Introduction: Meniscus tears represent a significant challenge in orthopaedic practice, in which the selection of an optimal therapeutic approach often depends on multiple factors. Materials and methods: This paper provides a comprehensive review of meniscus tear treatment with a focus on comparing non-surgical and surgical approaches. The anatomy and physiology of the meniscus are analysed in detail, as well as diagnostic methods for injuries, such as magnetic resonance imaging and clinical examinations. The paper explains the difference between traumatic and degenerative meniscus tears, describing their characteristics and optimal therapeutic approaches. The treatment methods described in this paper are compared, and further divided into non-surgical and surgical treatments. Results: Non-surgical treatment, including physical therapy, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular injections, is compared to surgical methods such as arthroscopic partial meniscectomy (APM) and meniscal repair techniques. While non-surgical treatment is the first choice for degenerative tears, surgical treatment is more commonly used in traumatic tears, especially in the treatment of younger patients. Platelet-rich plasma (PRP) has shown the best results as a form of therapy used for reducing pain and improving joint function in traumatic tears. Surgical treatment, especially meniscal repair surgery, shows better long-term functional outcomes despite a higher reoperation rate (16.5%) compared to arthroscopic partial meniscectomy (1.4%). Meniscal repair, despite the higher reoperation rate, ensures better long-term functional results than meniscectomy. Conclusion: The importance of an individualized treatment approach is emphasized, taking into account factors such as patient age, type of injury, and long-term functional outcomes. Recent studies have further highlighted the cost-effectiveness of meniscal repair procedures when considering the reduced risk of osteoarthritis development and the potential need for future knee replacement surgery.
Keywords: meniscus, meniscus tear, arthroscopy, physical therapy, meniscal repair
INTRODUCTION
The meniscus, as one of the key structures in the knee joint, has the primary role of distributing load between the articular surfaces, thereby protecting the cartilage (1). When a meniscus tear occurs, its ability to protect the cartilage is reduced, which can lead to the gradual development of degenerative changes in the knee known as osteoarthritis (1). Among knee injuries, meniscus tears are extremely common, with an estimated incidence of 60 to 70 cases per 100,000 knee injuries (1).
The menisci are crescent-shaped structures that play a key role in the biomechanics of the knee. Their specific structure allows for even load distribution and shock absorption, thus protecting the articular cartilage from excessive wear and tear. The diagnosis of meniscus tears has seen significant milestones throughout the history of medicine. An important breakthrough in diagnostics was made in 1928 by Thomas McMurray, a British orthopaedist, when he described the first specific clinical test for detecting meniscus tears (2). This test became the foundation for the later development of over twenty different clinical tests for the assessment of meniscus tears. A significant breakthrough in diagnostics also occurred in 1951, when Masaki Watanabe, a Japanese surgeon, constructed a prototype of a modern arthroscope (3). This invention enabled a direct visualization of the meniscus, thus significantly improving diagnostic capabilities. Although arthroscopy was initially used primarily for diagnostic purposes, today it is predominantly used as a therapeutic method. In the early 1970s, magnetic resonance imaging (MRI) was introduced, a non-invasive diagnostic method that allows for detailed visualization of the anatomical structures of the knee without the need for invasive procedures (3). The choice of treatment method for meniscus tears, which can be conservative or surgical, largely depends on the type of injury, i.e. whether it is traumatic or degenerative.
This article will highlight different treatment approaches, putting an emphasis on comparing non-surgical and surgical methods. Special attention will be paid to differences in therapeutic approach depending on the nature of the meniscus tear.
ANATOMY
The menisci are connective cartilaginous tissues located between the condyles of the femur and tibia. Viewed from above, the menisci have a characteristic, crescent-like, C-shape, while in cross-section they are wedge-shaped (3). They do not cover the entire articular surface between the tibia and femur. The medial meniscus covers approximately 60% of the medial tibial plateau, while the lateral meniscus covers approximately 80% of that area. (4). Looking from front to back, the menisci can be divided into three equal sections. The front part of the meniscus is called the anterior horn, the back part is called the posterior horn, and the middle part is called the body of the meniscus. Their main functions include load transfer, knee stabilization, and shock absorption. Vascularization is ensured by the popliteal artery, and blood supply is divided into three zones: red, red-white and white (3). The outer part of the meniscus, known as the red zone, is located near the perimeniscal capillary plexus and is highly vascularized. On the other hand, the inner part of the meniscus forms the white zone, and is characterized by complete avascularity. Between these two zones there is a red-white zone that is partially vascularized. The peroneal nerve is responsible for innervation (2).
