Meniscus tears are very common. Each knee has two menisci which serve as cushions. They can tear due to degeneration, or they can tear due to trauma or a sports injury. The treatment of a meniscus tear will depend on the type of tear you have, whether or not you also have osteoarthritis and the nature of your complaints.
Many people do not understand why many meniscus tears do not require surgery. Having a firm understanding of what the meniscus does and why some tears do not require surgery should go a long way in assisting you in your surgical decision-making.
Meniscus tears are a very common source of pain in the knee. They are also commonly seen on MRIs obtained for other reasons – and are not necessarily the cause of your pain. Many people come in on a daily basis and ask if surgery for their meniscus tear is always necessary. In this post, we will explore
- what a meniscus is,
- what are meniscus tears,
- why meniscus tears are so common
Meniscus Tears
What is a meniscus? It is a cartilage disk that’s found in the knee.
There are actually two of them. We have one on the inner side of the knee which we call the medial meniscus and one on the outer side of the knee which we call the lateral meniscus. These two disks function as shock absorbers or cushions to minimize the stress on another type of cartilage that we have in the knee which we call the articular cartilage. The articular cartilage is the cartilage that actually coats the ends of the bones. If the two menisci are not present or they’re torn, then the articular cartilage sees an increase in stress and can trigger the onset of osteoarthritis. Meniscus tears are by no means the only cause of osteoarthritis. However, they certainly are a significant contributor.
Why do meniscus tears occur?
Now I see many patients every week who present with knee pain and many of them are suffering from meniscus tears. Why/How do we get meniscus tears? Why do these little meniscal disks tear so easily once we reach our fourth, fifth decades and beyond? Our meniscal tissue is non-regenerative. It’s similar to our brain or our heart tissues. If we have a heart attack or a stroke, we do not regenerate those areas of our heart or our brain. It simply scars in. Yet if we cut our skin, our skin heals. Our skin tissue is regenerative, same with some muscle and a lot of other tissues in our body.
The meniscus tissue in our knee has very few mechanisms for repairing itself. Therefore, every step that you’ve taken, every twist that you’ve done, every time you’ve knelt down or squatted down, you’ve put a force across that meniscus and eventually it wears out and the meniscus tears. (This is why most tears are referred to as being “degenerative”. A lot of times people will note that they simply knelt down to pick up something up and when they went to stand up they felt something rip inside their knee and noted the onset of pain.
Why does a meniscus tear hurt?
The typical patient with a meniscus tear doesn’t have much in the way of pain with walking straight ahead. Sometimes they do. It depends on the size of the tear but usually, they’ll tolerate walking in a single direction very well. Patients with meniscus tears will occasionally complain of pain going downstairs. They’ll have pain getting up from a seated position. They’ll have pain with turning, pivoting and twisting and some patients, if the meniscus tear is large will complain that the knee is buckling or giving way or feels unstable. Many of you will also find you need to sleep with a pillow between your legs at night.
A meniscus tear hurts because they sometimes irritate the lining of the knee joint called the synovium. Tears can also hurt if there is a loose piece which is getting caught in the joint.
Types of meniscus tears?
What are the different types of meniscal tears? The majority of tears are degenerative meniscal tears. When you look at the cartilage disc, the edges are simply frayed. The tissue has been destroyed from years and years of use. Nothing you did wrong. The tissue simply wore out. It’s like the front of a pair of blue jeans that you’ve worn for decades and the material just simply wore out.
Then there are those who have suffered more acute meniscus tears and these tears can have different shapes and different patterns. The shape and pattern will determine how symptomatic or how bothersome the meniscus tear will be. If a loose flap of tissue is created and that flap is moving around within the knee – that’s when you’re going to have given way and you’re going to have pain with many activities. You’re not going to tolerate flap tears well and those patients with flap tears (or unstable tears) will usually (not always) go on to require an arthroscopy or a scope to try to either repair or remove that torn piece.
We Treat Patients, NOT MRI findings…
Many patients with meniscus tear pain will improve within a few weeks of onset… in many cases, there is no need to rush into surgery.
- If your pain is starting to improve and
- if the pain does not interfere with your quality of life
- If compression sleeves work to control the pain
- If your range of motion is well maintained and
- You can participate in your normal daily activities —
Then why would one consider meniscus surgery a necessity? Not all “tears” require surgery. Again, we as physicians need to treat the patient, and not the disease.
