Meniscal Tears

What is the meniscus?

The menisci are two fibrocartilaginous structures that are located between the femur and tibia. The menisci are C-shaped and are attached to the bone in the front and back of the tibia at root attachments. The periphery of the meniscus is attached to the tibia with coronary ligaments. The meniscus is composed of water, collagen and proteoglycans. The arrangement of the collagen and proteoglycans as well as bone attachments give the menisci their biomechanical properties.

Figure 1 This figure shows both the normal medial and lateral menisci as well as blood supply.

The menisci serve to aid in load transmission, shock absorption, stabilization and lubrication of the knee.

As the shape of the femur and tibia differ at the joint, the meniscus serves to fill the gap between the two bones and aid in load transmission.

Figure 2 MRI of the knee demonstrating how the meniscus conforms to the shape of the femur and tibia. The meniscus is outlined in red.

Figure 3 Arrows represent how load is spread throughout the knee along the meniscus.

Figure 4 With the meniscus removed, larger arrows now represent increased load seen by the tibia.

Shock absorption while walking occurs as the water portion of the meniscus is forced through the meniscus interstitial matrix giving the meniscus viscoelastic properties.

The shape and attachments of the menisci aid in providing additional stability to the knee. Both menisci move with knee flexion and extension. As the medial meniscus has more attachments, it serves a greater function in stability, acting as a secondary stabilizer in knees with an ACL tear.

The menisci function in lubrication of the knee by aiding in circulating knee synovial fluid during compression of the meniscus. Additionally, the presence of proteoglycans on the meniscus lower the amount of friction experienced by the knee.

What are the symptoms of a meniscus tear?

Symptoms of a meniscus tear will depend on the location of the tear, tear pattern and other factors. However, common symptoms include knee pain and swelling. Other symptoms may include catching, locking or giving out of the knee. Some large meniscus tears may even prevent full motion of the knee.

Are meniscus tears common?

Yes. Some estimate rates of 60-70 per 100,000 population. There is also an estimated 1 million meniscus surgeries performed in the US every year.

What causes meniscus tears?

Traumatic tears can occur from an increased load to the knee in either compression, rotation or shearing. This is common in sporting activities such as soccer, basketball, football and Jiu-Jitsu.

Degenerative tears occur as the meniscus loses elasticity and are associated with knee arthritis.

What are the types of meniscus tears?

Meniscus tears can be characterized as either traumatic or degenerative. There are also many different tear patterns of tears. Some examples of tear patterns include radial, horizontal, vertical, root, bucket handle and complex. Degenerative tears are often complex in appearance and are associated with arthritis. Meniscus root tears are located where the meniscus is attached to the tibia and often occur at the medial meniscus posterior root. Radial, bucket handle, horizontal and root tears, are associated with greater contact pressures in the knee.

Figure 5 Views of meniscus tear types.

Figure 6 Additional views of meniscus tears.

How are meniscus tears diagnosed?

Diagnosis begins with a history and physical examination. Examination may show tenderness at the knee where the meniscus is located. Special tests that apply stress to the meniscus may also be positive and suggest a tear. X-rays are also taken to evaluate for evidence of arthritis or other injuries to the bone. If a meniscus tear is suspected based on this an MRI is likely to be ordered to confirm the diagnosis.

Figure 7 MRI example showing a normal appearing meniscus.

Figure 8 MRI image of a medial meniscus tear with arrow pointing to the tear.

How are meniscus tears treated?

Treatment for meniscus tears is individualized and based on many factors. Factors that are considered include, but are not limited to, mechanism of tear (traumatic or degenerative), pattern of the tear, location of the tear, symptoms, age of the patient, and activity level of the patient.

Nonoperative Treatment

Nonoperative treatment is often indicated for complex, degenerative meniscus tears. This can include anti-inflammatory medications and physical therapy. Injections such as platelet rich plasma have also been shown to be effective in pain relief.

Surgical Treatment

Surgical options include meniscectomy and meniscus repair.

A meniscectomy is a removal of the torn area of the meniscus. This is often colloquially referred to as a “clean up.” This can be indicated in certain degenerative meniscus tears that have failed nonoperative treatment. The procedure is performed with an arthroscope utilizing two small incisions. One incision is used to place a camera for visualization of the knee while the other is used to place the instruments used to resect the torn meniscus tissue.

