Meniscal Lesions

Introduction

The medial and lateral menisci play an important suction role and assist in nourishing the knee joint. Injuries can lead to altered knee biomechanics and pain. This page explores what happens and what happens when the meniscus is injured (torn and/or ruptured). Meniscal tears are the most common injury, followed by meniscal cysts. They all have 2 reasons. The first is traumatic and the second is a degenerative meniscus tear. Meniscal cysts may present with signs and symptoms consistent with typical meniscal pathology. discoid meniscus is a rare congenital disorder in which the lateral meniscus remains around instead of its usual cup-like shape, resulting in instability of the lateral compartment. This condition usually has no symptoms, but symptoms may occur if a meniscal tear occurs.

Epidemiology/Etiology

Due to sports injuries, meniscal injuries are common among athletes, accounting for approximately 15% of all sports injury cases. The menisci may tear or completely rupture. Partial or complete rupture of the lateral or medial meniscus. [1] Medial tear reportMore Usually more than transverse tearing. In addition to tears that occur during sports, osteoarthritis can also lead to spontaneous meniscus tears through the destruction and weakening of the meniscus structure.

Epidemiological studies of meniscal injuries have been hampered by the fact that it is likely that many of these injuries have never been recognized, since meniscal tears do not necessarily present characteristic symptoms and some may heal spontaneously. [2]

Meniscus injuries are more common in men because they play more aggressive sports. Men are more likely than women to suffer from barrel handle injuries, which are associated with trauma. Females bear more peripheral detachments. [2] Another striking fact observed in the elderly People with a degenerated meniscus prone to minor trauma (55+). Today, meniscal lesions appear earlier. The average age has risen from 28 to 40. Meniscus injuries are uncommon in children under the age of 10. [2]

There were no significant differences in location or area of meniscal tear type and, more importantly, similar repair rates across age groups. Adolescents are more likely to have concurrent ligament injuries, possibly due in part to greater participation in competitive sports at that age. In children, complex tears were associated with boys (32% vs. 10% of girls) and children with a higher BMI. Most meniscus tears affect the lateral meniscus and involve the posterior horn of the meniscus. [3]

Traumatic meniscal tear:

• There are 2 criteria that define a meniscal injury as a traumatic injury. These two criteria must be met: the meniscal tissue must be healthy and macroscopically normal, and there must be an injury to the knee, such as a knee sprain or strenuous exercise.
• Most often, the traumatic injury is a vertical or longitudinal tear. [4] [5] [6]

A meniscus tear occurs either from excessive force being applied to the “normal” meniscus, or from normal force being applied to the degenerated meniscus. The most common mechanism of injury is a sprain to a semiflexed limb through the weight-bearing knee joint. it may also be related to other Ligament injuries are usually the ACL and MCL. There are two different types of meniscus tears:

• Acute tearing – this is usually the result of a trauma or sports injury (tennis, jogging, football, etc…). Acute tears have different shapes (horizontal vertical radial oblique and complex). If they do not respond to conservative treatment, surgery may be required.
• Chronic tears – These most commonly occur in older adults and are degenerative meniscus tears that occur after minor trauma or stress to the knee. Most of them are treated with physical therapy and anti-inflammatory drugs.

Degenerative meniscal tear:

• Occurs in the absence of a trauma.
• It is due to the person’s age and daily activities.
• The meniscal tissue has deteriorated to a certain extent.
• Men are more prone to degenerative tears than women.
• A degenerative tear can occur early in someone’s life, such as a young athlete, but it usually occurs in the fifth to fourth decade of life. [4] [7]

Meniscal rupture:

Meniscus injuries are usually caused by torsional movement between the femur and tibia under no-contact loading or sudden movements like squatting. Anything that allows the femur to slide too much anteriorly or posteriorly relative to the tibia can cause some of the force to be Transmission to the meniscus causes the meniscus to rupture.

