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Meniscal Tears

Robert C. Manske, PT, DPT, MEd, SCS, ATC, LAT, CSCS

Professor and Chair

Wichita State University

Department of Physical Therapy

Via Christi Health, Wichita, Kansas

Described originally as

functionless remains of leg

muscles

Sutton JB. Ligaments: their nature and

morphology. London: MK Lewis, 1897.

Meniscus – Meniskos – “Cresent”

Mene – “Moon”

Fox AJS, Bedi A, Rodeo SA. The basic science of

human knee menisci: Structure, composition, and

function. Sports Health. 2012; 4(4):340-351.

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Embyologic remnants which

when torn were potent generators

of arthritis

McDermott ED, Amis AA. The consequences

of meniscectomy. J Bone Joint Surg Br.

2006;88:1549-1556.

“A far too common error is

shown in the incomplete removal

of the injured meniscus”

McMurray T. The semilunar cartilages. Br J

Surg. 1942;29:407-414.

Incidence

One of most common injuries treated by

orthopedic surgeons

ABOS – most common procedure reported

during Part-II Examination was meniscal

debridement.

Howell G. Clinical presentation of the knee. In: Bulstrode C, Buckwalter

J, Carr A, et al (eds) Oxford Textbook of Orthopaedics and Trauma.

New York, NY. Oxford University Press, 2002.

Garrett WE JR, et al. American Board of Orthopaedic Surgery practice

of the orthopaedic surgeon: Part-2, certification examination case mix. J

Bone Joint Surg Am. 2006;88:660-667.

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Incidence

Approximately 1 Million meniscal surgeries

performed each year.

Incidence in athletes reported to be

61/100,000.

Cook JL. The current status of treatment for large meniscal defects. Clin

Orthop. 2005;435:88-95.

Baker BE, et al. Review of meniscal injury and associated sports. Am J

Sports Med. 1985;13:1-4.

Medial Mensicus

C-shaped (semicirular)

3.5 cm in length

Wider posterior than anterior

Attached to MCL and medial capsule

Semimembranosus attached to post horn and causes post translation of MM during knee flexion

Injured 2-5 times more than LM

Lateral Meniscus

Circular, O-shaped; 4/5

ring

Similar width anterior and

posterior

2 times as much mobility

as medial mensicus

Popliteus tendon attaches

to post horn of LM

causing post translation

during knee flexion

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Lateral Meniscus Lateral (80%) covers larger surface area of tibia

than medial (60%) meniscus

Johnson DL, et al. Insertion-site anatomy of the human menisci: Gross

arthroscopic and topographical anatomy as a basis for meniscal transplantation.

Arthroscopy. 1995;11:386-394.

Kettlekamp DB, Jacobs AW. Tibiofemoral contact area: Determination and

implications. J Bone Joint Surg Am. 1972;54:349-356.

Anterior and Posterior

Meniscofemoral Ligaments Run from posterior horn of lateral mensicus to medial

femoral condyle

Just in front of or behind the posterior cruciate ligament

Anterior – Ligament of Humphrey

Posterior – Ligament of Wrisberg

Ultrastructure

Debate as to whether cells of meniscus are

fibroblasts, chondrocytes, or mixture of

both

Classified as fibrous tissue or

fibrocartilage?

Ghadially FN. Fine structure of synovial joints.

London: Butterworths, 1983.

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Ultrastructure

Generally termed “fibrochondrocytes”

because of their chondrocyte appearance

and their ability to synthesize a

fibrocartilage matrix

McDevitt CA, Miller RR, Spindler KS. The cells and cell

matrix interaction of the meniscus, In: Mow VC, Arnoczky

SP, Jackson DW, eds. Knee Meniscus: Basic and Clinical

Foundations. New York, Raven Press: 1992.

Ghadially FN. Fine structure of synovial joints. London:

Butterworths, 1983.

Ultrastructure

Extracellular matrix of collagen (60-70% of

dry weight).

90% type I collagen

Types II, III, V and VI have been identified

Eyre DR, et al. Biochemistry of the meniscus:

unique profile of collagen types and site dependent

variations in composition. Orthop Trans 1983;8:56.

Ultrastructure

Electron Microscopy

Three different collagen framework layers

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Ultrastructure

Superficial layer

Fine fibrils woven

into mesh-like matrix

Aspiden RM, et al. Collagen orientations in the meniscus

of the knee joint. J Anat 1985;140:371-380.

Yashui K. The dimensiojal architecture of human normal

menisci. J Jpn Orthop Assoc 1978;52:391-399.

Ultrastructure

Surface layer

Just below superficial

layer

Irregularly aligned

collagen bundles





Ultrastructure

Middle layer

Collagen coarser, larger

and oriented in parallel

circumferential

direction

Aspiden RM, et al. Collagen orientations in the meniscus of the

knee joint. J Anat 1985;140:371-380.



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155528/figure/F4/


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Ultrastructure

Middle layer that

allows meniscus to

resist tensile forces and

functions to transmit

loads across knee joint





Bullough P, et al. The strength of the menisci of the knee as it relates

to their fine structure. J Bone Joint Surg Br. 1970;52:565-567.

