Meniscal tear fundamentals
A meniscal tear is a tear in the cartilages, or menisci, that are located between the femur and tibia bones in the lower leg. The menisci provide stability and help distribute body weight by keeping the bones from rubbing together. In addition, the menisci help distribute nutrients into the tissues and cartilage that cover the femur and tibia bones. Ensuring that these tissues are healthy helps prevent degenerative arthritis. As shock absorbers, the menisci help absorb the pressure exerted on the knee joint.
What causes a meniscal tear?
A meniscal tear is caused by sudden twisting or other movements that may occur from sports or related injuries. These types of injuries are more common for people over 30. Those that are younger have fewer injuries since the meniscus is fairly tough and rubbery and more resilient. As we get older, the meniscus weakens and injuries can occur more easily, even from simple movements such as squatting or stepping on an uneven surface. Meniscal tears can also occur from degenerative conditions such as osteoarthritis, rather than a specific injury.
What are the benefits of treatment for meniscal tears?
Treatment for meniscal tears focuses on keeping pain and inflammation under control. RICE, which stands for rest, ice, compression, and elevation, is the standard treatment. For the first few days after injury, ice should be applied every three or four hours for 30 minutes. Applying ice will help minimize the pain and discomfort. Wrapping the knee in an elastic bandage and taking non-steroidal anti-inflammatory medication such as ibuprofen or one that you can tolerate will also help keep the swelling down. With this treatment, you can gradually return to normal activity.
Arthroscopic surgery can help diagnose the pain associated with meniscal tears and is one of the most predominant forms of treatment when the pain is severe and occurs frequently. If the menisci are damaged, the knee can become very unstable and arthritis may result. Surgery may provide the best alternative to preserving the knee from further damage and later problems.
Some key benefits of this type of surgery are relief from pain and improvement in mobility. Repairs for meniscal tears with arthroscopic surgery are a safe procedure, allowing patients to maintain a normal and active lifestyle with greater comfort.
What are the risks of treatment for meniscal tears?
There may be some complications associated with surgery for meniscal tears, including unforeseen complications with anesthesia, such as respiratory or cardiac malfunction. Infections may result from surgery, in addition to injury to nerves and blood vessels, fracture, weakness, stiffness or instability of the joint, pain, inability to repair the meniscus, repeated rupture of the meniscus, or the need for additional surgeries.
Patients should be made aware that not all meniscal tears are repairable. The cartilage in the knee may have simply worn away over time, preventing the surgeon from repairing the remaining cartilage with sutures. In these cases, the surgeon will remove all the torn cartilage and repair any other problems in the knee.
Surgical procedures and risks associated with meniscal surgery will depend on the patient’s condition and his or her individual needs. Patients should keep in mind that their age does play an important role in the success of the procedure. Repairs tend to be most effective for people under the age of 30 who have the procedure done within the first two months after injury. For people over 30, the likelihood of success of surgery diminishes because the meniscal tissue begins to naturally deteriorate and weaken with age.
How do I prepare for surgery?
Do not eat or drink anything after midnight the night before surgery.
There are many things that you can do to prepare for meniscal surgery. Prior to your surgery, you will have a physical examination and will also be given a written prescription for pain medication. You should have your prescription filled at your local pharmacy several days before the date of surgery to make sure that you have the medication available to you immediately after surgery. You will also have an appointment with Cleveland Clinic Sports Medicine Physical Therapy to be fitted with crutches and instructed how to use them. It is important that you complete all of your testing and appointments prior to surgery, which may include bloodwork, X-rays, MRI, EKG, and medical and anesthesia clearance. Surgery may be postponed if clearance for these tests is not obtained. If you develop any health changes prior to surgery, such as a cold, fever, infection, rash or wound, you should contact your surgeon’s office prior to surgery.
What do I do the day of surgery?
On the day of surgery, patients are admitted at Desk P-20 (in the lobby of the P building). The physician’s assistant will advise you as to what time you will be admitted on the day of surgery. Parking is available in the E.90th Street Parking Street Garage adjacent to the P-20 Surgical Center.
