Meniscal injury of the knee
- Dennis A Cardone, DO
Dennis A Cardone, DO
- Associate Professor of Orthopedic Surgery
- Chief, Division of Primary Care Sports Medicine
- NYU Langone Medical Center
- Bret C Jacobs, DO, MA
Bret C Jacobs, DO, MA
- Clinical Assistant Professor of Orthopedic Surgery
- Division of Primary Care Sports Medicine
- NYU Langone Medical Center
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Meniscal injuries of the knee are common. Acute meniscal tears occur most often from twisting injuries; chronic degenerative tears occur in older patients and can occur with minimal twisting or stress. Tears are classified as partial or complex; anterior, lateral, or posterior; traumatic or degenerative; and horizontal, vertical, radial, "parrot-beak," or "bucket handle" .
Left untreated, large complex tears can impair smooth motion of the knee, cause joint effusions, and may lead to premature osteoarthritis. Meniscal injuries can occur in isolation or in association with collateral or cruciate ligament tears. (See "Medial collateral ligament injury of the knee" and "Anterior cruciate ligament injury".)
The diagnosis and treatment of meniscal injuries will be reviewed here. Undifferentiated knee pain in the adult, physical examination of the knee, and other specific knee injuries are discussed separately. (See "Approach to the adult with unspecified knee pain".)
The two menisci contained within the knee joint are crescent-shaped pads of fibrocartilage located between the femoral condyles and the tibial plateaus (figure 1 and figure 2) . They aid in dissipating loading forces placed on the knee, stabilizing the knee during rotation, and lubricating the knee joint.
In cross section, the medial and lateral menisci are wedge-shaped with the thicker portion along the joint periphery, where they attach to the joint capsule of the knee (sometimes referred to as root attachments). The medial meniscus is firmly attached to the medial collateral ligament; the lateral meniscus is not rigidly attached to the lateral collateral ligament and therefore more mobile. This may contribute to the lower injury rate of the lateral meniscus.
- Binfield PM, Maffulli N, King JB. Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes. Injury 1993; 24:557.
- Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed, WB Saunders, Philadelphia 1999.
- Smith BW, Green GA. Acute knee injuries: Part I. History and physical examination. Am Fam Physician 1995; 51:615.
- Jackson JL, O'Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med 2003; 139:575.
- Frobell R, Cooper R, Morris H, Arendt E. Acute knee injuries. In: Clinical Sports Medicine, 4th ed, Brukner P, Khan K (Eds), McGraw-Hill, 2012. p.634.
- Francavilla ML, Restrepo R, Zamora KW, et al. Meniscal pathology in children: differences and similarities with the adult meniscus. Pediatr Radiol 2014; 44:910.
- Scholten RJ, Devillé WL, Opstelten W, et al. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract 2001; 50:938.
- Konan S, Rayan F, Haddad FS. Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc 2009; 17:806.
- Dzoleva-Tolevska R, Poposka A, Samardziski M, Georgieva D. Comparative analysis of diagnostic methods in meniscal lesions. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2013; 34:79.
- Yan R, Wang H, Yang Z, et al. Predicted probability of meniscus tears: comparing history and physical examination with MRI. Swiss Med Wkly 2011; 141:w13314.
- Hoppenfeld S. Physical examination of the knee. In: Physical examination of the spine and extremities, Prentice Hall, Upper Saddle River 1976. p.171.
- Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am 2005; 87:955.
- Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med 2009; 19:9.
- Solomon DH, Simel DL, Bates DW, et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001; 286:1610.
- Ockert B, Haasters F, Polzer H, et al. [Value of the clinical examination in suspected meniscal injuries. A meta-analysis]. Unfallchirurg 2010; 113:293.
- Lee SY, Jee WH, Kim JM. Radial tear of the medial meniscal root: reliability and accuracy of MRI for diagnosis. AJR Am J Roentgenol 2008; 191:81.
- Bomberg BC, McGinty JB. Acute hemarthrosis of the knee: indications for diagnostic arthroscopy. Arthroscopy 1990; 6:221.
- Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br 1993; 75:945.
- Shetty AA, Tindall AJ, James KD, et al. Accuracy of hand-held ultrasound scanning in detecting meniscal tears. J Bone Joint Surg Br 2008; 90:1045.
- Park GY, Kim JM, Lee SM, Lee MY. The value of ultrasonography in the detection of meniscal tears diagnosed by magnetic resonance imaging. Am J Phys Med Rehabil 2008; 87:14.
- Shanbhogue AK, Sandhu MS, Singh P, et al. Real time spatial compound ultrasound in the evaluation of meniscal injuries: a comparison study with conventional ultrasound and MRI. Knee 2009; 16:191.
- Wareluk P, Szopinski KT. Value of modern sonography in the assessment of meniscal lesions. Eur J Radiol 2012; 81:2366.
- Cook JL, Cook CR, Stannard JP, et al. MRI versus ultrasonography to assess meniscal abnormalities in acute knees. J Knee Surg 2014; 27:319.