Clinically Relevant Anatomy

The 2 menisci are crescent-shaped fibrocartilaginous structures located between the femoral condyles and the tibial plateau of the knee. The anterior and posterior meniscal angles attach to the intercondylar eminence of the tibial plateau. Coronary ligaments provide peripheral attachment Between the tibial plateau and the perimeter of the two menisci. The inserting ligament of the anterior horn of the medial meniscus is fan-shaped and attaches to the tibia in the region of the intercondylar notch approximately 6 or 7 mm anterior to the insertion of the anterior cruciate ligament. [8] of The anterior intermeniscal ligament, also known as the transverse geniculate ligament, connects the anterior fibers of the anterior horns of the medial and lateral menisci. [9] The relevance of the ligament has not been studied, but it may play a role in moving the menisci during the tibia Rotate inside and out. The length of this ligament is 33 mm [9]. The medial meniscus is also attached to the medial collateral ligament which limits its mobility. The lateral meniscus is attached to the femur anteriorly (Humphrey’s ligament) and posteriorly (Wrisberg’s ligament) The meniscofemoral ligament tensions the posterior horn anteriorly and medially with increased knee flexion. The transverse ligament provides the connection between the anterior parts of the two menisci. The added stability provided by the ligamentous attachment prevents meniscal is squeezed out of the joint during compression.

Posterior View of Meniscus

Top View of the Menisci – Grays Anatomy

The meniscus is usually an avascular structure with a major blood supply limited to the periphery. Only 10% to 25% of the meniscal periphery is vascularized by vessels from the medial and lateral geniculate arteries. For this reason, when the meniscus is The central part is usually unable to undergo the normal healing process. The outermost part of the meniscus has a blood supply and heals more easily.

Characteristics/Clinical Presentation

Clinical presentation deals with symptoms associated with meniscal injury. But we must distinguish between traumatic meniscus injury and degenerative meniscus injury. Symptoms of a traumatic meniscus injury result from instability of the torn fragments. [10] These symptoms In the case of a “barrel handle” tear, a locked knee may result. It is also the cause of the knee bouncing, and you can also hear the knee click as the torn portion of the meniscus moves under the femoral condyle. Other more disturbing symptoms include medial or lateral Knee pain depends on the affected compartment and is caused by abnormally increased tension in the joint capsule.

The symptoms of a degenerative meniscus are the same as those of a traumatic meniscus injury, but there may also be problems with the patella or cartilage. Activities that bend and load the knee, such as squatting and kneeling, are poorly tolerated and often worsen symptoms.

Clinical manifestations of traumatic lesions/ruptures:

• Joint line tenderness Mc Murray test[11] Thessaly test and squat test

• Symptoms are crackling and intermittent residual pain.

• Occurs mainly in the elderly population. The age of onset is more than 50 years old.

• Excessive flexion of the knee joint under weight for prolonged periods of time results in excessive stress [12].

• The medial meniscus is more prone to tearing than the lateral meniscus when it is under load.

Risk Factors

Possible risk factors for meniscal tears are athletic older males and pre-existing conditions such as osteoarthritis. [13] An additional risk factor is that overweight intensive training reduces muscle strength for varus or valgus deformities of the lower leg. Lesions of the meniscus can also Increased risk factors for knee osteoarthritis (OA). [14]

Differential Diagnosis 

Knee examination and possibly arthroscopy provide definitive classification of meniscal injuries. The size and severity of a meniscus tear or rupture often predicts post-surgery recovery and eventual knee degenerative phenomena.

When we talk about a meniscus tear, we have to be specific about the type of injury we’re dealing with. Examination of the knee and any arthroscopy can definitively classify meniscal lesions. The extent and severity of a meniscal tear usually indicates recovery after surgery and any subsequent degenerative symptoms of the knee. Classification of meniscal tears can be done based on anatomical abnormalities. There are different types of meniscal tears, such as tear length, tear depth, and tear pattern. We’ll discuss the different injuries below.

