Before the proper treatment of a meniscal tear can be recommended by a physician, a proper diagnosis must be made and confirmed. The symptoms of a meniscus tear include pain and swelling of the knee joint. These symptoms are also common in cases of arthritis and ligament and / or tendon tears. A physical examination in the clinical setting as well as diagnostic imaging will be the first step in determining if a meniscal tear is present. The most common clinical diagnostic tests to be administered by the physician or designated allied health care provider are the McMurrary test, Apley grind test, and the bounce home test. All three of the tests are accomplished by the physician manipulating the knee joint with flexion and extension of the leg. Positive meniscus tears will cause pain and possible “clicking” sounds while the movement occurs. Radiological imagining is the next step to a proper diagnosis. An MRI scan is the most accurate imaging when looking for soft tissue abnormalities. For patients that have some metal implants, pacemakers, or spinal cord or nerve stimulators, etc., a CT scan is the next best diagnostic imaging test that can be performed. Once a positive clinical diagnosis is made and the diagnostic images confirm the clinical findings, a treatment can be recommended.
What Are The Treatment Options For A Meniscus Tear ?:
The degree of aggressiveness when approaching the treatment options is based on the extensiveness of the meniscal tear. Meniscal tears are classified based on the anatomical region of the meniscus that is affected and how deep into the tissue the tear occurs. Medial meniscal tears occur on the inside of the knee. Lateral meniscal tears occur on the outside of the knee. Horizontal tears occurs in the front part of the knee and run parallel with the tibial plateau (knee end of the tibia). Radial tears occurs at the center of the “C” shaped structure and go across the middle dividing the meniscus. Oblique or meniscal flap tears can occur at any part of the meniscus but are most likely to be found in the ends of the “C” shaped structure. Complex or degenerative tears include more than one tear and are typically gradual over time as opposed to a specific event causing an acute tear. The degree as to the amount of the tear is classified by partial thickness (does not tear completely through the structure) and full thickness tears (completely tears through the entire thickness of the structure).
How to Treat a Meniscus Tear with Conservative Management:
In almost all cases of a meniscus tear conservative management (non-operative) is the first treatment option. This treatment involves steroid knee injections to reduce infection and swelling, physical therapy for six to nine weeks, and wearing a knee brace in everyday life to help take some of the load off of the joint while the body has a chance to repair the tear on its own. Patients that have symptomatic meniscus tears can expect a 50% chance of full resolution of pain and symptoms with conservative treatment. The steroid injections reduce the inflammation and swelling of the knee joint. Some of the pain can be reduced from these injections as well. This can allow for more productive physical therapy appointments. The physical therapy can assist with realigning the body mechanisms with respect to movement. This will also stop the knee joint from freezing up and will reduce soreness. Physical Therapy is administrated by a licensed Physical Therapist. A list of exercises are performed by the patient concentrating on stretching and moving the knee joint in a controlled fashion under the supervision of the physical therapist. Some of the exercises can evoke a pain response. Careful consideration must be acknowledged while performing physical therapy to avoid further damage to the meniscus tear. The knee brace will protect the joint and reduce load weight while the body repairs the meniscus lowering the chances of re-injuring the healing tear. The body repairs the meniscus by way of a collagen layer that is regenerated inside the tear.
How to Treat a Meniscus Tear with Surgery:
Patients that fail to respond to conservative treatment must consider surgical options to pursue achievement of a reduction in pain and symptoms associated with a meniscal tear. The majority of tears that need this next step are typically advanced in the severity of the tear or have an abundance of scar tissue around the tear that has preceded the proper collagen tissue from being deposited. Traditionally open knee surgery was the only option available for partial or full meniscalectomy (removal of the meniscus) surgeries. State of the art standards of care now include arthroscopic surgical intervention options. The goal of all surgical options is to relieve pain and symptoms associated with the meniscal tear. Choosing the correct surgical option is based on the severity and location of the meniscus tear.
