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Knee

Meniscus Injuries

There are three bones that make up the knee joint – the femur (thigh bone), the tibia (shin bone), and the patella (kneecap). The menisci are two C-shaped structures in each knee that are located between the tibia and femur within the knee joint. The menisci play a crucial role in protecting the knee joint by maintaining its stability and cushioning. They are shock absorbers for the knee that are critical to the long-term health and function of the joint.

What is the meniscus?

The meniscus is a C-shaped shock absorber located between the tibia and femur within the knee joint. There are two menisci in each knee joint: the medial meniscus located on the inner side, and the lateral meniscus, positioned on the outer side of the knee. When viewed as a cross-section, they are wedge shaped.  Their wedge shape allows them to create a perfect fit between the round end of the femur and the flat edge of the tibia within the joint. This fit allows for an even distribution of forces and minimizes regions of high contact pressure. In doing so, the menisci serve a vital role in preventing excessive wear and tear on the articular cartilage. Additionally, the menisci help provide rotational stability to the joint. The menisci have many important roles in the knee, but their ability to absorb forces between the thigh bone and shin bone is the most crucial.

Meniscus tears can be acute, meaning they happen suddenly from a single injury, or degenerative, meaning they happen gradually over time with general wear and tear.

Acute meniscus tears are frequently the result of traumatic injuries and can occur during high-risk sports, including soccer, tennis, pickleball, football, or basketball. Typically, injury mechanisms involve aggressive movements in which the knee twists or rotates during pivoting, kneeling, or squatting. Tears can also result from hyperflexion when the knee is flexed beyond its normal range of motion (excessive bending). Everyday activities including getting in and out of a car, using stairs, squatting, or heavy lifting, can also cause tears.

Degenerative tears occur from chronic wear and tear of the meniscus cartilage that accumulates with age. As patients age, the cartilage can become stiff and brittle, leading to degenerative tearing or fraying of the menisci.

Acute meniscus tears are very common knee injuries that frequently affect active individuals. It is not uncommon to suffer a meniscus tear in the setting of a ligamentous injury. In contrast, degenerative meniscus tears are more common in older individuals, affecting 6 out of 10 patients over age 65.

Common symptoms of a meniscus injury include a popping sensation, localized pain and swelling on the inside or outside of the knee depending on the location of the tear. Other symptoms include stiffness, clicking, catching, or locking of the knee. Patients can also report instability, reduced range of motion, and difficulty walking.

Sometimes after 4-6 weeks from the injury, the knee will recover, and symptoms will improve. However, knee pain may return during daily activities including walking, running, and climbing stairs. This recurrent pain may also be associated with symptoms of intermittent swelling, instability, and locking of the knee. Over time, a torn meniscus can predispose the affected knee to the development of osteoarthritis.

The combination of a detailed history, comprehensive physical examination, x-rays, and an MRI (magnetic resonance imaging) is the key to a successful diagnosis of a meniscus injury.  Frequently, a torn meniscus can be diagnosed with a physical exam and special tests. Two common specialty exam maneuvers are the McMurray Test and the Apley’s compression test. These maneuvers test for meniscal injury by eliciting pain upon a twisting/rotating motion of the knee. X-rays cannot detect a tear but will identify fractures and degree of arthritis of the knee.  An MRI can be ordered to confirm a diagnosis, as well as provide an assessment of the extent of the damage and any associated arthritic or concomitant ligamentous conditions.

A meniscus tear can be treated either non-operatively or with surgery. The tear type, size, and location as well as your age, health, and activity level are all considered when deciding the best treatment for you.

Location plays a key role in deciding the appropriate treatment for a meniscus tear. The meniscus has three zones – the white zone, the red-white zone, and the red zone. The inner portion of the meniscus (white zone) has poor blood supply, which limits the body’s natural healing abilities. Tears in the white zone are generally treated by removing the torn portion (meniscectomy). 30% of the meniscus – the outer edges – has a good blood supply which is essential for the natural healing and repair process. Tears in the red zone may heal with conservative management or can be surgically repaired with confidence that these repairs will heal well.

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Types of Meniscus Tears

What are the most common types of meniscus tears?

There are many different types of meniscal tears. Common types of traumatic tears include bucket handle tears, flap tears, and radial/root tears.

Broadly, tears can be described as partial thickness, meaning they only affect one side, or full thickness, meaning the tear goes all the way through the meniscus. Tears can be further described based on their appearance. Tears are described as “complex tears” when they have more than one tear pattern. Typically, these involve both a radial and horizontal tear. Finally, the location of the tear has a significant impact on the ability of the tear to heal and the corresponding treatment.

