Meniscal TearsMeniscal Tears

By Michael LaBellaBy Michael LaBella

Objectives Objectives

You will be able to identify the two menisci in the kneeYou will be able to identify the two menisci in the knee You will know the most common mechanisms of You will know the most common mechanisms of

meniscal tearsmeniscal tears You will be able to recognize and evaluate a meniscal You will be able to recognize and evaluate a meniscal

teartear You will know the proper treatments and rehabilitation for You will know the proper treatments and rehabilitation for

a meniscal teara meniscal tear You will understand the requirements for an athlete to You will understand the requirements for an athlete to

return to playreturn to play You will learn various stretches and strengthening You will learn various stretches and strengthening

techniques for preventiontechniques for prevention

The Knee JointThe Knee Joint

The knee joint has two The knee joint has two menisci, a lateral and menisci, a lateral and medialmedial

They are fibrous cartilageThey are fibrous cartilage They rest on top of the They rest on top of the

tibia in shallow tibia in shallow indentationsindentations

The lateral meniscus is on The lateral meniscus is on the outside of your knee the outside of your knee and the medial the insideand the medial the inside

Functions of the menisciFunctions of the menisci

Aid in lubrication and Aid in lubrication and nutrition of the jointnutrition of the joint

Act as shock Act as shock absorbersabsorbers

Evenly distribute Evenly distribute weight throughout the weight throughout the kneeknee

Allows for smoother Allows for smoother motions between the motions between the femur and tibiafemur and tibia

The inner 2/3 of the The inner 2/3 of the menisci are avascular menisci are avascular (without blood supply)(without blood supply)

The remaining outer 1/3 The remaining outer 1/3 is vascular (with blood is vascular (with blood supply)supply)

Mechanisms of injuryMechanisms of injury

An acute twisting injury from An acute twisting injury from impact during a sportimpact during a sport Usually the foot stays fixed on the Usually the foot stays fixed on the

ground and the rest of body ground and the rest of body rotatesrotates

Getting up from a squatting or Getting up from a squatting or crouching positioncrouching position

Loading the knee from a fixed Loading the knee from a fixed positionposition

Injuring the meniscusInjuring the meniscus There are several types of tearsThere are several types of tears

Vertical Vertical Radial Radial HorizontalHorizontal DegenerateDegenerate Complex Complex HornHorn

A loss of any part of the meniscus causes A loss of any part of the meniscus causes uneven weight distribution and can lead to early uneven weight distribution and can lead to early wear of the kneewear of the knee

The lateral meniscus is not attached as firmly to The lateral meniscus is not attached as firmly to the tibia as the medial meniscus, making it less the tibia as the medial meniscus, making it less likely to become injuredlikely to become injured

Meniscal injury statsMeniscal injury stats Meniscal injuries occur in 15% of ACL injuriesMeniscal injuries occur in 15% of ACL injuries 80% of patients with a history of ACL tears will 80% of patients with a history of ACL tears will

likely tear their meniscus with incidences of likely tear their meniscus with incidences of instability of the kneeinstability of the knee

70.7% of meniscal injuries are to the medial 70.7% of meniscal injuries are to the medial meniscusmeniscus

Almost all meniscal injuries ages 20 and under Almost all meniscal injuries ages 20 and under are sports related 11 out of 12 casesare sports related 11 out of 12 cases

Ages 20-29, 64.5% were sports relatedAges 20-29, 64.5% were sports related Ages 30-39, 30.6% were sports relatedAges 30-39, 30.6% were sports related Ages 40-49 and 50-59 only 19.6% and 14.3% Ages 40-49 and 50-59 only 19.6% and 14.3%

were sports relatedwere sports related

What to look for?What to look for?

Not all meniscal tears are symptomaticNot all meniscal tears are symptomatic If there are symptoms you could look for:If there are symptoms you could look for:

SwellingSwelling Pain along the joint line (tenderness)Pain along the joint line (tenderness) Pain when squatting, kneeling or pivotingPain when squatting, kneeling or pivoting Locking of the kneeLocking of the knee Loss of full knee extensionLoss of full knee extension

How can the coach help?How can the coach help?

If there is a possible meniscal tear 80-90% of the If there is a possible meniscal tear 80-90% of the time an athlete will remember the mechanism of time an athlete will remember the mechanism of the injury and may report a “pop” or a “snap”the injury and may report a “pop” or a “snap”

You could ask the athlete if there is pain when You could ask the athlete if there is pain when weight bearing, or bending of the kneeweight bearing, or bending of the knee

You could also ask the athlete if they are having You could also ask the athlete if they are having any locking in their knee or trouble extending the any locking in their knee or trouble extending the knee all the wayknee all the way

When there is a meniscal injuryWhen there is a meniscal injury

As a coach in the event of a meniscal As a coach in the event of a meniscal injury you should injury you should Ice the area in painIce the area in pain Limit movement of the knee joint (rest)Limit movement of the knee joint (rest) Keep weight bearing limited to a tolerable Keep weight bearing limited to a tolerable

level of pain for the injured kneelevel of pain for the injured knee Sometimes a splint can be applied for comfortSometimes a splint can be applied for comfort

Rehabilitation optionsRehabilitation options There are two common ways that a meniscal tear There are two common ways that a meniscal tear

can be repaired surgically can be repaired surgically There is also a non surgical option because the There is also a non surgical option because the

menisci are partially vascular they have the menisci are partially vascular they have the ability to heal themselvesability to heal themselves

Why choose surgery?Why choose surgery?

