Meniscal TearsMeniscal Tears

Dr. D. N. BidDr. D. N. Bid

The Knee JointThe Knee Joint

The knee joint has two The knee joint has two menisci, a lateral and menisci, a lateral and medialmedial

They are fibrous They are fibrous cartilagecartilage

They rest on top of the They rest on top of the tibia in shallow tibia in shallow indentationsindentations

Functions of the menisciFunctions of the menisci

Aid in lubrication and Aid in lubrication and nutrition of the jointnutrition of the joint

Act as shock Act as shock absorbersabsorbers

Evenly distribute Evenly distribute weight throughout weight throughout the kneethe knee

Allows for smoother Allows for smoother motions between the motions between the femur and tibiafemur and tibia

Clinical BackgroundClinical Background By increasing the effective contact area between the By increasing the effective contact area between the

femur and the tibia, the menisci lower the load-per-unit femur and the tibia, the menisci lower the load-per-unit area borne by the articular surfaces.area borne by the articular surfaces.

Total meniscectomy results in a 50% reduction in contact Total meniscectomy results in a 50% reduction in contact area.area.

The menisci transmit central compressive loads out The menisci transmit central compressive loads out toward the periphery, further decreasing the contact toward the periphery, further decreasing the contact pressures on the articular cartilage. pressures on the articular cartilage.

Half of the compressive load in the knee passes through Half of the compressive load in the knee passes through the menisci with the knee in full extension and 85% of the the menisci with the knee in full extension and 85% of the load passes through the knee with the knee in 90 degrees load passes through the knee with the knee in 90 degrees of flexion.of flexion.

Meniscectomy has been shown to reduce the shock Meniscectomy has been shown to reduce the shock absorption capacity of the knee by 20%.absorption capacity of the knee by 20%.

The inner 2/3 of the The inner 2/3 of the menisci are menisci are avascular (without avascular (without blood supply)blood supply)

The remaining outer The remaining outer 1/3 is vascular (with 1/3 is vascular (with blood supply)blood supply)

Mechanisms of injuryMechanisms of injury

An acute twisting injury An acute twisting injury from impact during a sportfrom impact during a sport Usually the foot stays fixed on Usually the foot stays fixed on

the ground and the rest of the ground and the rest of body rotatesbody rotates

Getting up from a squatting Getting up from a squatting or crouching positionor crouching position

Loading the knee from a Loading the knee from a fixed positionfixed position

Injuring the meniscusInjuring the meniscus There are several types of tearsThere are several types of tears

Vertical Vertical Radial Radial HorizontalHorizontal DegenerateDegenerate Complex Complex HornHorn

A loss of any part of the meniscus causes A loss of any part of the meniscus causes uneven weight distribution and can lead to uneven weight distribution and can lead to early wear of the kneeearly wear of the knee

The lateral meniscus is not attached as The lateral meniscus is not attached as firmly to the tibia as the medial meniscus, firmly to the tibia as the medial meniscus, making it less likely to become injuredmaking it less likely to become injured

Axial Limb AlignmentAxial Limb Alignment Varus malalignment tends to overload the medial Varus malalignment tends to overload the medial

compartment of the knee, with increased stress placed compartment of the knee, with increased stress placed on the meniscus, and valgus malalignment has the on the meniscus, and valgus malalignment has the same effect on the lateral compartment and lateral same effect on the lateral compartment and lateral meniscus.meniscus.

These increased stresses may interfere or disrupt These increased stresses may interfere or disrupt meniscal healing after repair. Patients with limb meniscal healing after repair. Patients with limb malalignment tend to have more degenerative malalignment tend to have more degenerative meniscal tears, which have been suggested to have an meniscal tears, which have been suggested to have an inherently poorer healing capacity. The use of an inherently poorer healing capacity. The use of an "unloader" brace "unloader" brace has been recommended to help has been recommended to help protect the healing meniscus, although no scientific protect the healing meniscus, although no scientific data exist to support this approach.data exist to support this approach.

Meniscal injury statisticsMeniscal injury statistics Meniscal injuries occur in 15% of ACL Meniscal injuries occur in 15% of ACL

injuriesinjuries 80% of patients with a history of ACL tears 80% of patients with a history of ACL tears

will likely tear their meniscus with will likely tear their meniscus with incidences of instability of the kneeincidences of instability of the knee

70.7% of meniscal injuries are to the 70.7% of meniscal injuries are to the medial meniscusmedial meniscus

Almost all meniscal injuries- ages 20 and Almost all meniscal injuries- ages 20 and under are sports related 11 out of 12 casesunder are sports related 11 out of 12 cases

Ages 20-29, 64.5% were sports relatedAges 20-29, 64.5% were sports related Ages 30-39, 30.6% were sports relatedAges 30-39, 30.6% were sports related Ages 40-49 and 50-59 only 19.6% and Ages 40-49 and 50-59 only 19.6% and

14.3% were sports related14.3% were sports related

What to look for?What to look for?

