Root tears of the medial meniscus are being recognized on an MRI with increasing frequency. Most of you who have a root tear do not recall an injury to your knee. That is a degenerative meniscus root tear. A handful of you had a significant sports-related injury or ACL tear and find that you also have a root tear. How we treat these meniscus root tears will depend a lot on your age, how your tear occurred, the location of your root tear, and whether or not anything else is injured.
A root tear of the medial meniscus is a unique tear. Repairing a root tear of the medial meniscus requires a very different approach than a traditional meniscal repair. Root tears that occur after trauma and an ACL tear will require a meniscus root repair. This is in contrast to the more common degenerative root tear. Some degenerative root tears will benefit from a repair, and some may not. We can help guide you through that decision making. This article will discuss what root tears of the meniscus are and the thought process behind how we treat them.
The meniscus is a c-shaped cartilage cushion in the knee joint. It functions as a shock absorber and a stabilizer. Tears of the meniscus are prevalent. Root tears are not very common, but they are increasingly being recognized as a cause of severe arthritis. Your doctor must be well versed in root tears since they behave much differently than a typical meniscus tear.
What is the “Root” of the Meniscus?
The meniscus is attached or anchored to the tibia by two “roots.” There is a root attachment in the front of the meniscus and a root attachment in the back (posterior) of the meniscus. In most injuries, it is the posterior root attachment that is torn. Problems arise with root tears because if the root of the meniscus is torn, then the entire meniscus becomes non-functional. In other words, the meniscus needs to be well anchored to the tibia to function as a shock absorber.
How Did I Tear The Root of the Meniscus?
Many meniscus root tears occur as a result of trauma. Some root tears occur at the same time you tore your ACL. Other common causes of root tears might be a fall, slip on ice, or related to a sports injury. As we age, it is easier to tear the root of the meniscus, especially the medial meniscus root. Therefore you may tear the root by merely kneeling or squatting down. The average age of patients with root tears in my practice is between 25 and 65. The younger patients tend to have lateral root tears in association with ACL tears. The older patients tend to have medial root tears in association with early arthritic changes. Root tears that occur in association or with coexisting osteoarthritis are the most common form of root tear seen by orthopedic surgeons. Most of you will note that you knelt, bent your knee or twisted, felt a pop, and then noted increasingly more severe pain in the knee.
Patients with root tears of the medial meniscus often complain of giving way or instability. They are fearful that the knee will buckle or give-out. The onset of pain is often abrupt, and the pain is usually on the inner side of the knee, or in the back of the knee.
How Do You Fix A Root Tear of the meniscus?
To fix the root of the meniscus, we need to pull the root against the tibia in the same place where the root was before your injury. The procedure is mostly arthroscopic. It is a technically challenging procedure, so please be sure that your physician has performed many of these. After we put a suture around the root of the meniscus, we drill a hole from the front of your tibia into the root area. We then bring the stitches out through the hole and tie them over the front of the tibia. Therefore we are pulling the root down into the tibia, and the stitching will hold it in place until it heals. In the picture above, you can see how the stitch is through the root of the meniscus, and the meniscus is being pulled down into a small hole I created to encourage healing.
Do All Meniscus Root Tears Need Surgery?
The body of evidence about the treatment of root tears of the meniscus is growing. There is a generalized agreement that most medial root tears that occur in the setting of moderate or severe osteoarthritis should not be fixed. In these cases, the meniscus is usually degenerative or wearing out. Studies have shown that if these tears are fixed, they will commonly tear again in a very short time frame. If the arthritis is severe, then fixing the root tear may not alleviate your pain.
Root tears that occur in a severely arthritic knee should be treated with relative rest. Some of you may require a walker or crutches for limited weight-bearing. Many will benefit from the use of a compression sleeve, and after a month, a course of physical therapy.
Medial root tears with minimal osteoarthritis should likely be fixed or repaired. A successful repair will eliminate the sense of the knee giving way or feeling unstable. More importantly, fixing a medial meniscus root tear might slow the progression of osteoarthritis. But the critical issue here is that the severity of arthritis in the knee should be mild/moderate.
Root tears and ACL tears often occur together
Meniscus root tears often occur when you tear your ACL. If you have a traumatic root tear due to a severe injury, there is agreement amongst sports surgeons and orthopedic surgeons that these tears should be repaired at the same time that the ligament is reconstructed.
Do root repairs heal well?
Some studies show that a high percentage of these root repairs are successful, and there are studies that show that the success rate might be far lower. Many factors will often determine the success rate. First is whether or not you have anything else wrong with your joint… such as osteoarthritis. Other reasons for failure include lack of biological healing, resuming activities too quickly leading to a new tear, and over-tightening the repair, which could lead to a new tear somewhere else.
Bottom Line:
If you have a root tear as a result of a traumatic injury, be sure you see a Sports Medicine Trained Orthopedic Surgeon with experience repairing meniscus root tears. Some tears might be considered for repair, and others may not. IF you have osteoarthritis, and it is moderately severe, then having surgery for your root tear might not be advisable.
Hopefully, this has improved your understanding of meniscus root tears of the medial meniscus. Here is a review of root tears that might be worth reviewing.
