What is Meniscal Injury and how to handle a Meniscal Injury?

Introduction to Meniscal Injury

Sports injuries / other injuries affecting the knee are common and often result in withdrawal of the athlete from training regimen and competitions. The most common intra-articular lesion of the knee occurs in the meniscus; which being the most frequent surgical indication among the orthopedic procedures. (1)

What is a Meniscus?

The Meniscus is a crescent-shaped cartilage that sits atop the medial (inner) and lateral (outer) plateaus of the tibia, contacting the rounded femoral (thigh bone) condyles and distributing their weight across the broad surface.

Meniscus helps in (2):

1)     Shock absorption and distributing load throughout the joint.

2)     Increasing stability.

3)     Limiting Extreme Flexion and Extension.

4)     Providing Nutrition for Articular Cartilage.

5)     Stabilize the Movements of the Knee.

Meniscus Injury is common in Soccer players, women and athletes who had less time to practice prior to the injury. Running, Volleyball and Weight Lifting are in ascending order of risk for meniscal injury. Meniscal injury most of the time correlates to ACL injury.(1)

There are two types of meniscal injuries:

1) Acute tears: the kind of tears usually occurs when someone’s knee is bent or twisted forcefully, during the leg is in a weight-bearing position.

2) Degenerative tears: these types of tears are more common in aged people. 60% of the population over the age of 65 probably has some degenerative tear of the meniscus. As the meniscus ages, it becomes less elastic and weak.

How can you injure a Meniscus?

1)     The most common mechanism of injury is a twisting injury with the foot anchored on the ground, often by another player’s body. The twisting component may be a relatively slow speed. It is commonly seen in footballs, basketballers, and netballers. The degree of pain associated with this injury varies, some people report a tearing sensation at the time of the injury, a small tear may cause no immediate symptoms but typically pain and swelling increases over time (24hrs).

2)    Small tears may also occur in the older population with only very minimal twisting or trauma as a result of degenerative changes to the Meniscus.

A severe meniscal injury e.g. long radial tear called a “bucket handle” tear, can be severely painful and restrict the range of motion. Intermittent locking may occur as a result of a torn flap impinging between the articular surfaces. This may unlock spontaneously with a clicking sensation.

How do you know you have torn your meniscus?

There are signs and symptoms of the meniscus tear (that can vary between the type of tear), but to keep it nice and simple, we will put into 3 categories.

1)     Small meniscus tear symptoms: you’ll feel slight pain and there will be a little swelling (for 2-3 weeks)

2)     Moderate Meniscus tear symptoms:

  1. Pain localized on the left or right side of the knee (depending if it’s the lateral or medial meniscus).
  2. Progressive swelling over a couple of days (2-3days)
  3. The knee will feel sensitive and stiff
  4. There can be difficulty in fully flexing or extending the knee
  5. Sharp stabbing pain can be felt when twisting the knee
  6. Usually, pain settles within 2-3 weeks.

3)     Severe Meniscus tear symptoms:

  1. All of the symptoms mentioned above plus;
  2. Popping/clunking or locking sensation in the knee.
  3. You may have a giving away sensation without warning.

What to do if you are sensing Meniscal tear symptoms?

You need to see a medical professional and get a proper diagnosis. Just to make this clear – sensations of giving away or locking are not to be ignored –get it check out

Whom should you Visit for a Meniscal Tear?

Physiotherapists are qualified to evaluate your injuries. They are the best practitioner to either treat you or refer to the specialist in case of any systemic or non-muscular issues.

Information for Physiotherapists:

When to Suspect a Meniscal Issue?

History taking is very vital which will help you to rule in and out the chances of the meniscal tear. Mode of Injury and classical signs and symptoms should help you to filter the condition.

Physical findings that are significant in the examination of a patient with a possible meniscus injury include the following:

  • Joint line tenderness (77-86% of patients with a meniscal tear)
  • Effusion (~50% of patients presenting with a meniscal tear)
  • An impaired range of motion – A mechanical block to motion or frank locking can occur with displaced tears; restricted motion commonly results from pain or swelling

How can you confirm – Meniscal Tear?

MRI is a Gold standard to accurately Diagnose Meniscal Injury and its degrees of injury. But unfortunately, Physiotherapists cannot recommend one without referring to the physician. But there are various Special tests which when used accurately can help you to diagnose the injury.

Various Meta-analysis was performed (5,6,7,8) proving the sensitivity, specificity, and odds ratios of these special tests which assist you to diagnose the meniscal injury. To keep it simple, here is the analysis of several studies.

The results are not good when it comes to looking at the accuracy of individual tests thus it is recommended to combine the results of all three tests while ruling in and out Meniscal tear(3)

Does Meniscal Tear require a Surgical Intervention?

Surgical treatment is usually reserved for younger patients with a vertical longitudinal tear within the vascularised outer third of the meniscus. This is termed the ‘red-red zone’ (denoting area of vascularity) (9,10), repair of the ‘red-white zone’ (watershed area between vascular and avascular meniscus) is controversial (12) with many different surgical techniques tears in the ‘white-white zone’ (avascular zone) are rarely repaired – rather the damaged segment is resected (meniscectomy). Damaged avascular meniscus must be removed (12).

However, meniscectomy causes long-term osteoarthritis (13); so it is only performed when the patient suffers joint locking or mensical pain that is refractory to conservative management for more than 6 months. For patients requiring meniscectomy, meniscal autograft has been utilized with good outcomes but is only performed in specialist centers. Research is currently investigating the possibility of implantation of collagen, allogenic and xenogenic cells, embryonic and adult stem cells, or scaffolds derived from polymers, hydrogels, tissues and extracellular matrix, and action of biological stimuli (eg. growth factors) on meniscus tissue is being investigated.2These are currently only being trialled in younger patients and the routine use of most of these technologies is some time away.

