meniscal tears
TRANSCRIPT
Objectives Objectives
You will be able to identify the two menisci in the kneeYou will be able to identify the two menisci in the knee You will know the most common mechanisms of You will know the most common mechanisms of
meniscal tearsmeniscal tears You will be able to recognize and evaluate a meniscal You will be able to recognize and evaluate a meniscal
teartear You will know the proper treatments and rehabilitation for You will know the proper treatments and rehabilitation for
a meniscal teara meniscal tear You will understand the requirements for an athlete to You will understand the requirements for an athlete to
return to playreturn to play You will learn various stretches and strengthening You will learn various stretches and strengthening
techniques for preventiontechniques for prevention
The Knee JointThe Knee Joint
The knee joint has two The knee joint has two menisci, a lateral and menisci, a lateral and medialmedial
They are fibrous cartilageThey are fibrous cartilage They rest on top of the They rest on top of the
tibia in shallow tibia in shallow indentationsindentations
The lateral meniscus is on The lateral meniscus is on the outside of your knee the outside of your knee and the medial the insideand the medial the inside
Functions of the menisciFunctions of the menisci
Aid in lubrication and Aid in lubrication and nutrition of the jointnutrition of the joint
Act as shock Act as shock absorbersabsorbers
Evenly distribute Evenly distribute weight throughout the weight throughout the kneeknee
Allows for smoother Allows for smoother motions between the motions between the femur and tibiafemur and tibia
The inner 2/3 of the The inner 2/3 of the menisci are avascular menisci are avascular (without blood supply)(without blood supply)
The remaining outer 1/3 The remaining outer 1/3 is vascular (with blood is vascular (with blood supply)supply)
Mechanisms of injuryMechanisms of injury
An acute twisting injury from An acute twisting injury from impact during a sportimpact during a sport Usually the foot stays fixed on the Usually the foot stays fixed on the
ground and the rest of body ground and the rest of body rotatesrotates
Getting up from a squatting or Getting up from a squatting or crouching positioncrouching position
Loading the knee from a fixed Loading the knee from a fixed positionposition
Injuring the meniscusInjuring the meniscus There are several types of tearsThere are several types of tears
Vertical Vertical Radial Radial HorizontalHorizontal DegenerateDegenerate Complex Complex HornHorn
A loss of any part of the meniscus causes A loss of any part of the meniscus causes uneven weight distribution and can lead to early uneven weight distribution and can lead to early wear of the kneewear of the knee
The lateral meniscus is not attached as firmly to The lateral meniscus is not attached as firmly to the tibia as the medial meniscus, making it less the tibia as the medial meniscus, making it less likely to become injuredlikely to become injured
Meniscal injury statsMeniscal injury stats Meniscal injuries occur in 15% of ACL injuriesMeniscal injuries occur in 15% of ACL injuries 80% of patients with a history of ACL tears will 80% of patients with a history of ACL tears will
likely tear their meniscus with incidences of likely tear their meniscus with incidences of instability of the kneeinstability of the knee
70.7% of meniscal injuries are to the medial 70.7% of meniscal injuries are to the medial meniscusmeniscus
Almost all meniscal injuries ages 20 and under Almost all meniscal injuries ages 20 and under are sports related 11 out of 12 casesare sports related 11 out of 12 cases
Ages 20-29, 64.5% were sports relatedAges 20-29, 64.5% were sports related Ages 30-39, 30.6% were sports relatedAges 30-39, 30.6% were sports related Ages 40-49 and 50-59 only 19.6% and 14.3% Ages 40-49 and 50-59 only 19.6% and 14.3%
were sports relatedwere sports related
What to look for?What to look for?
Not all meniscal tears are symptomaticNot all meniscal tears are symptomatic If there are symptoms you could look for:If there are symptoms you could look for:
SwellingSwelling Pain along the joint line (tenderness)Pain along the joint line (tenderness) Pain when squatting, kneeling or pivotingPain when squatting, kneeling or pivoting Locking of the kneeLocking of the knee Loss of full knee extensionLoss of full knee extension
How can the coach help?How can the coach help?
