MR Pathology

of the Meniscus
Marcel Prasetyo
Division of MSK Imaging
Department of Radiology FKUI-RSCM
Outline

1. Meniscal avulsion
2. Meniscal extrusion
3. Meniscocapsular separation
4. Meniscal contusion
5. Degenerative meniscus
6. Meniscal tear
7. Meniscal cyst
8. Indirect sign of meniscal injury
Meniscal avulsion

• Detachment of some part of meniscus from the tibial

plateau, without complete meniscocapsular separation
• Commonly with rupture of meniscotibial ligaments, while
meniscofemoral ligaments remain intact
• Also called “floating meniscus”
• Medial meniscus > lateral meniscus
• Empty meniscus, with displaced fragment that still
connected to meniscofemoral ligaments
• Method of choice:
• Sagittal and coronal T2WI +/- FS
• MR arthrography
Meniscal avulsion

Sagittal T2WI FS (a) and sagittal PD FSE image (b) show the presence of and abnormal volume
between tibia and femur, with the anterior horn of the meniscus displaced anteriorly.
Meniscal extrusion

• Radial displacement of
meniscus beyond tibial margin
• Causes:
• Radial tear
• Oblique tear
• Anterior/posterior root tear
• Meniscal degeneration
• Cartilage defect

Coronal PD FSE image shows that medial meniscal

margin is displaced beyond the tibial plateau.
Meniscal extrusion

• Influence joint stability, may

lead to early development of
OA
• How to recognize:
• Coronal PD or T2WI
• Increased distance of the outer
margin of meniscus from adjacent
tibial margin (osteophyte
excluded)
• Medial meniscus: >3 mm
• Lateral meniscus: >1 mm
Coronal PD FSE image shows that medial meniscal
margin is displaced beyond the tibial plateau.
Meniscocapsular separation

• Disruption of the capsular

attachment of meniscus
• Two location can be seen:
• Meniscocapsular junction
• Peripheral zone of meniscus
• Best seen in coronal and
sagittal T2WI

Coronal oblique graphic shows separation of the capsule (black solid arrow) from the meniscus at the meniscocapsular
junction and surrounding edema (black open arrow) in the posteromedial aspect of the medial meniscus.
Meniscocapsular separation

How to detect:
• Fluid collection and increased
distance between MCL and medial
meniscus
• Meniscal displacement from tibia
• Peripheral tear of meniscus
• Irregular margin of meniscus
• Perimeniscal fluid collection
• Lateral meniscus:
• displaced meniscus
Coronal PD FSE image shows a linear high-signal
• disrupted popliteomeniscal fascicles intensity separation between the peripheral zone of
• edema in the posterolateral corner meniscus and the MCL.
Meniscocapsular separation

How to detect:
• Fluid collection and increased
distance between MCL and medial
meniscus
• Meniscal displacement from tibia
• Peripheral tear of meniscus
• Irregular margin of meniscus
• Perimeniscal fluid collection
• Lateral meniscus:
• displaced meniscus
• disrupted popliteomeniscal fascicles Coronal PD FSE fatsat image shows perimeniscal
• edema in the posterolateral corner hematoma between the lateral meniscus and the
LCL.
Mucoid degeneration of meniscus

• Intrasubstance degenerative
changes due to internal
derangement of normal meniscal
architecture
• Due to high and prolonged
mechanical loading
• All ages !
• More frequently found in posterior
horn of the medial meniscus
• May be asymptomatic
Sagittal graphic shows central mucinous degeneration of the meniscus
(white solid arrow) due to collagen breakdown and loss of fiber integrity.
There is no linear tear.
Mucoid degeneration of meniscus

• Typical appearance:
• Focal hyperintensity centrally, with
surrounding normal hypointense
meniscus
• Do not have linear pattern
• Do not extend to the articular
surface of meniscus
• May progress to horizontal tear
• Overdiagnosis should be avoided
Meniscal contusion

• Acute trauma
• Bone bruise adjacent to meniscus
• Biomechanic: compressive injury
• MR appearance :
• Diffuse hyperintensity that extending to articular surface
of meniscus (in contrary to mucoid degeneration)
• No linear pattern
• Arthroscopy shows no tear
• Follow up: resolve (transient)
Meniscal contusion