Figure 9 Arthroscopic view of a complex meniscus tear.

Figure 10 A view of the meniscus after a partial meniscectomy. An arthroscopic probe is seen in this view.

A meniscus repair involves placing sutures in or through the meniscus to allow the meniscus to heal. This is performed using the arthroscope as well. Many tear patterns can be repaired using two small incisions alone. However, certain other tear patterns may require the use of additional incisions. In the case of root tears, a drill tunnel in the tibia is often required to complete the repair.

Figure 11 Large bucket handle meniscus tear. Probe in place shows displacement of the tear.

Figure 12 After repair of the meniscus using an all inside type repair device.

Figure 13 Illustration of all inside meniscus repair technique.

Figure 14 Illustration of all inside meniscus repair technique.

Figure 15 Meniscus root tear.

Figure 16 Example of root repair.

Figure 17 Illustration of a meniscus root repair. This technique involves drilling a tunnel in the tibia to repair the meniscus. Credit: Arthrex.com

For certain patients, typically those that have previously had most of their meniscus removed, a meniscus transplant can also be performed. This uses an allograft meniscus from a donor to replace the meniscus tissue. This also uses tunnels and sutures to place the meniscus transplant.

Timing of Meniscus Surgery

For patients that have meniscus tears that are indicated for surgery, performing surgery sooner has shown to improve outcomes including healing after surgery.

Outcomes of Meniscus Surgery

Outcomes of meniscus repair are generally favorable. Some reviews show success rates of ~83%. Certain tear types such as radial tears and meniscus root tears may have a lower healing rate.

Return to sport after meniscus surgery

Return to sport is based on many factors after a meniscus surgery. Factors that determine timing to return to sport include type of surgery performed (meniscectomy, repair or transplant), tear pattern, tissue quality, health and activity level of the patient, physical and psychological readiness. After meniscectomy the return to sport for many is 4-12 weeks after surgery. After meniscus repair the return to sport is often 4-9 months.

Complications after meniscus surgery

The following list includes the more common complications and is not exhaustive.

Infection

An uncommon complication reported rate of ~ 0.2%. Prevention at the time of surgery includes the surgical sterilization of the skin and using the use of antibiotics at the time of surgery. Presentation of infections could include fever, chills, increased pain and swelling at the surgical site, redness, warmth and drainage. Management often includes antibiotics and possibly surgical irrigation and debridement.

Repair Failure

Incidence of meniscus repair failure is roughly 20% depending on the series reported. Prevention includes appropriate surgical technique, rehabilitation, recovery and timing to return to activity. Treatment of repair failure may include revision repair or meniscectomy. Augmentation to aid in healing of the repair may include platelet rich plasma or bone marrow venting procedures.

Knee Stiffness

Knee stiffness results from scar tissue formation leading to restricted range of motion and rarely occurs after isolated meniscus repair. Prevention includes timing to surgery and accelerated rehabilitation protocols. Treatment of knee stiffness includes rehabilitation, surgical lysis of adhesions and manipulation under anesthesia.

Deep Venous Thrombosis (Blood clot)

Deep venous thrombosis is typically rare with reports being lower than 1% of cases. Presentation of a blood clot can include increased pain and swelling in the leg with diagnosis confirmed with an ultrasound. Prevention includes early immobilization, possible use of compression stockings, and possible use of chemical prophylaxis such as aspirin. Treatment typically includes use of anticoagulation medications such as lovenox or apixaban.

Nerve injury

Nerve injury is uncommon after meniscus surgery. Most common type of nerve injury includes numbness around incision sites. However, there are also reports of injury to the saphenous or peroneal nerves around the knee. This usually resolves with continued observation. In rare case pain management may be required to aid in symptom management.

Hardware Irritation

Hardware is used to repair the meniscus. Uncommonly this hardware can cause continued pain in the area it is located. This can present as localized pain and swelling at the hardware sites. In rare cases the hardware may need to be surgically removed once the repair has fully healed.

Osteoarthritis

Osteoarthritis development after a meniscus injury is multifactorial and ultimately related to cartilage injury and increased contact pressure. Progression may be more rapid in certain cases of meniscectomy or conservative care of meniscus tears. Prevention includes rehabilitation focusing on quadriceps strengthening and resorting joint mechanics and stability. Treatment may include anti inflammatory medications, injection therapy, rehabilitation and possible joint preservation surgery.

