Knee Injuries

DISCOID MENISCUS #MaybeShe'sBornWithIt?

A discoid meniscus is an abnormally shaped meniscus (cartilage that cushions the bones of the knee) present in 1% to 3% of people born in the United States. The condition is the result of abnormal formation of the meniscus during development in the womb. While some people may be unaware of their discoid meniscus and never experience symptoms related to it, they live at a higher risk of injury than those born with a normal meniscus. A discoid meniscus is commonly detected in childhood or adolescence, and often requires surgical intervention. Physical therapists provide treatment prior to and following surgery, and for conditions not requiring surgery.

What is Discoid Meniscus?

Our knees contain 2 cushions between our thigh bone (femur) and shin bone (tibia), made of cartilage called meniscus. The meniscus is normally crescent-shaped. Its role is to provide stability to the knee joint and absorb forces when we stand and move. Both menisci are attached to the shin bone (tibia) by the meniscofemoral ligament.

A discoid meniscus is present at birth. It occurs when the cartilage does not properly develop, resulting in a thicker disc- or oval-shaped meniscus. The defect most often occurs in the meniscus on the outer (lateral) part of the knee joint. Approximately 20% of individuals diagnosed with a discoid meniscus have it in both knees.

There are 3 types of discoid menisci. The classifications are:

  • Incomplete Discoid Meniscus. The shape of the meniscus is a bit wider and thicker than a normal meniscus.
  • Complete Discoid Meniscus. The shape of the meniscus is significantly wider than a normal meniscus, covering the shin bone (tibia).
  • Wrisberg-Ligament Meniscus. The normally present meniscofemoral ligament is absent.

Their abnormal shape and thickness make discoid menisci more prone to injury and tearing. The meniscus tissue is often not capable of healing itself due to its limited blood supply, which is required for tissue healing.

Meniscal injuries most commonly occur in activities that require sudden stopping, pivoting, and "cutting," such as in sports. Pain may also be present, sometimes without a specific injury to, or a tear in, the discoid meniscus.

In some cases, arthroscopic surgery may be required to reshape the abnormal meniscus to make it as normal as possible.

How Does it Feel?

With a discoid meniscus or torn discoid meniscus, you may experience:

  • Pain in your knee, most often on the outer (lateral) side of the leg.
  • Sharp pain with running, jumping, cutting, or deep squatting.
  • Swelling in the knee.
  • Tenderness on the outer side, or less commonly on the inner side, of the knee.
  • Catching or locking of the knee while walking or squatting.
  • Loss of knee motion, particularly getting "stuck," while fully bending or straightening the knee.
  • Loss of strength in the quadriceps (thigh) muscle.
  • Discomfort with daily activities, like walking up and down stairs.

How Is It Diagnosed?

Diagnosis of a discoid meniscus begins with a thorough medical history and physical examination. Your physical therapist will assess different measures of the knee area, such as motion, strength, flexibility, tenderness, and swelling. Your physical therapist will perform several tests specific to the knee joint, and may ask you to briefly demonstrate the activities or positions that cause your pain, such as walking, squatting, and stepping up or down stairs.

If your physical therapist suspects there may be an injury inside the knee joint, such as a discoid meniscus, the therapist will likely recommend a referral to an orthopedic physician for diagnostic imaging, such as ultrasound, x-ray, or MRI. An MRI, which looks at bones, muscles, and cartilage, is the best imaging source to identify a discoid meniscus and a tear in the meniscus.

How Can a Physical Therapist Help?

When you have been diagnosed with a discoid meniscus, your physical therapist will work with you to develop a plan to help achieve your specific goals. If surgery is needed, your physical therapist will work with you after surgery. To do so, your physical therapist will select treatment strategies in any or all of the following areas:

Range of Motion. An injury or surgery to the knee joint causes the joint to be irritated, often resulting in swelling and stiffness, resulting in loss of normal motion. While it is important to regain your normal knee motion, it is also important to allow your injury to heal, without placing excessive stress on the healing joint. Your physical therapist will assess your motion, design gentle exercises to help you regain normal range of motion, and establish a plan that will balance joint protection with motion restoration.

Strength Training. Your physical therapist will teach you exercises to strengthen the muscles around the knee, so that each muscle is able to properly perform its job, and stresses are eased, so the knee joint is properly protected.

Manual Therapy.Physical therapists are trained in manual (hands-on) therapy. If needed, your physical therapist will gently move your knee cap (patella) or patellar tendon and surrounding muscles to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. 

Pain Management. Many pain-relief strategies may be implemented; the most beneficial with knee pain is to apply ice to the area, and decrease or eliminate specific activities for a certain length of time. Your physical therapist will help to identify specific movements or activities that continue to aggravate your knee joint, and will design an individual treatment plan for you, beginning with a period of rest, and gradually adding a return to certain activities as appropriate.

