MENISCUS TEARS

What is a meniscus tear?

• A meniscus tear is one of the most common causes of knee pain. The meniscus is a C-shaped fibrocartilage structure that acts as a shock absorber, load distributor, and stabilizer within the knee joint. Each knee contains two menisci: a medial meniscus on the inside of the knee and a lateral meniscus on the outside.

• The degree of meniscus injury can vary. Meniscus tears may occur suddenly after a twisting injury or develop gradually over time as part of the aging process. While traumatic tears are more common in younger athletes, degenerative meniscus tears frequently occur in adults over 40 and are often associated with early osteoarthritis. [Abram et al, 2018].

• Meniscus tears can be classified based on their morphology and location, including horizontal, longitudinal, radial, root, complex, displaced, and bucket-handle tears [Nguyen et al, 2014; Hevesi et al, 2019; Stensby et al, 2021].
• Not all meniscus tears require surgery. In many cases, symptoms can improve with conservative management, physical therapy, image-guided injections, and biologic treatments designed to preserve meniscal tissue.

Meniscus Anatomy

The meniscus performs several important functions within the knee:

• Shock absorption
• Load transmission
• Joint stability
• Cartilage protection
• Joint lubrication

The meniscus has a limited blood supply. The outer portion ("red zone") receives blood flow and has greater healing potential, whereas the inner portion ("white zone") has minimal blood supply and reduced capacity for spontaneous healing.

Because of this limited vascularity, treatment recommendations often depend on the location and pattern of the tear.

How do you know if you have a meniscus tear?

• Typical Symptoms include:
  

  • Knee pain, particularly along the joint line.

  • Swelling and stiffness.

  • Mechanical symptoms such as locking, catching, or giving way of the knee.

  • Difficulty bending and straightening the knee fully.

• Clinical Evaluation Methods:

  • A detailed history and physical examination are crucial. Not every meniscus tear causes symptoms. MRI studies have demonstrated that many adults have meniscal abnormalities without pain (Englund et al, 2008).

  • Key clinical tests also suggest a meniscal tear. The diagnosis can be confirmed with MRI or ultrasound.

  • • Role of Magnetic Resonance Imaging (MRI): MRI is the gold standard for confirming the diagnosis of a meniscal tear and provides detailed images of the meniscus and can identify the type and extent of the tear [Blyth et al, 2015]. MRI has high diagnostic accuracy for meniscal tears, with an overall accuracy of 88.8%, sensitivity of 95.7%, and specificity of 75.8% [Yan et al, 2011].
    • Evidence for Ultrasound in Diagnosing Meniscal Tears: Multiple studies have demonstrated that ultrasound can achieve high sensitivity and specificity in diagnosing meniscal tears.
      
      • In one study, ultrasound had a sensitivity of 91.2% and specificity of 84.2% for meniscal pathology, which was comparable to MRI's sensitivity of 91.7% but with a higher specificity [Cook et al, 2014].
        
      • In another study, point-of-care ultrasound (POCUS) had a sensitivity of 92.9% and specificity of 88.9% for meniscal injuries, closely matching MRI's performance [Elshimy et al, 2023].
      • A systematic review and meta-analysis by Xia et el., concluded that ultrasound has good diagnostic accuracy for meniscal injuries, with pooled sensitivity and specificity of 77.5% and 83.8%, respectively. The area under the curve (AUC) for ultrasound was 0.9107, indicating high overall diagnostic accuracy [Xia et al, 2016].

What are the treatments for meniscal tears?

Conservative treatment

• Conservative treatment options for meniscal tears, including rest, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs), have been shown to be effective and are often comparable to surgical interventions in many cases.
  

• A meta-analysis by Lee et al. found no significant differences in clinical outcomes such as knee pain relief and improved knee function between arthroscopic meniscal surgery and conservative management in patients aged 40 years and older [Lee et al, 2018]. Additionally, the five-year follow-up of the ESCAPE trial confirmed that exercise-based physical therapy remained noninferior to APM for patient-reported knee function, suggesting that PT should be the preferred treatment over surgery for degenerative meniscal tears [Noorduyn et al, 2022].
  

