Runners often develop knee pain. Some make the mistake of rushing for an MRI of the knee too soon. If given enough time, cross-training, and physical therapy your knee pain will often subside. Degenerative “posterior horn meniscus tears” are very common in runners. Most runners will not need knee meniscus surgery… and most runners will be able to return to running. As a matter of fact, meniscus surgery in some runners might end their running career.
When a runner sees an Orthopedic Surgeon they may be referred for an MRI. Keep in mind. Virtually no one over 40 has a “normal” knee MRI. Upwards of 30-35% of runners over 50 have meniscus tears. Does a runner have to stop running because of a meniscus tear?
Runners are often inclined to jump for surgical options thinking they might be able to get back to running sooner. That might be the wrong decision.
That’s not the best strategy if you wish to continue running for years to come. As we discussed earlier in this blog, having a portion of your meniscus taken out can predispose you to develop arthritis of the knee. For every runner who might have done well following an arthroscopy, there are one or two who never went back to running. The key, as we will discuss is patience, and not making quick emotional decisions about how to treat your meniscus tear if you are an active runner.
So an MRI of a runner’s knee with pain might show a meniscus tear. Does that mean that the meniscus is the cause of pain? Does that mean that the runner needs surgery? Can they continue running?
Running is a great exercise. Runners are a unique breed of athlete to treat. Running is meditative and enables us to relax, as we hit our goal of exercising a few days per week. If we cannot run because of a meniscus tear or knee pain we will be very upset. As you can imagine this blog receives hundreds of private comments each month. The following questions appeared three times recently in slightly different formats… The questions centered around running and meniscus tears.
Most common questions from runners with a meniscus tear:
- Can I continue to run with a meniscus tear?
- Can I make a meniscus tear worse if I run?
- Will meniscus surgery help me run better?
As you know, we have two menisci in each knee, we discuss what a meniscus is here. Most meniscus tears, especially in runners tend to occur along the posterior horn of the medial meniscus. These tears tend to be degenerative tears, possibly (but not proven to be) associated with a long running career.
Runners and meniscus tears:
Meniscus tears can present in two different ways in runners. Whether or not you can run depends on which group you are in.
Group 1: Most runners find out that they have a medial meniscus tear because they go to an Orthopedic Surgeon’s office when their knee hurts after a run. Most runners do not recall any one particular injury- that’s why we call these degenerative meniscus tears.
This group of runners with a meniscus tear is often able to run. They have varying amounts of pain after the run, or during the run, especially if they run on a cantered road or a trail.
This group is most concerned with making the tear worse if they continue to run. They wonder if they can continue to run despite having a meniscus tear. Most of these runners only require a good explanation that running will not make things worse.
Group 2: Sometimes a runner presents with pain on the inner side of the knee or the back of the knee. The pain is severe enough that they cannot run, squat, pivot, or twist. These runners are concerned because they are not able to run. Because runners are so committed, and often “need to” run, they may overreact and choose the wrong treatment option.
What is causing the pain? Often times when these degenerative tears initiate or occur the knee pain will be more severe for a few weeks. Yes, a few weeks… perhaps even a month or two. The pain is usually due to synovitis (inflammation) which will often settle down over time.
Here’s how many runners get into trouble…
Runners rush into a docs office, they get an MRI, and surgery is scheduled before they give the pain a chance to improve on its own. A meniscus does not have nerves in it. The tear itself doesn’t hurt. The inflammation because of the tear and the nearby tissues the torn piece irritates. It may take 6-12 weeks or more for that inflammation from the meniscus tear to settle down.
And yes, the inflammation within the knee due to a meniscus tear in a runner can, and often does settle down without having surgery on the tear.
The research into these degenerative meniscus tears that often occur in runners has been pretty clear. The vast majority of runners are able to avoid meniscus surgery.
Having part of your meniscus removed as a runner could end a long running career. Surgery for a meniscus tear in a runner might help for a short while, but the loss of meniscus might initiate an arthritic process causing more degeneration within the knee. Runners, in general, have a lower incidence of arthritis than a non-runner — but not if part of the meniscus is removed.
Can I run with a meniscus tear?
First off… many if not most meniscus tears do not require surgery. Surgery will not prevent arthritis from occurring. On the contrary, osteoarthritis may actually worsen faster if a runner has meniscus surgery.
Many runners get back on the road, even elite runners, with a degenerative meniscus tear. If you have a mild ache during the run, or a mildly sore knee after a run then you can often continue running. There is very little risk that running will worsen the tear. Meniscus tears can always worsen… remember, this is a process of degeneration. The meniscus has been changing or wearing out for a decade.