Material Properties

Different from that of other collagen tissues such as tendons and ligaments

Because of meniscus triangular shape –compressive forces tend to extrude meniscus outward toward periphery

Circumferential tensile stress often referred to as “hoop stress”

Derived from hoops of a barrel

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Mensicus

General features

Meniscopatellar

ligaments

Transverse

ligament

Meniscofemoral

ligaments

Anatomy of the Meniscus

Peripheral 1/3

Vascular

“Red – Red” Zone

Ability to heal if torn

Aneural

Middle 1/3

Less Vascular

Border of vascular supply

“Red-White” Zone

Aneural

White portion


Medial (inner) 1/3

Even Less Vascular

“White -White” Zone

Aneural

White portion



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Relatively avascular

Blood supply from superior and inferior medial and lateral genicular arteries

Branch off popliteal artery

Meniscus Vascular penetration

10-30% width of

medial meniscus

10-25% of lateral

meniscus

Arnoczky SP, et al. Microvasculature of the human meniscus. Am J

Sports Med 1982;10:90-95.

Arnoczky SP, et al. The microvasculature of the meniscus and its

response to injury: an experimental study in the dog. Am J Sports Med

1983;11:131-141.

Clark CR, Ogden JA. Development of the human knee joint. J Bone

Joint Surg 1983;65A:538-547.

Danzig L, et al. Blood supply to the normal and abnormal meniscus of

the human knee. Clin Orthop 1983;172:271-276.

Meniscus Birth – entire meniscus

vascularized

Avascular with age –

weight bearing?

2nd decade only peripheral

rim

Petersen W, Tillmann B, Age-related blood and lymph supply of the knee

menisci. A cadaver study. Acta Orthop Scand. 1995;66:308-312.

Arnoczky SP, et al. Microvasculature of the human meniscus. Am J

Sports Med 1982;10:90-95.

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Meniscus

Remaining portion of

each (65-75%) receive

nourishment from

synovial fluid via

diffusion

Meyers E, et al. Viscoelastic properties of articular cartilage and

meniscus. In: Nimni M, (ed): Collagen: Chemistry, Biology and

Biotechnology. Boco Raton, Fl. CRC Press, 1988.

Mow V, et al. Fundamentals of articular cartilage and meniscus

biomechanics. In: Ewing JW (ed). Articular Cartilage and Knee Joint

Function: Basic Science and Arthroscopy, New York, Raven Press.

1989.

Anatomy of Mensicus

Vast majority of mensicus is avascular

Derive nutrition through passive diffusion

or mechanical pumping

Intermittent compression

Arnoczky SP, et al. Meniscal diffusion: an experimental

study. Trans Orthop Res Soc 1980;5:42.

Anatomy of Mensicus

Some feel that because of the denseness of

the tissue, diffusion into central core may be

marginal.

Noble J, Hamblen DL. The pathology of the degenerative

meniscus lesion. J Bone Joint Surg 1975;57B:180-186.

Peters TJ, Smilie IS. Studies on the chemical composition

of the menisci of the knee joint with special reference to

the horizontal cleavage lesion. Clin Orthop 1972;86:245-

252.

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Anatomy of Mensicus

Thus “mechanical pumping” (e.g., joint

motion) may be essential for continued

tissue nutrition.

Arnoczky SP, et al. Meniscal diffusion: an experimental

study. Trans Orthop Res Soc 1980;5:42.

Coronary Ligaments

Highly innervated

Attach menisci to

tibial plateau

Source of joint line

pain with meniscal

tear

Neuroanatomy

Nerve fibers and sensory receptors

Found mainly in peripheral, vascular zone

In outer 1/3 of meniscus

Pacinian and Ruffini corpuscles and free nerve endings are found in the anterior and posterior horns

Provide some proprioceptive benefit when stimulated by motion and deformation

Day B, et al. The vascular and nerve supply of the

human meniscus. Arthroscopy 1985;1:58-62.

Zimney ML, et al. Mechanoreceptors in the human

medial meniscus. Acta Anat 1988;133:35-40.

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Neuroanatomy Most abundant in horns of meniscus

May play important proprioceptive role during extremes of knee flexion and extension when horns become taut.

May provide CNS with information regarding joint position

Kennedy JC, et al. Nerve supply of the human knee and its functional

importance. Am J Sports Med 1982; 10:329-335.

Day B, et al. The vascular and nerve supply of the human meniscus.

Arthroscopy 1985;1:58-62.

Zimney ML, et al. Mechanoreceptors in the human medial meniscus.

Acta Anat 1988;133:35-40.

O’Connor BL. The mechanoreceptor innervation of the posterior

attachment of the lateral meniscus of the dog knee joint. J Anat

1984;138:15-26.

Meniscus

Movement Unequal movement

Become distorted

Inefficient as a chop

block

Forward during

extension

Backward during

flexion

Biomechanics of Meniscus

Total excursion

AP

Medial

6 mm

Lateral

12 mm

Thompson WD, et al. Tibial meniscal dynamics using three-

dimensional reconstruction of magnetic resonance images.

Am J Sports Med 1991;19:210-215.

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Morphologic changes of OKC deep

knee flexion

20 healthy adults

0-147° flexion

Superconductive open-type MR system

Hamomoto K, et al. MRI Evaluation of the movement and

morphological changes of the meniscus during deep knee

flexion. J Phys Ther Sci 2004;16:143-149.