- Alizadeh A, Babaei Jandaghi A, Keshavarz Zirak A, et al. Knee sonography as a diagnostic test for medial meniscal tears in young patients. Eur J Orthop Surg Traumatol 2013; 23:927.
- Brimmo OA, Smith PA, Cook CR, et al. Sonographic diagnosis of an acute lateral meniscus tear in a division I collegiate American football player. J Knee Surg Rep 2015; 1:57.
- Gray SD, Kaplan PA, Dussault RG. Imaging of the knee. Current status. Orthop Clin North Am 1997; 28:643.
- Bureau NJ, Kaplan PA, Dussault RG. MRI of the knee: a simplified approach. Curr Probl Diagn Radiol 1995; 24:1.
- Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 2007; 84:5.
- Boden SD, Davis DO, Dina TS, et al. A prospective and blinded investigation of magnetic resonance imaging of the knee. Abnormal findings in asymptomatic subjects. Clin Orthop Relat Res 1992; :177.
- Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 2008; 359:1108.
- Zanetti M, Pfirrmann CW, Schmid MR, et al. Patients with suspected meniscal tears: prevalence of abnormalities seen on MRI of 100 symptomatic and 100 contralateral asymptomatic knees. AJR Am J Roentgenol 2003; 181:635.
- Bouguennec N, Meyer A, Graveleau N. Localized form of pigmented villonodular synovitis of the knee: the meniscal mime. Orthop Traumatol Surg Res 2014; 100:251.
- Venkatachalam S, Godsiff SP, Harding ML. Review of the clinical results of arthroscopic meniscal repair. Knee 2001; 8:129.
- McNally EG, Nasser KN, Dawson S, Goh LA. Role of magnetic resonance imaging in the clinical management of the acutely locked knee. Skeletal Radiol 2002; 31:570.
- Helmark IC, Neergaard K, Krogsgaard MR. Traumatic knee extension deficit (the locked knee): can MRI reduce the need for arthroscopy? Knee Surg Sports Traumatol Arthrosc 2007; 15:863.
- Ménétrey J, Siegrist O, Fritschy D. Medial meniscectomy in patients over the age of fifty: a six year follow-up study. Swiss Surg 2002; 8:113.
- Suter LG, Fraenkel L, Losina E, et al. Medical decision making in patients with knee pain, meniscal tear, and osteoarthritis. Arthritis Rheum 2009; 61:1531.
- Boyd KT, Myers PT. Meniscus preservation; rationale, repair techniques and results. Knee 2003; 10:1.
- Howell JR, Handoll HH. Surgical treatment for meniscal injuries of the knee in adults. Cochrane Database Syst Rev 2000; :CD001353.
- Yoon KH, Park KH. Meniscal repair. Knee Surg Relat Res 2014; 26:68.
- Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: significance, diagnosis, and treatment. Am J Sports Med 2014; 42:3016.
- Ericsson YB, Dahlberg LE, Roos EM. Effects of functional exercise training on performance and muscle strength after meniscectomy: a randomized trial. Scand J Med Sci Sports 2009; 19:156.
- Morrissey MC, Goodwin PC, Klarneta M, et al. Factors related to early recovery rate after partial knee meniscectomy. Orthopedics 2008; 31:752.
- Stensrud S, Risberg MA, Roos EM. Knee function and knee muscle strength in middle-aged patients with degenerative meniscal tears eligible for arthroscopic partial meniscectomy. Br J Sports Med 2014; 48:784.
- Herrlin S, Hållander M, Wange P, et al. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc 2007; 15:393.
- Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016; 354:i3740.
- Stensrud S, Risberg MA, Roos EM. Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a randomized controlled trial. Am J Phys Med Rehabil 2015; 94:460.
- Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369:2515.
- Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Br J Sports Med 2015; 49:1229.
- Mordecai SC, Al-Hadithy N, Ware HE, Gupte CM. Treatment of meniscal tears: An evidence based approach. World J Orthop 2014; 5:233.
- Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014; 186:1057.
- Weiss CB, Lundberg M, Hamberg P, et al. Non-operative treatment of meniscal tears. J Bone Joint Surg Am 1989; 71:811.
- Chatain F, Adeleine P, Chambat P, et al. A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up. Arthroscopy 2003; 19:842.
- Fabricant PD, Jokl P. Surgical outcomes after arthroscopic partial meniscectomy. J Am Acad Orthop Surg 2007; 15:647.
- Stein T, Mehling AP, Welsch F, et al. Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med 2010; 38:1542.
- MECHANISM AND PRESENTATION
- PHYSICAL EXAMINATION
- General knee function
- Provocative testing
- Detection of an effusion
- Plain radiographs
- Magnetic resonance imaging
- DIFFERENTIAL DIAGNOSIS
- Initial management
- Approach to treatment and orthopedic referral
- Persistent symptoms
- - Knee "locking"
- Arthroscopic or open surgery
- Chronic degenerative meniscal injury
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS