YOU’RE FINE, YOU’RE NORMAL.

What to do if you have a torn meniscus.

You have just seen your GP or allied health professional about your knee pain and they referred you for an MRI for a diagnosis. You receive the results back and to your horror it mentions the word ‘tear’ alongside a funny word beginning with ‘m’ - meniscal– great, now what?

Firstly, what actually is the meniscus and how on earth does it tear?

Your meniscus is a cartilage like structure that sits between your femur (thigh bone) and tibia (shin bone). In your knee there are two menisci, one on the inside of your knee, and the other on the outside. They look like two half-moon shaped structures and basically their job is to distribute and absorb impact that occurs at your knee joint when walking, running, jumping, dancing, etc.

Meniscal tears can occur through two different ways;

1.     TRAUMATIC / ACUTE INJURY

These tears are seen most commonly during sporting activities as a result of a forceful twist when the knee is bent. They are largely associated with other significant knee injuries such as cruciate ligament ruptures or tears, and present with a sudden onset of knee pain. You may also hear or feel a pop or click within the knee joint during this type of injury. These types of tears can be most commonly classified as vertical, longitudinal, or radial (based on the size, shape and orientation of the tear) (Kopf, et al. 2020).

2.     DEGENERATIVE

These are typically but not exclusively seen in older adults, and are a result of age-related changes within the knee. There is no episode or incident which causes these types of meniscal tears, so they are classified as non-traumatic, chronic and usually horizontal in direction and shape. These can be very common but they are not necessarily painful.

“If you are a healthy, pain-free individual over the age 50 years, there is a 60% chance you have evidence of a meniscal tear found in your knee.

— Englund, et al., 2008

It’s essentially more common and normal to have a meniscal tear, than it is to not have one, and degenerative tears can also be seen in young, healthy, pain free people.

Meniscal tears aren’t the only incidental findings that are seen on pain-free people; articular cartilage, tendon, bone marrow and ligament abnormalities can also be seen. One study demonstrated that out of 230 knees belonging to 115 adults without any symptoms, 97% of the knees viewed under MRI had “abnormalities” (Horga, et al. 2020).

So, if you have knee pain, and a torn meniscus, along with other findings on an MRI – it’s very likely that without a specific incident, these things were there long before your pain and had not caused any trouble.

Here are a few common questions we get asked about meniscal tears:

I HAVE BEEN TOLD I NEED MY KNEE “CLEANED OUT”, DO I NEED SURGERY?

Short answer: No.

Long Answer: If you have mechanical symptoms of “catching, locking, or buckling / giving-way” of the knee, arthroscopic partial meniscectomy (APM) was the common procedure performed. This surgery involved the removal of the torn fragment of your meniscus. If someone has both a meniscal tear confirmed on MRI, and mechanical symptoms deemed to originate from the tear, there was a strong rationale for surgery.

However, mechanical symptoms are not always consistent, they come and go, can be present in those without a meniscal tear, and are seen in only 50% of those with a tear (Thorlund et al. 2019). As time went on, people who had APM were still reporting ongoing symptoms of pain, and impaired function. Many studies have since compared having an arthroscopic surgery with a placebo surgery, where only an incision is made on the skin, and no further intervention occurs.

It was found that having an arthroscope was no better than a placebo surgery in improving pain and function short term, and was even associated with an increased risk of osteoarthritis (Sihvonen, et al. 2020).

Previously it was speculated that having a torn meniscus could lead to arthritis, but as it turns out, removing a portion of the meniscus affects the ability of the joint to absorb and distribute compressive forces during movement and activity. So you may actually be better off having a torn meniscus, than less of your meniscus.

Because “abnormalities” are found in almost every knee without pain, it’s no surprise that an arthroscopic knee surgery to resolve these are no better than sham surgeries. Many studies now recommend against an arthroscope for degenerative knee diseases, including meniscal tears (Sihvonen, et al. 2020).

WHAT IF MY TEAR IS ACUTE – DO I NEED SURGERY?  

Short Answer: Not necessarily – but we’d suggest reading the long answer

Long Answer: Usually meniscal tears occur alongside other extensive knee injuries, such as an anterior cruciate ligament (ACL) rupture or injury, but they can occur in circumstances where the major ligaments of the knee are preserved. We are beginning to see more evidence supporting the non-surgical pathway for ACL injuries in recreational and elite athletes, however the literature is still unclear on whether meniscal repairs are superior or no better than exercise therapy and rehabilitation alone – many factors are relevant such as the location of tear, size, shape, and your overall functional limitations.

There are some cases where traumatic sport related meniscal tears may benefit from early intervention surgery, in presence of locking (knee mechanically getting stuck), but this needs to be a shared decision made between you, your therapist and the involvement of an orthopaedic specialist if required, based on what your goals and needs are. However, for degenerative meniscal lesions, exercise therapy is recommended as primary treatment choice (Thorlund et al. 2019).

SO WHAT SHOULD I DO ABOUT MY MENISCAL TEAR?

Reach out to someone qualified who can help you with the next steps based on your situation.

If you have been told you have a meniscal tear after developing knee pain without an associated incident or injury, you are normal, and this doesn’t necessarily mean you need to have surgery.

If you have had an injury during sporting activity, this doesn’t automatically mean you need surgery, instead, consult your therapist and decide on what pathway forward best suits you.

If you are concerned about your knee pain or MRI findings, and want some assistance in getting back control over your body our highly qualified allied health team can help you out.

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REFERENCES

1. Kopf, S., Beaufils, P., Hirschmann, M. T., Rotigliano, N., Ollivier, M., Pereira, H., … Becker, R. (2020). Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surgery, Sports Traumatology, Arthroscopy. doi:10.1007/s00167-020-05847-3
2. Englund, M., Guermazi, A., Gale, D., Hunter, D. J., Aliabadi, P., Clancy, M., & Felson, D. T. (2008). Incidental meniscal findings on knee MRI in middle-aged and elderly persons. The New England journal of medicine, 359(11), 1108–1115. https://doi.org/10.1056/NEJMoa0800777
3. Horga, L. M., Hirschmann, A. C., Henckel, J., Fotiadou, A., Di Laura, A., Torlasco, C., D'Silva, A., Sharma, S., Moon, J. C., & Hart, A. J. (2020). Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal radiology, 49(7), 1099–1107. https://doi.org/10.1007/s00256-020-03394-z
4. Thorlund, J. B., Pihl, K., Nissen, N., Jørgensen, U., Fristed, J. V., Lohmander, L. S., & Englund, M. (2019). Conundrum of mechanical knee symptoms: signifying feature of a meniscal tear?. British journal of sports medicine, 53(5), 299–303. https://doi.org/10.1136/bjsports-2018-099431
5. Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Kalske, J., Nurmi, H., Kumm, J., Sillanpää, N., Kiekara, T., Turkiewicz, A., Toivonen, P., Englund, M., Taimela, S., Järvinen, T., & FIDELITY (Finnish Degenerative Meniscus Lesion Study) Investigators (2020). Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial. British journal of sports medicine, 54(22), 1332–1339. https://doi.org/10.1136/bjsports-2020-102813

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