Backward

excursion of

anterior horn sig

greater than

posterior horn





No difference in

excursion of

anterior horn of

medial vs lateral

meniscus




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Excursion of

posterior horn of

lateral meniscus sig

greater than that of

medial meniscus




Position Medial

Anterior horn

Medial

Posterior horn

Lateral

Anterior horn

Lateral

Posterior horn

Deep Knee

Flexion16.79 mm 8.91 mm 15.97 mm 13.15 mm


Excursion greater than Thompson

Frozen cadaveric knees

Age of subjects

Mean flexion angles of 120° vs 147°

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AP diameter

significantly

reduced in both

medial and lateral

meniscus





Indicates

movements of

meniscus ensures

maximal

congruency with

articulating

surfaces





This dynamic congruity

facilitates:

Load transmission

Shock absorption

Stability and

lubrication




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Knee

Extension Patella moves

cephalically

Tightens patellomeniscal ligaments (Kaplan’s Lig.) which attaches to anterior horn of meniscus and pulls anteriorly

Functions of Meniscus

Distribute weight bearing loads over a

larger surface area and increase stability

Medial = 50% of load in medial

compartment

**Lateral = 70% of load in lateral

compartment

Seedhom BB, et al. Proceedings: Functions of the

menisci. A preliminary study. Ann Rheum Dis.

1974;33:11.


Joint stability

Increase joint congruency by deepening

tibial plateau

Limits abnormal movements which you get

with a meniscectomy

Guides normal movements

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Joint Stability

Meniscectomy alone may not significantly

increase joint instability.

Meniscectomy with ACL insufficiency

significantly increases anterior laxity

Levy IM, et al. The effects of medial meniscectomy on

anterior-posterior motion of the knee. J Bone Joint Surg

1982;64A:883-888.


Joint Stability

Cadaver Study

Significant increased load on ACL graft

after medial mensiscectomy

Papageorgiou C, et al. The biomechanical

interdependence between the anterior cruciate ligament

replacement graft and the medial meniscus. Am J Sports

Med 2001;29:226-231.


Joint Stability

Cadaver Study

Significant increased varus and valgus laxity with

absent ACL and medial meniscus as compared to

ACL deficiency alone with intact medial

mensiscus

Markolf K, et al. Measurement of knee stiffness and

laxity in patients with documented absence of the

anterior cruciate ligament. J Bone Joint Surg

1984;66:242-252.

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Meniscus Crucial

Fairbank described

changes that accompany

meniscal removal:

Narrowing of joint

Flattening of femoral

condyle

Formation of

osteophytes

Fairbanks TJ. Knee joint changes after meniscectomy.

J Bone Joint Surg 1948;30B:664-670.


Improved articular nourishment (?)

Chondrocytes the cells of articular cartilage receive nutrition via imbibition

Joint approximation causes joint compression which forces the nutrients near the articular surface

CPM helps maintain the integrity of the articular cartilage

Problems When Meniscus

Removed Abnormal path mechanics

Results in OA

Results in DJD

Partial meniscectomy

Results in joint instability

Leads to degeneration of articular cartilage

ACL deficient knees

Leads to tears of the menisci within 6 months, secondary to instability

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Normal Load Distribution

When meniscus is

removed contact area

drops to 40% that of

normal

Right: Contact area of

intact meniscus

Abnormal Load Distribution

Less contact area gives

rise to increased stress

on articular cartilage,

mechanical damage to

chondrocytes and

matrix


Resection of as little

as 15-34% of

meniscus increased

contact pressures by

over 350%.


not benign!

Seedholm BB, Hargreaves DJ. Transmission of the load in

the knee joint with special reference to the role of the

menisci II. Eng Med 1979;8:220-228.

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11 models used to investigate

effect of location of

meniscectomy on tibial

articular cartilage

Atmaca H, Kesemenli CC, Memisoglu K, Ozkan A, Celik Y. Changes in loading

of tibial articular cartilage following medial meniscectomy: a finite element

analysis study. Knee Surg Sports Traumatol Arthrosc. 2012:DOI

10.1007/s00167-012-2318-6.


Atmaca H, Kesemenli CC, Memisoglu K, Ozkan A, Celik Y. Changes in loading

of tibial articular cartilage following medial meniscectomy: a finite element

analysis study. Knee Surg Sports Traumatol Arthrosc. 2012:DOI

10.1007/s00167-012-2318-6.


Extent of degenerative

changes are directly

proportional to amount

of excised meniscus

Cox J, et al. The degenerative effects of partial and total

resection of the medial meniscus in dogs’ knees. Clin

Orthop 1975;109:178-183.

Milachowski K, et al. Homologous meniscus

transplantation: experimental and clinical results. Int

Orthop 1989;13:1-11.

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Mechanism of Injury

Flexion/Rotation injury

Torsion and axial loading

In a flexed position and trying to turn or extend

Coupled movements occur commonly in athletic endeavors

Trapped posterior horn

May create a bucket handle tear

Wheatley WB, Krome J, Martin DF. Rehabilitation programmes

following arthroscopic meniscectomy in athletes. Sports Med

1996;21:447-446.

