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.
jason
I have been training for a marathon and started having some really bad pain in my knee. I went to visit my PT and he did several tests and found that I had a meniscus tear. I can not think of a traumatic event that caused the injury and my PT suggests that the injury has occurred due to wear and tear. The swelling went down between my first and second appointments substantially. The marathon is in 2.5 weeks. He says I can run it if the swelling is down and it is worth it to me. I asked if I could do more damage to it and he said yes, but if I am willing to deal with the risk I can do it. Needless to say I am torn in more than 1 ways (lol). Suggestions?
Howard J. Luks, MD
Hi Jason… It will take a few months for the inflammatory phase to subside fully. There are many, many runners who run with a meniscus tear that has not been operated on. There’s always a risk of causing more damage, but that risk is low. There is a risk of developing arthritis with a meniscus tear, but that risk will not be altered or reduced by having surgery. These are always tough decisions. Unfortunately, I cannot make that decision for you.
Jason
Hi Howard,
Thank you for the wealth of evidence based information, you have a wonderful website which I refer many friends and clients.
I am an avid runner and triathloner that was recently diagnosed with a medial meniscus tear. Degenerative…In June of last year 2 weeks after completing an Ironman which I had no knee discomfort I was doing some yard work and I developed some knee pain, by the following day I couldn’t walk. DX with a meniscus tear by physical exam, X-ray was normal. I did the holistic approach and by June of this year I was able to run the occasional 6 miles but any lateral or twisting. movement of my knee caused pain. Then in July for no apparent reason pain got worse, I could no longer run, I had discomfort walking (3/10) so I had an MRI which showed a Horizontal flap tear of the posterior horn of the medial meniscus with a fragment of meniscus flipped into the intercondylar notch margin. No signs of osteoarthritis, rest of the knee looks healthy. My knee doesn’t lock or catch but i need to be mindful of my positioning. Uneven terrain is unpleasant which makes hiking problematic. I just don’t know if i should trim the flap if it will change anything ? Is surgery only recommended when the knee locks? I am 51.
Howard J. Luks, MD
HI Jason…
Unstable flaps can continue to bother certain knees. After a number of months of failed non-surgical mgmt, the decision to proceed with trimming the flap is up to you. This would be considered a quality of life procedure. Just ask that they not be too aggressive at removing non-injured parts of the meniscus. Any frayed tissue can often be left in place.
Lynnette Tenorio
I have been a runner for 20+ years but 4 months ago I started to include HIIT workouts to add variety unfortunately I tore my medial meniscus. I haven’t run since then and it is extremely depressing as I have been told by one orthopedic surgeon that I need surgery while a second opinion suggests PT first and surgery as last resort. I have read all comments, inquiries shared on your website and would like to seek your input as to my situation. I’m a 58 year old female. My MRI reveals I have a flap tear at the junction of posterior horn and body of medial meniscus. The anterior horn, anterior root and posterior root are in tact. There is no intrasubstance degeneration, surface fraying or discrete meniscal tear demonstrated. Mild articular cartilage irregularity in all 3 compartments of the right knee. Normal lateral meniscus, anterior and posterior crucial to ligaments, medial collateral ligament and lateral collateral ligaments structures.
The second opinion of non-surgical route with PT also suggests hyaluronic acid injections.
My preferred option is no surgery. I have a high threshold for pain and would like very much to run again but I don’t want to cause any more damage. My knee was inflamed for nearly 4 months but good now. The only time I experience pain is when I bend deep at the knee. I cycle but only to keep me moving. I welcome any comments and suggestions you may have. Thank you!
Howard J. Luks, MD
HI Lynnette… Flap tears can remain bothersome if they are “unstable”. That means they may produce a clunk, or your knee might feel caught. For flap tears we sometimes need to consider trimming that loose piece off… but we always try 3-4 months of non-surgical mgmt first.
Good luck !
Tim
Thanks for this.
I’m a 55 year old male. I had a bucket handle tear in my right lateral meniscus and had surgery.
After about 4 weeks the pain was gone so I started doing more strenuous exercises like squats and lunges. While doing bulgarian split squats, with my right (the injured leg) foot on a bench and left foot in front, I experienced pain when I dipped low. Felt like maybe went too far and maybe didn’t have full range of motion. It hurt a bit but did some more exercises. Later that day, the pain got much worse and I needed to take pain relievers (NSAIDS) for a few days. It remained quite painful for days and couldn’t really exercise for over a week. I rested it a couple weeks but started feeling pain again after a long hike.
Is it possible I tore the meniscus just by doing those squats a month after having a partial meniscectomy? Is that likely? Or what is likely going on? I could go get an MRI but I don’t have insurance so would like to avoid. Is this common, re-injuring the meniscus by trying to do too much too soon? Whats my best course of action?
Thanks
Cathy A Strzempka
So I am not an elite runner and have never even run a marathon, but I am a 57 year old mother of seven, and running has kept me sane for nearly 40 years. I had to stop running about two and a half years ago after a fall down some icy cement steps a la Home Alone and was left with a bulging disc in my l5-s1. Steroid shots and pt have helped me heal, and this past May decided to try to ease back into running. Almost immediately I developed interior knee pain on my left knee, and after pushing thru using Aleve and arthritis strength Tylenol with no relief, I visited my gp, who put me on a course of steroids. When that too failed he sent me to an orthopedist (although I actually saw a PA). X-rays showed no arthritis, so I had and mri; that came back showing a small medial meniscus tear. I was offered a shot, which I got immediately. The first day was completely pain free, but I knew before I even got out of bed the next morning the pain was fully back. Of course the next step is arthroscopy, which I really don’t think is warranted, given the tear was so small it only showed up on one image of my mri. So this question might sound silly, but given that my pain and the tear itself was medial (on the inside of my knee), why was the shot given to me on the outside of my knee? I have been doing pt for my knee for three months now with only minimal improvement (although I do have a nice Don Joy knee brace I wear when exercising – and I should point out here I stopped running completely about 7 weeks ago), but I’m not sure what to do next. Lots of pain when standing up from sitting or trying to squat down, I’m getting quite depressed.
Howard J. Luks, MD
Sorry, Cathy :-( I definitely know how important running is for us. Perhaps a second opinion is worthwhile. You’re correct, small, stable, degenerative tears should not cause that much pain. Sometimes having someone else listen to your story and examine you can yield a better idea of what might be bothering your knee.
Cathy A Strzempka
Thanks for your response; I actually already took your advice and got a second opinion. It was her opinion that it was more likely an MCL injury and after her explanation I am inclined to feel the same. I am following a pt regimen with some success. She did tell me these kind of injuries can take quite a while to heal. So crossing my fingers.