That degenerating process won’t slow, even if you change to just walking. No one can promise you the tear will never become larger. That’s like guaranteeing you that you won’t need stronger glasses or won’t lose more hair as you age :-(.
You may wish to wear a compression sleeve during the run. Compression sleeves have been proven to improve knee pain and improve a sense of knee stability. If you run on a cantered road, perhaps change the direction you run. If you run single track trails perhaps run on carriage trails. Those little changes can make a big difference. Surgery for a meniscus tear in a runner should be considered only if:
- the pain continues beyond 3 months and is severe enough that you cannot run.
- your pain did not improve with appropriate physical therapy – yes it works.
- a compression sleeve does not improve your symptoms
- you waited at least 6-8 weeks for your knee to recover on its own.
- you have no evidence of moderate or severe osteoarthritis.
- your surgeon strongly believes that it is realistic that you could return to running after surgery.
Meniscus surgery in a runner.
If you are a runner and the pain you have from a meniscus tear is keeping you from doing what you love then there is a chance that surgery might be the right option for you. As long as you do not have confounding issues such as osteoarthritis then you might feel great after arthroscopy for your meniscus tear.
Runners with osteoarthritis and a meniscus tear are often considered a good candidate for a different procedure which I go into detail here.
But remember, there is a chance that you will not feel great after knee surgery for a meniscus tear. The decision-making variables here are key to ensure the best chance of success. Understand the principles of shared decision-making before signing the dotted line. Perhaps consider seeing an Orthopedic Surgeon who is also a runner.
Being an active trail/endurance runner gives me a much greater appreciation of just how important running is in your life!
When can I run after meniscus tear surgery?
Runners start to whither if we cannot run. I am one of you! I get it! But rushing back out onto the road is a recipe for a disaster if you return to running too soon. When a part of the meniscus is removed, the physics of how the knee works and the stress that certain parts of the knee are subject to change significantly.
You must allow for the knee to recover and get used to its new environment. That might mean returning to running at 4 weeks, or it might mean 6-8 weeks depending on the appearance of the other structures in your knee at the time of surgery. If you head back out on the road and your knee swells significantly then your knee is telling you that it is not ready.
Do your exercises and wait a few more weeks.
Plan on slowly adding your miles back. Plan on slowly adding to your pace. Do not plan on an intense interval, track or hill work for at least 3 months after meniscus surgery. Think long term… we are trying to prevent secondary damage to your knee and give you a longer running career.
Omar
I’m happy to find this form. I am 23 years old. I’ve been running for 2 years now until I fell and twisted knee. I made MRI scans later on and found a horn tear in my horizontal medial meniscus (left knee). I did physiotherapy for 6 months and I still have pain in the same area and swelling after running. Doctor says it needs repairs and possibly trimming some meniscus off. I would really like hear your thoughts sir.
Howard J. Luks, MD
HI Omar… it’s possible that these tears can continue to bother you. One thing I would mention is that we can actually repair horizontal cleavage tears quite often. That means we put sutures in the knee to heal the tear. We try to avoid trimming pieces if possible.
Sharryn McNeil
Dear Dr Howard
Thank you for making the time to answer my questions about my recent diagnosis of my lateral meniscus issue(s).
I was recently told that my right knee had a tear at the junction of the body and anterior horn of the lateral meniscus and there is oedema in the medial patella, with minimal overlying chondral fissuring in both facts. What I understand from the latter is that is swelling. Is that correct? The diagnosis did say that the meniscus, LCL, iliotibial band, biceps femoris and popliteus tendons are intact. Incidental small intramedullary lesion in the distal femur likely an enchondroma.
I am a runner and have been running for over 30 years and as you can appreciate it is very unpleasant not being able to run! I have been doing more trail runs over the past few months and I don’t feel sore after doing this. Some of the courses are quite technical but I never experience any significant knee pain afterwards. When I bend down doing day-to-day activities, my knees sometimes feel stiff and make crunching sounds (sounds more painful than it is!) and have been doing this for many years.
I realised the issue I had with straightening my right leg (felt like the knee was clogged up) maybe 6 weeks ago but it didn’t hurt whilst I was running. I did a sprint session about four weeks and went a bit too hard and believe that’s when the meniscus crossed the line to being broken as I was limping and hurting quite significantly for a good two weeks. I haven’t run for four weeks now.
When the doctor told me of the results, unfortunately, I didn’t ask many important questions (very unusual for me) and she said that my options were to get an operation (wait time could be 6 months or more under public health system in Australia) but in the meantime, go to physio and see how that goes. She is not a runner but got the feeling of being a bit brushed off.
One important question I didn’t ask her is what activities can I do in the meantime if I cannot run? Can I swim (freestyle) and do some form of yoga? I have found some exercises/stretches online that I have started doing which seem to be helping but don’t really match the same activity levels as running.
