Meniscus tears: When DO I need surgery?

We often hear of athletes tearing their knee cartilage—the common term for the meniscus. In an athlete, a torn meniscus most often happens from a twisting or rotating injury or getting hit on the side of the knee as might occur in a soccer or basketball game.

As we get older the meniscus becomes more brittle and it is not unusual to have meniscus damage in your 40s, 50s or 60s. In older adults, a meniscus is frequently torn as a result of activities involved in daily living such as squatting, kneeling, or lunging.

So how do you know if your meniscus is torn?

The first and most common symptom is sharp pain, catching, and locking. The knee can feel like it gets stuck at irregular times, sometimes with walking, sometimes standing from a seated position, and sometimes for no reason at all.  Frequently, there is swelling or fullness in the knee and often times the swelling is felt as pain in the back of the knee.

The best test to tell if your knee has a torn meniscus it an MRI scan. This test is very sensitive and shows a lot of detail including the hard cartilage that coats the ends of the bone called articular cartilage, the soft cartilage known as the meniscus and all of the ligaments in the knee such as the ACL, the MCL and others. It also shows if there is fluid in the knee—a sign of an underlying problem.

In fact the test is so good that it often shows damage that might not actually be causing a problem. For example, we have seen situations where a patient complains of pain on the right side of the knee while the MRI shows damage of the meniscus on the left side. The difficulty arises because the patient thinks the problem is a torn meniscus when in fact that finding is just a source of confusion.

If I have a torn meniscus do I need to get it fixed?

Because not all tears cause pain or locking, not every tear needs surgery. In fact there are many times when we will allow a patient to continue their activity or sport if pain and swelling are minimal, and of course if there are no mechanical symptoms such as locking. The treatment for a symptomatic torn meniscus is to have arthroscopic surgery to either stitch the tear or remove the torn fragment if it is too damaged to stitch. The older you are, the less likely that your meniscus will heal if stitched.

In some cases, athletes have to make a difficult decision. If a stitchable tear occurs during the season, they have to decide between having a piece of meniscus removed which would allow return to play in a week or two or to have the meniscus stitched which would require no athletics for three months or more. Of course the problem is that the knee works best for the rest of your life with as normal a meniscus as possible. The more meniscus that is removed, the greater the chance of developing arthritis later in life.

The most difficult problem occurs in people over 40 who injure their knee in a minor way and the MRI shows a tear. The patient thinks the tear is an acute injury but in fact it is due to a degenerative process.  This degenerative process is wear and tear which is really an early onset of osteoarthritis. As the cartilage in the knee begins to wear over time, the knee can swell on occasion and can feel achy. Remember that as we age, many of us have meniscus tears and don't even know it.

Results of arthroscopic surgery for meniscus tears

With just aching and swelling—and without catching and locking—surgery to treat the tear has a 50:50 success rate. The best option for this circumstance is a cortisone injection, anti-inflammatory medicine, and physical therapy. If you're under 40 and have an acute meniscus tear that is not degenerative and have mechanical symptoms of catching and locking, the success rate for surgery has been shown to be 85 percent or better.

So, the symptoms associated with the meniscus tear are the biggest indicator of the appropriate treatment.  If you have catching or locking, surgery is indicated and is very successful. If it's achy pain and intermittent swelling, conservative treatment of injections, medication, and physical therapy are the best treatment options.

Arthur Bartolozzi is Director of Sports Medicine at Aria 3B Orthopaedics.

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