Sagittal PD FSE (a) and PD FSE fatsat (b) show diffuse signal intensity changes in the anterior horn of
the medial meniscus that extends to the articular surface. Note the bone marrow contusion.
Meniscal tear

• Linear hyperintensity within the meniscus, extending to its

articular surface
• DeSmet (2012): MRI can made definitive diagnosis in 95% cases
of meniscal tear
• Menical grading I-III was widely used in the past, is now
considered obsolete clinically (Barber & McNally, 2013)
• Many classification were used, mixed up and inconsistent, result
in misunderstending and not helpful to distinguish important vs
non important lesion
• Role of MR:
• Detection: presence/absence of tear
• Description: orientation, location, length, stability
 Meniscal tear classification

Meniscal Tear

Vertical Tear Horizontal/Oblique Tear Complex Tear

Longitudinal Radial Complete Incomplete Horizontal+Vertical

Bucket-handle

Complete w/ root tear Flap (parrot-beak)

Incomplete w/o root tear
Free fragment
 Meniscal tear classification

incomplete stable Low clinical relevance

Longitudinal
tear unstable if extensive or with
complete high clinical relevance
Vertical tear meniscocapsular separation

without root tear

Radial tear Unstable high clinical relevance
with root tear

Low clinical relevance

incomplete Stable
Horizontal/ oblique tear
Clinical relevance depend
Complete Unstable/stable
on associated lesion

Horizontal+vertical tear
Bucket-handle tear
Complex tear Unstable high clinical relevance
Flap (parrot-beak) tear
Free meniscal fragment
 Meniscal tear classification

incomplete stable Low clinical relevance

Longitudinal
tear unstable if extensive or with
complete high clinical relevance
Vertical tear meniscocapsular separation

without root tear

Radial tear Unstable high clinical relevance
with root tear

Low clinical relevance

incomplete Stable
Horizontal/ oblique tear
Clinical relevance depend
Complete Unstable/stable
on associated lesion

Horizontal+vertical tear
Bucket-handle tear
Complex tear Unstable high clinical relevance
Flap (parrot-beak) tear
Free meniscal fragment
 Meniscal tear classification

incomplete stable Low clinical relevance

Longitudinal
tear unstable if extensive or with
complete high clinical relevance
Vertical tear meniscocapsular separation

without root tear

Radial tear Unstable high clinical relevance
with root tear

Low clinical relevance

incomplete Stable
Horizontal/ oblique tear
Clinical relevance depend
Complete Unstable/stable
on associated lesion

Horizontal+vertical tear
Bucket-handle tear
Complex tear Unstable high clinical relevance
Flap (parrot-beak) tear
Free meniscal fragment
 Meniscal tear classification

incomplete stable Low clinical relevance

Longitudinal
tear unstable if extensive or with
complete high clinical relevance
Vertical tear meniscocapsular separation

without root tear

Radial tear Unstable high clinical relevance
with root tear

Low clinical relevance

incomplete Stable
Horizontal/ oblique tear
Clinical relevance depend
Complete Unstable/stable
on associated lesion

Horizontal+vertical tear
Bucket-handle tear
Complex tear Unstable high clinical relevance
Flap (parrot-beak) tear
Free meniscal fragment
Meniscal tear

Vertical longitudinal tear

• Linear hyperintensity, parallel to the
long axis of the meniscus
• More frequent in peripheral zone
• May result in meniscocapsular
separation
• Associated with ACL deficiency
• Usually involve posterior horn
• May extend anteriorly
• May transform into bucket-handle tear
• Best view: sagittal Sagittal graphic shows a vertical longitudinal tear (white solid arrow) in the red-white
junction of a meniscus. Vertical tears usually arise in the posterior horn and may
propagate a variable distance anteriorly. They are commonly seen in the setting of
anterior cruciate ligament tears and may occur in either the medial or lateral meniscus.
Vertical longitudinal tear
Meniscal tear

Vertical radial tear

• Linear hyperintensity
perpendicular to the long
axis of the meniscus
• More frequent in central
zone and free margin

Axial graphic shows a partial thickness radial tear (white solid arrow) of
the lateral meniscus at the junction of the body and posterior horn.
Radial tears begin at the free edge of the meniscus and propagate a
variable distance toward the peripheral (capsular) margin.
 Meniscal tear

