Meniscus Injury
1. Introduction
The knee is a hinge joint where your shin bone (tibia) meets your thigh bone (femur). The knee joints bend and straighten and withstand considerable levels of force during weight-bearing activities of daily living (walking, stair climbing and running).
The menisci are half-moon-shaped pads of cartilage that are positioned at the top of the tibia (1) and in part they act as shock absorbers. The menisci also nourish the joint cartilage, lubricate the joint and provide stability to the knee. The medial meniscus is particularly important for knee joint stability. They are made of a particular type of cartilage that gives them a tough consistency that is resistant to stress and strain. In general, after adolescence, the menisci have a poor blood supply which means injuries can take longer to heal.
Acute meniscus injuries can occur following trauma, including sporting injuries (3). It has been proposed that specific subgroups of patients (younger patients with acute meniscus tears) benefit more from surgery than others but there is a lack of strong evidence to support this notion.
Frequently Asked Questions
- The meniscus is a C-shaped shaped piece of cartilage that lies between the femur (thigh bone) and the tibia (shin bone). Injury to the meniscus can either tend to be in the form of a tear due to a sudden movement, or through the natural wearing process (degenerative).
- It is reported that 12% to 14% of knee injuries are to the meniscus, with an increased incidence in those suffering anterior cruciate ligament (ACL) injury ranging from 22% to 86% (9).
- No.
- With appropriate advice and rehabilitation most meniscus injuries will improve.
- The majority of meniscus tears are asymptomatic (do not cause any pain).
- Some cases that have not improved with conservative management and have mechanical symptoms require surgery.
- Males are up to 4 times more likely to suffer a meniscus injury (3-5).
- Those that take part in contact and jumping sports, e.g. football and rugby (3).
- Degenerative meniscus tears are associated with the ageing process, thus are more prevalent in middle/older aged individuals.
- Acute meniscus injuries are more common in younger people as a result of trauma, often a sporting/twisting injury (4).
- Pain on the inside or outside of the knee (1-5).
- Mechanical signs: catching, locking, giving way (3-5).
- The knee may be swollen (1-3).
- Activity modification – attempt to remain active within your limitations but modify aggravating activities.
- Seek advice from a physiotherapist as in most cases they will be able to help.
- Exercises to strengthen the knee and reduce pressure on the joint (7).
- This depends on several factors including, but not limited to, location of injury, adherence to rehabilitation and other health concerns.
- It could take 3-6 months to improve, with ongoing improvements after that time (7).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain can be diffuse affecting the whole knee, or it can be felt on the inside (medial) part of the knee where the medial meniscus is located.
- Mechanical symptoms – locking (where the knee gets stuck in a certain position during movement) or giving way (where the knee buckles under load) (3,4).
- Swelling can occur a few hours after the injury.
- There may be the presence of crepitus, which is the sensation of grinding or catching from within the knee joint during movement or activity (5).
3. Causes
The most common cause of acute meniscus tears is through trauma, whereas degenerative tears should be considered a feature of knee osteoarthritis and the ageing process. Sporting injuries are the most common trauma associated with acute meniscal injuries. Twisting the knee whilst weight bearing causes an increase in sheer force on the meniscus which can result in a tear (3).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing a meniscus tear. It does not mean everyone with these risk factors will develop symptoms.
- Males are up to 4 times more likely to suffer a meniscus injury than women (1).
- Being overweight increases the load which can increase your risk of developing meniscus injuries.
- Twisting the knee whilst weight-bearing and contact injuries when playing a sport such as rugby or football (3,4).
5. Prevalence
Prevalence in the general population is low at less than 0.05%, however that is increased in athletes with figures of 12% to 14% of all knee injuries in this group(9). When another injury occurs such as those suffering anterior cruciate ligament (ACL) injury, this figure increases again ranging from 22% to 86% (7, 9). Men are thought to be up to 4 times more likely to suffer a meniscus injury than women (1). They are the most common knee injury for athletes as a result of trauma (3, 4, 7).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis. If the treating clinician suspects a large or more traumatic tear, they may refer you for magnetic resonance imaging (MRI) to evaluate the knee and aid in decision making.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRIs or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of your treatment, your treating clinician will help you understand the condition and what needs to be implemented to effectively manage your meniscal tear. This will include activity modification strategies as well as other useful treatments aimed at reducing discomfort. Regular adherence to a condition-specific rehabilitation programme is important in the management of this condition. It should be noted that rehabilitation exercises are not always a quick fix but, if adhered to on a consistent basis (weeks to months), have been shown to yield positive outcomes.
Depending on symptoms, conservative self-management may be appropriate. Acute injury management such as ice, compression and elevation may help initially before a guided rehabilitation programme to improve the function of the knee.
In some instances, such as when there is significant locking or giving way, it may be more appropriate to refer for a surgical opinion. If the decision is made to undergo surgery, it is paramount that rehabilitation takes place before and after surgery in an attempt to regain the function of the knee and achieve your goals.
