Practical PAIN MANAGEMENT, July/August 2010
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breakdown is to be expected with age, as joint wear will result from years of me-chanical stress. Unlike the anatomy of younger and more active patients, howev-er, the fibers in older patients are less ca-pable of healing themselves due to de-creased diffusion of synovial fluid as a re-sult of lessened motion.
Symptoms of Meniscal Tears
A basic ability to identify meniscal tearsymptoms is essential for diagnosis andtreatment of injury (see Table 1). The firstsymptom typically indicative of a menis-cal tear is pain. In the case of a traumat-ic tear, pain may present immediately atthe time of injury and is often accompa-nied by an audible pop. In a degenerativetear, the onset of pain may be more grad-ual, with no definite moment of injury. Inboth cases, pain may be accompanied byswelling and subsequent limitation inrange of motion. Another hallmark of meniscal tears is clicking, popping, orlocking in the knee joint. These symptomsare mostly likely a result of a torn flap of meniscal tissue which catches in the jointduring movement. Instability and weak-ness are also both common symptoms be-cause a damaged meniscus—as well asdamaged ligaments and tendons—in-hibits normal mechanical function.The severity of initiating trauma, as wellas the nature and characteristics of thetear, plays an important role in the menis-cus’ ability to heal (see Table 2). Tears thatare shorter, partial thickness, and locatedin the vascular red zone have a much bet-ter chance of healing than extensive, com-plete thickness tears located in the whitezone.
When other cartilages and liga-ments are injured in the knee, they canhave a detrimental effect on the menis-cus’ ability to heal on its own. Because of the interdependence of each of the knee’smechanisms, meniscal injuries oftenoccur in conjunction with other internalligament damage. The most common ex-ample of this is O’Donoghue’s “unhappytriad,” the correlated injury of the menis-cus (debatably either medial or lateral),tibial collateral ligament, and ACL.
The severity of meniscal lesions has beenfound to increase in direct proportion to ACL injury and/or laxity and create lessfavorable conditions for repair.
Further-more, previous injury to either the menis-cus or any other ligament inside the kneecan increase the risk of future injury to themeniscus, even if the injury has healed orbeen surgically repaired.
Discoid Meniscus Condition
Another condition which can be both acause and complication of meniscal tearsis a discoid meniscus (see Figure 6). A dis-coid meniscus occurs when the lateralmeniscus takes on the shape of a discrather than a crescent and is most oftenmanifested in adolescence.
Although thecause has never been officially deter-mined, the repercussions of a discoidmeniscus have been widely documented.Often referred to as “snapping knee syn-drome,” this condition is identified with itsonly symptom: snapping on extension.The “snap” is caused when the femur andthe meniscus are not able to move in sync with each other and the femur either slipsover a ridge in the meniscus or off themeniscus altogether.
Unlike the normalmeniscus, which is shaped to fit thecondyle of the femur, a discoid meniscuslacks the configuration to serve as a stablesurface for motion. This abnormal track-ing adds stress to the meniscus, increasingthe probability of lateral meniscus tears.
Unfortunately, discoid menisci often re-main undetected when no symptoms pres-ent prior to injury, and the only other wayto identify a discoid meniscus is by mag-netic resonance imaging (MRI).
For decades, MRI has been used as a pri-mary determinant for meniscal injuries butthe fact that it is more sensitive to some tis-sues than others, however, can prevent itfrom producing a completely accurate pic-ture of an injured area. This can cause in-
A hit on the knee causing a medial collateral ligament injury. If the hit is severeenough, the supporting ligaments of the knee could also be torn. (Used with permission from Hauser, R. Prolo Your Sports Injuries Away, Beulah Land Press, Oak Park, Ill. 2001)
False-positive MRIs of the knee inteenagers. Because significant abnormalities show up in the menisci on MRI in teenagers,when no true injury exists, relying on this modality to make a diagnosis is a scary propo- sition, especially if surgery is contemplated.(Used with permission of Beulah Land Press, 2001, Oak Park, Il. “Prolo Your Sports Injuries Away!” fig. 16-10.)
Discoid meniscus of right knee.