عبدالله رضوان
09-11-2006, 02:14 PM
Anatomy
The meniscus is a half moon shaped piece of cartilage that lies between the weight bearing joint surfaces of the femur and the tibia. It is triangular in cross section and is attached to the lining of the knee joint along its periphery. There are two menisci in a normal knee; the outside one is called the lateral meniscus, the inner one the medial meniscus.
The menisci play an important role in absorbing about a third of the impact load that the joint cartilage surface sees. It's been shown that complete removal of a meniscus can result in progressive arthritis in the joint within a decade or so in a younger patient, sooner in patients who are older with preexisting "wear-and-tear" osteoarthritis. The menisci also cup the joint surfaces of the femur and therefore provide some degree of stabilization to the knee.
The meniscus itself is for the most part avascular, that is it doesn't bleed if cut and doesn't have blood vessels inside. The exception to this is at the periphery where it joins to the vascular knee lining providing the outermost 20% of the meniscus with a blood supply. As a result of this avascularity a torn meniscus doesn't have the ability to heal itself unless there is just a small tear confined to the peripheral vascular zone. Similarly the nerve supply providing pain and sensation to the meniscus is for the most part limited to the zone where the blood vessels are located.
In terms of descriptive terminology orthopaedic surgeons divide the meniscus into thirds with three geographical zones; the front third is referred to as the anterior horn, the back third the posterior horn, and the middle third the body.
Medial Cartilage Meniscus Injury
What is a medial meniscus injury?
An injury to the medial meniscus can result from an impact on the outside of the knee. It will often be injured along with the medial ligament. Cartilage injuries can also occur as a result of deep knee bends. The cartilage gets squeezed between the bones with most of your bodyweight on top!
What are the symptoms?
• Pain on the inside of the joint during and after exercise.
• Pain if you pull your heel tightly up to your buttock or do a deep knee bend.
• Pain when you do this test.
• Locking in the joint and swelling.
• Weak and wasted quadriceps muscles at the front of the leg are also possible
Tests for Cartilage damage in the knee joint
Test 1
Lie on your front and bend your injured knee to 90 degrees.
Get someone to push down on your heel and twist the knee joint at the same time first one way and then the other. If you get pain when the heel is pushed down and twisted then you might have cartilage damage.
Test 2
You can pull the leg up yourself or get someone else to push for you. If you get pain then you might have cartilage damage.
Cold Therapy for the knee
Cold therapr or ice therapy for soft tissue injury (Dr..I.C.E.) should be applied for the first 24 to 48 hours after injury, although ice can also be beneficial in the later stages of treatment.
• D is for diagnosis - an accurate diagnosis
• R is for Rest - This slows down any bleeding and reduces the risk of further damage.
• I is for Ice - This can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (later).
• C is for compression - This reduces bleeding and reduces swelling.
• E is for Elevation - Uses gravity to reduce bleeding and reduces swelling by allowing fluids to flow away from the site of injury.
How can I apply cold therapy?
• Cold therapy can be applied in a number of ways with different products but the principles remain the same. Cold is not put into the body but heat is taken out. So anything that is colder than the body tissues will cause heat to be removed from the body.
• If using ice, it should never be applied directly to the skin but in a wet tea towel to prevent ice burns.
• Apply the ice for about 15 minutes every 2 hours. This will vary depending on the size of the area and depth of the tissue. This can be reduced gradually over the next 24 hours.
• If you have a bad circulation condition in a specific area then you should not apply ice to that area, or if you have a cold allergy.
What about cold therapy gels?
• Cold therapy gels can play a part in treatment and rehabilitation but should not be used as a substitute for proper cold therapy and compression. They will draw heat out over a longer period of time and are convenient to apply throughout the day reducing pain and inflammation but cannot remove large amounts of heat from the body in the way ice or other cold therapy products can.
In the first 24 hours you should not:
• Apply heat
• Apply a heat rub
• Drink alcohol (even if you play Rugby)
• Have a deep massage.
A Sports Injury Specialist or Doctor could:
• Advise on the success of rehabilitation or indicate if surgery is required.
• Apply a support bandage or plaster cast.
• Aspirate the joint (suck off a the fluid with a needle).
• Operate.
• Prescribe a training programme to maintain leg muscle strength.
• Use ultrasound or laser treatment.
It is important to fully rehabilitate the knee before starting sport again. Surgery for this type of injury is common and you shouldn't be out of action for too long.
Review of the condition
What are some general characteristics of torn meniscus cartilage in the knee? What are its usual manifestations?
A torn meniscus usually produces swelling and well-localized pain in the knee. The pain is made worse by twisting or squatting motions. Sometimes a fragment of torn meniscus can displace inside the knee in such a way as to "lock" the knee, allowing only a toggle of motion.
What are the different types of torn meniscus cartilage in the knee?