What will help my pain after surgery?

Medications including narcotic pain medications and anti inflammatories may be prescribed after surgery to help reduce pain. Nerve blocks at the time of surgery have been shown to be affective at reducing pain with low risk of long-term deficits. Additionally, use of cold compression devices has been shown to reduce pain and need for pain medications.

Are there other modalities that can improve my healing after meniscus surgery?

There are studies that show use of biologics such as platelet rich plasma can decrease of knee arthrofibrosis and improve healing of a meniscus repair. This can be injected at the time of surgery or after.

Neuromuscular Electrical Stimulation is used during knee rehabilitation to aid in muscle fiber recruitment. This can be applied both at home and during physical therapy sessions.

Use of blood flow restriction therapy involves use of a tourniquet like cuff placed on the lower extremity during exercise. Use of blood flow restriction therapy with low intensity exercise allows lower knee joint pain in comparison to high intensity training without blood flow restriction. This will be used during physical therapy sessions. Check with your physical therapy location if they have this modality available.

Supplement recommendations are often sought after surgery. There is low evidence to support the use of protein or collagen supplementation after surgery. No evidence is available to provide recommendations for a particular supplement. No significant evidence is available to support creatine supplementation or vitamin supplementation.

Do I need to use a brace after meniscus surgery?

In the immediate post operative period you will use a knee brace. The use of a knee brace that can lock in extension can prevent knee buckling while walking in the immediate post operative period. It is also used to prevent excessive knee flexion that may put excessive strain on the meniscus repair.

The use of knee bracing when return to sport is controversial. Functional knee bracing has been shown to have benefits in proprioception and limb symmetry. However, clinical studies show no significant benefit in functional stability, patient reported outcomes or retear rates. Your use of a brace will largely be determined on subjective stability, sporting type and activity level.

When can I return to work after surgery?

Return to work will largely depend on your specific occupational requirements. Many patients are no longer requiring the use of pain medications during the day by the fifth day after surgery. If your work is sedentary, you may be able to return as soon as this time. If you are required to stand for a significant period during the day return to work may need to be delayed until you are off crutches. This may be from week 1-6 after surgery depending on whether a meniscectomy or repair was performed. Work that involves heavy lifting may require longer periods away from work if light duty is not available.

When can I drive after surgery?

There is no definitive test we can do to determine when a patient is safe to return to driving. You should not be taking narcotic or sedating medications prior to driving. Studies attempting to look at when it is safe to return to driving have looked at brake response times. There are no definitive studies looking at isolated meniscus repair but in general guidelines following ACL reconstruction can be followed. In general, brake response time has been shown to return to normal by 4-6 weeks after right sided ACL surgery and 2-3 weeks after left sided ACL surgery.

Post operative Instructions

• Following your stay in the recovery room and when your vital signs are stable you will be discharged to your escort.
• Remember, it is normal to feel a little dizzy or drowsy for several hours after surgery. This is due to the action the medicine used during surgery.
• If you do not have a post operative appointment scheduled, please call the office as soon as possible to schedule this appointment.
• Take your pain medicine as directed. Begin the pain medicine before you start getting uncomfortable, as the nerve block will wear off. If you wait to take your pain medication until the pain is severe, you will have more difficulty in controlling the pain.
• Take 1 tablet (81 mg) of aspirin per day, starting the day after surgery and continuing for 4 weeks. The risk of blood clots is quite low after meniscus surgery, but aspirin is taken as a precaution to decrease the risk. Certain factors such as smoking, birth control pills and certain medical conditions increase the risk of blood clots, and it is especially important to take the aspirin for those situations. If you were previously on a blood thinner you will resume this medication, rather than starting aspirin, beginning the day after surgery.
• If you are taking narcotic pain medication you may need a stool softener to prevent constipation. Over-the-counter medication such as Docusate or Milk of Magnesia is recommended.
• Notify the office of any fever, chills, or temperature > 100.5.
• Notify the office of any wound drainage.
• You can begin the home exercises listed below the day after surgery. Perform the ankle pumps periodically, throughout the day. The remainder of the exercises can be performed once at least once a day.

