What is a meniscal tear?

A meniscal tear is an injury to a part of your knee called the meniscus. The meniscus is a special piece of cartilage inside your knee, which sits between your thigh bone (femur) and shinbone (tibia). There are two menisci, one in the inner (medial) side and one in the outer (lateral) side of the knee. The meniscal cartilages are at risk of tearing due to their constant exposure to repetitive loading as we walk, run, or perform other activities.

Any activity that causes you to forcefully twist or rotate your knee, especially when putting your full weight on it, can lead to a torn meniscus. A torn meniscus is one of the most common knee injuries.

Anatomy of a Meniscal Tear

The knee joint is made up of the femur (thigh bone), the tibia (lower leg bone), and the patella (kneecap). Ligaments and tendons connect the femur to the tibia and patella. The four main ligaments in the knee (anterior and posterior cruciate ligaments, and medial and lateral collateral ligaments) attach to the bones and act like strong ropes to hold the bones together and help stabilise the joint.

Every joint in the body is lined by extremely smooth tissue called “articular cartilage” (also known as hyaline cartilage). The articular cartilage of the knee coats the end of the femur, the top surface of the tibia and the back surface of the patella.

In addition to articular cartilage, the knee joint also has meniscal cartilages, which are specialised pieces of tissue that function as shock absorbers and stabilisers. You have two menisci in each knee called the ‘medial’ and ‘lateral’ meniscus. The menisci are thick, wedged, C-shaped, rubber like pads of cartilage tissue. As we walk, run, and jump, the knee absorbs tremendous forces. It is the shock absorbing capacity of the meniscus that protects the articular cartilage from wear and tear and reduces the risk of developing osteoarthritis. In addition to their role as ‘shock absorbers’, the wedge shape assists with the knee’s stability, and they also help to lubricate the joint and improve smooth movement of the knee.

As you can see from the diagram above, there is an outer and inner portion of the meniscus. The outer parts of the meniscus have adequate blood supply, but the middle and inner parts have poor blood supply. Because blood supply can affect healing, the location of a tear will affect treatment options and management.

The most important functions of the meniscus are:

• Shock absorption
• Load transmission (spreading weight more evenly throughout the knee joint)
• Increasing knee joint stability
• Joint lubrication

What causes a meniscal tear?

What are the symptoms of a torn meniscus?

Torn meniscus symptoms typically start with a mechanism of injury that involves a history of a painful twist occurring on a slightly bent knee. Degenerative meniscal tears can present slowly with less obvious signs.

The pain from a meniscal tear is often localised to the inner or outer part of the knee joint, and less so at the front of the joint.

Patients often describe pain with bending and twisting movements of the knee, and sometimes pain at night. Often people with meniscal tears complain of stiffness and recurrent swelling of the knee joint.

Some meniscal tears are large, and a fragment of the damaged meniscus may loosen partially and drift into the knee joint between the tibia and femur bone. When this occurs, the fragment may cause a block to movement and the knee becomes ‘locked’, limiting your ability to fully straighten or fully bend your knee.

The symptoms can vary from person to person, but the key signs and symptoms are:

• Swelling and stiffness – this normally takes 24 hours to develop after the onset of injury but can be more gradual in the case of degenerative tears.
• Tenderness on the inside (medial meniscus tear) or outside (lateral meniscus tear) of the knee
• Pain with fully straightening or fully bending the knee
• Locking or catching of the knee
• Pain at night
• Pain whilst squatting, twisting and kneeling
• Feeling of instability or the knee giving way

If you are experiencing any of these symptoms, or suspect that you have a meniscus injury and would like to see one of our expert physiotherapists, call 020 7482 3875 or email info@complete-physio.co.uk. If you would like to speak to a specialist before booking, then please send us an email with your details and we will call you back.

How is a meniscal tear diagnosed?

Meniscal tears are quite straightforward to diagnose. Clinical assessment has been shown to be around 80% accurate for diagnosis of meniscus tears. At Complete Physio our highly experienced physiotherapists will carry out a comprehensive assessment of your knee joint.

Your physiotherapist will firstly ask questions about your injury, symptoms, past health, and exercise regime. Following this, your physio will complete a series of clinical tests to help develop a diagnosis. These may include:

• Measuring the range of movement of your knee.
• Assessing muscle strength, in particular the quadriceps and hamstrings, and the muscles around your lower leg and hip.
• Assessing muscle length and flexibility of quadriceps, hamstrings, and calves.
• Watching you move your knee and how you perform activities such as squatting, hopping, jumping, running.
• Gently, but skilfully, feeling around your knee joint to find exactly where it is most painful.
• Functional tests – if your pain is present during a specific activity or task, you may be asked to perform these, so the physiotherapist can assess exactly what is aggravating your pain.
• There is a specific meniscal test called ‘McMurray’s test’ that your physiotherapist may additionally carry out to help establish your diagnosis.

Research has shown an increased risk of early onset of arthritis after damaging your meniscus and therefore an accurate diagnosis and appropriate treatment is paramount to a positive outcome.

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Will I need a scan?

MRI scan for meniscusl tear
If we are unsure of your diagnosis or we would like to understand more about the extent and type of the meniscal tear, then we may refer you for an MRI scan. MRI scans are also very useful to assess for any other contributing factors such as an associated ligament tear. We can refer you directly without going to your GP.

Diagnostic Ultrasound
Some of our clinicians are also fully qualified musculoskeletal sonographers and will carry out a diagnostic ultrasound scan of your knee.

Ultrasound is unable to assess the deep portion of the meniscus inside the joint. However, it can detect more superficial tears and is also an effective tool to assess for any swelling and inflammation in the knee. Ultrasound can also visualise meniscal cysts and other structures in the knee such as the medial and lateral collateral ligaments and the surrounding tendons. Meniscal cysts are small fluid-filled pockets that arise from the meniscus (see image below). These can occur secondary to a tear.

