Clinical presentation of the patient with a meniscal tear is variable depending on the mechanism of injury and degree of concomitant tibiofemoral insults.  The sensation of a "pop," with immediate effusion of the knee during high-impact activity or trauma is associated with an ACL tear with a possible associated medial meniscal tear, whereas effusion that develops more gradually over the course of 24 hours is more indicative of an isolated meniscal tear.  Symptoms can also be insidious in nature, in which low-grade effusion and stiffness develop over the course of several days despite the absence of an inciting event.  Pain is typically reported over the anteromedial or anterolateral joint line.  Depending on the type and extent of the meniscal lesion, there may also be symptoms of locking, clicking, catching, intermittent inability to fully extend the knee, or feeling of the knee giving way.

Physical examination should consist of inspection of the knee for edema, palpation of the joint line, standing and supine range of motion (ROM), muscle strength testing, and special testing.  Anteromedial and anterolateral joint line tenderness performed with the patient's knee at the edge of the table at 90 degrees of flexion is 83% sensitive and 83% specific for a meniscal tear.  There may be pain and deficits in either flexion or extension ROM depending on the type of tear and extent of effusion.  Deficits in open kinetic chain knee flexion/extension strength testing are unlikely, but antalgic gait or increased pain with single or double-leg squatting is possible due to increased compressive forces over the menisci.  There are several provocative special tests for the detection of meniscal tears.  The Thessaly test, in which the patient stands on one leg, squats down to 20 degrees of flexion, and internally/externally rotates the knee through active adduction/abduction of the hip is 75% sensitive and 87% specific.  McMurray's test has a sensitivity of 61% and specificity of 84% and involves passively extending the supine patient's knee from a fully flexed position to 90 degrees flexion while maintaining full external or internal rotation.  Apley's compression test, in which the prone patient's knee is passively flexed to 90 degrees and then externally/internally rotated with axial compressive force through the knee has been found to be < 20% sensitive and up to 80-90% specific.

When a meniscal tear is suspected, imaging should begin with radiographs that include AP, lateral, oblique, sunrise, and weight bearing views to assess for concomitant bony pathologies, loose bodies, and osteoarthritis. Using arthroscopy as the gold standard, MRI is the best mode of imaging to diagnose and characterize meniscal tears.  MR imaging has been found to be 93% sensitive and 88% specific for medial meniscal tears, and 79% sensitive and 96% specific for lateral meniscal tears.[8][9][10]

Initial treatment of the acutely painful, edematous knee in which meniscal tear is suspected should consist of the RICE principles for acute soft tissue injury (Rest, Ice, Compression, and Elevation).  Oral analgesics and NSAIDS may be prescribed to reduce pain and swelling.  Bracing or knee sleeves may be used for protection and compression, and early pain-free knee and ankle ROM exercise may help to limit the loss of motion and aid in edema control.  For simple tears confined to the outer 1/3 of the meniscus and degenerative tears, it is reasonable to perform a 4-6 week course of relative rest and physical therapy to determine if spontaneous healing and return to the desired level of function will occur. Patients with persistent pain, swelling, and mechanical symptoms despite conservative management should be assessed for potential surgical intervention.  For tears requiring arthroscopic surgery, meniscal repair is preferred over meniscectomy if possible, since the risk of accelerated osteoarthritis increases with the removal of meniscal tissue due to decreased cushioning and increased force transmission across articular cartilage surfaces.  Factors that increase the likelihood of successful meniscal repair include tears that occur in the red zone of the meniscus, tears that are shorter than 2cm, vertical longitudinal tears, and acute tears.  Rehabilitation following meniscal repair typically includes restrictions in knee flexion ROM and weight bearing status during the first 6 weeks postoperatively, depending on the location of the tear and type of repair. Meniscal allograft transplantation is considered a salvage procedure for symptomatic patients less than 50y/o with a meniscus-deficient compartment and otherwise stable knee.[11][12][13]

• Anterior cruciate ligament injury

• Contusions

• Iliotibial band syndrome

• Knee osteochondritis

• Lateral collateral knee ligament injury

• Lumbosacral radiculopathy

• Medial collateral ligament injury

• Medial synovial plica irritation

• Patellofemoral joint syndromes

• Posterior cruciate ligament injury

Patients with meniscal tears usually present to the emergency department with pain or difficulty moving the knee joint. These tears are best managed by an interprofessional team that includes the emergency department physician, nurse practitioner, orthopedic surgeon, physical therapist, and radiologist. 

The initial treatment of the acutely painful, edematous knee in which meniscal tear is suspected should consist of the RICE principles and pain control. Bracing or knee sleeves may be used for protection and compression, and early pain-free knee and ankle ROM exercise may help to limit the loss of motion and aid in edema control.

Simple injuries are managed conservatively but complex injuries are usually managed with surgery. Physical therapy will be part of the management plan in both conservatively managed and surgical cases; the PT should follow the plan laid out and inform the orthopedic team through the nurse regarding patient progress. Rehabilitation following meniscal repair typically includes restrictions in knee flexion ROM and the weight-bearing status during the first 6 weeks postoperatively. An orthopedic nurse can coordinate medical care and therapy, answer patient questions, and note patient progress or lack thereof, keeping the treating clinician abreast of all developments. The recovery is often prolonged but overall most patients achieve a satisfactory outcome with full use of the knee.[14] (Level V)