You should bring your crutches with you to surgery, as you will need them to walk following your surgery, in addition to loose-fitting shorts or non-constricting pants (warm-up style) that will fit over your dressing after surgery. Also, arrange for a responsible adult to drive you home after surgery and stay with you the first night after surgery.
What happens during surgery?
Arthroscopic surgery to diagnose and repair meniscal tears lasts for approximately one hour. If the surgeon can see the tear with the arthroscope, he or she can determine if the tear is repairable or if the meniscus should be removed. If the meniscus can be repaired, the procedure is completed during arthroscopic surgery; another incision is made, and the surgeon uses surgical instruments to repair the meniscus. A meniscus repair involves suturing the torn edges back into place and allowing the meniscus to heal on its own. Only 10 percent of menisci are repairable using this method. In the majority of cases, a partial meniscectomy is required where part of the meniscus is removed and the healthy tissue is left intact. Recovery from a partial meniscectomy is easier, but there are also future risks, such as the development of arthritis.
In most cases, if the meniscus is in good condition, despite the tear, repair is preferable to removing the meniscus. Tears on the outer edges of the meniscus, called a peripheral menisco-capsular tear, can be repaired using arthroscopic surgery leaving the meniscus to heal. In addition, tears that run vertically through the meniscus can frequently be repaired with arthroscopic surgery leaving the entire meniscus intact. Bucket handle tears may require partial removal, depending on the severity of the injury. Repairs are treated with a combination of sutures that are inserted to treat the torn cartilage.
What happens after surgery?
Knee arthroscopic surgery for meniscal tears lasts for approximately one hour. Following surgery, once patients are comfortable, able to walk on crutches, able to take fluids orally, and able to urinate, they will be discharged to go home in the care of a responsible adult. In the majority of cases, patients are discharged from the hospital to go home on the same day of surgery.
After surgery, a dressing will be applied to the knee, wrapped with an Ace bandage, which will help protect the knee and minimize swelling and pain. An ice pack will be applied to the knee, which will also help prevent swelling and pain. Patients should leave the bandage in place until they receive physical therapy. Patients will also be given pain medication after surgery to reduce the pain.
Many times there will be small amounts of bloody drainage on the dressing after surgery. Make sure to notify your surgeon’s office if you have any of the following: steadily increasing drainage on the dressing, elevated temperature above 101 degrees Fahrenheit, pus-like or foul smelling drainage from any of the incisions, breathing difficulties, pain in your calf when you flex your foot up and down that is unrelieved by rest or elevation, or swelling in your calf, foot or ankle.
When resting, elevate your knee higher than your heart level on two or three pillows with your back flat on the bed. This will also aid in preventing swelling of the joint after surgery. Also, make sure to use crutches to walk. The crutches will protect your knee from undo stress until it is fully rehabilitated.
Call your surgeon’s office if you have any questions or concerns following surgery. After hours you may call 216.444.2200 and ask to speak with the Cleveland Clinic orthopaedic doctor on call.
How long is the recovery period after surgery?
Following surgery, there is a recovery time of up to two weeks to allow time for frequent physical therapy and appropriate treating of the knee to ensure a quick return to normal activity. As part of physical therapy, patients will be taught exercises, in addition to having guided therapy. Patients will continue to receive physical therapy three times per week after they are discharged from the hospital. The length of the rehabilitation period depends on the patient’s condition and recovery progress. If a meniscal repair is done, the recovery time and rehabilitation period may be extended – up to six weeks in a knee brace or with crutches.
What is the rehab after surgery?
The physical therapy process is dependent on the patient’s general physical health and condition following surgery. Typically, a patient’s physical therapy program after knee arthroscopic surgery can be divided into three phases: regaining control of the leg muscles and weaning from crutches, regaining full knee motion and strength and returning to normal activity. Sometimes a physical therapy program is recommended as an alternative to surgery. Or, conservative treatment and physical therapy are recommended as alternatives to surgery to control inflammation, pain and swelling. This treatment includes the NICE method, which stands for non-steroidal anti-inflammatories, ice, compression and elevation.
