Everything you need to know about the diagnosis and treatment of meniscus tears: Part 2 of 3

In our older patients we often see medial meniscus tears. These normally occur in isolation and are the result of repetitive movements or overloading and form part of a degenerative process. Often these patients can’t tell when exactly they injured the meniscus. For example, the knee may have buckled or twisted slightly during a relatively minor, insignificant activity, like during a walk or stepping off a pavement, tearing the meniscus.

Recently we’ve seen an increase in older patients who have torn the root (or attachment) where the back of the meniscus connects to the bone. These usually occur during an activity with repeated deep flexion where the knee is bent quite forcefully, like during skipping, jumping, or squatting. In these cases, the patients often hear a popping or clicking sound at the back of the knee while doing the activity.

Signs and symptoms of a meniscus tear

Patients with a torn meniscus may experience sudden or gradual onset of pain.

Most patients with a lateral meniscus tear describe having heard a pop in their knee accompanied by a sharp shooting pain, which quickly disappears. Many continue to feel discomfort along the joint line on the inside or outside of the knee and will usually start experiencing swelling anything from 48 hours to two weeks after the injury occurred.

Patients have also reported feeling instability in the knee, the feeling that the knee is giving away, clicking, the knee wanting to bend further than normal, a decrease in the range of motion, or that the knee gets stuck or locks. Patients with a severe tear may struggle to weight bear.

The analogy I use with my older patients is that a medial meniscus tear is like a stone in your shoe. On some days you are very aware of it and on other days you won’t notice it at all.

Depending on a patient’s symptoms, we can often get a good idea of where the tear is situated and the urgency with which it needs to be treated.

Diagnosing a meniscus tear

When patients come to me with a potential meniscus tear, we  first take a detailed medical history before examining the knee.

During the examination, we look for pain along the joint line when the knee moves and a possible click, pain with deep flexion when the knee is pushed right back, and swelling or an effusion (water on the knee).

We take X-rays of all patients. In our older patients we do this to confirm whether they have severe arthritis which would influence our treatment plan. In younger patients we need to make sure that there isn’t a fracture.

If I suspect a meniscus injury and my patients are willing, I also do an MRI of the knee. This gives us the most accurate diagnosis, showing us the type and extent of the tear, to determine whether it needs surgical treatment. After an MRI we discuss treatment and rehabilitation options with a patient allowing them to make an informed decision regarding their treatment.

Types of meniscus tears

There are two overarching types of meniscus tears. Degenerative tears are more common in older patients and are a result of repetitive trauma. They are usually medial tears in the posterior third of the meniscus or at the root attachment.

Traumatic tears are commonly seen in younger sports people and are the result of a sudden trauma to the knee during an activity.

These are some of the most common types of meniscus tears we see, characterised by their appearance:

• Longitudinal (vertical) tear: The tear is in line with the fibres of the meniscus. Longitudinal tears in the outer two-thirds of the meniscus have the best chance of healing.
• Bucket handle tear: Usually starts as a longitudinal tear which elongates until the inner portion of the torn meniscus flips over towards the middle of the knee like a bucket handle. Patients with a bucket handle tear often feel the knee catching or getting stuck.
• Radial tear: The tear crosses through from the inner portion of the meniscus to the outer portion.
• Parrot beak tear: This tear creates a curved ‘V’ or wedge shape usually in the posterior medial meniscus and is caused by a traumatic event.
• Horizontal tear: Also known as a cleavage tear, these horizontal tears are associated with degeneration and are more common in older people.
• Flap tear: A small piece of the meniscus is torn and flipped over. Sometimes patients will experience catching in the knee. Some do not experience any pain at all.
• Root tear: The root (or attachment) where the back of the meniscus connects to the bone is torn. Root tears can lead to the development of early arthritis.
• Complex tear: A combination of different tears in multiple parts of the meniscus.

Treatment options

Many meniscus tears can be treated without surgery and will settle in time if you adjust your activities to rest the knee.

However, we recommend meniscus repair surgery for our young patients because it protects the function of the knee. We also suggest that older patients who want to return to sports or activities where they load or place the joint under stress consider a repair, provided they don’t have bad arthritis and that they are willing to undergo extensive rehabilitation after surgery.

Meniscus repair surgery: There has been a threefold increase in meniscus repair surgeries over the past few decades. A meniscus repair is an arthroscopic (keyhole) surgery done with the help of a camera. It involves suturing (stitching) the tear using a combination of three types of suturing techniques (all inside, inside-out, and outside-in). These stitches remain in the knee forever. Some patients may need an extra incision or two depending on the suturing technique used.

When repairing a meniscus tear, we suture in such a way that the patient experiences stability in the knee but that they can still move it and potentially weight bear.

Sometimes we use augmentation techniques to accelerate the healing process. This could include the use of platelet-rich plasma (PRP) or drilling holes in the bone to get fat to realign to that area.

It is important to note that repairs can only be done when the quality of the meniscus tissue is good. Often in older patients, the tissue quality is poor, which means that the stitches won’t hold.

Meniscectomy: If a patient doesn’t want a repair, we may be able to perform a meniscectomy. Here we use arthroscopy to trim a portion of the meniscus so that it’s shaped properly again. However, this procedure changes the shock absorber characteristics of the meniscus and the patient’s chances of developing arthritis in the future increases.

What to expect after treatment

Both meniscus repair surgery and meniscectomies are performed as same-day surgery, which means that the patient will be admitted in the morning and discharged in the afternoon depending on how they feel afterwards.

After meniscus repair surgery: After a meniscus repair surgery, the patient will wear a brace and use crutches for between six weeks and three months. A full recovery from meniscus surgery usually takes between seven to nine months and involves extensive rehabilitation with a physiotherapist. Runners will have to wait at least eight months before running again.

Meniscus repair surgery has a success rate of more than 75%, depending on the type and location of the tear. If the repaired tear has healed by five months post-surgery, then it is unlikely to tear again.

After a meniscectomy: There isn’t any healing needed after a meniscectomy. Patients can weight bear immediately and will have to use crutches until they can walk without limping. They will need to avoid all high impact activities for six weeks after the procedure.

Runners will be able to resume running, however it will feel different. Low load-bearing activities such as cycling and golf won’t be affected.

In the third and final article in this series, we will look at what rehabilitation with a physiotherapist will entail after meniscus repair surgery.

Reference list

Amoo-Achampong, K., Amendola, R.L., Amendola, A. (2021) Narrative review of lateral meniscus repair: techniques and outcomes. Annals of Joint 6(32). DOI http://dx.doi.org/10.21037/aoj-20-110

Meniscus Tear. Burnham Sports Medicine. https://www.jeremyburnhammd.com/meniscus-tear-arthroscopic-meniscus-surgery/

Pache, S., Aman, Z.S., Kenedy, M. et al. (2018) Meniscal Root Tears: Current Concepts Review. The Archives of Bone and Joint Surgery 6(4), pp250-259.

Pitts, J. (2021) 6 Meniscus Tear Types And How To Treat Them Properly. Centeno-Schultz Clinic. https://centenoschultz.com/meniscus-tear-types/

Schweizer, C., Hanreich, C., Tscholl, P.M. et al. (2021) Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta-analysis with a minimum follow-up of 5 years. Knee Surgery, Sports Traumatology, Arthroscopy 30, pp2267-2276. DOI https://doi.org/10.1007/s00167-021-06770-x