1. Meniscal Tears By :Mehdi Masumi

2. Objectives You will be able to identify the two menisci in the knee You will be able to identify the two menisci in the knee You will know the most common mechanisms of meniscal tears You will know the most common mechanisms of meniscal tears You will be able to recognize and evaluate a meniscal tear You will be able to recognize and evaluate a meniscal tear You will know the proper treatments and rehabilitation for a meniscal tear You will know the proper treatments and rehabilitation for a meniscal tear You will understand the requirements for an athlete to return to play You will understand the requirements for an athlete to return to play You will learn various stretches and strengthening techniques for prevention You will learn various stretches and strengthening techniques for prevention

3. The Knee Joint The knee joint has two menisci, a lateral and medial The knee joint has two menisci, a lateral and medial They are fibrous cartilage They are fibrous cartilage They rest on top of the tibia in shallow indentations They rest on top of the tibia in shallow indentations The lateral meniscus is on the outside of your knee and the medial the inside The lateral meniscus is on the outside of your knee and the medial the inside

4. Functions of the menisci Aid in lubrication and nutrition of the joint Aid in lubrication and nutrition of the joint Act as shock absorbers Act as shock absorbers Evenly distribute weight throughout the knee Evenly distribute weight throughout the knee Allows for smoother motions between the femur and tibia Allows for smoother motions between the femur and tibia

5. The inner 2/3 of the menisci are avascular (without blood supply) The inner 2/3 of the menisci are avascular (without blood supply) The remaining outer 1/3 is vascular (with blood supply) The remaining outer 1/3 is vascular (with blood supply)

6. Mechanisms of injury An acute twisting injury from impact during a sport An acute twisting injury from impact during a sport Usually the foot stays fixed on the ground and the rest of body rotates Usually the foot stays fixed on the ground and the rest of body rotates Getting up from a squatting or crouching position Getting up from a squatting or crouching position Loading the knee from a fixed position Loading the knee from a fixed position

7. Injuring the meniscus There are several types of tears There are several types of tears Vertical Vertical Radial Radial Horizontal Horizontal Degenerate Degenerate Complex Complex Horn Horn A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of the knee A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of the knee The lateral meniscus is not attached as firmly to the tibia as the medial meniscus, making it less likely to become injured The lateral meniscus is not attached as firmly to the tibia as the medial meniscus, making it less likely to become injured

8. Meniscal injury stats Meniscal injuries occur in 15% of ACL injuries Meniscal injuries occur in 15% of ACL injuries 80% of patients with a history of ACL tears will likely tear their meniscus with incidences of instability of the knee 80% of patients with a history of ACL tears will likely tear their meniscus with incidences of instability of the knee 70.7% of meniscal injuries are to the medial meniscus 70.7% of meniscal injuries are to the medial meniscus Almost all meniscal injuries ages 20 and under are sports related 11 out of 12 cases Almost all meniscal injuries ages 20 and under are sports related 11 out of 12 cases Ages 20-29, 64.5% were sports related Ages 20-29, 64.5% were sports related Ages 30-39, 30.6% were sports related Ages 30-39, 30.6% were sports related Ages 40-49 and 50-59 only 19.6% and 14.3% were sports related Ages 40-49 and 50-59 only 19.6% and 14.3% were sports related

9. What to look for? Not all meniscal tears are symptomatic Not all meniscal tears are symptomatic If there are symptoms you could look for: If there are symptoms you could look for: Swelling Swelling Pain along the joint line (tenderness) Pain along the joint line (tenderness) Pain when squatting, kneeling or pivoting Pain when squatting, kneeling or pivoting Locking of the knee Locking of the knee Loss of full knee extension Loss of full knee extension

10. How can the coach help? If there is a possible meniscal tear 80-90% of the time an athlete will remember the mechanism of the injury and may report a “pop” or a “snap” If there is a possible meniscal tear 80-90% of the time an athlete will remember the mechanism of the injury and may report a “pop” or a “snap” You could ask the athlete if there is pain when weight bearing, or bending of the knee You could ask the athlete if there is pain when weight bearing, or bending of the knee You could also ask the athlete if they are having any locking in their knee or trouble extending the knee all the way You could also ask the athlete if they are having any locking in their knee or trouble extending the knee all the way

11. When there is a meniscal injury As a coach in the event of a meniscal injury you should As a coach in the event of a meniscal injury you should Ice the area in pain Ice the area in pain Limit movement of the knee joint (rest) Limit movement of the knee joint (rest) Keep weight bearing limited to a tolerable level of pain for the injured knee Keep weight bearing limited to a tolerable level of pain for the injured knee Sometimes a splint can be applied for comfort Sometimes a splint can be applied for comfort

12. Rehabilitation options There are two common ways that a meniscal tear can be repaired surgically There are two common ways that a meniscal tear can be repaired surgically There is also a non surgical option because the menisci are partially vascular they have the ability to heal themselves There is also a non surgical option because the menisci are partially vascular they have the ability to heal themselves

13. Why choose surgery? Surgery is usually advised for a few different reasons Surgery is usually advised for a few different reasons The location of the tear, if the tear is in a avascular zone it will most likely not heal itself The location of the tear, if the tear is in a avascular zone it will most likely not heal itself If the tear is longer than 5-8mm If the tear is longer than 5-8mm If the pain limits activities of daily living If the pain limits activities of daily living Or if the individual is not happy with their level of function Or if the individual is not happy with their level of function

