Meniscal Lesions

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Definition/Description

A meniscus rupture is an injury that occurs when pieces of the meniscal cartilage are ruptured and when those pieces were injured by specific movements that rotate the knee with a lot of force, while the foot doesn’t rotate and is firmly planted on the floor. There are partial or total ruptures of a lateral or medial meniscus.⁵ (level of evidence: 2)

Clinically Relevant Anatomy

The clinical relevant anatomy is already described in Arthroscopic Meniscectomy⁹ and meniscus lesions⁸.

Epidemiology /Etiology

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Characteristics/Clinical Presentation

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Differential Diagnosis

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Diagnostic Procedures

A meniscus injury is generally caused by a torsional movement between the femur and the tibia under load without contact, or making an abrupt movement like a squat. Anything which allows the femur to slip too much forward or backward in relation to the tibia may cause some of the forces to be transmitted to the meniscus and result in a meniscus rupture.
During clinical trials, it’s important to pay attention to some specific data:
- Swelling, hydrops at the level of the knee
- Muscle atrophy
- Painful palpation zones, especially at the level of the joint space
- Limited mobility
- Positive McMurray – test⁶

When a meniscus rupture is suspected, a magnetic resonance imaging (MRI) is considered as the best medical imaging modality to confirm a meniscus rupture. This is necessary when the clinical trial and the anamnese aren’t specific enough.

Outcome Measures

See Outcome Measures Database

Examination

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Medical Management

Nonoperative treatment is rarely recommended for meniscal injuries. Sometimes it’s possible when there is a peripheral tear in the red-red junction. Then is healing possible without surgery because of the adequate vascularisation.
The nonoperative treatment consist of rest, ice, compression, elevation, nonsteroidal anti –inflammatory drugs, stretching and strengthening and various physical therapy modalities.

Operative:

An examination of the knee and possible arthroscopy provides a clear classification of meniscus injuries. The size and severity of the meniscus rupture are often indicative for the recovery after surgery  and for eventual later degenerative phenomena in the knee joint.
Different kinds of meniscus ruptures:
- Radial rupture
- Oblique rupture
- Longitudinal rupture
- Bucket handle
- Horizontal rupture
- Complex rupture

Arthroscopy is a small surgery. They look through a thin tube into the knee joint. The procedure can be performed to obtain information of the knee joint. In many cases, there can during the arthroscopy immediate a treatment be given. It’s possible that a larger operation is necessary ³. You can find more information about arthroscopy at the page Arthroscopic Meniscectomy⁸. (level of evidence : 2)

Certain meniscal tears like the bucket –handle rupture require operative treatment to prevent worsening of the rupture, to minimize additional damage to the torn portion of the meniscus and to optimize healing.
There are different kinds of operative treatment for meniscal tears as repair and partial resection.
If a rupture can’t be treated and it involves a large portion of the meniscus, or when repair failed, a significant portion of the meniscus must sometimes be removed. To avoid secondary osteoarthritis, meniscal transplantation may be the best solution.

Physical Therapy Management

The physical therapy consists mainly of RICE⁷ ( Rest, Ice, Compression, Elevation) when surgery isn’t necessary.
RICE is very important in the first 24 hours after an acute soft tissue injury. Especially when there are damaged blood vessels. It helps to reduce pain and swelling. ¹⁰ (level of evidence: 2)

Cryotherapy, also known as ice application, is a method in which the body is contacted with a medium with a lower temperature. Applying a cold source would decrease the temperature of the tissues. It causes superficial vasoconstriction and a decrease of the local blood flow. ¹ ( level of evidence: 1)

Strengthening and stretch exercises for quadriceps and hamstrings are also important when surgery isn’t necessary.