A tear can occur in one or more directions in the meniscus. Traumatic tears are usually vertical whereas degenerative tears are usually horizontal. The shape that the meniscus and its torn portion assume has led to names like "bucket handle tear," "parrot beak tear," and others. Sometimes the meniscus deteriorates to the point where the tear is no longer a "clean" tear, but rather the meniscus is shredded and resembles crab meat.
What else might be confused with or similar to torn meniscus cartilage in the knee? How can these be distinguished from the condition?
ometimes the symptoms from a torn meniscus can be confused with those from significant knee arthritis with loose articular (gliding) cartilage. Occasionally a chronically inflammed knee will produce similar findings. Usually these conditions can be distinguished from a torn meniscus by history and a good physical exam. Sometimes, though, they can only be distinguished by MRI or diagnostic arthroscopy.
How common is torn meniscus cartilage in the knee (statistics, demographics, risk factors)?
Meniscal tears are common especially in people participating in sports. Traumatic tears usually occur as a result of a twisting or hyperflexion injury. Degenerative tears are more common in people over 40 and may occur without a specific injury. Smokers are at higher risk for degenerative tears.
How is torn meniscus cartilage in the knee diagnosed? What tests or exams may be used?
A torn meniscus is diagnosed on the basis of the patient's history and a thorough physical exam. An MRI is often used to confirm the diagnosis.
Can medications help torn meniscus cartilage in the knee?
Medications can relieve pain and swelling temporarily, but will not actually produce healing of the torn meniscus.
Can exercises help torn meniscus cartilage in the knee?
Quadriceps strengthening exercises can help prevent the muscle atrophy that is associated with a painful, swollen knee.
Specifically, how is torn meniscus cartilage in the knee improved by arthroscopic meniscectomy-minimally invasive arthroscopic surgery?
When the torn part of the meniscus is removed, any catching or locking should be gone immediately. Pain is usually minimal by 1 week after surgery. Full motion of the knee returns as the swelling disappears, usually within 4-6 weeks after the surgery.
Considering surgery
What kinds of surgery are recommended for torn meniscus cartilage in the knee?
The surgical treatment for a torn meniscus is either to remove or repair the torn segment of the meniscus using an arthroscope and specially designed instruments. Because only the outer 1/4 of the meniscus has blood supply, repairs are successful when the tear occurs in this vascular region of the meniscus. Tears in the non-vascular region are unlikely to heal and therefore are removed. (For information on meniscal repair, see article on that topic).
Who should consider arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and in what cases?
Occasionally the symptoms from a degenerative tear will quiet down without surgery. Surgery for a torn meniscus should be considered when the knee is "locked", the knee is persistently swollen, the patient can not participate in normal activities, the patient understands and accepts the risks, and the surgeon is fellowship trained and experienced in arthroscopic meniscectomy.
What happens if nothing is done for torn meniscus cartilage in the knee (best case/worst case scenarios)?
In the best case scenario, the symptoms of swelling and pain will resolve and the patient will be able to resume activities. In the worst case scenario, the torn fragment of meniscus will "lock" the knee, preventing all but a small amount of motion. This makes activities of daily living difficult.
When performed by an experienced surgeon, how effective is arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee likely to be and how long will the benefit last?
In the hands of an experienced fellowship trained orthopaedic surgeon, removal of the torn part of a meniscus is very effective in restoring comfort and function to the knee. The knee will usually function normally for decades. If an entire meniscus needs to be removed, that section of the knee is likely to become arthritic 10-15 years later.
How urgent is arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee?
Removal of a torn segment of meniscus is urgent only when the knee is locked. Even then the urgency is about the patient's comfort and ability to get around more than it is about the long term effects on the rest of the knee joint. A torn segment of meniscus that catches, locks, or produces swelling on a frequent basis should be removed relatively quickly (within a few months) so that it does not damage the articular (gliding) cartilage in the rest of the knee. Waiting to remove the mobile torn fragment can also lead to muscle atrophy and joint contracture which make it more difficult for the patient to ultimately regain normal function after surgery.
What are the most frequent and most serious risks of arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee? How common are they?
The risks of arthroscopic meniscectomy include but are not limited to infection and deep vein thrombosis ( blood clot) in the operated leg. If a clot forms and travels to the lung, the situation can be life threatening. Fortunately this is uncommon. Sometimes there will be numbness around the small scars where the instruments have entered the knee. There are also risks to anesthesia. An experienced team will take care to minimize these risks, but cannot totally eliminate them.
If risks occur during or after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee how are they managed?
The risk of infection can be decreased by using intravenous antibiotics during surgery. If infection occurs, the patient is taken back to the operating room where the knee is washed out using arthroscopic equipment. The patient is then put on intravenous antibiotics, usually for 6 weeks depending on the organism causing the infection. If a blood clot forms in the leg, the patient is usually put on blood thinners to prevent the clot from expanding or moving. If the patient has concerns about the post operative course of events, the surgeon should be informed as soon as possible.
Preparing for surgery
What type of preparation needs to take place before arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee?
