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Meniscus Tear

by | Jan 2, 2023 | Musculoskeletal Injuries, Traumatic Injuries

Figure 1 A single leg shot.
Figure 1 A common mechanism of injury to a meniscus.

Meniscus Tear

Jan 2, 2023 | Musculoskeletal Injuries, Traumatic Injuries | 2 comments

Written by Megan Lisset Jimenez, DO

If you’re on the mats with little rest, then you’ve likely experienced some form of knee pain. If I had $1 for every time one of my teammates comes up to me before or after class, between rolls, or texted me “Doc, why does my knee hurt?”, I would probably have enough money to retire. Not really, but you get my point. An epidemiology study showed the knee is the most common joint affected in jiu jitsu (27.1% of injuries). The most frequent injuries to the knee in this study were meniscal tears, anterior cruciate ligament tears (ACL) and medial collateral ligament injuries (MCL).1 This article will focus on one of the most commonly injured structures, which is the meniscus.

  • Meniscus tears are extremely common. Among the general population, they have an annual incidence of 66 per 100,000 people.2
  • There is not much research regarding exercises that can specifically prevent meniscus tears.
  • Treatment can be non-surgical or surgical, depending on various factors
Continue Reading: 10min Read

Anatomy & Physiology

Even though it appears that the knee only moves in flexion and extension, there are far more planes of motion than meet the eye. In addition to these two motions there is also rotation and lateral movement (termed varus and valgus movement in medicine). The knee (Figure 2) consists of 4 main bones:

  1. Femur
  2. Tibia
  3. Fibula
  4. Patella

These bones form 3 joints in the knee:

  1. Tibiofemoral joint (the main knee joint)
  2. Patellofemoral joint (where the kneecap glides on the thigh bone)
  3. Tibiofibular joint (Mentioned here for completeness. It is less important in this discussion and less frequently injured compared to joints 1 & 2)

So, what holds these bones together? Extremely simplified, the predominant structures include the menisci and ligaments. There are 2 menisci called the medial meniscus (medial means inside) and lateral meniscus (lateral means outside). The main ligaments that people talk about are the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) (Figure 3). Our focus here is the tiny C shaped menisci (Figure 4).

You might be thinking: “how can these little structures cause such a big problem?” It is an excellent question. In the mid 1900s we used to remove a torn meniscus, and this led to rapid degeneration of the joint (in other words, early arthritis). The menisci provide shock absorption, increase joint congruity, and convert compressive forces provided by the body to tensile forces. Our menisci are thought to bear 40-70% of the load transmission across the joint. During walking, forces can go up to 300% body weight and during running, forces can exceed 4-8x that!3 So, I’d say these structures are quite important. For these reasons, us crazy Orthopaedic Surgeons spend a ton of time and energy trying to repair the meniscus whenever possible. More on this in the treatment section.

Figure 2 The knee joint.
Figure 2 The Knee Joint
Figure 3 Ligaments of the Knee
Figure 3 Ligaments of the Knee
Figure 4 Menisci of the Knee. Medial meniscus is shaded green while lateral meniscus is shaded orange.

Figure 4 Medial (shaded green) and Lateral (shaded orange) Menisci Viewed from Top.

Diagnosis
So, how do you know you have a meniscus tear? First, we look at injury mechanism. If you have a video of the injury, that can help your doctor in the diagnosis (if it occurred during a match or if your gym has cameras). The typical mechanism of injury is a twisting or pivoting injury. There will be associated swelling, stiffness, point tenderness over the inside or outside of the joint, and occasionally the athlete will notice some locking or catching. If you flex your knee and it “locks” or gets stuck bent, this may be an indication of meniscus tear blocking you from straightening the knee fully. This history in combination with the physical exam and diagnostic imaging are crucial for establishing the correct diagnosis. When you go to see your doctor, they will likely order x-rays to check for any fracture. Once this is done, the next step is magnetic resonance imaging (MRI) if there is high suspicion for meniscal pathology. Remember that every knee injury does NOT require an MRI. If your doctor doesn’t order an MRI, think of it as a blessing as they don’t think you did any significant damage based on the mechanism of injury and physical exam. Figure 5 shows MRI images of meniscus tears in 2 jiu jitsu athletes.
Figure 5 MR images of meniscal injuries. Green arrows show sites of injury. 5a and 5b are different views of a medial meniscus injury of one patient. 5c is a lateral meniscal injury of another patient.

Figure 5 MRIs of meniscal injuries. Green arrows show sites of injury. 5a and 5b are different views of a medial meniscus injury of one patient. 5c is a lateral meniscal injury of another patient.

