Meniscal Injuries

Meniscal Anatomy

Meniscal injuries are common in all age groups. You have a meniscus on the inside of your knee, or the medial side, and one on the outside of your knee, the lateral side. The meniscus is a protector for the knee joint and takes a lot of the stress off the knee joint.

The meniscus has a red zone and a white zone. The white zone has almost no blood supply and gets much of its nutrition from the joint fluid itself. The red zone has a good blood supply and gets blood flow from the vessels around the knee.

Meniscal Tears

There are different types of meniscal tears, including horizontal and vertical tears. The tears may be in the red zone, the white zone, or both.

There are two major times of life when meniscal tears are common.

  • Between ages 15 and 30
  • Between ages 40 and 70

When you’re younger, it’s more likely to be from a sports injury. When you’re older, it may be from a recreational sports injury or it may be from everyday activities of life or work.

Diagnosing Meniscal Tears and Other Knee Issues

As a clinician, the first thing we discuss with a patient is their history. How long has the pain been occurring? What kind of symptoms do you have? Is your knee locking or catching? Do you have pain going up and down stairs? Do you have instability, where you don’t trust your knee? Do you have swelling?

As a rule, the pain comes and goes with a meniscal tear. You may have a good day or week where sometimes it doesn’t bother you. This type of pain is distinct from arthritic pain, which is usually more consistent.

Your overall health history is also important. If you have an issue that may need surgery down the road, are you healthy enough to go through surgery? Are you on blood thinners? Have you had other things like pacemakers or spinal cord stimulators put in? We think about not only treating the current pain but also seeing if you’re a candidate to have an MRI.

After getting your history, we’ll examine you. Where is most of your pain: on the inside of your knee? The outside of your knee? Front of your knee? There are multiple ligaments and tendons around your knee, so where the pain is determines which ones may be affected. During the exam, we are touching your knee and moving it to see if we can stimulate what causes your pain and to examine the motion. We’ll compare your knees to see if one moves better than the other and to see if one is swollen. Swelling in the knee is typically a response to something going on inside the knee, such as arthritis, a meniscus tear or an injury to the ligament. If it’s a recent injury, depending on the type and severity of the injury, there may also be bruising.

As we’re going through the exam and talking to you, we’re thinking through the possible diagnoses and weeding out what could be the diagnosis and what could not be the diagnosis.

We’ll also have x-rays taken, because x-rays show your bony anatomy and will tell us what your knee joint looks like. We prefer to have the x-rays done weight bearing if you can, because that will give a better idea of what your knee joint looks like with the stress of carrying your body weight.

The x-rays only show the bony structure, not any of the soft tissue or ligaments. If we’re looking for a soft tissue injury, after examining the x-ray we may schedule an MRI if you’re eligible for one. The MRI will show if you have a meniscal tear or a ligament tear. Unfortunately, not everybody can have an MRI: some pacemakers and spinal cord stimulators are compatible with an MRI and some are not. People who may have certain types of metal in their body, such as from shrapnel, also may not be able to have an MRI. In those situations, you can have a CT arthrogram with dye injected in the knee. It doesn’t give as much information as an MRI, but it is another view of the anatomy.

Non-Surgical Treatments

Once we have all the information, we talk about options. A conservative option is anti-inflammatories like Advil and Motrin. You can do RICE: rest, ice, compression, elevation. You can do topical anti-inflammatories like Voltaren gel.

If you have arthritic conditions, a cortisone injection is an option. If those aren’t working well, you can get gel injections or viscosupplementation, although you usually need to do other steps first and get insurance approval for those injections.

Surgical Treatments

A meniscectomy, when you take out the torn meniscus, is about 30 minutes, done as an outpatient procedure where you go home that day. If it’s a straightforward meniscus tear, typically you’re walking on it that day. It usually takes about a month before you’re back doing most things you want to do, however you’re going to continue to make progress for 2-3 months after that.

Physical therapy after the surgery is a great modality. They can teach you many things that can encourage you to push through some of the pain that is normal after surgery. I don’t recommend starting formal physical therapy right away; I like to see how you’re doing two weeks after surgery and have a conversation with you about starting therapy.

A meniscus repair, where sutures are put in to repair the meniscus, is a different procedure. Unfortunately, not many meniscus tears are repairable due to the lack of blood flow in much of the meniscus. Your downtime after a meniscal repair is significantly different: you’re limited in your motion and can’t walk on it for six weeks.

Frequently asked questions

If you have had significant knee pain for several months, should you make an appointment to see a doctor or make an appointment for physical therapy first?

Make an appointment to see a doctor first. You may need a prescription for physical therapy from a physician, either your family doctor or an orthopedic specialist, so it’s better to start there. You can also get guidance on the type of therapy that you need.

How do you strengthen your knee to avoid further damage after it’s already been injured?

First things first, start walking. I typically tell people to do low impact activities like walking, biking, elliptical or Stairmaster.

Once you get your normal walk back, you can start doing leg extensions and leg curls in a weight room. You can also do bodyweight squats, but you want to be careful on how low you go. I don’t encourage patients to go lower than 90 degrees in a squat and sometimes even that is too low.

You want to work the affected side more than your good side. For example, if you’re doing sets with exercises, you would do two sets on your bad side and one set on your good side.

You don’t want to strengthen every day; aim for about three days a week. If you strengthen daily, you’re going to get to the point where that muscle gets fatigued, it will be more painful and the downsides are worse.

Is regular massage good for arthritis in the knee?

Massage won’t make your arthritis go away but it can help with your symptoms. It can help soften or loosen your musculature. Your massage therapist can also go through a good stretching routine. It may not make your pain zero, but if it can take it from a five to a two or three, it will make things more tolerable.

If we suspect a meniscal tear, what’s the risk of leaving it undiagnosed and untreated?

There’s nothing wrong with waiting. The downside is that if you have another injury on top of it, the small tear may become bigger. You can still take care of it surgically, but you may end up losing more meniscus than you would have if you addressed it right away.

How are hip and knee pain related? Can one cause the other one?

Yes, lots of times people with arthritic hips can get referred pain to their knee based on how nerves are distributed around the leg. If your gait is off and you’re limping because you have a bad hip or a bad back, that can also cause knee pain.

What is the difference between the meniscus and cartilage?

The meniscus is cartilage. It’s different from the articular cartilage between the bones, but both are considered cartilage.

How do the structures in the knee change as we age?

As a general rule, women are more knock-kneed and men are more bowlegged. Both conditions change the stresses in your knee and arthritis is more likely to develop in the part of the knee that has more stress.

If your kneecap is not perfectly aligned, that can also put more stress on one part of the kneecap than the other and also contribute to arthritis.