• Tear Length – A meniscal injury that occurs only on the surface of our meniscus.
• Depth of tear – A complete meniscal tear describes a tear that goes through both the upper and lower surfaces, whereas a partial tear includes only one surface. Longitudinal damage is often full crack; this means that the entire thickness of the meniscus is affected. often when we support our The pressure exerted by body weight on the meniscus with the femur pushes the crack open.
• Tear Pattern The tear pattern includes seven different meniscus injuries. [15] [16]

1. 1. Longitudinal/vertical tear – This type of tear can occur anywhere on the meniscus. If this tear grows, it can cause the barrel handle to tear. A “handle” or “bucket handle” tear runs nearly the entire length of the meniscus. This often results in the formation of a skin flap Can be sandwiched between the intercondylar spaces. [17]
   2. Horizontal tears or horizontal fissures – usually form part of a more complex fissure that contains more of the aforementioned fissures. This tear starts at the inner edge of the meniscus and continues towards the capsule. [18]
   3. Flap Tears – There are two types of flap tears: horizontal tears and vertical tears. A horizontal flap tear is the same as a horizontal tear but has complications. When you have a horizontal flap tear, the lower and upper surfaces of the menisci may not be injured, whereas vertical tears do not The flap is torn.
   4. Complex tears – These are patterns that describe tears in different planes, seen in degenerative menisci.
   5. Discoid meniscus – This type of tear usually occurs on the outer side of the meniscus. and is classified as
      1. An incomplete discoid, larger than normal meniscus, usually attached.
      2. A full disc will cover the entire tibial plateau and is usually attached as well.
      3. Attaches at the back of the capsule by default. Symptoms of this type are also more common than the other two types of discoid menisci.
   6. Angled tear – usually occurs at the height of the front or upper corner.
   7. Radial tear – starts at the inner edge of the meniscus and extends into the joint capsule. Radial cracks usually occur in the middle part of the meniscus. Radial tears of the lateral meniscus are often found with ACL tears. This tear can get worse. [19]

Meniscus tears due to sports accidents must be noted with regard to the high frequency of associated ACL tears (approximately 60% are associated with ACL tears). There is also what is called a silent meniscus tear; this is a radial tear of the lateral meniscus tears. In many cases, acute trauma is not recognized because there is no or only mild mechanical discomfort. In many cases, these are pains during and after exercise, although pain occurs at the level of the lateral joint line when pressure is applied, and in some cases Limitation of flexion, especially during squats and during painful hyperflexion-rotation tests.

Different types of meniscus ruptures:

• Radial rupture
• Oblique rupture
• Longitudinal rupture
• Bucket handle
• Horizontal rupture
• Complex rupture

Diagnostic Procedures 

Degenerative meniscus disease is often found during an MRI (magnetic resonance imaging) or in osteoarthritic knees during arthroscopic surgery. [20]

The diagnosis of knee instability prior to traumatic meniscal injury is based on physical examination and a positive Lachmann test. Establishing a correct diagnosis is important because treatment of a meniscal tear and unstable treatment interact. [21] Degenerative Meniscal Lesions The prevalence of abnormal meniscal MRI images suggestive of a lesion should be emphasized, but should not be overinterpreted as indications for meniscal tears or surgical treatment as they reflect natural changes associated with aging of meniscal tissue. two important The questions the examiner needs to answer are what are the symptoms associated with the meniscus problem and what is the condition of the articular cartilage? [21] Arthroscopy This procedure allows the doctor to make a thin incision in the knee into which he inserts a camera with a light so that he can see directly Inside the joint, any injury can be seen and a definitive diagnosis made, leading to an informed decision on management options. MRI scan Magnetic resonance imaging is the most extensive imaging evaluation of the knee, it is also cost-effective and helps in prognosis and further treatment options When it’s done early after an injury. [22] [23]

There are 3 orthogonal planes:[24]-Sagittal-Coronal-Transverse Assessment of bone injury. [twenty four]

Outcome Measures

There are many outcome measures for this case. Here are some examples; [25] [26] [27]