Not all meniscal tears are symptomaticNot all meniscal tears are symptomatic If there are symptoms you could look for:If there are symptoms you could look for:

SwellingSwelling Pain along the joint line (tenderness)Pain along the joint line (tenderness) Pain when squatting, kneeling or pivotingPain when squatting, kneeling or pivoting Locking of the kneeLocking of the knee Loss of full knee extensionLoss of full knee extension

How can the Physiotherapist How can the Physiotherapist help?help?

If there is a possible meniscal tear 80-90% of If there is a possible meniscal tear 80-90% of the time an athlete will remember the the time an athlete will remember the mechanism of the injury and may report a mechanism of the injury and may report a “pop” or a “snap”“pop” or a “snap”

You could ask the athlete if there is pain You could ask the athlete if there is pain when weight bearing, or bending of the kneewhen weight bearing, or bending of the knee

You could also ask the athlete if they are You could also ask the athlete if they are having any locking in their knee or trouble having any locking in their knee or trouble extending the knee all the wayextending the knee all the way

When there is a meniscal When there is a meniscal injuryinjury

As a Physio in the event of a meniscal As a Physio in the event of a meniscal injury you should injury you should Ice the area in painIce the area in pain Limit movement of the knee joint (rest)Limit movement of the knee joint (rest) Keep weight bearing limited to a tolerable Keep weight bearing limited to a tolerable

level of pain for the injured kneelevel of pain for the injured knee Sometimes a splint can be applied for Sometimes a splint can be applied for

comfortcomfort

Rehabilitation optionsRehabilitation options

There are two common ways that a There are two common ways that a meniscal tear can be repaired surgically : meniscal tear can be repaired surgically : Open/ArthroscopicOpen/Arthroscopic

There is also a non surgical option because There is also a non surgical option because the menisci are partially vascular they the menisci are partially vascular they have the ability to heal themselveshave the ability to heal themselves

Why choose surgery?Why choose surgery?

Surgery is usually advised for a few Surgery is usually advised for a few different reasonsdifferent reasons The location of the tear, if the tear is in a The location of the tear, if the tear is in a

avascular zone it will most likely not heal avascular zone it will most likely not heal itselfitself

If the tear is longer than 5-8mm If the tear is longer than 5-8mm If the pain limits activities of daily livingIf the pain limits activities of daily living Or if the individual is not happy with their Or if the individual is not happy with their

level of functionlevel of function

Rehabilitation after Meniscal Rehabilitation after Meniscal RepairRepair Current studies support the use of unmodified accelerated ACL Current studies support the use of unmodified accelerated ACL

rehabilitation protocols after combined ACL reconstruction and rehabilitation protocols after combined ACL reconstruction and meniscal repair. meniscal repair.

In tears with decreased healing potential (such as white-In tears with decreased healing potential (such as white-white tears, radial tears, or complex pattern tears), white tears, radial tears, or complex pattern tears), limiting weightbearing and limiting flexion to 60 limiting weightbearing and limiting flexion to 60 degrees for the first 4 weeks have been suggested to degrees for the first 4 weeks have been suggested to better protect the repair and increase the healing better protect the repair and increase the healing potential of these difficult tears.potential of these difficult tears.

Rehabilitation after isolated meniscal repair remains controversial. The Rehabilitation after isolated meniscal repair remains controversial. The healing environment clearly is inferior to that with concomitant ACL healing environment clearly is inferior to that with concomitant ACL reconstruction, but good results have been obtained with accelerated reconstruction, but good results have been obtained with accelerated rehabilitation protocols after isolated meniscal repairs.rehabilitation protocols after isolated meniscal repairs.

Surgical techniquesSurgical techniques

The more common technique is arthroscopic The more common technique is arthroscopic partial menisectomy, which consists of partial menisectomy, which consists of removing the torn fragment of the meniscusremoving the torn fragment of the meniscus This reduces irritation, but can effect the weight This reduces irritation, but can effect the weight

distribution in the kneedistribution in the knee The other option is an arthroscopic repair, The other option is an arthroscopic repair,

which requires suturing the meniscus back which requires suturing the meniscus back togethertogether This option attempts to conserve the meniscus This option attempts to conserve the meniscus

in hopes of preventing the early onset of arthritisin hopes of preventing the early onset of arthritis

Rehabilitation after Rehabilitation after MeniscectomyMeniscectomy

Because there is no anatomic Because there is no anatomic structure that must be protected structure that must be protected during a healing phase, rehabilitation during a healing phase, rehabilitation may progress aggressively. may progress aggressively.

The goals are early control of pain and The goals are early control of pain and swelling, immediate weight-bearing, swelling, immediate weight-bearing, obtaining and maintaining a full ROM, obtaining and maintaining a full ROM, and regaining quadriceps strength.and regaining quadriceps strength.