How to Treat A Meniscus Tear With Arthroscopic Surgery:
Advances in arthroscopic procedures have allowed the meniscus to be surgically repaired by the use of a camera and endoscopic surgical instrumentation. These surgeries are typically performed outpatient at a surgery center. The most common surgery is an arthroscopic meniscal “shaving” technique. A scope is inserted into the knee joint and then the joint is filled with a saline solution. The scope is connected to an intra-operative television monitor allowing the surgeon to view the inside of the knee joint. Next a shaver is inserted into the knee to shave off scar tissue and the jagged edges of the tear. Again this will allow the body to heal the tear with collagen. More extensive surgery is needed for some full thickness and or broken pieces that are 'free floating.' For these extreme cases the use of a grasper is needed. The surgeon will insert the grasper into the knee joint in the same fashion as the shaver. Once the broken or floating piece of meniscus cartilage is identified the grasper can clinch it and the instrument is dropped from the knee removing the broken specimen. More extensive arthroscopic surgery techniques may include partial removal of the meniscus and / or arthroscopic suturing of the meniscal tear. These techniques are performed with the same set up and instrumentation. Closure is minimal only requiring a few sutures to close up in most cases only two or three small inclusions measuring 4 mm.
How to Treat a Meniscus Tear with Open Knee Surgery:
Open knee surgery is the most extensive and invasive form of meniscus surgery and is used as a last resort. Patients that fail to respond to arthroscopic surgery or have extremely damaged meniscus will require open knee surgery in hopes of achieving a reduction of pain and symptoms associated with meniscal tears. This surgery is usually performed inpatient requiring at least one night in the hospital.
To expose the knee joint an incision from an inch or so above the patella (knee cap) to an inch or so below the patella. The patella is moved to the side with retractors and then the surgeon will flex the knee exposing the interior of the joint. From this approach a significant portion of the meniscus can be visualized and removed. If the entire meniscus needs to be removed a meniscus transplant can be performed. A fresh meniscus is surgically recovered from a cadaveric (false) tissue donor. The donor is tested for communicable diseases such as HIV, HEP B, HEP C, Syphilis, etc. The transplant graft is pre-sized based on the recipient's needs. The new meniscus is anchored with metal screws and synthetic monofilament sutures. Infection and biorejection are the leading causes of failure for this surgery. The best results for this surgery have been reported on patients less than 40 years of age.
Lastly, for patients that fail to respond to open meniscus surgery or for elderly patients that have severe meniscal damage due to arthritic changes a total knee arthroplasty (knee joint replacement) is the final step. This surgery is performed with the same exposure technique. The ends of the tibia (shin bone) and the femur (thigh bone) are carefully reshaped with an oscillating and then fitted with metal implants that are cemented on. A synthetic plastic spacer is used to replace the meniscus. Closure of this incision that typically measures 6 inches will take several sutures.
How to Treat a Meniscus Tear Postoperatively:
Once surgery is completed rehabilitative physical therapy is required along with a knee brace. It is important for the knee joint to be rehabilitated with the proper movement so that normal body mechanics can be realigned. Returning to normal body mechanics will ensure that the joint will function in the normal capacity and re-injury is reduced.
For arthroscopic patients the postoperative physical therapy exercises are similar to conservative management physical therapy. Usually only a couple of appointments are needed with the physical therapist for training the patient. The patient is encouraged to perform the daily exercises at home once they have been trained how to perform them. Typically this regiment lasts for 6-9 weeks depending on how the patient responds to the post-operative treatment.
Patients that undergo open knee surgery can expect a more stringent form of postoperative physical therapy. In addition to general flexion and extension exercises, the patient must perform walking and mobility exercises as well. Although some of the exercises are performed at home the patient must go to multiple physical therapy appointments at the physical therapists facility. The physical therapist will closely monitor the progress and communicate the findings to the patient's physician. This postoperative physical therapy program can last from 12-16 weeks depending on the progress of the patient.