Vertical radial tear

• Radial tear is considered less
common than other types
• Longitudinal and oblique tear are
usually amenable to repair, while
radial, horizontal and complex
tear generally cannot be repaired
and usually require partial
meniscectomy.
• Impair meniscal function, leading
to degenerative changes.
Axial graphic shows a partial thickness radial tear (white solid arrow) of
the lateral meniscus at the junction of the body and posterior horn.
Radial tears begin at the free edge of the meniscus and propagate a
variable distance toward the peripheral (capsular) margin.
Meniscal tear
Radial tear
Meniscal tear

Vertical radial tear

• Sagittal or coronal view, depends
on the location:
• The Cleft Sign: defect of signal if the
view is perpendicular to the tear
• Marching cleft sign: cleft sign in
multipel sequential slices
• The Ghost Meniscus: defect of
signal if the view is in-line with the
tear (one slice only)
• Truncated triangle sign
Coronal (a) and axial (b) T2WI fatsat images show the
cleft sign of the posterior horn of lateral meniscus
Meniscal tear

Vertical radial tear

• Sagittal or coronal view, depends
on the location:
• The Cleft Sign: defect of signal if the
view is perpendicular to the tear
• Marching cleft sign: cleft sign in
multipel sequential slices
• The Ghost Meniscus: defect of
signal if the view is in-line with the
tear (one slice only) Coronal PD FSE image shows the cleft sign: vertical high-
signal extending through the meniscus.
• Truncated triangle sign
Meniscal tear

Vertical radial tear

• Sagittal or coronal view, depends
on the location:
• The Cleft Sign: defect of signal if the
view is perpendicular to the tear
• Marching cleft sign: cleft sign in
multipel sequential slices
• The Ghost Meniscus: defect of
signal if the view is in-line with the
tear (one slice only)
• Truncated triangle sign
Meniscal tear

Vertical radial tear

• Sagittal or coronal view, depends
on the location:
• The Cleft Sign: defect of signal if the
view is perpendicular to the tear
• Marching cleft sign: cleft sign in
multipel sequential slices
• The Ghost Meniscus: defect of
signal if the view is in-line with the
tear (one slice only) The Ghost Meniscus. Sagittal PD FSE image shows high-
signal intensity area replacing normal low-signal intensity of
• Truncated triangle sign the meniscus. This sign appears when the sagittal image is
through the area of radial tear, and usually appears only on
one frame.
Meniscal tear

Vertical radial tear

• Sagittal or coronal view, depends
on the location:
• The Cleft Sign: defect of signal if the
view is perpendicular to the tear
• Marching cleft sign: cleft sign in
multipel sequential slices
• The Ghost Meniscus: defect of Truncation of the free edge of meniscus. Sagittal T2WI fatsat
signal if the view is in-line with the at the level of tear shows defect of the medial part of the
posterior horn of lateral meniscus.
tear (one slice only)
• Truncated triangle sign
Radial tear

Cleft sign Truncated triangle sign Ghost meniscus sign

 Radial tear

• Four sign of radial tears can

identified 89% of radial tears
• Most effective :
• Cleft sign
• Truncated triangle sign

Harper KW, Helms CA, Lambert HS, Higgins LD. Radial meniscal tears: significance, incidence, and MR appearance.
AJR, 2005; 185:1429-34
Meniscal tear

Radial meniscal root tear

• Radial tear involving meniscal root
ligament
• Posterior root tear of the medial
meniscus associated with:
• DJD
• Cartilage defect
• Medial meniscal extrusion
• Posterior root tear of the lateral
meniscus may have better
prognosis
Oblique axial graphic shows a radial tear of the posterior root of the medial meniscus
(white solid arrow). This tear is commonly seen in the setting of osteoarthritis and
probably occurs due to increased axial loading of the meniscus.
Meniscal tear

Radial meniscal root tear

• MR diagnostic criteria:
• Cleft of high signal intensity of T2WI at the root area
• Meniscal horn does not cover the most medial aspect of the tibial
plateau

