para>Meniscal tears in older patients are typically due to chronic degeneration. ‚
Pediatric Considerations
Meniscal injuries are rare in children <10 years old (prior to physial fusion).
Meniscal tears in young children are often due to a discoid meniscus (anatomic variant with thicker and wider meniscus " ”usually the lateral meniscus).
MRI is less sensitive and specific for diagnosing meniscal tears in children <12 years of age.
‚
EPIDEMIOLOGY
- More common in the 3rd to 5th decades of life
- More common in males
Incidence
- Medial meniscus more commonly injured
- Injuries can be acute or degenerative.
- Acute tears more likely <40 years old and due to trauma
- Degenerative tears more likely >40 years old
Prevalence
One of the most common musculoskeletal injuries ‚
ETIOLOGY AND PATHOPHYSIOLOGY
- Acute tears typically occur due to a twisting motion of the knee with foot planted.
- Degenerative tears occur with minimal trauma.
Genetics
A congenital abnormality leading to discoid meniscus increases the risk of meniscal tear among children. No specific gene locus has been identified. ‚
RISK FACTORS
- Increased age (>60 years), male
- Obesity
- High degree of physical activity (especially cutting sports like soccer, football, basketball, and rugby)
- Anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) insufficiency:
- Waiting >12 months between ACL injury and surgery increases risk of medial meniscal tear (1)[C].
GENERAL PREVENTION
- Treatment and rehabilitation of previous knee injuries, particularly ACL injuries
- Strengthening and increased flexibility of quadriceps and hamstring muscles
COMMONLY ASSOCIATED CONDITIONS
- ACL is concomitantly torn in ¢ … “; of cases.
- Medial and lateral collateral ligament tears
- Tibial plateau or femoral shaft fractures
- Baker cyst " ”strong association with medial meniscal tears (2)[C]
DIAGNOSIS
HISTORY
- Noncontact twisting or hyperflexion mechanism
- Delayed swelling, typically >24 hours postinjury
- Knee pain (on affected side):
- Increased with knee flexion (i.e., stairs, squatting)
- Increased with weight bearing
- Locking, catching, popping
- Sensation of buckling or giving out
PHYSICAL EXAM
- Pertinent findings on physical exam are the following:
- Effusion (mild " “moderate)
- Joint line tenderness
- Decreased range of motion, locking
- Pain with full flexion (posterior horn tear) or extension (anterior horn tear)
- Accuracy of special tests varies (3)[C]
- Positive McMurray test: pain, clicking of meniscus being stressed
- Positive Apley grind test is neither sensitive nor specific.
- Positive Thessaly test: Patient rotates knee and body three times with knee flexed 20 degrees; has pain along joint line.
DIFFERENTIAL DIAGNOSIS
- ACL or collateral ligament tear
- Pathologic plica
- Osteochondritis dissecans
- Loose body or fracture
- Osteoarthritis (OA) " ”symptoms of OA may be caused by meniscal tears (4)[C]
- Patellofemoral syndrome
- Gout, pseudogout, rheumatoid arthritis
DIAGNOSTIC TESTS & INTERPRETATION
- Laboratory evaluation not indicated unless signs of septic arthritis.
- Plain radiographs can detect fractures, loose bodies, or arthritic changes.
- Ultrasound may help screen for meniscal tears. Less helpful for lateral tears (5)[C]
Follow-Up Tests & Special Considerations
- MRI is the primary study to diagnose meniscal tears.
- Increased signal within a meniscus corresponds to degenerative changes; signal contacting the articular surface indicates an acute tear.
- Meniscal tears are often found incidentally on MRI and may not be the cause of patient 's symptoms.
- 36 " “76% of meniscal tears found on MRI were asymptomatic. Asymptomatic tears increase with age and in the setting of OA.
- Patients with synovitis and displacement of meniscus on MRI may benefit from intervention (6)[C].
Diagnostic Procedures/Other
Arthroscopy may be needed if the MRI is indeterminate. ‚
TREATMENT
GENERAL MEASURES
- Treatment depends on the type/location/extent of the tear, as well as age and activity level of the patient
- Conservative treatment (RICE [rest, ice, compression, elevation], activity modification, physical therapy, intra-articular corticosteroid injections) are effective first-line options for many patients, especially those with degenerative tears.
- No increased benefit from surgery versus physical therapy for symptomatic meniscal tears in patients with mild to moderate OA (7)[C].
- Small, partial thickness, or peripheral tears may heal on their own or remain asymptomatic.
