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What is the best treatment for a Torn Meniscus?

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Meniscus tears in the knee is an extremely common injury in the sporting as well as non-sporting community. Treatment for this condition usually follows one of two routes: 1. Conservative management through an exercise programme or 2. Surgical management.

But what is the best treatment for a torn meniscus and are you just delaying the inevitable by not opting for surgery immediately? A recent study published on the BMJ open access website may hold the answers to these questions.


In this article:

  • What is a meniscus?

  • What causes a meniscus to tear?

  • Surgery for meniscus tears – is it a good idea?

  • What is the best treatment for meniscus tears?

  • Exercise programme for meniscus injuries.

I discuss how to choose your rehab exercises in much more detail in this video:



What is a meniscus?


Your knee joint is formed between the Femur (thigh bone) and Tibia (shin bone) and the kneecap. All the joint surfaces are covered in smooth cartilage. The medial and lateral menisci are found between the Femur and Tibia.


They are c-shaped discs of cartilage that help to absorb some of the shock that goes through the knee joint when you are standing, walking and running. By doing this, they protect the cartilage that covers the joint surfaces. They also increase the congruency of the joint surfaces so that the bones “sit” better on top of each other.



What causes a meniscus to tear?


There are 2 main reasons why you may tear a meniscus:

  1. Trauma. A sudden strong force that usually involves a rotation movement of the knee can tear a meniscus. An example of this is when a footballer’s foot remains planted in the ground while he then forcefully turns around.

  2. Wear and tear. As we age (researchers puts anyone over age 35 in this group!) the menisci becomes a bit weaker and they can sometimes spontaneously tear with very simple activities e.g. squatting to the floor or walking up a hill or struggling to turn a heavy shopping trolley in Tesco.

Reasons for this wear and tear include genetics, being overweight, if you have done lots of sport or activities that strained them in your younger days etc.


Surgery for meniscus tears – is it a good idea?


Arthroscopic partial meniscectomy is the most frequent surgical procedure performed by orthopedic surgeons for meniscus injuries. This is where they enter the knee through a few small incisions and, with the help of a camera, remove part of the meniscus.


The problem is that research has shown that people, in whom this procedure has been performed, are at increased risk of developing knee osteoarthritis.


This makes sense when you think about the function of the menisci. They are there to absorb shock and protect the joint surfaces. If you take them out you leave the joint surfaces exposed and you are likely to wear their cartilage out quicker.


There is also strong evidence that meniscal tears are a very common natural process and that a tear in itself does not necessarily cause you pain in the long run. Several large studies have been performed where they have scanned hundreds of people’s knees. Some of these people did have knee pain, but others did not.


What they found was that meniscal tears were present in both groups of people (with and without pain). What this means is that while tearing a meniscus is a painful event, that pain will likely settle over time and surgery is not routinely needed to “fix” it.


Saying this, there are of course always exceptions to the rule. In some cases a torn meniscus can fold back on itself and cause locking of the knee. Surgery may be needed when this happens.


What is the best treatment for meniscus tears?


It appears that the research is ruling in favour of non-surgical treatment that focusses on strengthening the muscles in the legs.


A good example of this is a study that has just been published on the BMJ website where researches compared the outcomes of 2 groups of people who have all sustained degenerative tears of their menisci. One group underwent a 12 week exercise programme while the other underwent partial meniscectomy surgery.


The results:

  • No clinically relevant difference was found between the two groups for pain and function at two years

  • At three months, muscle strength had improved in the exercise group.

  • No serious adverse events occurred in either group during the two year follow-up.

  • 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.

If you take into account that surgery has been shown to increase your risk of developing osteoarthritis in the knee, I would choose exercise every time!


Exercise programme for a torn meniscus


There are a few things that you have to understand, before you start this exercise programme.

  1. Please consult a physiotherapist before you start this programme as I cannot guarantee that it is the correct exercises for you.

  2. Your knee will likely be very painful and swollen and have some restricted range of motion immediately after injuring it.

  3. This exercise programme is for people whose knees have settle down a bit.

  4. You should not force any movements into pain. It is OK to feel some mild discomfort while doing the exercises and for a short period afterwards, but you should not experience a big increase in pain or swelling.

  5. This programme will only provide you with basic strength. It is not sufficient to be able to get you back to doing sport. You need to add in sport specific exercises before you return to your sport – a physio can help you with this.

  6. I have broadly based this programme on the exercises that they used in the Norwegian study discussed above. I have left out the more dynamic exercises since you are at risk of injuring yourself if you do not perform them with good technique.

  7. I have tried to stick to exercises that can be performed at home so that anyone can do it.

You are also welcome to book an online physio consultation with me if you wanted a diagnosis of your injury, a bespoke programme or just want to make sure that you are doing the right things. These appointments are done over Skype and you can read more about the online consultation process here.


Meniscus Injury Rehab Programme


Frequency: You should perform these exercises at least twice a week and at most three times a week. Do not do them on consecutive days.


Duration: Continue the exercises for at least 12 weeks.