Many times, meniscus tears occur in combination with an ACL tear. When an ACL tear occurs, there is often an audible “pop” at the time of the injury. ACL tears are typically caused by noncontact pivoting injuries and the presentation can look quite similar to an isolated meniscus tear. From experience, I have noticed that ACL tears tend to be more swollen than isolated meniscus tears. So, if you have significant swelling plus a loud pop, that gets an MRI almost always in my book. An experienced doc can often perform a physical exam and feel for a loose ACL, although this is not always possible with athletes who are very swollen or protecting the knee during examination. Figure 6 is a video that shows common knee exams used in the diagnosis of meniscus and ACL tears. Side note: there are many other physical exam tests for diagnosing various injuries of the knee. For the purpose of this video, we will just stick to the meniscus and commonly injured ligaments.
Figure 6 Knee Exam
Treatment

Conservative (that is, non-surgical) versus operative management is decided on a case-by-case basis. This depends on many factors including a patient’s age, body mass index (BMI), activity level, type of tear, and associated injuries. Conservative management consists of physical therapy. Operative management includes partial meniscectomy (fancy wording for removing the torn portion) versus repairing the meniscus. Degenerative tears are typically seen in older patients or young patients who waited to seek treatment and kept grinding away at the tear. These tears can often be treated nonoperatively. A randomized control trial by Katz et al compared patients over the age of 45 with some arthritis who were either treated operatively with meniscectomy or nonoperatively with physical therapy alone. They showed no difference at 12 month follow up, although there was a 30% crossover of patients from nonoperative treatment to operative treatment.4 These patients did the same as patients who had surgery immediately, which means that trying conservative care first in these degenerative tears is a great option. In addition to physical therapy a brace can be added if the patient would like one. There is limited research for or against the use of a brace, so they are seldomly used in my practice unless a patient really wants one. Contrary to popular belief, there is no literature to support the claim that braces cause weakness of the muscles surrounding the leg. So, if you’d like one and it doesn’t interfere with jiu jitsu (which they typically do) then go for it.

As previously discussed, there is commonly an ACL tear along with a meniscus tear following a substantial twisting type injury and a loud pop. In these cases, surgery is often recommended. ACL tears can be treated conservatively for older patients, particularly in athletes who perform straight line sports (ie: running, cycling, swimming). In my young jiu jitsu athletes with combined ACL and meniscus tears, I often recommend surgery to prevent recurrent injuries and the potential for further damage. For fixable meniscus tears in younger patients, I typically recommend early surgery (within 3-4 months) to avoid worsening the tear. When surgery is needed, I am a proponent of trying to fix every meniscus possible because it has been proven in the literature that removing meniscus results in rapid, deleterious effects on the joint. There are many techniques for meniscus repair. Figure 7 shows intraoperative pictures of the two jiu jitsu athletes whose MRIs are above. I was able to repair their menisci and they both returned to sport between 4-6 months post operatively.

Figure 7 Intraoperative pictures of torn menisci before and after repair.
Figure 7 Intraoperative Before and After
There are many rehabilitation protocols following meniscus repair and the literature does not agree on 1 single protocol.5 Because of this it will depend on your surgeon. I place my patients in a brace for 6 weeks and we start weight bearing in full extension along with range of motion exercises. Even though protocols vary, the literature supports return to play no earlier than 4-6 months following meniscus repair.6 While the earliest return to sport is 4-6 months, for some it can take longer. Reassuringly, 80% of athletes return to sport following meniscal repair. On the other side of the coin, if you have a meniscectomy (partial removal) then return to sport is quicker at about 2-6 weeks. A meniscectomy may be enticing because of the faster return to sport, but as I have cautioned throughout this article removing the meniscus comes with a lot of issues down the road. So, if you are younger and have a repairable meniscus tear, I recommend getting it fixed and taking your time with the rehab.
Prevention
This is a complex question with very little support from the literature. Specifically for the meniscus, there is not much research regarding exercises that can prevent its injury, however there are modifiable risk factors and nonmodifiable risk factors that affect our chances of a meniscal injury. Modifiable risk factors are those in which we can typically do something to change and include BMI<25, sports participation, and occupation. Nonmodifiable risk factors on the other hand are things out of our control and include age >60, male sex, leg alignment, discoid meniscus (an anatomical variant that some people have at birth), hyperlaxity, and certain tibia shapes.7 Knowing that none of us on here are willing to change our sport (myself included) and you likely want to keep your job, the biggest change for some of us is maintaining a healthy weight as several studies have shown a 5x increased risk of meniscus injury in people with a BMI > 25.8 While not much is known on exercises one can do to prevent a meniscal injury, knee pain in general is a different story. Chronic, annoying knee pain not associated with a ligamentous injury is typically due to weak hips, core, quadriceps, gluts, or more commonly: a combination of all 4. There is an easy, yet time consuming, fix for this which includes daily physical therapy (at home is fine) with little time away from the mats! I know, I know… I just made your day. You must do the therapy though if you want to keep training and get better. If not, then suck it up butter cup because that pain isn’t going anywhere without doing the work and strong recovery. I not only know this professionally but personally as well. It was my chiropractor who called me out on over-training, which I took to heart, and then made changes to my regimen and began scheduling in recovery time. This has allowed me to be virtually pain free from my old nagging overuse injuries. So, don’t forget to schedule rest and recovery for yourself.

