Meniscal Injuries - Clinicals, Diagnosis, and Management

Sports Medicine

Clinicals - 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. 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.
Knee swelling Due to synovitis and effusion inside the joint cavity. Knee swelling
Due to synovitis and effusion inside the joint cavity.
Mechanical symptoms such as catching, locking and giving away. 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. Mechanical symptoms such as catching, locking and giving away.
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.

Clinicals - Examination

Fact Explanation
Joint line tenderness on the affected side Inflammation of the knee joint due to the torn meniscus. Joint line tenderness on the affected side
Inflammation of the knee joint due to the torn meniscus.
Joint effusion Extravasation of plasma into the joint cavity due to an inflammatory reaction. Joint effusion
Extravasation of plasma into the joint cavity due to an inflammatory reaction.
Limited extension Mechanical limitation of the range of movement by interfering menisci fragments or knee joint effusion. Limited extension
Mechanical limitation of the range of movement by interfering menisci fragments or knee joint effusion.
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. Specificity of this test is 80–99% and sensitivity is16–58% 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. Specificity of this test is 80–99% and sensitivity is16–58%
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. Specificity of this test is 57–98%, while sensitivity is 10–66%.
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. Specificity of this test is 57–98%, while sensitivity is 10–66%.
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%. 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%.
Quadriceps wasting 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. Quadriceps wasting
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.

Investigations - 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. 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.
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. Sensitivity and specificity of MRI for the detection of medial meniscal tears is 93%, 88% while for lateral meniscal tears it is 79%, 95% . 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. Sensitivity and specificity of MRI for the detection of medial meniscal tears is 93%, 88% while for lateral meniscal tears it is 79%, 95% .
Arthrography Involves injecting contrast medium into the joint space. Has largely been replaced by MRI. Arthrography
Involves injecting contrast medium into the joint space. Has largely been replaced by MRI.

Investigations - 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. 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.
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)
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)

Management - Supportive

Fact Explanation
Rest with activity modification Avoidance of offending activities such as prolonged standing and prevention of exerting more strain over the affected area. Training errors can be precipitating factors. Rest with activity modification
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 Promotes local vasoconstriction and provides some analgesia. Application of ice
Promotes local vasoconstriction and provides some analgesia.
Non steroidal anti inflammatory drugs (NSAIDS) Provides an analgesic effect and anti-Inflammatory effect. It is recommended for 8–12 weeks. Non steroidal anti inflammatory drugs (NSAIDS)
Provides an analgesic effect and anti-Inflammatory effect. It is recommended for 8–12 weeks.
Elevation of the affected limb Minimizes acute swelling and
inflammation and prevents the exertion of more strain over the affected area.
Elevation of the affected limb
Minimizes acute swelling and
inflammation and prevents the exertion of more strain over the affected area.
Intensive physiotherapy Physiotherapy is recommended twice a week for at least 8 weeks. This includes proprioceptive work and muscle strengthening which strengthen the
quadriceps. Stronger muscles will protect the meniscus by absorbing the force of impact.
Intensive physiotherapy
Physiotherapy is recommended twice a week for at least 8 weeks. This includes proprioceptive work and muscle strengthening which strengthen the
quadriceps. Stronger muscles will protect the meniscus by absorbing the force of impact.

Management - Specific

Fact Explanation
Partial meniscectomy 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. Partial meniscectomy
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 . Total meniscectomy
Not commonly performed as it may be potentially damaging and cause unfavorable long-term outcome results .
Arthroscopic repair Fixation can be accomplished with outside-in, inside-out, or an all-inside arthroscopic procedure. Arthroscopic repair
Fixation can be accomplished with outside-in, inside-out, or an all-inside arthroscopic procedure.
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.
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.
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.
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.

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