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sports radiology

Meniscal pathology
in the development
and progression
of knee
relevance for sports medicine
– Written by Ali Guermazi et al

INTRODUCTION ANATOMY OF THE MENISCI AND MENISCAL meniscal roots, to the tibial plateau (Figure
The menisci are vital to the normal ROOTS 1). Medially, the posterior root inserts into
function of the knee joint. Injuries to the The menisci in the knee are two semi- the posterior slope of the medial tibial
menisci are commonly seen in athletes, lunar discs made of fibrocartilage. The tubercle, while the anterior root of the
including players of football, tennis, major components of the meniscus are medial meniscus inserts broadly into the
basketball, baseball, rugby and track and water, collagen and proteoglycans. They anterior intercondylar crest. Laterally, most
field. Without normal menisci, the knee are located between the distal femur of the posterior root inserts into a horizontal
joint cannot support its full mechanical and the proximal tibia in the medial and part of the posterior intercondylar area, but
load, which will lead to pain and limited lateral compartments of the knee. The some fibres attach to the posterior slope
function in the short-term. In the long normal meniscus is wedge-shaped in cross of the lateral tubercle. The anterior root of
run, osteoarthritic changes will develop section, with the peripheral base attached the lateral meniscus inserts into a portion
and worsen over time. Thus, for sports to the joint capsule. The meniscal surface of the anterior intercondylar crest in front
physicians who treat athletes, knowledge facing the femur is concave and the tibial of the lateral tibial tubercle and lateral to
of the meniscal anatomy and pathology, as surface is flat. The anterior and posterior the anterior cruciate ligament, with which
well as its relation to knee osteoarthritis, is horns of the meniscus are anchored to the it partially blends. The medial meniscus
important in their daily clinical practice. tibia by ligamentous attachments, the is firmly attached to the medial collateral

Anterior roots Transverse ligament

Figure 1: Anatomical configuration of the

menisci, meniscal roots and ligaments
in the right knee. LM=lateral meniscus;
MM=medial meniscus, ACL=anterior cruciate
ligament , PCL=posterior cruciate ligament.



Wrisberg ligament Posterior roots

ligament. In contrast, the lateral meniscus should be set at 3 mm or less. Both sagittal determine the associations between the
is more mobile because it is separated from and coronal images are essential and, in components of the menisci and the forces
the lateral collateral ligament and the joint addition, axial images can be useful for to which it is subject and the pathogenesis
capsule at the popliteal hiatus. detection and characterisation of meniscal of knee osteoarthritis. These techniques
The outer third has vascular supplies and pathology. Currently, a fat-suppressed supplement the several published semi-
is called the ‘red zone’. If a small tear occurs intermediate-weighted fast spin-echo quantitative MRI scoring systems that
here, natural healing may occur. The nerve sequence with an echo time of about 35 ms incorporate visual assessment of meniscal
fibres mostly follow the blood vessels, with and a long repetition time is the preferred morphology and positioning3.
the two horns of the meniscus being the choice to achieve the maximum contrast-to- Modern MRI techniques using delayed
most richly innervated. The inner two thirds, noise ratio. This MRI sequence is also useful gadolinium-enhanced MRI (dGEMRIC),
called the ‘white zone’, have no vascular or for visualising cartilage, subchondral bone, T1rho and T2-mapping techniques enable
nerve supply. ligaments and joint fluid. The sensitivity visualisation of the physiological status of
The most important properties of the and specificity of MRI for detecting meniscal normal and pathologic menisci4,5. Ultrashort
collagen-proteoglycan meniscal matrix are tears are reported to be in the range of 82 to echo time-enhanced T2* mapping can
its ability to resist tension, compression 96%, and use of the ‘two-slice touch’ rule in show collagen disorganisation within
and shear stress. The menisci distribute bi-dimensional techniques i.e. visualisation the meniscus and may aid detection of
mechanical stress over a large area of the of the tear on at least two adjacent slices, has subclinical meniscal degeneration6. These
articular cartilage of the femur and tibia. been shown to be highly specific1. Detailed imaging methods can help to understand
When the knee is loaded, the tensile strength reviews of imaging of the meniscus and the relevance of early-stage intrameniscal
of the healthy meniscal matrix counteracts its pathology using conventional MRI changes and gain new insights into the
extrusion of the meniscus. Thus, the healthy techniques have been published by Niitsu disease process well before morphological
meniscus mainly responds to load with and colleagues2. changes detectable by conventional MRI
compression rather than extrusion. such as tears of the menisci occur.
MRI enables visualisation of the meniscus Three-dimensional segmentation tech- APPEARANCES
and its pathologies non-invasively with high niques based on MRI make detailed analysis Traumatic meniscal tears
spatial resolution and a high signal-to-noise of meniscal positioning and estimation Acute knee trauma during sports is a
ratio. For optimum imaging, a dedicated of meniscal tissue volume possible. major cause of internal injuries of the knee
knee coil should be used. Slice thickness These techniques will, hopefully, help to such as damage to the menisci, cartilage,