• Lee et al (2008): Accuracy of coronal T2WI 96% (compare

to coronal PD 85%)
• Typical pitfalls involve particular location: meniscal root,
intermeniscal connection, and ligamentous attachment
of meniscus (Bolog & Andreisek, 2016)
Meniscal tear

Radial meniscal root tear

Coronal PD and axial T2WI fatsat show a complete posterior root tear.
Meniscal tear

Radial meniscal root tear

Sagittal PD FSE (a) and coronal PD FSE fatsat (b) show a tear of the anterior root of lateral meniscus.
 Meniscal tear

Horizontal/oblique tear
• Linear hyperintensity parallel or
oblique-parallel to the tibial plateau
• Not always related to the symptoms
• May be complete or incomplete
• Complete tear may result in
subluxation and flap formation
• Related to meniscal mucoid
degeneration and cyst formation
Sagittal graphic shows a horizontal cleavage tear of a meniscus. The tear propagates from the free edge of
the meniscus (white solid arrow) peripherally and may reach the capsular margin (white curved arrow).
Horizontal tears often occur in menisci with underlying mucinous degeneration (white open arrow).
 Meniscal tear

Horizontal/oblique tear
• Linear hyperintensity parallel or
oblique-parallel to the tibial plateau
• Not always related to the symptoms
• May be complete or incomplete
• Complete tear may result in
subluxation and flap formation
• Related to meniscal mucoid
degeneration and cyst formation
Sagittal PD FSE image shows a linear signal intensity lesion, oblique-horizontal in orientation, with the tibial
plateau in the posterior horn of the medial meniscus. It is a complete lesion that divides the menisci into an
upper and lower segment. The tear is in contact with tibial articular surface of the meniscus (should be reported).
 Meniscal tear

Horizontal/oblique tear
• Linear hyperintensity parallel or
oblique-parallel to the tibial plateau
• Not always related to the symptoms
• May be complete or incomplete
• Complete tear may result in
subluxation and flap formation
• Related to meniscal mucoid
degeneration and cyst formation
Coronal PD FSE image shows horizontal tear of the posterior
horn of the medial meniscus.
 Meniscal tear

Complex tear
• Linear hyperintensity as
combination of radial, oblique,
horizontal, and vertical/
longitudinal
• Considered very unstable

Sagittal graphic of a complex meniscal tear shows vertical (white curved arrow) and horizontal (white
solid arrow) components in the tear. Complex tears can manifest in a variety of shapes, and a portion
of the meniscus may displace. Complex tears are often seen in the setting of osteoarthritis.
 Meniscal tear

Complex tear
• Linear hyperintensity as
combination of radial, oblique,
horizontal, and vertical/
longitudinal
• Considered very unstable

Sagittal T2WI FSE fatsat shows a tear with complex pattern of the posterior horn: vertical longitudinal
tear (small arrow) combined with horizontal tear (large arrow).
Meniscal tear

Bucket-handle tear
• Extensive vertical longitudinal tear
• Divide the meniscus into a central and peripheral segment that are
still connected anteriorly and posteriorly
• Peripheral non-displaced segment may have only a small truncated
shape
Meniscal tear

Bucket-handle tear
• Central segment displaced
medially in the intercondylar
notch  mechanical locking

Oblique coronal graphic with the knee hyperflexed shows a displaced bucket-
handle tear of the medial meniscus. A vertical longitudinal tear of the meniscus
separates and a displaced mesial fragment (white solid arrow) remains attached
anteriorly (white open arrow) and posteriorly (white curved arrow).
Meniscal tear

Bucket-handle tear
Double PCL sign
• Medial displacement of
central segment, located
parallel dan inferior to PCL
• 100% specificity
• Best seen in sagittal or
Sagittal (a) and coronal (b) PD FSE image shows the displaced central fragment of
coronal view the meniscus parallel and inferior to PCL.
Meniscal tear

Bucket-handle tear
Absent bow-tie sign
• Absence of meniscus body on
3 or more adjacent 3-mm
sagittal slices parallel dan
inferior to PCL
Truncated meniscus sign
Sagittal PD FSE image more medially shows the absent bow-tie
• Loss of normal triangular sign, defined as no visualization of the body of meniscus.