• Non-surgical treatment includes activity modification (i.e. avoiding deep squats and twisting/pivoting activities), medications, physical therapy, braces and steroid or viscosupplemention injections.

  • Rest and Physical Therapy: Several randomized controlled trials (RCTs) and systematic reviews have demonstrated that physical therapy (PT) can be as effective as arthroscopic partial meniscectomy (APM) for improving knee function and reducing pain in patients with meniscal tears. The ESCAPE trial found that PT was noninferior to surgery for improving patient-reported knee function over a 24-month follow-up period in patients with nonobstructive meniscal tears [van de Graaf, 2018]. This was true even at the 5-year follow-up, suggesting that PT should be the preferred treatment over surgery for degenerative meniscal tears [Noorduyn et al, 2022]. Similarly, a systematic review by Giuffrida et al. concluded that degenerative meniscal tears without symptoms of locking and catching can be successfully managed with physical therapy as a first-line treatment [Giuffrida et al, 2020].
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are commonly used to manage pain and inflammation associated with meniscal tears. The American Society of Pain and Neuroscience supports the use of NSAIDs for knee pain, including meniscal injuries, citing multiple studies that demonstrate significant pain reduction with NSAID use [Hunter et al, 2022]. NSAIDs can be particularly useful in the initial management phase to alleviate symptoms and facilitate participation in physical therapy.

Orthobiologic Treatment

• There is some evidence supporting the use of orthobiologic injections in the non-surgical management of meniscal tears.
• Platelet-rich plasma (PRP) injections: PRP injections have shown promise in improving clinical outcomes and reducing the need for surgical intervention in patients with chronic and stable meniscal lesions.
  • Kaminski et al. conducted a prospective, randomized, double-blind, placebo-controlled study that demonstrated significant improvements in the healing rate of chronic meniscal tears with PRP injections. The study found that the failure rate was significantly lower in the PRP group compared to the control group (48% vs. 70%, p = 0.04), and patients treated with PRP showed significant improvements in visual analogue scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS) symptom scores [Kaminski et al, 2019].
  • Sánchez et al. evaluated the efficacy of combined intrameniscal and
    intraarticular PRP infiltrations in a large cohort of patients with meniscal tears. The study reported a high survival rate (90.3%) and significant improvements in KOOS scores from baseline to 6 and 18 months post-treatment. The study concluded that PRP is a valid conservative treatment for meniscal injuries, particularly effective in horizontal tears and less effective in the presence of joint degeneration [Sanchez et al, 2023].
    
  • Medina-Porqueres et al. described significant clinical and functional improvements in patients with stable meniscal injuries treated with intraarticular and percutaneous PRP injections. Patients reported high satisfaction and significant improvements in KOOS and Tegner activity level scores [Medina-Porqueres et al, 2022].
• Mesenchymal Stem Cells (MSC) are typically derived from bone marrow or adipose tissue and in a systematic review by Rinonapoli et al. showed good results in terms of laboratory markers, clinical, and radiologic evaluation for meniscal tears. In this reveiw, bone marrow-derived MSCs delivered through injection were the most studied approach with promising results [Rinonapoli et al, 2021].
  

• Microfragmented Adipose Tissue (MFAT) (Learn more about MFAT here):
  • A prospective pilot study of 20 patients by Malanga et al. demonstrated that MFAT injections significantly reduced pain and improved knee function in patients with meniscal tears and osteoarthritis who had failed conservative management. The study reported significant improvements in Numeric Pain Scale (NPS) and Knee Injury and Osteoarthritis Outcome Scale (KOOS) scores at 12 months, indicating that MFAT is a safe and potentially efficacious treatment option [Malanga et al, 2021].
• Bone Marrow Aspirate Concentrate (BMAC) (Learn more about BMAC here):
  • Koch et al. evaluated BMAC in an in vivo model and found that it significantly enhanced the regeneration of avascular meniscus lesions compared to controls. The study suggested that BMAC, combined with meniscus suturing, promotes meniscus regeneration in the avascular zone using a one-step procedure [Koch et al, 2019]. Additionally, Desando et al. reported that BMAC combined with hyaluronic acid (HA) showed the best results in supporting regenerative processes in cartilage, meniscus, and synovium in a sheep model of osteoarthritis [Desando et al, 2016].