Prior to surgery, the patient should have no ongoing infections, and the knee should have no sores or scratches. The patient should NOT shave the knee the day before surgery. The patient should have someone to help at home for 24-36 hours after the surgery. Because airplane flight is also associated with blood clots in the leg, we recommend that patients not travel by plane in the first 5 days after surgery. Similarly, because dental work releases bacteria into the blood stream, we recommend that dental work be put off until after the knee has fully recovered from surgery, typically 4-6 weeks. When this is not possible, we recommend antibiotic coverage around the time of the dental work.
How can the costs of arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee be anticipated?
The surgeon's office should provide a reasonable estimate of the surgeon's fee, the hospital fee, the anesthesia fee, and the degree to which these should be covered by the patient's insurance.
Who should perform arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and where?
Arthroscopic meniscectomy should be performed by an orthopaedic surgeon fellowship trained in arthroscopic surgery of the knee. The procedure should be done in a medical center or outpatient surgical facility that is accustomed to doing arthroscopic meniscectomies frequently.
How can surgeons experienced in arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee be found?
Surgeons specializing in arthroscopic meniscectomy can be located through university schools of medicine, county medical societies or state orthopaedic associations. Other resources include the American Orthopaedic Society for Sports Medicine and the American Academy of Orthopaedic Surgeons.
Recovering from surgery
How much pain do patients usually have after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and what medications are used to manage it?
In the first 24-48 hours after arthroscopic meniscectomy, the operated knee is swollen and moderately painful. However most patients are able to return to sedentary jobs by the third postoperative day. Medications used to manage pain in the first 48 hours include oral narcotics such as hydrocodone or oxycodone. Some patients obtain good pain relief in the immediate postoperative period with Vioxx. Subsequently, acetaminophen or ibuprofen are sufficient. The application of ice or other cold therapeutic devices to the knee are also very helpful in controlling pain and swelling.
How are medications after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee administered? How long will they be needed?
Most patients do not use any pain relievers after the first postoperative week.
What are the most frequent and most serious side effects of taking pain medication after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee?
Narcotic pain medications can cause drowsiness, slowness of breathing, difficulties emptying bowel and bladder, nausea, vomiting, and allergic reactions. Anti-inflammatory medications can cause stomach irritation, nausea and headaches. Patients who have had substantial exposure to narcotic medications or alcohol in the recent past may find that the usual doses of pain medication are less effective. For some patients, balancing the benefit and the side effects of pain medication is challenging. Patients should notify their surgeon if they have had previous difficulties with pain medication or pain control.
After arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee, what happens in the hospital and when is the patient usually discharged?
Arthroscopic meniscectomy is an outpatient procedure. After surgery the patient remains in the recovery room until the effects of anesthesia have worn off, usually for 1-2 hours.
After arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee, what happens at hospital discharge and what are the patient's limitations at that time?
By the time the patient leaves the recovery room, he or she may put as much weight as tolerated on the operated limb. Many patients choose to use crutches for a few days. Staying relatively quiet, keeping the limb elevated and the knee iced for 48 hours is the best way to keep swelling to a minimum thus speeding return to full activities. During the first 48 hours, before the patient is fully up and around, it is also important to flex one's feet up and down regularly to help prevent blood clots from forming in the calf veins.
What type of help do patients need after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and for how long? Can they go home or do they require a convalescent facility?
Patients do not require a convalescent facility after arthroscopic meniscectomy. They may require some assistance with self-care for the first day or two. Driving may be difficult in the first postoperative week until the swelling has resolved enough to allow sufficient knee motion.
Ultrasound Therapy
What is Ultrasound?
Ultrasound is simply high frequency sounds waves above the range that we can hear. It is applied to the body from the 'head' of an ultrasound machine. A gel is used to help the waves travel into the body rather than be reflected off the skin.
What are the benefits of ultrasound?
• increased blood supply which promotes healing,
• produces a pain killing effect which can reduce muscle spasm, and promote normal funtion,
• softens fibrous tissues and scar tissue which are formed during healing.
How is it used?
• The therapist will apply a little gel to the skin and place the head of the ultrasound machine on the skin. Usually it will be moved in small circles. Treatment time can vary according to the injury but is usually about a few minutes.
• Ultrasound can be applied in two modes, pulse and continuous. With continuous the beam od ultrasound waves is well, continuous. This means that heat will be transferred to the body tissues. Pulsed means the waves go in short pulses which prevents the tissues heating.
Knee Supports
Why do I need one?
A support or brace provides protection and support. They prevent injury to healthy joints and support unstable joints. Some retain the heat produced by the body in a specific area and so aids healing.
Heat encourages blood vessels to dilate and so allows more blood to the injured area. The more blood that gets to the injured area, the more nutrients it will get and the faster it will heal.
A hinged brace contains @_@@_@@_@@_@l reinforcements in the sides, combined with a gear in the middle to allow it to move. This provides excellent lateral support to protect the medial and lateral ligaments.
