Meniscus Tear- A common knee injury

Like many knee injuries, a meniscus tear can be painful and debilitating. Unfortunately, a meniscus tear is a most common cartilage injuries of the knee joint. Get to know the importance of meniscus in our knee and, the available treatment options if you get injured, what are the primary measures to be taken care, and more in detail.

About Meniscus Tear

The meniscus is a piece of cartilage in your knee that cushions and stabilizes the joint. It protects the bones from wear and tear. However, all it takes is a good twist of the knee to tear the meniscus. In some cases, a piece of the torn cartilage breaks loose and catches in the knee joint, causing it to lock up. Moreover, meniscus protects the joint surface and absorbs the shock produced by activities such as walking, jumping and running.^[1]

The meniscus is a crescent-shaped cartilage that sits atop the medial (inner) and lateral (outer) plateaus of the tibia, contacting the rounded femoral (thigh bone) condyles and distributing their weight across a broad surface area.^[1]

The menisci act as shock absorbers and by working as a doorjamb, stabilizing the joint. Our meniscus functions as a cushion to minimize pressure on other cartilage in the knee that we call the articular cartilage. The articular cartilage covers the lower ends of bones in a joint by protecting articular cartilage, meniscus prevents the onset of arthritis. The meniscus also serves to improve the stability of the knee. The meniscus acts as a block stuck behind a tire to prevent a car from rolling. If the meniscus is injured, the stress on the knees is increased, and the joint become unstable.^{[1, 2]}

The meniscus has some of the essential functions in the knee such as:

• shock absorption and distributing load throughout the joint
• increasing stability
• limiting extreme flexion and extension
• providing nutrition for articular cartilage
• stabilize the movements of the knee^[4]

Types of meniscal injuries

There are two types of meniscal injuries:

• Acute tears
• Degenerative tears

Acute tears: This kind of tears usually occurs when someone’s knee is bent or twisted forcefully, during the leg is in a weight bearing position.

Degenerative tears: These types of tears are more common in aged people. 60% of the population over the age of 65 probably has some degenerative tear of the meniscus. As the meniscus ages, it becomes less elastic and weak.

Causes of meniscus tear

Aged people often get meniscus tears because their menisci become less flexible and brittle with age. However, for teens, meniscus tears usually happen because of an injury often after turning or twisting the knee while it is bent, and the foot is firmly planted. This might occur during:

• Sudden changes in direction or stop quickly, in sports such as baseball, football, basketball, tennis, and cricket.
• Direct blow to the knee joint while playing a sport such as hockey, football, cricket, rugby or where the knee joint may be forced to twist or rotate awkwardly.
• Falling in a way that puts much strain on the knee during a fall as can happen in sports such as skiing or snowboarding.
• Lifting heavy objects^[1]

Symptoms of meniscal tears

Torn meniscus symptoms may vary depending on the severity of the tears. Someone who gets a minor tear may only have acute pain and swelling that goes away after two or three weeks.

• The patient hears a “pop” sound in the knee when the tear occurs
• Pain in the side or center of the knee joint, especially when squatting or twisting the knee joint.
• Stiffness and swelling in the knee that gets worse over the first two or three days after the injury occur
• The knee feeling as if it is popping or locking when bending; it might not straighten
• Joint range of motion is limited
• knee joint feels like it is giving way without warning^{[1, 3]}

Difference between medial and lateral meniscus

The medial meniscus, semi-circular fibrocartilage band is located on the inside of the knee, between medial condyle of femur and tibia. The medial meniscus is commonly injured because it is firmly attached to the medial collateral ligament and joint capsule.

The lateral meniscus is circular in shape. Moreover, attached outside (lateral) in between lateral condyle of femur and tibia. It is more mobile than the medial meniscus as there is no attachment to the lateral collateral ligament or joint capsule. ^[3]

Diagnosis

• X-rays are not much use, however, may help in diagnosing another follow-up.
• MRI scans can detect meniscal tears and can also delineate the type of tear and thereby help in treatment.
• Physical examination it is relatively reliable and significant tool for the detection of a meniscus. With a symptomatic meniscus tear, you will likely have:

1. Knee joint swelling
2. Tenderness along the joint line when the doctor presses on the meniscus (palpation)
3. Also, loading the knee with specific maneuvers or a squat causes pain in the compartment with the meniscus tear.