Surgical Treatment

• Evidence supporting surgical intervention for meniscal tears is mixed and context-dependent. When considering surgical options understanding the type of tear and symptoms is important in predicting outcomes. Traumatic meniscal tears are often viewed as a different injury than degenerative meniscal tears, and surgery is often offered for traumatic meniscal tears with the hope of providing short-term benefit.

  • Short-term Benefits: Arthroscopic partial meniscectomy (APM) has been shown to provide small, statistically significant improvements in physical function and pain relief at 2 to 6 months after the surgery when compared to conservative treatments, but these differences were not sustained at 12 and 24 months [van de Graaf, 2016].

  • Traumatic Meniscal Tears: For younger patients with traumatic meniscal tears, a randomized controlled trial by van der Graaff et al. found no significant difference in outcomes between early APM and physical therapy with optional delayed APM at 24 months. This suggests that conservative management can be a viable initial approach even in this population [van der Graaff et al, 2022].
  • Degenerative Meniscal Tears: A meta-analysis by Khan et al. concluded that there is no significant long-term benefit of arthroscopic partial meniscectomy over conservative treatments for degenerative meniscal tears. The study emphasized that nonoperative management should be the first-line treatment for middle-aged patients with mild or no concomitant osteoarthritis [Khan et al, 2014].

Learn more about minimally invasive treatment

options for chronic degenerative meniscus tears here.

