Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Meniscus Injuries Treatment & Management

  • Author: Bradley S Baker, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Jul 25, 2016
 

Acute Phase

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.[19]

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.[20]

The basic principle of meniscus surgery is to save the meniscus.[21] 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.[22]

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, are root tears, 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.[6, 23, 24, 25] 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, sliding knot sutures with extracapsular anchor fixation).

Over the past decade, there have been multiple laboratory and clinical studies investigating the efficacy and safety of third- and fourth-generation all-inside devices. The current literature on the efficacy of the all-inside technique is best summarized by 3 independent systematic reviews.[26, 27, 28]

In a 2007 systematic review of the all-inside technique, Lozano et al reported a failure rate of 0-43%.[26] There were no significant differences in efficacy noted among the different all-inside devices included in the review.

In a 2012 systematic review that compared the all-inside and outside-in techniques in isolated meniscal tears (eg, without concomitant ACL reconstruction), Grant et al reported the failure rates of the all-inside and outside-in techniques were 19% and 17%, respectively.[27] The final Lysholm and Tegner activity scores were similar between the techniques.

In the same year (2012), Nepple et al provided the most comprehensive systematic review of all meniscal repair techniques to date, in which they pooled outcomes data at greater than 5 years of these procedures, and observed no difference in outcome among the open, outside-in, inside-out, and all-inside techniques.[28] The pooled clinical failure rate of open repair was 23.1%; inside-out, 22.3%; outside-in, 23.9%; and all-inside, 24%.

Prospective, randomized controlled trials are lacking; ultimately, they are necessary to determine the most effective method of surgical repair.

In recent years, meniscal root tears have been investigated as a unique type of meniscal tear that requires special attention. Multiple biochemical studies have shown that the joint contact mechanics of a posterior root tear is almost identical to that of a complete meniscectomy, and that repair restores normal mechanics.[29, 30] The global loss of circumferential hoop tension caused by root tears is believed to be the source of the increased joint contact forces observed in affected patients. Therefore, there has been an increased focus to surgically repair root tears more aggressively.

Surgical repair of root tears, however, poses a unique challenge in that the meniscus must be repaired to bone. The root is fixed to bone by either arthroscopically-assisted bone suture anchors (all-inside technique) or an intraosseous suture technique ("pullout technique").[31, 32, 33, 34, 35]

In a study comparing the results of the pullout technique with partial meniscectomy, investigators showed that repair improved functional outcomes and decreased progression of arthritic changes.[36] A separate study that compared the results of the all-inside and pullout techniques showed no difference in function or repair characteristics between the 2 techniques[37] : Complete structural healing was observed in 86% of patients who underwent the all-inside technique and 65% of those who underwent the pullout technique (P >0.05). In another study, investigators assessed the results of the all-inside repair and reported significant improvement in the amount of sagittal extrusion; however, improvement of coronal extrusion was not observed.[38]

Future prospective, randomized controlled trials are needed to compare the effectiveness of these techniques with respect to healing rates and prevention of arthritic changes.

A systematic review and meta-analysis found that arthroscopic surgery for patients with degenerative meniscal tears and mild or no osteoarthritis provided no benefit when compared with nonoperative management.[39]

A study by Kise et al that included 140 adults looked to determine if exercise therapy is as effective as arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears. The subjects were randomly assigned to the treatment groups. The study found no differences at 2 years between the exercise therapy group and the arthroscopic surgery group in knee function and found greater muscle strength in the exercise group at 3 months and 12 months.[40, 41]

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.

Next

Recovery Phase

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.[25] 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.

Previous
 
 
Contributor Information and Disclosures
Author

Bradley S Baker, MD Clinical Professor, Department of Orthopedic Surgery and Orthopedic Sports Medicine, Sanford School of Medicine, University of South Dakota; Orthopedic Consultant/Team Physician, Sanford Sports Medicine

Bradley S Baker, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Mid-America Orthopaedic Association, Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Coauthor(s)

James H Lubowitz, MD Director, Taos Orthopaedic Institute, Taos Orthopaedic Institute Research Foundation (TOIRF), and Taos Orthopaedic Institute Sports Medicine Fellowship Training Program; Clinical Professor, Department of Orthopaedic Surgery, University of New Mexico School of Medicine

James H Lubowitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America

Disclosure: Received consulting fee from Arthrex for consulting; Received salary from AANA for employment; Received royalty from Arthrex for other.

Bryce T Wolf, MD Sports Medicine Fellow, Taos Orthopedic Institute

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Leslie Milne, MD Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine

Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine

Disclosure: Nothing to disclose.

References
  1. Costa CR, Morrison WB, Carrino JA. Medial meniscus extrusion on knee MRI: is extent associated with severity of degeneration or type of tear?. AJR Am J Roentgenol. 2004 Jul. 183(1):17-23. [Medline].

