• Meniscus disorders, knee. In: The medical disability advisor: workplace for guidelines for disability duration. 6th ed. Westminster (CO): Reed Group; 2009. p. 9. [9 references]

This is the current release of the guideline.

It updates a previous version: Reed Group. Meniscus disorders, knee. Westminster (CO): Reed Group; 2005. 10 p. [8 references]

Diagnosis

History

In younger individuals, there is usually a history of trauma. The individual may recall feeling a popping or snapping sensation when the trauma occurred. In older individuals, the trauma may be nonspecific, such as repeated squatting or kneeling. The individual may complain of knee pain, swelling, limited range of motion, and a clicking sound. Locking (an inability to straighten the knee) or buckling (a sudden giving way of the knee) may occur.

Physical Exam

The exam may reveal tenderness over the medial or lateral joint line of the knee. There may be evidence of fluid buildup (effusion) in the joint. Squatting may cause pain. Tests that apply rotational and axial compression forces to the knee (such as Apley's compression test or McMurray's test) often reveal a palpable click or localized pain suggestive of meniscal injury.

Tests

Plain x-rays are not diagnostic but can rule out fracture, arthritis, and most loose bodies. Magnetic resonance imaging (MRI) is a non-invasive method of evaluating the condition of the menisci and is the standard imaging method used. On MRI, the menisci of older individuals may show evidence of aging that is not related to injury. Individuals who cannot undergo MRI testing may be evaluated by an arthrogram (x-rays taken after dye is injected into the joint) or computed tomography (CT) arthrogram. The interior of the joint can be examined directly by exploratory arthroscopy, the insertion of a very small viewing scope (arthroscope) into the knee joint through a small surgical opening. The diagnostic accuracy, sensitivity, and specificity of arthroscopy approach 100%. If indicated, arthroscopic surgery to trim or repair a meniscal tear may be performed at the same time.

Treatment

Smaller meniscal tears with mild, tolerable symptoms may be treated with rehabilitative exercise, activity modification, and analgesics in individuals unwilling to undergo surgery. More symptomatic meniscus injuries are treated surgically. Successful surgery preserves as much of the meniscus as possible while offering relief of symptoms. Some meniscal tears can be repaired by suturing. The surgeon must determine the possibility of repair at the time of surgery. Meniscus repair is generally reserved for younger individuals, and it is estimated that only 10% to 15% of meniscal tears are reparable. Most tears require removal of the damaged part of the meniscus (subtotal or partial meniscectomy). Subtotal meniscectomy removes the minimum amount necessary so as to leave behind the maximum amount of undamaged meniscus. Subtotal meniscectomy is preferable to total meniscectomy even though remaining meniscal tissue may be subject to subsequent tears or degeneration. Subtotal meniscectomy is the most commonly performed meniscal surgery. Because removal of the entire meniscus (complete or total meniscectomy) leads to bone remodeling and cartilage degeneration (osteoarthritis), it is avoided whenever possible. If a complex tear requires total meniscectomy in a younger person who does not yet have significant arthritic change in the knee, the option of meniscal transplant may be considered.

Arthroscopy is now the standard of care for meniscal surgery. Arthroscopy has the advantage of producing less pain and a quicker recovery. However, arthroscopic meniscectomy is occasionally difficult, depending on the type and location of the tear and the presence of adhesions. In those cases when the entire meniscus must be removed, open surgery may be preferable to avoid damaging the articular surfaces.

See the original guideline document for information on prognosis and differential diagnoses.

Rehabilitation

The primary focus of rehabilitation for a meniscus disorder of the knee is to control pain and restore function. The rehabilitation program will depend on the extent of injury, length of time since injury, integrity of the knee joint, possibility of surgery, and the functional goals of the individual.

Initially, if pain is an issue, modalities such as heat and cold may be used. Unless the knee is swollen, it is common to initiate physical therapy with a heat treatment and conclude with cold. Additionally, cold may be used as needed to control the edema often associated with meniscus disorders. Gait training with an assistive device may be necessary for independent ambulation; the treating physician will determine the individual's ability to bear weight on the affected knee.