Post-Surgery Diet

Resume your diet as tolerated and include vegetables, fruits, and proteins (such as meats, fish, chicken, nuts, and eggs) to promote healing. Also, remember to have adequate fluid intake. It is common after surgery to lack an appetite. This may be the result of anesthesia and the medications. Proper nutrition is needed for healing. During the healing process, the body needs increased amounts of calories and protein. Eat a variety of foods to get all the calories, proteins, vitamins, and minerals you need. If you have been told to follow a specific diet, please follow it.

If you’re not eating well after surgery, contact your healthcare provider about nutritional supplements.

How should I manage my surgical site and bandages?

You can remove your surgical dressing on the third day after your surgery. You will remove everything except the Steri-strips if present. See picture below for example of Steri strips.

Allow the steri-strips to fall off on their own. If necessary, sutures will be removed at your first post-operative visit.

Example of Steri strips:

You may shower with a waterproof bandage covering the incisions in three days. Example of waterproof bandage shown in picture below. These can typically be purchased at CVS or Walgreens. Keep the incisions dry until the Steri strips fall off or are removed in clinic. Try not to let the direct spray of water from the showerhead hit the incision.

You can cover your incision with a bandage if needed to prevent irritation with clothing.

A small amount of drainage from the surgical sites is common. If this occurs, you may apply a bandage to the affected area.

Leakage immediately after surgery is normal and helps to drain some of the fluid that accumulates in the joint during surgery.

The dressings may become moist or blood-stained; this is normal and not typically a cause for alarm.

Example of waterproof bandage:

Do I need to wear a knee brace?

You will use a knee brace such as this:

Instructions for fitting and adjustment can be found at:
https://www.breg.com/products/knee-bracing/post-op/t-scope-premier-post-op-knee-brace/

You will lock the brace straight when walking but can unlock the brace at rest. The prescribed range of motion settings will be set in the operating room.

You may remove the knee brace for exercises as prescribed by the surgeon/therapist, icing, dressing, and showering.

What is my activity level after surgery?

You will use crutches to aid with walking after surgery.

Elevate the operative leg to chest level whenever possible to decrease swelling. Do not place pillows under knees (i.e. do not maintain knee in a flexed or bent position) but rather place pillows under foot/ankle.

Do not engage in activities which increase knee pain/swelling (prolonged periods of standing or walking) over the first 7-10 days following surgery.

Avoid long periods of sitting (without leg elevated) or long distance traveling for 2 weeks.

Physical therapy should begin by post-operative day 5 or sooner.

You can begin motion of your ankle and toes now.

How do I use my ice machine?

Use of cold compression can help with post operative pain and swelling after surgery. One example is the following:

Instructions for use can be found at:
https://www.breg.com/products/cold-therapy/devices/polar-care-wave/

If you have another machine please check that manufacturer’s website for use instructions.

Use every waking hour for 15 minutes for the first 24 hours. After this time you can use the machine at least three times a day for 15 minutes.

Do not sleep with the automated device on.

Keep a layer of fabric between the skin and icing device at all times.

How do I use the neuromuscular electrical stimulation?

An example of an NMES machine includes:

Instructions for use can be found at:
https://www.zynex.com/products/nexwave/

Electrodes will be placed at the quadriceps. For example:

With the knee in extension, increase the stimulation amplitude until contraction of the quadriceps is visualized. Increase amplitude to your tolerance level. Contractions should last 10 seconds with 30-50 second rest periods between contractions. This can be started once the bandages are removed on the third day after surgery. This can be performed at least 5 days a week for one hour per day.

Can I smoke following surgery?

You should not smoke after surgery as it interferes with healing.

Questions or Concerns

If at any time you have questions or concerns you can either contact your surgeon’s medical assistant via email or you can call the main office numbers at: 855-624-3306. You can also use the electronic medical record’s online portal to send questions.

Exercises you can perform at home at this time:

Straight Leg Raise

While lying on your back, raise up your leg with a straight knee. Keep the opposite knee bent with the foot planted on the ground.

Short Arc Quad

Place a rolled up towel or object under your knee and slowly straighten your knee as you raise up your foot.

Heel Slides- Supine

Lying on your back with knees straight, slide the affected heel towards your buttocks as you bend your knee. Hold a gentle stretch in this position and then return to original position.

Ankle Pumps

Bend your foot up and down at your ankle joint as shown.

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