MENISCUS TEARS
The European Society of Sports Traumatology, Knee Surgery & Arthroscopy (hereinafter: ESSKA) has defined the characteristics of traumatic and degenerative lesions and issued guidelines for their treatment (5). A traumatic meniscus injury is defined as a ‘meniscus tear’, which is associated with a sufficient knee injury and a sudden onset of knee pain. Meanwhile, a ‘meniscus lesion’ is a degenerative meniscus tear marked by a slow progression of tissue degeneration without a history of an acute trauma. Meniscus tears are morphologically divided into horizontal tears, root tears, and vertical tears, which include longitudinal and radial tears (5). It is important to distinguish between traumatic and degenerative meniscus tears, given the fundamental differences in their optimal treatment.
Traumatic meniscus injury
Traumatic meniscus injury most often occurs in sports injuries, falls, or blows to the knee, which causes sudden rotation or hyperflexion in the knee joint (6). It can occur on its own, but is more often associated with knee ligament injuries (5). Trauma-related meniscus tears are more common among individuals under 30. Furthermore, athletes such as football players, track and field athletes, and skiers are at significantly increased risk of this type of injury (7). Trauma-related meniscus tears are manifested by a painful reaction and sensitivity along the joint line, as well as a skipping or locking sensation during an activity (8). Early and accurate diagnosis of these injuries through clinical examination and MRI is crucial for an adequate and successful treatment. Trauma-related meniscus tears usually result in vertical tears or meniscus root tears (5). Most often, these are radial tears that can significantly damage the meniscus, especially because they are often located in areas of the meniscus with poor blood supply, making spontaneous healing difficult (6). Longitudinal tears are characteristic in that they follow the natural curvature of the meniscus and are often associated with chronic ligament injuries.
Degenerative meniscus injury
The meniscus is subject to degenerative changes that occur over a long period of time due to wear and tear of the knee joint, and are often associated with chronic ligament injuries. These changes are common in the general population, and their incidence increases with age, thus they can be present in 50% of patients over the age of 70 (9). They can be seen as an indicator of increased risk for osteoarthritis or as part of the degenerative process in the knee itself. Degenerative meniscus tears usually manifest gradually, with characteristic horizontal or complex tears. It is important to note that most degenerative lesions do not cause symptoms, and even when symptoms are present, they may not necessarily be related to the lesion (9). Possible signs include knee pain, swelling, stiffness, and limited mobility (6). The diagnosis is made through a combination of clinical examination and X-ray imaging. A knee X-ray is always performed with the patient in a standing position, and is primarily used to assess the degree of osteoarthritis. MRI is not used as the first line of diagnosis in elderly people with knee pain. It is used only in specific cases with persistent symptoms or to plan surgical treatment (9).
DIAGNOSIS
The diagnosis of meniscus tears has evolved over time. Clinical examinations, such as the McMurray test that was first described in 1928, are still important for distinguishing meniscus tears from other knee injuries. Arthrography, which was a crucial procedure in the past, has been replaced by MRI, while arthroscopy, although considered the most accurate method, is currently used primarily for treatment, and in exceptional cases for diagnosis when clinical findings and MRI findings do not match (2). Ultrasound is also used in the initial assessment of meniscus tears due to its speed and availability.
Clinical examination
The diagnosis of a meniscus tear begins with a patient’s medical history and clinical examination. The McMurray test, while significant, is not sufficient when used on its own. The modern practice relies on multiple tests, and recent research suggests that a combination of three specific tests (the Thessaly test, the McMurray test, and the joint line tenderness of the knee test) can provide results similar to MRI (10).
The McMurray test is performed while the patient is lying on their back. The examiner carefully manipulates the patient’s leg, performing a combination of knee rotation and flexion (2). During this procedure, the joint space is simultaneously palpated, while the examiner attempts to detect any signs of meniscus damage (Figure 1). A positive McMurray test is indicated by pain or a noticeable popping sensation in the knee (2).
The Thessaly test is performed while the patient is in a standing position, standing on one leg, while the examiner provides support by holding their outstretched hands. The patient then turns their body from side to side three times, first maintaining the 5° knee flexion, and then three times at 20° flexion (Figure 2). The procedure must be repeated on the opposite leg. If the patient experiences discomfort in the joint space during rotation that indicates a possible meniscus tear (2).