meniscal shape
Meniscal tear

Flap tear
• Displaced flap fragment
results from horizontal,
oblique or vertical tear
• Flap fragment may be
dislocated/flipped adjacent
to the meniscus horns or
synovial recess

Axial graphic demonstrates a lateral flipped meniscus. In this tear, a large portion of the posterior horn (white curved
arrow) is displaced anteriorly and lies adjacent to the anterior horn (white open arrow). This usually involves a
longitudinal tear of the meniscus (white solid arrow) and disruption of its posterior capsular attachments.
Meniscal tear

Flap tear
• Flipped meniscus fragment may
be seen lying anteriorly or
posteriorly to the intact anterior
or posterior horn
• Disproportionate posterior horn sign
• Double (large) anterior horn
appearance
• Missing meniscus sign
Sagittal T2WI fatsat image shows a flipped meniscus
lying adjacent to the intact posterior meniscal horn
resulting into a disproportionate posterior horn sign.
Meniscal tear

Flap tear
• Flipped meniscus fragment may
be seen lying anteriorly or
posteriorly to the intact anterior
or posterior horn
• Disproportionate posterior horn sign
• Double (large) anterior horn
appearance
• Missing meniscus sign
Sagittal PD FSE image shows anterior dislocation of a
fragment of the posterior horn after a vertical longitudinal
tear.
Meniscal tear

Flap tear
• Flipped meniscus fragment may
be seen lying anteriorly or
posteriorly to the intact anterior
or posterior horn
• Disproportionate posterior horn sign
• Double (large) anterior horn
appearance
• Missing meniscus sign
Coronal posterior PD FSE image shows absent of
meniscus (missing meniscus sign) due to dislocation of
the posterior meniscus. The popliteal tendon should not
be misinterpreted as a meniscal fragment.
Meniscal tear

Flap tear: Inferior flap tear

• Complete horizontal tear may
result in flap formation of the
inferior segment, that
displaced inferior to the body
of meniscus between tibial
cortex and MCL.

Coronal PD image shows flipped meniscal fragment inferiorly intu medial gutter deep to MCL.
Meniscal tear

Flap tear: Parrot-beak tear

• Unstable vertical tear with
radial and horizontal pattern
• Mostly involve free margin of
posterior horn of lateral
meniscus
• Flap may be displaced into the
intercondylar notch, mimicking
bucket-handle tear

Axial graphic shows a flap or parrot-beak tear of the posterior horn of the medial meniscus. This is an oblique
radial or longitudinal tear entering the free edge of the meniscus with displacement of the edge, resulting in a
defect shaped like a parrot's beak or the letter "V" (white solid arrow).
Meniscal tear

Flap tear: Parrot-beak tear

• “Parrot-beak” : because of the
curved beak appearance of
the flap noted at arthroscopy.
• DeSmet (2012): The term
reserved for arthroscopy
reports and not to be used in
the MR description.

Axial graphic shows a flap or parrot-beak tear of the posterior horn of the medial meniscus. This is an oblique
radial or longitudinal tear entering the free edge of the meniscus with displacement of the edge, resulting in a
defect shaped like a parrot's beak or the letter "V" (white solid arrow).
Meniscal tear

Free meniscal fragment

• Completely detached meniscal
fragment; may displaced into:
• Joint recesses
• Intercondylar notch
• Suprapatellar pouch
• Fragment has the same signal
intensity as normal meniscus
• Differentiation with osteochondral
fragment Coronal PD fatsat image show a small meniscal fragment
• Origin of the fragment should be detached form the medial meniscus and displaced next
to PCL.
identified
Para meniscal cyst

• Cystic lesion adjacent to the

meniscus, communicating with
the intra meniscal substance
• Result from meniscal tear and
degeneration, and horizontal
tear most frequently associated
• Clinical symptoms are:
• Swelling
• Palpable mass Coronal graphic shows a parameniscal cyst (white open
arrow) arising at the peripheral margin of the meniscus
• Pain related to a horizontal cleavage tear (white solid arrow).
Joint fluid tracks through the tear and fills the cyst.
• Asymptomatic
Para meniscal cyst