• Cincinnati Knee Rating System
• Knee Injury and Osteoarthritis Outcome Score (KOOS)
• Lysholm Knee Score
• The Kujala Anterior Knee Pain Scale
• International Knee Documentation Committee (IKDC)
• Western Ontario Meniscus Evaluation Tool (WOMET)
• Numeric Rating Scale for pain (NRS)
• Visual Analogue Scale for pain (VAS)

See Outcome Measures Database

Examination

Before the physical examination, the medical history should be carefully asked, which will help the examiner to select the appropriate clinical trials to be included in the physical examination. During the physical examination, the affected and unaffected legs were compared with qualitative and quantitative results. thoroughly Investigation is warranted when there is a history of sudden pain with mechanical locking and recurrent effusions from excessive knee flexion. [27] Physical examination should include examination of palpable range of motion (ROM) and gait as well as integrity testing of menisci and other structures knee joint. [27]

Inspection[28]

• Height and weight of patient;
• Alignment of the knee joint;
• Fluid scars or cuts? check the healing status;
• Muscle atrophy;
• Assess for skin and muscle tone (abrasions, tears, ecchymosis, erythema.

Palpation [27]

• Reproduce pain/tenderness or discomfort by palpation of the joint line.
• Fluid shift tests are performed and evaluated for the presence of fluctuations to evaluate for fluid effusions that do not confirm the presence of meniscal injury.

Joint Line Tenderness Video Courtesy of Clinically Relevant

ROM and Gait [27]

• Active and passive range of motion.
• Difficulty fully extending the knee.
• Pain caused by full or inability to flex the knee fully.
• Deviation or compensation of gait pattern (analgesic gait).

Clinical Tests

In a clinical setting, irritating movements that cause compression of the meniscal fragments between the tibia and femur often result in pain. Therefore, pain from varus stress may suggest a medial meniscus injury. This concept is supported by operations such as the Payr and Bohler tests in the former. The operation The patient sits cross-legged, exerting pressure on the medial meniscus, whereas in the latter, simple varus and valgus stress causes pain when the meniscus is compressed. It is further suggested by more modern tests in which weight bearing is incorporated into rotational motion, such as In the Thessaly test. However, when a meniscal fragment flips over and inserts between the MCL and the deep fibers of the tibial valgus, the stress will cause compression of the fragment between these structures and medial pain.

McMurray Test [29]

• The McMurray test is performed with the patient lying on their back. The examiner stands on the side of the affected knee and places one hand on the heel, the thumb of the other hand on the inside of the knee, and the other fingers on the outside of the knee to stabilize and provide eversion strength. The knee is extended from full flexion to 90° of flexion while applying varus force and internally and externally rotating the tibia.
• If it causes pain or bursts, the test is considered positive. Pain or crackling with internal rotation suggests a lateral meniscus injury, and pain or popping with external rotation suggests a medial meniscus injury.

McMurray test video courtesy of Clinically Relevant

Apley Grind Test [30]

• The Apley grind test consists of a set of provocative maneuvers. It is performed with the patient in the prone position with the affected knee flexed to 90°. The tibia is compressed to the distal femur and rotated externally to assess the medial meniscus and internally rotated to assess the lateral meniscus meniscus.
• The thigh rests firmly on the examination table. When the knee is bent to 90°, apply traction to the calf and again apply external rotation.
• The examiner should note whether external rotation and distraction cause pain and whether the pain is worse than without distraction.
• If it causes pain, the test is considered positive. But when the action is repeated with distraction, the pain is bound to lessen or lessen.

Apley’s test video courtesy of Clinically Relevant

Thessaly Test [31]

• The Thessaly test is performed with the patient standing with all weight on one limb. With the foot on the ground, bend the knee first 5°, then 20°. The patient is then asked to rotate the body internally and externally while holding the examiner’s hand for support. this The test combines axial load and rotational force.
• The test is considered positive by pain.