sports radiology

Figure 2: 20-year-old
2a 2b basketball player. a) Coronal
MRI shows an amputated
posterior horn of the medial
meniscus (red arrow) and
medial collateral ligament
tear (black arrow). b) Sagittal
intermediate-weighted MRI
shows shattered posterior
horn of the medial meniscus
with a meniscal fragment
anteriorly displaced (red
arrow) just posterior to the
anterior horn. There is also
partial thickness loss of the
weight-bearing central medial
femoral condyle (black arrow).
Figure 3: 28-year-old
football player with injury 6
months earlier. a) Coronal
3a 3b MRI shows avulsion of
* the posterior root and
posterior horn of the lateral
meniscus (arrow). b) Sagittal
intermediate-weighted MRI
confirms the findings in a)
and shows that the posterior
horn is not lying in anteriorly
to the anterior horn (red
arrow). There is a large focal
cartilage defect at the central
weight bearing lateral femur
with subchondral bone
marrow cystic changes (white
arrow). There is also a large
joint effusion (star).

cruciate and collateral ligaments (Figures tears or tears of the meniscal roots are absence of normal meniscal tissue, which
2 and 3). According to a published report, very important because they may lead to is not classified as a meniscal tear but is
the incidence of acute meniscal tears substantial meniscal extrusion, which in commonly associated with radiographic
presented at an emergency department is turn results in a loss of normal meniscal evidence of osteoarthritis. Interestingly,
approximately 70 per 100,000 persons per function as well as progression of cartilage MRI-detected meniscal damage was found
year7. A recent systematic review found damage within the tibiofemoral joint9. in 24% of persons who had no radiographic
that playing football or rugby is a strong osteoarthritis, with or without knee
risk factor for acute meniscal tear8. The Degenerative meniscal tears pain11. Such studies demonstrate the high
same study also showed that waiting more Meniscal tears can also occur as an prevalence of meniscal damage in the
than 12 months between anterior cruciate age-related degenerative process in general population, and also the fact that
ligament injury and reconstructive surgery persons without a known history of knee meniscal tears do not necessarily cause
is a strong risk factor for a subsequent trauma (Figure 4). A population-based pain. Thus, meniscal tears are a common
medial meniscal tear but not for a lateral epidemiological study in Framingham, finding, often found incidentally on MRIs of
meniscal tear8. On impact, the meniscus Massachusetts, USA, showed that the the knee. These types of meniscal tears are
typically splits vertically, in line with the prevalence of MRI-detected meniscal tears considered ‘degenerative’. They are typically
circumferentially oriented collagen fibres, increased with age, ranging from 16% horizontal cleavage lesions or flap tears of
leading to a longitudinal tear. The torn in the knees in 50 to 59-year-old women the body or posterior horn of the medial
part may dislocate and become wedged to over 50% in the knees of men aged 70 meniscus, and may be associated with
between the femoral condyles causing a to 90 years regardless of the presence of varying degrees of meniscal destruction.
‘locked knee’ – a condition that requires radiographic osteoarthritis10. In addition, Risk factors for non-traumatic degenerative
arthroscopic surgical treatment such as in this population-based sample, 10% meniscal tears include generalised
a partial meniscectomy. Complete radial had partial destruction or a complete osteoarthritis expressed as the presence

Figure 4: 34-year-old football player. Sagittal intermediate-
weighted MRI shows degenerative complex horizontal and radial 5
tear of the posterior horn of the medial meniscus. There is also a
diffuse partial thickness loss of the weight-bearing central tibial
and femoral cartilage.
Figure 5: 57-year-old woman with normal posterior root of the
right medial meniscus. Coronal STIR MRI shows a continuity of
the band-like hypointensity between the posterior horn of the
medial meniscus and the tibial plateau (white arrow). There is
no meniscal tear or extrusion. Similarly, the posterior root of the
lateral meniscus is also intact (red arrow).