The meniscus has three zones of vascularity.  The Red zone is the outer perimeter and has an adequate blood supply to facilitate healing. The Red-White zone is the transitional area in the middle of the meniscus with an intermediate blood supply and capacity for healing. Finally, the White zone is the innermost part with no blood supply and no ability to heal. Tears in the white zone are generally treated by removal of the meniscus, also called a meniscectomy. Tears in the red zone have a good blood supply which provides the necessary biological substances for healing following surgical repair. Tears in the red-white zone need to be assessed to determine whether surgical repair is required for healing.

Radial Tears:

Radial tears are tears that originate from the more central region of the meniscus and extend outwards towards the peripheral edges. Because of their orientation, radial tears disrupt the circumferential protein fibers that allow the meniscus to absorb forces. This can potentially compromise the function of the meniscus. For that reason, surgery is usually required. This pattern of tears is most commonly located in the posterior portion of the medial meniscus or in the middle and anterior sections of the lateral meniscus.

Radial tears can be subdivided into complete tears and incomplete tears. As the tear extends outwards it has the potential to extend all the way to the peripheral rim of the meniscus. If it is able to tear completely across the meniscus and reach this rim it is called a complete radial tear. If it does not reach the rim, it is termed an incomplete radial tear.

Root tears – The meniscal roots are its insertions into the tibia. Each meniscus has an anterior root attachment at the front of the tibia near the kneecap and a posterior root attachment that is near the back of the tibia.

Approximately 10-20% of meniscus tears are root tears. Root tears are a special type of radial tear that occurs within 1 cm of the meniscus attachment or a bony avulsion of the root attachment itself. Root tears lead to extrusion of the meniscus, or the shifting of the meniscus from its natural anatomic position, causing the meniscus to become nonfunctional. Studies have shown that meniscal root tears are biomechanically equivalent to having no meniscus at all, which can accelerate cartilage damage and lead to early progression of osteoarthritis.

Meniscus root tears tend to be traumatic injuries that occur in two groups of patients. The first group is typically younger athletes in their 20s. The second group is adults in their 50s. For both groups, the rapid onset of arthritis associated with these injuries means that surgical repair is typically recommended.

Bucket handle tears are larger tears that occur along the long axis of the meniscus. They run from anterior to posterior along the meniscus, creating a long strip of torn tissue that is separated from the rest of the meniscus, typically displacing into the joint and resembling the handle of a bucket. Bucket handle tears can be acutely debilitating as they are associated with the catching/locking symptoms that trap the knee and prevent patients from straightening out their leg. Like many of the acutely symptomatic tears, bucket handle tears are typically caused by trauma, usually a sporting injury, that occurs when the patient is twisting or pivoting their leg while trying to abruptly change direction. Bucket handle tears are most commonly seen in young athletes, under age 35.

Horizontal tears occur parallel to the meniscus surface. These types of tears can frequently be surgically repaired if they occur in an area of the meniscus that has good blood supply to facilitate healing after the repair. These tears are typically associated with degenerative changes within the meniscus as opposed to acute trauma.

Meniscal ramp lesions are lesions that occur with an ACL injury and lead to damage of the meniscus in the periphery of its posterior segment. This would be the back inner corner of the medial aspect of the knee. These tears will disrupt the attachment between the posterior medial meniscus and the surrounding knee joint capsule.

Ramp lesions have been colloquially termed the “hidden lesion” because they were historically under-recognized. This is in part due to the fact that the tear is located in a portion of the knee termed the “blind-spot.” After an ACL rupture, the knee will have some level of instability in multiple directions. In this situation, the meniscus plays an even larger role in maintaining stability within the knee. Moreover, studies have shown that an ACL reconstruction will be biomechanically inferior to a normal knee if a significant ramp lesion is present but not repaired. While this might be true in a laboratory setting, it is unclear if this remains true in a real-patient context.

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Meniscus Injuries Non-Surgical Treatment

Some people live active lives, never knowing they have a meniscus tear and don’t have any knee pain.  Depending on the type and severity of the meniscus tear, meniscus tears can be treated without surgery.  For patients who are candidates for conservative treatment, the focus of care will be on reducing pain, swelling, and inflammation, while also improving overall stability and function of the knee.