Thessaly test video courtesy of Clinically Relevant

The clinical diagnosis of a meniscal tear has been found to be more accurate when combined with the test. Because some have low diagnostic accuracy when performed alone; when they are used in combination, they can improve sensitivity and specificity. [32]

Medical Management

Conservative management is rarely successful in treating meniscus tears in young athletes and repair of the torn meniscus is usually required (level of evidence: 5) [47][33] If the tear is peripherally and longitudinally concurrent, meniscus repair should be strongly considered plate injury anterior cruciate ligament (ACL) reconstruction and young patients. Complex or degenerative tears are less likely to heal central tears and tears in unstable knees. There are many restorative techniques available. Preservation of meniscal tissue is recommended regardless of age – for active patients – whenever possible. (Level of Evidence: 3a)[48][34]

Another consideration is whether meniscus repair or meniscectomy is appropriate. Total meniscectomy is the last option if normal surgical treatment is not suitable. Factors that should be considered in making a decision should be:

• The clinical evaluation
• Related lesions
• The exact type, location and extent of a meniscal tear. [35]

Operative:

Arthroscopy is a minor surgery. They looked at the knee joint through a thin tube. This procedure can be performed to obtain information on the knee joint. In many cases, immediate treatment is possible during arthroscopy. Major surgery may be required. [36][37] You can find more information about arthroscopy on the Meniscus Repair page.

Certain meniscus tears, such as a bucket handle rupture, require surgical treatment to prevent the rupture from getting worse, to minimize additional damage to the torn portion of the meniscus and to optimize healing.

There are different types of surgical treatment for a meniscus tear, such as repair and partial resection.

Sometimes most of the meniscus must be removed if the rupture cannot be treated and involves most of the meniscus, or when repairs have failed. To avoid secondary osteoarthritis and relieve pain, meniscus transplantation may be the best solution [38].

Meniscus allograft (MAT) is now considered an effective method of biologically reconstructing symptomatic meniscectomy knees. [39]

For further reading, see Meniscal Repair

Physiotherapy Management

Not all meniscal lesions require surgery Conservative treatment is another option. In the treatment options, we recognize that the conservative approach is arthroscopic resection or meniscus suture. [40] Physiotherapy is an example of conservative treatment. It focuses on strengthening the quadriceps Prevents secondary quadriceps atrophy. This treatment is most successful with incomplete tears or small stable tears in areas with a blood supply. Meniscus tears with few symptoms of irregularity are initially managed conservatively.

Exercise therapy has been recognized as an effective treatment option for patients with degenerative knee joints. The goals of treatment are to improve knee function and limit joint pain. There is strong evidence that physical activity plays an important role in reducing symptoms and improving muscle strength [41]

Acute Management

When surgery is not required, physical therapy mainly consists of RICE (resting ice compression elevation).

RICE is important in the first 24 hours after acute soft tissue injury. Especially when blood vessels are damaged. It helps reduce pain and swelling. [42]

Cryotherapy, also known as ice packs, is a method of exposing the body to a cooler medium. Using a cold source lowers the temperature of the tissue. It causes superficial vasoconstriction and decreased local blood flow. [43] How often? This is a view that few agree with. The most common recommendation is to apply ice for 20 minutes every 2 hours for the first 48 to 72 hours. You have to take into account that some people are more sensitive to cold than others.

Rehabilitation (Conservative treatments)

Strengthening and stretching exercises for the quadriceps and hamstrings are important.

The method of improving strength depends on the timing of the rehabilitation program and also depends on the patient’s responsiveness to the availability of equipment and the preference of the rehabilitation clinician. [43]

Strength Exercises

Isometric exercises to strengthen the quadriceps

• Quadriceps group: The patient lies supine with the unaffected knee flexed and the affected knee extended. Patient trying to press knees on table
• Straight-leg raise

Isometric Exercises to Strengthen Hamstrings

• Hamstring group: The patient lies supine with the unaffected knee extended and the affected knee partially flexed.
• Pushing heel into the table or pillow.

