Meniscus Tear | Diagnosis & Treatment for Physios
The meniscus is essential for stability, shock absorption, distribution of forces, lubrication in the knee as well as proprioception. (Englund et al. 2009)
The medial meniscus has the form of a C and is approximately 3cm wide and 4-5cm long. The posterior horn of the meniscus is bigger than its anterior portion. The medial horn is generally attached to the tibia. The anterior horn is loose in 3-14% of the population. In general, the medial meniscus has a good capsular attachment via the coronary ligaments.
The lateral meniscus has the form of a half-circle and has a greater tibial surface area than the medial meniscus. It is approximately 3cm wide and 3-4 cm long and is attached to the tibia anteriorly and posteriorly. The ligamentous attachment of the lateral meniscus is less developed, which gives it more freedom of movement than the medial meniscus.
Meniscus injuries are mostly caused by rotation of a flexed knee into extension (Bansal et al. 2002).
All movements which can lead to ligament injuries in the knee can also cause meniscus injuries (Solomon et al. 2002). For this reason, meniscal tears are often seen together with anterior cruciate ligament (ACL) tears. In acute injuries, the lateral meniscus is torn more often than its medial counterpart (Smith et al. 2001). On the other hand, the medial meniscus tears more often in patients with chronic ACL- insufficient knees who suffer a new trauma (Murrel et al. 2001, Keene et al. 1993, Irvine et al. 1992).
These different scenarios also lead to a different localization and type of rupture: In the case of a medial meniscus tear (with a chronic ACL tear) peripheral ruptures in the dorsal horn are seen more often and with a lateral meniscus tear (in the case of an acute ACL tear) more ruptures are seen in the dorsal horn or the mid-lateral third. (Shelbourne et al. 1991, Thompson et al. 1993, Smith et al. 2001).
The menisci can be damaged through acute trauma or long-lasting overuse. Partial or full tears in the medial or lateral meniscus are further categorized into:
– Vertical/longitudinal tears may progress to Bucket Handle Tears
– Radial/Transverse tears may progress to Parrot Beak Tears
– Horizontal tears may progress to Flap tears
The incidence of a meniscus injury presenting to the general practitioner is estimated at 2 out of 1.000 patients per year with a male: female ratio of 2,5:1 (Belo et al. 2010). In a prospective cohort study in a primary care setting in the Netherlands, 35% of patients between 18 and 65 with an acute knee injury were diagnosed with a meniscus tear. In the same study, 11% had a combined ACL and meniscus tear, while 9% had a combined medial collateral ligament tear and meniscus tear (Kastelein et al. 2008).
While traumatic tears often occur in the menisci periphery and are seen in patients younger than 30, more complex and degenerative patterns tend to occur in older adults (Poehling et al. 1990).
It should be mentioned that meniscus abnormalities seen on MRI seem to be extremely common in the asymptomatic population as well.
In a study by Beattie et al. (2005) 43 out of 44 asymptomatic individuals with mean age of 41.1 (age range 20-68) showed at least one meniscal abnormality.
27 individuals (61.4%) had abnormalities in at least three of the four regions of the knee.
It is important to add that meniscal tears can lead to knee osteoarthritis (OA), but knee OA can also lead to a spontaneous meniscal tear through the breakdown and weakening of meniscal structure (Englund et al. 2009). While the prevalence of meniscus tears is very high in asymptomatic individuals, Bhattacharyya et al. (2003) found a significantly higher frequency of meniscal tears in individuals with symptomatic OA. On top of that, a study by Hunter et al. (2006) found a strong association between meniscal damage and cartilage loss.
Clinical Picture & Examination
A meniscal injury can cause pain and edema and a locking knee during flexion and extension.
The chance of a meniscus lesion is increased in case the patient is older than 40 years of age and has suffered from a rotation trauma during weight-bearing of the knee, which makes continuing activity impossible. Furthermore, a popping sensation during trauma makes a meniscal tear more probable (Wagemakers et al. 2008).
– Isolated medial or diffuse knee pain location
– Knee complaint with progressive onset in degenerative meniscus tears
– Mild to severe pain while pivoting on the knee during activities of daily living or sports
– Joint swelling 12-24 hours after trauma
– Joint line tenderness
– Reduced AROM
– Pain in the end ranges of motion
Shrier et al. (2010) argue that the physical examination for meniscal tears is different than diagnostic tests as meniscal tears are heterogeneous in nature, for example, posterior vs. anterior tears. Therefore, the authors reason that sensitivity and specificity values should not be relied on for meniscus injuries, but the choice of physical tests should rather be based on the logic underlying how different tests stress different parts of the meniscus.
Another very common test to diagnose meniscus tears is the Appley Test:
Other orthopedic tests to assess patellofemoral pain are:
- Joint Line Tenderness
- Jump Sign /Finochietto Test
- Thessaly Test
- Ege’s Test
- Duck Walk Test
- Bounce Home Test
Meniscectomy or partial surgical meniscus repair is one of the most common orthopedic surgeries worldwide. However, in recent decades, this procedure has come under fire as several randomized controlled trials have shown equally satisfactory results with conservative management. Furthermore, Sihvonen et al conducted a randomized trial that compared arthroscopic partial meniscectomy to sham surgery which showed no difference and an even slightly higher risk of developing knee OA 5 years after surgery. Let that sink in for a moment.
So, the described conservative management of meniscus tears in the literature typically involved a combination of a warm-up, range of motion, strength, and joint control/proprioceptive exercises done for 2-3 sessions per week over the course of 12 weeks. These sessions were either supervised or done independently by the patient. Patients were assessed with validated outcome measures such as the KOOS, Lysholm knee score, Tegner activity scale, and isokinetic strength measurements.