What do you suggest?
I read that the meniscus tears are categorised in red and white zones. Can you please advise if this tear is in the red or white zone? I can walk fine without pain but I notice discomfort more so when I walk downhill. It sometimes feels that that diagnosis was incorrect but I guess the MRI scan doesn’t lie! I may still be in denial. I really want to fix this without the need for surgery.
Thank you.
Howard J. Luks, MD
HI
These tears are common.. they are usually radial tears and involve both the “red” and “white” zones. These radial tears do not always require surgery. The pain associated with them will often settle down. If the pain does not settle down then we can consider repairing them. Despite partially being in the white zone many of these tears can be fixed by suturing the two halves together. Without seeing you or your studies I cannot tell what type of tear you have though.
There is often no harm in trying the activities you mentioned. Far too many people decondition and lose muscle bulk because they have stopped exercising. The risks associated with loss of conditioning and loss of muscle bulk and cardiovascular status are worse than the risk to the knee. I often advise people to let pain be your guide. If the pain is 3 or less on a pain scale out of 10 then they can continue… if the pain migrates to a 4 or above then they should cross-train. I hope that helps
Zoe Pike
Hello,
Any help would be hugely appreciated. I am a very desperate and depressed injured 47 years old female runner. I have run many marathons (PB sub 3hrs). I tore my meniscus 3 years ago and had surgery. I went back to running and happily ran for the past 3 years pain free. I ran the London Marathon this year (first one for 7 years) and since then my knee has not been right and it feels like I have torn the meniscus again…similar pain on impact (even walking) and I have not run for 8 weeks and my mental health is not good – running is very much my stress buster and my therapy. I had an MRI scan but the results seem inconclusive as to whether there is a fresh tear or it is showing the old tear? I am waiting (long wait here in UK to see a surgeon). The report said ‘There is heterogeneous signal in the posterior horn of the medial meniscus extending towards the body with what appears to be an oblique horizontal longitudinal tear. The heterogeneous signal may represent healing material and previous tear. There is some oedema deep to the medial collateral ligament but this is likely reactive oedema from meniscal changes. There is some reactive oedema in the medial gutter deep to the MCL. There is almost full thickness fissure on the tibial articular surface. ‘
In your opinion do you think I have torn is again? I have rested for 8 weeks and no improvement and now my hip is sore as I am slightly limping. Do you think surgery is the only option or will this end my running career?
Any advice would be greatly appreciated.
Regards
Howard J. Luks, MD
Most MRIs do not look normal after you have had meniscus surgery. So those findings aren’t too worrisome. Other than that, without seeing you, examining you and looking at your MRI I cannot tell you what is causing your pain. Edema near the MCL can also be localized bursitis that can hurt- something to discuss with your knee doctor.
Tricia
I am addicted to running. I have been doing PT to strengthen my glutes, hamstrings, hips, and so on. My tear is described as medial meniscus, radial posterior horn, 6 mm from the posterior root, with loss of circumferential hoop containment of the meniscus and partial extrusion of body segment from medial joint line.
My question is if the root is involved, what is the likelihood that I will be able to get back out there. I am swimming and cycling and lifting, but running is my nirvana.
Howard J. Luks, MD
Root tears do complicate the issue. Complete root tears pose a risk for developing progressive arthritic changes. Many of us would consider fixing a root tear if there is minimal arthritis present. I have a post on root tears that you may want to read.
Laura
Hi,
I dislocated my patella in May this year and went through the recovery process. At the time doctors/physio told me my ROM would return once swelling had reduced and muscle strength returned. I was unable to extend my knee fully or fully flex. I seeked more medical advice and was told my knee appears locked and a bucket handle meniscus tear could be what’s wrong. I had an urgent MRI scan which came back inconclusive due to movement. The only thing they were able to see was bone bruises. I continued with PT and also had hydrotherapy. The doctor wanted to do another scan which I had last week. This was again blurry and the report said I had a previous ACL sprain (this I am unaware of) patella dislocations( I had suffered as a teenager) and a possible meniscus tear. The doctor told me this tear is only possible because scan quality not great but added that this tear would not be enough to lock the knee. So now I am still unable to straighten my left knee. I have made small progress with sitting/lying with legs straight. I also suffer pain under knee every day. My leg/knee feels a little stronger every day but it bothers me that I walk with a significant limp. I’m getting quite fed up now and my doctor has said my brain needs to reconnect to my knee. Is this right? Or is there a tear causing my issue?
Thanks
Howard J. Luks, MD
Unless there is a displaced large bucket handle tear of the meniscus then it is unlikely that the tear is the reason you cannot fully extend the knee.