Background

Meniscal tears are a common source of pain around the knee. There are two menisci found within your knee, once on the inside (medial) and one on the outside (lateral). Both are designed to increase the surface area of your knee and serve as shock absorbers against load. For that reason your meniscus helps maintain the joint and thus prevent against the development of arthritis.

Meniscal tears may occur due to trauma or degeneration within the knee. Trauma may take many forms: from an athletic injury to a sudden twist or fall on a slippery surface. When a tear does occur the now-loose meniscal fragment may get caught within you knee. This causes pain and a sensation of ‘locking’ or ‘catching’.  For some, they may only notice this at extremes of motion (such as deep squats).

Once a tear occurs your body is often unable to heal it on its own (with rare exceptions). However, the pain associated with many tears recover with time and therapy. For that reason, the presence of a meniscal tear on MRI does not mean you need an operation!

It is also important to know that meniscal tears can also be the result of arthritis within the knee. The chance of having arthritis increases as we age, and is an important consideration when considering how to manage a meniscal tear. For example, arthritic knees do not respond to arthroscopic (or minimally invasive) surgeries. An overview of the treatment options for knee arthritis can be found here XXXX.

 

Work-Up

Patients are often seen first in their family physician’s office. For any patient with knee pain where a fracture has been ruled out, we first recommend a minimum of 6-12 weeks of formal physical therapy before considering additional investigations. Should pain persist beyond this point, the next step is to obtain an X-ray to rule out arthritis in at risk populations. If an X-ray identifies severe arthritis, then the results of an MRI no longer matter as it will not change treatment options. Only after this should other imaging (such as an MRI) be obtained.

Please note that the above approach to knee pain is not designed to ‘with-hold’ or ‘gate keep’ MRIs, but instead it reflects the fact that a significant proportion of painful knees resolve with time and therapy alone.

 

Treatment

If time and therapy do not resolve knee pain, and an MRI demonstrates a meniscal tear, you may be referred to an orthopaedic surgeon. The surgeon may still recommend one or more of the following non-surgical treatment options depending on the individual patients’ case and medical history:

  • Ongoing Physical Therapy: Not all therapists are alike. We favor ones that encourage movement and strengthening of the quadriceps, core and hip muscles over less proven ‘adjuvant’ modalities (i.e. ultrasound or laser). The best therapy makes you move, sweat and helps build muscle. Ensuring the proper therapy is performed is key to your recovery.
  • Injections: There are multiple injections around the knee that may be considered. All seek to provide pain relief. Newer injections, such as Platelet Rich Plasma, may have regenerative properties for other conditions around the knee but have limited evidence supporting their use in meniscal tears.
  • Weight Loss: Obesity can place great strain on knees, exacerbating pain associated with meniscal tears. Achieving and maintaining a healthy weight is an important consideration in helping rehabilitate a knee from any injury or arthritis.
  • Bracing: In instances of combined arthritis and meniscal tears, an off-loader brace may be considered. The purpose of these braces is to decrease the amount of force going through the affected side of the knee, and may be of use in certain circumstances. Similarly, knees with combined ligament and meniscal injuries may benefit from a brace designed to help compensate for the injured ligament. Bracing in isolated meniscal tears is, in our opinion, of limited use.

 

If the above recommended options are not successful in relieving pain, or in specific unique meniscal tears (i.e. a bucket handle tear with a locked knee), surgery will be discussed. The following are commonly recommended surgical procedures that may be recommended depending on your symptoms and imaging:

  • Knee Arthroscopy with Partial Meniscal Resection: For many tears around the knee, it is not possible for us to simply stitch a meniscal tear back together. Due to poor blood supply and often complex forms of tears, a repair is not possible in the vast majority of cases. As such, arthroscopic (or minimally invasive) knee surgery is recommended to resect the loose and torn meniscus. This alleviates pain by avoiding the loose fragments from becoming caught within the knee, and allows for immediate weight bearing and quick return to function.
  • Knee Arthroscopy with Meniscal Repair: In specific circumstances, it may be possible to repair a torn meniscus. A meniscus that is torn around the edge of its attachment (the so-called ‘bucket-handle meniscal tear’) may be amenable to repair if the meniscus comes away as a single large piece without degeneration in an area with a good blood supply. The rehab and recovery of a meniscal repair is prolonged when compared to a resection alone, and often requires a period of non-weight bearing. There is also a higher risk of failure with meniscal repairs, which depends on a complex interplay between tear appearance and location during surgery, age and activity level.
  • Total Knee Replacement: This treatment is here because it is not uncommon when we are referred a patient with a meniscal tear on MRI, only to diagnose them with severe arthritis on X-ray. Meniscal surgery in no way addresses symptoms related to knee arthritis. As such, patients with arthritis may be better served with knee replacement – an option your surgeon will discuss with you if relevant.