Consider this article which demonstrated that a sham surgery (incisions made, but nothing done) was no better than treating a meniscus tear when the patient had a degenerative meniscus tear. There are also plenty of studies which show that a degenerative tear can be treated with physical therapy.
How are meniscus tears treated?
If you have knee pain, and you’re found to have a degenerative meniscus tear — I typically advise patients to simply just wait. A lot of times your symptoms will go away. If you sustain an injury and you have an unstable tear, a tear we call a horizontal cleavage tear, a radial tear or a flap tear — those are the tears tend to remain bothersome. If after four, five, six weeks, you still have the same degree of discomfort and quality of life issues, then you might be a good candidate for surgery, which we call an arthroscopy.
Physical therapy can help those of you whose knees feel unstable or weak, and it can help those of you with significant swelling to gain back your motion, stability and strength. Therapy can be beneficial before surgery (pre-habilitation), instead of surgery, or after surgery.
Many patients feel that a compression sleeve makes them feel better and improves their sense of stability – see some of our patients’ favorite knee compression sleeves here.
Do all meniscus tears require an arthroscopy?
What exactly is an arthroscopy?
Basically, an arthroscopy involves bringing you into the operating room, inducing a light sleep, injecting local anesthesia and then placing a fiber-optic camera into your knee through a ¼ inch incision. We then inspect the entire joint, find the tear and determine if it will be removed or stitched back into place. Most procedures take 15-45 minutes and you are able to go home the same day. Whether or not you can return to sports soon will depend on which procedure you had — repair versus removal. More on the recovery from meniscus surgery here.
So if you have a meniscus tear, it’s not all doom and gloom. Many tears do not require meniscus surgery. Some of them do. Some meniscus tears are repairable. Sometimes the torn portion of the meniscus is simply removed.
We try to repair – or suture- meniscus tears whenever possible — but only certain tears are in fact repairable. One caveat: If you have a meniscal tear and you’re experiencing instability or giving way, be very careful with your activities. You don’t want to find yourself on the stairway carrying a load of objects and your knee gives way. If you have instability symptoms, make sure that you have a hand available to hold onto something at all times while you are in your recuperative phase or awaiting surgery or simply waiting to see if the symptoms are going to recover on their own.
Hope you enjoyed this post. For more information there is a more in depth section on meniscus tears here.
And by no means is meniscus surgery or emergency surgery. Take your time, rest and consider a second opinion.
After your meniscus surgery, what should you expect as your recovery from an arthroscopy for a meniscus tear?
Due to the overwhelming popularity of this post, I want to make sure that the many and varied needs that each of you have is met during your visit here. With that in mind, you may benefit in reviewing these related posts on this site:
Ankur
Good Evening Dr Luks,
I recently twisted my knee and was recommended MRI. Following is the report of my MRI scan. Can you please have a look and suggest me what should I do next. The examining doctor has suggested surgery.
MRI OF THE LEFT KNEE.
CLINICAL HISTORY: Twisting injury while running. Possible ligament or cartilage injury.
TECHNIQUE: Multiplanar, mu1tisequential HRI of the left knee without intravenoue contrast.
COMPARISON: Conparison was made to the previous x-rays of the left knee done on July 21, 2013.
FlNDINGS:
There io a high-grade partial-thickness tear of the anterior cruciate ligament. There is a small area demonstrating mild depression in the posterior cortex at the lateral tibial plateau, indicating a mild impaction fracture associated with mild bone marrow edema in the posterior aspect of the lateral tibial plateau (image 20 of series 7). There is also mild edema in the posterior aspect of the medial femoral condyle, in the lateral aspect of the medial femoral condyle, and in the head of the fibula (styloid proceoo of the fibula). These are consistent with bone contusions from a pivot shift injury.
There is also a small incidental oval-shaped low signal intensity lesion in the proximal tibia metaphysis which is probably a bone island.
The posterior cruciate ligament is intact.
The medial collateral ligament and lateral collateral ligament complex are intact.
There is a T2 hyperintensity at the junction of the body and posterior horn of the medial meniscus, which is probably due to a post traumatic meniacal contusion. No distinct tear.
The lateral meniscus is intact.
The articular cartilage in all 3 compartments is grossly intact.
The extensor tendons are intact.
There is a small-to-moderate knee joint effusion.
No popliteal cyst.