The joint line tenderness (JLT) test is a physical exam that is performed while the patient is lying on their back. The patient’s knees are flexed at 90° and their feet are on the table (Figure 3). The examiner palpates the joint line with their thumb and if the patient experiences pain, the test is considered positive (2).
Magnetic resonance imaging
MRI has become the leading method for imaging meniscus tears due to its non-invasiveness and ability to visualize other knee structures. However, this method also has its limitations. In addition to its high cost and limited availability, it presents several challenges: it is contraindicated in the presence of internal metallic objects and cardiac pacemakers, problematic for people with claustrophobia, and long examination times and waiting lists can delay timely treatment (11). MRI is used after a thorough clinical examination, especially in unclear cases. The MRI analysis of the meniscus includes assessment of its shape and signal intensity. Meniscus damage is classified into three grades: grade 0 indicates a normal, healthy meniscus, grades I and II indicate changes that do not extend to the meniscus surface, while grade III indicates a tear that passes through the meniscus surface (12). The diagnosis of a meniscus tear using MRI is based on two key signs: increased signal intensity that extends to the surface of the meniscus and a change in the shape of the meniscus (13). The presence of both signs strongly suggests a tear. MRI also provides insight into the characteristics of a meniscus tear, which is crucial for the therapeutic approach (13).
Ultrasound
In recent years, knee ultrasound has seen increasing use in numerous medical specialties, including sports medicine, rheumatology, and pain medicine. As a diagnostic method, ultrasound offers significant advantages: it is non-invasive, economical and faster than MRI. It also has the ability of providing a real-time diagnosis, which enables early treatment (11). MRI has been shown to be superior in detecting meniscus tears. The MRI tests revealed a sensitivity of 94% and a specificity of 87.8% in identifying meniscus tears, which is significantly higher compared to ultrasound, especially for lateral meniscus tears (14). Its ability to provide detailed visualization of the medial and lateral meniscus allows for precise assessment of complex injuries, including ligament tears and joint effusions (15). Nevertheless, ultrasound diagnostics is also a cornerstone of clinical practice. Although the interpretation of findings is significantly dependent on the experience of the physician performing the examination, which can result in variability in results, ultrasound often serves as a valuable alternative in settings where MRI is not available or where its use is contraindicated (16). This is especially important in smaller healthcare facilities where it can serve as an effective tool for initial injury assessment.
TREATMENT
The selection of appropriate treatment for meniscus tears depends on several crucial factors, such as the type of tear and its mechanism. Traumatic tears often require surgery, while degenerative tears, according to ESSKA guidelines, always require conservative treatment first, for a minimum of 3 months. Surgical treatment for degenerative tears is considered if conservative treatment has not yielded the desired results and provided that the person does not have pronounced degenerative changes in the joint on X-ray (17). The prognosis for treatment also depends on the location of the tear, with better prospects for peripheral injuries in the red zone, where meniscus healing may occur without surgical treatment (1).
Non-surgical treatment
Non-surgical treatment of the meniscus includes physical therapy, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular injection (18). A conservative approach is the primary treatment choice for degenerative meniscus tears. Certain traumatic meniscus tears, such as minor vertical tears in childhood, can also be successfully treated with a conservative approach, including physical therapy and activity reduction, without the need for surgery (19).
Physical therapy is crucial in treating meniscus tears in the elderly. Studies indicate that up to 10 weeks of regular quadriceps strengthening exercises can improve knee function by up to 35% in patients with meniscus tears and knee osteoarthritis (20). Research indicates equal effectiveness of physical therapy and arthroscopic partial meniscectomy (APM) for degenerative meniscus tears in people over 45 (21). The goal of physical therapy is to improve the range of motion, stability, and functional ability of the knee, which ultimately contributes to the successful recovery of meniscus tears (21). Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce pain and inflammation in meniscus tears (21). Although they alleviate the symptoms, they do not cure the structural damage of the meniscus, and are therefore used as an addition to other conservative treatment methods. It is important to adhere to the prescribed doses and duration of therapy due to possible side effects. The main side effects include gastrointestinal problems, cardiovascular problems, and kidney damage (22). Patients with a history of gastrointestinal bleeding or high cardiovascular risk are at significant risk, and therefore the use of NSAIDs should be avoided in these patients (23).