Once the diagnosis of a meniscal tear is made, you should discuss treatment options with a doctor or take medical opinion from an orthopedic surgeon. In most patients who have a symptomatic meniscal tear, arthroscopic surgery is selected to remove or repair the torn tissue.^[4]

Meniscal tears types

The meniscus tear can occur in one or more directions.

• Traumatic lacerations are usually vertical.
• Degenerative tears are commonly horizontal.
• Bucket handle tear refers to when inner rim of the medial meniscus suffers a tear.
• In some cases, the meniscus is crushed and resembles crab meat tear.

Treatment

Non-operative treatment

Non-operative treatments are an essential part of the management of all patients, regardless of whether surgery is considered. Immediate conservative measures include the RICE protocol:

• Rest
• Ice
• Compression bandaging
• Elevation of the affected limb to minimize acute swelling and inflammation.

Long term measures include activity modification, non-steroidal anti-inflammatory drugs (NSAIDs) and physiotherapy. Non-steroidal anti-inflammatory drugs often recommended for 8–12 weeks, although paracetamol can be considered if NSAIDs are contraindicated or poorly tolerated. Where available, intensive physical therapy is very useful and should include a range of motion, strengthening exercises, proprioceptive work.^{[1, 5]}

Tynor Hot and Cold Pack

Non-operative treatments are often successful in patients with certain types of meniscal tear  such as;

• Patients who have no loss of joint function
• Suffer minimal pain or swelling
• Patients who are willing to reduce their activities – temporarily or in the long term.

Knee Wrap (Neoprene)

To avoid future occurrence of meniscus tears, activity modification is necessary; for example, ceasing sports such as soccer or cricket. Patients are often aware of movements during activities that aggravate pain, but should also be conscious of avoid twisting on a weight-bearing, flexed knee.^[5]

Surgical management

If the non-surgical management fails to relieve the symptoms, your specialist may suggest arthroscopic knee surgery.

Knee arthroscopic surgery is most commonly performed surgical procedures. In this, a miniature camera is inserted through a small incision. This offers a clear view of the inside of the knee. The orthopedic surgeon inserts miniature surgical instruments through other portals cut or repairs the break.^[1]

Partial meniscectomy: In this surgery, the damaged meniscus tissue is trimmed (cut) away.

Meniscus repair:  Some meniscus tears can be repaired by suturing (stitching) the torn pieces together. Whether a tear can successfully be treated with repair depends upon the condition of the injured meniscus, as well as the size, and type of tear. Because the meniscus must heal back together, the recovery time for a repair is much longer than from a meniscectomy. ^{[3, 5]}

Meniscal transplant surgery: When your meniscus is severely damaged, it may lead to the articular cartilage protecting your knee joint begin to wear. As this articular cartilage wears away, it becomes rough and degenerated. Moving the joint along this exposed surface is painful. This condition is osteoarthritis.

In this condition, meniscal transplant surgery (allograft) is done to replace the meniscus cushion before the articular cartilage is damaged. It helps in

• Supporting and stabilizing the knee joint
• Relieving the knee pain
• Delaying the development of arthritis

Allograft: Healthy cartilage tissue is taken from a cadaver (human donor). This tissue is called an allograft. ^[5]

Complications after meniscectomy

Meniscectomy is well tolerated and does not usually cause complications. This document does not provide a complete list of the possible complications, but it does highlight some of the most common problems following meniscal surgery are:

• Infection
• Anesthesia complications
• Thrombophlebitis
• Suture anchor problems
• Graft failure
• Slow recovery
• Ongoing pain^[5]

Recovery after surgery

Recovery from an operation varies for different people and different clinical problems: If the meniscus has been repaired, weight bearing may be limited to the use of crutches for four to six weeks. This time period allows the repaired meniscus to heal. If we compare with open surgery, arthroscopic surgery causes limited scarring, has a quicker recovery time, and allows a more rapid return to work or sports.

