I have a question for Dr. Cunningham. I am a finish carpenter from Eagle and recently had immediate pain in my knee after simply standing up from a squatting position. There is now sharp pain at times in my knee especially when I rotate or pivot on the knee. What do you think it is?
— In Pain, Eagle
Dear In Pain,
You probably tore one of the meniscus cartilages in your knee. I see a large number of patients like yourself in the office who suffer isolated meniscal tear in their 40s or 50s given all the stress the meniscus takes over the years working and playing here in the Vail Valley. Most meniscus tears are “degenerative.” In other words, they tear due to a person living an active life and the meniscus tissue weakens over time and tears without much trauma. It may happen just by turning in your kitchen. My analogy is that the meniscus is like the fan belt in your car. After so many miles of driving, it can just tear. A quarter of all knee injuries are meniscus tears. While not as severe as an ACL tear nor as common as an MCL tear, a meniscus tear can still be painful and prevent you from doing your work or the sports you enjoy.
As for the treatment of meniscus tears, I am quite aggressive about repairing meniscal tears whenever possible as maintaining them is critical to preventing early knee arthritis. The meniscus cartilages are the “shock absorbers” in your knees and, without them, the coating cartilage on the ends of your knee bones wears at an accelerated rate resulting in arthritis.
There are newer meniscal repair devices that make it somewhat easier to do meniscal repairs arthroscopically, although making a small incision and doing “inside-out” meniscal repairs with sutures is still the “gold standard.” Orthopedic sports medicine physicians have tried adding platelet rich plasma or other stem cell preparations to the repair site in the hopes of increasing the chances of getting the meniscus to heal. But the meniscus cartilage has poor blood supply so healing potential of this method is limited. The jury is still out as to whether these biological additives increase the chances of healing or not.
In the case of a degenerative meniscus tear, the meniscus is not repairable as there is no blood supply that would allow it to heal. Instead, I arthroscopically remove only the torn portion. I am always very careful to only remove the torn flap that is causing the pain and leave as much of the meniscus remaining as possible. This torn flap is not helping the patient in any way and is only generating pain so it is best to remove it.
Although I usually see meniscal tears as isolated injuries, they are also commonly found in combination with other injuries such as ACL tears. Usually, both the meniscus and the ACL can be repaired in the same surgery but sometimes, I’ll recommend staging the two surgeries. In other words, if someone tears their ACL and also suffers the dreaded “bucket handle” meniscus tear (where the majority of the meniscus is torn circumferentially and is flipped into the front of the knee), I may first fix the meniscus tear and get the patient into physical therapy to restore their range of motion prior to fixing their ACL. The decision to do these repairs as staged procedures or all at the same time depends on how much swelling there is and how limited the patient’s knee range of motion is.
A torn meniscus is very common. With proper diagnosis, treatment and rehabilitation, your chances of returning to your pre-injury abilities are very good.
Dr. Rick Cunningham is a knee and shoulder sports medicine specialist with Vail-Summit Orthopaedics. He is a physician for the U.S. Ski Team and chief of surgery at Vail Valley Medical Center. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit www.vsortho.com.