21 Feb What is the Meniscus? Injuries, Rehab, and Surgery
Orthopedic surgeons and physical therapists work hand in hand to deliver the best possible care to their patients. We both work in the field of orthopedic and sports and one of the most prevalent injuries we see are injuries to the meniscus. For that reason, we teamed up with a fellowship-trained and board-certified orthopedic surgeon, Dr. Nima Mehran (@drnimamehran), to give you the most straightforward answers to all of your burning questions about the meniscus. What is it? Do I have a tear? Do I need surgery? What is rehab like? We answer all of that and more in this multi-disciplinary and collaborative interview and article!
Full-Length Q&A with Dr. Nima Mehran
What is Meniscus?
The meniscus is a C-shaped tissue between your femur (thigh bone) and your tibia (shin bone). Each knee has a medial (inner side) meniscus and a lateral (outer side) meniscus. The meniscus is composed of water, collagen, proteins and other cellular elements.
Normal Medial Meniscus – View From a Knee Arthroscopy
What is the Function of a Meniscus?
The meniscus is a shock absorber that helps optimize force transmission across the knee and protects the cartilage at the end of our femur and tibia. The medial meniscus is also a secondary stabilizer to the ACL as it can prevent anterior translation (forward shifting) of the tibia.
READ: What is the ACL?
Does the Meniscus Have Good Healing Ability?
Tears in the outer 1/3 of the meniscus have healing potential because there is blood flow to that area. However, tears in the inner 2/3 generally do not heal well as a result of poor circulation.
Normal Lateral Meniscus – View From a Knee Arthroscopy
Knee [P]Rehab Program
The Knee [P]Rehab Program is for anyone looking to get more out of their knee(s)! Whether you’re a weekend warrior, competitive athlete, superhero parent, or just someone interested in improving their knee health, you can benefit from this program. We make it easy and teach you how to self [P]Rehab your knees and keep them healthy for anything life throws at you. Using the latest evidence-based research and our clinical experience, we have pioneered a very safe and effective [P]Rehab program that can take you from rehabbing old aches and pains all the way to maximizing your athletic performance on the field or in the gym. Learn more by clicking HERE
What are the Symptoms of Meniscus Tears?
- Pain at the joint line of the medial or lateral side.
- Swelling, can be intermittent.
- Mechanical symptoms such as locking or catching/clicking with pain.
Which Meniscus is Torn More Often?
Lateral meniscus tears are more common with acute ACL tears. However, medial meniscus tears are most common especially in older patients with degenerative changes.
Bucket Handle Meniscus Tear – View From a Knee Arthroscopy
Do All Meniscus Tears Need Surgery?
No. All meniscus tears do not require surgery. Surgery is indicated if you have mechanical symptoms such as locking. Otherwise, you should try conservative management first. This includes NSAIDs (anti-inflammatories), physical therapy, and finally – injections. If you fail conservative therapy and do not have arthritis, you may then be a candidate for surgery.
Below, we will cover an extensive conservative, non-operative meniscal injury rehab program to help those that are not candidates for surgery!
Complex Medial Meniscus Tear
When do you Repair the Meniscus VS When do you Remove the Torn Tissue (Partial Meniscectomy)?
The goal is always to save as much meniscus as possible, but that is not always possible. Generally, we try to repair the meniscus in younger patients (<40), with more acute tears (<6 weeks), and depending on tear location and pattern (repair is much more successful if the tear is vertical and in the outer ⅓ of the meniscus). Additionally, in patients who are having an ACL reconstruction, repairs are more likely to succeed due to the bleeding created by the reconstruction. Tears in areas of poor blood flow and patterns that are not amenable to repair are more likely to be excised (cut out).
What Happens to My Knee if I Lose My Meniscus?
The more meniscus you lose, the less protection your knee has from the force it faces. As a result, your knee will develop arthritis at a much faster rate compared to your uninjured knee.
Conservative Non-Operative Meniscus Injury Rehab Program
As Dr. Nima Mehran mentioned, most meniscal injuries respond very well to physical therapy – as long as there are no mechanical symptoms presents or complex meniscal injuries. Again, if you have mechanical symptoms like locking or catching/clicking with pain please go and see an orthopedic surgeon in your local area for a consultation. If you do NOT have mechanical symptoms, then check out the exercises below from a comprehensive early phase knee rehab program to help get your knee back on track! These exercises are just some of the MANY that you can perform. Furthermore, this program is just for early phase rehab, once you have progressed past exercises like these, you can perform just about ANY leg exercise, with an emphasis on the quadriceps!
Free [P]Rehab Workout
Some general rehabilitation rules that I want you to follow if doing these exercises:
- If there is any sharp pain with an exercise, then STOP immediately
- Think about your baseline level of pain. During your exercises, I am okay with discomfort/pain that is 1 point higher than your baseline. This rule also applies to any delayed soreness/pain later on in the day or the next day. For example, if your baseline knee discomfort is a 3/10, I am okay with 4/10 discomfort while exercising or after that, but no higher than 1 point over your baseline.