Intra-articular drug administration involves direct injection of the drug into the joint, most commonly in patients with degenerative meniscus tears and osteoarthritis (24). Glucocorticoids, hyaluronic acid, PRP therapy, and the administration of mesenchymal stem cells are used (22). Glucocorticoids, known for their immunomodulatory effects, are used to reduce inflammation and joint pain (22). A 2019 study conducted by Wilderman et al. showed that ultrasound-guided meniscus-targeted glucocorticoid injections provided significant pain relief lasting approximately 5.68 weeks (25). In addition to that, it was demonstrated that intra-articular injection of hyaluronic acid improved joint function and reduced pain in patients with degenerative meniscus tears (24). PRP therapy utilizes the patient’s concentrated blood to stimulate tissue regeneration (22). Bondariev et al. conducted a study in 2022 that compared the effectiveness of PRP, NSAIDs in combination with physical therapy, and arthroscopic partial meniscectomy (APM) in traumatic meniscus tears (26). PRP has emerged as the most effective treatment for reducing pain and improving joint function, both in the short and long term (26). NSAIDs and physical therapy were the least effective treatments, while APM showed initial improvement, but with worsening symptoms after the second year (26). A 2020 study conducted by Guenoun et al. showed promising results in the treatment of degenerative meniscus tears (27). Their study confirmed that PRP can be safely and effectively administered directly into the meniscal tissue (27). Patients who received this type of intra-meniscal therapy showed significant improvement, with reduced pain and improved knee function (27). Research on intra-articular injection of mesenchymal stem cells in patients with meniscus tears is still in its early stages, and it is largely limited to in vitro studies and animal studies (28).
Surgical treatment
Studies conducted in the 1980s addressed the importance of the meniscus for knee stability, which prompted the development of methods for its preservation and repair (20). Surgical intervention is recommended in patients with meniscus tears in the vascularized, red zone, complex and larger lesions longer than 1 cm, acute injuries that occurred within the last 6 weeks, patients under 40, and in case of concomitant anterior cruciate ligament (ACL) tear (20).
Nowadays, meniscectomy is performed using open or arthroscopic approaches, and it can be partial or total (complete). Total meniscectomy is avoided because of the risk of early osteoarthritis (29). With the development of modern arthroscopic surgery, the open approach has become obsolete and is only used in exceptional situations when the meniscus is severely damaged and causes significant discomfort (30). This includes cases such as large radial meniscus tears or meniscus root tears, especially in knees already affected by osteoarthritis (30). APM is the preferred method because it is less invasive and enables faster recovery. The recommended indications for APM are degenerative lesions that do not respond to conservative therapy, and radial tears located in the avascular, white zone of the meniscus (31). The goal of APM is to remove the damaged portion of the meniscus while preserving the peripheral tissue (32). Although it is a common, minimally invasive procedure, APM may accelerate the development of osteoarthritis due to altered knee biomechanics (1). Clinical studies indicate poorer outcomes and lower levels of satisfaction in patients with degenerative meniscus tears and osteoarthritis compared to traumatic tears (31).
Arthroscopic meniscal repair (suturing) is divided into three main techniques: : inside-out, outside-in and all-inside (29). In the inside-out technique, needles with threads are passed from the joint to the skin, then a skin incision is made in the area of the threads, after which the knot is fixed over the joint capsule (29). This method is applicable for suturing tears located in the middle part of the meniscus, i.e. in the body of the meniscus (1). The outside-in technique uses threads that are passed through two pre-inserted needles from the skin towards the joint, crossing the meniscus tear (29). The ends of these sutures are then tied to the capsule as in the inside-out technique. The all-inside meniscal repair technique is performed completely intra-articularly without the need for additional skin incisions (1). This technique is particularly suitable for suturing posterior horn meniscus tears, but it is also the most expensive suturing method due to the use of specific implants. With every technique there is a risk of neurovascular complications. They are primarily used for acute traumatic injuries in the vascularized zone, but also for horizontal tears in athletes, meniscus root tears, and radial tears (29). In younger patients, meniscal repair is also recommended in the less vascularized red-white and white zones, with a high success rate of 75% (33). Meniscal repair surgeries show a higher reoperation rate compared to arthroscopic partial meniscectomy (APM). The results of a 2011 study conducted by Paxton et al. show that, in the short-term follow-up of patients (up to 4 years), the percentage of reoperations after meniscal repair is 16.5%, while after APM it is significantly lower, at only 1.4% (34). Reoperations are more common with meniscal repair due to the complexity of the injuries themselves, which are more difficult to operate on, as well as the healing process – if the meniscus does not heal properly, persistent pain and joint dysfunction often require reoperation (35). However, despite this difference in reoperation rates, meniscal repair provides superior long-term results (34). Patients undergoing meniscal repair surgery achieve better functional outcomes, maintain a higher level of physical activity, and have a lower likelihood of long-term procedure failure compared with those who underwent APM (29). The key advantage lies in the preservation of the meniscus tissue, which plays an essential role in load distribution and shock absorption in the knee joint. When the meniscus is successfully sutured and preserved, patients have better knee function and a lower risk of developing osteoarthritis in the future (35).
