What is the meniscus:

Your knee is made up of bones and soft tissue which hold the joint in place and allow it to function properly, moving through the various motions of the knee smoothly and with stability. The meniscus is a form of cartilaginous tissue. In your knee you have two c-shaped menisci, which sit in the joint space between the upper leg bone (the femur) and the primary lower leg bone (the tibia); one on the inner side of the knee joint (medial meniscus) and one on the outer side of the knee joint (lateral meniscus). The functions of the menisci include distributing the body weight over the knee joint when standing, reducing friction in the joint, and acting as shock absorbers.

Meniscus tears:

Meniscus tears are one of the most common injuries to the knee. They can occur during simple activities such as walking or squatting, or as the result of a traumatic injury to the knee. They commonly arise as a result of sports injuries. Meniscus tears often occur during twisting motions of the knee, and occur frequently along with other knee injuries, such as injuries to the anterior cruciate ligament (ACL) or the medial collateral ligament (MCL). Degenerative meniscal injuries can also occur as a result of over-use and wear-and-tear, particularly in older patients.

Meniscal tears come in many different forms and are defined by their size, location, availability of blood supply, and displacement. The characteristics of the tear will impact the severity of symptoms as well as the appropriate treatment options.

Symptoms of a meniscus tear:

The particular symptoms of a meniscus tear depend on the characteristics of the tear. The most common symptoms of a meniscal tear are pain, catching and swelling. The severity of the pain varies from person to person, but in many cases individuals are able to continue to perform activities of daily life and to participate in some forms of athletic activities following meniscal injuries. The pain is often worse during activities which involve weight bearing (such as walking or running), during twisting movements of the knee, and when squatting. Pain is also often felt when palpating along the joint line.

If the tear involves a loose flap or piece of displaced meniscus in the knee joint, the patient may also experience joint locking, clicking, a loss of range of motion, and/or the sensation of a loose body in the joint. Some patients also experience a sensation of instability in the knee or of the knee giving way.

In the long run, damage to the meniscus can lead to articular cartilage damage and arthritis later in life, due to the loss of its shock absorbing and friction reducing effects.

How are meniscus tears diagnosed:

Meniscus tears are diagnosed in several ways. Firstly, the doctor will take a history of any knee injury sustained, the mechanism of the injury, and any knee symptoms and pain. This will allow the doctor to determine whether your symptoms fit the picture of a meniscus tear. The doctor will also physically examine your knee to determine which movements cause pain, and where the pain is located. These two pieces of information should give the doctor a good idea about whether or not there is a meniscal injury. Finally, an MRI scan will be ordered to confirm the diagnosis. Unlike x-rays, MRI’s show soft tissue, allowing damage to the menisci to be visualized. X-rays may also be taken to rule out any fractures or bone injuries to the knee, or to visualize any degenerative changes to the bone or articular cartilage.

Treatment options:

In many cases, before a surgical route is undertaken, a more conservative management path will be attempted. This could involve any of the following: rest, activity modification, protected weight bearing, and physiotherapy and exercises to increase joint strength and range of motion. The goal is to promote the healing of the meniscus, to increase the strength of the muscles which stabilize the knee joint, and to regain normal function of the joint. Non-surgical treatment can be very successful in alleviating symptoms, particularly in those patients with small, non-detached lesions.

If symptoms persist, surgical treatment may be considered. Surgical treatment for meniscus tears is divided into two broad categories: 1) partial meniscectomy and 2) meniscal repair. The choice of procedure depends on the characteristics of the tear, and in many cases is only determined during surgery, once the surgeon is able to visualize the meniscus. In either case, the goals of surgery are to alleviate symptoms, improve the function of the joint, and allow the patient to return to all forms of physical activity.

Partial meniscectomy:

The meniscus only has a small amount of blood supply to its outer edge. Normal healing in the body requires many nutrients which are supplied through the blood, and therefore healing of the meniscus is only possible if the tear occurs in the region of the meniscus with a blood supply. If the tear is very extensive, or in a region without a blood supply, the meniscus will not heal, even if a repair is attempted, and thus a partial meniscectomy will be undertaken in order to remove the damaged meniscus.

Partial meniscectomies are performed arthroscopically. The surgeon will trim the meniscus in order to remove any torn pieces and any loose flaps, and will create a clean edge to prevent the meniscus from catching in the joint. Any floating pieces will also be removed from the knee joint.

Meniscal repair:

The meniscus only has a small amount of blood supply to its outer edge. Normal healing in the body requires many nutrients which are supplied through the blood, and therefore healing of the meniscus is only possible if the tear occurs in the region of the meniscus with a blood supply. Repairs require the ability of the meniscus to heal and are therefore only possible with clean cut tears which occur in this region.