If there is a possible meniscal tear 80-90% of the If there is a possible meniscal tear 80-90% of the time an athlete will remember the mechanism of time an athlete will remember the mechanism of the injury and may report a “pop” or a “snap”the injury and may report a “pop” or a “snap”
You could ask the athlete if there is pain when You could ask the athlete if there is pain when weight bearing, or bending of the kneeweight bearing, or bending of the knee
You could also ask the athlete if they are having You could also ask the athlete if they are having any locking in their knee or trouble extending the any locking in their knee or trouble extending the knee all the wayknee all the way
When there is a meniscal injuryWhen there is a meniscal injury
As a coach in the event of a meniscal As a coach in the event of a meniscal injury you should injury you should Ice the area in painIce the area in pain Limit movement of the knee joint (rest)Limit movement of the knee joint (rest) Keep weight bearing limited to a tolerable Keep weight bearing limited to a tolerable
level of pain for the injured kneelevel of pain for the injured knee Sometimes a splint can be applied for comfortSometimes a splint can be applied for comfort
Rehabilitation optionsRehabilitation options There are two common ways that a meniscal tear There are two common ways that a meniscal tear
can be repaired surgically can be repaired surgically There is also a non surgical option because the There is also a non surgical option because the
menisci are partially vascular they have the menisci are partially vascular they have the ability to heal themselvesability to heal themselves
Why choose surgery?Why choose surgery?
Surgery is usually advised for a few Surgery is usually advised for a few different reasonsdifferent reasons The location of the tear, if the tear is in a The location of the tear, if the tear is in a
avascular zone it will most likely not heal itselfavascular zone it will most likely not heal itself If the tear is longer than 5-8mm If the tear is longer than 5-8mm If the pain limits activities of daily livingIf the pain limits activities of daily living Or if the individual is not happy with their level Or if the individual is not happy with their level
of functionof function
Surgical techniquesSurgical techniques
The more common technique is arthroscopic The more common technique is arthroscopic partial menisectomy, which consists of removing partial menisectomy, which consists of removing the torn fragment of the meniscusthe torn fragment of the meniscus This reduces irritation, but can effect the weight This reduces irritation, but can effect the weight
distribution in the kneedistribution in the knee The other option is an arthroscopic repair, which The other option is an arthroscopic repair, which
requires suturing the meniscus back togetherrequires suturing the meniscus back together This option attempts to conserve the meniscus in This option attempts to conserve the meniscus in
hopes of preventing the early onset of arthritishopes of preventing the early onset of arthritis
Road to recoveryRoad to recovery
Whether you choose the surgical or Whether you choose the surgical or conservative approach, the rehabilitation is conservative approach, the rehabilitation is similar similar
The rehabilitation time frames can vary The rehabilitation time frames can vary depending on the individual and the severity of depending on the individual and the severity of the tearthe tear
The protocols may vary depending on the The protocols may vary depending on the surgical approach and physician. A common surgical approach and physician. A common protocol may include the followingprotocol may include the following
Steps to recoverySteps to recovery The patient may be full weight bearing right after The patient may be full weight bearing right after
the surgery with or without crutchesthe surgery with or without crutches Initial symptoms can be reduced using certain Initial symptoms can be reduced using certain
modalities and manual techniquesmodalities and manual techniques Stretching/ flexibility exercises focusing on Stretching/ flexibility exercises focusing on
hamstrings, quadriceps, hip flexors, hip hamstrings, quadriceps, hip flexors, hip adductors and calf muscles adductors and calf muscles
Strengthening Strengthening Balance trainingBalance training Dynamic exercises/plyometricsDynamic exercises/plyometrics
Initial physical therapyInitial physical therapy The first few sessions of physical therapy may The first few sessions of physical therapy may