Road to recoveryRoad to recovery

Whether you choose the surgical or Whether you choose the surgical or conservative approach, the rehabilitation is conservative approach, the rehabilitation is similar similar

The rehabilitation time frames can vary The rehabilitation time frames can vary depending on the individual and the depending on the individual and the severity of the tearseverity of the tear

The protocols may vary depending on the The protocols may vary depending on the surgical approach and physician. A surgical approach and physician. A common protocol may include the followingcommon protocol may include the following

Steps to recoverySteps to recovery The patient may be full weight bearing The patient may be full weight bearing

right after the surgery with or without right after the surgery with or without crutchescrutches

Initial symptoms can be reduced using Initial symptoms can be reduced using certain modalities and manual techniquescertain modalities and manual techniques

Stretching/ flexibility exercises focusing on Stretching/ flexibility exercises focusing on hamstrings, quadriceps, hip flexors, hip hamstrings, quadriceps, hip flexors, hip adductors and calf muscles adductors and calf muscles

Strengthening Strengthening Balance trainingBalance training Dynamic exercises/plyometricsDynamic exercises/plyometrics

Initial physical therapyInitial physical therapy The first few sessions of physical therapy The first few sessions of physical therapy

may consist more of modalities and some may consist more of modalities and some manual techniques to address manual techniques to address inflammation, pain and ROM such as:inflammation, pain and ROM such as: Heat/iceHeat/ice UltrasoundUltrasound Electrical stimulationElectrical stimulation Manual stretchingManual stretching Scar and patella mobilizationsScar and patella mobilizations Passive range of motion for full knee flexion Passive range of motion for full knee flexion

and extensionand extension Retrograde massage to decrease swellingRetrograde massage to decrease swelling

Once pain and swelling are reduced Once pain and swelling are reduced the sessions mainly focus on the sessions mainly focus on increasing the strength and flexibility increasing the strength and flexibility of the lower extremity as toleratedof the lower extremity as tolerated

The progression will vary depending The progression will vary depending on the individualon the individual

Some examples of stretching and Some examples of stretching and strengthening exercises are strengthening exercises are illustrated in the following slidesillustrated in the following slides

StretchingStretching HamstringsHamstrings

QuadricepsQuadriceps

Calf musclesCalf muscles

Stretching continuedStretching continued

Hip flexorsHip flexors

Hip adductorsHip adductors

StrengtheningStrengthening Focusing on strengthening the muscles Focusing on strengthening the muscles

around the knee is essential in around the knee is essential in rehabilitation rehabilitation

Quad sets Straight leg raises (in all planes)Quad sets Straight leg raises (in all planes)

Heel raises Leg Curl Heel raises Leg Curl

Leg extensionLeg extension

BalanceBalance

Balance can Balance can sometimes be sometimes be compromised after compromised after an injury or surgeryan injury or surgery

Here are some Here are some balance exercises balance exercises that can helpthat can help

Dynamic Dynamic exercises/plyometricsexercises/plyometrics

Progression to more Progression to more dynamic sports dynamic sports specific exercises specific exercises helps with the helps with the transition back into transition back into sportssports

Return to playReturn to play

This can vary widely from athlete to This can vary widely from athlete to athleteathlete

When the athlete can participate in When the athlete can participate in sport specific exercises without pain or sport specific exercises without pain or weaknessweakness

Full ROM is apparent in the injured Full ROM is apparent in the injured kneeknee

Collaborate decision between athlete, Collaborate decision between athlete, physical therapist and physicianphysical therapist and physician

PreventionPrevention

The prevention of meniscal tears is The prevention of meniscal tears is very similar to the rehabilitation very similar to the rehabilitation

Research has shown that more Research has shown that more flexible and stronger joints are less flexible and stronger joints are less likely to get injuredlikely to get injured

The athlete would continue The athlete would continue stretching and strengthening the stretching and strengthening the lower extremitieslower extremities

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Brindle, Timothy. Nyland, John. Johnson, Darren. “The Meniscus: Review of Basic Brindle, Timothy. Nyland, John. Johnson, Darren. “The Meniscus: Review of Basic Principles With Application of Surgery and Rehabilitation.” Journal of Athletic Principles With Application of Surgery and Rehabilitation.” Journal of Athletic Training. Apr-Jun. 2001. Vol. 36 p. 160-169Training. Apr-Jun. 2001. Vol. 36 p. 160-169

Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and non-sporting environment in an unselected population.” The sporting and non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 Iss. 2 p. 143-149Knee. April 2004. Vol. 11 Iss. 2 p. 143-149

Magee, David. “Orthopedic Physical Assessment 2Magee, David. “Orthopedic Physical Assessment 2ndnd edition.” Philadelphia: W.B. edition.” Philadelphia: W.B. Saunders Company, 1992 Saunders Company, 1992

Meniscus ProtocolsMeniscus Protocols

See pdf.See pdf. 1. Meniscus repair Palomar1. Meniscus repair Palomar 2. Meniscus repair protocol 2. Meniscus repair protocol