The following exercises (in three phases) are designed to optimize patients’ recovery following surgery. The timeline for these phases depends on the specific patient and his or her physical condition and progress following surgery.
Exercises during this early phase help patients regain balance and coordination and should be started immediately following discharge from the hospital. Crutch walking is not considered an exercise, but it is an important part of the physical therapy program after surgery. Patients should use crutches provided by their physical therapist until they have good muscular control over their leg and can bear weight on the knee without much discomfort.
The isometric quadriceps exercise (also known as "quad sets") may be started in the sitting or lying position. For patients with low back trouble, this exercise is best done in the sitting position. During the exercise, press your knee down against a table or floor, holding the position for 6 seconds. The exercise can be repeated 10 to 15 times for each set. Two to three sets should be completed in each exercise period.
The straight leg raising exercise is done sitting or lying. The ankle of the leg to be exercised should be bent at a 90-degree angle, and the knee is straightened as much as possible. Then, the entire leg and thigh are lifted off the floor to a height of approximately 1 to 1-1/2 feet and held in the air for 6 seconds. The exercise should be repeated 10 to 15 times for each set; two to three sets should be completed in each exercise period. Patients may add weights for this exercise, beginning with 2 lb weights and adding increments of 1-2 lbs.
These exercises help patients regain full knee motion and strength once they discontinue using crutches.
The range of motion exercise is done by sitting on the table and letting the leg hang over the edge. Patients may use their good leg to help straighten (extension) and bend (flex) the knee.
Patients can begin doing bicycle exercises on a stationary bicycle as soon as the knee has a fairly good range of motion.
Short arc quadriceps extensions are used for the development of the quadriceps muscle. To perform this exercise, patients should be lying down with the unaffected knee bent placing a flat foot on a resting surface. The affected knee is supported off the table by a firm, padded object. The knee is then extended fully to zero degrees from its bent position of approximately 30 to 40 degrees. The leg is then held straight for 6 seconds and then gently lowered.
Initially, no ankle weights are used for this exercise, but as patients gain strength, they may choose to add weight to the ankle. Patients can start with 2 lbs and add increments of 1-2 lbs.
The knee flexion exercise is done while lying face down. The foot is rested on a rolled towel to prevent the toes from striking the table. The foot is slowly raised and lowered to the table. Initially, no weights are used, but as the patient’s knee gains strength weights may be added.
When patients have reached Phase 3 of the physical therapy program, they are ready to return to normal physical activity. The length of time leading up to this phase depends on the individual patient and their recovery progress following surgery.
How can I manage at home during recovery from the procedure?
Once patients are comfortable, able to walk on crutches, able to take fluids orally, and able to urinate, they will be discharged to go home. In the majority of cases, patients are discharged from the hospital to go home on the same day of surgery. To reduce pain and swelling, make sure to elevate your leg while at home, and for the first several days (48 hours), ice the knee 20 to 30 minutes a few times per day to minimize pain and swelling. On discharge, patients will receive a prescription for pain medication. Patients should not drive or operate dangerous equipment while taking prescription pain medication.
Patients are able to shower when they receive the confirmation that it is okay to do so from their doctor. Patients may be asked to cover their leg with plastic to avoid wetting the bandage and incisions, which increases the chance of infection. Patients may drive a car as soon as they have good control and mobility of the knee. When patients can comfortably put full weight on their leg, and have good muscular control, they may discard their crutches.
If patients develop a fever of 101 degrees or higher, redness or increasing amounts of pain not relieved by rest, ice or pain medication, they should contact their doctor’s office.
How frequently should I schedule follow up appointments with my doctor following surgery?
Patients will schedule a follow up appointment with their surgeon nine days to two weeks following their surgery. Additional appointments may be scheduled based on the patient’s individual condition and recovery.