Meniscus Tears: Moving on From Meniscal Injury

Meniscus Tears: Moving on From Meniscal Injury

Decades ago, the menisci were thought to be functionless structures, but with several advancements in technology, they are shown to be important structures in regard to overall knee function. Meniscus tears are one of the most common orthopedic injuries, affecting about 16% of the population. Although meniscus tears can affect anyone, some populations are at higher risk, such as men, athletes, patients with higher bmi, and certain occupations, including those in which squatting, climbing, and lifting heavy objects are necessary.

Let us first review the basic anatomy and biomechanics of the knee to better understand the role of the meniscus. The menisci are two semilunar wedges of fibrocartilage between the femur or thigh bone and the tibia or shin bone. You have one located on the inside of the knee called the medial meniscus, and one on the outside of the knee called the lateral meniscus. Looking down at the shin bone, the medial meniscus resembles the letter C, and the lateral meniscus resembles the letter O. The menisci cover approximately half of the knee portion of the shin bone.

The menisci are comprised mostly of water, followed by collagen and protein. Collagen is responsible for the tensile strength, and as you can see, the menisci appear triangular or wedge-like in shape. They are thick and convex in the outer periphery, thinning out to a free inner edge. The menisci increase stability for articulation or connection of the thigh and shin bones. They also distribute axial load, absorb shock, and provide lubrication and nutrition to the knee joint.

All populations are subject to meniscal tears when there is an external force causing the knee to twist. Meniscal tears can occur from trauma such as sports-related, which are called acute. They can also occur over time, which are called chronic or degenerative tears. Patients with arthritis are also more susceptible to degenerative-type meniscus tears. There are 5 types of meniscus tears, including radial or perpendicular to the shin bone, horizontal and vertical, longitudinal or parallel to the shin bone, oblique, and complex, which includes bucket–handle–type tears.

Presentation of symptoms can vary depending on the injury mechanism, location and type of tear and other concomitant knee injuries. Classic symptoms include joint line tenderness with palpation and activities such as walking and squatting. This pain can be generalized or point-specific. Patients with degenerative or chronic tears will complain of more achiness after activity and some swelling. Those patients with acute injuries might complain of large amounts of swelling and mechanical symptoms such as locking and catching.

Initially, most patients self-treat their pain with the RICE method and medications. RICE stands for rest, ice, compression, and elevation. Oral medications such as Tylenol and NSAIDs, including Aleve or ibuprofen can be added for swelling and pain control. These medications can be found over-the-counter or prescribed if symptoms persist or increase. Seeking care from a health care professional such as a physician, physician assistant or nurse practitioner is recommended.

First, the health care professional will obtain a detailed history of injury mechanism, symptoms, and prior health history and medications. Next, the health care professional will do a thorough exam, including palpation of the knee joint and specific maneuvers, testing for a meniscus tear and other associated injuries. These tests may elicit pain but direct the health care professional to a possible diagnosis. Although a radiograph, or X-ray for short, will not show soft-tissue injuries such as a meniscus tear, the healthcare professional will likely order them.

X-rays will show other important pathologies, such as fractures and osteoarthritis, both of which are used to decide on proper treatment options. Advanced imaging, such as an MRI may be ordered to further evaluate the knee structures, including the meniscus and ligaments. The menisci are small triangular structures, and injury to the meniscus would show as an abnormal shape and/or increased signal or white on the image.

Once a meniscus tear is diagnosed, further discussion between the patient and health care professional will help guide the best treatment options. These options are dictated by several factors, including patient age, complexity of tear, tissue quality, severity of symptoms, acute versus chronic injury, and surgical risk of the patient. This discussion will include conservative and/or surgical treatment options.

Conservative treatment may be the preferred option for smaller tears, patients with advanced arthritis and patients unable to undergo surgery. Although these measures cannot heal the torn meniscus, symptoms can be significantly reduced with implementation. Typical treatment will include one or more of the following: physical therapy, injections, over-the-counter or prescribed medications, and rest or activity modifications.

If surgery is the treatment option of choice, it will likely be done at in outpatient setting via arthroscopy. Arthroscopic surgery is a minimally invasive procedure in which the joint is examined and treated by inserting a camera and tools into the knee through small incisions made in the skin. This picture illustrates the use of the Arthrex NanoScope system. The surgeon will make the decision to either repair or resect the torn meniscus.

The decision to repair or resect the meniscus is determined by several factors, including chronicity, age of the patient, other issues present, such as arthritis, pattern and location of the tear. Only certain parts of the meniscus receive good blood supply, therefore, the decision to repair may be limited due to healing purposes. If the choice is to resect the tear, the surgeon uses one hand to hold the arthroscope and the other for tools such as a cartilage shaver or biter.

The torn portion of the meniscus is resected, as demonstrated in this video animation. Typically, the surgeon removes only the torn portion, leaving as much viable meniscus as possible. Contrary, this video animation highlights an Arthrex meniscal repair device called the FiberStitch implant. As you can see, sutures are placed around the vertical tear to approximate the edges, facilitating healing.

Postoperative care can vary depending on surgeon preference. Most likely the surgeon will encourage the use of an assistive device like a walker, crutches, and possibly a brace. The time of use will depend on the type of surgery performed. Other measures encouraged include medications, compression, ice, elevation, activity modifications, and physical therapy.

Physical therapy is not only important for regaining strength and range of motion postoperatively, but aids in the ability to return to sports, recreational, exercise, or the next adventure. It is beneficial to continue the exercises even after being fully discharged from care to maintain strength and flexibility, which can help prevent future injury.

Whether your ideal activity is hiking mountains, learning to play pickleball, or returning to basketball, the goal is the same. Optimal recovery after meniscal injury. Because after all, adventure is waiting.