 

 
Rest and Activity Modification:

Meniscus Injuries Non-Surgical Treatment

Some people live active lives, never knowing they have a meniscus tear and don’t have any knee pain.  Depending on the type and severity of the meniscus tear, meniscus tears can be treated without surgery.  For patients who are candidates for conservative treatment, the focus of care will be on reducing pain, swelling, and inflammation, while also improving overall stability and function of the knee.

 

Initially following the injury, it’s essential to rest the knee and avoid activities that worsen the pain.

Oral anti-inflammatory and pain-relieving medications, such as Meloxicam, Naproxen, Advil, or Ibuprofen, may help to manage the pain and reduce inflammation of the knee following a meniscus injury. Applying ice packs and compression to the knee can also help reduce swelling and inflammation. Remember to use a cloth or towel between the ice pack and your skin to avoid frostbite.

Meniscus Injuries Non-Surgical Treatment

Some people live active lives, never knowing they have a meniscus tear and don’t have any knee pain.  Depending on the type and severity of the meniscus tear, meniscus tears can be treated without surgery.  For patients who are candidates for conservative treatment, the focus of care will be on reducing pain, swelling, and inflammation, while also improving overall stability and function of the knee.

 

Initially following the injury, it’s essential to rest the knee and avoid activities that worsen the pain.

 

Oral anti-inflammatory and pain-relieving medications, such as Meloxicam, Naproxen, Advil, or Ibuprofen, may help to manage the pain and reduce inflammation of the knee following a meniscus injury. Applying ice packs and compression to the knee can also help reduce swelling and inflammation. Remember to use a cloth or towel between the ice pack and your skin to avoid frostbite.

 

A structured physical therapy program can be beneficial for strengthening the muscles around the knee and improving overall joint function. A physical therapist can guide you through exercises that focus on the quadriceps, hamstrings, and calf muscles to provide this additional support to the knee. It is important to complete any home exercises that your physical therapist provides to you in order to optimize your recovery.

The goal of an intra-articular injection is to manage pain and inflammation of the knee. Therefore, injections may be used as a short-term measure to manage these symptoms following an injury. However, it’s crucial to understand that an intra-articular injection will not heal the torn meniscus. Examples of intra-articular knee injection options: cortisone, hyaluronic acid (gel), and platelet rich plasma (PRP).

An unloader brace is a specific type of knee brace designed to offload an overloaded compartment of the knee. In cases of a medial meniscus tear, a medial unloader brace is ordered to alleviate some of the stress on the medial (inside) compartment of the knee. In cases of a lateral meniscus tear, a lateral unloader brace is ordered to decrease the load of the lateral compartment. The unloader brace offers mechanical support, stabilization, and symptomatic relief while also protecting the knee compartment and promoting overall joint health and preservation.

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Meniscus Injuries Surgical Treatment

Overview

What are the surgical options for meniscus tears?

When symptoms of pain and swelling persist after conservative treatment or in cases of specific types of meniscal tears such as root, radial, and bucket handle tears, arthroscopic surgery may be the most effective option.

The goal of arthroscopic knee surgery is to preserve the meniscus whenever possible. Knee arthroscopy is a commonly performed procedure to repair a tear or trim and remove the torn meniscus, remove loose pieces of cartilage in the joint, and assess the knee joint for other concomitant injuries. In arthroscopic surgery, a small, thin tube containing a camera is inserted into the knee joint to examine the meniscus. Based on what is seen in the joint, Dr. Bryan Penalosa will then either repair, trim, or remove a small portion of the meniscus. Small tools are also inserted through tiny incisions for repair or trimming of the meniscus.

This minimally invasive surgery limits damage, reduces bleeding, and helps promote a quicker recovery. It is usually performed in an outpatient surgery center under general anesthesia. Physical therapy will be recommended. The majority of patients are able to fully recover and return to normal activity.

Arthroscopic Procedures Include:

  • Arthroscopic Debridement and Partial Meniscectomy

  • Meniscus Repair

  • Meniscus Transplant

Arthroscopic debridement is a procedure performed to remove frayed edges and clean up damaged tissue, including fragments of torn cartilage. The aim is to relieve pain and improve function. Debridement is typically performed in tears involving the white zone of the meniscus to preserve a smaller healthy meniscus.

Partial meniscectomy is the removal of the small portion of the meniscus that contains the meniscal tear. Complete removal of the meniscus can result in persistent and potentially progressive knee pain due to accelerated arthritis, and therefore, is not a part of Dr. Bryan Penalosa’s surgical practice.