IMPRESSION:
1. Partial-thickness t:ear of t:he anterior cruciate ligament. Mild impaction fracture in the posterior aspect of the lateral tibial plateau. Additional bone contusions in the medial tibial plateau, medical
femoral condyle and in the head of the fibula in a pattern that is consistent with a pivot shift injury.
2 . Medial meniscal contusion at the junction of the body and posterior horn of the medial meniscus. No distinct meniscal tear.
3. Small-to-moderate knee joint effusion.
4. Additional findings as described above.
Thank you.
Regards, Ankur.
Howard J. Luks, MD
Ankur…
The proper treatment for you will take into account more than just your MRI findings. Some ACL injuries do not result in instability or a feeling that your knee is loose. Some ACL tears cause significant instability issues. IF you are young, active and have an unstable knee then a reconstruction of the ACL might help restore stability to your knee. If your knee is stable and getting better with physiotherapy or time then you can wait and see what happens. In certain situations where people put themselves in precarious situations because of work (on rooftops or climbing trees, etc) then we usually recommend a reconstruction. The same goes for people who enjoy extreme sports such as rock climbing.
Good luck to you.
Howard Luks
Ankur
Thank you Dr Luks.
Asem
Hello Dr. Luks,
I suffered an odd ‘injury’ 4 years ago (by standing and walking on one leg for a prolonged period of time). This was in the 8th grade. Ever since, I have had constant cracking and popping of my knee but it was very mild. A few months later, I was doing a trivial physical activity when I heard and felt a very loud pop in my knee. For the following 4 days, I was in a lot of pain and was hardly able to walk.
The doctor told me I had suffered ‘knee trauma’ and x-rays showed nothing was wrong.
I went on to do physical therapy (straight leg exercises) for 6 weeks. This therapy seemed to help for the time (less pain and popping) but unfortunately I did not follow through with my exercises (I do not know if I was meant to continue doing them). The pain and popping came back but it was always mild.
I continued to play sports and never truly gave my knee rest for more than a couple weeks. I play sports vigorously and I guess I tend to put a lot of stress on my knee as a result.
I am now a freshman in college and I have realized that the last few years have not helped my knee to heal.
After consulting another doctor and getting an MRI, it was found that I have a “small radial tear on the posterior horn of the lateral meniscus.” I have an appointment with a renowned surgeon in 6 days. However, I was wondering if you had any input before I see him.
The reason I am asking for input is because as he is a surgeon, I imagine he might directly assume surgery is necessary.
However, I would like to see if you think it might be possible for my tear to heal given I have this new information. I know they say that if it has not healed after a certain number of months (and my 4 years far exceeds that), then the patient probably needs surgery. But is it possible that my injury has not healed because I did not stop playing sports? Maybe if I do the right physical therapy, perform exercises that increase blood flow to the damaged area, and stop strenuous exercise for at least 3 months, my meniscus might have a chance to heal?
Thank you so much for your time,
Highly appreciated,
Asem
Peter
Hello Dr. Luks,
I am writing this to get your opinion regarding my knee.
I had an ACL reconstruction surgery about 2 years ago and I have been playing basketball and lifting after 5 months of surgery.
Recently, when I was playing basketball, I heard a pop in my knee and I could not extend my knee.
The knee swell up slowly the day after.
Got my knee checked out by my orthopedic doctor and he advised me to take a MRI.
The MRI discovered “Complex Tear of the medial meniscal posterior horn and body. The medial meniscal tear demonstrates a posterior horn horizontal component, as well as a bucket handle tear component displaced into the lateral aspect of the medial compartment. Lateral meniscus remains intact without tear, degeneration or discoid morphology.”
The swelling has gone down a lot and I have good range of motion without any pain except when I squat down all the way or last 2-3 degree of full extension (very little pain; more of a restrict feel?)
Do you think it would be necessary to have a surgery?
I feel like I should wait and see how my knee does after the swelling has gone down completely.
Your opinion and advise is greatly appreciated.
Thank you in advance! =)
Howard J. Luks, MD
A bucket handle tear means that a large piece has flipped over and is caught in “the middle” of the knee. You may find it impossible to obtain full motion until that piece is repaired back to its normal position… or removed if it is not repairable. Good Luck
Howard Luks
Walt
Dr. Luks, thanks so much for having a site like this with great information and providing personal responses. If I end up needing surgery, I will definitely consider coming to you.