Conclusion

Conclusion
Meniscus tears are commonly seen in all sports and jiu jitsu is no different. Remember that the majority of knee injuries do not require an MRI or surgery. It is important to reach out to a medical professional if you have any of the symptoms mentioned in this article. Sustaining a meniscus tear is not career ending, with a quicker return to sport than a combined ACL tear. Although there isn’t any literature supporting preventive exercises for meniscus tears, I do recommend keeping the lower extremities strong with physical therapy and cross training.

References

  1. Hinz M, Kleim BD, Berthold DP, Geyer S, Lambert C, Imhoff AB, Mehl J. Injury Patterns, Risk Factors, and Return to Sport in Brazilian Jiu Jitsu: A Cross-sectional Survey of 1140 Athletes. Orthop J Sports Med. 2021 Dec 20;9(12):23259671211062568. doi: 10.1177/23259671211062568. PMID: 34988235.
  2. Mordecai SC, Al-Hadithy N, Ware HE, Gupte CM. Treatment of meniscal tears: An evidence based approach. World J Orthop. 2014 Jul 18;5(3):233-41. doi: 10.5312/wjo.v5.i3.233. PMID: 25035825.
  3. Zhang, K.Y. et al.The relationship between lateral meniscus shape and joint contact parameters in the knee: a study using data from the Osteoarthritis Initiative. Arthritis Res Ther 16, R27 (2014). https://doi.org/10.1186/ar4455
  4. Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA, Mandl LA, Martin SD, Marx RG, Miniaci A, Matava MJ, Palmisano J, Reinke EK, Richardson BE, Rome BN, Safran-Norton CE, Skoniecki DJ, Solomon DH, Smith MV, Spindler KP, Stuart MJ, Wright J, Wright RW, Losina E. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. doi: 10.1056/NEJMoa1301408. Epub 2013 Mar 18. Erratum in: N Engl J Med. 2013 Aug 15;369(7):683. PMID: 23506518.
  5. O’Donnell K, Freedman KB, Tjoumakaris FP. Rehabilitation Protocols After Isolated Meniscal Repair: A Systematic Review. The American Journal of Sports Medicine. 2017;45(7):1687-1697. doi:10.1177/0363546516667578
  6. Blanchard ER, Hadley CJ, Wicks ED, Emper W, Cohen SB. Return to Play After Isolated Meniscal Repairs in Athletes: A Systematic Review. Orthop J Sports Med. 2020;8(11):2325967120962093. Published 2020 Nov 20. doi:10.1177/2325967120962093
  7. Adams BG, Houston MN, Cameron KL. The Epidemiology of Meniscus Injury. Sports Med Arthrosc Rev. 2021 Sep 1;29(3):e24-e33. doi: 10.1097/JSA.0000000000000329. PMID: 34398119.
  8. Gee SM, Tennent DJ, Cameron KL, Posner MA. The Burden of Meniscus Injury in Young and Physically Active Populations. Clin Sports Med. 2020 Jan;39(1):13-27. doi: 10.1016/j.csm.2019.08.008. PMID: 31767103.
  9. Figure 2 was obtained via commons copyright permission, Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014“. WikiJournal of Medicine1 (2). DOI:15347/wjm/2014.010. ISSN 2002-4436
  10. Figures 3 and 4 were obtained via public domain copyright. Henry Gray (1918). Anatomy of the Human Body.
  11. Other figures were created by author, patients involved gave full written consent complying with HIPAA guidelines.

2 Comments

  1. JON SERRANO
    JON SERRANO on January 3, 2023 at 1:32 am

    Very interesting article, Dr. Jimenez. It is helpful to know what factors we can address to decrease our injury risk, or to at least know that we are at increased risk in some case.

    Reply
    • Megan Jimenez
      Megan Jimenez on January 3, 2023 at 2:19 pm

      Thanks for the feedback Jon. I’ll be posting more videos on exercises and other tips for various body parts soon on my Instagram! Glad this was helpful.

      Reply

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