It’s high time a layman knows some facts about meniscal injuries that happen while playing various sports. one of them and the most important being u don’t need surgery to recover properly from a meniscal tear!!

This Meniscal injury is common in sports such as football, rugby and other high-intensity contact sports but is also common, with no major trauma, as degenerative tears in older athletes or sedentary individuals. They occur either in isolation or combined with a ligament injury, for example, of the MCL or ACL Injury (all 3 together injured are known as the unholy triad)

WHAT ARE MENISCI?

• The menisci are cartilaginous structures that deepen their respective tibial articular
• By increasing the concavity of the tibia, they play a role in stabilizing the knee. In addition, the menisci contribute to joint lubrication and nutrition.
• The menisci have an important role as a buffer absorbing some of the forces placed through
  the knee joint, thus protecting the otherwise exposed articular surfaces from damage.
• The medial meniscus is crescent shaped and attaches to the tibia in front of the ACL and in the intercondylar fossa at the back
• The lateral meniscus is more circular and attaches to the tibia in front of the ACL and posteriorly behind the tibial eminence but anterior to the medial meniscus.
• It also is attached to many other ligaments which connect the tibia and the femur within the knee joint.
• The front portion of the menisci (known as the anterior horn) are further connected with each other via a ligament and are more stable while,
• The back portion of both the menisci (known as the posterior horn) is connected to different structures.
• The back portion of the medial menisci is the most susceptible to injury.
• Thus, it is important to preserve as much of the menisci as possible after injury

MECHANISM OF INJURY:-

For Acute injuries:- usually startes with uncontrolled pivot in the knee or during cutting activity in any game. initailly the knee swells up and there will be pain in the innner portion of the knee. if the tear is bad then the knee might get locked up during the episode, rendering the athelete unable to play.

TYPE OF MENISCAL TEARS:-

• Meniscal tears can be classified as acute or degenerative.
• Acute tears are from excessive force applied to a normal knee and meniscus.
• This is different from a degenerative tear, which results from repetitive normal forces acting upon a worn down meniscus.
• Tears can also be described based on pattern and location.
• These tear patterns include vertical longitudinal, oblique, transverse (radial), horizontal, meniscal root, bucket-handle, and complex.
• Tears can located in the avascular or vascular zone (e., white, red-white, red-red), which influences healing potential either spontaneously or after surgical repair.

 

RISK FACTORS FOR MENISCAL INJURY:-

 

A systematic research study showed strong evidence that age (older than 60 years), gender (male), work-related kneeling and squatting, and climbing stairs (greater than 30 flights) were risk factors for degenerative meniscal tears. They also found strong evidence that playing soccer and playing rugby were strong risk factors for acute meniscal tears. Waiting longer than 12 months between the anterior cruciate ligament injury and reconstructive surgery was a strong risk factor for a medial meniscal tear but not for a lateral meniscal tear.

PHYSICAL EXAMINATION:-

Usually acute knee injuries show the signs and symptoms below, however they may be symptomless in case of degenerative tears

• Effusion,
• Joint line tenderness,
• Pain with squatting, and
• A positive McMurray test.
• Locked knee, which cannot reach full extension, may be caused by a “bucket handle” meniscal tear that has displaced centrally into the joint, blocking a full range of motion.

INVESTIGATIONS REQUIRED:-

Usually an X-ray and MRI are suggested. Acute isolated meniscal injuries rarely produce changes
on plain radiograph, whereas chronic meniscal pathology may produce the Fairbank’s
changes previously discussed. MRI imaging is useful in cases of questionable meniscal
damage

MANAGEMENT OF MENISCAL INJURIES:-

An athlete with effusion and suspected meniscus injuries should be seen by an on field health care provider who usually follows the Acute injury management protocol & is further responsible for directing the athlete to an orthopaedic or a sports physio . A regular individual walking into clinics or hospitals with knee pain history indicating of degenerative meniscal tear is usually send for rehab with a physio first. At Physiocure we practice evidence based therapy. Below are lists of factor which help health care providers decide whether to send the patient for surgery or rehab.

