About 50% of patients with ACL tears also have meniscus tears, whether the ACL injury is acute, subacute or chronic, according to Shelbourne Knee Center research. (1, 2)
Most of these meniscus tears are asymptomatic (2) and don’t require treatment. “Even most symptomatic meniscus tears will get better on their own,” says K. Donald Shelbourne, MD, orthopedic surgeon at Shelbourne Knee Center.
Over-treatment for meniscus tears found incidentally when evaluating ACL tears is common. Most orthopedic surgeons don’t distinguish between meniscus tears that would benefit from repair and those that can be left in situ or treated with trephination or physical therapy. Patients with symptomatic meniscus tears aren’t aware that in about 80% of cases, proper physical therapy will relieve pain and facilitate healing. (3)
“The decision on whether to treat a meniscus tear depends on many factors, including the type of meniscus tear, how symptomatic it is, and its capacity for healing,” says Dr. Shelbourne.
Lateral Meniscus Tears
Lateral meniscus tears are the most common type of meniscus tears seen at ACL reconstruction. Most are asymptomatic and can be left in situ, says Dr. Shelbourne, based on data from patients at Shelbourne Knee Center.
Between 1982 and 1991, 598 lateral meniscus tears were seen in 1,146 ACL reconstruction patients. (1) Treatment was:
- Partial removal: 256 patients
- Repair: 135 patients
- Left in situ: 207 patients
None of the patients had a subsequent removal of the lateral meniscus tear.
In a later study of 332 ACL reconstruction patients with lateral meniscus tears that were left in situ, only 8 required subsequent meniscus surgery (2.4%) at a mean of seven years after ACL reconstruction. (4)
Peripheral Stable Medial Meniscus Tears
Peripheral stable medial meniscus tears are another common type of meniscus tear seen with acute ACL injury that can be left in situ or treated with trephination. In trephination, the needle going through the meniscus into the capsule creates the blood channels for healing. Trephination avoids the risks of meniscus repair with sutures.
One Shelbourne Research Center study compared 312 patients with ACL tears and peripheral stable medial meniscus tears treated with trephination to a control group of 343 patients with intact menisci. (5) The rate of subsequent symptomatic medial meniscus tears was:
- 16% for patients with stable medial meniscus tears treated with trephination
- 6% in patients with intact menisci
Radiographic and subjective results showed no statistically significant differences between the groups.
Consequences of Unnecessary Meniscus Repair
Unnecessary meniscus repair can jeopardize ACL rehab by restricting weight-bearing and range of motion (ROM). It can also lead to possible complications:
- Damage to articular surfaces
- Repair device left in meniscus causing symptoms
Many orthopedic surgeons restrict weight-bearing for six weeks after meniscus repair. But Dr. Shelbourne’s experience performing a 2-stage procedure has proven that this is not necessary.
The 2-stage procedure involves:
- Meniscus repair
- Physical therapy
- ACL reconstruction 2-3 months after meniscus repair
During the delayed ACL reconstruction, Dr. Shelbourne found that the sutures were gone and the meniscus tear had healed. “I determined that placing the needle through the meniscus stimulated healing, and that trephination with many needle sticks is all that is necessary with most types of repairable meniscus tears.”
Through the physical therapy between the first and second procedures, Dr. Shelbourne learned that weight-bearing as tolerated and working on ROM both helped the meniscus heal. “Our data show that almost all tears can heal with allowing full ROM and weight-bearing,” he says. This is now a routine part of physical therapy at Shelbourne Knee Center.
“Treatment for a meniscus tear should make the patient better than leaving the tear alone,” says Dr. Shelbourne. “We need to focus on helping the patient.”
For more information about appropriate treatment for meniscus tears, please call 888-FIX-KNEE.
References
- Fitzgibbons RE, Shelbourne KD. “Aggressive” nontreatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction. Am J Sports Med. 1995 Mar-Apr;23(2):156-9.
- Shelbourne KD, Benner RW. Correlation of joint line tenderness and meniscus pathology in patients with subacute and chronic anterior cruciate ligament injuries. J Knee Surg. 2009 Jul;22(3):187-90.
- Shelbourne KD and Gray T. Treatment of meniscal tears seen with anterior cruciate ligament reconstruction.
- Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction. Arthroscopy.2004 Apr;20(4):346-51.
- Shelbourne KD, Benner RW, Nixon RA, Gray T. Evaluation of Peripheral Vertical Nondegenerative Medial Meniscus Tears Treated With Trephination Alone at the Time of Anterior Cruciate Ligament Reconstruction. Arthroscopy.2015 Dec;31(12):2411-6. doi: 10.1016/j.arthro.2015.06.024. Epub 2015 Jul 26.