Non-weight-bearing isotonic exercises

• Short Arc Quadriceps Exercise: Also known as terminal knee extension.
• Full-arc quad exercise
• Hamstring curls

Weight-bearing resistance exercises (when the patient is able to bear weight on the injured knee)

• Reciprocal training: training on a stationary bike.
• Platform Leg Press Wall Squat plié Lunge Step Up Buck Lateral Step Up.

Flexibility Exercises

Flexibility exercises and joint mobility are techniques for improving range of motion and flexibility. [43]

These exercises can be active or passive. The technique used depends on the type of tissue.

Extended extension stretches are used to increase knee extension. This exercise can be performed in prone or sedentary positions. The long flexion stretch is an exercise that increases knee flexion. The position used for this exercise depends on how the flexion movement is presented.

Active stretching of the quadriceps and hamstrings is also important.

Joint Mobilizations

Reduced range of motion may be a result of injury edema surgery and immobilization. If this happens, it can make the knee painful and even affect the mobility of the ankle.

Joint mobilization is important for the following joints:

• Superior Tibiofibular joint;

• Patellofemoral joint. Full flexion and extension of the knee requires patellar range of motion;

• Tibiofemoral joint. It is the most frequently moved joint and improves the range of motion in the knee.

Balance & Agility

Balance and agility exercises begin with double-supported weight-bearing activities and progress to single-limb static balance on a stable surface. [43]

Post-Surgical Care

If surgery is required, there are two options: meniscus repair or meniscectomy (partial or total).

After surgery, expect your patient to be on crutches for at least three weeks. Full recovery using a comprehensive rehabilitation program typically takes 3-4 months, and athletes involved in high-level sports can be back on the field around 6-8 months after surgery (be sure to verify this specific protocol to follow with the surgeon and you). This timeline does not take into account whether other structures (such as ACLs) are also involved.

It goes without saying that recovery from meniscus repair after surgery depends on the size of the surgery. Surgery and subsequent rehabilitation plans need to be individualized.

It has been suggested that unstructured rehabilitation after meniscus repair is safe but may increase failure rates compared with well-structured and evidence-based rehabilitation. [16]

Overall Take Home Clinical Considerations

• Control Pain and Inflammation – Cryotherapy Pain Relievers NSAIDs.
• To regain good knee control.[41]
• Restore ROM (Range of motion) [41]
• Perform ROM exercises in any range requested by the advisor[44]
• Restore the flexibility[41]
• Restore muscle function[41]
• Specific strengthening exercises, including quadriceps (medial meniscus injury affects the strength of the vastus medialis.[45] hamstrings calf glutes. Exercise programs should include concentric and eccentric exercises to accept muscle hypertrophy and neuromuscular Function. [41]
• Optimizing Neuromuscular Coordination – Proprioceptive Reeducation [46]
• Progressive weight bearing and joint stress are necessary to enhance the function of the meniscus repair and should therefore be progressed as directed by the consultant. Excessive shear forces can be damaging and should be avoided initially.

For further discussion of physical therapy management, see Meniscal Repair

Clinical Bottom Line

• The menisci are often damaged from high-impact sports such as soccer, often from a semi-flexed limb through a weight-bearing knee sprain.
• The surgical approach for a meniscus tear generally depends on the type and location of the tear, the age of the patient, and how chronic the tear is. [47]
• When the meniscus tea is stable and relatively small and is in a well-perfused area, surgery is not required. These can be treated with physical therapy.
• However, surgery is necessary if it affects the unstable and large tear located on the non-perfusing medial side of the meniscus. Often the surgeon must remove the torn portion of the meniscus, which is called a partial meniscectomy. Plastic surgeons try to remove as little as possible so that The meniscus retains its shock-absorbing effect. Occasionally a tear of the meniscus can be stitched. Only in cases where the meniscus is too torn beyond repair can the meniscus be completely resected and the meniscus margins preserved as much as possible. [48]