Functional Training.Physical therapists are experts at training athletes to function at their best. Your physical therapist will assess your movements, and teach you to adjust them to relieve any extra stress in your knee.

Education. Your physical therapist will work with you to identify and change any external factors causing your pain, such as exercise selection, footwear, or the amount of exercises you complete. Your physical therapist will develop a personal exercise program to help you return to your desired activities.

Can this Injury or Condition be Prevented?

A discoid meniscus is present at birth and, therefore, cannot be prevented. Maintaining appropriate lower-extremity mobility and muscular strength are the best methods for preventing any type of knee injury. Unfortunately, the structure of some individuals’ menisci can increase the risk of sustaining an injury. It is imperative to be aware of any knee pain that you experience, particularly with squatting, running, or cutting, as these are signs of a potential knee injury. Identifying and addressing these injuries early is helpful in their treatment.

Real Life Experiences

Ashleigh is a 15-year-old girl who has been playing soccer since she was in the first grade. She plays with her high school team during the week, and competes in tournaments with her club team on the weekends. Last weekend, while she was running and cutting in her soccer game, she felt a sharp pain in her right knee. She was able to finish playing, but after the game, she told her dad her knee was hurting. She said it had begun getting sore during one of the practices that week, but she didn’t want to tell her coach because she was worried she would not be allowed to continue to play. Now she said she felt like her knee was swollen. Her dad immediately called their local physical therapist.

Ashleigh's physical therapist performed a comprehensive health history and examination. The physical examination revealed that Ashleigh’s knee was tender, swollen, and that she had lost leg motion and strength. Because Ashleigh’s knee was so tender, her physical therapist referred her to an orthopedic surgeon. Her MRI results showed that Ashleigh had a discoid meniscus in her right knee that required surgery.

Ashleigh underwent an outpatient arthroscopic surgery, which required 2 small incision holes in the front of her knee. She was able to return home the same day. After her surgery, Ashleigh returned to physical therapy. Ashleigh used crutches for about 2 weeks after her surgery, until her leg was strong enough to walk without support. Together, Ashleigh and her physical therapist, father, and coach developed a treatment plan to help get her back on the soccer field. The treatment process began with exercises to regain motion and strength.

After about 2 months, when her knee was less tender and she had met some of the goals set in physical therapy, Ashleigh began light running, in preparation for her return to soccer. Throughout her rehabilitation, Ashleigh and her physical therapist worked together to improve the ways she moved, including her sqatting, running, and jumping form, in order to decrease the chance of her developing another knee injury. Along with her physical therapist, coach, and parents, Ashleigh developed a gradual reintegration plan for her return to soccer.

A month later, Ashleigh was back playing soccer! In order to minimize her risk of further knee problems, she continued to perform the daily exercises her physical therapist had prescribed. She also changed her routine to allow for adequate warm-up time before and after each practice. At the end of the season, thanks to Ashleigh’s goal scoring, her team won the high-school state championship!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:

  • A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, injuries.
  • A physical therapist who is a board-certified specialist, or has completed a residency in orthopedic or sports physical therapy, as the therapist will have advanced knowledge, experience, and skills that apply to an athletic population.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping athletes with knee pain.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.

 

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of discoid meniscus. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Sun Y, Jiang Q. Review of discoid meniscus. Orthorp Surg. 2011;3(4):219–223. Article Summary on PubMed.

Davidson D, Letts M, Glasgow R. Discoid meniscus in children: treatment and outcome. Can J Surg. 2003;46(5):350–358. Free Article.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Allison Mumbleau, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.

MENISCUS TEARS

 

Meniscus tears are among the most common knee injuries. Athletes, particularly those who play contact sports, are at risk for meniscus tears. However, anyone at any age can tear a meniscus, and by doing any activity. Here at CHAMPION, many of our meniscus patients injured theirs while running - felt a pop, the knee gave out - and they still finished the race.  Many times, you'll know something's wrong but it's not like a quad tendon rupture or an achilles tendon rupture, where you won't be able to walk on that leg. You'll definitely have pain later on as the day continues and your body recognizes the injury, but many times, no one recognizes the severity of the injury that just occurred. When people talk about torn cartilage in the knee, they are usually referring to a torn meniscus.  

The menisci are two wedge-shaped pieces of cartilage act as "shock absorbers" between your thighbone and shinbone. These are called meniscus. They are tough and rubbery to help cushion the joint and keep it stable.

Description

Menisci tear in different ways. Tears are noted by how they look, as well as where the tear occurs in the meniscus. Common tears include bucket handle, flap, and radial.

Sports-related meniscus tears often occur along with other knee injuries, such as anterior cruciate ligament tears.