Mechanism of Injury

Older – degenerative tears may be

asymptomatic

Mechanism of Injury

More common with ACL tears as a result of

abnormal tibial translation

Lateral meniscal injury usually associated with

acute ACL tear

Medial mensical injury more often in persons with

chronic ACL insufficiency

Shelbourne KD, Nitz PA. The O’Donoghue triad revisited: combined

knee injuries involving anterior cruciate and medial collateral

ligament tears. Am J Sports Med 1991;19:474-477.

Smith JP, Barrett GR. Medial and lateral meniscal tear patterns in

anterior cruciate ligament-deficient knees. A prospective analysis of

575 tears. Am J Sports Med 2001;29:415-419.

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O’Donoghue Triad

Lateral meniscus?

Shelbourne KD, Nitz PA. The O’Donoghue triad revisited: combined

knee injuries involving anterior cruciate and medial collateral

ligament tears. Am J Sports Med 1991;19:474-477.

Barber F. Accelerated rehabilitation for meniscus repairs. Arthroscopy

1994;10:206-210.

Barber F. Snow skiing combined anterior cruciate ligament/medial

collateral ligament disruptions. Arthroscopy 1994;10:85-89.

Duncan JB, et al. Meniscal injureis associated with acture anterior

cruciate ligament tears in alpine skiers. Am J sports Med

1995;23:170-172.

Names of Medial Tears

Bucket handle

Flap

Horizontal cleavage

Radial

Degenerative

Double radial

Names of Medial Tears

Bucket handle

Flap

Horizontal cleavage

Radial

Degenerative

Double radial



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Names of Lateral Tears

Bucket handle

Symptoms of Meniscal Injury

Popping, catching, and locking

Pain – Poor localization.

Effusion (?)

Pain or popping along joint line with forced

flexion and rotation

Dye S, et al. Conscious neurosensory mapping of the internal

structures of the human knee without intra-articular anesthesia. Am J

Sports Med 1998;26:773-776.

Knee Locking

16 year old boy

motorcycle accident

Fractured pelvis and

injuries to both limbs

10 cm laceration lat

knee

Boye S, et al. Cases J 2010;3:2.

www.casesjournal.com/cpmtemt/3/1/72

http://www.casesjournal.com/cpmtemt/3/1/72

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Knee Locking Immediate debridement

Long saphenous vein grafting to severed

femoral artery

Fasciotomies

Skin grafts applied to faciotomies

Non displaced patellar fracture

Uneventful recovery

Returned 6 moths later with locking in knee

Boye S, et al. Cases J 2010;3:2.


Knee Locking

Boye S, et al. Arthroscopic removal of a plastic soft drink bottle cap in

the knee: a case report. Cases J 2010;3:2.




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Physical Examination

Diagnosis can be made accurately in 75%

of knees based on history alone!

DeHaven KE, Collins HR. Diagnosis of internal derangements of

the knee. The role of arthroscopy. J Bone Joint Surg. 1975;57:802-

810.

Daniel D, Daniels G, Aronson D. The diagnosis of meniscus

pathology. Clin Orthop. 1982;163:218-224.

Physical Examination

Joint line tenderness – 77-89% sensitivity

McMurray test – 79% sensitivity

Eren OT, The accuracy of joint line tenderness by physical examination

in the diagnosis of meniscal tears. Arthroscopy. 2003;19:850-854.

Shakespeare DT, Rigby HS. The bucket-handle tear of the meniscus. A

clinical and arthrographic study. J bone Joint Surg Br. 1983;65:383-387.

Andersen AF, Lipscomb AB. Clinical diagnosis of meniscal tears.

Description of a new manipulative test. Am J Sports Med. 1986;14:291-

293.

Chan S, Gang D, Arthroscopic correlation of clinical diagnosis of

meniscal injuries using the McMurray test. J Hong Kong Med Assoc.

1994;46:187-189.

Examination

Snoeker B, et al. Detecting meniscal tears in primary are: Reproducibility

and accuracy of 2 weight-bearing tests and 1 non-weight-bearing test. J

Orthop Sports Phys Ther. 2015;45(9):693-702.

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Examination Pearls

Vertical vs. horizontal pain.

Vertically oriented pain probably MCL/LCL pain

Horizontal pain probably meniscus

Most posterior horn so pain posterior to midline

Cox CL, Spindler KP. Meniscal Injuries. Orthopaedic Knowledge

Update: Sports Medicine 4. AAOS 2009.

Effect on High Level Athletes Describe risk, time

lost effect on

performance of

isolated meniscus tears

in NBA.

Preinjury and

postinjury player

efficiency ratings used

to compare

Yeh PC, et al. Epidemiology of isolated meniscal injury and its

effect on performance in athletes from the National Basketball

Association. Am J Sports Med. 2012;40:589-594.

Effect on High Level Athletes 21 season span

129 isolated meniscal tears

59.7% lateral

40.3% medial

Most occurred during

games

Left and right equally

effected




27

Effect on High Level Athletes Lateral more likely up to

age of 30 years

Then after medial

BMI > 25 higher chance of

tear

19.4% did not return to play

For those that did return no

sig change in PER




Treatment Options

No treatment

Total meniscectomy


Meniscus repair

Meniscal Healing

Formation of fibrin clot

Acts as scaffold for repair

Meniscal and synovial cells migrate into

fibrin clot

Vessels from capillary plexus and synovial

fringe grow into clot

Arnoczky SP, Warren RF. The microvasculature of the meniscus

and its response to injury. An experimental study in the dog. Am J

Sports Med 1983;11:131-141.