If you would like to book an ultrasound scan as part of your clinical assessment, then please call 020 7482 3875 or email info@complete-physio.co.uk. If you would like to speak to a specialist before booking, then please send us an email with your details and we will call you back.

X-Ray for meniscal tear

Because a meniscus is made of cartilage, it won’t show up on x-rays, but it can be helpful to check for any bone damage which might have also occurred with the injury. X-ray is regarded as a gold standard imaging technique capable of accurately diagnosing the presence and severity of bone and joint pathology, including osteoarthritis and broken bones.

How do we treat a meniscal tear?

Meniscal cartilage does not always heal very well once it is torn. This is mainly because it does not have a good blood supply. The outer edge of each meniscus has some blood vessels, but the area in the centre has no direct blood supply. This means that although some small outer tears may heal in time, larger tears, or a tear in the middle, will tend not to heal so well. The good news is most of these tears, even though they may not heal, become pain and symptom free. This is supported by a significant body of evidence that patients with a meniscus tear in their knee observed on MRI, are often asymptomatic.

At Complete Physio, each patient is treated as an individual. Following a comprehensive assessment your physiotherapist will present the best treatment options available to you. Most clients we see with a meniscal tear do improve with a course of physiotherapy; surgery is rare.

The best solution for you will vary depending on your own individual circumstances. There are a number of factors that will determine your treatment:

• Your age
• Your overall health and medical history
• The size and location of the tear
• Your pre-injury activity levels
• How well you can tolerate specific medications, procedures, and therapies
• The length of time it will take to heal
• Your opinion or preference

Physiotherapy for Meniscal Tears

Most meniscal tears improve with time and physiotherapy. Your physiotherapist at Complete will provide you with a tailored regime based on your personal profile.

This will often include:

• Activity modification – advice on rest and activity modification allowing the pain to settle.
• Pain management – ice can be effective in reducing pain when applied to the affected area. Some of our physiotherapists may use acupuncture as an adjunct as part of your treatment programme. You may also benefit from taking some anti-inflammatory medication.
• Patient education – it is important to understand your condition and to be active in your recovery. You will be given a clear explanation of the diagnosis and any other underlying causes, and we will discuss what is required to address these issues and reach your goals.
• Range of movement exercises and muscle stretches – your physiotherapist will assess your movement and apply the necessary techniques to normalise your joint and muscle range of movement. You will also likely be given range of movement and stretching exercises to do at home.
• Manual therapy – your physiotherapist may use ‘hands on’, manual therapy such as joint mobilisation techniques, massage or soft tissue release techniques to the surrounding muscles. This will help improve movement and reduce muscle stiffness or soreness.
• Specific strengthening exercises – with a meniscal tear the muscles around the knee can become weakened increasing the risk of further injury. Your muscles also help to act as shock absorbers; having strong muscles can reduce the amount of stress on your bone and articular cartilage. Your physiotherapist will design a safe resistance training program to ensure all your muscle groups are strong and working in synergy, to aid your recovery and prevent recurrence of injury.
• Balance and proprioception – this will involve balance and coordination retraining exercises which will help you return to full function and reduce the chance of reinjury.
  
• Functional and sports specific training – once your pain, strength, and range of movement have improved, functional and sport-specific training can help you safely resume more demanding activities and get you back to playing the sports that you love and reduce your chance of future injury.

Throughout your treatment at Complete Physio, we will keep revisiting your personal goals, so that we maintain the focus on making your life easier and ensuring that you feel supported and involved in your rehab process. We are dedicated to getting you back to full function and we have the correct skills and knowledge within the practice to ensure this goal is achieved.

What if my pain and symptoms don’t improve?

Ultrasound Guided Injections for Meniscal Tear

Often the pain associated with a meniscal tear is not coming from the tear itself but inflammation of the joint lining. The lining of the joint is called the synovium. When the synovium becomes inflamed it is called ‘synovitis’. Diagnostic ultrasound is the best way of diagnosing synovitis.

At Complete, we will always perform a diagnostic ultrasound of your knee before we consider injection therapy for a meniscal tear. This also helps us target the correct area of the knee with an injection. We do not charge extra for the ultrasound prior to injection.

Types of injection suitable for Meniscal Tears

1) Steroid injection for Meniscal Tears
If pain persists, then a steroid injection may be required. A mixture of local anaesthetic and corticosteroid (a potent anti-inflammatory) is injected under the guidance of a real time ultrasound scan. This is to ensure the affected area is accurately targeted. Research has shown that guided injections are more accurate and are more effective at reducing pain than landmark guided injections.

2) Hyaluronic Acid injection for Meniscal Tears

Hyaluronic acid is not a drug, it is classified as a medical device. It has no side effects and is an alternative to steroid. It does have anti-inflammatory properties but is not a strong anti-inflammatory like steroid. It works by lubricating the knee joint and improving the shock absorbing properties of the joint. The products we use are called Ostenil Plus and Durolane. These have the highest molecular weight of hyaluronic acid on the market. They can be used as a one-off injection, or repeated.

If you have been diagnosed with a meniscal cyst, an ultrasound guided aspiration and steroid injection can be an effective treatment option. This procedure involves ‘sucking’ the fluid out of the cyst and injecting steroid to stop it returning.

Injection therapy should not be used as a stand-alone treatment. For the best, long-term results it is important that you use the pain relieving effects of the injection to commence a programme of physiotherapy within 2 weeks.

If you would like more information about injection therapy, or would like to book an appointment, please contact us on 020 7482 3875 or email injections@complete-physio.co.uk.