The rehabilitation of a meniscus rupture after surgery depends on the size of the operation.
Each operation is different.
Therefore it’s so important that the physiotherapist makes every time a complete rehabilitation program. (level of evidence: 1)

1. The method of advancing strength depends on the timing of the rehabilitation program but also on          the patient response, availability of equipment and the rehabilitation clinician’s preference. ¹ (level of evidence: 1)
     - Strength exercises:

Isometric exercises for strengthening the quadriceps:
             • Quad set: With patient supine, uninvolved knee flexed and involved knee straight. The patient tries to push the 

               knee down on the table

             • Straight-leg raise

Isometric exercises for strengthening the hamstrings:
             • Hamstrings sets: The patient supine, uninvolved knee straight and involved knee in partial flexion. The patient

               tries to push the heel into the table.

Non-weight-bearing isotonic exercises:
            • Short-arc quad exercise: also called terminal knee extensions.
            • Full-arc quad exercise
            • Hamstring curls

Weight-bearing resistive exercises: When the patient is able to carry weight on the injured knee.
            • Reciprocal training:  training on a stationary bike. 
            • Platform leg press, wall squats, plié, lunge, step-up, step-down, lateral step-up,…

2. Balance and agility exercises begin with double-support weight-bearing activities and progress to single-limb static balancing on a stable surface.¹ (level of evidence: 1)

3. Flexibility exercises and joint mobilization are techniques who improve the range of motion and the flexibility.¹ (level of evidence: 1)

   - Flexibility exercises:
These exercises can be active or passive. The techniques who are used, depend on the type of tissue.
Prolonged extension stretch is used to increase knee extension. This exercise can be performed in two positions, prone or long sitting. Prolonged flexion stretch is an exercise for increasing flexion in the knee. The position used for this exercise depends on how the flexion movement is present.
Active stretches for quadriceps and hamstrings are also important.

   - Joint mobilization:
Reduced joint mobility could be the result of injury, edema, surgery and immobilization. If this develops it can refer pain to the knee and even effect ankle mobility.
Joint mobilization is important for following joints:
          • Superior Tibiofibular joint
          • Patellofemoral joint. Patellar mobility is necessary for full flexion- extension motion for the knee.
          • Tibiofemoral joint. It’s the most often mobilized joint to improve range of motion in the knee.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

 

Book

¹HOUGLUM P.A., ‘Therapeutic Exercise for Musculoskeletal Injuries’ 2005 (level of evidence: 1)

Article

²POULSEN M.R., JOHNSON D.L., ‘Meniscal injuries in the young, athletically active patient.’, 2011 (level of evidence: 2)

Sites

³CHIRURG EN OPERATIE, http://www.chirurgenoperatie.nl/pagina/traumatologie/arthroscopie_knie.php, geraadpleegd op 24 november 2011 ( level of evidence: 2)

⁴HEALTH.COM, http://www.health.com/health/library/topic/0,,uh2071_uh2073,00.html, geraadpleegd op 20 december 2011 (level of evidence: 2)

⁵KNIESLIJTAGE, http://www.knie-slijtage.nl/knie-aandoeningen/meniscus/wat-is-een-meniscusscheur, geraadpleegd op 26 november 2011 ( level of evidence: no references)

⁶MCMURRAY’S TEST, http://www.youtube.com/watch?v=fkt1TOn1UfI, geraadpleegd op 38 november 2011 ( level of evidence: no references)
 
⁷PHYSIOPEDIA, http://www.physio-pedia.com/index.php/RICE, geraadpleegd op 26 november 2011 (level of evidence: 2)

⁸PHYSIOPEDIA, http://www.physio-pedia.com/index.php/Meniscal_Lesions, geraadpleegd op 20 november 2011 (level of evidence: 2)

⁹HYSIOPEDIA, http://www.physio-pedia.com/index.php/Arthroscopic_Meniscectomy, geraadpleegd op 20 november 2011 ( level of evidence: 2)

¹⁰THE STRETCHING INSTITUTE, http://www.thestretchinghandbook.com/archives/meniscus-tear.php, geraadpleegd op 20 november 2011 (level of evidence: 2)