28

Meniscal Healing

Heal by formation of fibrovascular scar

tissue

2 weeks fibrin clot



Sports Med 1983;11:131-141.

Arnoczky SP, Warren RF, Kaplan N. Meniscal remodeling

following partial meniscectomy – an experimental study in the dog.


Meniscal Healing

5 weeks histological evidence of

regeneration

In the canine model occurs by 10th week

Full remodeling of scar - up to 6 months



Sports Med 1983;11:131-141.




Meniscal Healing

Full strength of repair tissue as a function of

time has not been delineated!



Sports Med 1983;11:131-141.




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No Treatment

Not all tears symptomatic

Prevalence of tears found in asymptomatic

individuals 5-36%

Laprade RF, et al. Prevalence of abnormal MRI findings in

asymptomatic knees. With correlation of MRI to arthroscopic

findings in symptomatic knees. Am J Sports Med. 1994;22:739-

745.

Zanetti M, et al. Patients with suspected meniscal tears: Prevalence

of abnormalities seen on MRI of 100 symptomatic and 100

asymptomatic knees. Am J Roentgenol. 2003;181:635-641.

No Treatment

Small stable asymptomatic tears do not

need to be treated surgically

Vertical longitudinal tears < 1 cm long

Small radial split tears < 3 mm

If significant and left alone can degrade

hyaline cartilage

Partial Meniscectomy

For tears in the white, inner area that won’t heal on own

Flap tears

Radial tears in the inner avascular (white-white) area

Horizontal cleavage tear

Very common procedure

Motorized shaver to smooth out edges

No soft tissue healing restraints

Rehab symptom limited

100% return in 3-4 weeks

30

Treatment

Young or middle

aged?

Presence or absence of

arthritis?

Meniscus Repair

Save meniscus at all cost

Most common for peripheral, vascular area tears

Small tears in this region may heal on own, while

larger tears may require sutures

Have attempted to pack fibrin clot to speed-up and

improve healing

Creation of vascular channels

Henning C, et al. Arthroscopic meniscal repair using

an exogenous fibrin clot. Clin Orthop 1990;252:64-72.

Fibrin Clot

Have attempted to pack fibrin clot to speed-up and

improve healing

Brings hematoma chemotactic

factors to tissue

Arnoczky SP, Warren RF, Spivak JM. Meniscal repair

using exogenous fibrin clot: an experimental study in

dogs. J Bone Joint Surg Am. 1988;70:1209-1217.

Henning C, et al. Arthroscopic meniscal repair using

an exogenous fibrin clot. Clin Orthop 1990;252:64-72.

31

Trephination

Creation of vascular channels from peripheral (red

zone) to central avascular area (white zone)

Fox – patient survey and clinical exam

(90% good to excellent results)

Zhang 25% healing in goat model

Fox JM, Ritz KG, Ferkel RD. Trephination of incomplete meniscal tears.

Arthroscopy. 1993;9:451-455.

Zhang Z, Arnold JA, Williams T, McCann B. Repairs by trephination and

suturing of longitudinal injuries in the avascular area of the meniscus in goats.

Am J Sports Med. 1995;23:35-41.

Synovial Abrasion

Use of surgical rasp

Activates chemotactic factors stimulate

healing

Abrade margins and superficial layer

Mooney M, Rosenberg T. Meniscus repair: zone-specific technique. Sports

Med Arthrosc Rev. 1993;1:136-144.

Inside-Out Meniscus Repair Placement of sutures

depend on tear size

and location

All inside repairs may

use fewer sutures and

may require a delay in

full weight bearing

32

Meniscal Repair

Requires soft tissue

healing restraint times

Slower rehabilitation

Now performing

meniscal allografts

Outside-In Techniques

Passage of spinal

needle through skin

into meniscus tear

with arthroscopic

visualization

Tied off in the joint

Fairly weak construct

McCarty EC, Marx RG, DeHaven KE. Meniscus repair:

Considerations in treatment and update of clinical results. Clin

Orthop Relat Res. 2002;402:122-134.

All-Inside Using Implants

Use of nonsuture

implants for fixation

FastT-Fix

Meniscal arrows

Surgeon must be

cognizant of potential

for articular cartilage

damage

Watch for proud head!

33

Bionix Arrows

Arthrex Darts

Clearfix

Screw

34

Distinction: Repair vs

Mensicectomy Important to know how rehabilitation is affected

by meniscus repair vs. meniscectomy

Standard exercises detrimental to meniscus repair

Very small stresses may disrupt healing process

Full ROM may place undue stress on meniscus

repair


Meniscectomy Repair must heal without stress or abnormal

laxity

Undue stress may cause scar to elongate

Weight-bearing limited initially

Watch for over aggressive therapy, postoperative synovitis, or overuse synovitis

Need normal inflammatory cycle to run its course


Meniscectomy

Must treat each patient with individualized

program

Understand biomechanics of the joint, the

healing process and the biomechanics of

therapeutic exercise program

35

Tear Location and Sport

Medial > Lateral

Meniscus

Soccer

Basketball

Skiing

Baseball

No difference

Volleyball

Gymnastics

Sailing

Rowing

Wrestling

Judo

Handball

Terzidis IP et al. Mensical tear characteristics in young athletes with

a stable knee. Am J Sports Med 2006;34(7):1170-1175.

