All about Meniscus and Meniscal Injuries

The meniscus is a fibrocartilage component of some synovial

joints. The menisci (commonly referred to as cartilage) of
the knee are the most widely known examples. Another joint
containing fibrocartilage is the A-C joint. This discussion will be
concerned with the knee.

The menisci of the knee have unique shape. They are a

wedged, “C” shape. The “C” shape corresponds to the surface
area of the femur that would contact the surface of the tibia if
the menisci were not present. The wedge shape corresponds to
the shape of the heads of the femur as well. The ends of the
femur are rounded for maximal flexion of the knee. The
menisci act like a wedge to assist with the rotational stability
created by the anterior cruciate ligament; like a wooden block
placed behind the wheel of a car prevents the car from rolling.

The menisci also act as a shock absorber. As we walk, run, and

jump the knee absorbs tremendous forces. The menisci help to
absorb these forces so that the joint surfaces are not
damaged. The compressive forces on the knee have been
described as equivalent to the “amount of compression that
would be exerted on the skin if a 300 pound person would
hang from a ledge by a fingertip.” The amount of force
increases exponentially as the speed of movement increases
from walking to running to jumping. The menisci disperse the
compressive forces over the entire knee rather than isolating
them.

Mensical blood supply is limited: the menisci get nutrition from

blood and synovial fluid. The outside border (red zone) of the
meniscus has a blood supply that proliferates from the synovial
capsule while the inside border (white zone) gets its nutrition
from the synovial fluid. Due to this tears nearer the middle of
the knee (white zone) do not heal due to a lack of blood supply
to trigger an inflammatory response. Because of this many
meniscal tears do not heal.
Injuries

The meniscus in the knee is usually torn, in young adults, by a

twist occurring on a slightly flexed knee. In the older adult, the
tear may be due to a natural degeneration of the menisci that
occurs with age. The traumatic type of injuries are quite
common in the athletic setting. The meniscus can be torn
anterior to posterior, radially, or can have a bucket handle
appearance. Due to this, repair of the meniscus can be a
complicated issue. If the meniscus tear is large enough and
not addressed surgically, the torn flap of cartilage can cause
further damage by causing degenerative arthritis (Fairbank’s
changes).

Evaluation

Diagnosing a meniscal tear begins with a complete history.

Often, the history alone will be the indicator of a meniscal tear.
The athlete may also complain of clicking, popping, or locking
of the knee. These symptoms are usually accompanied by pain
along the joint line and a joint effusion. If the surgeon
aspirates (drains) the knee and the fluid is bloody, further
studies need to be done to rule out possible ACL damage. If
there is no other damage, this could be an indicator of a tear
in the red zone of the meniscus. These injuries are excellent
candidates for repair rather than resection.

Physical examination may reveal point tenderness along the

joint line, a positive McMurray test, positive meniscal
compression test, or pain with squats. Manual tests for
meniscal tears are only about 50% reliable even for the most
experienced orthopaedists. Due to this an MRI may be ordered
to rule out a meniscal tear. The normal meniscus appears as a
solid black wedge, while the torn meniscus has an area of
white with in the black wedge.

Treatment

A meniscal tear that is symptomatic (painful with activities of

daily living) needs to be addressed surgically. There are two
treatment options available, depending upon the location of
the meniscus tear. Surgery is performed arthroscopically (a
fiber-optic camera about the size of a pencil) to either resect a
tear in the white zone or repair a tear in the red zone. The
best treatment option is to repair the torn cartilage. This will
leave the athlete with his “normal” structures and decrease the
likelihood of degenerative arthritic changes.

Rehabilitation after a meniscus repair is usually different than

a resection. Most physicians will have the athlete be non-
weight bearing for one month to allow the meniscus to heal.
The theory is that the movement of the femoral heads over the
tear will disrupt the healing. Rehab should focus on early
mobilization of the knee joint and quad and hamstring
strength. This is done by performing quad sets straight leg
raises, hamstring curls, knee extensions, and Theraband® calf
pumps. Weight bearing exercises are added as directed by the
physician.

Rehabilitation for resected meniscal tears is usually very

aggressive, targeting early return to participation. These
athletes are allowed to progress through rehabilitation as pain
and swelling allow.

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