Meniscal Injury Treatment & Management

Updated: Nov 19, 2021
  • Author: Sarjoo M Bhagia, MD; Chief Editor: Ryan O Stephenson, DO  more...
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Treatment

Approach Considerations

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 can abrade articular cartilage, resulting in arthritis.

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Rehabilitation Program

Physical therapy

The goals of the physical therapy program are to minimize effusion, normalize gait, normalize pain-free ROM, prevent muscular atrophy, maintain proprioception, and maintain cardiovascular fitness.

A report by El Ghazaly et al indicated that in patients with symptomatic, unstable meniscal tears, better treatment results can be achieved with arthroscopic partial meniscectomy (APM) than with physical therapy. The study, on 70 patients, found that although pain and swelling were reduced in the physical therapy patients, their injured knees continued to have limited ROM, with greater knee function and treatment satisfaction found in the APM patients. [28]

On the other hand, a study by Stensrud et al reported that in middle-aged patients with degenerative meniscal tears, a 12-week supervised exercise therapy program can yield similar results to APM. Indeed, isokinetic knee extension peak torque was a mean 16% greater in the exercise group. [29]

When a meniscal 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 meniscal repairs: knee motion, weight bearing, and return to sports. [5]

The protocols for rehabilitation of a meniscal injury take into consideration biomechanical principles and the results of the physical examination. Factors such as the extent and location of the lesion, the amount of articular cartilage degeneration on weight-bearing surfaces, the duration of injury, and joint stability affect the pace and aggressiveness of the rehabilitation program. No preset duration for any phase of rehabilitation is described in this section, and phases may overlap, depending upon the patient's progress and symptoms. The protocols should be adjusted to each patient's status, progress, and goals.

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Rehabilitation Following Meniscectomy

Initial phase

When the patient first reports to outpatient physical therapy 4-7 days after surgery, he or she usually is able to bear full weight or as much weight as tolerated on the involved leg. Modalities are used as needed to decrease pain or swelling, including heat/ice contrasts, ice alone, transcutaneous electrical nerve stimulation (TENS), electric galvanic stimulation, and phonophoresis. As needed, the patient should perform flexibility exercises for the lower extremity musculature, including the hamstrings, quadriceps femoris, hip flexors, hip adductors, and calf muscles.

During the initial stage, the emphasis should be placed on overcoming any limitations to ROM. To increase passive flexion ROM, the patient should complete exercises such as wall slides. The uninvolved leg is used to control the speed of descent and to push the involved leg back up into extension. The patient does not have to use the quadriceps muscle of the involved leg for this exercise, but he or she can use it if there is no pain.

After the patient attains 110-115° of flexion, he or she may substitute heel slides for supine wall slides to increase flexion ROM. Isometric exercises for the quadriceps muscle assist in strengthening the quadriceps muscle, especially the VMO segment. Electrical muscle stimulation may be used to help retrain poorly contracting VMO or quadriceps femoris muscles. Short-arc quadriceps femoris muscle exercises strengthen the quadriceps femoris muscle.

Additional exercises to strengthen the lower extremity musculature (eg, hamstrings, hip adductors, hip abductors, calf muscles) are included in the program. The patient can begin isotonic strengthening exercises for the hamstring muscles when he or she can flex the knee to at least 80-90°. Hip abduction strengthening may begin when VMO muscle contraction and strength are adequate. If the patient begins hip abduction exercises before the quadriceps femoris muscle is strong enough, the exercises may contribute to increased lateral tracking of the patella. The tensor fasciae latae muscle inserts into the iliotibial band distally, and contraction of this muscle increases the tightness of the fascial sheath, contributing to lateral patellar tracking.

Depending on weight-bearing ability and other symptoms, the patient can begin toe raise exercises to strengthen the lower leg. Proper foot placement is important, as it influences the stresses at the knee. Supination of the foot causes tibial external rotation and a varus force at the knee joint, resulting in increased pressure in the medial compartment. Pronation causes tibial internal rotation, a valgus force at the knee joint, and increased lateral compartment pressure.

Stationary bicycling may be implemented into the rehabilitation program when the patient attains 115-120° of knee flexion. This exercise increases joint lubrication, which helps to improve ROM. Tension and resistance should be adjusted according to the presence of effusion or the patient's complaints of pain. If the patient's ROM is not adequate, bicycling may cause forced motion and increased pressure, irritating the knee.