  2. Bland-Sutton J. Ligaments: Their Nature and Morphology. 2nd ed. London, UK: HK Lewis; 1887.

  3. Fairbanks TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948. 30:664-70. [Full Text].

  4. Bin SI, Kim JM, Shin SJ. Radial tears of the posterior horn of the medial meniscus. Arthroscopy. 2004 Apr. 20(4):373-8. [Medline].

  5. Arendt EA, ed. Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999.

  6. Insall JN, Scott WN, eds. Surgery of the Knee. 3rd ed. Philadelphia, Pa: WB Saunders Co; 2001.

  7. Rodkey WG. Basic biology of the meniscus and response to injury. Instr Course Lect. 2000. 49:189-93. [Medline].

  8. Fu FH, Harner CD, Vince KG, eds. Knee Surgery. Philadelphia, Pa: Lippincott Williams & Wilkins; 1994.

  9. Arnoczky SP, Warren RF. The microvasculature of the meniscus and its response to injury. An experimental study in the dog. Am J Sports Med. 1983 May-Jun. 11(3):131-41. [Medline].

  10. Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med. 1982 Mar-Apr. 10(2):90-5. [Medline].

  11. Vaziri A, Nayeb-Hashemi H, Singh A, Tafti BA. Influence of meniscectomy and meniscus replacement on the stress distribution in human knee joint. Ann Biomed Eng. 2008 May 22. epub ahead of print. [Medline].

  12. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: radiographic and clinical results with a 2-year follow-up. Arthroscopy. 2009 Sep. 25(9):951-8. [Medline].

  13. Eren OT. The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears. Arthroscopy. 2003 Oct. 19(8):850-4. [Medline].

  14. Behairy NH, Dorgham MA, Khaled SA. Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: comparison with arthroscopy. Int Orthop. 2008 May 28. epub ahead of print. [Medline].

  15. Nikolaou VS, Chronopoulos E, Savvidou C, et al. MRI efficacy in diagnosing internal lesions of the knee: a retrospective analysis. J Trauma Manag Outcomes. 2008 Jun 2. 2(1):4. [Medline].

  16. Lerer DB, Umans HR, Hu MX, Jones MH. The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol. 2004 Oct. 33(10):569-74. [Medline].

  17. Spindler KP, McCarty EC, Warren TA, Devin C, Connor JT. Prospective comparison of arthroscopic medial meniscal repair technique: inside-out suture versus entirely arthroscopic arrows. Am J Sports Med. 2003 Nov-Dec. 31(6):929-34. [Medline].

  18. Bin SI, Kim JM, Shin SJ. Radial tears of the posterior horn of the medial meniscus. Arthroscopy. 2004 Apr. 20(4):373-8. [Medline].

  19. Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction. Arthroscopy. 2004 Apr. 20(4):346-51. [Medline].

  20. Nicholas SJ, Golant A, Schachter AK, Lee SJ. A new surgical technique for arthroscopic repair of the meniscus root tear. Knee Surg Sports Traumatol Arthrosc. 2009 Dec. 17(12):1433-6. [Medline].

  21. Logan M, Watts M, Owen J, Myers P. Meniscal repair in the elite athlete: results of 45 repairs with a minimum 5-year follow-up. Am J Sports Med. 2009 Jun. 37(6):1131-4. [Medline].

  22. Kim SB, Ha JK, Lee SW, Kim DW, Shim JC, Kim JG, et al. Medial meniscus root tear refixation: comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy. 2011 Mar. 27(3):346-54. [Medline].

  23. Adachi N, Ochi M, Uchio Y, Kuriwaka M, Shinomiya R. Torn discoid lateral meniscus treated using partial central meniscectomy and suture of the peripheral tear. Arthroscopy. 2004 May. 20(5):536-42. [Medline].

  24. Kelly JD 4th, Ebrahimpour P. Chondral injury and synovitis after arthroscopic meniscal repair using an outside-in mulberry knot suture technique. Arthroscopy. 2004 May. 20(5):e49-52. [Medline].

  25. Barber FA, Harding NR. Meniscal repair rehabilitation. Instr Course Lect. 2000. 49:207-10. [Medline].

  26. Lozano J, Ma CB, Cannon WD. All-inside meniscus repair: a systematic review. Clin Orthop Relat Res. 2007 Feb. 455:134-41. [Medline].

  27. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review. Am J Sports Med. 2012 Feb. 40(2):459-68. [Medline].

  28. Nepple JJ, Dunn WR, Wright RW. Meniscal repair outcomes at greater than five years: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012 Dec 19. 94(24):2222-7. [Medline]. [Full Text].

  29. Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg Am. 2008 Sep. 90(9):1922-31. [Medline].

  30. LaPrade CM, Jansson KS, Dornan G, Smith SD, Wijdicks CA, LaPrade RF. Altered tibiofemoral contact mechanics due to lateral meniscus posterior horn root avulsions and radial tears can be restored with in situ pull-out suture repairs. J Bone Joint Surg Am. 2014 Mar 19. 96(6):471-9. [Medline].

  31. Marzo JM, Kumar BA. Primary repair of medial meniscal avulsions: 2 case studies. Am J Sports Med. 2007 Aug. 35(8):1380-3. [Medline].