8. Rehabilitation
Physiotherapy has good evidence for the management of meniscal tears. Based on your individual goals, your musculoskeletal physiotherapist will prescribe specific exercises to strengthen and mobilise the structures around the knee joint. This in turn will help reduce load on the knee joint and allow the meniscal tear to settle over time (7).
There are no quick fixes but with appropriate adherence to rehabilitation, with or without surgery, you can expect to see improvements in 3 – 6 months which may continue beyond this. Throughout your treatment, you will be given ongoing support and advice so that you can continue to manage your symptoms independently and mitigate the likelihood of reinjury.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing meniscus injuries. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation; this would be particularly suggested for those wanting to return to higher levels of function and/or sport. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Meniscus Injury
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
At this stage, exercises are focused on reducing stiffness often associated with the condition and helping to promote movement and blood flow that can, in turn, reduce any swelling that has occurred. Pain should not exceed 3/10 on your self-perceived pain scale whilst completing this exercise programme.
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- 910
Here the emphasis is on starting to regain strength around the hip and thigh to reduce the stress on the knee. Pain should not exceed 4/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
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- 910
This programme provides a progression of hip and knee strength exercises including a move towards more functional positions ensuring a return to normal day-to-day activities. Pain should not exceed 2/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
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- 910
10. Return to Sport / Normal life
Return to sport is entirely possible after a meniscus injury, regardless of if you have surgery or not. For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a musculoskeletal physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting, and sprinting exercises.
11. Other Treatment Options
In younger patients with no osteoarthritis, the meniscus is important in protecting the joint, and sometimes a surgical repair may be recommended. Repairing the meniscus has been shown to reduce the risk of early onset osteoarthritis when compared to removing the meniscus (meniscectomy) so is recommended as the surgical option of choice. However, studies in various countries have shown that meniscectomy is much more commonly used than surgical repair (8). Both surgeries are completed arthroscopically (keyhole surgery) and require a progressive rehabilitation after surgical intervention (7,8).
12. Links for Further Reading
References
- Makris, E.A., Hadidi, P. and Athanasiou, K.A. (2011). The knee meniscus: structure–function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials, 32(30), 7411-7431.
- Twomey-Kozak, J. and Jayasuriya, C.T. (2020). Meniscus Repair and Regeneration: A Systematic Review from a Basic and Translational Science Perspective. Clinics in Sports Medicine, 39(1), 125-163.
- Doral, M.N., Bilge, O., Huri, G., Turhan, E. and Verdonk, R. (2018). Modern treatment of meniscal tears. EFORT open reviews, 3(5), 260-268.
- Greis, P.E., Bardana, D.D., Holmstrom, M.C. and Burks, R.T. (2002). Meniscal injury: I. Basic science and evaluation. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 10(3),168-176.
- Cks.nice.org.uk. (2017). Traumatic Causes | Diagnosis | Knee Pain – Assessment | CKS | NICE. [online] Available at: <https://cks.nice.org.uk/topics/knee-pain-assessment/diagnosis/traumatic-causes/> [Accessed 15 January 2021].
- Beaufils, P., Becker, R., Kopf, S., Englund, M., Verdonk, R., Ollivier, M. and Seil, R. (2017). Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surgery, Sports Traumatology, Arthroscopy, 25(2), 335-346.
- Beaufils, P., Becker, R., Kopf, S., Matthieu, O. and Pujol, N. (2017). The knee meniscus: management of traumatic tears and degenerative lesions. EFORT open reviews, 2(5), 195-203.
- Kopf, S., Beaufils, P., Hirschmann, M.T., Rotigliano, N., Ollivier, M., Pereira, H., … Seil, R. (2020). Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surgery, Sports Traumatology, Arthroscopy,1-18.
- Logerstedt, D.S., Scalzitti, D.A., Bennell, K.L., Hinman, R.S., Silvers-Granelli, H., Ebert, J.(2018). Knee pain and mobility impairments: meniscal and articular cartilage lesions revision 2018: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 48(2), 1-50.
Other Conditions in
Knees, Orthopaedics
Patellofemoral Pain Syndrome (PFPS)
Knee pain around the kneecap usually worse in static positions, squatting or kneeling.
Patellar Tendinopathy
Knee pain at the lower border of the kneecap which is also known as ‘jumper’s knee’.
Osgood-Schlatter Disease
Pain in an area just below the knee on the shin bone, often with a lump.
Knee Replacement Surgery
Replacement of the knee hinge joint, typically as a result of severe osteoarthritis or trauma.
Knee Osteoarthritis
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Fat Pad Impingement
A rare condition affecting the adipose (fat) tissue that sits under the kneecap (patella) between the joint spaces of the knee.
Degenerative Meniscus
Seen to be normal as we age, but in some situations can result in knee aches, pain or joint swelling.
Bowed Knees
A condition in which the legs are bowed outwards leaving a greater space in between your knees.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.
Anterior Cruciate Ligament (ACL) Injury
Injury to a major stability ligmant in the knee, normally occuring following a significant twisting injury.