Figure 6: 33-year-old baseball player. Coronal intermediate-

weighted MRI demonstrates posterior root tear (arrow) of the medial
meniscus associated with meniscal extrusion.

of multiple bony enlargements of finger render the meniscus incapable of its normal radiography. Thus, extrusion is an integral
joints, varus alignment of the lower limbs function as a buffer of the load on the part of knee osteoarthritis as the disease is
and a history of an occupation that involves tibiofemoral joint. Thus, meniscal root tears often clinically defined by the combination
kneeling such as carpet laying. seem to have an effect that is equivalent to a of symptoms and radiographic evidence of
‘pseudomeniscectomy’. joint space narrowing.
Meniscal root tears
The meniscal roots are readily Meniscal extrusion MENISCAL PATHOLOGY AS A RISK FACTOR
identifiable on MRI (Figures 5 and 6). Tears Tears of the menisci as well as of the FOR DEVELOPMENT AND PROGRESSION OF
of the meniscal roots are distinctly different meniscal roots are often associated with KNEE OSTEOARTHRITIS
than tears of the anterior or posterior horn some degree of meniscal extrusion i.e. radial Meniscal tears and extrusion, as well
of the meniscus. Isolated meniscal root tears displacement of the meniscus outside the as meniscal root tears, are key factors
can occur with no tearing of the meniscus joint margin (Figure 5). Extrusion of the in the early-stage development of knee
itself. Tears of the medial posterior meniscal body of the meniscus occurs commonly in osteoarthritis.
root are not unusual in daily clinical osteoarthritic knees. Meniscal extrusion
practice, while tears of the lateral posterior and the resultant reduced coverage of Pathologic pathway leading to knee
root are less common and tears of the the tibial surface can lead to tibiofemoral osteoarthritis
anterior meniscal root are extremely rare9. cartilage loss, as well as bone marrow Knee osteoarthritis is often a result
When the meniscal root tears, the meniscus lesions. It is important to note that meniscal of increased mechanical loading and
is no longer held within the joint, possibly extrusion contributes to the tibiofemoral the pathologic response of joint tissues
resulting in meniscal extrusion, which will joint space narrowing seen on conventional to excessive mechanical stress. Knee

sports radiology

An ongoing trial on patients 45 years

or older reported no statistically
significant benefit from partial
meniscectomy compared to physical
therapy in the short-term

malalignment, high body mass index Certain types of meniscal tears may cause aged and elderly patients with knee pain.
and occupational hazards are factors more pain and discomfort (e.g. catching An ongoing multi-centre randomised
that contribute to chronic overloading or locking symptoms) and/or functional clinical trial involving symptomatic patients
of the knee joint. Such overloading, limitation than others. For example, a 45 years of age or older with a meniscal
together with degenerative changes in ‘bucket-handle’ tear can cause locking tear and evidence of mild-to-moderate
the meniscal matrix that may be related of the knee and may require surgical osteoarthritis on imaging has reported no
to early stage osteoarthritis can result in treatment such as arthroscopic partial statistically significant benefit from partial
meniscal fatigue, rupture and extrusion. If meniscectomy. However, sports physicians meniscectomy as compared to physical
the meniscus loses its critical function in should be aware that a meniscal tear itself therapy in the short-term (6 months)12.
the knee joint, the effects of the changes may not be the direct cause of symptoms Currently, there are ongoing randomised
in the patterns of mechanical loading on in some patients with knee pain. Just trials in both Europe and USA that will
joint cartilage can result in cartilage loss, because a tear is detected by knee MRI or hopefully cast further light on how to
bone alterations including trabecular arthroscopy, surgical resection of the torn determine which patients will benefit from
bone changes, increased bone mineral meniscal tissue will not necessarily be the surgical intervention for a degenerative
density, development of subchondral bone immediate solution for the patient’s pain meniscal tear in the absence of radiographic
marrow oedema-like lesions and worsening or provide a long-term solution. Other osteoarthritis and which will benefit from
malalignment. pathologic features of osteoarthritis such as physical therapy alone.
This pathologic pathway leading to joint effusion, synovitis and bone marrow
osteoarthritis can also result from injuries oedema-like lesions can also cause pain. Surgical repair and replacement
of the knee, in which normal meniscal This is particularly likely in patients with Currently, meniscal repair surgery is
function is lost in a previously healthy pre-existing knee osteoarthritis. There is a commonly used to treat younger patients
knee. Therefore, preservation of as much speculation that meniscal extrusion may when a traumatic tear is located within
functional meniscal tissue as possible cause stretching and/or irritation of the or close to the vascularised zone of the
is crucial. The meniscal tissue may still synovial capsule, and consequent knee meniscus. In contrast, meniscal lesions in
contribute substantially to buffering of pain, but exactly how meniscal extrusion the middle-aged and elderly are typically
the mechanical load to the knee, and contributes to knee pain is unknown. located away from the vascularised zone
preservation is important not only when and consequently are not amenable to
treating traumatic tears but also in patients Is surgical therapy more beneficial than repair. Also, rehabilitation after surgical
with horizontal tears and/or intrasubstance conservative management? repair tends to be more extensive than after
signal changes on MRI. Cartilage loss occurs Partial meniscectomy vs physical therapy meniscectomy, and the long-term outcome
mainly in the vicinity of the damage to the Nowadays, partial meniscectomy is of meniscal repair compared with partial
meniscus suggesting a cause and effect a common surgical procedure to treat meniscectomy is unclear.
relationship between the meniscal damage patients with meniscal damage that causes Meniscal lesions found in the avascular
and structural disease progression. mechanical interference with movement inner region, which functions in a highly
of the knee joint. However, there is little demanding mechanical environment, are
Meniscal pathologies and knee symptoms scientific evidence to show that arthroscopic considered to be a significant challenge
The association between meniscal meniscectomy provides more benefit than for surgery. Meniscal replacement
tears and knee symptoms is complex in non-surgical management in the treatment using transplants or scaffolds has been
all knees, with or without osteoarthritis. of degenerative meniscal lesions in middle- attempted, but there is a paucity of evidence