  32. Kim YM, Rhee KJ, Lee JK, Hwang DS, Yang JY, Kim SJ. Arthroscopic pullout repair of a complete radial tear of the tibial attachment site of the medial meniscus posterior horn. Arthroscopy. 2006 Jul. 22(7):795.e1-4. [Medline].

  33. West RV, Kim JG, Armfield D, Harner CD. Lateral meniscal root tears associated with anterior cruciate ligament injury: classification and management (SS-70). Arthroscopy. 2004. 20:e32-e33.

  34. Ahn JH, Wang JH, Lim HC, et al. Double transosseous pull out suture technique for transection of posterior horn of medial meniscus. Arch Orthop Trauma Surg. 2009 Mar. 129(3):387-92. [Medline].

  35. Kim JH, Shin DE, Dan JM, Nam KS, Ahn TK, Lee DH. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: technical note. Arch Orthop Trauma Surg. 2009 Aug. 129(8):1085-8. [Medline].

  36. Kim SB, Ha JK, Lee SW, et al. Medial meniscus root tear refixation: comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy. 2011 Mar. 27(3):346-54. [Medline].

  37. Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: a prospective comparison study. Arthroscopy. 2011 Dec. 27(12):1644-53. [Medline].

  38. Ahn JH, Lee YS, Yoo JC, Chang MJ, Park SJ, Pae YR. Results of arthroscopic all-inside repair for lateral meniscus root tear in patients undergoing concomitant anterior cruciate ligament reconstruction. Arthroscopy. 2010 Jan. 26(1):67-75. [Medline].

  39. Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014 Oct 7. 186 (14):1057-64. [Medline].

  40. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016 Jul 20. 354:i3740. [Medline].

  41. Frellick M. Exercise as Effective as Surgery for Meniscal Tears. Medscape Medical News. Available at http://www.medscape.com/viewarticle/866424. July 21, 2016; Accessed: July 25, 2016.

  42. Hart ES, Kalra KP, Grottkau BE, Albright M, Shannon EG. Discoid lateral meniscus in children. Orthop Nurs. 2008 May/June. 27(3):174-9. [Medline].

  43. Choi NH, Kim TH, Victoroff BN. Comparison of arthroscopic medial meniscal suture repair techniques: inside-out versus all-inside repair. Am J Sports Med. 2009 Nov. 37(11):2144-50. [Medline].

  44. Cox CL, Deangelis JP, Magnussen RA, Fitch RW, Spindler KP. Meniscal tears in athletes. J Surg Orthop Adv. 2009 Spring. 18(1):2-8. [Medline].

  45. Ding J, Zhao J, He Y, Huangfu X, Zeng B. Risk factors for articular cartilage lesions in symptomatic discoid lateral meniscus. Arthroscopy. 2009 Dec. 25(12):1423-6. [Medline].

  46. Freedman KB, Nho SJ, Cole BJ. Marrow stimulating technique to augment meniscus repair. Arthroscopy. 2003 Sep. 19(7):794-8. [Medline].

  47. Iwamoto J, Takeda T, Sato Y, Matsumoto H. Retrospective case evaluation of gender differences in sports injuries in a Japanese sports medicine clinic. Gend Med. 2008 Dec. 5(4):405-14. [Medline].

  48. Jerosch J, Riemer S. [How good are clinical investigative procedures for diagnosing meniscus lesions?] [German]. Sportverletz Sportschaden. 2004 Jun. 18(2):59-67. [Medline].

  49. Kisiday JD, Vanderploeg EJ, McIlwraith CW, Grodzinsky AJ, Frisbie DD. Mechanical injury of explants from the articulating surface of the inner meniscus. Arch Biochem Biophys. 2009 Nov 24. epub ahead of print. [Medline].

  50. Lowry F. Real knee surgery no better than sham for meniscal tear. Medscape Medical News. December 27, 2013. Available at http://www.medscape.com/viewarticle/818399. Accessed: January 7, 2014.

  51. Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees. Am J Sports Med. 2004 Apr-May. 32(3):675-80. [Medline].

  52. Oei EH, Koster IM, Hensen JH, et al. MRI follow-up of conservatively treated meniscal knee lesions in general practice. Eur Radiol. 2009 Nov 17. epub ahead of print. [Medline]. [Full Text].

  53. Pearse EO, Craig DM. Partial meniscectomy in the presence of severe osteoarthritis does not hasten the symptomatic progression of osteoarthritis. Arthroscopy. 2003 Nov. 19(9):963-8. [Medline].

  54. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26. 369(26):2515-24. [Medline].

  55. Uysal M, Akpinar S, Bolat F, et al. Apoptosis in the traumatic and degenerative tears of human meniscus. Knee Surg Sports Traumatol Arthrosc. 2008 Apr 30. epub ahead of print. [Medline].

 
Previous
Next
 
Magnetic resonance imaging scan showing a normal meniscus.
Magnetic resonance imaging scan showing a torn medial meniscus.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.