We will present a couple of exercise progressions for each domain:
Make sure you identify the specific needs of your patient. For example, for some people, a lunge may be necessary for their ADL or work so you would incorporate those in your training as well. This is also a long list of exercises and we shouldn’t overwhelm our patients with a ton of exercises. Keep it to a minimum of 3-5 exercises.
What about patients with mechanical symptoms like knee locking or catching?
Sihvonen et al. (2016) compared the outcomes of 900 consecutive patients with symptomatic degenerative knee disease and meniscus tear undergoing arthroscopic partial meniscectomy. They then compared the outcomes of patients with mechanical knee catching or locking and patients without mechanical symptoms. Surprisingly and in obvious contrast to the prevailing consensus and most guideline recommendations, the study indicates that a preoperative self-report of mechanical symptoms is actually associated with a less favorable outcome of surgery than the absence of these symptoms. Of all patients with mechanical symptoms, locking or catching was alleviated in only 53%. At the same time, 11% of patients without prior mechanical symptoms experienced locking or catching after surgery.
One of the key findings of the study was that mechanical symptoms were more prevalent in patients with knee OA. This data suggests that mechanical symptoms are actually attributable to general knee degeneration, rather than a distinct lesion such as a degenerative meniscus tear.
Progressive Exercise therapy consisting of neuromuscular and strength exercises for the lower limbs, mainly the quadriceps, and performed 2-3 times a week for a duration of 12 weeks has been shown to be effective in middle-aged patients with degenerative meniscus tears (Kise et al. 2016). While the effectiveness of an exercise program for younger patients under 40 with traumatic meniscus tears yet has to prove its effectiveness, the general focus of exercise is no different compared to that of degenerative tears.
Beattie, K. A., Boulos, P., Pui, M., O’Neill, J., Inglis, D., Webber, C. E., & Adachi, J. D. (2005). Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis and cartilage, 13(3), 181-186.
Bhattacharyya, T., Gale, D., Dewire, P., Totterman, S., Gale, M. E., Mclaughlin, S., … & Felson, D. T. (2003). The Clinical Importance Of Meniscal Tears Demonstrated By Magnetic Resonance Imaging In Osteoarthritis Of The Knee☆. JBJS, 85(1), 4-9.
Décary S, Fallaha M, Frémont P, Martel-Pelletier J, Pelletier JP, Feldman DE, Sylvestre MP, Vendittoli PA, Desmeules F. Diagnostic validity of combining history elements and physical examination tests for traumatic and degenerative symptomatic meniscal tears. PM&R. 2018 May 1;10(5):472-82.
Hegedus EJ, Cook C, Hasselblad V, Goode A, Mccrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. journal of orthopaedic & sports physical therapy. 2007 Sep;37(9):541-50.
Hunter, D. J., Zhang, Y. Q., Niu, J. B., Tu, X., Amin, S., Clancy, M., … & Felson, D. T. (2006). The association of meniscal pathologic changes with cartilage loss in symptomatic knee osteoarthritis. Arthritis & Rheumatism, 54(3), 795-801.
Kastelein M, Wagemakers H, Luijsterburg P, Berger M, Koes B, Bierma-Zeinstra S. De waarde van anamnese en lichamelijk onderzoek bij het diagnosticeren van traumatisch knieletsel. Huisarts en wetenschap. 2008 Nov 1;51(11):528-35.
Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. bmj, 354, i3740.
Keene, G. C., Bickerstaff, D., Rae, P. J., & Paterson, R. S. (1993). The natural history of meniscal tears in anterior cruciate ligament insufficiency. The American journal of sports medicine, 21(5), 672-679.
Lowery DJ, Farley TD, Wing DW, Sterett WI, Steadman JR. A clinical composite score accurately detects meniscal pathology. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2006 Nov 1;22(11):1174-9.
Mine, T., Kimura, M., Sakka, A., & Kawai, S. (2000). Innervation of nociceptors in the menisci of the knee joint: an immunohistochemical study. Archives of orthopaedic and trauma surgery, 120(3-4), 201-204.
Murrell, G. A., Maddali, S., Horovitz, L., Oakley, S. P., & Warren, R. F. (2001). The effects of time course after anterior cruciate ligament injury in correlation with meniscal and cartilage loss. The American Journal of Sports Medicine, 29(1), 9-14.
Rongen, J. J., et al. “Increased risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears: a multi-center longitudinal observational study using data from the osteoarthritis initiative.” Osteoarthritis and cartilage25.1 (2017): 23-29.
Shelbourne, K. D., & Nitz, P. A. (1991). The O’Donoghue triad revisited: combined knee injuries involving anterior cruciate and medial collateral ligament tears. The American journal of sports medicine, 19(5), 474-477.
Sihvonen R, Englund M, Turkiewicz A, Järvinen TL. Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study. Osteoarthritis and cartilage. 2016 Aug 1;24(8):1367-75.
Solomon, D. H., Simel, D. L., Bates, D. W., Katz, J. N., & Schaffer, J. L. (2001). Does this patient have a torn meniscus or ligament of the knee?: value of the physical examination. Jama, 286(13), 1610-1620.
Skou, S. T., & Thorlund, J. B. (2018). A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study. Journal of bodywork and movement therapies, 22(3), 786-791.
Thorlund JB, Juhl CB, Ingelsrud LH, Skou ST. Risk factors, diagnosis and non-surgical treatment for meniscal tears: evidence and recommendations: a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF). Br J Sports Med. 2018 May 1;52(9):557-65.
Wagemakers HP, Heintjes EM, Boks SS, Berger MY, Verhaar JA, Koes BW, Bierma-Zeinstra SM. Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice. Clinical Journal of Sport Medicine. 2008 Jan 1;18(1):24-30.
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