The next goal is to restore motion and strength to the involved knee, with exercise progression according to the recommendations of the physician. Knee range of motion exercises can help to restore full mobility to the joint. Therapy should progress to strengthening exercises as tolerated. Throughout the period of strengthening, therapy should include flexibility exercises. Although strong muscles around the joint are critical, flexibility of the same muscle groups must be considered. It is important to emphasize closed chain exercises, in which the foot is stabilized, as well as open chain exercises, in which the foot is free to move, during this stage of rehabilitation. It may also be necessary to strengthen the adjacent joints if limited weight bearing was necessary after the injury.

The therapist should continue to use modalities as needed to control pain and swelling, and, when appropriate, the therapist should instruct individuals in a home exercise program to be performed independently, complementing the supervised exercise regimen.

When full, pain-free motion is regained and the individual has sufficient strength for all activities of daily living, the individual may be progressed to balance and proprioceptive exercises. The extent of these exercises will be determined by the physician, individual, and physical therapist.

Prior to discharge from physical therapy, individuals should understand both the need for continued exercise to maintain the stability of the knee joint and ways to protect the joint during work and leisure activities. Although a meniscus can heal within approximately 12 weeks, the joint should be protected from heavy loading until the meniscus has regained its full strength.

Frequency of Rehabilitation Visits

Rehabilitation Disclaimer: The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

See the original guideline document for information about comorbid conditions, complications, and factors influencing duration.

Length of Disability

Duration depends on job requirements.

Medical Treatment, Meniscus Disorder

Surgical Treatment, Arthroscopic Meniscectomy

Surgical Treatment, Meniscus Repair

Surgical Treatment, Open Meniscectomy

Return to Work (Restrictions/Accommodations)

The individual may need to use crutches or a cane temporarily when walking. Standing and walking may need to be limited temporarily. Squatting, kneeling, and crawling may need to be limited permanently. Increased awareness of the knee's position while twisting, turning, or lifting, and reestablishing knee fitness, emphasizing strength and flexibility, will help prevent recurrent problems.

Failure to Recover

If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.

Regarding Diagnosis

• Does individual have a history of trauma, especially twisting of the knee?
• Did individual feel a popping or snapping sensation when the trauma occurred?
• Does repeated squatting or kneeling cause pain?
• Is knee swollen and does it have a limited range of motion?
• Were x-rays done to rule out a fracture?
• Was an MRI done to confirm the diagnosis? If not, was an arthrogram done?
• Was meniscus examined directly by exploratory arthroscopy?
• Was arthroscopic surgery done at the same time?
• Is individual a candidate for meniscal reconstruction?

Regarding Treatment

• Is individual actively participating in the rehabilitation regimen?
• Has individual demonstrated an increase in range of motion at each physical therapy session?
• Has a post-operative MRI been done to determine if additional surgery is indicated?
• Is chondromalacia of the articular surface of the patella or of the weight bearing portion of the femur or tibia present on MRI or noted in the operation note?

Regarding Prognosis

• What is extent and location of meniscal tear?
• Was tear located in a region of the meniscus with no blood supply (avascular)? If so, was a partial meniscectomy performed?
• Has physical therapy been effective?
• Is individual prolonging rehabilitation out of fear of sustaining another knee injury?
• Are knee ligaments torn?
• Is there evidence of joint deterioration?

None provided

The type of evidence supporting the recommendations is not specifically stated.

• Meniscus disorders, knee. In: The medical disability advisor: workplace for guidelines for disability duration. 6th ed. Westminster (CO): Reed Group; 2009. p. 9. [9 references]

Not applicable: The guideline was not adapted from another source.

2005 (revised 2009)

REED Group - Private For Profit Organization

REED Group

Not stated

Not stated

Not stated

This is the current release of the guideline.

It updates a previous version: Reed Group. Meniscus disorders, knee. Westminster (CO): Reed Group; 2005. 10 p. [8 references]

None available

None available

This NGC summary was updated by ECRI Institute on August 20, 2009. The information was verified by the guideline developer on August 24, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.