- Consider surgical intervention if:
- Mechanical symptoms, locking
- Concurrent injuries (i.e., ACL tear)
- Persistent symptoms following 3 to 6 months of conservative treatment
- Young patients (<30 years) or very active patients with an acute tear
MEDICATION
First Line
NSAIDs, opioid analgesics if severe pain ‚
ISSUES FOR REFERRAL
Surgical consult for patients meeting operative criteria or wishing surgical repair ‚
ADDITIONAL THERAPIES
- Rehabilitation is required for both surgical and nonsurgical patients.
- Electrical stimulation may help improve recovery when coupled with physical therapy.
- Weight control: Weight gain is associated with increased cartilage loss and pain in adults with medial meniscal tears.
- Platelet-rich plasma (PRP) may or may not improve symptoms of meniscal tears (8)[C].
SURGERY/OTHER PROCEDURES
- Most surgeries can be performed arthroscopically.
- Meniscectomy (partial or total) removes the injured portion of the meniscus.
- Can lead to articular cartilage degeneration and OA. Higher risk if 40 years of age, high BMI, valgus malalignment (9)[C]
- Meniscal repairs decrease future OA and often have better outcomes than meniscectomy (10)[C].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Return to play requires that the patient be pain-free, have full range of motion, and full strength.
- Following meniscal repair, patients can generally return to all activities in 3 to 6 months.
- Combined ACL and meniscal repair requires 6 months of postoperative rehabilitation before the patient can return to sports.
PATIENT EDUCATION
Patients should be aware of the risks and benefits of surgery compared with conservative treatment. ‚
PROGNOSIS
Prognosis better if surgery is done within 8 weeks, patient is <30 years of age, or tear is peripheral/lateral <2.5 cm. ‚
COMPLICATIONS
- Meniscectomies may eventually lead to OA. Consequently, meniscal repair is preferred to meniscectomy whenever possible.
- Risk of developing OA increases 6-fold 20 years after a meniscectomy.
REFERENCES
11 Snoeker ‚ BA, Bakker ‚ EW, Kegel ‚ CA, et al. Risk factors for meniscal tears: a systematic review including meta-analysis. J Orthop Sports Phys Ther. 2013;43(6):352 " “367.22 Artul ‚ S, Jabaly-Habib ‚ A, Artoul ‚ F, et al. The association between Baker 's cyst and medial meniscal tear in patients with symptomatic knee using ultrasonography. Clin Imaging. 2015;39(4):659 " “661.33 Smith ‚ BE, Thacker ‚ D, Crewesmith ‚ A, et al. Special tests for assessing meniscal tears within the knee: a systematic review and meta-analysis. Evid Based Med. 2015;20(3):88 " “97.44 Kamimura ‚ M, Umehara ‚ J, Takahashi ‚ A, et al. Medial meniscus tear morphology and related clinical symptoms in patients with medical knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):158 " “163.55 Akatsu ‚ Y, Yamaguchi ‚ S, Mukoyama ‚ S, et al. Accuracy of high-resolution ultrasound in the detection of meniscal tears and determination of the visible area of menisci. J Bone Joint Surg Am. 2015;97(10):799 " “806.66 Troupis ‚ JM, Batt ‚ MJ, Pasricha ‚ SS, et al. Magnetic resonance imaging in knee synovitis: clinical utility in differentiating asymptomatic and symptomatic meniscal tears. J Med Imaging Radiat Oncol. 2015;59(1):1 " “6.77 Katz ‚ JN, Brophy ‚ RH, Chaisson ‚ CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675 " “1684.88 Pujol ‚ N, Salle De Chou ‚ E, Boisrenoult ‚ P, et al. Platelet-rich plasma for open meniscal repair in young patients: any benefit? Knee Surg Sports Traumatol Arthrosc. 2015;23(1):51 " “58.99 Hulet ‚ C, Menetrey ‚ J, Beaufils ‚ P, et al. Clinical and radiographic results of arthroscopic partial lateral meniscectomies in stable knees with a minimum follow up of 20 years. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):225 " “231.1010 Xu ‚ C, Zhao ‚ J. A meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears: the more meniscus, the better outcome? Knee Surg Sports Traumatol Arthrosc. 2015;23(1):164 " “170.
ADDITIONAL READING
- El Ghazaly ‚ SA, Rahman ‚ AA, Yusry ‚ AH, et al. Arthroscopic partial meniscectomy is superior to physical rehabilitation in the management of symptomatic unstable meniscal tears. Int orthop. 2015;39(4):769 " “775.
- Goossens ‚ P, Keijsers ‚ E, van Geenen ‚ RJ, et al. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. J Orthop Sports Phys Ther. 2015; 45(1):18 " “24.
- Griffin ‚ JW, Hadeed ‚ MM, Werner ‚ BC, et al. Platelet-rich plastma in meniscal repair: does augmentation improve surgical outcomes? Clin Orthop Relat Res. 2015;473(5):1665 " “1672.
