Tips for Diagnosis and Management of Meniscal Tear

Download PDF of below Clinicians Tips for Meniscal Tear

Diagnosing

”Background

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Clinical Features

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  • There are no clinical features proven to distinguish a DMT from OA and little consensus between expert groups about how to reliably identify or diagnose a DMT.
  • Mechanical symptoms traditionally used to diagnose a DMT clinically (clicking. locking and catching) have been proven to be more closely related to articular cartilage degradation.
  • Meniscal tests have limited diagnostic accuracy.
  • A combination of McMurray test (61% sensitivity and 84% specificity) and joint line tenderness (83% sensitivity and 83% specificity) have been recommended, but the accuracy of these tests have mainly been investigated in younger patients with traumatic meniscal tears.
  • Thessaly’s test (or stand and pivot test) whereby the patient rotates their body while standing on a slightly flexed knee has also been recommended.
  • While there is no consensus on diagnosis the following symptoms and clinical features are characteristic of a DMT and/or early OA;
    1. Activity related pain
    2. Insidious onset
    3. No history of significant trauma
    4. Sensations of clicking, catching, pseudo-locking and ‘giving way’
    5. Pain on a deep squat (usually posterior or medial joint line)
    6. Sharp joint line pain when twisting or turning
    7. Medial joint line pain/tenderness
    8. Knee flexion and extension- range not limited but pain on overpressure
  • An acutely obstructed knee requires further investigation. A bucket handle meniscal tear is one potential cause whereby a loose section can block the hinge mechanism. More commonly affects younger people as a result of a sports injury.
  • When to investigate further or refer on;
    1. Atypical presentation- prolonged joint stiffness, severe/constant pain
    2. Unexpected rapid progression of symptoms (rapidly progressive OA, subchondral insufficiency fracture)
    3. Continued deterioration in pain and function despite treatment and modifying activities
    4. Another presentation is suspected (pseudogout or gout)
    5. Change in clinical characteristics -red, hot swollen knee or unremitting night pain (septic arthritis or bone tumor)
    6. Any history of significant trauma, acutely obstructed knee, or unstable knee
    7. A block to extension

Management

Clinical practice guidelines published by the British Journal of Sports Medicine make a strong recommendation for non-operative management of DMTs and other types of knee pain attributed to degenerative knee disease.

This recommendation (see figure) was based on thirteen randomised trials that have examined partial meniscectomy versus non-surgical management or placebo.

Click on the image to expand in a new page.

Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. Siemieniuk et al. Br J Sports Med 2018;52:313

Education

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  • Try to set realistic timescales for improvements to manifest with conservative management. Research suggests that 70% of patients with pain attributed to a DMT can take up to 6 months to demonstrate a substantial improvement.
  • DMTs have usually develop gradually over time. Structural changes don’t have to be reversed for the joint for substantial improvements in pain and function.
  • Patients should understand that exercise won’t heal the meniscus but neither will it cause damage, in fact gradual progressive loading is safe and can improve the health of the joint tissues. Moderate repetitive loading has been shown to stimulate proteoglycan production in articular cartilage, whereas prolonged physical inactivity is associated with articular cartilage thinning.
  • Educate patients about building up the tolerance of the knee to load, using exercise, in a gradual and progressive manner (see figure below).
  • Patients should understand that DMTs are generally not repairable. Keyhole surgery will generally remove a portion of the meniscus but not ‘repair’ the tear.

Exercise and other treatments

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  • No significant difference has been found between various types of exercise therapy for pain in people with DMT.
  • Like knee OA, structured exercise interventions that typically focus on strengthening of lower extremity muscles offer improvements in pain and function and should be carried out at least twice per week.
  • Poor knee muscle strength is a risk factor for OA progression and poorer outcome in people with a DMT therefore target the quadriceps and hamstring with a strengthening programme.
  • Tailor exercise type to patient’s likes, preferences and prior experience. Long-term adherence to exercise and physical activity will help target modifiable risk factors for development and progression of knee OA (obesity, weaker quadriceps).
  • According to research in other musculoskeletal conditions, exercise prescribed by a trusted source or clinician is perceived by patients to be more effective, as is receiving a programme they believe to be tailored to their specific presentation.
  • Set realistic expectations that it may take time (several months) to see results with an exercise programme.
  • Other management options are similar to knee OA and include watchful waiting, weight loss if overweight, oral or topical pain medications such as non-steroidal anti-inflammatory drugs, and intra-articular corticosteroid.

