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Meniscal Injuries
Raeann Lippitt
Weber State University
July 29, 2014
Knee injuries are among one of the most popular types of injuries.
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The knee is one of the
biggest joints in the body, therefore, it tends to endure a lot of trauma and forces. The knee
contains several ligaments, tendons, muscles, bones, and cartilage.
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This complex mechanism is
at risk of several pathologic injuries and disorders. One pathologic injury that is common among
athletes are meniscus injuries.
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The meniscal cartilage in the knee plays an important role in the function of the knee. A
meniscus is a cartilage fiber that forms a cushioning pad between the femur and the tibia. There
are two menisci per knee. The meniscus that is medial to the joint is known as the medial
meniscus and the meniscus that is lateral to the joint is known as the lateral meniscus. The
medial meniscus is shaped like a C, whereas the lateral meniscus is shaped more like an O.
When you look at it transversely, the meniscus forms a triangular shape. This shape allows for
the stress between the femur and the tibia to be dispersed throughout the cartilage instead of
directly on the bone. The outer edges of the meniscus help to fill the area between the femur and
the tibia. The head of the femur is round whereas the head of the tibia is more of a plateau.
Because there is a larger gap on the outer edge of the joint than in the middle, the meniscus
allows for the joint to move without irritation between bones.
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The meniscus is thought to consist
of two types of fibers that pose different purposes. The first type is known as circumferential
fibers. They grow circumferentially around the meniscus to help generate the tension between
the femur and the tibia and translate it in an outward motion. The other type of fiber is known as
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radial tie fibers. They form toward the center of the meniscus and grow outward. These fibers are
collagen fibers that are interwoven within the circumferential fibers to prevent the meniscus from
tearing longitudinally.
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When an individual receives a meniscus injury, there are several structures that are
involved. The first two that are involved are both the femur and the tibia. The meniscus is
connected to the tibia and the meniscus often becomes torn or ripped off of the bone. When this
happens, a lack of cushioning between the bones occurs causing the bones to rub together and
cause an irritation.
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Along with an irritation between bones, there are ligaments within the knee
that are affected. Depending on the mechanism of injury, the anterior cruciate ligament, the
medial collateral ligament, lateral collateral ligament, or the posterior cruciate ligament may be
involved. When one of these structures are injured, it increases the amount of time needed for
recovery.
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There are five types of meniscal tears; longitudinal, bucket handle, flap, transverse,
and torn horn.
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The longitudinal tear is a tear between the circumferential fibers which typically
occurs on the most superficial part of the meniscus. The bucket handle tear is similar to the
longitudinal tear, except it is on the deepest edge of the meniscus. It is called a bucket handle tear
because it looks like the handle to a bucket when it is torn. The flap is a deterioration of the
deepest portion of the meniscus. The transverse tear is when the meniscus is torn perpendicular
to the circumferential fibers. The torn horn tear is when either the anterior or posterior horn is
torn.
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An injury to the meniscus can be problematic and debilitating.
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Since the knee joint has a meniscus on both the medial and anterior sides, there are
several ways that an individual can experience a meniscal injury.
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The most common mechanism
of injury is a deterioration of the meniscus. This is most often seen in the lateral meniscus. This
type of meniscal injury is most often observed in individual 65 years old or older or who have
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had previous meniscal surgeries.
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The second most common form of meniscal injury is with a
slight flexion and internal rotation of the knee joint. When this type of injury occurs, the medial
meniscus is most likely affected.
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Often with this type of injury, the medical collateral ligament
and the anterior cruciate ligament are involved as well.
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Degenerative meniscal injuries are the
most common with an occurrence rate of 60%.
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Because the meniscus plays such an important
role in the knee, it needs to be taken care of immediately to avoid further damage.
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There are several risk factors that can occur if the meniscus is not taken care of properly.
Studies have shown that a delay in meniscal repair may result in a more severe form of
degenerative meniscal injuries.
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The optimal time to repair a meniscus is less than 3 months post
injury. After that, it becomes too difficult for a meniscus to heal properly.
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The longer an
individual waits to have a meniscus repaired, the greater their risk if of suffering from a severe
form of degenerative meniscus.
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There are specific populations who are more susceptible to obtaining a meniscus injury.
Males, to begin are two and a half times more likely to receive a meniscal injury than females;
particularly males between the ages of 31-40. Females 11-20 years of age, and individuals older
than 65 years of age are also at an increased risk of developing a meniscal injury. Individuals 65
years of age or older are at the greatest risk of developing a degenerative meniscal injury.
