History

Fact Explanation
Knee pain Sharp, stabbing pain that is more prominent during tortional or weight bearing movements of the knee. Followed by a dull aching pain that lasts several hours. Meniscal injuries can cause a synovitis that stretches the knee joint capsule causing pain. Abnormal motion at the knee due to an unstable meniscus fragment may also contribute.[1]
Knee swelling [2] Due to synovitis and effusion inside the joint cavity[2].
Mechanical symptoms such as catching, locking and giving away. [1,2,3] Catching occurs due to a difficulty in knee flexion, while locking is due to the inability of extending the knee fully. A sudden feeling of the knee giving away is due to the joint instability caused by the meniscal injury.
References
  1. SHIRAEV T. et al. Meniscal tear - presentation, diagnosis and management. Australian Family Physician. [Online] 2012 Apr,41(4),182-7. [viewed 8 March 2014]. Available from: http://www.racgp.org.au/afp/201204/46219
  2. YAN R. et al. Predicted probability of meniscus tears: comparing history and physical examination with MRI. Swiss Medicine Weekly. [Online] 2011 Dec 14,14,w13314. [viewed 8 March 2014]. Available from: doi: 10.4414/smw.2011.13314.
  3. NICOLA M. et al. Meniscal tears. Open Access J Sports.Med.[Online] 2010, 1, 45–54. [viewed 8 March 2014]. Available from: https://www.dovepress.com/getfile.php?fileID=6180

Examination

Fact Explanation
Joint line tenderness on the affected side [1,2] Inflammation of the knee joint due to the torn meniscus.
Joint effusion [1,2] Extravasation of plasma into the joint cavity due to an inflammatory reaction.
Limited extension [1,2] Mechanical limitation of the range of movement by interfering menisci fragments or knee joint effusion.[3]
Apley's Test - positive The patient lies prone, with knee flexed to 90 degrees and the hip extended. Axial pressure is applied to the foot while the leg is internally and externally rotated. A positive test is defined as pain and/or clicking. [4,5] Specificity of this test is 80–99% and sensitivity is16–58% [6,7,8]
McMurray's Test - positive The patient lies supine with the hip and knee in flexion. The clinician should hold the knee joint (with fingers along the joint line) with one hand, and while the other hand rotates the tibia internally and externally; while extending and flexing the knee. A positive test is defined as pain on movement while the clinician may feel and/or hear meniscal movement when the meniscus is compressed between the tibia and femur.[4] Specificity of this test is 57–98%, while sensitivity is 10–66%.[7,8]
Thessaly test - positive Hold the patient’s outstretched hands for support, while the patient stands flat-footed with the knee flexed to 20 degrees and rotates the body and knee three times, alternating between internal and external rotation. A positive test is defined as pain during rotation. Specificity of the test is 98% while sensitivity is 90%. [6]
Quadriceps wasting [9] A relatively late presentation. There is marked atrophy of the quadriceps femoris muscles, because the patient is either unwilling or unable to achieve full extension.
References
  1. SHIRAEV T. et al. Meniscal tear - presentation, diagnosis and management. Aust Fam Physician.[Online] 2012 Apr,41(4),182-7. [viewed 8 March 2014]. Available from: http://www.racgp.org.au/afp/201204/46219
  2. NICOLA M. et al. Meniscal tears. Open Access J Sports.Med. [Online] 2010, 1, 45–54. [viewed 8 March 2014]. Available from: https://www.dovepress.com/getfile.php?fileID=6180
  3. YAN R. et al. Predicted probability of meniscus tears: comparing history and physical examination with MRI.Swiss Med Wkly. [Online] 2011 Dec 14,14,w13314. [viewed 8 March 2014]. Available from: doi: 10.4414/smw.2011.13314.
  4. ERCIN E. et al. History, clinical findings, magnetic resonance imaging, and arthroscopic correlation in meniscal lesions.Knee Surg Sports Traumatol Arthrosc, [Online] 2012 May,20(5),851-6. [viewed 8 March 2014]. Available from: doi: 10.1007/s00167-011-1636-4.
  5. SOLOMON DH. et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination.JAMA. [Online] 2001 Oct 3,286(13),1610-20. [viewed 8 March 2014]. Available from: http://jama.jamanetwork.com/article.aspx?articleid=194256
  6. HARRISON BK, BE ABELL, TW GIBSON. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med,[Online] 2009,19,9–12. [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19124977
  7. JARIT G, BOSCO J. Meniscal repair and reconstruction. Bull NYU Hosp Jt Dis [Online], 2010,68,84–90. [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20632982
  8. SCHOLTEN RJ et al. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract [Online] 2001;50:938–44. [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11711009
  9. KONAN S et al. Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc. [Online] 2009 Jul,17(7),806-11.[viewed 8 March 2014]. Available from: doi: 10.1007/s00167-009-0803-3.

