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Josh in NSW Australia asks:
"I have torn my meniscus. Is there any way that this can heal without having surgery?"
Marc Bernier and Douglas Palma, at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), reply:
"As recently as 1970, the meniscus was thought to be a vestigial structure with little function. However, our knowledge has since expanded and we now realize their importance in the normal function of the knee. The functions of the meniscus include load bearing, shock absorption, and joint stabilization, all of which are vital characteristics in preventing deterioration of the joint, which is very vulnerable in the sport of soccer due to the nature of the game (extensive cutting, pivoting, etc).
"The meniscus is composed of two semilunar fibrocartilaginous disks that are found between the distal femoral condyles and tibial plateau. They both are approximately c-shaped with a thick peripheral rim that taper to a thin inner edge, which in cross section appear as a triangle. Each one has a distinct shape and features. The medial meniscus is semicircular, approximately 3.5 cm in length, and is wider posteriorly than anteriorly. It has an average excursion on flexion and extension of the knee of 5mm, which is less than the lateral meniscus. It is also continuously attached to the joint capsule and at its midpoint to the deep medial collateral ligament. The lateral meniscus is circular and covers a larger portion of the tibial plateau than the medial meniscus. It has loose peripheral attachments to the joint capsule and an average excursion of approximately 11mm during flexion-extension movements of the knee.
"The annual incidence of injury to the meniscus ranges from 60 to 70 per 100,000, with an estimated 850,000 meniscal procedures performed each year. There has been found a male-to female ratio of approximately 2.5-4 to 1. Higher incidences of meniscal injuries have been found with anterior cruciate ligament injuries (lateral meniscus more commonly affected) and tibial plateau fractures.
"A thorough history and physical are essential to diagnosis. Most injuries are sustained from a twisting injury with the knee flexed and the foot planted on the ground. A pop could have been felt but is not always the case. A history of catching, locking, or popping may aid in the diagnosis of a meniscal tear. On physical exam, joint line tenderness and provocative testing (i.e. McMurray or Apley tests) are essential to confirm the pathology. MRI can be confirmatory, but is not 100% sensitive or specific.
"Once the diagnosis has been made and confirmed, a treatment plan can be implemented. The decision must be made to either perform an excision of the torn fragment of the meniscus (partial menisectomy), or perform a repair of the tear. Many years ago, total menisectomies were the treatment of choice; however, it has since been found that removal of the entire meniscus resulted in a 200% increase in contact pressure within the joint. As a result, the technique of performing partial menisectomies was developed.
"Initial research indicates that even with partial menisectomies, contact pressures increase by approximately 65%. This has lead to attempts at repairing meniscal tears, in which the "loose ends" of the tear are sutured or anchored together, and allowing healing to occur similar to that seen in skin lacerations. Unfortunately, research indicates that a small minority of all meniscus tears are amenable to repair.
"Tears that occur in the vascular zone of the meniscus ("red-red" zone, outer 20-30%) have the greatest potential to heal, while tears at the vascular boundary ("red-white" zone) have somewhat less healing potential. Tears located entirely within the avascular zone ("white-white" zone) have limited potential to heal; nutrients are supplied by the synovial fluid. However, some physicians have advocated repairs of meniscal tears in this avascular region, with reports of acceptable success rates.
"Other determining factors in the ability to repair meniscal tears include the size, type and location of the tear, degree of degeneration within the joint, and complexity of the tear. If the characteristics of the tear are not conducive to repair, partial menisectomy is the next treatment option in the soccer athlete.
"Rehabilitation in the post-operative phase and return to play differ depending on the surgical procedure performed. In the case of partial menisectomies, weight bearing is allowed to tolerance, with an accelerated progression to closed kinetic chain and proprioceptive exercises. Typically, the rate of progression is dependent upon pain and effusion, with a usual return to play in 4-6 weeks. If a meniscal repair is performed, a much slower program is followed, with a more restricted weight bearing gait pattern that is gradually increased. Progression to closed chain activities occurs more slowly, with a goal of a return to play in 5-6 months.
Thanks to Dr Douglas Palma MD for his help in compiling this article.