 

Expected Follow-up and Recovery

Recovery can be unique to each patient depending on the extent of meniscal damage, and the presence of ligamentous injury or arthritis. The following is a common recovery pathway experienced by most patients:

  1. No Surgery: Most meniscal injuries should be initially treated with physical therapy and avoidance of aggravating activity. As symptoms resolve, the goal is to regain and maintain strength followed by a return to activity. Ideally, a patient continues at their place of work as part of their rehabilitation program. Return to full function depends on the nature of the injury and may range from 1-10 weeks.
  2. Surgical Partial Meniscectomy: Patients are able to walk out of hospital post-surgery and progress activity rapidly from there. We recommend walking and light cycling for 2 weeks following the operation, and progressing to full activity 4-6 weeks after that. Office workers can return within 1-2 weeks while taking time off for ongoing physical therapy. Extremely physical jobs may require 4-6 weeks before returning to work on progressive hours and duties.
  3. Surgical Meniscal Repair: Attempt at meniscal repair requires a brief period of minimal weight bearing, which greatly impacts recovery timelines. According to our protocol, patients remain non-weight bearing in a knee immobilizer for 6 weeks, but may perform focused physical therapy with an experienced provider.  At 6 weeks patients begin gait retraining and progressive strengthening.  Return to work occurs between 2-6 weeks (for office jobs) and 6-12 weeks (for laborers). Maximal recovery is expected somewhere between 3-5 months after surgery.

 

General Information

  • See our Knee Arthroscopy Patient Handout for specific post-operative recommendations.
  • The presence of arthritis is thought to delay recovery by 1-2 weeks depending on severity.
  • Surgery is designed to take away the catching/locking feeling within a knee and the pain associated with this. It will not address arthritis symptoms (i.e. stiffness, activity related ache).
  • Arthroscopic surgery is performed in a water environment under pressures of 60mmHg. Due to this, swelling for 2-4 weeks following an operation is to be expected.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.

 Post-operative rehabilitation should be guided by the procedure performed. Obtain your surgeons post-operative protocol, in advance if possible, so that you and your therapist fully understand any rehabilitation required following surgery.

 

The general non-operative rehabilitation protocol is as follows

  • Brief RICE: A brief period of rest, ice, compression and elevation can be useful for a few days but detrimental in the long run if range of motion is not started ASAP.
  • Early Range of Motion: As pain subsides, you can begin to perform light range of motion exercises with the goal of regaining active range of motion of the knee as quickly as possible. Inability to bend or straighten your knee should prompt return to your physician.
  • Strengthening: Once range of motion is approaching pre-injury levels, strengthening may begin. Strengthening should focus on quadriceps, core and hip abductor strengthening to improve function and decrease risk of future re-injury.
  • Maintenance: As with any injury, exercises should be incorporated into a philosophy of active and healthy living to prevent the risk of future re-injury.

 

Expected Outcomes

Meniscal injuries can be expected to have an excellent result in the majority of people, regardless of what treatment is required. The more meniscus damaged, the greater the chance of developing arthritis later in life. An active lifestyle with maintenance of a healthy weight can decrease those risks as much as possible.

 

Notable Challenges

  • Knee Stiffness: May develop due to post-injury scarring or due to the meniscal tear blocking movement within your knee. Follow-up with your family physician or surgeon to discuss management options.
  • Knee Swelling: Swelling is expected for a few weeks post injury or surgery. Persistent swelling may impede rehabilitation or necessitate more aggressive therapies to manage. Follow-up with your family physician or surgeon to discuss management options.
  • Arthritis: a meniscal tear may be the cause of development of post-traumatic arthritis. Alternatively, arthritis may be the cause of the meniscal tear. Regardless, the presence of a meniscal tear may signal the development of ongoing issues with the affected knee. Your physician will be able to help predict future treatment requirements for your knee.

 

Summary of Common Treatment/Rehabilitation Pathway