Differential Diagnoses

Fact Explanation
Medial collateral ligament (MCL) injury [1] Knee pain is worsened by standing or stressing. Patient complains of a tearing or ripping sensation along the inner joint line of the knee. There is swelling and instability at the knee joint. On examination there is tenderness at the insertion of the MCL into the upper medial tibia. While a valgus stress test will reveal laxity and/or pain.
Anterior cruciate ligament (ACL) injury [1] Presents with knee pain and swelling. Occurs after a blow to the back of the tibia with our without rotation. Feeling of giving away of the knee. On examination there is reduced range of movement of the knee. While Lachman's Test and anterior drawer test will be positive.
Osteochondritis dissecans [1,2,3] Commonly occurs in teenagers due to a disorder of the ossification centres. Presents with intermittent knee pain, swelling, feeling of giving away and locking of the knee. On examination the joint appears normal though an effusion can be detected at times.
Osteochondral fracture [1] Commonly a sports injury that causes pain,swelling and catching at the knee. Occurs due to sudden twisting movement that causes tearing of the articular cartilage.
Pre and Infra-patellar bursitis [3] Commonly seen in adolescent females. Anterior knee pain on ascending and descending stairs or prolonged sitting. Examination reveals tenderness of the joint and a fluctuant swelling.
Osteoarthritis [4] Presents in the fifth decade of life. Common in the obese.Pain worsens after walking or ascending stairs. Joint stiffness occurs following a period of rest. May have swelling,locking or giving away of the knee. Joint deformity, crepitation and wasting of quadriceps is noted on examination.
Patello-femoral pain syndrome [3] Anterior knee or retropatellar pain which worsens with crouching down or ascent and descent of stairs.
References
  1. GREGORY A, MD SCHMALE. Adolescent Knee Pain Management, Pediatric Annals [Online] 2013 March, 42,3,122-127. [viewed 8 March 2014]. Available from: DOI 10.3928/00904481-20130222-12.
  2. MOORE O. et al. English Premier Academy knee injuries: lessons from a 5 year study. J Sports Sci [Online] ,2011,29(14),1535-1544. [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21988085
  3. LIPORACI RF et al.Contribution of the evaluation of the clinical signals in patients with patellofemoral pain syndrome.Acta Ortop Bras [Online] ,2013 Jul-Aug,21(4),198–201..[viewed 8 March 2014]. Available from: doi 10.1590/S1413-78522013000400003
  4. YAN R et al. Predicted probability of meniscus tears: comparing history and physical examination with MRI.Swiss Med Wkly. [Online] 2011 Dec 14,14,w13314. [viewed 8 March 2014]. Available from: doi: 10.4414/smw.2011.13314.

