Knee Injury - Meniscus Cartilage Tear

The knee joint

The diagrams below illustrate the knee joint.

Meniscus cartilage injury

The lateral meniscus (on the outside of the knee) is more commonly damaged than the medial meniscus (the one nearest to the other knee).

The knee is commonly injured in sports, especially rugby, football and skiing. You may tear a meniscus by a forceful knee movement whilst you are weight-bearing on the same leg. The classical injury is for a footballer to rotate (twist) the knee whilst the foot is still on the ground, for example, whilst dribbling round a defender. Another example is a tennis player who twists to hit a ball hard, but with the foot remaining in the same position. The meniscus may tear fully or partially. How serious the injury is depends on how much is torn and the exact site of the tear.

Meniscus tears may also occur without a sudden severe injury. In some cases a tear develops due to repeated small injuries to the cartilage or to degeneration ('wear and tear') of the meniscus cartilage in older people. In severe injuries, other parts of the knee may also be damaged in addition to a meniscus tear. For example, you may also sprain or tear a ligament.

Meniscus cartilage does not 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 of a meniscus, tend not to heal.

What are the symptoms of a meniscus tear?

The symptoms of a meniscal injury depend on the type and position of the meniscal tear. Many people have meniscal tears without any knee symptoms, especially if they are due to wear and tear.

• Pain. The pain is often worse when you straighten the leg. If the pain is mild, you may be able to continue to walk. You may have severe pain if a torn fragment of meniscus catches between the tibia and femur. Sometimes, an injury that you had in the past causes pain months or years later, particularly if you injure the knee again.
• Swelling. The knee often swells within a day or two of the injury. Many people notice that their knee is slightly swollen for several months if the tear is due to degeneration.
• Knee function. You may be unable to straighten the knee fully. In severe cases you may not be able to walk without a lot of pain. The knee may 'lock' from time to time if the torn fragment interferes with normal knee movement. Some people notice a clicking or catching feeling when they walk. (A locked knee means that it gets stuck when you bend it and you can't straighten it without moving the leg with your hands.)

Note: A "clicking joint" (especially without pain) does not usually mean you have a meniscal tear.

For some people the symptoms of meniscus injury go away on their own after a few weeks. However, for most people the symptoms persist long-term, or flare up from time to time, until the tear is treated.

How is a meniscus tear diagnosed?

• The story and symptoms often suggest a meniscus tear. A doctor will examine the knee. Certain features of the examination may point towards a meniscus tear. For example, a doctor may bend the leg, then twist the leg slightly as he or she straightens the leg. During this movement, pain or a 'click' often indicates a meniscus tear.
• Your doctor may sometimes advise an X-ray of the knee. An X-ray will not show cartilage tissue, but it can check for any bone damage which might have also occurred with the injury.
• The diagnosis can be confirmed by an MRI scan of the knee (see separate leaflet called 'MRI Scan' for more detail) or by arthroscopy ('keyhole surgery' - see below.)

What is the treatment for a meniscus tear?

When you first injure your knee the initial treatment should follow the PRICE formula: protect, rest, ice, compression (with a bandage) and elevation. This, combined with painkillers, helps to settle the initial pain and swelling. Further treatment may then depend on the size of the tear, the severity of symptoms, how any persisting symptoms are affecting your life, your age and your general health.

Non-operative treatment

Small tears may heal by themselves in time, usually over about six weeks. Some tears which do not heal do not cause long-term symptoms once the initial pain and swelling subside, or cause only intermittent or mild symptoms. In these cases surgery may not be needed. You may be advised to have physiotherapy to strengthen the supporting structures of the knee such as the quadriceps and hamstring muscles.

Surgery

If the tear causes persistent troublesome symptoms then an operation may be advised. Unfortunately, only about 1 in 4 meniscal cartilage tears can be repaired by an operation. Most operations are done by arthroscopy (see below). The types of operations which may be considered include the following:

• The torn meniscus may be repaired and stitched back into place.
• In some cases repair is not possible and a small portion of the meniscus may be trimmed or cut out to even-up the surface.
• Occasionally, the entire meniscus is removed.
• Meniscus transplants have recently been introduced. The missing meniscal cartilage is replaced with donor tissue, which is screened and sterilised much in the same way as for other donor tissues such as for kidney transplants. These are more commonly performed in America than in the UK.
• There is a new operation in which collagen meniscal implants are inserted. The implants are made from a natural substance and allow your cells to grow into it so that the missing meniscal tissue regrows. This is not yet available at all hospitals.