documenting the long-term outcome the prevalence of meniscal damage is high to the risk for developing knee osteoarthritis
of repair surgery in the inner avascular in the general population10,11. Thus, surgical later on. We also need to better understand
region. Nevertheless, meniscal replacement techniques such as meniscal replacement indications for surgical therapy and the
may have potential in selected patients, are only likely to be indicated in highly implications of healthcare economics. In
particularly those with an otherwise selected patients. younger patients, surgical techniques of
healthy knee in which a large portion of meniscal repair or replacement appear
the meniscus cannot be saved due to the Clinical challenges concerning management promising, but again we need more
extent of damage, as is often the case in of meniscal tears evidence for the long-term outcome.
severe first time knee injuries in athletes. The main clinical challenge we
Meniscus-like tissue ingrowth may occur face currently is understanding the CONCLUSIONS
in polyurethane scaffolds implanted to long-term efficacy of arthroscopic Sports physicians treating athletes
treat partial meniscal lesions. However, partial meniscectomy vs conservative regularly encounter patients with acute
a considerable amount of time will be management of patients with degenerative knee trauma, including tears of the menisci
required to learn more about the value of meniscal tears and knee pain. We need to and the meniscal roots. These structures
implants for them to become more widely know if the long-term prognosis differs with are highly important for maintaining a
used clinically. We should keep in mind that respect to clinically relevant outcomes and healthy knee joint. When a meniscus or
a meniscal root is torn by a knee injury
or degenerative processes, the risk of
developing knee osteoarthritis later in life
increases. Meniscal damage and extrusion
often have a key role in the morphological
progression of the disease. We should keep
in mind that most meniscal tears are found
in middle-aged and elderly persons without
knee pain or history of knee trauma. In fact,
knee pain can be caused by other structures
or pathophysiological processes within the
osteoarthritic joint. In other words, surgical
management may not always be required
just because that is the structural pathology
demonstrated by MRI or arthroscopy.
Degenerative meniscal tears, for example,
may by conservatively managed with
exercise therapy first. However, if traumatic
or degenerative tears of the meniscus or
meniscal roots are causing symptomatic
mechanical interference, surgery should
be considered. An extensive meniscal
resection may help some patients in
the short-term but the long-term risk
of developing osteoarthritis needs to be
weighed carefully in the decision-making
process. Excessive resection during partial
meniscectomy may facilitate progression of
osteoarthritic changes. Recent development
of advanced MRI protocols and image
processing techniques for research purposes
shows promise for uncovering early-stage
changes of meniscal matrix and other
associated tissues. Modern MRI techniques,
therefore, may help us better understand
the pathological mechanism of the onset
of osteoarthritis of the knee and to further
evaluate surgical techniques of damaged
menisci and meniscal roots.

sports radiology

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Department of Radiology, Bridgeport
meniscus magnetic resonance relaxation 11. Guermazi A, Niu J, Hayashi D, Roemer Hospital, Yale University School of
Bridgeport, CT
United States

Michel D. Crema M.D.

Quantitative Imaging Center

The main clinical

Department of Radiology, Boston
University School of Medicine

challenge is
Boston, MA, United States
Department of Radiology, Hospital do
Coração (HCor); and Teleimagem

understanding the São Paulo, SP, Brazil

long-term efficacy... Frank W. Roemer M.D.

Quantitative Imaging Center
Department of Radiology, Boston
University School of Medicine
Boston, MA, United States
Department of Radiology, University of
Erlangen, Germany