(781) 591-7855

info@BSBortho.com

20 Walnut St

Suite 14

Wellesley MA 02481

References

• Abram SGF, Beard DJ, Price AJ; BASK Meniscal Working Group. National consensus on the definition, investigation, and classification of meniscal lesions of the knee. Knee. 2018 Oct;25(5):834-840.
• Blyth M, Anthony I, Francq B, Brooksbank K, Downie P, Powell A, Jones B, MacLean A, McConnachie A, Norrie J. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley's, McMurray's and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis. Health Technol Assess. 2015 Aug;19(62):1-62.
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• Desando G, Giavaresi G, Cavallo C, Bartolotti I, Sartoni F, Nicoli Aldini N, Martini L, Parrilli A, Mariani E, Fini M, Grigolo B. Autologous Bone Marrow Concentrate in a Sheep Model of Osteoarthritis: New Perspectives for Cartilage and Meniscus Repair. Tissue Eng Part C Methods. 2016 Jun;22(6):608-19.
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• Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, SayedD, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res. 2022 Sep 8;15:2683-2745.
• Kaminski R, Maksymowicz-Wleklik M, Kulinski K, Kozar-Kaminska K, Dabrowska-Thing A, Pomianowski S. Short-Term Outcomes of Percutaneous Trephination with a Platelet Rich Plasma Intrameniscal Injection for the Repair of Degenerative Meniscal Lesions. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study. Int J Mol Sci. 2019 Feb 16;20(4):856.
• Khan M, Evaniew N, Bedi A, Ayeni OR, BhandariM. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014 Oct 7;186(14):1057-64.
• Koch M, Hammer S, Fuellerer J, Lang S, Pfeifer CG, Pattappa G, Weber J, Loibl M, Nerlich M, Angele P, Zellner J. Bone Marrow Aspirate Concentrate for the Treatment of Avascular Meniscus Tears in a One-Step Procedure-Evaluation of an In Vivo Model. Int J Mol Sci. 2019 Mar 5;20(5):1120.
• Lee DY, Park YJ, Kim HJ, Nam DC, Park JS, Song SY, Kang DG. Arthroscopic meniscal surgery versus conservative management in patients aged 40 years and older: a meta-analysis. Arch Orthop Trauma Surg. 2018 Dec;138(12):1731-1739.
• Malanga GA, Chirichella PS, Hogaboom NS, Capella T. Clinical evaluation of micro-fragmented adipose tissue as a treatment option for patients with meniscus tears with osteoarthritis: a prospective pilot study. Int Orthop. 2021 Feb;45(2):473-480.
• Medina-Porqueres I, Martin-Garcia P, Sanz-De-Diego S, Gomez-Caceres A, Moya-Torrecilla F, Reyes-Eldblom M, Rosado-Velazquez D. Clinical and Functional Outcome of Meniscal Injuries Treated with Platelet-Rich Plasma: A Single-Center Case Series. Int J Environ Res Public Health. 2022 Jun 10;19(12):7118.
• Mureşan S, Mureşan M, Voidăzan S, Neagoe R. The accuracy of musculoskeletal ultrasound examination for the exploration of meniscus injuries in athletes. J Sports Med Phys Fitness.2017 May;57(5):589-594.
• Nguyen JC, De Smet AA, Graf BK, Rosas HG. MR imaging-based diagnosis and classification of meniscal tears. Radiographics. 2014 Jul-Aug;34(4):981-99.
• Noorduyn JCA, van de Graaf VA, Willigenburg NW, Scholten-Peeters GGM, Kret EJ, van Dijk RA, Buchbinder R, Hawker GA, Coppieters MW, Poolman RW; ESCAPE Research Group. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022 Jul 1;5(7):e2220394.
• Rinonapoli G, Gregori P, Di Matteo B, Impieri L, Ceccarini P, Manfreda F, Campofreda G, Caraffa A. Stem cells application in meniscal tears: a systematic review of pre-clinical and clinical evidence. Eur Rev Med Pharmacol Sci. 2021 Dec;25(24):7754-7764.
• Sánchez M, Jorquera C, Bilbao AM, García S, Beitia M, Espregueira-Mendes J, González S, Oraa J, Guadilla J, Delgado D. High survival rate after the combination of intrameniscal and intraarticular infiltrations of platelet-rich plasma as conservative treatment for meniscal lesions. Knee Surg Sports Traumatol Arthrosc. 2023 Oct;31(10):4246-4256.
• Stensby JD, Pringle LC, Crim J. MRI of the Meniscus. Clin Sports Med. 2021 Oct;40(4):641-655.
• Taljanovic MS, Chang EY, Ha AS, Bartolotta RJ, Bucknor M, Chen KC, Gorbachova T, Khurana B, Klitzke AK, Lee KS, Mooar PA, Nguyen JC, Ross AB, Shih RD, Singer AD, Smith SE, Thomas JM, Yost WJ, Kransdorf MJ. ACR Appropriateness Criteria® Acute Trauma to the Knee. J Am Coll Radiol. 2020 May;17(5S):S12-S25.
• van der Graaff SJA, Eijgenraam SM, Meuffels DE, van Es EM, Verhaar JAN, Hofstee DJ, Auw Yang KG, Noorduyn JCA, van Arkel ERA, van den Brand ICJB, Janssen RPA, Liu WY, Bierma-Zeinstra SMA, Reijman M. Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in a young study population: a randomised controlled trial. Br J Sports Med. 2022 Jun 8;56(15):870–6.
• van de Graaf VA, Noorduyn JCA, Willigenburg NW, Butter IK, de Gast A, Mol BW, Saris DBF, Twisk JWR, Poolman RW; ESCAPE Research Group. Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. JAMA. 2018 Oct 2;320(13):1328-1337.
• van de Graaf VA, Wolterbeek N, Mutsaerts EL, Scholtes VA, Saris DB, de Gast A, Poolman RW. Arthroscopic Partial Meniscectomy or Conservative Treatment for Nonobstructive Meniscal Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroscopy. 2016 Sep;32(9):1855-1865.e4.

• Xia XP, Chen HL, Zhou B. Ultrasonography for meniscal injuries in knee joint: a systematic review and meta-analysis. JSports Med Phys Fitness. 2016 Oct;56(10):1179-1187. Epub 2015 Jul 7.

• Yan R, Wang H, Yang Z, Ji ZH, Guo YM. Predicted probability of meniscus tears: comparing history and physical examination with MRI. Swiss Med Wkly. 2011 Dec 14;141:w13314.

(781) 591-7855

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OTHER KNEE/LEG CONDITIONS

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