CONCLUSION
The key to successful treatment of a meniscus tear lies in an individualized approach that takes into account the patient’s age, comorbidities, symptoms, and characteristics of the injury. Conservative treatment shows good results, especially in degenerative injuries and elderly patients. Surgical procedures, such as APM and meniscal suturing or repair, have specific indications and are preferred in traumatic injuries, with suturing providing better long-term functional outcomes despite a higher rate of reoperation.
Advances in understanding knee biomechanics and the development of new therapeutic methods are continuously improving treatment approaches. In conclusion, successful treatment of meniscus tears requires careful assessment, an individualized approach, and balancing between conservative and surgical options, always keeping in mind the long-term health and functionality of the knee.
Author Contributions: MŠV – responsible for the conception, design, analysis and interpretation of data, writing the first version of the text (draft) and critical revision of the paper. AM – responsible for the conception, design and critical revision of the paper.
Acknowledgments: The authors report no acknowledgments.
Funding: For this work authors did not receive any funding.
Conflict of interest statement: The authors declare that they have no conflict of interest relevant to this manuscript.
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Figure 1. McMurray test; A – initial position of the patient during the medial meniscus tear test, leg in external rotation and flexion; B – final position of the patient during the medial meniscus tear test, leg in external rotation and extension; C – initial position of the patient during the lateral meniscus tear test, leg in internal rotation and flexion; D – final position of the patient during the lateral meniscus tear test, leg in internal rotation and extension
Slika 1. McMurrayev test; A – početni ležeći položaj pacijenta pri testiranju ozljede medijalnog meniska, noga u vanjskoj rotaciji i fleksiji; B – krajnji položaj pacijenta pri testiranju ozljede medijalnog meniska, noga u vanjskoj rotaciji i ekstenziji; C – početni položaj pacijenta pri testiranju ozljede lateralnog meniska, noga u unutarnjoj rotaciji i fleksiji; D – krajnji položaj pacijenta pri testiranju ozljede lateralnog meniska, noga u unutarnjoj rotaciji i ekstenziji
Figure 2. Thessaly test (A – rotation of the body into maximum external rotation around the tested leg to assess lateral meniscus tear; B – rotation of the body into maximum internal rotation around the tested leg to assess medial meniscus tear).
Slika 2. Thessaly test (A – okret tijela u maksimalnu vanjsku rotaciju oko noge koja se ispituje za procjenu ozljede lateralnog meniskusa; B – okret tijela u maksimalnu unutarnju rotaciju oko noge koja se ispituje za procjenu ozljede medijalnog meniskusa)
Figure 3. Joint line tenderness test (A – leg position during joint line tenderness test with the knee flexed at 90° and the examiner’s thumb palpating the medial joint line during the medial meniscus tear test; B – leg position during the joint line tenderness test with the knee flexed at 90° and the examiner’s thumb palpating the lateral joint line during the lateral meniscus tear test).
Slika 3. Test bolnosti zglobne pukotine na palpaciju (A – položaj noge pri izvođenju testa bolnosti zglobne pukotine na palpaciju u položaju od 90° fleksije koljena i s palcem ispitivača u medijalnoj zglobnoj pukotini pri testiranju ozljede medijalnog meniska; B – položaj noge pri izvođenju testa bolnosti zglobne pukotine na palpaciju u položaju od 90° fleksije koljena i s palcem ispitivača u lateralnoj zglobnoj pukotini pri testiranju ozljede lateralnog meniska)