Meniscus injury

Acute

Acute meniscal tears more commonly occur in younger population following trauma such as twisting on a loaded flexed knee. The types of tears associated with these are longitudinal, bucket handle and radial.

Patient reported symptoms: history of trauma, intermittent swelling, pain on joint loading or twisting, intermittent catching and locking, and difficulty positioning in bed at night where the pressure of one knee against the other produces tenderness then an ache.

Clinical signs: include joint line tenderness, pain on forced knee flexion, a block to full knee extension, positive McMurrays test producing a click within the joint (Fowler & Lubliner, 1989; Brukner et al., 2007; Mohan & Gosal, 2007), and muscle wasting (Aichroth, 1996).

Degenerative

Patient reported symptoms: Older age group (40+), minor or repeated trauma (e.g. rising from squatting, 50% occur spontaneously (McDermott, 2011)), fluctuant symptoms, positional night pain.

Clinical signs: pain on forced knee flexion, joint line tenderness, positive McMurrays and/or Thessaly’s test, inability to fully squat leading to posterior, lateral or medial painful block, concurrent early OA changes.

Acute (Day et al, 2009)

Clinical tests (e.g. lack of full extension and McMurrays test) are more reliable after about six weeks when the acute phase is over.  For example:

• Joint line tenderness
• Pin point tenderness
• McMurrays Test (video link)
  
  
• The patient is positioned in supine close to the edge of the plinth on the side to be tested. The clinician stands on the side of the knee to be tested. Clinician supports the patient’s thigh above the joint line. The other hand grasps the foot around the ankle applying lateral rotation of the tibia on the femur. The clinician then applies medial rotation with medial glide to the lower leg, in small sweeping movements. The movement is repeated for the lateral compartment with lateral glide and lateral rotation of the tibia. Movements are performed while moving knee from full flexion to extension. A positive test is an audible “click” or “pop” with reported pain.
• Loss of extension
• Thessaly’s Test (video link)
  
  
  
  The patient is positioned in single leg standing with support from clinician. The clinician asks the patient to rotate medially and laterally three times while keeping the knee in slight flexion. This is then repeated in approximately 20° flexion. Positive test is pain over medial or lateral joint line, they may also complain of ‘locking’ or ‘catching’ sensation.
• Apleys test/manoeuvre (video link)
  
  
  
  The patient is positioned in prone with knee flexed to 90°. Clinician stands on the side to be tested and places hand over the posterior aspect of the thigh as close to the knee as possible. The other hand grasps the foot around the ankle and impacts a vertical pull (distraction force). Maintaining distraction force clinician medially and laterally rotates the tibia on the femur. Repeat with a compression force. Positive test if pain during compression stage but absent during distraction stage.

Degenerative

For example:

• Joint line tenderness
• McMurrays Test (see above)
• Loss of extension
• Thessaly’s test (see above)
• Apleys test/manoeuvre (see above)

Non/low impact strength/conditioning

Degenerate meniscus - in presence of other degenerate knee conditions - See OA.

Degenerate - 8-12 weeks rehab

Traumatic - 6-8 weeks rehab

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved.  Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Acute

Initial treatment for managing acute meniscal tears should be aimed at relieving symptoms through PEACE and LOVE protocol. Physiotherapy should be tried for 6 to 8 weeks in acute knee pain patients without significant injury (Button et al., 2012).

The following meniscal lesions are more commonly treated surgically: torn discoid lateral meniscus, peripheral detachment and instability of posterior horn lateral meniscus (posterolateral corner), radial tears of the lateral meniscus in young athletes (McDermott, 2011).

Meniscal repair is considered in tears that occur in the outer third where there is sufficient blood supply and cells are metabolically active.

Post-surgery:

• Consult local guidelines where available
• There is no clear consensus on the best rehabilitation post-surgery. Evidence of most common practice in the UK is provided by (McDermott, 2011)

Degenerative

Overall evidence strongly suggests that horizontal, flap, and complex tears are more commonly degenerative in origin and occur more frequently in older populations (Larking, 2010). Degenerative tears tend to occur in patients over the age of 40 years due to changes within the menisci where loss of elasticity causes them to become more friable.

In patients over the age of 40 years conservative management is advised, particularly if there are no significant functional problems or mechanical symptoms of locking/instability.