Surgery is usually advised for a few Surgery is usually advised for a few different reasonsdifferent reasons The location of the tear, if the tear is in a The location of the tear, if the tear is in a

avascular zone it will most likely not heal itselfavascular zone it will most likely not heal itself If the tear is longer than 5-8mm If the tear is longer than 5-8mm If the pain limits activities of daily livingIf the pain limits activities of daily living Or if the individual is not happy with their level Or if the individual is not happy with their level

of functionof function

Surgical techniquesSurgical techniques

The more common technique is arthroscopic The more common technique is arthroscopic partial menisectomy, which consists of removing partial menisectomy, which consists of removing the torn fragment of the meniscusthe torn fragment of the meniscus This reduces irritation, but can effect the weight This reduces irritation, but can effect the weight

distribution in the kneedistribution in the knee The other option is an arthroscopic repair, which The other option is an arthroscopic repair, which

requires suturing the meniscus back togetherrequires suturing the meniscus back together This option attempts to conserve the meniscus in This option attempts to conserve the meniscus in

hopes of preventing the early onset of arthritishopes of preventing the early onset of arthritis

Road to recoveryRoad to recovery

Whether you choose the surgical or Whether you choose the surgical or conservative approach, the rehabilitation is conservative approach, the rehabilitation is similar similar

The rehabilitation time frames can vary The rehabilitation time frames can vary depending on the individual and the severity of depending on the individual and the severity of the tearthe tear

The protocols may vary depending on the The protocols may vary depending on the surgical approach and physician. A common surgical approach and physician. A common protocol may include the followingprotocol may include the following

Steps to recoverySteps to recovery The patient may be full weight bearing right after The patient may be full weight bearing right after

the surgery with or without crutchesthe surgery with or without crutches Initial symptoms can be reduced using certain Initial symptoms can be reduced using certain

modalities and manual techniquesmodalities and manual techniques Stretching/ flexibility exercises focusing on Stretching/ flexibility exercises focusing on

hamstrings, quadriceps, hip flexors, hip hamstrings, quadriceps, hip flexors, hip adductors and calf muscles adductors and calf muscles

Strengthening Strengthening Balance trainingBalance training Dynamic exercises/plyometricsDynamic exercises/plyometrics

Initial physical therapyInitial physical therapy The first few sessions of physical therapy may The first few sessions of physical therapy may

consist more of modalities and some manual consist more of modalities and some manual techniques to address inflammation, pain and techniques to address inflammation, pain and ROM such as:ROM such as: Heat/iceHeat/ice UltrasoundUltrasound Electrical stimulationElectrical stimulation Manual stretchingManual stretching Scar and patella mobilizationsScar and patella mobilizations Passive range of motion for full knee flexion and Passive range of motion for full knee flexion and

extensionextension Retrograde massage to decrease swellingRetrograde massage to decrease swelling

Once pain and swelling are reduced the Once pain and swelling are reduced the sessions mainly focus on increasing the sessions mainly focus on increasing the strength and flexibility of the lower strength and flexibility of the lower extremity as toleratedextremity as tolerated

The progression will vary depending on The progression will vary depending on the individualthe individual

Some examples of stretching and Some examples of stretching and strengthening exercises are illustrated in strengthening exercises are illustrated in the following slidesthe following slides

StretchingStretching HamstringsHamstrings

QuadricepsQuadriceps

Calf musclesCalf muscles

Stretching continuedStretching continued

Hip flexorsHip flexors

Hip adductorsHip adductors

StrengtheningStrengthening Focusing on strengthening the muscles around Focusing on strengthening the muscles around

the knee is essential in rehabilitation the knee is essential in rehabilitation Quad sets Straight leg raises (in all planes)Quad sets Straight leg raises (in all planes)

Heel raises Leg Curl Heel raises Leg Curl

Leg extensionLeg extension

BalanceBalance

Balance can Balance can sometimes be sometimes be compromised after an compromised after an injury or surgeryinjury or surgery

Here are some Here are some balance exercises balance exercises that can helpthat can help

Dynamic exercises/plyometricsDynamic exercises/plyometrics

Progression to more Progression to more dynamic sports dynamic sports specific exercises specific exercises helps with the helps with the transition back into transition back into sportssports

Return to playReturn to play

This can vary widely from athlete to This can vary widely from athlete to athleteathlete

When the athlete can participate in sport When the athlete can participate in sport specific exercises without pain or specific exercises without pain or weaknessweakness

Full ROM is apparent in the injured kneeFull ROM is apparent in the injured knee Collaborate decision between athlete, Collaborate decision between athlete,

physical therapist and physicianphysical therapist and physician

PreventionPrevention

The prevention of meniscal tears is very The prevention of meniscal tears is very similar to the rehabilitation similar to the rehabilitation

Research has shown that more flexible Research has shown that more flexible and stronger joints are less likely to get and stronger joints are less likely to get injuredinjured

The athlete would continue stretching and The athlete would continue stretching and strengthening the lower extremitiesstrengthening the lower extremities

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Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 Iss. 2 p. 143-149Iss. 2 p. 143-149

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