The menisci are two crescent-shaped fibrocartilage structures between the femur and the tibia. They distribute load across the joint, absorb shock, contribute to stability and help lubricate the cartilage. Losing meniscal tissue significantly increases the contact pressure on the articular cartilage, which is why modern practice preserves the meniscus whenever it can.
Traumatic tears occur in younger patients through a twisting injury on a loaded, flexed knee, often alongside an ACL rupture. Degenerative tears occur in patients over forty with no clear injury and are frequently part of early osteoarthritis. Morphologically, tears are described as longitudinal, bucket-handle, radial, horizontal, flap or complex. The medial meniscus is torn more often than the lateral.
Pain localised to the medial or lateral joint line, worse on twisting, squatting or getting out of a car. Swelling that develops over a day rather than within minutes. Clicking or catching. True locking — an inability to fully straighten the knee — suggests a displaced bucket-handle fragment and requires urgent assessment. Giving way may occur, though it is more typical of ligament injury.
Joint line tenderness, a positive McMurray or Thessaly test and an effusion form the clinical picture. Radiographs are taken to assess joint space and exclude other causes. MRI defines the tear pattern, its location relative to the blood supply and any associated ligament or cartilage damage. Importantly, MRI shows degenerate meniscal changes in a large proportion of asymptomatic middle-aged knees, so imaging must always be interpreted alongside the examination.
Many degenerative tears settle with a period of activity modification, anti-inflammatory treatment and a progressive strengthening programme, and randomised trials show that physiotherapy is as effective as surgery for this group. Surgery is indicated for a locked knee, for symptomatic traumatic tears, and where symptoms persist despite adequate conservative treatment. Where the tear lies in the vascular peripheral zone, meniscal repair with sutures preserves function and protects the cartilage; where the tissue is not repairable, a partial meniscectomy removes only the unstable fragment and keeps the rim intact. Both are performed arthroscopically.
After partial meniscectomy, patients walk immediately, return to desk work within one to two weeks and to sport at four to six weeks. After a meniscal repair, weight-bearing and flexion beyond ninety degrees are restricted for four to six weeks to allow healing, with return to running at three to four months and to pivoting sport at five to six months. The longer rehabilitation after repair is the price of keeping the meniscus — and it is usually worth paying.
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