- Guenther ‚ ZD, Swami ‚ V, Dhillon ‚ SS, et al. Meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk? Clin Orthop Relat Res. 2014;472(3):990 " “997.
- Hall ‚ M, Juhl ‚ CB, Lund ‚ H, et al. Knee extensor muscle strength in middle-aged and older individuals undergoing arthroscopic partial meniscectomy: a systematic review and meta-analysis [published online ahead of print March 16, 2015]. Arthritis Care Res (Hoboken).
- Katz ‚ JN, Brophy ‚ RH, Chaisson ‚ CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675 " “1684.
- Vermesan ‚ D, Prejbeanu ‚ R, Laitin ‚ S, et al. Arthroscopic debridement compared to intra-articular steroids in treating degenerative medial meniscal tears. Eur Rev Med Pharmacol Sci. 2013;17(23):3192 " “3196.
SEE ALSO
Algorithm: Knee Pain ‚
CODES
ICD10
- S83.209A Unsp tear of unsp meniscus, current injury, unsp knee, init
- S83.249A Oth tear of medial meniscus, current injury, unsp knee, init
- S83.289A Oth tear of lat mensc, current injury, unsp knee, init
- Q68.6 Discoid meniscus
- S83.281A Oth tear of lat mensc, current injury, right knee, init
- S83.251A Bucket-hndl tear of lat mensc, current injury, r knee, init
- S83.252A Bucket-hndl tear of lat mensc, current injury, l knee, init
- S83.242A Oth tear of medial meniscus, current injury, left knee, init
- S83.259A Bucket-hndl tear of lat mensc, crnt injury, unsp knee, init
- S83.261A Prph tear of lat mensc, current injury, right knee, init
- S83.262A Prph tear of lat mensc, current injury, left knee, init
- S83.269A Prph tear of lat mensc, current injury, unsp knee, init
- S83.271A Complex tear of lat mensc, current injury, right knee, init
- S83.279A Complex tear of lat mensc, current injury, unsp knee, init
- S83.205A Other tear of unspecified meniscus, current injury, unspecified knee, initial encounter
- S83.282A Oth tear of lat mensc, current injury, left knee, init
- S83.241A Oth tear of medial meniscus, current injury, r knee, init
- S83.272A Complex tear of lat mensc, current injury, left knee, init
- S83.203A Oth tear of unsp meniscus, current injury, right knee, init
- S83.200A Bucket-hndl tear of unsp mensc, current injury, r knee, init
- S83.207A Unsp tear of unsp meniscus, current injury, left knee, init
- S83.202A Bucket-hndl tear of unsp mensc, crnt injury, unsp knee, init
- S83.239A Cmplx tear of medial mensc, current injury, unsp knee, init
- S83.204A Oth tear of unsp meniscus, current injury, left knee, init
- S83.206A Unsp tear of unsp meniscus, current injury, right knee, init
- S83.211A Bucket-hndl tear of medial mensc, crnt injury, r knee, init
- S83.232A Complex tear of medial mensc, current injury, l knee, init
- S83.219A Bucket-hndl tear of medial mensc, crnt inj, unsp knee, init
- S83.201A Bucket-hndl tear of unsp mensc, current injury, l knee, init
- S83.221A Prph tear of medial meniscus, current injury, r knee, init
- S83.222A Prph tear of medial meniscus, current injury, l knee, init
- S83.229A Prph tear of medial mensc, current injury, unsp knee, init
- S83.231A Complex tear of medial mensc, current injury, r knee, init
- S83.212A Bucket-hndl tear of medial mensc, crnt injury, l knee, init
ICD9
- 836.2 Other tear of cartilage or meniscus of knee, current
- 836.0 Tear of medial cartilage or meniscus of knee, current
- 836.1 Tear of lateral cartilage or meniscus of knee, current
- 717.5 Derangement of meniscus, not elsewhere classified
SNOMED
- 239720000 tear of meniscus of knee (disorder)
- 302932006 Tear of medial meniscus of knee
- 302933001 Tear of lateral meniscus of knee
- 239721001 Discoid meniscus of knee (disorder)
- 263123005 Bucket handle tear of medial meniscus of knee (disorder)
- 275326005 bucket handle tear of lateral meniscus of knee (disorder)
CLINICAL PEARLS
- Degenerative meniscal tears are common in patients >40 years of age and generally do not require surgical repair.
- MRI is imaging modality of choice to identify meniscal tears.
- Functional outcomes following meniscal injury are improved with a comprehensive plan of rehabilitation involving strengthening and stretching of knee musculature.
- In patients opting for surgery, meniscal preservation should be the goal. Meniscal repairs have a better functional outcome and decreased risk of OA compared with meniscectomy.
- Improving core strength, proprioception, and quadricep/hamstring flexibility may prevent knee injuries, especially in female athletes.