152. Knee Meniscal Tears: Anatomy, Diagnosis, and Treatment that Makes Sense

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In this episode, we cover the anatomy and functions of the menisci, the mechanisms behind various types of meniscal tears, and clinical assessment techniques. We also discuss when to opt for conservative care versus surgical treatment, and reviews special tests and imaging standards like MRIs. Tune in to enhance your understanding of knee meniscal injuries and improve your clinical practice.

00:00 Introduction to Bets Snacks Podcast

00:23 Overview of Knee Meniscal Tears

00:54 Anatomy and Function of the Menisci

03:03 Types of Meniscal Tears

05:58 Clinical Assessment Techniques

08:15 Imaging and Diagnosis

09:04 Conservative vs. Surgical Treatment

12:03 Conclusion and Additional Resources

Beamer BS, Walley KC, Okajima S, et al. (2017). Meniscal Repair vs Partial Meniscectomy: A Comparative Analysis of Clinical Outcomes. Arthroscopy, 33(9), 1635–1643.

Englund M, Guermazi A, Gale D, et al. (2008). Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. New England Journal of Medicine, 359(11), 1108–1115.

Logerstedt DS, Scalzitti D, Risberg MA, et al. (2010). Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions. Journal of Orthopaedic & Sports Physical Therapy (JOSPT) Clinical Practice Guidelines, 40(6), A1–A35.

LaPrade RF, Geeslin AG, Everett CR, et al. (2015). Diagnosis and Treatment of Meniscal Injuries: A Review. Sports Health, 7(2), 147–154.

Stensrud S, Risberg MA, Roos EM. (2012). Effect of Exercise Therapy on Meniscal Tear Outcomes in Middle-Aged Adults: A Randomized Controlled Trial. British Medical Journal (BMJ), 344:e533.