Arthroscopy for debridement of degenerative meniscal tears can sometimes be indicated when other non-surgical approaches have failed. Recovery for these types of procedures is very short. Physical therapy will be recommended to assist with healing, regaining full range of motion, and improving overall function. Crutches can be used as needed to take weight off the operated knee. Patients can return to daily activities in a week, and sports within two months after surgery.

For most patients with acute traumatic meniscus tears, the best treatment modality is a meniscal repair when indicated. The goal of arthroscopic meniscal repair is to use a minimally invasive surgical technique to bring the torn ends of the meniscus together. These ends are then sutured (stitched) together in an attempt to facilitate healing and restoration of a patient’s natural meniscal contour, shape, and function. This will allow for maximal preservation of a patient’s healthy meniscal tissue and minimize long-term damage to the cartilage of the knee. Dr. Bryan Penalosa believes that a meniscus repair can be considered depending on the state of your cartilage and underlying arthritis, not necessarily on your age. If you are still active, willing to have the repair, and undergo post-operative rehabilitation, you should strongly consider a meniscus repair when indicated.

There are several techniques used for meniscal repair. Like meniscectomies, the procedure is a minimally invasive arthroscopic surgery that uses small incisions to insert an arthroscope (camera) and arthroscopic tools into the knee joint. Several techniques that are used to bring the meniscal ends together include the all-inside technique, the inside-out technique, the outside-in technique, and the trans-tibial tunnel technique. Each technique has its own respective strengths and weaknesses based on a meniscal tear size/location, and they can be used in combination with each other for larger tears. During the procedure, Dr. Bryan Penalosa will use the most optimal combination of techniques to achieve the repair that best restores a patient’s native meniscus structure and function.

All-inside technique:

Dr. Bryan Penalosa sutures the meniscus without having to make additional incisions. This technique is commonly used for repair of vertical, horizontal, oblique, and some radial tears. Following this repair technique, patients will begin physical therapy the day after surgery, with an emphasis on regaining range of motion and quad activation. Typically, patients are restricted to non-weight bearing for 2 weeks following surgery. However, if the tear was a radial tear, then Dr. Bryan Penalosa will recommend 6 weeks of non-weight bearing after surgery.

This technique is usually utilized for larger meniscal tears. The inside-out technique places sutures into the meniscus by passing needles from inside the joint to outside the joint. Dr. Bryan Penalosa will then tie the sutures through an incision on the medial or lateral aspect of the joint depending on the location of the meniscus tear. This technique is considered the gold standard for bucket handle tears because many more sutures can be used, and it can be used to repair complex tears with a high rate of success. The downside of this technique is that it does require an additional incision (which is a small price to pay to save one’s meniscus). Following this repair technique, patients will begin physical therapy the day after surgery, with an emphasis on regaining range of motion and quad activation. Patients will be non-weight bearing for 6 weeks after surgery.

This is a less common technique that involves making a small incision in the front of the knee and passing sutures from outside the knee to inside the knee. This technique is especially important for repairing tears in the front of the meniscus where an inside-out or all-inside meniscus repair technique cannot be used. Following this repair technique, patients will begin physical therapy the day after surgery, with an emphasis on regaining range of motion and quad activation. Patients will be non-weight bearing for 6 weeks after surgery.

The most common root repair technique is called a transtibial technique. In this technique, sutures are placed into the torn meniscus root and then shuttled down one or two tunnels created in the tibia. Once the meniscus is reduced to its anatomical position, a non-metal anchor is placed in the tibia to hold the tension of the sutures, allowing the meniscus to heal in the correct anatomical location. Following this repair technique, patients will begin physical therapy the day after surgery, with an emphasis on regaining range of motion and quad activation. Patients will be non-weight bearing for 6 weeks after surgery.

 

A meniscal transplant is a technically challenging procedure that is available to patients who have failed a prior meniscal repair and subsequently underwent a total meniscectomy or who simply had a prior total meniscectomy with an outside orthopedic knee surgeon. These patients are typically followed closely for the rapid development of osteoarthritis and are offered meniscal replacement to preserve their joint health. The goal of a meniscal transplant is to restore proper function and structure to a knee that has lost its native meniscus. This will allow for improved shock absorption within the knee and an improved fit between the bones of the knee.

Who is a candidate for a meniscal transplant?

