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Meniscal Injury

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Meniscal Injury

para>Meniscal tears in older patients are typically due to chronic degeneration. ‚

A congenital abnormality leading to discoid meniscus increases the risk of meniscal tear among children. No specific gene locus has been identified. ‚

Arthroscopy may be needed if the MRI is indeterminate. ‚

NSAIDs, opioid analgesics if severe pain ‚

Surgical consult for patients meeting operative criteria or wishing surgical repair ‚

Patients should be aware of the risks and benefits of surgery compared with conservative treatment. ‚

Prognosis better if surgery is done within 8 weeks, patient is <30 years of age, or tear is peripheral/lateral <2.5 cm. ‚

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.

  • 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.

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
  • Medial meniscus more commonly injured
  • Injuries can be acute or degenerative.Acute tears more likely <40 years old and due to traumaDegenerative tears more likely >40 years old
  • Acute tears more likely <40 years old and due to trauma
  • Degenerative tears more likely >40 years old

ETIOLOGY AND PATHOPHYSIOLOGY

  • Acute tears typically occur due to a twisting motion of the knee with foot planted.
  • Degenerative tears occur with minimal trauma.

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].
  • 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
  • Increased with knee flexion (i.e., stairs, squatting)
  • Increased with weight bearing

PHYSICAL EXAM

  • Pertinent findings on physical exam are the following:Effusion (mild " “moderate)Joint line tendernessDecreased range of motion, lockingPain 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 stressedPositive 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.
  • Effusion (mild " “moderate)
  • Joint line tenderness
  • Decreased range of motion, locking
  • Pain with full flexion (posterior horn tear) or extension (anterior horn tear)
  • 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]
  • 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].
  • Increased signal within a meniscus corresponds to degenerative changes; signal contacting the articular surface indicates an acute tear.
  • 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].

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, lockingConcurrent injuries (i.e., ACL tear)Persistent symptoms following 3 to 6 months of conservative treatmentYoung patients (<30 years) or very active patients with an acute tear
  • 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.
  • 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

ISSUES FOR REFERRAL

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].
  • Can lead to articular cartilage degeneration and OA. Higher risk if 40 years of age, high BMI, valgus malalignment (9)[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

PROGNOSIS

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

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

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.