The meniscus - much misunderstood
By guest blogger Mr Adil Ajuied, Consultant Orthopaedic Knee Surgeon...
As a dedicated knee surgeon with a specific interest in sports injuries, I am passionate about helping my patients return to full sporting capability. I think this is best achieved with a wider multi-disciplinary team that includes physiotherapists and primary care. Together, we aim to understand the exact nature of any injury, manage the acute phase of the injury, start physiotherapy rehabilitation, and intervene surgically only when absolutely necessary.
Our surgical goals are to preserve much of the knee’s structural anatomy as possible and reconstruct where needed. A critical structure, about which there is often much discussion and debate, is the meniscus, which helps to provide stability to the knee joint.
The most frequent questions I’m often asked about meniscal tears are:
- “How should we manage meniscal tears?”
- “Which ones need surgery?”
- “The MRI found an unexpected tear, what should we do?”
I would like to explore some of these questions and bring a little structure and clarity to how we approach this common knee injury.
Diagnosis and treatment of meniscal tears
A meniscal tear can be diagnosed upon history and clinical examination, and confirmed by MRI scanning.
There are many misconceptions around meniscal tears and the best treatment approach - this is not helped by the many classifications and descriptions of this common injury. I find it most helpful to think of meniscal tears as three types:
- Asymptomatic (show no symptoms)
- Painful symptoms only
- Painful and mechanical symptoms
Asymptomatic meniscal tears
These are very common, - around 30-40% of people over the age of 40 years have been shown to have meniscal tears that are asymptomatic. The rate of tears increases with age and approaches 100% in the presence of osteoarthritis.
An asymptomatic tear is picked up by an MRI scan for another knee complaint. The tear itself does not give the patient any pain at the location of the tear, nor does it result in any mechanical symptoms (such as clicking, catching, locking, or popping sensations).
These tears never require surgery - a combination of conservative treatment and rehabilitation can be used to target the original knee complaint, such as patellofemoral pain, tendonitis etc.
Painful symptomatic tears
These are either fresh tears or asymptomatic meniscal tears that have been aggravated and made to become symptomatic. In either case, the first line of treatment is non-operative treatment that includes rest, ice and physiotherapy rehabilitation. Only if a concerted effort at this non-operative treatment fails, and pains persist, should surgery be considered.
Surgery, following appropriate assessment, discussion and counselling, takes the form of a knee arthroscopy. The tear is assessed and, if feasible, the meniscus is repaired or alternatively debrided (meniscectomy). This would then be followed by an appropriate course of rehabilitation.
Painful and mechanical symptomatic tears
These are either fresh tears or are asymptomatic meniscal tears that have been aggravated and made to become mechanically symptomatic. While non-operative treatment may be considered for cases where the torn meniscus is sitting in an anatomical position, it is likely to be unsuccessful as the mechanical symptoms are unlikely to resolve. Therefore early surgical intervention may be necessary.
- Meniscal tears are common
- Rehabilitation is very important
- Surgery is a last resort and often dependant on the type of tear:
- Asymptomatic: never need surgery
- Painful symptoms only: sometimes need surgery
- Painful and Mechanical symptoms: often need surgery
- ESSKA Meniscus Consensus Project: Degenerative meniscus lesions. Available here.
- Beattie KA et al. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis Cartilage.2005 Mar;13(3):181-6.
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