Physiotherapy should be tried for 8 to 12 weeks with ongoing mechanical symptoms in acute knee pain patients without significant injury.

• Exercise
  • No difference in either short term or long term outcomes between surgery and exercise, (however no control group) (Herrlin et al., 2012)
  • Exercise alone was as effective as surgery and exercise (Herrlin et al., 2007)
  • 46% of patients avoid surgery with conservative treatment alone (McCarthy et al., 2000)
  • Programmes should be attempted with all but the most severe cases of locked knees secondary to displaced bucket handle tears (Oei et al.,2009)
  • Methods that empower patients with knee injuries to self-care by rehabilitation in their own environment are required(Button et al., 2012)
  • A brief summary of what was found to be generally helpful: low impact, eccentric strengthening; maintenance of proprioception and use of multi-component exercise programmes.

Non evidence based strategies

Degenerative

• Electrotherapy: Short term or no benefit (Button et al., 2012)
• Taping: Short term or no benefit (Button et al., 2012)
• Manual therapy isolated treatments: Short term or no benefit (Button et al., 2012)

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

Criteria to refer on:

Acute

• Urgent referral if knee locked.
• Surgery considered if mechanical symptoms are significant or persist despite rehabilitation (traumatic 6-8 weeks, degenerative 8-12 weeks), subject to further imaging (NHS Scotland 2011).
• Consider early referral for those less than 20 years of age as may be suitable for meniscal repair.

Degenerative

• Mechanical symptoms following 8 to 12 weeks of rehabilitation, such as locking or instability, inability to return to work/usual activities of daily living.

Aichroch P. Degenerative meniscal tears. The Knee 1996 /7;3(1):70-71. Click here to access full text (link correct as at 20.8.15)

Brukner P, Khan K. Clinical sports medicine. 3rd ed. ed. Australia: McGraw-Hill; 2007

Fowler PJ, Lubliner JA. The predictive value of five clinical signs in the evaluation of meniscal pathology. Arthroscopy 1989;5(3):184-186. Click here to access full text version (link correct as at 20.8.15)

Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. Int Orthop 2007 Feb;31(1):57-60. Click here to access full text version (link correct as at 20.8.15)

MCCARTY, E.C., MARX, R.G. and WICKIEWICZ, T.L., 2000. Meniscal tears in the athlete. Operative and nonoperative management. Physical Medicine and Rehabilitation Clinics of North America, 11(4), pp. 867-880.

BUTTON, K., IQBAL, A.S., LETCHFORD, R.H. and VAN DEURSEN, R.W., 2012. Clinical effectiveness of knee rehabilitation techniques and implications for a self-care treatment model. Physiotherapy, 98(4), pp. 288-299. Link here (link correct as at 21/8/15)

HERRLIN, S., HALLANDER, M., WANGE, P., WEIDENHIELM, L. and WERNER, S., 2007. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 15(4), pp. 393-401. Link here (link correct as at 21/8/15)

HERRLIN, S.V., WANGE, P.O., LAPIDUS, G., HALLANDER, M., WERNER, S. and WEIDENHIELM, L., 2013. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 21(2), pp. 358-364. Link here (link correct as at 21/8/15)

MAFFULLI, N. and LONGO, U.G., 2008. Conservative management for tendinopathy: is there enough scientific evidence? Rheumatology (Oxford, England), 47(4), pp. 390-391. Link here (link correct as at 21/8/15)

MCDERMOTT, I., 2011. Meniscal tears, repairs and replacement: their relevance to osteoarthritis of the knee. British journal of sports medicine, 45(4), pp. 292-297. Link here (link correct as at 21/8/15)

NHS SCOTLAND, 2011. National musculoskeletal guidelines for knee pain. NHS Scotland. Link here (link correct as at 21/8/15)

OEI, E.H., KOSTER, I.M., HENSEN, J.H., BOKS, S.S., WAGEMAKERS, H.P., KOES, B.W., VROEGINDEWEIJ, D., BIERMA-ZEINSTRA, S.M. and HUNINK, M.G., 2010. MRI follow-up of conservatively treated meniscal knee lesions in general practice. European radiology, 20(5), pp. 1242-1250. Link here (link correct as at 21/8/15)