Middle-aged with no to mild symptoms should refrain from surgery as the benefits post 2 years of surgery is similar to conservative treatment with no complications.

Complication of post-Meniscal Repair (14):

1)     Early Knee OA,

2)     DVT,

3)     Pulmonary embolism and

4)     CV disease.

When to Visit a Physiotherapist:

Whether you opted for Surgery or not, in either case, consult a Physiotherapist immediately.

A physiotherapist cannot repair your meniscus but can help you with pain, swelling, inflammation, knee motion and improve function. PT will help to accelerate the recovery process.

Treatment way include irrespective of surgery :

1)     RICE: Rest, Ice, compression and elevation

2)     Manual therapy – to help reduce inflammation and improve knee motion

3)     Electro modality – assisting in reducing pain

4)     Assistive device

5)     Mobilization – to improve knee range of motion

6)     Strengthening and Stability exercise – To help reducing pain and improve function and prevent knee locking

7)     Balance exercise – to prevent falls or re-injury

8)     Stretching

9)     Functional Exercise

10)  Lifestyle modification

How to Prevent Meniscal Injury?

Meniscus injuries are hard to prevent as they usually occur as a result of an accident. However, there are some precautions to keep in mind to help minimize the risks of knee injuries:

1)     Keep your leg muscles strong by actively stretching to strengthen your muscles and help stabilize and protect your knee joints.

2)     Begin your exercise routine slowly and gradually increase your intensity over time.

3)     Wear protective gear and proper footwear when playing sports.

4)     Stretch before and after physical exercise.

Research shows the sooner you start reversing your pain or injury, the better your chances of feeling relief faster.

Things to do immediately after Meniscal Injury?

1)     Rest your knee.

2)     Avoid putting weight on your knee as much as possible. Use crutches if required.

3)     Ice your knee to reduce inflammation, pain, and swelling. Apply an ice pack 10 -15 minutes every 3 hours for 2 days or until the pain and swelling is gone.

4)     Compress your knee. Control the swelling by using a knee brace or elastic bandage around the injured knee.

5)     Elevate your knees when you’re sitting or lying down.

6)     Take anti-inflammatory medications. Please consult your physician first.

7)     Practice stretching and strengthening exercises recommended to you by your physiotherapist.

8)     Avoid impact activities such as running and jumping.

9)     Do not twist the knee or forcefully try to extend it.

It is important to seek the advice and follow through on full rehabilitation with a physiotherapist to return your knee to its pre-injury level of function. Consult your physiotherapist to see whether a knee brace or cold therapy is right for you to alleviate your knee pains.

When can you Return to Sports?

Return to play after a meniscus injury is expected. The timing varies and depends on the injury, treatment, and rehabilitation protocol. In many cases, athletes can return to their sport as soon as 2-3 weeks status post arthroscopic partial meniscectomy or 6-8 weeks status post meniscal repair. But always wait till your Physiotherapists allows you to start playing.

If you want to know more about the Meniscal injury, contact us at info@endorushapp.com.

Reference:

1)     Diego Costa Astur, Marcos Xerez, João Rozas, Pedro Vargas Debieux, Carlos Eduardo Franciozi, Moises Cohen. Anterior cruciate ligament and meniscal injuries in sports: incidence, time of practice until injury, and limitations caused after trauma. revbrasortop.2016;51(6):652–656

2)     Shiraev T1Anderson SEHope N. Meniscal tear – presentation, diagnosis and management. Aust Fam Physician. 2012 Apr;41(4):182-7.

3)     Ricardo da Rocha Gobbo1, Victor de Oliveira Rangel2, Francisco Consoli Karam3, Luiz Antônio Simões Pires4. PHYSICAL EXAMINATIONS FOR DIAGNOSING MENISCAL INJURIES: CORRELATION WITH SURGICAL FINDINGS. Rev Bras Ortop. 2011;46(6):726-29

4)     Scholten R. et al. The accuracy of physical diagnostic test for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract 2001;50(11):938-944.

5)     17. Hegedus et al. Physical examination test for assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports Phys Ther 2007;37(9):541-550.

6)     18. Jackson J.L. et al. Evaluation of acute knee pain in primary care. Ann Intern Med 2003;139(7):575-588.

7)     19.Meserve B.B. et al. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clinical Rehabilitation 2008;22:143-161.

8)     20. Solomon D.H. et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001;286(13):1610-1620.

9)     Jarit G, Bosco J. Meniscal repair and reconstruction. Bull NYU Hosp Jt Dis 2010;68:84–90. Search PubMed

10)  Scuderi G, Tria A. The knee: a comprehensive review. Singapore: World Scientific, 2010. Search PubMed

11)  Krych AJ, McIntosh AL, Voll AE, Stuart MJ, Dahm DL. Arthroscopic repair of isolated meniscal tears in patients 18 years and younger. Am J Sports Med 2008;36:1283–9. Search PubMed

12)  Gillquist J, Hamberg P, Lysholm J. Endoscopic partial and total meniscectomy. A comparative study with a short-term follow up. Acta Orthop Scand 1982;53:975–9. Search PubMed

13)  apalia R, Del Buono A, Osti L, Denaro V, Maffulli N. Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull 2011;2011:89–106. Search PubMed

14)  J B Thorlund,1 C B Juhl,1, 2 E M Roos,1 L S Lohmander1, 3, 4Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015;350:h2747