Torn Meniscus: To Scope or Not to Scope?

Source: Pixabay
Source: Pixabay

I received a call from a dear friend of mine regarding his knee injury.  I get lots of these.  He had some anterior knee pain during his long runs over 10 miles with minimal swelling.  As an Ironman triathlete, this guy is a machine.  He swims, bikes and runs….almost every day!  That is not a typo.

Needless to say, my friend “Tom” is not your typical weekend warrior and his pain tolerance is quite impressive.  With this being said, when Tom complains of pain, it’s not taken lightly.

Tom had already been evaluated by an orthopedic surgeon and an MRI was ordered.  The MRI revealed a kneecap stress fracture, a knee cartilage injury and a knee scope was schedule.  Tom’s question to me was simple: “Do you think I need a knee surgery for a torn meniscus?”

I get lots of knee torn meniscus management questions on MikeRyanFitness.com.  I think Tom’s knee injury is a perfect opportunity to help many of my readers by sharing my thoughts on knee cartilage injuries.

Tom’s Knee Cartilage Injury Facts

No Known Mechanism – No falls, no twists and no knee injury history.

Knee Pain – Anterior pain only after 10+ miles running.  No joint-line pain over the medial or lateral menisci.

Symptoms – Patella soreness after long runs only.  No catching, no joint locking, no giving way and no swelling inside or outside the joint.

Torn Meniscus Management

If It’s Not Broke, Don’t Fix It – If there is no mechanical signs or concerns related to a knee meniscus tear, I’m a firm believer in not bothering it.  There’s an old saying in sports medicine: “Don’t do surgery on an x-ray or MRI.”  In other words, trust you evaluation and what the patient is telling you not just what the film looks like.

Common Findings – A great deal of individuals, athletes and couch potatoes alike, are walking around with pain-free meniscal tears, myself included.  It’s very common and not a reason to do a surgery compared to so many more serious knee injuries.

Location, Location, Location – The knee cartilage is a valuable piece of real estate.  Where the tear is located will have a huge impact on the person’s symptoms and the need for surgery.

Lateral vs Medial – A tearing of the lateral or outside meniscus is more concerning than a medical or inside meniscus tear.  This is because the outer compartment of the knee bears more weight and is much more prone to knee arthritis.

Happy Knee? – If there is no inner “locking” or “catching” of the knee, no pain over the inner or outer joint lines and no significant swelling within the joint, a scope is probably not necessary.  In most cases, scoping a happy and asymptomatic knee will simply create problems for the athlete.

Ice + Strength – Controlling swelling by applying 15 minutes of ice every hour and increasing quad strength with limited range of motion (ROM) leg exercises are crucially important sports medicine tricks to help avoid surgery for a torn cartilage.

In Summary

My recommendation to Tom: To pass on the knee scope, avoid running until the doctor clear him to do so, get aggressive with his pain-free leg exercises to keep his legs strong, utilize Russian electrical stimulation to assist with this quad and hamstring strength, focus on his swimming, use a bone-growth stimulator to help speed the healing of the patella and to be consistent with his knee icing.

What did Tom do?  He had the scope to trim his meniscal tear.  It’s been about 2 month since the knee surgery, he’s now has joint-line symptoms where his meniscus was cut during the scope and he’s still trying very hard to regain the quad strength he had before the scope.  He recently return to running.  He’s a great person and we all hope to see him back to competing aggressively at a very high level.

 

Tackling a Lateral Meniscus Tear of the Knee


Understanding a Lateral Meniscus Tear

“I tore my cartilage” is the term most athletes use to describe the possible source of their knee joint line pain.  About 40% of the time, they’re correct.  Now ask them to identify culprit, aka “the cartilage”, in a police lineup and they’ll probably have the look of a cow staring at a fence.

The medial (inner) and lateral (outer) menisci are made up of very resilient cartilage.  Their design and cellular structure allows them to assist in the stability of the distal femur (thigh bone), distribute body weight forces across the joint surfaces and absorb compressive forces as we move.

Injuries to the menisci can significantly impair knee functions. Because of their relationship with other structures in the knee joint, the lateral meniscus is less prone to injury when compared with the medial meniscus. The lateral meniscus has less direct attachments to other structures in the knee. However, the long-term impact of a lateral meniscal injury is more concerning due to the high weight-bearing forces in the lateral compartment of the knee.  In other words, if you have a lateral meniscal injury, your likelihood of needing to have it addressed surgically increases and the presence of accelerated arthritic damage rises with time when compared to the medial meniscus.
The types of injuries to the lateral meniscus vary in location and severity, ranging from splitting into two segments to tearing around its more “C” shaped borders. Over time, meniscal micro trauma can result.

The lateral meniscus has minimal blood supply around its periphery.  With no direct blood supply to its central region, one can typically expect minimal healing with injuries involving this region of the lateral meniscus.

The two most common causes for meniscus tears are direct trauma and degenerative conditions. More often, the traumatic injuries involve twisting of the knee with the knee in a bent position.  This is commonly seen in contact sports. With this mechanism of injury, the foot is fixed to the ground resulting in a stretching of the meniscus. A direct blow to the inner part of the knee joint can also injure the lateral meniscus.

The degenerative damage is more commonly seen in the older population and is often associated with underlying arthritic changes. As the meniscus lose significant blood supply and weakens, it becomes more prone to injury. In this population, simpler twists and forces associated with daily activities may prove to be the cause of a meniscal injury.

Signs & Symptoms of Lateral Meniscus Tear

  • Excruciating pain and swelling immediately or up to 3 days after the activity in question.  Lateral joint line pain increases with rotation of the knee and weight-bearing.
  • Difficulty walking, bending or rotating the knee against resistance due to lateral knee pain.
  • The knee joint may become locked or “catch” if the loose piece of the meniscus is in a position of pain within the joint.  This flipping of the flap or unstable section of the cartilage will typically prevent full extension more often than it will limit full flexion.
  • Joint stiffness and tenderness around the outer edge and back ridge of the lateral joint line.
  • A general sense of insecurity with the knee with increased activity contributing to what older athletes tend to refer to as a “trick knee” due to its unpredictability.

Professional Treatment for Lateral Meniscus Tear

The best treatment is often a treatment of the symptoms and not the injury itself due to the limited healing capability of the meniscal tissue.

  • Ice the knee at least 4 times per day and immediately after all athletic activities.
  • Utilize the latest physical therapy modalities and rehabilitation equipments to control the pain, swelling and tenderness in the in and around the joint.
  • Strengthen the muscles directly influencing the knee joint. Strengthening exercise should be mostly pain-free. Muscles of the thigh, quads in front and the hamstrings in back, should be the main focus along with the hip rotators and the calves.
  • Soft tissue massage and stretching of the surrounding muscles and fascia needs to be included. This encourages the muscles to stay pliable which will accelerate the recovery time.
  • Surgery?  Let the doctor and YOU determine the answer to this question.  Closely monitor your symptoms and your activity level before you decide to “go under the knife”.  If unsure, gradually test your knee with functional activities along with the watchful eye a sports medicine specialist.
  • Eat right and drink right.
  • Be cautious of activities that twist the knee to avoid aggravating the injury.
  • Rest as needed.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this injury related to my athletic activities?
  2. What structures in my knee are damaged?
  3. Do I need further diagnostic test like an MRI?
  4. Do I need to have a knee scope and/or a micro fracture surgery?
  5. What kind of exercises do you recommend?
  6. Are there any long-term complications that we should discuss now?

Elite Sports Medicine Tips from Mike Ryan

  • Train With “Training” Specifications: Train smarter.  You can be aggressive and keep your knee pain-free by minimizing the twisting motions during your training.
  • Surgery is Just One Option on the Menu:  Many doctors may tell you otherwise but here is the truth: Just because you have a meniscal tear does not necessarily mean you need to have surgery.  The location of your injury, your pain level, the present knee limitations and your past medical history are the most important factors in determining whether you need to be walking around the surgical center trying to look cool in one of those drafty Johnnies!
  • Grocery Choices: You know when it’s junk or healthy. Help yourself to a healthy diet if you’re serious about getting back to competing like you did 10 years ago.
  • Ride Your Way Up: Don’t play “hero” on day #1 with your agility drills and running.  Bike riding is a great way to get your range of motion back and to start the leg strengthening process the smart way.  It’s time to change your mindset and getting on the bike and in the swimming pool is a great way to start.
  • Employ Proper Techniques: You accidentally did something wrong to incur the meniscal tear so now your focus should be to doing it right. Proper techniques and progression are the keys along with getting in with the right physical therapist.