A stabilized knee support shown below has reinforced side panels to provide extra support over the standard knee support - again helping to provent sideways stress on the knee ligaments.
Use it for helping to get better but do not rely on it indefinitely. By wearing it too long your muscles will weaken as they will not be needed as much. If you find you need to wear it for more than a week then you really need professional help. Always use it as part of an overall rehabilitation programme.
Supplements to aid joint healing
(Glucosamine Sulphate, Chondroitin & MSM)
Sport causes high rates of wear & tear on connective tissue cartlidge, tendons and ligaments). By contrast the body's speed of repair is only average in the very young and it declines with age. Joint and connective tissue can easily be damaged faster than it can be repaired, which ultimatley leads to injury.
Glucosamine Sulphate
Glucosamine is a natural products derived from shrimp and crab shells. It is found largely in cartilage and plays an important role in its health. It is thought that supplementing with Glucosamine may help in the healing of joint injuries and arthritis.
If the body has a ready supply of the building blocks it needs to repair damaged joints then the healing process my be accelerated. Glucosamine is made from the combination of a sugar (glucose) and an amine (derived from ammonia).
Chondroitin Sulphate
Chondroitin sulfate is a major constituent of cartilage. It provides structure, holds water and nutrients. One important property of Chondroitin is that it allows other molecules (nutirents) to move through cartilage. This is especially important as the blood supply to cartilage is particularly poor. If nutirents cannot get to the damaged area then healing is unlikely to take place.
Chondroitin sulphate consists of repeating chains of molecules called glycosaminoglycans. Studies with animals have shown that chondroitin may help in the healing of bone. Chondroitin sulphate has also been shown, in numerous trials to relieve symptoms and possibly slow the progression of osteoarthritis or even reverse it.
Knee
Rehabilitation
(Medial cartilage meniscus injury)
The following example is meant for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.
Is non surgical rehabilitation likely to work?
Rehabilitation of cartilage injuries may be possible without surgery if:
• There is little swelling.
• Symptoms have developed 1 to 2 days after injuring the knee.
• The athlete has a full range of movement with pain only at the ends of range of movement.
• The athlete is able to bear weights on the injured leg.
• If this injury has occurred before and healed fairly rapidly.
Surgery may be required if:
• The athlete suffered a severe twisting injury.
• The athlete was unable to walk following injury.
• There may also be damage to the anterior cruciate ligament.
• There is little improvement in the knee three weeks after starting a non surgical rehabilitation programme.
Aims of rehabilitation:
• Decrease pain and swelling.
• Maintain and restore full mobility.
• Restore equal strength to both legs.
• Gradually return to full fitness.
The rehabilitation guidelines for a medial cartilage meniscus tear are similar whether the athlete has surgery or not and can be split into 4 phases. Please note the timescales will vary depending on the severity of injury.
Phase 1: Immediately following surgery.
• Aims - To reduce swelling, restore almost full mobility and begin strengthening exercises.
• Duration - 1 week.
• Rest. Use crutches, partial weight bearing at first but progress to full weight bearing as soon as pain will allow.
• Apply cold therapy and compression. Apply ice for 15 to 20 minutes every 2 hours for the first day or two. Gradually reduce frequency of application over the rest of the week as swelling is reduced.
• Begin mobility exercises aiming to completely straighten the knee by the end of week 1.
• Strength exercises - static quads, hamstring holds, calf raises, hamstring and hip exercises with rehabilitation bands.
• Maintain aerobic fitness with stationary cycling if pain allows.
Phase 2: 1 week after injury.
• Aims - To eliminate swelling completely, regain full range of motion and progress with strengthening exercises.
• Duration - 1 week.
• The athlete should aim to be full weight bearing on the knee and walking with normal gait. No sports specific training but light swimming (not breaststroke!) and cycling may be possible.
• Apply cold therapy and compression 3 times a day if swelling is present. If not then apply ice after training sessions.
• Mobility exercises should continue if full range of motion has not returned.
• Strength exercises may now include leg press, half squats (if not painful) as well as progressing the exercises of Phase 1.
Phase 3: 2 weeks after injury.
• Aims - To maintain full range of motion, equal leg strength and begin to return to sports specific training.
• Duration - 1 week.
• Cold therapy and compression should hopefully not be required now.
• Continue to build on strengthening exercises of Phase 2, concentrating more on squats, step ups, hamstring curl and leg extension.
• Begin to include forwards, backwards and sideways running as well as changing direction.
• Plyometric exercises such as hopping and bounding may be introduced towards the end of the week. For footballers, kicking may be possible.
Phase 4: 3 weeks after injury.
• Aims - To return to sports specific training and finally competition.
• Duration - 2 to 3 weeks.
• Sports massage techniques to the surrounding muscles will aid return to fitness.
• Strengthening exercises should now be highly sports specific. Drop the static contractions and concentrate on traditional weights and plyometric exercises.
• Sprinting should be introduced gradually and built on.