If the surgeon determines the tear is repairable and is located in a region that will heal, sutures will be used to close the tear, and/or to reattach any loose pieces. The procedure is performed arthroscopically, though sometimes a larger incision is required. Following a meniscal repair, weight bearing and range of motion limitations will be imposed to protect the repair and give the meniscus time to heal. It is important to adhere to these limitations in order to achieve a successful outcome as it is possible for the meniscus to re-tear following surgery.

Timeline/recovery – Partial Meniscectomy:

Recovery is a process that will be different for everyone. It depends on a number of factors including the work and motivation the individual puts into rehab, the individual’s pre- and post-injury levels of physical activity, and the particular injuries sustained. Recovery should be a steady improvement in the long-run, however there will be bumps along the way. A successful recovery depends on the patient putting in the work to increase strength and mobility, while still protecting the joint.

The following outlines a timeline of what is typically expected post partial meniscectomy, but once again, this will differ from person to person. Dr. Murnaghan and your physiotherapist will monitor your progress and may recommend modifying the timeline slightly if necessary.

Post-op (0-2 weeks):

 

During this time you will be using crutches for comfort, but may weight bear as tolerated.

You should maintain the full Tensor bandage for 2 days, and then can reduce it to just the steri-strips over the incisions.

During this time it is not uncommon to experience some pain, discomfort, swelling and discolouration in your knee and calf.

Pain medication, ice, and elevation can be used to minimize this discomfort. Ankle pumps are also useful in reducing swelling.

You should begin working on range of motion exercises as tolerated, including gently bending and straightening the knee ten times, three times a day. You may also begin some strengthening exercises such as straight leg raises ten times, three times a day.

You should begin physiotherapy during this time – your physiotherapy should be underway before your first post-op visit to the clinic.

You will come in to the clinic for a follow-up appointment at about 2 weeks post-op. At this point we will check your progress and the healing of your incisions.

See the “FAQ” section for more details regarding the first two weeks after surgery.

Post-op (2-4 weeks):

 

During this time, the pain in your knee should decrease greatly, although you will likely still notice some pain and swelling during or after exercise and range of motion activities.

At this point you do not require any dressings or brace.

You may return to full activities of daily living.

You may also begin light exercise if you have regained full range of motion and have no swelling.

Post-op (4 weeks):

 

At this point you should begin strengthening exercises. “Closed-chain” strengthening exercises (those which keep the foot planted on the ground, such as squats and lunges) are the best form of exercise because they better imitate the types of stresses that will be placed on your knee during sports, and do not cause unnecessary stresses on the joint.

You may return to all physical activity as tolerated, including sports or manual labour.

Timeline/recovery – Meniscal repair:

Recovery is a process that will be different for everyone. It depends on a number of factors including the work and motivation the individual puts into rehab, the individual’s pre- and post-injury levels of physical activity, and the particular injuries sustained. Recovery should be a steady improvement in the long-run, however there will be bumps along the way.  A successful recovery depends on the patient putting in the work to increase strength and mobility, while still protecting the repair.

The following outlines a timeline of what is typically expected post-op, but once again, this will differ from person to person. Dr. Murnaghan and your physiotherapist will monitor your progress and may recommend modifying the timeline slightly if necessary. Recovery following meniscal repair is more extensive than following a partial meniscectomy, and it’s important to adhere to the weight bearing and range of motion limitations set out by your surgeon in order to achieve a successful outcome.

Post-op (0-2 weeks): 

Your knee will be in a hinged knee brace, locked in extension (with the knee straight).

You will be using crutches for protected weight bearing.

During this time it is not uncommon to experience some pain, discomfort, swelling and discolouration in your knee and calf.

Pain medication, ice, and elevation can be used to minimize this discomfort. Ankle pumps are also useful in reducing swelling.

You will come in to the clinic for a follow-up appointment at about 2 weeks post-op. At this point we will check your progress and the healing of your incisions.

See the “FAQ” section for more details regarding the first two weeks following surgery.

Post-op (2-6 weeks):

 

At this point, you may progress to weight bearing as tolerated.

You may begin working on range of motion exercises, but must limit your flexion (bending) to 90 degrees.

During this time, the pain in your knee should decrease greatly, although you will likely still notice some pain and swelling during or after exercise and range of motion activities.

You may not perform any leg presses or squats (loading in flexion) for 6 months.

You will come in for a follow-up appointment at about 6 weeks post-op, at which point we will check your progress.

Post-op (6 -12 weeks):

 

At this point, you can progress to full weight bearing.

You can also progress to full range of motion exercises.

Remember, no leg presses or squats (loading in flexion) for 6 months.

You will come in for a follow-up appointment at about 3 months post-op, at which point we will check your progress.

Post-op (3 months):

 

At this point you can allow weight bearing through the full range of motion.

You may also return to training and sport – but no cutting and twisting, and no game play.

Post-op (6 months):

 

At this point you may carefully return to full sport.

You will come in for a follow-up appointment at about 6 months, at which point you will be cleared for leg press, squats and pivoting activities.