consist more of modalities and some manual consist more of modalities and some manual techniques to address inflammation, pain and techniques to address inflammation, pain and ROM such as:ROM such as: Heat/iceHeat/ice UltrasoundUltrasound Electrical stimulationElectrical stimulation Manual stretchingManual stretching Scar and patella mobilizationsScar and patella mobilizations Passive range of motion for full knee flexion and Passive range of motion for full knee flexion and
extensionextension Retrograde massage to decrease swellingRetrograde massage to decrease swelling
Once pain and swelling are reduced the Once pain and swelling are reduced the sessions mainly focus on increasing the sessions mainly focus on increasing the strength and flexibility of the lower strength and flexibility of the lower extremity as toleratedextremity as tolerated
The progression will vary depending on The progression will vary depending on the individualthe individual
Some examples of stretching and Some examples of stretching and strengthening exercises are illustrated in strengthening exercises are illustrated in the following slidesthe following slides
StretchingStretching HamstringsHamstrings
QuadricepsQuadriceps
Calf musclesCalf muscles
Stretching continuedStretching continued
Hip flexorsHip flexors
Hip adductorsHip adductors
StrengtheningStrengthening Focusing on strengthening the muscles around Focusing on strengthening the muscles around
the knee is essential in rehabilitation the knee is essential in rehabilitation Quad sets Straight leg raises (in all planes)Quad sets Straight leg raises (in all planes)
Heel raises Leg Curl Heel raises Leg Curl
Leg extensionLeg extension
BalanceBalance
Balance can Balance can sometimes be sometimes be compromised after an compromised after an injury or surgeryinjury or surgery
Here are some Here are some balance exercises balance exercises that can helpthat can help
Dynamic exercises/plyometricsDynamic exercises/plyometrics
Progression to more Progression to more dynamic sports dynamic sports specific exercises specific exercises helps with the helps with the transition back into transition back into sportssports
Return to playReturn to play
This can vary widely from athlete to This can vary widely from athlete to athleteathlete
When the athlete can participate in sport When the athlete can participate in sport specific exercises without pain or specific exercises without pain or weaknessweakness
Full ROM is apparent in the injured kneeFull ROM is apparent in the injured knee Collaborate decision between athlete, Collaborate decision between athlete,
physical therapist and physicianphysical therapist and physician
PreventionPrevention
The prevention of meniscal tears is very The prevention of meniscal tears is very similar to the rehabilitation similar to the rehabilitation
Research has shown that more flexible Research has shown that more flexible and stronger joints are less likely to get and stronger joints are less likely to get injuredinjured
The athlete would continue stretching and The athlete would continue stretching and strengthening the lower extremitiesstrengthening the lower extremities
BibliographyBibliographyLearmonth, DJA. “Aspects of the knee: meniscal injury and surgery.” Trauma. 2000. Vol. 2 Learmonth, DJA. “Aspects of the knee: meniscal injury and surgery.” Trauma. 2000. Vol. 2
p. 223-230p. 223-230
Gilbert, Rob. Ashwood, Neil. “Meniscal repair and replacement: a review of efficacy.” Gilbert, Rob. Ashwood, Neil. “Meniscal repair and replacement: a review of efficacy.” Trauma. 2007. Vol. 9 p. 189-194Trauma. 2007. Vol. 9 p. 189-194
Lento, Paul. Akuthota, Venu. “Meniscal injuries: A critical review.” Journal of Back and Lento, Paul. Akuthota, Venu. “Meniscal injuries: A critical review.” Journal of Back and Musculoskeletal Rehabilitation. 2000. Vol. 15 p. 55-62Musculoskeletal Rehabilitation. 2000. Vol. 15 p. 55-62
Boyd, Kevin. Myers, Peter. “Meniscus preservation; rationale, repair techniques and results.” Boyd, Kevin. Myers, Peter. “Meniscus preservation; rationale, repair techniques and results.” The Knee. March 2003. Vol. 10 Iss. 1 p. 1-11The Knee. March 2003. Vol. 10 Iss. 1 p. 1-11
Brindle, Timothy. Nyland, John. Johnson, Darren. “The Meniscus: Review of Basic Brindle, Timothy. Nyland, John. Johnson, Darren. “The Meniscus: Review of Basic Principles With Application of Surgery and Rehabilitation.” Journal of Athletic Training. Principles With Application of Surgery and Rehabilitation.” Journal of Athletic Training. Apr-Jun. 2001. Vol. 36 p. 160-169Apr-Jun. 2001. Vol. 36 p. 160-169
Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 Iss. 2 p. 143-149Iss. 2 p. 143-149
Magee, David. “Orthopedic Physical Assessment 2Magee, David. “Orthopedic Physical Assessment 2ndnd edition.” Philadelphia: W.B. Saunders edition.” Philadelphia: W.B. Saunders Company, 1992 Company, 1992