1. MEDIAL MENISCUS INJURY
MUSKAN RASTOGI
17/FAS/BPT/019
BPT SEM 7A

2. CONTENTS Anatomy of menisci Functions of menisci Types of menisci
Biomechanics {Screw-home mechanism}
Classification
Mechanism of injury
Predisposing factors
Clinical features
Symptoms
Signs
Investigations and Examination
Differential Diagnosis
Treatment

3. ANATOMY OF MENISCI Fibrocartilaginous discs Shaped like crescents
Placed on tibial condyles
Each meniscus has following
2 ends- anterior and posterior ends
2 borders- outer and inner border
2 surfaces- upper & lower surfaces , peripheral part and inner part

4. FUNCTIONS OF MENISCI Stability of joint Helps in weight transmission
Shock absorber
Increase contact area
Supply nutrition to articular cartilage
Helps in locking mechanism
Assists and controls gliding and sliding motion of knee
Proprioceptive impulses

5. tYPES Lateral menisci Medial menisci semicircular wider from behind
Posterior fibers of anterior end continuous with transverse ligament
Peripheral margin adherent to deep part of tibial collateral ligament

6. SCREW-HOME MECHANISM
The "screw-home" mechanism, considered to be a key element to knee stability, is the rotation between the tibia and femur and occurs at the end of knee extension, between full extension (0o) and 20o of knee flexion. The tibia rotates internally during the open chain movements (swing phase) and externally during closed chain movements (stance phase). External rotation occurs during the terminal degrees of knee extension and results in tightening of both cruciate ligaments, which locks the knee. The tibia is then in the position of maximal stability with respect to the femur.

7. MEDIAL MENISCUS INJURY
Injury to the medial meniscus of the knee
The medial meniscal injury is more common than lateral meniscal injury because lateral meniscus has:-
small diameter
Thicker periphery
More mobility
Attachment to both cruciate ligaments
Stabilization to femoral condyle by popliteus

8. CLASSIFICATION O’CONNOR CLASSIFICATION SMILLE’S CLASSIFICATION
LONGITUDNAL TEARS
peripheral attachment tear 10%
complete tears 23%
segmental tear 2%
HORIZONTAL TEARS- 48% posterior anterior and middle
CYSTIC DEGENERATION- 2%
CONGENITAL ANOMALIES 5%
DEGENERATIVE LESIONS
Based on tear pattern found during surgery
A. Longitudinal Tear
B. Radial Tear
C. Horizontal Tear
D. Bucket Handle Tear
E. Parrot Beak Tear
F. Segmental/Flap tear

9. THE ISAKOS CLASSIFICATION OF MENISCAL TEARS

10. Tear of meniscus from periphery and its longitudinal splitting
Excessive force leads to
Trapping of posterior horn in this position by sudden extension of knee
Posterior segment of medial meniscus is forced towards joint’s center
Internal Rotation of femur over tibia with knee in flexion
MECHANISM OF INJURY

11. Pre-disposing factors
Abnormal menisci shape
Chronic ligament laxity

12. Clinical features
Pain
Limp
Locking
Swelling
Painful Restricted Knee Movement

13. symptoms ON INITIAL INJURY FURTHER INCIDENTS
Pain on inner side of knee
History of locking
Swelling over knee
4. Recovery after initial episode
FURTHER INCIDENTS
Knee periodically gives trouble
Locking history may or may not be present
Unlocking (Pathognomonic)
Click
Feeling something moving within the joint
Pain on inner side of knee
BETWEEN INCIDENTS
Knee is normal

14. signs
Locking ve
McMurray’s Test ve
Apley’s Squat test ve
Duck Waddle test ve
Steinmann’s Sign ve
Helfet Sign ve
Quadriceps Atrophy ve
Medial Joint line tenderness ve

15. THESSALY TEST examination Test Position: Standing.
Performing the Test:
Have the patient stand on the test leg with the knee bent to 20 degrees of flexion (the opposite leg is flexed behind the patient).
The patient may place his/her hands on the hands of the examiner for balance during the test.
The patient then rotates the knee medially and laterally 3 times each direction.
A positive test occurs when the patient experiences joint line discomfort or if locking/catching occurs.

16. Medial joint line tenderness
Test Position: Sitting. Performing the Test: With the patient sitting at the edge of the table and the patient's knees bent 90 degrees, palpate the lateral and medial tibiofemoral joint line. A positive test occurs when pain is produced.

17. MCMURRAY TEST Test Position: Supine. Performing the Test:
Place the patient's tested leg in maximal hip and knee flexion.
While palpating the joint line, apply a valgus force to the knee, while simultaneously externally rotating and extending the knee completely.
Place the tested leg back in maximal hip and knee flexion. While palpating the joint line, apply a varus force to the knee, while simultaneously internally rotating and extending the knee completely.
A positive test occurs when pain or clicking/thudding is produced

18. Apley’s grinding test
Test position: prone position with the knee flexed to 90 degrees.
Performing the test:
The patient's thigh is rooted to the examining table with the examiner's knee.
The examiner laterally and medially rotates the tibia, combined first with distraction, while noting any excessive movement, restriction or discomfort.
The process is then repeated using compression instead of distraction.
If rotation plus distraction is more painful or shows increased rotation relative to the normal side, the lesion is most likely to be ligamentous.
If the rotation plus compression is more painful or shows decreased rotation relative to the normal side, the lesion is most likely to be a meniscus injury.

19. investigations
Radiography
Arthroscopy

20. Arthrography
MRI

21. DIFFERENTIAL DIAGNOSIS
Osteochondritis dissecans
Proximal fracture of tibia
ACL tear

22. Steroid injections RICE protocol Arthroscopy Meniscectomy management
CONSERVATIVE MANAGEMENT
SURGICAL MANAGEMENT
Steroid injections
RICE protocol
Arthroscopy
Meniscectomy

23. PRE-OPERATIVE PHYSIOTHERAPY
Aim to make rehabilitation programme more effective and faster recovery.
Measures:-
Quadriceps exercises during swelling
Knee swinging for early return of function
Raised SLR to strengthen knee
To improve posterior stability of knee resistive exercises of hamstrings and calf muscles

24. POST-OPERATIVE PHYSIOTHERAPY
During first five days
a.Thermotherapy to reduce pain
b. To reduce effusion – quadriceps exercises, resistive ankle and foot exercise,SLR
c. To prevent reflex inhibition- - sustained quadriceps exercises with 5-10 sec hold
d. Relaxed knee swinging to improve ROM
During 5-15 days
a. Above measures are made more vigorous
b. Knee rachet and pedo cycle regime
c. Ambulation with supported or full weight bearing
d. 90 degree knee movements
During 2-3 weeks
a. 120 degree knee movements
b. Should be able to stand alone at unaffected leg
c. PRE to Quadriceps
d. Floor Squatting , Cross leg sitting, Prone kneeling
e. Ambulation with minimum or no support
During 3-5 weeks a. Isotonic knee exercises
b. ART to quadriceps c. Balancing to improve Proprioception d. Gait training e. Patient is permitted to resume work
After 6 weeks
Return to sports and allowed for jogging, running, jumping, hopping

25. Some exercises related to medial meniscal injury

26. HOPE SO I HAVE NOT ERODED YOUR PATIENCE!