Meniscus Injuries

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The menisci are fibrocartilaginous structures situated on the tibial plateau both medially and laterally that help disperse the weight-bearing contact forces across the knee joint cartilage surfaces (Fig. 30-28). In the presence of a meniscus tear or the complete absence of a meniscus, focal stresses

Figure 30-27 Counterforce brace (Cho-Pat strap) can be effective in reducing symptoms of patellar tendinosis (jumper's knee).

Posterior cruciate ligament

Ligament of Wrisberg Ligament of Humphry

Popliteal tendon

Medial meniscus

Fibular collateral ligament

Popliteal hiatus (recess)

Lateral

Coronary ligament A (meniscotibial)

Popliteal tendon

Medial meniscus

Fibular collateral ligament

Popliteal hiatus (recess)

Lateral

Deep medial collateral ligament

Superficial medial collateral ligament

Capsule Transverse ligament

Anterior cruciate ligament

Deep medial collateral ligament

Superficial medial collateral ligament

Capsule Transverse ligament

Anterior cruciate ligament

Figure 30-27 Counterforce brace (Cho-Pat strap) can be effective in reducing symptoms of patellar tendinosis (jumper's knee).

increase. This in turn increases the loading of the hyaline cartilage and early progressive degenerative arthritis (Sherman, 1996). Meniscus tears can occur with axial loading but primarily occur because of twisting, cutting, or rotational forces. In older patients, meniscus tears may simply be a progression of the normal degenerative process. On physical examination, patients have pain over the medial or lateral joint line and may complain of snapping, popping, or catching within the knee (Greis et al., 2002a, 2002b). Varus or valgus loading may exacerbate pain as the meniscus is squeezed between the bony structures. Recurrent effusions may also represent intra-articular pathology. The most common test for meniscus injury is McMurray's test (Fig. 30-29). The knee is hyperflexed, stressed with varus or valgus load, as well as internally and externally rotated, as the knee is brought into full extension. More simply, the examiner uses the lower leg and tibia to try to trap the torn meniscus between the tibia and the femur through a full knee ROM. If the examiner feels a snapping or a pop along the joint-line and the patient simultaneously complains of pain, the test is considered positive and highly indicative of a meniscus tear. A single finding may raise suspicion of a tear but does not confirm its presence. Indeed, sensitivity of both findings, the pop and pain, is over 90%. MRI can be used to confirm the diagnosis or assist preoperative planning but should never replace a thorough physical examination.

Definitive treatment of meniscus pathology depends on the actual damage and pattern of the meniscus injury on MRI (Sherman, 1996; Greis et al., 2002a, 2002b) (Fig. 30-30). Depending on the pattern, the meniscus can either be reparable or nonreparable. Because of its essential role in sharing load and preventing the progression of degenerative arthritis, salvageable meniscus tears should always be repaired if possible. After debridement, patients can bear weight as

Figure 30-28 Medial and lateral meniscus anatomy as viewed from above (A) and via cross section (B). Note the circulation provided to the peripheral third of the meniscus only.

Figure 30-28 Medial and lateral meniscus anatomy as viewed from above (A) and via cross section (B). Note the circulation provided to the peripheral third of the meniscus only.

tolerated and usually return to full activities by about 3 or 4 weeks. With meniscus repair, recovery is extended and requires restricted weight bearing for 3 to 6 weeks, with 2 to 3 months needed before return to unrestricted activities.

EVIDENCE-BASED SUMMARY

With no RCTs, no conclusions about surgical or nonsurgical treatment of meniscal injuries can be drawn, or about meniscal tear repair versus excision. Partial meniscectomy seems preferable to total removal and improves overall recovery in the short term (Howell and Handoll, 2005) (SOR: B).

In a meta-analysis, sensitivity and specificity were 70% and 71% for McMurray's test, 60% and 70% for Apley's test, and 63% and 77% for joint line tenderness; no single test appears to diagnose a torn tibial meniscus accurately (Hegedus et al., 2007) (SOR: A).

Figure 30-29 Classic examination for meniscal pathology. A, Medial McMurray's test is performed by palpating along the medial joint line (thin arrow) while creating a varus force (solid triangle), ranging the knee through flexion and extension, and internally and externally rotating the leg (yellow arrows). A positive finding is noted when the maneuver recreates the symptoms and the examiner feels a palpable click. B, Lateral McMurray's test is done in a similar manner with valgus stress. (Courtesy Mark R. Hutchinson, MD.)

Figure 30-29 Classic examination for meniscal pathology. A, Medial McMurray's test is performed by palpating along the medial joint line (thin arrow) while creating a varus force (solid triangle), ranging the knee through flexion and extension, and internally and externally rotating the leg (yellow arrows). A positive finding is noted when the maneuver recreates the symptoms and the examiner feels a palpable click. B, Lateral McMurray's test is done in a similar manner with valgus stress. (Courtesy Mark R. Hutchinson, MD.)

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