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  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.


Kneecap Pain and Running

Understanding Kneecap Pain for Runners

Patellofemoral pain syndrome (PFPS) typically presents with a dull pain just beneath the kneecap and lower front part of the thigh just above the knee joint.  It is very common injury for runners. Hence, patellofemoral pain syndrome is sometimes referred to as “runner’s knee” or misalignment of the patella.

The patella pain can be elicited during walking, running, going up/down stairs, squatting and even during long periods of rest, without moving the joint. One or both knees can be affected simultaneously and it is more common with women than it is with men.  The reason for the gender issue is based on the fact that women tend to have wider hips, which results in a significantly greater “Q angle” at the patellofemoral joint of the knee.

A number of risk factors for Runners knee have been identified and linked with the onset of patellofemoral pain syndrome in runners. Athletes who log excessive repetitive stress on their knee joint are the most predisposed population to develop patellofemoral pain with an overuse injury.  Other factors include knocked knees, wide hips, flat feet and excessive foot pronation.

The perceived kneecap pain is a result of abnormal forces associated with the patellofemoral joint such as abnormal muscle pulling on the painful patella, weak quadriceps muscles, tight hamstrings, subluxations, dislocations, arthritis, stiff Achilles tendon, tendonitis, and degenerating knee cartilages losing their cushioning effects.

This results in an inflammatory response that unleashes a cascade of protective patella pain.  Interestingly, this area is more often not swollen.

Signs & Symptoms of Patella Pain for Runners

  • Dull aching pain around the kneecap.
  • An increase in symptoms during and/or after lower extremity activities such as walking, running, squatting as well after long periods of rest with the joint in a fixed position.
  • Pain may also be perceived behind the knee.
  • Patella tenderness but not necessarily swelling around the knee.
  • Knee joint catching or locking.
  • Difficulties attaining full range of movement with popping or snapping sensations noted with active movement.

Professional Treatment for Runners Knee

  • Rest, elevate and ice the area for 15-30 minutes, up to 4 times a day.
  • Stretching of the quadriceps, hamstrings, hips, ankles and Achilles is a must.
  • Significantly limit or postpone your running for now.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Avoid excessive weight bearing activities.
  • Utilize a self myofascial roller to be used regularly on the quads, lateral thigh, hamstrings and calves.
  • Utilize a knee compression sleeve or patella brace as needed.  They can either decrease or increase the symptoms, depending upon the athlete.
  • Avoid making sharp movements on the knee joint, changing direction with the foot fixed to the ground, bending the knee back and forth.

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. What type of tissue around my knee is the source of my pain?
  2. Is there any arthritis in my knee and if so, where is it located?
  3. What type of exercise or physical therapy can I do to minimize or eliminate this pain?
  4. Do you recommend I take glucosamine?
  5. Are there any long term complications I should be concerned about?
  6. Do you recommend the use of orthotics for my injury?

Elite Sports Medicine Tips from Mike Ryan

  • Healthy Mind & Body – A healthy body and mind makes for a quicker recovery. Stay positive.
  • AM Stretches – Stretch the muscles around your knee joint before you begin your day.  A proper warm up is always smart if reducing kneecap pain is your goal.
  • Keep Rollin – Lower extremity rolling to increase the blood flow and mobility of the muscles associated with the knee is a must.
  • Gear Up the Right Way – Make sure your equipment from your shoes to your exercise equipment is right for you and not contriputing to the problem.
  • Level Hipped & Level Head – Make sure you don’t have a leg length discrepancy or alignment problem.  When it comes to eliminating kneecap pain, correcting this is priority #1.