• Training can include preparation for competition. Return to competition should be gradual for example a footballer may start with 10 to 20 minutes play and progress to a full game
The meniscus is a half moon shaped piece of cartilage that lies between the weight bearing joint surfaces of the femur and the tibia. It is triangular in cross section and is attached to the lining of the knee joint along its periphery. There are two menisci in a normal knee; the outside one is called the lateral meniscus, the inner one the medial meniscus.
The menisci play an important role in absorbing about a third of the impact load that the joint cartilage surface sees. It's been shown that complete removal of a meniscus can result in progressive arthritis in the joint within a decade or so in a younger patient, sooner in patients who are older with preexisting "wear-and-tear" osteoarthritis. The menisci also cup the joint surfaces of the femur and therefore provide some degree of stabilization to the knee.
The meniscus itself is for the most part avascular, that is it doesn't bleed if cut and doesn't have blood vessels inside. The exception to this is at the periphery where it joins to the vascular knee lining providing the outermost 20% of the meniscus with a blood supply. As a result of this avascularity a torn meniscus doesn't have the ability to heal itself unless there is just a small tear confined to the peripheral vascular zone. Similarly the nerve supply providing pain and sensation to the meniscus is for the most part limited to the zone where the blood vessels are located.
In terms of descriptive terminology orthopaedic surgeons divide the meniscus into thirds with three geographical zones; the front third is referred to as the anterior horn, the back third the posterior horn, and the middle third the body.
Medial Cartilage Meniscus Injury
What is a medial meniscus injury?
An injury to the medial meniscus can result from an impact on the outside of the knee. It will often be injured along with the medial ligament. Cartilage injuries can also occur as a result of deep knee bends. The cartilage gets squeezed between the bones with most of your bodyweight on top!
What are the symptoms?
• Pain on the inside of the joint during and after exercise.
• Pain if you pull your heel tightly up to your buttock or do a deep knee bend.
• Pain when you do this test.
• Locking in the joint and swelling.
• Weak and wasted quadriceps muscles at the front of the leg are also possible
Tests for Cartilage damage in the knee joint
Test 1
Lie on your front and bend your injured knee to 90 degrees.
Get someone to push down on your heel and twist the knee joint at the same time first one way and then the other. If you get pain when the heel is pushed down and twisted then you might have cartilage damage.
Test 2
You can pull the leg up yourself or get someone else to push for you. If you get pain then you might have cartilage damage.
Cold Therapy for the knee
Cold therapr or ice therapy for soft tissue injury (Dr..I.C.E.) should be applied for the first 24 to 48 hours after injury, although ice can also be beneficial in the later stages of treatment.
• D is for diagnosis - an accurate diagnosis
• R is for Rest - This slows down any bleeding and reduces the risk of further damage.
• I is for Ice - This can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (later).
• C is for compression - This reduces bleeding and reduces swelling.
• E is for Elevation - Uses gravity to reduce bleeding and reduces swelling by allowing fluids to flow away from the site of injury.
How can I apply cold therapy?
• Cold therapy can be applied in a number of ways with different products but the principles remain the same. Cold is not put into the body but heat is taken out. So anything that is colder than the body tissues will cause heat to be removed from the body.
• If using ice, it should never be applied directly to the skin but in a wet tea towel to prevent ice burns.
• Apply the ice for about 15 minutes every 2 hours. This will vary depending on the size of the area and depth of the tissue. This can be reduced gradually over the next 24 hours.
• If you have a bad circulation condition in a specific area then you should not apply ice to that area, or if you have a cold allergy.
What about cold therapy gels?
• Cold therapy gels can play a part in treatment and rehabilitation but should not be used as a substitute for proper cold therapy and compression. They will draw heat out over a longer period of time and are convenient to apply throughout the day reducing pain and inflammation but cannot remove large amounts of heat from the body in the way ice or other cold therapy products can.
In the first 24 hours you should not:
• Apply heat
• Apply a heat rub
• Drink alcohol (even if you play Rugby)
• Have a deep massage.
A Sports Injury Specialist or Doctor could:
• Advise on the success of rehabilitation or indicate if surgery is required.
• Apply a support bandage or plaster cast.
• Aspirate the joint (suck off a the fluid with a needle).
• Operate.
• Prescribe a training programme to maintain leg muscle strength.
• Use ultrasound or laser treatment.
It is important to fully rehabilitate the knee before starting sport again. Surgery for this type of injury is common and you shouldn't be out of action for too long.
Review of the condition
What are some general characteristics of torn meniscus cartilage in the knee? What are its usual manifestations?
A torn meniscus usually produces swelling and well-localized pain in the knee. The pain is made worse by twisting or squatting motions. Sometimes a fragment of torn meniscus can displace inside the knee in such a way as to "lock" the knee, allowing only a toggle of motion.
What are the different types of torn meniscus cartilage in the knee?
A tear can occur in one or more directions in the meniscus. Traumatic tears are usually vertical whereas degenerative tears are usually horizontal. The shape that the meniscus and its torn portion assume has led to names like "bucket handle tear," "parrot beak tear," and others. Sometimes the meniscus deteriorates to the point where the tear is no longer a "clean" tear, but rather the meniscus is shredded and resembles crab meat.
