Meniscal injuries are one of the commonest problems seen by the knee specialists at Schoen Clinic.
At the Schoen Clinic, our knee specialists commonly treat professional sportsmen and women sustaining meniscal cartilage injuries, but the majority of our patients tear their cartilage undertaking relatively common day-to-day activities.
Every knee has two menisci within it, one on the inner (medial) aspect of the knee and one on the outside (lateral). They act as shock absorbers within the knee also helping to provide stability to the joint.
Meniscus Tear Symptoms
A significant twisting injury whilst playing sport (eg football or skiing) may well result in a meniscal tear, but equally even day-to-day actions such as getting up from sitting on the floor (eg in a yoga class) can produce exactly the same result, especially in the older age group. In orthopaedic terms, the phrase “older age group” sadly refers to patients over 40 years as after this age, the cartilage has already started to turn from a very resilient, tough rubbery construct to a more brittle one that is not as elastic as it once was. It is for this reason that a simple twisting injury can cause a small split within the cartilage.
The meniscus has a very limited capacity to heal by itself because the vast majority of it doesn’t have a blood supply. This means that symptoms from a torn cartilage will often persist long after one would expect other injuries to have healed, leading the patient to seek specialist advice for a pain that doesn’t seem to be getting better. It is not unusual however for the sharp pain to improve after several weeks, only for it to return each time a return to sport is attempted.
Some classical symptoms for meniscal injury include some or all of the following:
- Occasional sharp stabbing pain on either the inside or outside of the knee
- Limitation in the range of motion, particularly deep bending
- Pain on kneeling/squatting
- Pain climbing stairs
- Pain made worse by exercising
- A catching/clicking sensation
- A feeling of ‘giving way’/instability
- Pain at the back of the knee - often due to a Bakers cyst (due to excess fluid related to the meniscal tear)
Pain from a torn cartilage may vary between a sharp stabbing pain to a dull ache and it may be intermittent or continuous.
Occasionally, there is no pain at all associated with these injuries but simply an inability to completely straighten the leg. This is referred to as a locked knee, and is normally caused by the torn meniscus jamming the joint.
The diagnosis of meniscal cartilage injury is made by combination of a thorough consultation, a careful physical examination and appropriate imaging of the injured knee.
Listening to the history of the injury and is very helpful.
Examination may reveal the following tell-tale signs of a meniscal tear, such as:
- Fluid present in the knee, known as an “effusion”
- Marked pain on direct compression of the meniscus along the joint line
- Discomfort when squatting
- Clicking within the knee
After an initial examination, your consultant may refer you for x-rays and an MRI scan of your knee.
MRI scans produce high resolution images of the soft tissues in and around the knee and are very useful to assess cartilage tears. The high degree of definition within MRI scans allows the Radiologist we work with at Schoen Clinic to identify any tears within a meniscus with an extemely high level of accuracy. By working exclusively with specialist Radiologists with a clear interest in this area creates a very real advantage for the treating surgical team.
X-rays also can be useful in conjunction with MRI scans to assess concurrent bony pathology within the knee (eg osteoarthritis, loose bodies, fractures etc).
It is however useful for your consultant to have seen and assessed your knee prior to the MRI, as he will be able to tailor the scan to assess the damaged part in question in more detail.
Types of Meniscal Injury
Due to the absence of a blood supply to most of the meniscus, a tear is unlikely to heal by itself (a white-white tear).
If your symptoms are ongoing, and an MRI proven meniscal tear is seen, arthroscopic (keyhole) knee surgery is a very successful method of permanently curing the pain and instability that is felt.
This is done as a short day case procedure, and the torn part of meniscus which may be jamming the joint is trimmed and smoothened, so as to not catch and cause pain. Your surgeon will attempt to preserve as much normal meniscus as possible at this procedure.
Occasionally in the younger patient, the meniscus is torn within the zone of the meniscus which has a good blood supply (a red-red tear), and these tears may be suitable for surgical repair, preserving and regaining normal shock absorber function following successful healing.
Your surgeon will carefully go through the suitability and necessity of each procedure with you in clinic, prior to any planned surgery.
In older patients, we know that the lining of the articular surface of the joint may already be significantly diminished (osteoarthritis). In a known osteoarthritic knee, an MRI scan may reveal a crushed and macerated meniscus. This is often referred to as a “degenerate meniscal tear”. Keyhole surgery to treat a degenerate meniscal tear may not only fail to treat the symptoms, but can sometimes, actually aggravate the knee further.
Clearly, this can be disappointing for both patient and surgeon alike. Thus, when significant degeneration exists within the knee in addition to a meniscal tear, it is likely that your surgeon may advise you against keyhole surgery and seek alternative methods of treating the problem.
It is always your symptoms which should lead to consideration of an operation rather than just the presence of an MRI-proven tear alone.
If the decision has been made to proceed to surgery, this is a procedure known as an arthroscopic partial meniscectomy. This is a relatively straightforward keyhole operation carried out under general anaesthetic, lasting approximately 20-30 minutes under a light general anaesthetic.
The operation involves the insertion of a camera or “arthroscope” into the knee through two small 4mm incisions or “portals” in the front of the knee. The damaged part of the cartilage is trimmed and the residual rim of cartilage shaped. As little of the cartilage (usually approximately 20-25%) is removed as possible in order to preserve the function of the remaining healthy portion.
Once the whole of the inside of the joint cavity has been thoroughly inspected and any other defects/damage noted, the instruments are removed and the portals closed. After surgery, the knee is dressed with a woollen bandage and you will be encouraged to walk within an hour after you have woken up and have had a meal.
You will be able to walk without sticks or crutches but we advise that limiting walking to short distances initially and build up gradually to normal activity.
Driving is normally possible after two days and once you are confident enough to be able to do an emergency stop.
Any pain is normally controlled with a combination of anti-inflammatory drugs and painkillers, which may include simple paracetamol as well as some codeine and or anti-inflammatory medications such as Ibuprofen.
Physiotherapy should start within a few days of your discharge and plays a vital part in post-operative recovery.
You will normally be seen at Schoen Clinic two weeks after your operation to check wounds and to remove the stitches if necessary. We expect you to be making good progress by this stage, but not to be fully recovered.
Generally, full recovery takes about six weeks, but most patients can return to work within the first week. However, attempting to do too much too early on, can often be counterproductive, irritating the sensitive remnant of the meniscus, and causing a recurrence of pain.
It is very important for the knee to be given appropriate care and respect in the early stages including regular icing and the vast majority of patients will return to professional and amateur sports by six weeks post-surgery.