Meniscus Injuries: Rehabilitation, Resect, or Repair?

The knee is made of two main weight bearing bones, the femur on top and tibia below. The top of the tibia forms a table top type structure or ‘plateau’ that creates a stable base to support the lower extremity’s weight. The tibial plateau is divided into a ‘lateral’ outer half and a ‘medial’ inner half. Each half contains its own meniscus, a ‘c-shaped’ structured design to act as a cushion and shock-absorber between the two hard bones.

The inner or medial half of the tibia is designed to accompany more weight, commonly experiencing 60% of total forces of the given extremity. The corresponding medial meniscus is larger with more robust tissue, with the overall c-shape of the cushion larger from front to back. The medial meniscus is also well-stabilized by secondary ligaments, offering less motion and more support for weight bearing. With age, the ‘posterior’ or back portion of the meniscus undergoes natural wear and tear and breakdown. This leads to a typical pattern of posteromedial meniscus tears which are an expected finding with age and early arthritis. While such injuries used to be routinely treated with arthroscopic surgery, newer data has suggested that surgery for a posterior-medial meniscus tear often results in NO BENEFIT versus rehabilitation, and can sometimes even speed up or worsen the formation of arthritis.

By contrast, the ‘lateral’ or outside meniscus is smaller and highly mobile. This configuration makes the lateral meniscus much more important for maintaining the health of the lateral or outside portion of the knee. Tears of the lateral meniscus are poorly tolerated when compared to the medial side, often resulting in progressive symptoms and worsening breakdown or arthritis. Especially in younger or more active individuals, lateral meniscus tears should be monitored closely to prevent progressive symptoms.

While every meniscus injury should be evaluated on an individual basis, meniscus surgery is usually recommended with patients experiencing so-called 'mechanical symptoms.' These include feelings of catch and locking, buckling, or giving-way of the extremity when walking.

Surgical management is often also recommended with certain injury patterns, such as a flipped tear that can become trapped or incarcerated during normal bending of the knee joint. Many meniscus tear patterns exist, and are best evaluated with a physician-ordered MRI of the knee. Tears on the periphery or 'red zone' of the meniscus, have much greater healing potential due to a robust blood-supply, where inner or 'white zone' tears have much less chance of healing. 

When surgery is indicated, the decision must be made to attempt a repair versus a resection or shaving out of the torn tissue.  As a general rule, meniscus injuries in younger patients are more likely to require surgery, and a repair should always be attempted in the hopes of preserving as much of the joints natural cushion as possible, preventing arthritis at a young age. By contrast, older patients with less robust tissue, may benefit from a resection, which does remove natural tissue, but allow for a much quicker recovery. Ultimately, a treatment plan for a meniscus injury, surgical or otherwise, should be based upon an individualized discussion between patient and physician.

Author
Elan Golan, MD

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