Frayed Meniscus

author : AMSSM

comments : 0

Knee problems needn't mean the end of the road.

Member Question from livertrans2:

I had an MRI and it shows that I've got fraying on the posterior horn of the medial meniscus. I haven't been able to run for 6 months - only bike and swim. And I can only swim with a pull buoy. I've been doing 2k swimming/day and easy spinning. Getting physio (physical therapy) 3 times per week, including ultrasound, laser, tens and graston technique, but little improvement. Would surgery would help? My general practitioner says no and due to my age (55), says I should give up tri's and take up golf! She says I've got an overuse degenerative issue.

Answer from David Li, D.O. and Andrew Getzin, M.D.
Members AMSSM

I am sorry to hear that you have not been able to run. Based on the information that you provided, you likely have wear and tear degenerative changes to your meniscus. The meniscus is a c-shape cartilage structure located between your thighbone (the femur) and your shinbone (the tibia). There are two menisci in each knee joint: one on the inside of the knee- the medial meniscus and one on the outside of the knee- the lateral meniscus. They help protect the knee joint from stresses in our daily activities such as walking, running, bending, and climbing by evenly distributing the forces across the joint and by acting as a shock absorber. In children and young adults, the meniscus is well hydrated and is quite resilient but as we age, the meniscus changes. It tends to dry out with time and become vulnerable to degenerative tears, or fraying. In some people, the meniscus breaks down in conjunction with overall degenerative changes in the knee joint. While you did not comment on an x-ray or what the cartilage that lines the bones looks like on your MRI, you most likely also have some osteoarthritis of your knee.

Historically, our surgical colleagues would perform a surgery called a partial menisectomy where they would make small incisions and insert tools (an arthroscopy) to shave down the degenerative meniscus in an effort to calm down the inflammation. However, more recent evidence shows that knee surgery for a fraying meniscus does not improve long-term knee outcome and should be restricted to those individuals who have mechanical symptoms such as locking and catching. In fact, the American Medical Society of Sports Medicine recommends against surgery for degenerative menisci as part of the “Choose Wisely” campaign, which is aimed at helpful physicians practice evidence-based cost-effective medicine.

However, all hope is not lost. There are a variety of treatment options that it does not appear that you have explored based on the history you have provided. You have wisely started with conservative management such as activity modification, physical therapy, and soft tissue work. If you are overweight, weight loss can help unload the knee joint. Medication can also be helpful either oral or topical anti-inflammatories or topical analgesics. Perhaps a brace might help, such as a simple pull up knee sleeve, which can provide relief while you run. If pain still persists then there are several different types of injections that could help. Cortisone injections can decrease pain and inflammation. These can be done up to 3-4 times per year if they achieve pain relief.

Viscosupplementation is also an option. “Visco” is made up of hyaluronic acid, which is a substance that exists in normal joint fluid and acts to lubricate the joint. They are usually performed as a series of injection anywhere from a one-time injection up to one injection per week for five weeks, depending on which product you and your doctor choose to use. The injections seem to work by acting as an anti-inflammatory as well as a lubricant. Finally, there is a growing body of evidence to support using platelet rich plasma (PRP) for degenerative knees. PRP is made from your own blood that is drawn like a normal phlebotomy and then spun down to obtain a concentration of serum that is high platelets, which are rich in growth factors. The platelets are then injected into the knee joint.

The last piece to consider is how you restart running. Most people start too fast. Consider an easy ¼ or ½ mile run at a slow pace a few times a week and progress slowly. You may be surprised to find that your knee tolerates running a little and building slowly so the muscles adapt to handle the forces and less load goes to the knee joint itself. We have many patients in our practice with degeneration in their knees who are still able to run. Good luck!

David Li, DO Andrew Getzin, MD Clinical Director Sports Medicine and Athletic Performance Cayuga Medical Center Ithaca, NY

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date: April 29, 2016