
            • Short-arc quad exercise: also called terminal knee extensions.
            • Full-arc quad exercise
            • Hamstring curls

Weight-bearing resistive exercises: When the patient is able to carry weight on the injured knee.
            • Reciprocal training:  training on a stationary bike. 
            • Platform leg press, wall squats, plié, lunge, step-up, step-down, lateral step-up,…

2. Balance and agility exercises begin with double-support weight-bearing activities and progress to single-limb static balancing on a stable surface.

3. Flexibility exercises and joint mobilization are techniques who improve the range of motion and the flexibility. 

   - Flexibility exercises:
These exercises can be active or passive. The techniques who are used, depend on the type of tissue.
Prolonged extension stretch is used to increase knee extension. This exercise can be performed in two positions, prone or long sitting. Prolonged flexion stretch is an exercise for increasing flexion in the knee. The position used for this exercise depends on how the flexion movement is present.
Active stretches for quadriceps and hamstrings are also important.

   - Joint mobilization:
Reduced joint mobility could be the result of injury, edema, surgery and immobilization. If this develops it can refer pain to the knee and even effect ankle mobility.
Joint mobilization is important for following joints:
          • Superior Tibiofibular joint
          • Patellofemoral joint. Patellar mobility is necessary for full flexion- extension motion for the knee.
          • Tibiofemoral joint. It’s the most often mobilized joint to improve range of motion in the knee.

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Clinical Bottom Line

Meniscus injuries are often seen in athletes as a result of a sports injury and represent approximately 15 % of all cases sports injuries. There are partial or total ruptures of a lateral or medial meniscus. Medial tears are reported more commonly than lateral tears. In addition to tears occurring in sports, osteoarthritis can also lead to a spontaneous meniscal tear through breakdown and weakening of the meniscal structure. Possible risk factors for meniscal tears are sports, older age, male sex, and pre-existing pathologies such as osteoarthritis.
A problem of a meniscus can be solved in 2 ways. Surgically and not surgically. Not surgically, is rare, is mainly based on the rice principle followed by stretch and strength exercises for quadriceps and hamstrings. Surgically, there are 2types: Meniscus repair if the area is highly vascular and meniscectomy if the part of the meniscus has no blood supply.
Each operation and each person are different. The rehabilitation will depend on the physical therapist and the specific patient. General program: strength training quadriceps and hamstrings, balance and agility exercises, flexibility exercises and joint mobilization.

Recent Related Research (from Pubmed)

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