What is a meniscal injury?

The meniscus is a crescentic-shaped fibrocartilaginous structure which sits inside the knee joint. It has a number of functions, the main function being to dissipate axial loads into hoop stresses (shock absorber of the knee). Other functions include providing stability to the knee, nutrition to the joint along with proprioception. Injury to the meniscus can occur from a broad range of activities ranging from relatively low-velocity twisting mechanisms through to more high-velocity sporting injuries.

What can cause it?

Injury to the meniscus can occur from a broad range of activities ranging from relatively low-velocity twisting mechanisms through to more high-velocity sporting injuries. Often there is instantaneous pain and the classic description is associated delayed onset of swelling (hours after the injury).

What are the symptoms and signs?

Patients often describe mechanical knee symptoms. This can involve ongoing pain in and around the site of the injury, locking and inability to fully extend the knee and inability to fully flex the knee, along with instability. There is a number of described tests and examinations in the literature:

In the office, asking a patient to fully crouch from a standing position to see if the pain is reproduced is often a relatively reliable way to make the diagnosis.

Can the problem get worse?

Sometimes degenerate type of tears can spontaneously resolve. Non-degenerative tears often continue to cause intermittent mechanical symptoms.

What investigations may be required?

MRI scan is the gold standard investigation.

Non-surgical management

It is often very difficult to predict the natural history of the condition. Often with the degenerative type of tears, there may be some merit in watching and waiting to see whether symptoms can resolve.

Differential diagnosis

  • ACL rupture
  • Patella fracture
  • Patella dislocation
  • Patella tendon rupture
  • Osteochondral defect
  • Chondromalacia patellae
  • Fat pad impingement
  • Housemaids knee
  • Iliotibial band syndrome
  • Patella tendonitis (jumper’s knee)
  • Medial collateral ligament sprain/rupture
  • Osteoarthritis
  • Pes anserine bursitis
  • Popliteal cyst
  • Posterolateral corner injury
  • Quadriceps tendinopathy
  • Quadriceps tendon rupture
  • Plica syndrome
  • Tibial plateau fracture
  • Biceps femoris tendinopathy

Surgical treatment

In the younger, symptomatic, non-degenerative type of tears, keyhole knee surgery is invariably required. Also in such cases, earlier interventions increase the likelihood of success when performing meniscal repairs since the freshly torn tissue is always more biologically more active.

In chronic tears or patients who present later, it is always well worth considering non-operative options prior to proceeding to keyhole knee surgery and partial meniscectomy (trimming of the torn segment).

Click here for more information on knee arthroscopy surgery.

Postoperative period & recovery

Following a partial meniscectomy (trimming) one can fully weight bear. Physiotherapy and rehab is often quite rapid i.e. within weeks.

Following a repair, one is normally on crutches for a six-week period alone with a brace which limits flexion to 90 degrees.

FAQs

What are the potential complications of surgery?

Failure of meniscal repair, infection, residual symptoms, nerve damage, swelling, clots

When would you repair and when would you trim the meniscus?

A number of factors determine this:-

  • Site of tear
  • Shape of tear
  • Duration of symptoms
What is an Anterior Cruciate Ligament Injury?

The Anterior Cruciate Ligament (ACL) is a very important stabiliser of the knee joint. Ligaments connect bone to bone, providing stability. An ACL injury results when this important ligament is damaged. It is the most commonly injured ligament in the knee.

What can cause it?

The classically described injury mechanism involves an indirect valgus (knee bent inwards) force coupled with a twist of the knee.

What are the symptoms and signs?

In the acute stage pain is a factor, however, this rapidly settles and the main symptoms are a feeling of instability or loss of confidence in the knee following repeated episodes of giving way.

There is often an instantaneous swelling of the knee following the injury. There may even be an audible ‘pop’ or ‘click’ heard at the time.

In summary symptoms following an anterior cruciate ligament injury include:

  • Pain
  • Popping sensation at the time of the injury
  • Swelling
  • Bruising
  • Limp

Once the acute swelling and bruising have settled, a thorough clinical examination is performed including the following special tests:

  • Lachman’s test
  • Anterior drawer +/- a pivot shift

Your knee surgeon Mr. Mann will also examine you to rule out or confirm the presence of any associated injury such as:

  • Focal meniscal injury
  • Osteochondral damage
  • Medial collateral ligament injury
  • Lateral collateral ligament injury
  • Posterior cruciate injury
  • Posterolateral corner injury
Can the problem get worse?

In isolated anterior cruciate ligament ruptures the natural history is often quite difficult to predict.

Some patients’ symptoms do settle with a dedicated course of ACL rehabilitation physiotherapy, which is directed towards neuromuscular optimisation of the knee joint.

A recent Scandinavian cohort/observational study, published in the British Medical Journal, showed that a significant proportion of patients do settle with just physiotherapy alone.

Non-surgical management

Acute phase

We recommend the PRICE regime:
Protection – minimise the risk of re-injury, for moderate to severe sprains, the use of crutches is recommended as well as the use of a knee brace
Rest – by avoiding walking on the knee while it remains painful and swollen (at least 48 hrs)
Ice – apply immediately or as soon as possible following the injury to minimise swelling (make sure ice is wrapped in a towel and you apply until area becomes numb, remove and discontinue the ice at this stage, continued application following numbing may result in tissue damage)
Compression – bandages and dressings help immobilise the injured knee, reducing pain and swelling
Elevation – of the knee to at least heart level to help minimise swelling and aid soft tissue healing

During the initial stages of this injury, it is often difficult to perform a meaningful clinical examination as the knee is too painful. Your surgeon will guide you according to the grade of your ligament injury.

Rehabilitation phase

Effective rehabilitation is critical to ensuring full recovery: resolution of painful symptoms, swelling and restoration of stability. It is also important as it will prevent the risk of chronic knee instability. Using an experienced physiotherapist can help with your recovery and rehabilitation.

The different stages of rehabilitation include:
Stage 1 –  this involves resting, protecting the knee and reducing the swelling (week 1)
Stage 2 – this involves restoring the range of motion, strength, flexibility and most importantly proprioception exercises of the knee (week 2-3)
Stage 3 – at this stage return to activities that do not require twisting or turning, and commence pool based exercises
Stage 4 – return to activities that require sharp, sudden turns (cutting activities) such as tennis and football (weeks to months)

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