Surgery

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  • Arthroscopic meniscectomy is no longer recommended for a DMT.
  • The placebo-controlled FIDELITY trial found no clinically important difference in pain and function between sham surgery partial meniscectomy for patients with a DMT.
  • “Mechanical symptoms” together with DMT have been considered an indication for meniscal, however no predictable patient sub-groups have been identified that benefit from.
  • Some (but not all) studies have demonstrated partial meniscectomy to be associated with a slightly increased risk for knee OA compared with non-operative management.
  • Meniscectomy have been found to be associated with a threefold increase in the risk for total knee arthroplasty.
  • No study has suggested that partial meniscectomy has a protective effect or is beneficial for long-term knee health.
  • Excision of a greater amount of the meniscus is associated with poorer outcomes and greater likelihood of future OA. Removal of the entire meniscus is a strong risk factor for the development of OA.
  • Arthroscopic meniscectomy is indicated in acutely locked knee due to a displaced bucket-handle meniscal tear.
  • Two recent trials have studied younger populations with meniscal tears (DREAM trial and STARR trial). Both studies concluded a strategy of early surgery was not superior to a strategy of physiotherapy first with optional delayed arthroscopic partial meniscectomy. One in four people from the exercise group crossed over to surgery.

Download Tips for Diagnosis and Management of Meniscal Tear
SOURCES OF INFORMATION

The information in this website page was informed by the following sources/references:

  • Antony, B, et al. “The relationship between meniscal pathology and osteoarthritis depends on the type of meniscal damage visible on magnetic resonance images: data from the Osteoarthritis Initiative.” Osteoarthritis and cartilage 25.1 (2017): 76-84.

  • Berg B, Roos EM, Englund M, et al. Development of osteoarthritis in patients with degenerative meniscal tears treated with exercise therapy or surgery: a randomized controlled trial. Osteoarthritis Cartilage. 2020;28(7): 897-906. doi:10.1016/j.joca.2020.01.020
  • Culvenor AG, Øiestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med. 2019;53(20):1268-1278.
  • Foreman, S.C., Liu, Y., Nevitt, M.C., Neumann, J., Joseph, G.B., Lane, N.E., McCulloch, C.E. and Link, T.M., 2021. Meniscal root tears and extrusion are significantly associated with the development of accelerated knee osteoarthritis: data from the osteoarthritis initiative. Cartilage, 13(1_suppl), pp.239S-248S.
  • Foreman, Sarah C., et al. “Meniscal root tears and extrusion are significantly associated with the development of accelerated knee osteoarthritis: data from the osteoarthritis initiative.” Cartilage 13.1_suppl (2021): 239S-248S.
  • Herrlin S et al. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? a five year follow-up. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):358-364. doi:10.1007/s00167-012-1960-3.
  • Hohmann E, Angelo R, Arciero R, Bach B R, Cole B, Cote M, et al.
    Degenerative meniscus lesions: an expert consensus statement using the modified delphi technique. Arthroscopy 2020; 36(2): 501-12.
  • Hunter, N. Arden, P.G. Conaghan, F. Eckstein, G. Gold, A. Grainger, et al.
    Definition of osteoarthritis on MRI: results of a Delphi exercise
    Osteoarthritis Cartilage, 19 (2011), pp. 963-969.
  • Katz JN et al. Five-year outcome of operative and non-operative management of meniscal tear in persons greater than 45 years old. Arthritis Rheumatol. 2020;72(2):273-281. doi:10.1002/ art.41082.
  • Lee, NH., Seo, HY., Sung, MJ. et al. Does meniscectomy have any advantage over conservative treatment in middle-aged patients with degenerative medial meniscus posterior root tear?. BMC Musculoskelet Disord 22, 742 (2021). https://doi.org/10.1186/s12891-021-04632-8
  • Papalia, R. et al. Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull, 99 (2011), pp. 89-106.
  • Pihl, K, et al. “Wild goose chase–no predictable patient subgroups benefit from meniscal surgery: patient-reported outcomes of 641 patients 1 year after surgery.” . Br J Sports Med.54.1 (2020): 13-22.
  • Sihvonen R et al; FIDELITY (Finnish Degenerative Meniscus Lesion Study) Investigators. 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. Br J Sports Med. 2020; 54(22):1332-1339. doi:10.1136/bjsports-2020-102813.
  • Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BJSM 2018;52:313.
  • Skou, Søren T., et al. “Early surgery or exercise and education for meniscal tears in young adults.” NEJM evidence 1.2 (2022): EVIDoa2100038.
  • Snoeker BAM, Bakker EWP, Kegel CAT, Lucas C. Risk factors for meniscal tears: a systematic review including meta-analysis.J Orthop Sports Phys Ther. 2013;43(6):352-367. doi:10.2519/jospt.2013.4295
  • Sonesson S, Kvist J, Yakob J, Hedevik H, Gauffin H. Knee arthroscopic surgery in middle-aged patients with meniscal symptoms: a 5-year follow-up of a prospective, randomized study. Orthop J Sports Med. 2020;8(1): 2325967119893920. doi:10.1177/2325967119893920
  • Swart, N. M., et al. “Effectiveness of exercise therapy for meniscal lesions in adults: a systematic review and meta-analysis.” Journal of Science and Medicine in Sport 19.12 (2016): 990-998.
  • Stone J A, Salzler M J, Parker D A, Becker R, Harner C D. Degenerative meniscus tears—assimilation of evidence and consensus statements across three continents: state of the art. J ISAKOS 2017a; 2(2): 108-19.
  • van der Graaff, Sabine JA, et al. “Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in a young study population: a randomised controlled trial.” British Journal of Sports Medicine 56.15 (2022): 870-876.