Stages: You will notice that each exercise will give you clear instructions of when you are ready for the more advanced version. Start by doing the beginner exercises. When you reach their progression goals, replace them with the suggested progression exercise.


Download programme as PDF


Cycle


Use a stationary bike so that you do not risk injuring your knee if you have to stop quickly. Aim for 20 to 30 minutes easy cycling.






Swim


Do NOT do breast stroke – the circular movement of the legs will likely aggravate your injury. Use a floating device and kick slowly and controlled up and down the pool. You can start doing freestyle if you feel your knee is OK with straight kicking. You can also practice to balance and walk up and down in the water for exercise.


Basic Balance Exercise

You can start doing this as soon as pain allows. I usually don’t want my patients to feel more than a 2/10 discomfort during or after this exercise.

Starting position: Stand on both feet and correct your foot posture if needed. Place your hands on your hip.

Movement: Slowly lift your uninjured leg up in front of you.

Check that: Your pelvis stays level and your foot arch stays up.

Dosage: You should aim to be able to stand on one leg for 30 seconds without your foot shaking or your body swaying. You may have to start with 10 seconds and slowly work your way up to 30. I find that you get better results if you do this often during the day.

Progression: Once you've mastered standing on one leg, see if you can do it while slowly moving your head from side to side. Then see if you can do it while moving your arms.


Double Leg Squat (Beginner)


You can start this exercise as soon as pain allows. You may find that you cannot go down very low to start with. That’s OK. Only go down to where it is comfortable. You will be able to go down lower as your knee recovers.

Starting position: Standing with feet pointing forwards and spaced hip distance apart.

Movement: Squat down by pushing your bottom out to the back (pretend you want to sit on a chair) and bending your knees. Hold the position for 3 seconds and return to standing upright.

Check that: Your feet stays in a good neutral position. Your knees should move in line with your second toe. Your bottom sticks far out to the back.

Dosage: Start with whatever your knee allows you to do but you should aim to get up to 3 sets of 12 repetitions over time. Rest 2 minutes between the sets. Once you can easily achieve this, progress by replacing it with the single leg squat.

Single Leg Squat (Progression)


Starting position: Balance on one leg.

Movement: Slowly bend your knee and stick your bottom out to the back (pretend you want to sit on an imaginary chair). Hold the position for 3 seconds and return to upright.

Check that: Your ankle and foot should remain in a good position and not collapse in. Your supporting knee should move in line with your second toe and your bottom must stick out backwards to activate your glutes. Your hips/pelvis should remain level.

Dosage: Start by doing 3 sets of 6 repetitions and slowly build up to doing 3 sets of 12 repetitions. Rest 2 minutes between sets.

Double Leg Bridge (Beginner)



Starting position: Lie on your back with your hips and knees bent to 90 degrees and your feet on a chair.

Movement: Tighten up your stomach muscles and lift your bottom off the floor until your trunk and pelvis is in a straight line. Squeeze your buttocks and stomach muscles and hold the position.

Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. If you find that your hamstrings cramp, shift your bottom closer to your feet.

Dosage: Hold the position for 10 seconds. Rest for 10 seconds Repeat 10 times. Once this is easy progress this exercise by replacing it with the bridge with leg lifts.

Bridge With Leg Lifts (Progression)



Starting position: Lie on your back with your hips and knees bent to 90 degrees and your feet on a chair.

Movement: Tighten up your stomach muscles and lift your bottom off the floor until your trunk and pelvis is in a straight line. Squeeze your buttocks and stomach muscles and hold the position. Now slowly lift your one leg off the chair, but make sure that your pelvis remains absolutely level. Replace that leg and lift the other one.

Check that: Your pelvis stays absolutely level. If you find that your hamstrings cramp, shift your bottom closer to your feet.

Dosage: Lift your legs 10 times alternating the left and right. Rest 2 minutes. Do 3 sets in total. Aim to build up to 3 sets of 20 lifts.

Step Ups (Beginner & Progression)


Starting position: Stand facing a low step. You can even use a thick book to start with.

Movement: Place your injured leg on the step and use it to lift you onto the step or book. Try not to push with the uninjured leg. Then slowly lower yourself back down placing the uninjured leg down first.

Check that: Your knee moves in a straight line over your foot – it should not turn in or out.

Dosage: Aim to do 10 slow repetitions. Rest 2 minutes. Repeat 3 times. Start with a very low step that does not cause you pain when you step onto it. You can progress the exercise by increasing the height of the step or by putting some extra weight in a back pack on your back (e.g. 2kg bag of sugar).

Let me know if you have any questions. Need more help with an injury? You can consult me online using Skype video calls. I've also created a free Facebook group where you can ask question and get injury prevention advice.

Best wishes

Maryke

Sports Physiotherapist


References:

  1.  Englund  M, Guermazi  A, Gale  D, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. New England Journal of Medicine 2008;359(11):1108-15. doi: doi:10.1056/NEJMoa0800777

  2. Kise Nina Jullum RMA, Stensrud Silje, Ranstam Jonas, Engebretsen Lars, Roos Ewa M Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016;354 :i3740(http://www.bmj.com/content/354/bmj.i3740)

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