Betty Petron
Great informative article, but doesn’t sound like there is much hope for a meniscus root tear to heal. I’ve had mine for six weeks and there is pain every day! Can a person get a total knee replacement to take care of the problem? Thanks
Howard J. Luks, MD
Most of these tears occur in the setting of an arthritic knee. A knee replacement is the ultimate treatment for painful arthritis that does not respond to any other treatments. This is something you should review with your Orthopedist
Nicole
Here is my MRI results, I’m getting two different option’s, what would your do?
There is a vertical tear near the posterior root medial meniscus with meniscal subluxation. Hyaline cartilage thinning and mild subchondral edema in the medial compartment.
2. Mild edema associated with intact MCL which may be due to recent or chronic strain.
3. Distal quadriceps and proximal infrapatellar tendinopathy.
4. Joint effusion and mild periarticular edema. Small Baker’s cyst.
Howard J. Luks, MD
Very few sports docs would operate on that… The scientific literature and sports medicine community would support non-surgical management. The edema in the bone (swelling of the bone due to stress) is likely what it bothering you. Surgery for the meniscus tear could actually make that pain worse. These root tears occur in an arthritic of degenerative knee. In most cases within 6 weeks you are starting to feel better.
MANGESH SHRIDHAR BHAGWAT
Dr. Luks,
I am Mangesh Bhagwat, India, Amravati, I am 48 year old, working as a Lawyer,
recently to lower down my weight which is 73 kg and to lower LIPID level, I started running for about 4-5 K.M and that i have done about for 10 days with cycling and trekking in jungle, but after some days it have started pain in Right knee, for which my Orthopedic Doctor suggested me MRI of 1.5 T power, which I have done before 1 Week, I have sown MRI to Orthopedic Surgeon at Nagpur, both are well qualified but both suggested me root surgery,
MRI report says that,
Early Changes of medial femorotibial osteoarthrosis
Radial tear of posterior horn of medial meniscus also involving its roots attachment with mild extrusion of the body segment into the medial gutter.
Pl. suggest, whether surgery is best option or conservative treatment. I dont’t want to go for surgery.
Howard J. Luks, MD
This is a very common picture or presentation in an early arthritic knee. We often see these degenerative root tears in the setting of osteoarthritis. Surgery is generally not recommended, or successful once there is extrusion associated with arthritic changes. We usually start treatment with physio, a compression sleeve, and we give the knee 6-8 weeks to see if it improves. It might be better to consider non-impact forms of exercise too — such as a rowing machine, swimming or an elliptical trainer.
Elizabeth
Hello Doctor Luks,
I am 55 years old and scheduled for surgery next week. I have a tear of the posterior root of the medial meniscus with associated Meniscal extrusion and degenerative signal extending into the posterior horn and body. Degenerative signal within the anterior root of the lateral meniscus without a discrete tear. Mucoid degeneration of the anterior cruciate ligament and minimal early medial and patellofemoral compartment. I was carrying something heavy when I felt a pop and snap 8 weeks ago. I was on crutches for 3 weeks and felt a little better but once I started walking again the severe pain came back gradually. My Orthopedist is going in to clean it up and if needed perform the root repair based on what he sees. He does about one root repair a month. Is this enough experience? Could this heal if I continue to wait? I just want to get back to normal activity which includes walking 3-4 miles about every other day. I would appreciate your recommendation. Thank you
Howard J. Luks, MD
Root tears will not heal by themselves. However, root repairs, when there is also arthritis present in the knee joint dramatically diminishes the success rate of surgery. Unless a repair is going to be performed, there is no need to consider a “clean out”. Many of these tears are treated without surgery if arthritis is present- because the research shows that time and PT can frequently results in the same degree of improvement. So… if there is minimal or no arthritis a repair is possible and can be considered. If there is significant arthritic change then the repair will likely fail. It can be a tough call. IF your surgeon does one root repair a month, then they are doing more than many orthopedic surgeons.
Brian
Sounds like 90% of the Root tears, where as our ortho Dr suggest repair vs rehab, conflicts with your opinion, which convinces me to not have surgery….
My MRI: Complex Root tear involving the Posterior hrn of medial meniscus which extends to the Posterior Root attachment. 2mm peripheral extrusion of medial meniscus body. Oblique tear involving the inner free margin of Post horn.. bakers cycst , ruptured at one point, fluid… Full thickness articular cart loss involving Medial femoral condyle, large region of full thickness cart loss involving medial tibial platuea… alot of other stuff going on, just to much to transpose from Report…. basically, My knee hurts…..lol….
Howard J. Luks, MD
Good choice… that’s an arthritic knee.
Linda Yeager
Dr Dr Luks. I’m female 70, took a fall about six months ago and broke my shoulder. my knees were bruised. Slowly the pain in my right knee has been getting to be more and more of a problem. MRI shows a tear at the root on the inside of my knee. I have a slight narrowing of the space …one doc says mild osteo and another says moderate. I’m going to take your advice and find someone who has done this kind of surgery plenty! Do you know of anyone in the Eugene Oregon area? We are Track Town USA and lots of sport happens here so I’m guessing there might be someone! Thank you.
Howard J. Luks, MD
good luck to you…. hopefully you can find someone who can speak to the advantages / disadvantages of a medial meniscus root repair in your case.
Howard Luks