Partial Meniscectomy Post Operative

Protocol


Immediate ROM and WBAT

Patients will normally resume work after 1-2

weeks

Full activity 2-4 weeks

Competition in 4-6 weeks

Wheatley WB, Krome J, Martin DF. Rehabilitation programmes

following arthroscopic meniscectomy in athletes. Sports Med

1996;21:447-446.

Rangger C, et al. Partial meniscectomy and osteoarthritis.

Implications for treatment of athletes. Sports Med 1997;23:61-68.

36

Supervised Therapy

Controversial

Meniscectomy

120 patients

RCT – 3 groups

HEP = 47

NSAIDS = 52

PT = 21

Follow-up = 42 days

Birch NC, Sly C, Brooks S, Powles DP. Anti-inflammatory drug

therapy after arthroscopy of the knee. A prospective, randomized,

controlled trial of diclofenac or physiotherapy. J Bone Joint Surg Br.

1993;75:650-652.

Meniscectomy

Neither routine administration of NSAIDs nor

routine physiotherapy is justified after

arthroscopy of the knee

Birch NC, Sly C, Brooks S, Powles DP. Anti-inflammatory drug

therapy after arthroscopy of the knee. A prospective, randomized,

controlled trial of diclofenac or physiotherapy. J Bone Joint Surg Br.

1993;75:650-652.

37


Early supervised PT has

not been associated with

better outcomes when

compared to a HEP

84 patients; 41 HEP; 45

PT + HEP

Blinded sessions 5 and 50

days after surgery

Goodwin PC, et al. Effectiveness of supervised physical therapy in

the early period after arthroscopic partial meniscectomy. Phys Ther

2003;83:520-535.


Outcome measures

subjective scales

Kinematic knee function

Level walking

Stairs

Horizontal and vertical

hops



2003;83:520-535.


3x/wk x 6 wks

No significant change

between supervised with

home program and home

program only.



2003;83:520-535.

38


Prospective study

30 patients following arthroscopic PMM

HEP (15); Supervised PT (15)

Supervised PT vs. HEP

Function at 2,4,8 weeks

Jokl P, Stull PA, Lynch JK, Vaughan V. Independent home versus

supervised rehabilitation following arthroscopic knee surgery: a

prospective randomized trial. Arthroscopy. 1989;5:298-305.


Outcomes included isokinetic strength tests and

subjective outcomes

No difference in strength or outcomes between

two groups

% Deficit in quadriceps peak torque

HEP = 22%

Supervised PT = 22.1%

Jokl P, Stull PA, Lynch JK, Vaughan V. Independent home versus

supervised rehabilitation following arthroscopic knee surgery: a

prospective randomized trial. Arthroscopy. 1989;5:298-305.


Prospective RCT

31 men; PT + HEP (15); HEP only (16)

Assessed pre op and 3 weeks PO

Maximum voluntary isokinetic strength quads

Supervised 9 visits (15) vs instruction in PO

management (16)

Moffet H, Richards CL, Malouin F, Bravo G, Paradis G. Early and

intensive physiotherapy accelerates recovery post-arthroscopic

meniscectomy: results of a randomized controlled study. Arch Phys

Med Rehabil. 1994;75:415-426.

39


Experimental group ( supervised therapy) had

better knee extensor strength recover than control

group

Strength difference was 26% better in supervised

therapy group

Pain and patient reported knee function – NSD

Moffet H, Richards CL, Malouin F, Bravo G, Paradis G. Early and

intensive physiotherapy accelerates recovery post-arthroscopic

meniscectomy: results of a randomized controlled study. Arch Phys

Med Rehabil. 1994;75:415-426.


Significant isokinetic

torque deficits of knee

extensors for as long as 6

months after arthroscopic

meniscectomy.

Gapejeva H, et al. Isokinetic torque deficit of the knee extensor

muscles after arthroscopic partial meniscectomy. Knee Surg Sports

Traumatol Arthrosc 2000;8:301-304.


16 patients

Early training delayed 2

weeks + HEP

Late training delayed 6

weeks + HEP

NSD

Training in early stages

did not improve recovery

of strength

St. Pierre DM, Laforest S, Paradis S, et al. Isokinetic rehabilitation

after arthroscopic meniscectomy. Eur J Appl Physiol Occup Physiol.

1992;64:437-443.

40


These knee flexor and

extensor deficits increase

the need for supervised

rehabilitation

St. Pierre DM. Rehabilitation following arthroscopic meniscectomy.

Sports Med. 1995;20:338-347.


Many have persistent medial knee pain, narrow

medial joint space, and varus alignment when

compared to non-operative knees.

Jones RE, et al. The effect of medial meniscectomy in patients older

then forty years. J Bone Joint Surg 1978;60A:783.


