Meniscus Injuries Treatment & Management

Rehabilitation Program

Physical Therapy

A home physical therapy program or simple rest with activity modification, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) is the nonoperative management of possible meniscus tears. The physical therapy program goals are to minimize the effusion, normalize gait, normalize pain-free range of motion, prevent muscular atrophy, maintain proprioception, and maintain cardiovascular fitness. Choosing this course of treatment must include consideration of the patient's age, activity level, duration of symptoms, type of meniscus tear, and associated injuries such as ligamentous pathology. A trial of conservative treatment should be attempted in all but the most severe cases, such as a locked knee secondary to a displaced bucket-handle tear.

Medical Issues/Complications

The main complication at this stage of treatment is the absence of healing and failure of symptoms to resolve. The natural history of a short (< 1 cm), vascular, longitudinal tear is often one of healing or resolution of symptoms. Stable tears with minimal displacement, degenerative tears, or partial-thickness tears may become asymptomatic with nonoperative management.^[15]

Most meniscal tears do not heal without intervention. If conservative treatment does not allow the patient to resume desired activities, his or her occupation, or a sport, surgical treatment is considered. Surgical treatment of symptomatic meniscal tears is recommended because untreated tears may increase in size and may abrade articular cartilage, resulting in arthritis (see Treatment, Acute Phase, Surgical Intervention).

Surgical Intervention

If symptoms persist, if the patient cannot risk the delay of a potentially unsuccessful period of observation (eg, elite athletes), or in cases of a locked knee, surgical treatment is indicated.^[16]

The basic principle of meniscus surgery is to save the meniscus.^[17] Tears with a high probability of healing with surgical intervention are repaired. However, most tears are not repairable and resection must be restricted to only the dysfunctional portions, preserving as much normal meniscus as possible.

Surgical options include partial meniscectomy or meniscus repair (and in cases of previous total or subtotal meniscectomy, meniscus transplantation). Arthroscopy, a minimally invasive outpatient procedure with lower morbidity, improved visualization, faster rehabilitation, and better outcomes than open meniscal surgery, is now the standard of care. One study found that arthroscopic pullout repair of a medial meniscus root tear provided better results than partial meniscectomy.^[18]

Partial meniscectomy is the treatment of choice for tears in the avascular portion of the meniscus or complex tears that are not amenable to repair. Torn tissue is removed, and the remaining healthy meniscal tissue is contoured to a stable, balanced peripheral rim.

Meniscus repair is recommended for tears that occur in the vascular region (red zone or red-white zone), are longer than 1 cm, involve greater than 50% of the meniscal thickness, and are unstable to arthroscopic probing. A stable knee is important for successful meniscus repair and healing. Thus, associated ligamentous injuries must be addressed. The most commonly associated ligamentous disruption is complete tear of the ACL, which must be reconstructed to prevent recurrent meniscal tears. Fortunately, the increased blood and growth factors in the knee during meniscal repair combined with cruciate reconstruction significantly improves the outcome of the meniscal repair. In ACL-intact knees with isolated meniscal tears, healing rates are less than those in ACL-reconstructed knees, but they are higher than those in ACL-deficient knees.

The principles of repair include smoothing and abrading the torn edges and bordering synovium to promote bleeding and healing. Likewise, needle trephination of the meniscal body (poking holes to create vascular channels) can be performed.

Meniscus repair fixation techniques are numerous and variable. Fixation can be accomplished with outside-in, inside-out, or all-inside arthroscopic procedures.^{[4, 19, 20, 21]} The outside-in and inside-out methods are usually performed with sutures and require additional incisions. Suture repair can be accomplished with vertical or horizontal stitches. The all-inside method is very popular, and a plethora of commercially available meniscus repair devices are available (eg, biodegradable arrows or darts). Note: A word of caution may be appropriate. Peer-reviewed clinical studies regarding the efficacy of these new devices are lacking. The criterion standard to which these devices must be compared remains the inside-out vertical mattress suture.

A small Korean study by Choi et al investigated whether a difference exists in meniscal healing between inside-out and all-inside suture repairs in conjunction with anterior cruciate ligament reconstruction with hamstring tendon.^[22] Although at a mean follow-up of 35.7 months, the investigators noted no significant difference between the 2 surgical groups in range of motion and meniscal healing, as well as in other parameters measured,^[22] it should be noted that different types of tears were repaired with each technique. All-inside repair was only attempted when the tears were located exclusively in the red-red zone or the ramp area of the meniscus. Whereas the inside-out repair technique was done if the tear extended to the midbody of the meniscus, or if there was a tear in the red-white zone.

Human allograft meniscal transplantation is a relatively new procedure but is being performed increasingly frequently. Specific indications and long-term results have not yet been clearly established. Meniscus transplantation requires further investigation to assess its efficacy in restoring normal meniscus function and preventing arthrosis.

Rehabilitation Program

Physical Therapy

Physical therapy during recovery is directed toward the same goals as those in the acute phase. For partial meniscectomy, patients may return to low-impact or nonimpact workouts such as stationary cycling or straight-leg raising on the first postoperative day and may advance rapidly to preoperative activities. In most patients, this can usually be accomplished without formal physical therapy. However, evidence suggests that the quadriceps remains weaker than that of the contralateral side for up to 12 weeks; therefore, therapy should be initiated if deficits persist.

When a meniscus repair is performed, the rehabilitation is typically more intensive. Many different protocols are described in the literature. Three main issues are considered in the rehabilitation of meniscus repairs: knee motion, weight bearing, and return to sports.^[21] A common protocol is avoidance of weight bearing for 4-6 weeks, with full motion encouraged. A more aggressive approach is promoted by some surgeons. The authors' protocol is to allow full weight bearing with the knee braced and locked in full extension for 6 weeks, while encouraging full motion when the knee is not bearing weight. Note that meniscal rehabilitation must not interfere with concomitant ACL rehabilitation.

Medical Issues/Complications

Reported complication rates for arthroscopic meniscectomy range from 0.5-1.7%, and these can occur intraoperatively or postoperatively. Intraoperative complications include anesthetic problems, articular cartilage damage, vessel or nerve injury, or instrument failure. Postoperative complications include anesthetic concerns, thrombophlebitis, hemarthrosis, infection, stiffness, persistent pain, effusion, or synovitis.

Reported complication rates for meniscus repairs range from 1-30%. The list of complications is the same as that for meniscectomies, with a greater concern for neurovascular injury. Additionally, failure to heal or meniscal reinjury can occur.