What else might be confused with or similar to torn meniscus cartilage in the knee? How can these be distinguished from the condition?
ometimes the symptoms from a torn meniscus can be confused with those from significant knee arthritis with loose articular (gliding) cartilage. Occasionally a chronically inflammed knee will produce similar findings. Usually these conditions can be distinguished from a torn meniscus by history and a good physical exam. Sometimes, though, they can only be distinguished by MRI or diagnostic arthroscopy.
How common is torn meniscus cartilage in the knee (statistics, demographics, risk factors)?
Meniscal tears are common especially in people participating in sports. Traumatic tears usually occur as a result of a twisting or hyperflexion injury. Degenerative tears are more common in people over 40 and may occur without a specific injury. Smokers are at higher risk for degenerative tears.
How is torn meniscus cartilage in the knee diagnosed? What tests or exams may be used?
A torn meniscus is diagnosed on the basis of the patient's history and a thorough physical exam. An MRI is often used to confirm the diagnosis.
Can medications help torn meniscus cartilage in the knee?
Medications can relieve pain and swelling temporarily, but will not actually produce healing of the torn meniscus.
Can exercises help torn meniscus cartilage in the knee?
Quadriceps strengthening exercises can help prevent the muscle atrophy that is associated with a painful, swollen knee.
Specifically, how is torn meniscus cartilage in the knee improved by arthroscopic meniscectomy-minimally invasive arthroscopic surgery?
When the torn part of the meniscus is removed, any catching or locking should be gone immediately. Pain is usually minimal by 1 week after surgery. Full motion of the knee returns as the swelling disappears, usually within 4-6 weeks after the surgery.
Considering surgery
What kinds of surgery are recommended for torn meniscus cartilage in the knee?
The surgical treatment for a torn meniscus is either to remove or repair the torn segment of the meniscus using an arthroscope and specially designed instruments. Because only the outer 1/4 of the meniscus has blood supply, repairs are successful when the tear occurs in this vascular region of the meniscus. Tears in the non-vascular region are unlikely to heal and therefore are removed. (For information on meniscal repair, see article on that topic).
Who should consider arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and in what cases?
Occasionally the symptoms from a degenerative tear will quiet down without surgery. Surgery for a torn meniscus should be considered when the knee is "locked", the knee is persistently swollen, the patient can not participate in normal activities, the patient understands and accepts the risks, and the surgeon is fellowship trained and experienced in arthroscopic meniscectomy.
What happens if nothing is done for torn meniscus cartilage in the knee (best case/worst case scenarios)?
In the best case scenario, the symptoms of swelling and pain will resolve and the patient will be able to resume activities. In the worst case scenario, the torn fragment of meniscus will "lock" the knee, preventing all but a small amount of motion. This makes activities of daily living difficult.
When performed by an experienced surgeon, how effective is arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee likely to be and how long will the benefit last?
In the hands of an experienced fellowship trained orthopaedic surgeon, removal of the torn part of a meniscus is very effective in restoring comfort and function to the knee. The knee will usually function normally for decades. If an entire meniscus needs to be removed, that section of the knee is likely to become arthritic 10-15 years later.
How urgent is arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee?
Removal of a torn segment of meniscus is urgent only when the knee is locked. Even then the urgency is about the patient's comfort and ability to get around more than it is about the long term effects on the rest of the knee joint. A torn segment of meniscus that catches, locks, or produces swelling on a frequent basis should be removed relatively quickly (within a few months) so that it does not damage the articular (gliding) cartilage in the rest of the knee. Waiting to remove the mobile torn fragment can also lead to muscle atrophy and joint contracture which make it more difficult for the patient to ultimately regain normal function after surgery.
What are the most frequent and most serious risks of arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee? How common are they?
The risks of arthroscopic meniscectomy include but are not limited to infection and deep vein thrombosis ( blood clot) in the operated leg. If a clot forms and travels to the lung, the situation can be life threatening. Fortunately this is uncommon. Sometimes there will be numbness around the small scars where the instruments have entered the knee. There are also risks to anesthesia. An experienced team will take care to minimize these risks, but cannot totally eliminate them.
If risks occur during or after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee how are they managed?
The risk of infection can be decreased by using intravenous antibiotics during surgery. If infection occurs, the patient is taken back to the operating room where the knee is washed out using arthroscopic equipment. The patient is then put on intravenous antibiotics, usually for 6 weeks depending on the organism causing the infection. If a blood clot forms in the leg, the patient is usually put on blood thinners to prevent the clot from expanding or moving. If the patient has concerns about the post operative course of events, the surgeon should be informed as soon as possible.
Preparing for surgery
What type of preparation needs to take place before arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee?