• Cystic lesion adjacent to the

meniscus, communicating with
the intra meniscal substance
• Result from meniscal tear and
degeneration, and horizontal
tear most frequently associated
• Clinical symptoms are:
• Swelling
• Palpable mass
• Pain Coronal graphic shows a parameniscal cyst (white open
arrow) arising at the peripheral margin of the meniscus
• Asymptomatic related to a horizontal cleavage tear (white solid arrow).
Joint fluid tracks through the tear and fills the cyst.
Para meniscal cyst

Para meniscal cyst with horizontal tear of the anterior horn of the lateral meniscus. Coronal PD fatsat (a)
and sagittal PD image (b) show a lobulated cyst anteriorly, communicating with horizontal tear of the
meniscus.
Para meniscal cyst

Sagittal T2WI fatsat FSE image (a) and coronal PD FSE image show a lobulated cystic lesion of intermediate signal,
adjacent to the anterior horn of the lateral meniscus.
Indirect sign of meniscal injury

If identified, carefully evaluate the meniscus

1. Subchondral bone marrow edema (bone bruise) beneath
a meniscus
• PPV 92-100% (Bergin et al, 2008)
2. Meniscal extrusion
• There is a close association between meniscal extrusion and
root tears. Specifically, 76% of medial root tears have extrusion,
and 39% of extrusions have medial root tears (Choi et al, 2010)
3. Para meniscal cyst
• Association is reported in 90-100% of MRI series (De Smet et
al, 2011)
How to improve MR interpretation?

Two Slice Touch Rule (DeSmet, 2006)

• If intrameniscal signal contacted the surface of the
meniscus on only one MR image 18–55% likelihood
• If there was surface contact on two or more images 
90–96% likelihood of meniscal tear
• The signal to the surface must be in the same area on
the two images, but one image can be in the coronal
plane and one, in the sagittal plane.
About meniscal fraying

• Irregular surface of meniscal free

edge without discrete tear
• May be clinically significant and
treated by resection as free-edge
tearing. However, in most patients it
is asymptomatic.
• Fraying noted on MRI may or may
not be described in an arthroscopic
report depending on the extent of
fraying and symptoms.
Coronal graphic shows fraying of the free edge of the meniscus (white solid arrow) consisting
of fibrillation and multiple tiny irregularities in the normally smooth, tapered surface.
About meniscal fraying

• MR appearance: loss of
sharp tapered of the free
edge
• Nguyen et al (2014):
Although require further
research, fraying can be
reported if it is found in
younger patients after an
acute trauma.

Coronal graphic shows fraying of the free edge of the meniscus (white solid arrow) consisting
of fibrillation and multiple tiny irregularities in the normally smooth, tapered surface.
Summary

1. MR interpretation of the meniscus should focus on

identification and accurate description.
• Identification: presence/absence of tear
• Description: orientation, location, length, stability
2. Special attention for the use of proper terminology
• associated with clinical relevance
• influence the decision for surgery
3. Sagittal and coronal view in PD and T2WI +/- fatsat is
very important
References

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knee: a guide to evaluation and reporting. Switzerland: Springer International Publishing, 2015. p.65-
94
2. Lee SY, Jee WH, Kim JM. Radial tear of the medial meniscal root: reliability and accuracy of MRI for
diagnosis. AJR Am J Roentgenol, 2008;191(1):81–5
3. Barber BR, McNally EG. Meniscal injuries and imaging the post operative meniscus. Radiol Clin North
Am, 2013;51(3):371-91
4. Bolog NV, Andreisek G. Reporting knee meniscal tears: technical aspects, typical pitfalls, and how to
avoid them. Insights Imaging, 2016;7:385-98
5. DeSmet AA. How i diagnose meniscal tears on knee MRI. AJR Sep 2012, 199;481-99
6. Jee WH, McCauley TR, Kim JM, et al. Meniscal tear configurations: categorization with MR imaging.
AJR 2003; 180:93–97
7. De Smet AA, Tuite MJ. Use of the “two-slice- touch” rule for the MRI diagnosis of meniscal tears. AJR
2006; 187:911–914.
8. Nguyen JC, DeSmet AA, Graf BK, Rosas HG. MRI imaging-based diagnosis and classification of
meniscal tears. Radiographics. 2014;34:981-99
 MR Pathology
of the Meniscus
Marcel Prasetyo
Division of MSK Imaging
Department of Radiology FKUI-RSCM