Intermediate phase

The patient should have full ROM to begin this phase. Modalities are continued as indicated by symptoms. Flexibility and strengthening exercises are continued, increasing resistance as tolerated. The patient may progress to isokinetic strength and endurance training.

The patient also may begin closed kinetic chain exercises during this phase. If the quadriceps femoris muscle is strong enough (ie, if the patient can lift 10 lb during short-arc quadriceps femoris muscle exercise), the running program may be initiated. The first stage of the running program is jogging in place on a trampoline. Unless pain or swelling occurs, the patient gradually progresses to jogging for 10-15 minutes.

Advanced phase

During the advanced phase, the patient continues to progress in strength-training exercises while beginning to return to sports activities. Track running may start when the patient is able to run on the treadmill for 10-15 minutes at a pace of 7-8 minutes per mile (depending upon the patient's previous activity level). Once mileage on the track has reached 2-3 miles, agility drills and sport-specific activities may be performed.

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Rehabilitation Following Meniscal Repair

The program for rehabilitation following meniscal repair is similar in principle to the program that follows meniscectomy; however, more limitations are put on the patient's weight-bearing status, and the duration of each phase of rehabilitation is longer to allow for healing. Full weight bearing is postponed until 4-6 weeks after surgery to reduce the tensile and compressive forces on the repair site. During the initial phase of rehabilitation, more attention should be paid to applying modalities to decrease pain and effusion. ROM exercises are performed with caution so that the healing process is not delayed. Mobilization of the patella may be required to ensure proper mechanics of the patellofemoral joint. Stretching exercises include calf stretches to reduce the possibility of Achilles tendinitis when the patient resumes weight bearing on the involved leg. Ankle ROM exercises also may be required to maintain adequate ankle ROM before weight bearing begins.

Open kinetic chain strengthening exercises may begin during the initial phase, but caution must be used, and the exercises must be reduced or suspended if the patient reports pain. Isokinetic training should not begin until the patient is able to lift 10 lb on the short-arc quadriceps muscle exercise. The running program may begin when the quadriceps femoris and hamstring muscles of the involved leg have reached approximately 70% of the strength of the same muscles of the uninvolved leg, as demonstrated by an isokinetic strength test.

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Nonoperative Rehabilitation

The program for nonoperative rehabilitation is similar in principle to the program that follows meniscectomy. Cryotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) play a very important role in the management of nonoperative meniscal injury. These medications help to control the amount of swelling and provide some pain relief. Sometimes, aspiration is useful to decrease the effusion, and, rarely, an athlete may need a judicious one-time corticosteroid injection. Although not routinely advocated, an injection may provide an athlete with a way to control the irritation within the knee so that performance may not falter. Maintenance of ROM of the knee is important, as are muscular strength and endurance.

A reasonable goal before return to athletic activity is strength of the injured lower extremity within 20-30% of the contralateral side. Initially, activity modification is useful, particularly in athletes who are "weekend warriors." The time frame for return to activity depends on a number of factors. Returning to competition depends on the demands and motivation of the athlete, as well as on the severity of the meniscal tear.

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Surgical Intervention

Operative versus nonoperative treatment

Multiple factors are involved in making decisions regarding the management of an athlete with a known or suspected meniscal tear. [30] Factors such as the severity of the symptoms, the ability to perform one's activity, and the timing of possible surgery must be taken into account. The need for surgical management is quite evident in an individual with significant symptoms, such as a locked knee or debilitating pain with clinical or MRI evidence of a meniscal tear. A treatment decision may be much more difficult to make for an individual who has relatively mild symptoms of a meniscal tear and who is participating in a sporting event that is in the middle-to-late part of the season.

The severity of the symptoms can vary for different types of meniscal tears. A bucket-handle tear may cause the knee to lock and be quite painful, whereas a small vertical or radial tear that displaces may cause occasional symptoms of giving way and only mild pain. If the symptoms are infrequent and locking does not occur, then an initial period of conservative management may be indicated, depending on the activity level and demands of the athlete. If the athlete's ability to compete is impaired because of the symptoms, then nonoperative management is unlikely to be satisfactory and arthroscopic surgery should be helpful, although it may mean a delay of 1-4 weeks in returning to competition.