Transcript

0:30

Hey guys. Welcome to Bets Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in vice eye segments of time. This is not medical advice, so use this information to your discretion. Now, today we are going to cover the knee, specifically knee meniscal, tears, all there's a ton of different types. But before we do, if you've been listening to show more than three times and you found it to be helpful to you. If you wouldn't mind leaving a review wherever you listen to the podcasts, that would mean the world to me. And for those of you who have already done so, thank you so much for spending your time and being willing to help invest into the future of this show. I really appreciate that. Now what we're gonna do today is cover a very brief review of the anatomy and function of the anatomy and function of the menisci, how and why meniscal tears happen in the different types, as well as just briefly, some clinical success, clinical assessment techniques, and when to consider conservative care versus surgical treatment. Now in terms of the anatomy of the menisci when we say menisci, I am referring to the media and lateral meniscus. These are CS shaped pieces of fibrocartilage that sit between the femur and the tibia. So the role, of the menisci would be for helping with low transmission and shock absorption, joint stability. And joint lubrication and nutrition, as well as limiting excessive motion, particularly rotation. The medial meniscus tends to be injured more commonly just because it's less mobile. It's firmly attached into the joint capsule in the MCL, whereas the lateral meniscus is more mobile and therefore a little bit more protected because it can move. There's less strain on it that can happen. Another important aspect of the anatomy of the menisci would be that vascular supply is an important consideration. The outer third of the meniscus is considered the red zone, meaning it's vascularized while the inner two third is less vascularized. So we have the white zone, white red zone. The white zone has very poor blood supply, so what you should take away from this is basically the healing potential based on where that tear is gonna occur. Oftentimes, mechanisms of injury can be acute, like from twisting injuries. Maybe someone is had a planted foot while they're cutting. Pivoting sports. It can also be degenerative. So seen in older adults, not really a lot of trauma. It's just something that may or may not be symptomatic. And then combined injuries, so something that maybe occurs with ACL. Tears, diving into the types of tears. I'm going to talk about seven, so stay tuned. I think a good challenge for you would be see how many you can recall by the end of this episode. So number one is longitudinal or vertical tears. These run parallel to the long axis of the meniscus, usually on the outer edge. So in the red zone, common in our younger athletes. So these are more likely to be repairable due to better blood supply because where are they in the red zone. Radial tear number two. It extends from the inner free edge of the meniscus towards the periphery, like spokes on a wheel, right? So these can disrupt hoop stress. Transmission hoop stress is just referring to the meniscus ability to help with low transmission and shock absorption and joint stability. So these are less likely to heal, especially if they are in the white zone. A horizontal tear splits the meniscus in into a top and a bottom layer parallel to the tibial plateau. So we see this a little bit more commonly in degenerative knees. This could create a flap if one layer becomes unstable. And number four, we have an oblique or a parrot beak tear. It starts as a radial tear and then it curves obliquely so it can create an unstable flap. It's named para B'cause of how it looks, and it can cause mechanical symptoms like catching if the flap moves. Number five. We have a complex tear, so it can be a combination of two or more tear patterns like radial and horizontal. Hence the name complex. It's more than one, is complex. We see this more commonly in older degenerative knees. Not always the most suitable for repair, bucket handle tear. This is a large vertical longitudinal tear where the inner fragment displaces centrally. So this can cause the knee to actually lock up because of the displaced fragment. It's common in young athletes and usually requires surgical repair. And then number seven, we have a flap tear, so a portion of the meniscus becomes loose or folds over like a flap, and it can happen from a horizontal or an oblique tear and may create catching or locking sensations. So again, briefly, the names number one, longitudinal or vertical tear, two radial tear, three horizontal tear, four oblique or parit beak tear, five complex tear, six bucket handle tear, or seven flap tear. I just spent the last few minutes talking about how these tears can create flaps and cause catching and all these sort of things. So if your patient comes in and you're suspicious of a meniscus, it might be'cause they're complaining of locking or catching sensations. They may also have joint line pain with twisting or squatting, and they may notice some swelling after an activity. As I have mentioned on this Special tests are for special moments, and they're not the thing that you should run right to because a lot of them are pretty provocative. And if you flare up your patient for your evaluation, you're probably gonna get a lot of false positives in the following assessments that you're doing. So it's good to start with the basics that are relative. Looking at your patient's knee range of motion, their strength, their function before we dive right into the special test. Comparing side to side, unless you're assessing both knees for the same thing. But you are going to be looking for if they have joint line tenderness. So palpating their median lateral joint line. Palpation is something you could do earlier, though it is sensitive, but not specific. Meaning if they're not painful there, they may not have a problem there. The McMurray's test is where you're gonna flex and extend the knee with rotation and a valgus or varus stress. So you're looking for if you can reproduce a click or a pop basically trying to take the knee through as much range of motion. Where, if there is some sort of flap, you capture that. Cecily test is where the patient stands on one leg with slight knee flexion and you're rotating side to side. To clarify, you're rotating them at their knee joint. A lot of times what happens is they stand there on their leg and they just twist, like at their low back. So make sure you're actually testing what you wanna test. And then athlete compression test is where you're gonna add a downward force with rotation and prone flexion. So with these tests, some of them are less irritable, like joint line tenderness, palpation. Again, you could do that early on. Some of them look at axial load with kind of grinding on the meniscus and varying amounts or more range of motion. And essentially you're trying to put a test to the job of the meniscus and see if it's irritable. In terms of imaging, the MRI is gonna be the gold standard for a non-invasive diagnosis. Obviously, if you cut somebody open and you see a meniscal tear, it's probably a meniscal tear, right? But it can help to identify the location and the pattern of the tear. Is this a surgical repair? Is this conservative? If there's any sort of meniscal extrusion if there's any associated injuries such as an ACL or articular cartilage damage. But also keep in mind, it can be common for meniscal abnormalities to also happen in asymptomatic individuals, especially in older adults. So it's really important to combine your clinical tests with your imaging and see if they match together. Use all the pieces of the puzzle, and then you can see the full picture, not just one piece. Now let's talk a little bit more about who's gonna start with conservative versus is surgical. So conservative management is probably gonna be where most patients start out who have a small, stable tear, maybe degenerative tears in the white zone, that probably aren't going to heal well if you try and stitch them up. Or older patients or those maybe who don't even have mechanical symptoms. So basically the interruption to the tissue we'll say has not. Vastly affected its ability to do its job. Conservative treatment can include activity modification, strengthening, like at the quads, at the hips, whatever's applicable for what that patient is trying to get back to. Doing neuromuscular control and balance training as needed. Manual therapy for mobility as needed as well too. And then if they are trying to get back to sport, it's helpful to utilize return to sport criteria so that we're not just throwing them back to the wolves. However, surgical treatment is probably gonna be more likely indicated, whether it's a menisectomy or a repair. If a patient has a bucket handle tear, especially if that patient's knee is locking, that's not good, right? If they have large, unstable longitudinal tears in the red zone, meaning, hey, if we stitch it, it'll probably heal. Failure of conservative care after three to six months. And if they've had associated injuries like an ACL reconstruction at the same time, might as well go ahead and do both. minuscule repairs are often preferred over meniscectomies, where they're just basically shaving the meniscus away, just whenever is possible to help preserve as much of the meniscus as possible for joint health and prevention of early osteoarthritis. However, if it's in a white zone or just not feasible for the patient, then they may get a menisectomy. So these can be tricky because there's a lot of different meniscal types, right? Not all meniscal tears are the same. And depending on what the tear is, can affect our ability to be able to help our patient either. Go through conservative care or be screened and sent off to surgery and cared for after their surgery. And then after their surgery, we're gonna protect the meniscus for however long it needs. Repairs usually take longer and slowly add stress in a way to where it's productive, meaning helping the meniscus to add. More and more of its previous job back into the picture so it can adjust and then take over from there. Again, remember the functions of the Minna sky are load, transmission and shock absorption, so our ability to retrain it to be able to take those tests. Joint stability, joint lubrication, limiting excessive motion. We're probably not from the get go, gonna have them do a whole bunch of jumping and cutting, but we do want them to get there at some point if they're trying to get back to those activities. Right. Is there a lot more I could have covered? Absolutely. But if you have any questions, there is a link in the show notes where you can submit a question or you can email me at pt Snacks podcast@gmail.com, where I love to hear from you guys. Now that's it for today on Meniscal Tears. If you are in need of either more cu, you wanna take a deeper dive on different topics, or you're preparing for a specialty exam, med Bridge is actually offering listeners over a hundred dollars off their year subscription. So all you'd have to do is use the promo code in the show notes and then plug it in a checkout. Now you'll have access to tons of courses, webinars. I used the specialty exam for my OCS and it was really helpful to be able to take practice exams and the lessons that were with it and get used to staring at a screen for a long period of time.'cause if you've taken the OCS, you know that's real I fatigue, but if you're a student, there's an even better discount for you in the show notes as well. So make sure you utilize that one. Plus there's also an exercise builder for those of you who are treating patients, and you want to plug some exercises together, you can either print it off for your patient, tell'em exactly what to do, has pictures, sets, and reps, or if you have a tech savvy patient. You can literally email them or have them scan a QR code and they can follow along in their app and watch videos. So definitely pretty cool. But other than that, I hope you guys have a great rest of your day and into next time.