Meniscal Tears

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Meniscal Tears

• By Michael LaBella

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Objectives

• You will be able to identify the two menisci in
  the knee
• You will know the most common mechanisms of
  meniscal tears
• You will be able to recognize and evaluate a
  meniscal tear
• You will know the proper treatments and
  rehabilitation for a meniscal tear
• You will understand the requirements for an
  athlete to return to play
• You will learn various stretches and
  strengthening techniques for prevention

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The Knee Joint

• The knee joint has two menisci, a lateral and
  medial
• They are fibrous cartilage
• They rest on top of the tibia in shallow
  indentations
• The lateral meniscus is on the outside of your
  knee and the medial the inside

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Functions of the menisci

• Aid in lubrication and nutrition of the joint
• Act as shock absorbers
• Evenly distribute weight throughout the knee
• Allows for smoother motions between the femur and
  tibia

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• The inner 2/3 of the menisci are avascular
  (without blood supply)
• The remaining outer 1/3 is vascular (with blood
  supply)

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Mechanisms of injury

• An acute twisting injury from impact during a
  sport
• Usually the foot stays fixed on the ground and
  the rest of body rotates
• Getting up from a squatting or crouching position
• Loading the knee from a fixed position

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Injuring the meniscus

• There are several types of tears
• Vertical
• Radial
• Horizontal
• Degenerate
• Complex
• Horn
• A loss of any part of the meniscus causes uneven
  weight distribution and can lead to early wear of
  the knee
• The lateral meniscus is not attached as firmly to
  the tibia as the medial meniscus, making it less
  likely to become injured

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Meniscal injury stats

• Meniscal injuries occur in 15 of ACL injuries
• 80 of patients with a history of ACL tears will
  likely tear their meniscus with incidences of
  instability of the knee
• 70.7 of meniscal injuries are to the medial
  meniscus
• Almost all meniscal injuries ages 20 and under
  are sports related 11 out of 12 cases
• Ages 20-29, 64.5 were sports related
• Ages 30-39, 30.6 were sports related
• Ages 40-49 and 50-59 only 19.6 and 14.3 were
  sports related

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What to look for?

• Not all meniscal tears are symptomatic
• If there are symptoms you could look for
• Swelling
• Pain along the joint line (tenderness)
• Pain when squatting, kneeling or pivoting
• Locking of the knee
• Loss of full knee extension

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How can the coach help?

• If there is a possible meniscal tear 80-90 of
  the time an athlete will remember the mechanism
  of the injury and may report a pop or a snap
• You could ask the athlete if there is pain when
  weight bearing, or bending of the knee
• You could also ask the athlete if they are having
  any locking in their knee or trouble extending
  the knee all the way

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When there is a meniscal injury

• As a coach in the event of a meniscal injury you
  should
• Ice the area in pain
• Limit movement of the knee joint (rest)
• Keep weight bearing limited to a tolerable level
  of pain for the injured knee
• Sometimes a splint can be applied for comfort

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Rehabilitation options

• There are two common ways that a meniscal tear
  can be repaired surgically
• There is also a non surgical option because the
  menisci are partially vascular they have the
  ability to heal themselves

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Why choose surgery?

• Surgery is usually advised for a few different
  reasons
• The location of the tear, if the tear is in a
  avascular zone it will most likely not heal
  itself
• If the tear is longer than 5-8mm
• If the pain limits activities of daily living
• Or if the individual is not happy with their
  level of function

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Surgical techniques

• The more common technique is arthroscopic partial
  menisectomy, which consists of removing the torn
  fragment of the meniscus
• This reduces irritation, but can effect the
  weight distribution in the knee
• The other option is an arthroscopic repair, which
  requires suturing the meniscus back together
• This option attempts to conserve the meniscus in
  hopes of preventing the early onset of arthritis

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Road to recovery

• Whether you choose the surgical or conservative
  approach, the rehabilitation is similar
• The rehabilitation time frames can vary depending
  on the individual and the severity of the tear
• The protocols may vary depending on the surgical
  approach and physician. A common protocol may
  include the following

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Steps to recovery

• The patient may be full weight bearing right
  after the surgery with or without crutches
• Initial symptoms can be reduced using certain
  modalities and manual techniques
• Stretching/ flexibility exercises focusing on
  hamstrings, quadriceps, hip flexors, hip
  adductors and calf muscles
• Strengthening
• Balance training
• Dynamic exercises/plyometrics

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Initial physical therapy

• The first few sessions of physical therapy may
  consist more of modalities and some manual
  techniques to address inflammation, pain and ROM
  such as
• Heat/ice
• Ultrasound
• Electrical stimulation
• Manual stretching
• Scar and patella mobilizations
• Passive range of motion for full knee flexion and
  extension
• Retrograde massage to decrease swelling

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• Once pain and swelling are reduced the sessions
  mainly focus on increasing the strength and
  flexibility of the lower extremity as tolerated
• The progression will vary depending on the
  individual
• Some examples of stretching and strengthening
  exercises are illustrated in the following slides

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Stretching

• Hamstrings
• Quadriceps
• Calf muscles

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Stretching continued

• Hip flexors
• Hip adductors

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Strengthening

• Focusing on strengthening the muscles around the
  knee is essential in rehabilitation
• Quad sets Straight leg
  raises (in all planes)
• Heel raises Leg Curl
• Leg extension

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Balance

• Balance can sometimes be compromised after an
  injury or surgery
• Here are some balance exercises that can help

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Dynamic exercises/plyometrics

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

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Return to play

• This can vary widely from athlete to athlete
• When the athlete can participate in sport
  specific exercises without pain or weakness
• Full ROM is apparent in the injured knee
• Collaborate decision between athlete, physical
  therapist and physician

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Prevention

• The prevention of meniscal tears is very similar
  to the rehabilitation
• Research has shown that more flexible and
  stronger joints are less likely to get injured
• The athlete would continue stretching and
  strengthening the lower extremities

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Bibliography

• Learmonth, DJA. Aspects of the knee meniscal
  injury and surgery. Trauma. 2000. Vol. 2 p.
  223-230
• Gilbert, Rob. Ashwood, Neil. Meniscal repair and
  replacement a review of efficacy. Trauma.
  2007. Vol. 9 p. 189-194
• Lento, Paul. Akuthota, Venu. Meniscal injuries
  A critical review. Journal of Back and
  Musculoskeletal Rehabilitation. 2000. Vol. 15 p.
  55-62
• Boyd, Kevin. Myers, Peter. Meniscus
  preservation rationale, repair techniques and
  results. The Knee. March 2003. Vol. 10 Iss. 1 p.
  1-11
• Brindle, Timothy. Nyland, John. Johnson, Darren.
  The Meniscus Review of Basic Principles With
  Application of Surgery and Rehabilitation.
  Journal of Athletic Training. Apr-Jun. 2001. Vol.
  36 p. 160-169
• 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 Knee. April 2004. Vol. 11 Iss. 2
  p. 143-149
• Magee, David. Orthopedic Physical Assessment 2nd
  edition. Philadelphia W.B. Saunders Company,
  1992