Cause

Sudden meniscus tears often happen during sports. Players may squat and twist the knee, causing a tear. Direct contact, like a tackle, is sometimes involved.

Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

Symptoms

You might feel a "pop" when you tear a meniscus. Most people can still walk on their injured knee. Many athletes keep playing with a tear. Over 2 to 3 days, your knee will gradually become more stiff and swollen.

The most common symptoms of meniscus tear are:

  • Pain
  • Stiffness and swelling
  • Catching or locking of your knee
  • The sensation of your knee "giving way"
  • You are not able to move your knee through its full range of motion

Without treatment, a piece of meniscus may come loose and drift into the joint. This can cause your knee to slip, pop, or lock.

Doctor Examination

Physical Examination and Patient History

After discussing your symptoms and medical history, your doctor will examine your knee. He or she will check for tenderness along the joint line where the meniscus sits. This often signals a tear.

One of the main tests for meniscus tears is the McMurray test. Your doctor will bend your knee, then straighten and rotate it. This puts tension on a torn meniscus. If you have a meniscus tear, this movement will cause a clicking sound. Your knee will click each time your doctor does the test.

Imaging Tests

Because other knee problems cause similar symptoms, your doctor may order imaging tests to help confirm the diagnosis.

X-rays: Although x-rays do not show meniscus tears, they may show other causes of knee pain, such as osteoarthritis.

Magnetic resonance imaging (MRI): This study can create better images of the soft tissues of your knee joint, like a meniscus.

Treatment

How your orthopaedic surgeon treats your tear will depend on the type of tear you have, its size, and location.

The outside one-third of the meniscus has a rich blood supply. A tear in this "red" zone may heal on its own, or can often be repaired with surgery. A longitudinal tear is an example of this kind of tear.

In contrast, the inner two-thirds of the meniscus lacks a blood supply. Without nutrients from blood, tears in this "white" zone cannot heal. These complex tears are often in thin, worn cartilage. Because the pieces cannot grow back together, tears in this zone are usually surgically trimmed away.

Along with the type of tear you have, your age, activity level, and any related injuries will factor into your treatment plan.

Nonsurgical Treatment

If your tear is small and on the outer edge of the meniscus, it may not require surgical repair. As long as your symptoms do not persist and your knee is stable, nonsurgical treatment may be all you need. Physical therapy may be necessary to strengthen the muscles around the joint to somewhat replicate the aspects of stability you lose when the meniscus is severely damaged so as to return to higher level activity. Immediately, however, the RICE protocol is going to manage swelling and pain until strengthening becomes an option. 

RICE. The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice, Compression, and Elevation.

  • Rest: Take a break from the activity that caused the injury. Your doctor may recommend that you use crutches to avoid putting weight on your leg.
  • Ice: Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.
  • Compression: To prevent additional swelling and blood loss, wear an elastic compression bandage.
  • Elevation: To reduce swelling, recline when you rest, and put your leg up higher than your heart.
  • Non-steroidal anti-inflammatory medicines: Drugs like aspirin and ibuprofen reduce pain and swelling.

Surgical Treatment

If your symptoms persist with nonsurgical treatment, your doctor may suggest arthroscopic surgery.

Procedure

Knee arthroscopy is one of the most commonly performed surgical procedures. In it, a miniature camera is inserted through a small incision (portal). This provides a clear view of the inside of the knee. Your orthopaedic surgeon inserts miniature surgical instruments through other portals to trim or repair the tear.

Knee arthroscopy

  • Partial meniscectomy. In this procedure, the damaged meniscus tissue is trimmed away.
  • Meniscus repair. Some meniscus tears can be repaired by suturing (stitching) the torn pieces together. Whether a tear can be successfully treated with repair depends upon the type of tear, as well as the overall condition of the injured meniscus. Because the meniscus must heal back together, recovery time for a repair is much longer than from a meniscectomy.

Rehabilitation

After surgery, your doctor may put your knee in a cast or brace to keep it from moving. If you have had a meniscus repair procedure, you will need to use crutches for about a month to keep weight off of your knee.  Meniscus tears can occur concurrently with another injury, such as an ACL rupture, or alone. An ACL rupture would not usually require weight-bearing limitations, but adding a meniscus repair in will require weight-bearing restrictions until the meniscus heals because of the pressure it endures from the joint.

Once the initial healing is complete, your doctor will prescribe rehabilitation exercises. Regular exercise to restore your knee mobility and strength is necessary. You will start with exercises to improve your range of motion. Strengthening exercises will gradually be added to your rehabilitation plan.

For the most part, rehabilitation is carried out at a physical therapy clinic. Rehabilitation time for a meniscus repair is about 3 months. A meniscectomy requires less time for healing — approximately 3 to 4 weeks.