Investigations - for Diagnosis

Fact Explanation
X-Ray of the Knee joint Will exclude osteoarthritis as possible differential. Look for features such as reduction of the medial joint space width,osteophyte formation, subchondral bone cysts and sclerosis that is suggestive of osteoarthritis. [1]
Magnetic Resonance Imaging (MRI) Highly accurate in the diagnosis of meniscal tears and exclusion of other soft tissue pathologies such as ACL or collateral ligament injuries. [2,3,4] Sensitivity and specificity of MRI for the detection of medial meniscal tears is 93%, 88% while for lateral meniscal tears it is 79%, 95% . [5]
Arthrography Involves injecting contrast medium into the joint space. Has largely been replaced by MRI. [3]
References
  1. SHIRAEV T. et al. Meniscal tear - presentation, diagnosis and management. Aust Fam Physician.[Online] 2012 Apr,41(4),182-7. [viewed 8 March 2014]. Available from: http://www.racgp.org.au/afp/201204/46219
  2. BRIDGMAN S. et al. The effect of magnetic resonance imaging scans on knee arthroscopy: randomized controlled trial. Arthroscopy.[Online] 2007,23(11),1167–1173.[viewed 8 March 2014]. Available from: http://bmb.oxfordjournals.org/content/84/1/5.short
  3. CRAWFORD R. et al. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review.Br Med Bull, [Online] 2007,84,5–23. [viewed 8 March 2014]. Available from: http://bmb.oxfordjournals.org/content/84/1/5.long
  4. DERRETT S. et al. Magnetic resonance imaging, knee arthroscopy, and clinical decision making: a descriptive study of five surgeons. Int J Technol Assess Health Care [Online], 2009,25(4),577–583.[viewed 8 March 2014]. Available from: http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6375884
  5. OEI EHG. et al. MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology [Online]. 2003,226(3),837–848. [viewed 8 March 2014]. Available from: http://pubs.rsna.org/doi/pdf/10.1148/radiol.2263011892

Investigations - Fitness for Management

Fact Explanation
Magnetic Resonance Imaging (MRI) Classification of injury is important when deciding on repair of the injury.Radial tears cannot be repaired. Horizontal tears are associated with meniscal cysts and can lead to a localized swelling. [1]
References
  1. NICOLA M. et al. Meniscal tears. Open Access J Sports.Med.[Online] 2010, vol-1 45–54. [viewed 8 March 2014]. Available from: https://www.dovepress.com/getfile.php?fileID=6180

Investigations - Screening/Staging

Fact Explanation
MRI Classification is important when considering surgical repair.Tears can be classified as longitudinal, radial,oblique,horizontal or complex (degenerative). Meniscal pathology is often found in the posterior horns of the cartilage. Another system of classification is based on the disruption of normal homogeneous low signal. Grade I – Small area of increased signal within the meniscus Grade II – Linear area of increased signal that does not extend to an articulating surface Grade III – Abnormal increased signal that reaches the surface or edge of the meniscus. (Grade I,II - usually degenerative changes. Grade III - Meniscal tears) [1,2]
References
  1. NICOLA,M. et al. Meniscal tears. Open Access J Sports.Med.[Online] 2010, 1, 45–54. [viewed 8 March 2014]. Available from: https://www.dovepress.com/getfile.php?fileID=6180
  2. BEHAIRY,N.H. et al. Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: comparison with arthroscopy.Int Orthop [Online],Aug 2009,33(4),961–967.[viewed 8 March 2014]. Available from: doi: 10.1007/s00264-008-0580-5

