There is not one but several meniscus cracks. Two parameters come into play to decide between them: the age of the patient and the context of the trauma. In all cases, the objective is to save the meniscus as much as possible to protect the knee joint and limit the risk of osteoarthritis in the medium or long term.
At the knee, the meniscus can be cracked or torn. Depending on the severity of the meniscal injury, the treatment will be different. What are the symptoms ? Is it necessarily painful? Is surgery useful and if so via what type of operations? Is sport the only cause of these injuries? All the answers from Dr Nicolas Graveleau, orthopedic surgeon at the Center for Orthopedic and Sports Surgery (CCOS) and at the Bordeaux-Mérignac sports clinic.
What is the meniscus?
The meniscus is located at the knee. There are two per knee, specifies Dr Nicolas Graveleau: “There is a medial, or internal, meniscus and a lateral, or external, meniscus. They are located between the two joint surfaces, that is to say between the tissue (cartilage) which covers the femur bone and that which covers the tibia bone..
They have a crescent moon shape, which goes around the joint, and are thicker on their border – the central part is occupied by the 2 cruciate ligaments. Their tasks are multiple. “Due to their rubbery structure, the menisci act as shock absorbers, they also contribute to improving joint congruence, in other words the contact between the two bones, the bottom of the femur being rather rounded while the top of the tibia appears like a plateau, and therefore they also have a stabilizing role, helping certain ligaments to hold the knee. Finally, they participate in the lubrication of the joint “explains Dr Graveleau.
Without these cartilaginous discs, the joint would wear out prematurely.
What is a meniscus crack?
Basically, we speak of a crack when there is a loss of continuity of the meniscus. But depending on the circumstances and the origin of this discontinuity, we will consider either a crack, a tear, or a tear with a displaced fragment (moving tongue). These different stages of severity are accompanied by a graduation in the patient’s feelings.
In addition to these nuances, there is another element to take into account, particularly at the time of diagnosis: the true false crack. “The clinical examination may point to a crack when it is only a change in the quality of the meniscus, due to natural wear., attests the specialist. This is why a meniscus crack must be confirmed with an MRI. In summary, if it is not normal to have a meniscus crack at 15 years old, at 85 years old, or even before, this is not exceptional: it is physiological.
“On the other hand, continues Dr. Graveleau, if it is a tear, the risk is that part of the affected meniscus will move a little in the joint, causing pain, swelling, cracking and locking. When the broken piece of meniscus moves in the knee, preventing the passage of the femur over the tibia, we preferentially speak of a mobile tongue.
Note that the internal meniscus tends to be more frequently symptomatic than the external meniscus. This is because most people have their legs bowed inward a little.
What could be the causes?
Meniscus cracks are of two types: degenerative or post-traumatic.
Among the causes:
- Age – and incidentally excess weight. Two scenarios can arise: “Schematically, if you are under 40 years old, these are often traumatic injuries, which follow an accident with a tear of the meniscus. Beyond that, it is often the meniscus which ages a little and which, under the effect of a trauma which is not necessarily major, will trigger symptoms”, explains Dr. Graveleau. Implied: after a certain age, there is no need to rush to the surgeon. Removing the meniscus is not at all the solution, argues our interlocutor.
- Certain professional activitieswith repeated squatting or kneeling – as in construction.
- Certain populationstypically in Asian countries where the habit is to live kneeling or with knees bent.
- Certain sports which “hit” the meniscus, like running. “Often the crack has been there for a very long time.” remarks Dr. Graveleau. “The person just pushed too hard and/or prepared poorly. But the objective, in this case, is to find the point of balance before, then see if it is possible to put the stress back on the knee. Usually it goes well with activities such as swimming or cycling. When it comes to running, it’s often more complicated. The meniscus is not a very well vascularized tissue. As a result, it doesn’t repair well.” This crack is quite common.
- Meniscal trauma – often during sports. This can occur following the execution of violent squatting and/or rising positions (squats, for example), ligament accidents (the rupture of the anterior cruciate ligament is often associated with a tear of the meniscus, as in skiers or rugby players), from a sprain or blow to the knee.
What are the symptoms ?
They are not specific. These are symptoms specific to the knee and they obviously depend on the cause, with more or less tolerable signs which can add up. Among these :
- A pain ;
- Swelling – there is often synovial effusions;
- Mechanical signs – in the event of tearing, or even a moving tongue: cracking, rigidity, feeling of internal disturbance, hooking, or even dislocation;
- A real blockage – the meniscal tongue dislocates, blocks the knee and it is no longer possible to straighten or bend the knee. A quick consultation follows;
- The inability to endure certain activities.
With the exception of mechanical symptoms, which no longer allow the leg to be straightened, in 90% of cases, conservative treatment proves sufficient, insists Dr. Graveleau.
Comment pose-t-on le diagnostic ?
In the case of pain that appears gradually in a person around sixty years old, with manifestations during exercise or when squatting, it is always necessary to start with a standard x-ray to check that the patient has normal cartilage. . “Meniscus wear can be associated with osteoarthritis, specifies Dr. Graveleau. In this case, the treatment must be comprehensive, to avoid ending up with a meniscectomy which accelerates the osteoarthritic process. Above all, do not dispense with it, therefore.
But after this essential precaution, depending on the age of the patient and the preliminary clinical assessment, the reference examination remains MRI, which allows meniscus cracks to be seen and evaluated.
What are the treatments ?
“Except in exceptional cases, conservative treatment is sufficient”, underlines Dr. Graveleau. Concretely, we put the knee to rest – at least in relation to the activity which triggered the pain. We cool the knee, with ice, to deflate it and we take another check after a week: “Sometimes symptoms disappear as quickly as they appeared. There is therefore no need to rush into doing radiological examinations.”.
If the signs persist after a week, consult your doctor. And we carry out the required examinations, including the MRI. “Even if it is a degenerative crack, it is important to have a diagnosis, to guide the patient”continues the expert.
In the event of a degenerative crack, functional treatment revolves around 3 axes, in accordance with the recommendations of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (Esska):
- Rest : we leave the knee alone. And if the person has slightly bowed legs, they can be sent to a podiatrist who will suggest orthopedic insoles to relieve the pressure. “When you start running again, this allows you not to put too much pressure on the meniscus”, illustrates the orthopedic surgeon. And of course, you should also avoid squatting or climbing stairs;
- Management of inflammation : ice with or without anti-inflammatory Per os (by mouth). And if that is not enough, we will prescribe anti-inflammatories infiltrations, ideally in contact with the crack – “We then speak of intra-mural meniscal injections carried out under ultrasound by the doctor or radiologist., describes Dr. Graveleau. The only limitation is that if the cause is truly mechanical, this medical treatment is necessarily transient. The treatment will then be surgical, but this remains very rare;
- Support for the gradual resumption of activities : “Putting weight on the knee again requires support from a physiotherapist, to work without hurting the meniscus, thanks to adapted exercises.notes Dr. Graveleau.
In the event of a traumatic crack (torn cruciate ligaments, for example), that is to say a real tear of the meniscus, we quickly consult a specialized doctor or a surgeon, knowing that today, the priority is to preserve the meniscus so that this shock absorber can continue to protect the cartilage of the patient’s joint for years to come. Very often, observes the orthopedic surgeon, this occurs in an area where the meniscus is vascularized and in young people: clearly, there is a potential for healing. “By taking care of the patient’s anterior ligaments, we operate to stabilize the knee and, during the same operation, we…