I am a veteran and had my knee evaluated by a Veteran hospital PMR doctor. The VA is not known for the best care, so I would love a second opinion. After moving my leg around, I was told it appears my meniscus was torn. I have not yet had an MRI and the doctor did not suggest one. He seemed to think it is minor and I can’t do much about it. He suggested I stop activities that aggravate it. I am a competitive mixed martial artist and instructor, and stopping forever is not really an option.
I am trying to decide if there is a reason for me to insist on an MRI or further evaluation. The inside of my knee is sometimes in minor pain and movement is not hindered. It just sort of feels like there is something wrong. There is a tightness if I bend my heel toward my butt, but it doesn’t hurt. It feels more like a tight knuckle that wants to get cracked. If I continue bending it, the knee pops and then feels fine. Sometimes it is a little sore the next day and I ice it etc. Is that popping a bad thing if it doesn’t hurt? The popping noise scares me.
How would you suggest I proceed? Just rest, insist on MRI, continue activity lightly, surgery or what? I haven’t stopped my training, but am taking it much easier than normal.
Thank you very much in advance. I look forward to your response.
Walt
Howard J. Luks, MD
Thanks Walt !!!!
This is exactly why I often say that we need to look at patients as individuals. The same pain affects each person differently. We all have different goals, activities, etc.
You’re correct.. the popping in your knee could be an issue.. such as a meniscus tear. Frequently a physical exam and Xray can give us a good idea about what the likely problem is, but an MRI may be needed to prove it. Why not start by asking to see the Orthopedist? If that’s not an option then you may want to take it out of the VA system ???
Good Luck ~!
HJL
Walt
Thanks for the speedy reply. My plan is to insist on being seen by ortho and having an MRI. I definitely need more answers than I was given last time. If there is something wrong, then I want to know exactly what is wrong. I at least need to speak with another doctor, as the last doctor basically told me to simply stop doing anything that hurts. I actually have a friend in ortho that also trains in martial arts. I will try to get in touch with him and see what he thinks. After that, I expect to follow up outside the VA System, so maybe I’ll be talking to you again soon.
Thanks Again,
Walt
Patricia
Dear Dr. Luks,
Six weeks ago I started with severe knee pain and effusion with knee instability. The only previous history is I went to a triplex vacatiojn home for a wekend and I used the stairs quite a bit. The pain was better aftyer a week, not mobility though. Then a week later it came back with revenge all the pain, it lasted for 4-5 days and better again. It just a little instable but the pain hits me with just walking some times, when I go downstairs and when I get up from sitting position. I cannot kneel because of the pain. My knee feels tight and supino position does not help, it only relieves the pain ice and crossin my legs with the sore knee on top of the healthy one. I don’t like to take anti-inflammatory drugs unless the pain is unbearable. I just got the MRI results of:
1- Complex tearing of the posterior half of the emdial meniscus with reactive marrow edema in the medial tibial condyle. It says horizontal cleavage tearing of the mid third segment of the medial meniscus and partial thickness, inferior surface tearing of the posterior horn of the medial meniscus on sagital image. Coronal image shows partial-thickness inferior surface tear of the mid third segment of the lateral meniscus.
2- It also says partial thickness inferior surface tearing of the mid third segment of the lateral meniscus.
3- Mild chondromalacia of the medial patellar facet and mild cartilage thinning diffusely in the medial compartment?
What is your opinion about my best choice of treatrment? I am secretly expecting a : physical therapy. Knee brace makes my knee burn after a while. I don’t know hat is recommended or not while I wait for my long waiting list on my orthopedic doctor.
I would really appreciate your expert opinion. Thank you for the website.
Howard J. Luks, MD
Patricia… the “injury” you sustained is not enough to have caused the meniscus tear. You likely had it before the pain occurred. Reactive edema in bone under the meniscus is a common and very painful situation. The pain from the edema can go away in as little as 3-4 weeks. Many people live with meniscus tears for a long time without the need to “treat” it. A very astute surgeon can tell you whether or not the pain is from the meniscus or the edema or fluid in the bone. Time will tell… there’s certainly no rush as long as you symptoms are improving and your feeling of instability is no longer present. I might hold off on PT and use a cane to help the bone heal and allow the fluid to decrease. Then you can start therapy after a month or so…. but that’s not an actual treatment recommendation! It is something for you to research, consider and discuss with your doctor when you come up with a plan.
Good Luck
Howard Luks