Results in degenerative arthritis and ligamentous

laxity.

Patients do worse after lateral than after medial

mensicectomy.

Johnson RJ, et al. Factos affecting late results after meniscectomy. J

Bone Joint Surg 1969;51A:517.

41


A partial medial meniscectomy generally

does better than a partial lateral

meniscectomy

Gilquist J, Oretorp N. Arthroscopic partial meniscectomy: technique and

long term results. Clin Orthop 1982;167:29-33.

Northmore-Ball MD, Dandy DJ. Long term results of arthroscopic

partial meniscectomy. Clin Orthop 1982;167:34-42.

McNicholas, et al. Total meniscectomy in adolescence: a 30-year follow-

up. J Bone Joint Surg Br. 2000;82:217-221.


54% satisfactory results after lateral

mensicectomy.

Increased interval from injury to surgery resulted

in less satisfactory results.

Yocum LA, et al. Isolated lateral meniscectomy. J Bone Joint Surg

1979;61A:338.


15 years after meniscectomy –

46% of patients reduced

sporting activity

89% had degenerative changes

on radiographs

Some seen as early as 4.5 yrs

Radiographic changes more

often lateral compared to

medial.

Jorgenson U, et al. Long-term follow-up of meniscectomy in

athletes. J Bone Joint Surg 1987;69B:80.

42


210 patients at 10-22 years after meniscectomy

61% satisfactory results

Adverse factors

Increased age

Abnormal alignment

Lateral vs medial mensiscectomy

Allen PR, et al. Late degenerative changes after meniscectomu:

factors affecting the knee after operation. J Bone Joint Surg

1984;66B:666-671.

Partial

Meniscectomy

Search 1950-2013

18 RCT – 6 for MA

PT + HEP improved

function and ROM more

than HEP alone

Most studies have high

to moderate bias risk

Marcelino Dias J, et al. The effectiveness of postoperative physical therapy

treatment in patients who have undergone arthroscopic partial

meniscectomy: Systematic review with meta-analysis. J Orthop Sports

Phys Ther. 2013;43(8):560-576.

Methodological flaws of

studies

Small sample size

Lack of

standardization of

outcomes

Not using standardized

guidelines -

CONSORT

Marcelino Dias J, et al. The effectiveness of postoperative physical therapy

treatment in patients who have undergone arthroscopic partial

meniscectomy: Systematic review with meta-analysis. J Orthop Sports

Phys Ther. 2013;43(8):560-576.

43

Case control study

Assessed for adverse

events

17,774 patients PMM

208 had adverse events

Patients with diabetes and

pulmonary disorders had

higher risk

Smokers had increased

odds of readmissions

Smoking cessation?

Basques BA, et al. Risk factors for short-term adverse events and

readmission after arthroscopic meniscectomy. Does age matter? Am J

Sports Med. 2014;43(1):169-175.

Meniscal Repair

Repair Guidelines

Two schools of thought

Conservative

Limit early weight bearing

Limit knee flexion > 90 for 4-6 weeks

Hold sports competition for 5-6 mo.

Accelerated

Full early weight bearing

Unrestricted ROM

44

Repair Guidelines

ROM of Brace Week

30-70 Week 1

20-80 Week 2

10-90 Week 3

0-135 Week 4

Conservative Repair Guidelines

Weight Bearing Week

NWB Week 1-2

PWB (25%) Week 3

PWB (50%) Week 4

PWB (75%) Week 5

FWB Week 6

Mensicus Repair Weight Bearing

Status

DeHaven KE, Clin

Orthop 1985;198

FWB delayed 8 weeks

Scott et al, J Bone Joint

Surg 1986;68

FWB delayed 8 weeks

McLaughlin et al,

Orthopedics 1994;17

FWB delayed 3 weeks

Buseck MS, Noyes FR,

Am J Sports Med 1991;19

Immediate FWB

45

All Had Successful Healing Rates

Despite Varying Protocols

Aggressive Protocols

Immediate unrestricted weight

bearing

Unlimited brace less

ROM

50% failure

Changed their protocol to restricted

weight bearing, crutches 4 weeks,

no squatting for 4 months.

Kurzweil PR, Tifford CD, Ignacio EM. Unsatisfactory clinical results of

meniscal repair using the meniscus arrow. Arthroscopy. 2005;21:905-910.

Postoperative Immobilization

To protect sutured cartilage, motion may be

restricted to safe portion of range

Motion may be controlled to allow 0-90 or

20-90 degrees of knee flexion

May be required to wear protective motion

brace

Cryotherapy, compression, and elevation

46

Maximum Protection Phase

(0-4 weeks) Goals

Wound healing

Quadriceps activation

Decreased effusion

Normal patellar

mobility

Proximal strengthening

(TLS)


(0-4 weeks)

Restrictions

WBAT with crutches (braced locked at 0

or 20)

PROM limited 0-90 for 4-weeks

47


(0-4 weeks)

One exception to

early weight

bearing is a radial

tear in the

periphery that may

cause a distraction

force

Roth C, Rodeo SA. Indications and techniques for meniscus repair. In:

Simonian PT, Cole BJ, Bach BR (eds) Sports Injuries of the Knee. Surgical

Approaches. Theime, 2007.