Management - General Measures

Fact Explanation
Rest with activity modification [1] Avoidance of offending activities such as prolonged standing and prevention of exerting more strain over the affected area. Training errors can be precipitating factors.
Application of ice [2] Promotes local vasoconstriction and provides some analgesia.
Non steroidal anti inflammatory drugs (NSAIDS) [1,2] Provides an analgesic effect and anti-Inflammatory effect. It is recommended for 8–12 weeks.
Elevation of the affected limb [1,3] Minimizes acute swelling and inflammation and prevents the exertion of more strain over the affected area. [3]
Intensive physiotherapy [4,5] Physiotherapy is recommended twice a week for at least 8 weeks.[5] This includes proprioceptive work and muscle strengthening which strengthen the quadriceps. Stronger muscles will protect the meniscus by absorbing the force of impact. [6]
References
  1. SHIRAEV T. et al. Meniscal tear - presentation, diagnosis and management. Aust Fam Physician. [Online] 2012 Apr,41(4),182-7. [viewed 8 March 2014]. Available from: http://www.racgp.org.au/afp/201204/46219
  2. OEI EH. et al. MRI follow-up of conservatively treated meniscal knee lesions in general practice.Eur Radiol [Online] 2010 May,20(5),1242-50. [viewed 8 March 2014]. Available from: doi: 10.1007/s00330-009-1648-3.
  3. LIM HC et al.Non-operative treatment of degenerative posterior root tear of the medial meniscus. Knee Surg Sports Traumatol Arthrosc[online],2010 Apr,18(4),535-9. [viewed 8 March 2014]. Available from: doi: 10.1007/s00167-009-0891-0
  4. BUSECK MS, NOYES FR. Arthroscopic evaluation of meniscal repairs After anterior cruciate ligament reconstruction and immediate motion. Am J of Sports Med [online], 1991,19(50), 489-494 [viewed 8 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/1962715
  5. LIM HC et al.Non-operative treatment of degenerative posterior root tear of the medial meniscus. Knee Surg Sports Traumatol Arthrosc [Online]. 2010,18,535–9. [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1962715
  6. GOLDBLATT JP et al. Managing meniscal injuries: The treatment. Journal of Musculoskeletal Medicine [online],2009,26(12), 471-477. [viewed 8 March 2014]. Available from: http://www.urmc.rochester.edu/people/20164942-john-p-goldblatt/researchers

Management - Specific Treatments

Fact Explanation
Partial meniscectomy [1] Treatment of choice for tears in the avascular portion of the meniscus or for complex tears. Fragments of the torn cartilage are removed and the remaining healthy meniscal tissue is fixed.
Total meniscectomy Not commonly performed as it may be potentially damaging and cause unfavorable long-term outcome results [2].
Arthroscopic repair Fixation can be accomplished with outside-in, inside-out, or an all-inside arthroscopic procedure.[3]
Meniscal transplantation An alternative option for carefully selected symptomatic patients with a previous complete or near-complete meniscectomy. A fresh allograft, frozen,cryopreserved and freeze-dried grafts can be used. [4]
Post surgical rehabilitation Following a partial meniscectomy low-impact or non-impact exercise such as stationary cycling and straight-leg raising maybe attempted on the first postoperative day. Later the patient may advance rapidly to usually preoperative activities. Following meniscal repair a more aggressive rehabilitation program can be attempted. Important aspects to be considered are knee motion, weight bearing, and return to sports.[5]
References
  1. KIM SB et al. Medial meniscus root tear refixation: comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy [Online]. Mar 2011,27(3),346-54. [viewed 8 March 2014]. Available from: doi: 10.1016/j.arthro.2010.08.005
  2. FAIRBANK TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Am [Online], 1948,30B(4),664–670. [viewed 8 March 2014]. Available from: http://www.bjj.boneandjoint.org.uk/content/30-B/4/664.short
  3. ADACHI N. Torn discoid lateral meniscus treated using partial central meniscectomy and suture of the peripheral tear. Arthroscopy [Online],May 2004,20(5),536-42. [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15122147
  4. BUCK BE et al.Human immunodeficiency virus cultured from bone. Implications for transplantation. Clin Orthop Relat Res [Online],1990,(251),249–253. [viewed 8 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/2295182
  5. HECKMANN TP et al.Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome.J Orthop Sports Phys Ther [Online],2006 Oct,36(10),795-814. [viewed 8 March 2014]. Available from: http://www.jospt.org/doi/pdf/10.2519/jospt.2006.2177