Prior to surgery, the patient should have no ongoing infections, and the knee should have no sores or scratches. The patient should NOT shave the knee the day before surgery. The patient should have someone to help at home for 24-36 hours after the surgery. Because airplane flight is also associated with blood clots in the leg, we recommend that patients not travel by plane in the first 5 days after surgery. Similarly, because dental work releases bacteria into the blood stream, we recommend that dental work be put off until after the knee has fully recovered from surgery, typically 4-6 weeks. When this is not possible, we recommend antibiotic coverage around the time of the dental work.
How can the costs of arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee be anticipated?
The surgeon's office should provide a reasonable estimate of the surgeon's fee, the hospital fee, the anesthesia fee, and the degree to which these should be covered by the patient's insurance.
Who should perform arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and where?
Arthroscopic meniscectomy should be performed by an orthopaedic surgeon fellowship trained in arthroscopic surgery of the knee. The procedure should be done in a medical center or outpatient surgical facility that is accustomed to doing arthroscopic meniscectomies frequently.
How can surgeons experienced in arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee be found?
Surgeons specializing in arthroscopic meniscectomy can be located through university schools of medicine, county medical societies or state orthopaedic associations. Other resources include the American Orthopaedic Society for Sports Medicine and the American Academy of Orthopaedic Surgeons.
Recovering from surgery
How much pain do patients usually have after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and what medications are used to manage it?
In the first 24-48 hours after arthroscopic meniscectomy, the operated knee is swollen and moderately painful. However most patients are able to return to sedentary jobs by the third postoperative day. Medications used to manage pain in the first 48 hours include oral narcotics such as hydrocodone or oxycodone. Some patients obtain good pain relief in the immediate postoperative period with Vioxx. Subsequently, acetaminophen or ibuprofen are sufficient. The application of ice or other cold therapeutic devices to the knee are also very helpful in controlling pain and swelling.
How are medications after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee administered? How long will they be needed?
Most patients do not use any pain relievers after the first postoperative week.
What are the most frequent and most serious side effects of taking pain medication after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee?
Narcotic pain medications can cause drowsiness, slowness of breathing, difficulties emptying bowel and bladder, nausea, vomiting, and allergic reactions. Anti-inflammatory medications can cause stomach irritation, nausea and headaches. Patients who have had substantial exposure to narcotic medications or alcohol in the recent past may find that the usual doses of pain medication are less effective. For some patients, balancing the benefit and the side effects of pain medication is challenging. Patients should notify their surgeon if they have had previous difficulties with pain medication or pain control.
After arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee, what happens in the hospital and when is the patient usually discharged?
Arthroscopic meniscectomy is an outpatient procedure. After surgery the patient remains in the recovery room until the effects of anesthesia have worn off, usually for 1-2 hours.
After arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee, what happens at hospital discharge and what are the patient's limitations at that time?
By the time the patient leaves the recovery room, he or she may put as much weight as tolerated on the operated limb. Many patients choose to use crutches for a few days. Staying relatively quiet, keeping the limb elevated and the knee iced for 48 hours is the best way to keep swelling to a minimum thus speeding return to full activities. During the first 48 hours, before the patient is fully up and around, it is also important to flex one's feet up and down regularly to help prevent blood clots from forming in the calf veins.
What type of help do patients need after arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee and for how long? Can they go home or do they require a convalescent facility?
Patients do not require a convalescent facility after arthroscopic meniscectomy. They may require some assistance with self-care for the first day or two. Driving may be difficult in the first postoperative week until the swelling has resolved enough to allow sufficient knee motion.
Ultrasound Therapy
What is Ultrasound?
Ultrasound is simply high frequency sounds waves above the range that we can hear. It is applied to the body from the 'head' of an ultrasound machine. A gel is used to help the waves travel into the body rather than be reflected off the skin.
What are the benefits of ultrasound?
• increased blood supply which promotes healing,
• produces a pain killing effect which can reduce muscle spasm, and promote normal funtion,
• softens fibrous tissues and scar tissue which are formed during healing.
How is it used?
• The therapist will apply a little gel to the skin and place the head of the ultrasound machine on the skin. Usually it will be moved in small circles. Treatment time can vary according to the injury but is usually about a few minutes.
• Ultrasound can be applied in two modes, pulse and continuous. With continuous the beam od ultrasound waves is well, continuous. This means that heat will be transferred to the body tissues. Pulsed means the waves go in short pulses which prevents the tissues heating.
Knee Supports
Why do I need one?
A support or brace provides protection and support. They prevent injury to healthy joints and support unstable joints. Some retain the heat produced by the body in a specific area and so aids healing.
Heat encourages blood vessels to dilate and so allows more blood to the injured area. The more blood that gets to the injured area, the more nutrients it will get and the faster it will heal.
A hinged brace contains @_@@_@@_@@_@l reinforcements in the sides, combined with a gear in the middle to allow it to move. This provides excellent lateral support to protect the medial and lateral ligaments.
A stabilized knee support shown below has reinforced side panels to provide extra support over the standard knee support - again helping to provent sideways stress on the knee ligaments.