WB rationale

Fibrin clot formation at 2 weeks

Shear stress detrimental

Hoop stress may be beneficial?

The most stable position seen in full

extension (with arthroscopy)!

Clinical application of Wolff’s law!

Morgan CD, et al. Arthroscopic meniscal repair

evaluated by second look arthroscopy. Am J Sports

Med 1991;19(6):632-637.

WB rationale

Hoop stresses are primarily absorbed at the

periphery of the meniscus

May actually approximate healing tissue

Brindle T, et al. The meniscus: review of basic

principles with application to surgery and

rehabilitation. J Athletic Train 2001;36(2):160-169.

48

WB rationale

Weight bearing with

tibiofemoral rotation during

knee flexion

Produce shear forces capable

of disrupting healing meniscal

tissue

Irrgang JJ, Pezzulo D. Rehabilitation following surgical

procedures to address articular cartilage lesions in the

knee. J Orthop Sports Phys Ther 1998;28:232-240.

ROM Rationale

Active ROM (dogs)

More collagen laid

down

Increased uniformity

of repair at 10 weeks

Dowdy et al. The effect of cast immobilization on meniscal

healing: an experimental study in the dog. Am J Sports Med

1995;23:721-728.

ROM Rationale

Dogs with no motion

restrictions

Allowed immediate weight

bearing

Fibrin clot becomes

fibrovascular scar tissue

Complete healing

Arnoczky S, et al. Meniscal repair using an exogenous fibrin

clot. An experimental study in dogs. J Bone Joint Surg

1988;70A:1209-1217.

49

Immobilization Immobilized dogs

Negative impact on

outcomes

Loss of meniscus dry

weight

Klein L et al. Isotopic evidence for resorption of soft

tissues and bone in immobilized dogs. J Bone Joint Surg

1982;64A:225-230.


(0-4 weeks) Treatment

RICE

EMS

Patellar mobilization

Scar tissue mobilization

AAROM

Strengthening - Hip (TLS) – SLR x 4

Quad/Ham isometrics


(0-4 weeks) Clinical Milestones

Minimal effusion

Good quad tone

Good patellar mobility

Min to no pain

AROM 0-90

Single limb stance

without compensation

Koski JA, et al. Meniscal injury and repair: clinical status.

Orthop Clin N Am. 2000;31:419-436.

50

Moderate Protection Phase

(4 to 6 weeks)

Goals

WBAT with crutches

braced locked 0-90

Progression of CKC

exercises

No patellar pain


(4 to 6 weeks)

Restrictions

Gradually increase ROM of flexion to 90

based on pain assessment

Flexion to 90 after 4 weeks

Progress slowly after to protect posterior

horn tears


(4 to 6 weeks) Treatment

Pain management

Control effusion

NMS of quads

Mini-squats –slowly introduce more CKC

Step-ups

AROM

51


(4 to 6 weeks)

Treatment

Flexibility exercises

CV training

Toes raises

Cycling (ROM only – low load)


(4 to 6 weeks) Clinical Milestones

Full weight bearing with no compensation

Normal gait

AROM 0-90

Good quad tone

SLR without lag

Normal patellar mobility

Minimum Protection Phase

(6-10 weeks)

Progression dependent on ROM, knee strength, endurance, absence of effusion

Progress strengthening with step-ups, step-downs, lunges, slide board

Continue to progress general endurance

When meniscal integrity tests are normal may begin light jogging, and mini plyometrics increasing to sprinting and jumping as patient tolerates

52


(6-10 weeks)

Goals

Increase:

Strength

Power

Endurance

Normal knee ROM

Prepare athlete for full participation/work


(6-10 weeks)

Restrictions

Avoidance of pivoting

Flexion ROM to 130º


(6-10 weeks)

Treatment

All exercises as previous

Progress quad strengthening

Balance training

Leg presses

Mini-squat

Lunge

Step-ups (6” step)

53


(6-10 weeks)

Clinical Milestones

Improved stability with unilateral stance

Minimal to no pain

Full ROM

Equal hip strength

Quad strength < 20% of contralateral side

When Safe to Return to Pivoting

Morgan CD et al, Am J

Sports Med 1991;19

4 Months

Jakob RP et al, Am J

Sports Med 1988;16

12 Weeks

Barber FA, Arthroscopy

1994;10(2)

ASAP

Shelbourne KD et al, Clin

Sports Med 1996;15(3):595-

612

Full ROM, 75% strength

Return to activity Phase (11-16 weeks)

Goals

Increased power and endurance

Return to skills

Preparation for return to full unrestricted

activity

54


Restrictions

Avoidance of full hyper-flexion (deep

squatting) for up to 6 months


Treatment

Exercise as previous

Endurance exercises

Agility drills (low - level)

Plyometric training (14 weeks)

Sport specific training

Initiation of running

Initiation of cutting drills


Clinical Milestones

Full confidence in knee

Pain free activity at 5 months

Satisfactory clinical examination

Functional testing 90% of contralateral

leg

Isokinetic testing 90% of contralateral leg

55

Discharge Criteria

Satisfactory clinical exam

No swelling

No joint line tenderness

Negative McMurray and Apley test

Satisfactory isokinetic test

Satisfactory functional tests

Physician approval

Thank You!

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