- If your discomfort does in fact increase during/after exercises, it must come back down to your baseline levels within 24 hours. If it does not drop back down to your baseline levels, then you pushed a little too hard and you need to decrease your volume, intensity, or range of motion in your exercises.
- Know that many meniscal injuries are in the back of the meniscus in an area called the posterior horn. This area is more sensitive to end range flexion or bending your knee. So be cautious with how much you bend your knee, especially when doing standing exercises like squats and lunges.
This quad setting exercises should form the foundation of your rehab plan. If you cannot strongly squeeze your quadriceps muscle and feel it contract, then you shouldn’t move onto any more advanced exercise. Must work on the basics before progressing!
Straight Leg Raises
Similar to quad sets, this exercise is vital in learning how to contract your quadriceps – especially the rectus femoris muscle which extends your knee and flexes your hip!
Knee Range of Motion Exercises
There is numerous way to improve your knee range of motion. Shown in the video are just some of the many ways we like to improve knee range of motion. In general, we can classify the exercises as either passive, active-assisted, or active range of motion exercises.
Many mensical injuries are sensitive to end range flexion – when you knee is fully bent. Be cautious with stretching in this direction and make sure to adhere to the rules of rehab principles from above!
Passive exercises rely simply on gravity to do the ‘stretching’ work. Exercises like supine knee props, bag hangs, or seated knee flexion all rely on gravity to stretch the knee. Active-assisted exercises incorporate active movement into the exercise, in addition to an external force like gravity, your other leg, or even another person’s body. An example of this is the supine knee flexion against wall exercise. Gravity is pushing Craig’s knee into flexion, while he contracts his hamstring at the same time to add a further stretch to the quads. Note that this exercise and others can easily be made passive if Craig doesn’t contract! Active range of motion exercises uses the agonist muscle to move into the range. Some examples of this are the long arc quad to achieve full knee extension (using quadriceps) or supine heel slide to achieve full knee flexion (hamstrings).
Single Leg Balance
It doesn’t have to be this difficult or fancy by any means! Just simply standing on one leg and improving your knee proprioception is enough! Try with the knee locked out and with the knee slightly bent!
Long Arc Quads
You can easily add a theraband or ankle weight to this exercise to make it harder! Check out this video to learn how to set up a theraband without it slipping!
Terminal Knee Extensions (TKEs)
It’s extremely common to stop just shy of end range extension at the top of reps. Naturally, end range is the “end” because it’s neurologically past whatever zone of ROM we are “comfortable” with. That being said, instead of spending an hour hanging out into passive extension or doing a more fancy drill to work terminal knee extension, just push and remind your clients to fully extend. Drive through their heel. Fully squeeze their quad. And feel a stretch at the top of every rep.
Sidelying clams are stable in any lower extremity rehab program just simply to get you to feel your glutes. That way once you progress into more challenging exercises in standing, you will have a better mind-body connection to your glutes!
This exercise is great because you have to tighten your thigh and use your quadriceps muscle – no matter what direction we lift. We also get the added benefit of working on the hip flexors, abduction, extensors, and adductors as well!
Similar to clams, bridges are a great foundational exercise to master first before progressing onto more advanced exercises.
Staggered Box Squats
Staggered box squats are one of my favorite exercises. Not only is it ‘functional’ as you have to get up and down from chairs multiple times throughout the day, but we can also bias and load your injured leg more by placing further back.
Forward Step Ups
Demonstrated first is the forward step up followed by the reverse step down. Demonstrated is stepping up with the left and down with the right, working the left side. The next exercise is reverse step-downs working on the left side. This is a small variation working the left side harder, which also may feel better on the knee as it limits shear forces. Lastly is the reverse step tap, keeping as much weight as possible on the left and just tapping the ground with the right. I love the cue “don’t crush the egg” and people get it!
Lateral Step Ups
Demonstrated first is the lateral step up followed by the lateral step down. Demonstrated is stepping up with the left and down with the right, working the left side. The next exercise is lateral step-downs working the left side. This is a small variation working the left side harder, which also may feel better on the knee as it limits shear forces. Lastly is the lateral step tap, keeping as much weight as possible on the left and just tapping the ground with the right. I love the cue “don’t crush the egg” and people get it!
About the Co-Author: Dr. Nima Mehran
Nima Mehran, M.D., is an orthopedic surgeon specializing in sports medicine and joint replacements. He earned his undergraduate degree at the University of Southern California, attended the Chicago Medical School and was Chief Resident during his orthopedic surgery residency at Henry Ford Hospital. Dr. Mehran has published several scientific papers and has delivered numerous scientific lectures. He has been on the physician team for the USC Trojan Football team, Los Angeles Lakers, Los Angeles Sparks, Los Angeles Dodgers, Los Angeles Kings, and Anaheim Ducks.