Rupture of the meniscus of the knee joint: when surgery is needed and when not - examination in Tashkent

Two different breaks under one name

The words “meniscus tear” hide two fundamentally different stories. The first is traumatic: the young man turns sharply on his supporting leg, the meniscus is pinched between the bones and tears. There is a clear moment of injury, pain, swelling, and often blockage. The second is degenerative: the meniscus loses its elasticity over the years, becomes brittle and at some point tears on its own, without any injury, sometimes just when getting up from a squat. This is not an event, but a stage of natural wear and tear of the joint, often going hand in hand with the onset of arthrosis.

• Traumatic rupture - sudden twisting of the knee with a fixed foot, sports, fall
• Degenerative tear - thinning and disintegration of meniscus tissue with age
• A watering can handle tear is a large longitudinal tear, the flap of which is displaced into the joint
• Flap, radial, horizontal tears - differ in direction and prognosis
• Damage to the root of the meniscus - separation of its attachment site, the consequences of which are close to removal of the entire meniscus
• Rupture of the discoid meniscus is a congenital form, more often in children and adolescents

How it manifests itself

The classic manifestation is pain along the inner or outer surface of the knee, exactly along the line of the joint space, which intensifies when squatting, turning around, and going down stairs. There is often a sensation of clicking, rolling, or something interfering inside the joint. Swelling does not develop immediately, but after a few hours or by the next day, in contrast to a ligament rupture, in which the joint swells almost instantly due to blood.

The inner and outer menisci behave differently. The internal one is firmly fused with the capsule and internal collateral ligament, so it is less mobile and breaks much more often. The outer one is more mobile and is damaged less frequently, but when it ruptures, a meniscus cyst is more often formed - a dense, painful protrusion along the outer surface of the knee, which is sometimes mistaken for a tumor. Another detail that is useful to know: pain under the knee from behind when the meniscus is torn is often accompanied by a cyst in the popliteal region, and it is the cause that needs to be treated, and not the cyst itself, because after eliminating the problem inside the joint, it usually decreases on its own.

• Pain along the joint space, usually on the inside of the knee
• Clicking, crunching, sensation of interference inside the joint
• Swelling that increases towards the end of the first day
• Increased pain when squatting deeply and when going down stairs
• Difficulty in full knee extension
• Feeling of your leg buckling on an uneven surface

A separate blockade is a condition when a torn fragment of the meniscus moves and jams the joint in a bent position. In this case, it is impossible to straighten the knee; the movement rests on an elastic obstacle. A true blockade is a strong argument in favor of surgery because the mechanical obstruction inside the joint does not dissolve with exercise and damages the cartilage. It is important not to confuse it with a reflex limitation of extension due to pain and swelling: the latter goes away as the inflammation subsides.

Examination and trap MRI

1. Расспрос о механизме травмы — было ли скручивание, был ли отчётливый момент повреждения, как быстро развился отёк.
2. Осмотр с проверкой болезненности по линии сустава, объёма движений, наличия выпота и функциональными пробами на мениск.
3. Обязательная проверка связок — разрыв мениска нередко сочетается с повреждением передней крестообразной связки.
4. Рентген коленного сустава, желательно с нагрузкой, стоя: он не показывает мениск, но выявляет артроз, сужение суставной щели и переломы. Без него нельзя правильно оценить ситуацию у пациента старше сорока лет.
5. МРТ коленного сустава — метод, который показывает мениск, связки, хрящ и костный отёк.
6. Сопоставление данных МРТ с жалобами и осмотром — самый важный и самый часто пропускаемый этап.

Treatment without surgery

For a degenerative rupture without joint blockade, treatment begins with conservative treatment, and in most cases this is sufficient. The point is to relieve inflammation and relieve the internal part of the joint using the muscles. Strong quadriceps, gluteal muscles and proper foot function reduce stress on the meniscus much more effectively than any brace.