Patients who have a torn meniscus trimmed or removed can expect to use crutches or a walker for four to seven days. They may have some swelling for three to six weeks and can return to their normal activities in four to six weeks, if not sooner.[1]

Rehabilitation: After the surgery, the doctor may put the knee in a brace or cast to keep it from moving. If you have had a meniscus repair surgery, you need to use crutches for about a month to maintain the weight off of your knee.

Tynor Walker Invalid’s Reciprocating – All Pods – AL

Once the initial healing is complete, the doctor prescribes some of the exercises. Regular exercise to restore mobility and strength of your knee joint. You start with exercises to improve your range of motion. Strengthening exercises gradually added to your rehabilitation plan.

The rehab program can be carried out at home, although your doctor may recommend physiotherapy. Rehab time for a meniscus repair is about three months. A meniscectomy requires less time for healing — approximately 3 to 4 weeks.^[1,2]

Post-operative physiotherapy

For most of the tears, some simple exercises can help to maintain the strength of the quadriceps, hamstrings, calf and hip muscles. All these areas are important to your overall leg function after surgery. Exercises should only be done on the advice of your physiotherapist and only if you feel slight or no pain while you do them at home.

Exercises such as:

• Quad sets
• Straight leg raise to the front
• Straight leg raise to the back
• Hamstring curls
• Heel raises
• Heel dig bridging
• Shallow standing knee bends

Tips to prevent meniscal tears

You can prevent meniscal tears by performing exercises to strengthen your leg muscles. This will help stabilize your knee joint to protect it from damage.

Use protective gear such as braces to support the knee during activities that may increase your risk of injury.

Always use proper form when exercising or participate in activities that may put pressure on the knee joint. It is a good idea:

• Warm up and stretch before exercise
• Use proper gear, such as sports shoes designed specifically for your activity
• Lace up your shoes properly
• Learn the proper techniques those who participate in sports^[2]

Key points

• Meniscal injury is common, and the medial meniscus (inner) is more commonly injured or tend to tear.
• Young and elderly patients typically sustain different types of tears.
• Proper diagnosis and management are essential to prevent long-term squeal.
• The Thessaly test is the specific clinical test to diagnose the meniscal injury.
• Magnetic resonance imaging (MRI) is the first line for investigating potential meniscal lesions, but should not replace thorough clinical history and examination.
• Conservative management is necessary for all patients with acute rest, intensive rehabilitation with physiotherapy and modification of activity. Referral to an orthopedic surgeon is important if the diagnosis is uncertain or there is a minimal improvement in the clinical review.

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References

1. MENISCUS INJURIES OF THE KNEE IN THE ELDERLY, EICHENHOLTZ, SIDNEY N.; JACOBS, BERNARD; PATTERSON, ROBERT L.Journal of American Geriatrics Society, Volume 16 (3) – Mar 1, 1968
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095015/
3. MR Imaging–based Diagnosis and Classification of MeniscalTears Nguyen, Jie C.; De Smet, Arthur A.; Graf, Ben K.; Rosas, Humberto G.Radiographics, Volume 34 (4) – Jul 1, 2014
4. http://www.ncbi.nlm.nih.gov/pubmed/22472678
5. http://bjsm.bmj.com/content/34/4/252.full

Dr Kaleem Mohd

Dr. Kaleem Mohammed graduated as a Bachelor of Physiotherapy in 2014 from Deccan College of Physiotherapy, affiliated to Dr. N.T.R. University of Health Sciences, Vijayawada, India. Dr. Kaleem is an expert at handling physiotherapy needs of patients suffering from orthopedic and spinal conditions and post-surgery rehabilitation. Dr. Kaleem is associated with HealthClues since its inception where he facilitates diagnosis and advanced consultation with senior doctors. He is also a medical researcher and prolific writer who loves sharing insightful commentaries and useful tips to educate the patient community about fitness, treatment options, and post-treatment recovery.