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Diagnosing and Treating Meniscal Tears

9/1/2015

2 Comments

 
One knee injury that is frequently encountered in the clinic is the meniscus tear. The injury often presents after an acute incident with moderate swelling, pain and dysfunctional motion. Often, we hear about athletes needing surgery to treat these injuries (either meniscal repair or partial meniscectomy). Whether or not surgery is indicated is a different issue, but due to potential treatment options, it is beneficial to be aware of the tissue involved.

How do we diagnose meniscal tears?

There are a plethora of tests out there with varying diagnostic accuracy used for diagnosing meniscal tears. Probably the single test with best diagnostic accuracy is Thessaly's (Sn = .90; Sp = .98). Unfortunately, the test actually recreates the mechanism of injury and could potentially increase the tear, so it is not recommended. Instead, it is better to use a diagnostic cluster of tests by Lowery et al. The cluster utilizes 5 exam measures: Joint Line Tenderness, McMurray's, pain with knee flexion overpressure, pain with knee extension overpressure, and hx of joint locking/catching. With 4/5 positive tests, Sn = .17 and Sp = .96. With 5/5 positive tests, Sn = .11 and Sp = .98. While none of the clustered tests have great diagnostic accuracy by themselves, when utilized together, they become much more beneficial.
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How do we treat meniscal tears?

With recent research finding no difference between surgery and conservative treatment, as physical therapists we must be aware of providing our patients with the best opportunity to successfully complete rehabilitation. Early research has shown that cartilage and meniscus healing occurs with high repetition-low load training (Khan and Scott, 2009). That means thousands of repetitions at 15-20% 1RM in addition to treating any impairments present. I typically utilize either a recumbent bike or shuttle leg press. Should patients fail the conservative route, often they are sent on for a surgical option: meniscal repair in the younger population, partial meniscectomy in the middle-aged population, and total knee arthroplasty in the geriatric population.

What does this mean to me?

While I appreciate the evidence that supports conservative treatment compared to surgical, one of the often under-emphasized points is that meniscal tears often occur as natural aging, similar to how herniated disks naturally occur in the spine. Imaging is not as beneficial as we once thought, because most people will have some sort of degenerative findings. Personally, I focus on the primary impairments and address those. For example, in this patient population, I often find the patients present with either a lack of tibial IR or knee extension on the involved side. These patients frequently respond to repeated motions with improvements and pain and ROM. I also include IASTM and treatment of remaining impairments and movement patterns in addition to high rep-low load training. As always, an eclectic approach is best, but it doesn't hurt to include treatment for the suspected injured tissue. Whether or not it is true "healing" or has more of a pain-science desensitization effect, it may be effective. For this reason, I still advocate using special tests to determine potential tissue involvement.
References:

Khan and Scott. (2009) "Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair." 
British Journal of Sports Medicine. 2009; 43: 247-251. Web. 5 Dec. 2013.

Lowery DJ, Farley TD, Wing DW, Sterett WI, Steadman JR. "A clinical composite score accurately detects meniscal pathology." Arthroscopy. Nov 2006; 22(11):1174-1179.

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Exercise and Tissue Repair
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2 Comments
David
9/3/2015 06:34:18 pm

I like the specific prescription of 15-20% 1RM. I feel these parameters are not used enough in the clinic. What do you think the reasoning is for the presentation you described of lack of full extension and IR?

Reply
Chris link
9/3/2015 07:30:25 pm

Hi David,

As a pattern, I have noticed the painful knee to be lacking in tibial IR or end-range extension (I'm talking about just a couple degrees!) or both compared to the other side. I think they are positions that are often lacking due to postures throughout the day, but when injury occurs they are almost amplified. I use them as part of the SFMA and repeated motions breakout. Hope this helps!

Reply



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  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test