Delayed surgery

An athlete with recurrent mild symptoms but without impairment in the ability to compete may be a suitable candidate for delayed operative management. Thorough consultation between the athlete, the physician, and the athletic trainer must be undertaken before any decision is made. The athlete must be given a clear explanation of what a meniscal tear is and what the potential ramifications of delaying surgery are. Such ramifications include the possibility of propagation of the tear or significant symptoms during a competition, which may preclude further participation at a particular event. Few published studies have examined the results of nonoperative treatment of meniscal tears.

Operative plus physical therapy

A study by Gauffin et al indicated that in middle-aged patients with meniscal injury, arthroscopic knee surgery combined with physical therapy brings greater pain relief than does physical therapy alone. In the prospective, randomized, single-blind trial, 150 patients aged 45-64 years who had been suffering from meniscal symptoms for more than 3 months were treated with physical therapy, including a 3-month exercise program. Within this group, however, some patients were also treated with arthroscopic resection of meniscal injury, performed within 4 weeks of inclusion in the study. At 12-month follow-up, evaluation using the Knee Injury and Osteoarthritis Outcome Score determined that pain reduction was significantly greater in the patients who had been treated with physical therapy and surgery than in those treated only with physical therapy. [31]

A literature review by Thorlund et al for the Danish Society of Sports Physical Therapy found moderate-level evidence that self-reported pain and function in degenerative meniscal tears can be improved as much with exercise as with surgery, with muscle strength improved to an even greater extent. In contrast to the Gauffin study, the investigators also stated that in cases of degenerative meniscal tears, high-quality evidence showed that using surgery in addition to exercise did not have a clinically significant impact on pain and function. [32]

Arthroscopic surgery

Despite the Gauffin study’s findings, 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. [33]

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. [34, 35]

The results from this study led to the formation of an expert multidisciplinary panel to review the literature for or against the use of arthroscopy for patients with degenerative knee disease. A clinical practice guideline released by an international panel strongly recommended, based on a systematic review, that almost no patients with degenerative knee disease be treated with arthroscopic surgery. The panel included orthopedic surgeons, a rheumatologist, physical therapists, a general practitioner, general internists, epidemiologists, methodologists, and patients with degenerative knee disease who had or had not undergone arthroscopic treatment. It cited, with regard to the surgery, “a modest probability (< 15%) of small or very small improvement in short term pain and function that does not persist to 1 year,” as well as the postoperative limitations and, in rare cases, serious adverse effects that can occur. [36]

Operative management

Once a decision has been made to proceed with operative management, further decisions regarding the surgical treatment of the meniscus tear need to be made (see images below). Surgical options include partial meniscectomy or meniscal 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 meniscal root tear provided better results than partial meniscectomy. [37] As previously stated, however, some controversy is now associated with arthroscopic treatment, with an international panel recommending that in most cases, such surgery not be used for degenerative knee conditions and finding the procedure to lack effectiveness. [36]

Arthroscopic probing of a posterior horn complex m Arthroscopic probing of a posterior horn complex meniscal tear with multiple flaps.
Arthroscopic view of medial meniscus after excisio Arthroscopic view of medial meniscus after excision of flap tear.

Numerous factors are involved in the determination of treatment of a meniscal tear. In assessing these factors, the clinician must be cognizant of meniscal biomechanics, including the role in load transmission and congruity of the knee joint. Because of the importance of intact functional meniscal tissue, the first goal is to preserve as much of the viable tissue as possible. Many factors (eg, the location, length, pattern, stability, and chronicity of the tear; the athlete's age; presence of degenerative changes; concurrent intra-articular injuries; desired timing of return to competition) need to be taken into consideration during the decision-making process. [4, 38]

The basic principle of meniscal surgery is to save the meniscus. [39] 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.

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.

Meniscal 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 meniscal 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.

Meniscal repair fixation techniques are numerous and variable. Fixation can be accomplished with outside-in, inside-out, or all-inside arthroscopic procedures. [6, 40, 41, 5] 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 there is a plethora of commercially available meniscal repair devices (eg, biodegradable arrows or darts, sliding knot sutures with extracapsular anchor fixation).

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 are almost identical to those of a complete meniscectomy and that repair restores normal mechanics. [42, 43] 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). [44, 45, 46, 47, 48]

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. [37] A separate study that compared the results of the all-inside and pullout techniques showed no difference in function or repair characteristics between the two procedures; [49] complete structural healing was observed in 86% of patients who underwent the all-inside technique and in 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. [50]

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

Human allograft meniscal transplantation is a relatively new procedure but is being performed with greater frequency. 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.

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