Use it for helping to get better but do not rely on it indefinitely. By wearing it too long your muscles will weaken as they will not be needed as much. If you find you need to wear it for more than a week then you really need professional help. Always use it as part of an overall rehabilitation programme.
Supplements to aid joint healing
(Glucosamine Sulphate, Chondroitin & MSM)
Sport causes high rates of wear & tear on connective tissue cartlidge, tendons and ligaments). By contrast the body's speed of repair is only average in the very young and it declines with age. Joint and connective tissue can easily be damaged faster than it can be repaired, which ultimatley leads to injury.
Glucosamine Sulphate
Glucosamine is a natural products derived from shrimp and crab shells. It is found largely in cartilage and plays an important role in its health. It is thought that supplementing with Glucosamine may help in the healing of joint injuries and arthritis.
If the body has a ready supply of the building blocks it needs to repair damaged joints then the healing process my be accelerated. Glucosamine is made from the combination of a sugar (glucose) and an amine (derived from ammonia).
Chondroitin Sulphate
Chondroitin sulfate is a major constituent of cartilage. It provides structure, holds water and nutrients. One important property of Chondroitin is that it allows other molecules (nutirents) to move through cartilage. This is especially important as the blood supply to cartilage is particularly poor. If nutirents cannot get to the damaged area then healing is unlikely to take place.
Chondroitin sulphate consists of repeating chains of molecules called glycosaminoglycans. Studies with animals have shown that chondroitin may help in the healing of bone. Chondroitin sulphate has also been shown, in numerous trials to relieve symptoms and possibly slow the progression of osteoarthritis or even reverse it.
Knee
Rehabilitation
(Medial cartilage meniscus injury)
The following example is meant for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.
Is non surgical rehabilitation likely to work?
Rehabilitation of cartilage injuries may be possible without surgery if:
• There is little swelling.
• Symptoms have developed 1 to 2 days after injuring the knee.
• The athlete has a full range of movement with pain only at the ends of range of movement.
• The athlete is able to bear weights on the injured leg.
• If this injury has occurred before and healed fairly rapidly.
Surgery may be required if:
• The athlete suffered a severe twisting injury.
• The athlete was unable to walk following injury.
• There may also be damage to the anterior cruciate ligament.
• There is little improvement in the knee three weeks after starting a non surgical rehabilitation programme.
Aims of rehabilitation:
• Decrease pain and swelling.
• Maintain and restore full mobility.
• Restore equal strength to both legs.
• Gradually return to full fitness.
The rehabilitation guidelines for a medial cartilage meniscus tear are similar whether the athlete has surgery or not and can be split into 4 phases. Please note the timescales will vary depending on the severity of injury.
Phase 1: Immediately following surgery.
• Aims - To reduce swelling, restore almost full mobility and begin strengthening exercises.
• Duration - 1 week.
• Rest. Use crutches, partial weight bearing at first but progress to full weight bearing as soon as pain will allow.
• Apply cold therapy and compression. Apply ice for 15 to 20 minutes every 2 hours for the first day or two. Gradually reduce frequency of application over the rest of the week as swelling is reduced.
• Begin mobility exercises aiming to completely straighten the knee by the end of week 1.
• Strength exercises - static quads, hamstring holds, calf raises, hamstring and hip exercises with rehabilitation bands.
• Maintain aerobic fitness with stationary cycling if pain allows.
Phase 2: 1 week after injury.
• Aims - To eliminate swelling completely, regain full range of motion and progress with strengthening exercises.
• Duration - 1 week.
• The athlete should aim to be full weight bearing on the knee and walking with normal gait. No sports specific training but light swimming (not breaststroke!) and cycling may be possible.
• Apply cold therapy and compression 3 times a day if swelling is present. If not then apply ice after training sessions.
• Mobility exercises should continue if full range of motion has not returned.
• Strength exercises may now include leg press, half squats (if not painful) as well as progressing the exercises of Phase 1.
Phase 3: 2 weeks after injury.
• Aims - To maintain full range of motion, equal leg strength and begin to return to sports specific training.
• Duration - 1 week.
• Cold therapy and compression should hopefully not be required now.
• Continue to build on strengthening exercises of Phase 2, concentrating more on squats, step ups, hamstring curl and leg extension.
• Begin to include forwards, backwards and sideways running as well as changing direction.
• Plyometric exercises such as hopping and bounding may be introduced towards the end of the week. For footballers, kicking may be possible.
Phase 4: 3 weeks after injury.
• Aims - To return to sports specific training and finally competition.
• Duration - 2 to 3 weeks.
• Sports massage techniques to the surrounding muscles will aid return to fitness.
• Strengthening exercises should now be highly sports specific. Drop the static contractions and concentrate on traditional weights and plyometric exercises.
• Sprinting should be introduced gradually and built on.
• Training can include preparation for competition. Return to competition should be gradual for example a footballer may start with 10 to 20 minutes play and progress to a full game