 

Factors that may indicate that conservative treatment is likely to be successful

Factors that may indicate that surgery will be required

·     Symptoms develop over 24–48 hours after injury ·     Injury minimal or no recall of specific injury ·     Able to weight-bear ·     Minimal swelling ·     Full range of movement with pain only at end of range of motion ·     Pain on McMurray’s test only in inner range of flexion ·     Previous history of rapid recovery from similar injury ·     Early degenerative changes on plain radiographs

·       Severe twisting injury, athlete is unable to continue playing ·       Locked knee or severely restricted range of motion ·       Positive McMurray’s test (palpable clunk) ·       Pain on McMurray’s test with minimal knee flexion ·       Presence of associated ACL tear ·       Little improvement of clinical features after 3 weeks of conservative treatment

 

WHAT DOES RESEARCH SAY ABOUT SELECTING TREATMENT OPTIONS?

 

• Treatment options for meniscal tears fall into three broad categories; non-operative, meniscectomy or meniscal repair.
• Selecting the most appropriate treatment for a given patient involves both patient factors (g., age, co-morbidities and compliance) and tear characteristics (e.g., location of tear/age/reducibility of tear).
• There is evidence suggesting that degenerative tears in older patients without mechanical symptoms can be effectively treated non-operatively with a structured physical therapy programme as a first line.
• Even if these patients later require meniscectomy they will still achieve similar functional outcomes than if they had initially been treated surgically.
• Partial meniscectomy is suitable for symptomatic tears not amenable to repair, and can still preserve meniscal function especially when the peripheral meniscal rim is intact.

• Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (g., nearer the capsular attachment) and horizontal or longitudinal in nature.
• However, careful patient selection and repair technique is required with good compliance to post- operative rehabilitation.⁽⁶⁾

 

WHEN SHOULD YOU START REHABILITATION?

Rehabilitation should commence prior to surgery. In this period it is important to:
• reduce pain and swelling with the use of electrotherapeutic modalities and gentle range
of motion exercises
• maintain strength of the quadriceps, hamstrings, and hip abductor and extensor muscles
• protect against further damage to the joint (patient may use crutches if necessary)
• explain the surgical procedure and the postoperative rehabilitation program to the patient

Rehabilitation principles after arthroscopic partial menisectomy are:
• to control pain and swelling
• to regain pain-free active range of motion
• graduated weight-bearing
• progressive strengthening within the available range of motion
• progressive balance, proprioceptive, and coordination exercises
• return to functional activities

WHAT DOES RESEARCH SAY ABOUT REHABILITATION?

There was wide variation in rehabilitation protocols among clinical studies. Biomechanical evidence from small cadaveric studies suggests that higher degrees of knee flexion and weight-bearing may be safe following meniscal repair and may not compromise the repair. An accelerated protocol with immediate weight-bearing at tolerance and early motion to non-weight-bearing with immobilising up to 6 weeks postoperatively is reported. Accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.

There are wide opinion differences on whether to start the rehabilitation and weight bearing early or late amongst the orthopaedics. Well the above systematic research study says that an accelerated rehab protocol for meniscal injuries that is improving ROM and weight bearing early is acceptable and that it is not associated with failure rates. Hence the athletes can be put through an accelerated rehab program based on their findings based on the above evidence

Must try this exercise if u have a meniscal injury. click on this sentence!!!

PROGNOSIS POST-SURGERY FOR MENISCAL INJURIES:-

Surgery (partial excision, timing or meniscus suture) will allow a return to professional sports in two weeks to several months. The knee will be more vulnerable to stress at the site of meniscus excision and in the long term, 10 to 20 years, the risk of developing local osteoarthritis is significant compared to a non-injured knee

 

CONTACT US FOR MENISCAL REHAB ON 9821066050 OR EMAIL US AT BOOK AN APPOINTMENT

REFERENCES:-

1. Clinical Sports Medicine (3^rd edition- by Peter Brukner and Karim Khan with collegues
2. The sports injuries handbook, diagnosis and management by Christofer Rolf
3. Sports Injuires: Mechanisms, Prevention, Treatment (2^nd edition) by Freddie H. Fu (Editor), David A., M.D. Stone (Editor)
4. Risk factors for meniscal tears: a systematic review including meta-analysis.