The logic here is simple, although not obvious at first glance. The meniscus is damaged and cannot be sutured, but the pain is not caused by the tear itself, but by overload and inflammation in this part of the joint. The muscles, working in concert, absorb the shock load of each step before it reaches the cartilage and meniscus, and take on that part of the work that the damaged tissue has ceased to perform. That is why, in a person with strong legs, the same gap on an MRI may not hurt at all, but in a weakened person it may cause constant discomfort. You shouldn’t expect results before six to eight weeks of regular exercise: this is not an ointment, but a restructuring of the functioning of the entire leg.

1. Первые дни — относительный покой, отказ от глубоких приседаний, разворотов и лестниц, холод на сустав.
2. Противовоспалительная терапия коротким курсом по назначению врача.
3. С первой недели — упражнения на четырёхглавую мышцу бедра, начиная с изометрических, без боли.
4. Next — программа лечебной физкультуры на 8–12 недель с постепенным усложнением, обязательно включающая ягодичные мышцы и баланс.
5. Снижение веса при его избытке: каждый лишний килограмм многократно умножается при ходьбе и особенно при спуске по лестнице.
6. Повторная оценка через 2–3 месяца — если жалобы ушли, операция не нужна вовсе.

Separately, about what does not work as advertised. Chondroprotectors in tablets do not restore tissue when a meniscus is torn. Injections of hyaluronic acid can temporarily reduce pain with concomitant arthrosis, but the rupture itself does not heal. Repeated injections of hormonal drugs into the joint provide quick relief at the cost of deterioration of the cartilage and are prescribed on a limited basis.

When is surgery really necessary?

Arthroscopy is an intervention through two or three punctures, during which a camera and instruments are inserted into the joint. It is appropriate not as “prevention”, but for specific indications, when the behavior of the meniscus mechanically prevents the joint from working or when the tear has a chance to heal.

• True joint block that has not resolved
• A tear similar to a watering can handle with a fragment displaced into the joint
• Fresh traumatic rupture in a young active person, especially in the blood supply area
• Avulsion of the meniscus root - in terms of consequences it is comparable to complete removal of the meniscus and often requires refixation
• Combination of a torn meniscus with a torn anterior cruciate ligament - both injuries are usually repaired in one operation
• Persistent mechanical symptoms after a full course of physical therapy

There is a fork inside the operation that is more important than the fact of the intervention itself: suture or resection. The suture preserves the meniscus and its function, but is only possible where the tissue is alive and has a blood supply, and requires long-term gentle treatment after surgery. Partial resection—removal of an unstable fragment—provides quick relief, but reduces the area of ​​the meniscus, which means increases pressure on the cartilage. The modern principle is formulated simply: preserve the meniscus wherever possible and remove the minimum necessary.

Recovery and life after

The timing after arthroscopy depends on what exactly was done. After partial resection, walking with full support is allowed almost immediately, office work is returned within 1–2 weeks, and running after 6–8 weeks. After meniscus suture, the regime is stricter: the load and depth of flexion are limited for several weeks to allow the tissue to heal; full recovery takes 4–6 months. This seems unfair - they pay for the preservation of the meniscus in time, but the benefits will be extended over decades.

1. Ранняя активизация и работа с четырёхглавой мышцей — с первых дней после операции.
2. Контроль отёка: возвышенное положение, холод, компрессия.
3. Постепенное восстановление полного разгибания — приоритет номер один, потерянное разгибание вернуть труднее всего.
4. Тренировка баланса и проприоцепции, затем силовые упражнения.
5. Возврат к спорту — по функциональным тестам и разрешению врача, а не по календарю.
6. Долгосрочно: контроль веса, регулярная силовая работа с мышцами бедра, отказ от длительной работы на корточках.

It’s worth setting expectations with yourself in advance. Arthroscopy is good at removing mechanical symptoms - jamming, clicking with a dip, a feeling of interference in the joint. It copes much worse with diffuse aching pain due to arthrosis, because the cause of such pain is not the meniscus. If before the operation the knee hurt constantly and equally with any movement, and the pictures show a narrowing of the joint space, you should not expect that after arthroscopy the pain will disappear completely, and an honest conversation about this before the intervention will save you from disappointment afterwards.