Tales of A Torn Meniscus… Do they all need surgery?
Tales of a torn meniscus from a physiotherapist who has one!
Let me tell a tale of a torn meniscus from a person who is fortunate to get to help people with them every day. Let me previse this article with the notion that not all meniscus tears are the same. Rather, it is my intentions to share a personal story that will help some of you understand why some knees require surgical intervention while others do not.
I will not speak of percentages, but I will instead share some insight into my own personal clinical reasoning as to who needs an MRI, who does not, who needs rehabilitation and who needs surgery. I am one of the fortunate individuals who have not needed surgery and am able to perform almost all tasks that I ask of my knee, including soccer, water skiing and even squash.
The Back Story
15 years ago I was injured playing rugby. My knee was bridged across another players body when a larger individual, we call them “props” in rugby, fell onto my knee causing it to hyperextend. I immediately sensed that something was wrong, but was able to carry my own weight off of the field. In fact, despite some swelling, I was able to finish the season without any treatment.
Fast forward 5 years, and while doing some work around our home that required me to climb a ladder repetitively, I began to get sharp pain on the inside of my knee. At this point I realized that my rugby days would never be forgotten.
What complaints will suggest that I have a tear?
There are a few tell-tale signs of meniscus damage that I look for while taking a history from a patient. One of them is localized pain on the inside of the knee, something we refer to as medial joint line pain which is what I was getting. It can also be localized pain in the back and outside of the knee, referred to a posterior lateral knee pain.
The pain may be sharp or instead it can just be a constant dull ache sensation. It usually hurts more when bending the knee deeply or straightening it fully. It can also hurt when twisting on the knee with your foot fixed on the ground. These locations and natures of pain may indicate meniscus damage. In my case, at around this time my knee began to lock, especially when I was squatting to the floor or kneeling onto my heels. Locking in the knee is when it literally gets stuck. If this is happening to you, you may very well have a torn meniscus. Clicking in the knee is not the same as locking and can be very benign.
What findings during assessment indicate a torn meniscus?
At this time, I underwent an assessment from a colleague to confirm what I was quite sure was a torn meniscus. When assessing a knee, we perform certain tests. These tests are mostly provocative, meaning that we are trying to cause or reproduce the pain that you are getting. One test is called a bounce test. We take your knee and let it hyperextend just using the weight of the knee itself. This causes a pain on the inside of the knee and may also cause the knee to spring once it is bounced. This test in my opinion simply indicates that there is something within the joint that is evoking pain. The next test that I utilize is called McMurray’s exam. The knee is compressed, flexed (bent) and rotated all at once and throughout the range of motion. A positive exam is again one that reproduces pain and can even sometimes reproduce locking. Apley’s exam is the third test I use. Laying on your stomache, the knee is placed at a 90 degree bend and the examiner pushes down through the heel and rotates the leg. Again, we are looking for pain. Finally, I use a test called the swipe test. This exam will provoke a pocket of swelling to appear in the location of the tear after swiping the knee with our hand.
These tests are usually pretty reliable. However, the absence of positive findings does not mean that there is not a tear, and when the knee pain, dysfunction and swelling persist, a MRI may be indicated to confirm the presence of a tear.
These exams are brought together to give a clinical picture. In my case, all of these examinations are positive. My knee also locks but I have not needed surgery… so far anyway.
In my opinion, a diagnosis of torn meniscus is not an indication for surgery.
Certain tears can be quite inconsequential. Even major tears that are found on MRI do not necessarily require surgery. In these cases, you may have an episode of swelling, pain and even locking that with treatment resolves within a window of 2 to 3 months. In my opinion, all tears should be treated first with physiotherapy and not just because I am a physiotherapist. Often, with treatment aimed at reducing swelling, inflammation and increasing ROM and functional strength, your knee can function normally.
So I have learned that the result of treatment (rehabilitation) over time is one of the best indicators of the necessity for surgery. If the swelling and or pain persists or if the pain and swelling return again once rehab has finished, then it is likely that surgery will be required. If the knee pain and swelling persistently keep one from work or activity, again over time, then surgery may be required.
If not, then in my opinion a knee with torn cartilage is better than one with removed cartilage. Not to mention that despite the skill of our orthopedic surgeons, surgery is in itself another trauma and recovery is not guaranteed. Please note that this is based on my experience to date and I believe that there will be research results forthcoming that will support this notion.
In my case, my knee still locks and will intermittently get sore. I am able to play all of the sports that I enjoy and I have no swelling. I have a significant tear but I will avoid surgery for now.
Conversely, I have some patients who have minor tears and unfortunately their knee pain and swelling persist. Their knee may or may not lock, but they have difficulty with everyday activity or enjoying the sports that they want to play. This has persisted for a period greater than a year. If this is you, then surgery may be your best option.
In conclusion, it appears to me that the irritability of the tear, the nature of your work or sport and the ability for you to enjoy activity is what may make surgery necessary. Just don’t rush to it!
In Health, Grant Fedoruk
This information is not meant to replace the advice or treatment of a qualified physician or physiotherapist. It is meant for information only. Please seek an assessment and discuss your treatment options with your caregiver prior to making a decision about your treatment path.