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Meniscal injuries are most commonly associated with athletes but they are often seen in
the general population as well. The athletes that are at the greatest risk are those that perform a
lot of squatting and twisting movements. They are at an even greater risk if it is a contact sport.
The athletes that are at the greatest risk of meniscal injuries are basketball and soccer players.
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Other individuals that are at an increased risk of meniscal injuries are military personnel, adults
over the age of 65, over-weight individuals, or individuals with a history of meniscal injuries.
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The excessive amount of stress that is applied to the meniscus causes deterioration of the
meniscus. This is known as degenerative meniscus.
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With such a wide spectrum for meniscal injuries that occur, knowing how to evaluate for
one is important. The most common method to determine if an individual obtained a meniscal
injury is using joint line tenderness. Joint line tenderness is when an evaluator uses their thumbs
to palpate the joint line between the femur and the tibia. Eighty six percent of patients with a
meniscal injury will complain of pain using this method.
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Other special tests that are commonly
used are the Thessaly test, McMurrays test and Apleys test. The Thessaly test is when the
patient stands on the affected leg and twists left and right. As they twist, they should be in a
squat just deep enough to take the bend out of their knees. After they twist left and right a couple
of times, they should lower their squat a little bit more, and once again for a third time. A
positive sign would be a pop, lock, or a replication of pain. The McMurrays test is when the
patient lays supine on a table. The evaluator lifts the patients affected leg into a 90 degree angle
ensuring that the evaluator has their thumb and fingers along the joint line. The evaluator then
inverts the patients foot and rotates the leg in a figure eight motion. The evaluator is paying
attention to any popping noises, clicking, catching, or pain. The Apleys test is when the patient
lays prone on a table. The evaluator then lifts the patients leg so that it forms a 90 degree angle.
The evaluator applies pressure down the shaft of the tibia and rotates the patients tibia left and
right. A positive sign would be popping, clicking, catching, or pain. If the evaluator pulls up on
the tibia and the pain goes away, that is a sign that the patient has an injury within the knee joint.
These tests are useful when trying to develop a hypothesis of the injury, but the best way to
confirm a meniscal injury is through image testing.
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The image testing best to determine a
meniscus injury is Magnetic resonance imaging (MRI). Magnetic resonance imaging creates
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images of the soft tissues within the body. Another image test that may be performed is an x-
ray.
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Although they cannot specifically detect a meniscus injury, they can detect fractures and
other possible knee injuries which can help to eliminate other knee injuries.
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If a meniscal injury is detected, there are a number of treatments, and rehabilitations that
will lead to recovery.
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The first step is to determine the severity of the injury. There are three
levels of severity; grades I, II, and III.
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Grade I is a small area that can be treated with the
R.I.C.E technique and non-steroidal anti-inflammatory drugs (NSAIDs). R.I.C.E. stands for rest,
ice, compression, and elevation.
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Grade II is an increased tear in the meniscus that doesnt extend
to an articulating area. This is usually treated with surgery, depending on the area of the tear. If
the tear is in the vascular zone of the meniscus, then rehabilitation exercises and rest may be the
best solution.
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If, however, the tear is in the nonvascular zone, then surgery is required to repair
the meniscus.
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Grade III is a complete tear in the meniscus that passes through an articulation
surface. This requires surgery and rehabilitation. A grade III meniscal injury requires several
months of healing and rehabilitation.
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During surgery, there are a couple of popular methods for
repairing a meniscus. The first way is to stich the meniscus back together. This is popular for a
meniscus that has torn in the vascular and partially vascular portion of the meniscus.
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The other
type of meniscal repair is a meniscectomy. During a meniscectomy, the surgeon may take out
either a portion of the meniscus, a layer of the meniscus, or the entire meniscus.
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This method is
avoided but may be required based off of the condition of the meniscus.
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After surgery, the
patient will be put through a rehabilitation program to help gain back their range of motion. The
average rehabilitation program for a meniscus injury is about three months.
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Knee injuries can be very debilitating.
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Meniscus injuries are one of the most common
types of knee injuries.
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Meniscus injuries have two common mechanisms of injury. The first is a
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degeneration of the cartilage due to the femur rubbing against it.
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The second is a tear or a
rupture often seen in sports when an athlete squats and turns.
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Through rehabilitation
techniques, rest, and possible surgeries, the injury can be repaired and many individuals can live
a normal life.
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