It is typically indicated for younger patients who have undergone a total meniscectomy and continued to have symptoms that are affecting their quality of life or ability to perform the activities of daily living. These patients must fail to have adequate improvement with non-operative management before a meniscus transplant can be recommended. Patients with extensive cartilage damage are also poor candidates for the procedure as there will be difficulty in placing the transplanted meniscus due to the reduced joint space associated with an arthritic joint. Other typical drawbacks and limitations of a meniscal transplant are similar to transplants of other organs: there is always an inherent immunologic risk, a limited risk of disease transmission, and limited donor availability.

If a patient elects to proceed with a meniscal transplant, they will have preoperative imaging to allow for proper sizing. When a size-matched and immunologically matched graft is available, the patient will be scheduled for surgery with Dr. Bryan Penalosa. During the procedure, an incision is made alongside the patellar tendon to allow for insertion of the meniscal allograft. The meniscal graft can be secured using a variety of techniques including a bone plug technique and a bone fixation technique. Currently, there is no evidence to suggest one technique is superior to the other.

Among the rehabilitation regimens after a meniscal surgery, rehabilitation for a meniscal transplant is the strictest. The transplanted meniscus needs to be allowed a generous amount of time to integrate with the surrounding tissue. Failure to adhere to the strict rehabilitation regimen could lead to the ultimate failure of the surgical intervention. For the first 6 weeks, the patient is required to use a knee immobilizer and maintain a strict non-weight bearing with crutches. From 6-8 weeks, the patient will begin weight bearing and progress to full weight bearing. They will continue to have a restricted range of motion until 8 weeks. By 12 weeks, they can begin higher strain functional activities including lunges.

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Recovering from Meniscus Surgery

What is the expected recovery from a meniscus injury?

Here at Midwest Orthopaedics at Rush in Chicago, Dr. Bryan Penalosa and his team of physical therapists design and carefully structure rehabilitation to advance patients based on milestones. This allows patients to advance when they are functionally ready rather than at non-specific set time points. The major goal is to restore daily function and pain-free living.

Conservative Treatment:

For patients who are candidates for conservative treatment, the focus of care will be on reducing pain, swelling, and inflammation, while also improving overall stability and function of the knee. Typically, if conservative treatment is successful, patients will experience significant relief after approximately 6-8 weeks of treatment.

After an arthroscopic debridement or partial meniscectomy, you will rely on crutches for the first few days after surgery based off your level of pain. A short course of physical therapy will begin the day after surgery. Patients usually continue physical therapy for about 4-8 weeks following surgery depending on how quickly their strength and function is restored. Patients usually return to normal daily activities within a week of surgery. However, it can take up to a month to return to pre-injury activities and sports.

After Dr. Bryan Penalosa performs a meniscus repair, the meniscus requires 3-4 months to heal. Following a meniscus repair, patients will begin physical therapy the day after surgery. The goal of physical therapy includes quadriceps re-activation, range of motion, gait mechanics, and strength restoration. Patients will typically be allowed to progressively return to running at 4 months post-op with anticipation of full recovery from surgery approximately 6 months after surgery.

It is important to note that immediately after a meniscus repair, Dr. Bryan Penalosa will recommend a period of non-weightbearing. The length of this time period will depend on the type of meniscus repair that is performed:

  • Degenerative, Horizontal Cleavage, Vertical/Longitudinal, Oblique Tears: 2 weeks non-weightbearing post-op.

  • Root, Radial, Bucket Handle Tears: 6 weeks non-weightbearing post-op

Meniscal repairs tend to heal well when the tear occurs in the peripheral regions of the meniscus (zones 1 and 2 of the meniscus). This is due to the higher blood supply, and thus, healing potential, of the peripheral meniscus. Classically, it has been thought that tears in the central regions of the meniscus do poorly with meniscal repair due to their limited healing ability. While this is true, there is evidence to suggest that meniscal repair can be successful in the more central meniscal regions with less healing potential (zone 3 of the meniscus). Other reasons that may impact the success of meniscal healing include a patient’s age, general health, BMI, and willingness to comply with a postoperative rehabilitation regimen. More recent evidence suggests that patients in their 50s and patients with a BMI below 35 can successfully undergo meniscal repair so long as the patient is compliant with post-operative instructions and rehabilitation.

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Patient Resources

Orthopedic surgeon Dr. Bryan Penalosa and his team are dedicated to providing an industry-leading patient experience—one that is smooth, efficient, and convenient. Our team has compiled a comprehensive set of orthopedic patient resources to assist you with insurance information, patient forms, and much more.
Explore the patient resources below to learn more.

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