14. Surgical techniques The more common technique is arthroscopic partial menisectomy, which consists of removing the torn fragment of the meniscus The more common technique is arthroscopic partial menisectomy, which consists of removing the torn fragment of the meniscus This reduces irritation, but can effect the weight distribution in the knee This reduces irritation, but can effect the weight distribution in the knee The other option is an arthroscopic repair, which requires suturing the meniscus back together The other option is an arthroscopic repair, which requires suturing the meniscus back together This option attempts to conserve the meniscus in hopes of preventing the early onset of arthritis This option attempts to conserve the meniscus in hopes of preventing the early onset of arthritis

15. Road to recovery Whether you choose the surgical or conservative approach, the rehabilitation is similar Whether you choose the surgical or conservative approach, the rehabilitation is similar The rehabilitation time frames can vary depending on the individual and the severity of the tear The rehabilitation time frames can vary depending on the individual and the severity of the tear The protocols may vary depending on the surgical approach and physician. A common protocol may include the following The protocols may vary depending on the surgical approach and physician. A common protocol may include the following

16. Steps to recovery The patient may be full weight bearing right after the surgery with or without crutches The patient may be full weight bearing right after the surgery with or without crutches Initial symptoms can be reduced using certain modalities and manual techniques Initial symptoms can be reduced using certain modalities and manual techniques Stretching/ flexibility exercises focusing on hamstrings, quadriceps, hip flexors, hip adductors and calf muscles Stretching/ flexibility exercises focusing on hamstrings, quadriceps, hip flexors, hip adductors and calf muscles Strengthening Strengthening Balance training Balance training Dynamic exercises/plyometrics Dynamic exercises/plyometrics

17. Initial physical therapy The first few sessions of physical therapy may consist more of modalities and some manual techniques to address inflammation, pain and ROM such as: The first few sessions of physical therapy may consist more of modalities and some manual techniques to address inflammation, pain and ROM such as: Heat/ice Heat/ice Ultrasound Ultrasound Electrical stimulation Electrical stimulation Manual stretching Manual stretching Scar and patella mobilizations Scar and patella mobilizations Passive range of motion for full knee flexion and extension Passive range of motion for full knee flexion and extension Retrograde massage to decrease swelling Retrograde massage to decrease swelling

18. Once pain and swelling are reduced the sessions mainly focus on increasing the strength and flexibility of the lower extremity as tolerated Once pain and swelling are reduced the sessions mainly focus on increasing the strength and flexibility of the lower extremity as tolerated The progression will vary depending on the individual The progression will vary depending on the individual Some examples of stretching and strengthening exercises are illustrated in the following slides Some examples of stretching and strengthening exercises are illustrated in the following slides

19. Stretching Hamstrings Hamstrings Quadriceps Quadriceps Calf muscles Calf muscles

20. Stretching continued Hip flexors Hip flexors Hip adductors Hip adductors

21. Strengthening Focusing on strengthening the muscles around the knee is essential in rehabilitation Focusing on strengthening the muscles around the knee is essential in rehabilitation Quad sets Straight leg raises (in all planes) Quad sets Straight leg raises (in all planes) Heel raises Leg Curl Heel raises Leg Curl Leg extension Leg extension

22. Balance Balance can sometimes be compromised after an injury or surgery Balance can sometimes be compromised after an injury or surgery Here are some balance exercises that can help Here are some balance exercises that can help

23. Dynamic exercises/plyometrics Progression to more dynamic sports specific exercises helps with the transition back into sports Progression to more dynamic sports specific exercises helps with the transition back into sports

24. Return to play This can vary widely from athlete to athlete This can vary widely from athlete to athlete When the athlete can participate in sport specific exercises without pain or weakness When the athlete can participate in sport specific exercises without pain or weakness Full ROM is apparent in the injured knee Full ROM is apparent in the injured knee Collaborate decision between athlete, physical therapist and physician Collaborate decision between athlete, physical therapist and physician

25. Prevention The prevention of meniscal tears is very similar to the rehabilitation The prevention of meniscal tears is very similar to the rehabilitation Research has shown that more flexible and stronger joints are less likely to get injured Research has shown that more flexible and stronger joints are less likely to get injured The athlete would continue stretching and strengthening the lower extremities The athlete would continue stretching and strengthening the lower extremities

26. Bibliography Learmonth, DJA. “Aspects of the knee: meniscal injury and surgery.” Trauma. 2000. Vol. 2 p. 223-230 Gilbert, Rob. Ashwood, Neil. “Meniscal repair and replacement: a review of efficacy.” Trauma. 2007. Vol. 9 p. 189-194 Lento, Paul. Akuthota, Venu. “Meniscal injuries: A critical review.” Journal of Back and Musculoskeletal Rehabilitation. 2000. Vol. 15 p. 55-62 Boyd, Kevin. Myers, Peter. “Meniscus preservation; rationale, repair techniques and results.” The Knee. March 2003. Vol. 10 Iss. 1 p. 1-11 Brindle, Timothy. Nyland, John. Johnson, Darren. “The Meniscus: Review of Basic Principles With Application of Surgery and Rehabilitation.” Journal of Athletic Training. Apr-Jun. 2001. Vol. 36 p. 160-169 Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 Iss. 2 p. 143-149 Magee, David. “Orthopedic Physical Assessment 2 nd edition.” Philadelphia: W.B. Saunders Company, 1992