A patient guide to physiotherapy following a meniscal tear
Frank Gilroy (BSc MCSP, Consultant Physiotherapist)
Kaitlin Mugford (BKin, MSc Physiotherapy Student)
Anatomy of the meniscus
The meniscus is a piece of cartilage within your knee joint made mostly of collagen (72%) and water (22%). The meniscus provides shock absorption (cushioning), stability, lubrication and proprioception (senses joint position and movement) to the knee joint.
You have a medial (toward the middle) meniscus and lateral (toward the outside) meniscus in each knee.
Meniscus Injury
Meniscus tears are very common. The meniscus can be injured by trauma, for example twisting your knee during a football game, or degenerative changes (age-related changes that occur over time).
The most common way to injure the meniscus is twisting on a bent knee. Meniscal tears can cause pain, swelling, locking, popping or clicking of the knee. It is also possible to have a meniscal tear with no symptoms at all, and some meniscal tears can heal on their own.
Types of meniscal tears
There are several types of meniscus tears:
Vertical– runs vertically along the meniscus. This tear can progress into a ‘bucket-handle’ tear.
Bucket-handle– this type of tear may result in a flap which can get caught and cause locking of the knee.
Transverse– runs horizontally across the meniscus.
Degeneration– tears form in different directions (commonly happens with ageing).
Zones
Menisci have three layers referred to as ‘zones’. There is a good blood supply in the outer layer (red-red zone), reduced blood supply in the middle layer (red-white zone) and very poor blood supply in the inner layer (white-white zone), which causes reduced healing ability.
Depending on which zone the meniscal tear is in, it may not have sufficient blood supply to heal with or without surgery. In some cases, part of the meniscus may need to be removed.
Treatment of Meniscus Tears
Surgical Intervention and Physiotherapy
Meniscal tears can be seen with an MRI scan. The type and location of the tear guides its management which will be discussed with a surgeon. For example, bucket handle tears may cause locking of the knee which often requires surgery to fix.
Evidence supports that small, stable tears in areas of the meniscus with a good blood supply can be treated with physiotherapy. Physiotherapy is just as effective as early surgery for improving pain, function and quality of life at 12 months post-injury (Soren et al., 2022).
Rehabilitation
Whether you follow a conservative or surgical approach for a meniscal injury, physiotherapy can help manage pain and swelling and improve the movement of your knee joint.
It is important to be realistic about the time scale for your injury to heal. Timescales for recovery and return to sport may differ based on type of tear, extent of other injuries, and management (conservative/non-operative, meniscal repair or meniscectomy).
Always follow advice from your surgeon or physiotherapist. If your knee is locking or giving way, you need to see a specialist.
Self-Management of Knee Injury
Please follow the Joint Recovery Clinic videos, which can be found by clicking here.
Phase 1: Acute Phase (0-48 hours post-injury)
In the early stages after injuring your knee you may have some pain and swelling. This is to be expected and will improve with rest, application of ice and gentle exercise.
REST
Once the knee is swollen and inflamed, it is important to let it settle by resting it. Excessive exercise or activity will cause the knee to swell further.
Try to reduce your activity – walk shorter distances and restrict day to day activities to the most important tasks. Take a break from your sport, and try to avoid running, jumping, squatting, kneeling and deep bending.
If your injury is more severe, crutches may be required. In general, it is better to walk with crutches and a normal gait pattern than hobble around on a bent knee.
Your doctor may prescribe a knee brace to protect your knee.
ICE
Ice limits swelling following an injury.
Apply ice to your knee 4-5 times a day for 10-20 minutes, using a pack of frozen peas or cubes of ice wrapped in a damp towel or tea towel.
Do not apply ice directly onto skin as it can burn your skin.
COMPRESS
Compression can help reduce acute knee pain and swelling. Wearing a tubegrip or bandage from mid-thigh to mid-calf during the day is beneficial, but always remove it at night to avoid circulation problems.
ELEVATION
Fluid from swelling moves down under gravity. Elevating the leg helps move fluid out of the leg.
Keep your leg elevated when you are not walking, supporting your heel on pillows or cushions. Try to keep your heel above your hip as much as possible. Place phone books or pillows under the foot of your mattress to elevate your legs at night.
PAINKILLERS
Painkillers such as paracetamol or ibuprofen can be bought at the chemist or supermarket. Always check the label before use.
Gentle Exercises
It is important to regain the movement and strength in your knee as soon as possible to prevent stiffness in the future.
The following exercises should be repeated every 2 hours during the day
Exercise 1 – Flexion/Extension Movement
- Lie with your legs straight.
- Bend your hip and knee by slowly sliding your heel toward your buttock as far as feels comfortable.
- Straighten your knee and hip.
- Repeat 10 times as pain allows
Exercise 2- Static Quadriceps
- Lie with your legs straight
- Pull your toes back towards you and push your knee down into the floor. Hold for 5 seconds then release.
- Repeat 10 times as pain allows.
Exercise 3- Straight Leg Raise
- Lie on your back with your legs straight
- Tighten your thigh muscles and straighten your knee.
- Lift your straight leg 4-5 inches. Hold for 5 seconds.
- Repeat 10 times as pain allows.
*As the exercises get easier, you can increase the number of times you repeat them.
Continue to take painkillers if you need them.
Walking
Try to walk as normally as possible without limping, even if you are using crutches. Begin by walking short distances and gradually increase the distance as pain allows.
Completion of Phase 1
To progress to the next phase of exercises, you should have achieved the following goals:
- Knee swelling significantly reduced
- Almost full range of motion of the knee
- Able to straight leg raise
If you are unable to straight leg raise (exercise 3) after 72 hours, you should arrange to see your doctor or physiotherapist and continue using crutches.
Prevention of recurrence
Maintain your recovery by continuing with the exercises above, keeping active with regular walking, swimming, cycling or other activities, and progressing through Phase 2 and 3 of the Acute Knee Pain Programme found here.
References
BOLOG NV & ANDREISEK G, 2016. Reporting knee meniscal tears: technical aspects, typical pitfalls and how to avoid them. Insights Imaging [online]. 7(3), pp. 385–398. Available from: https://doi.org/10.1007/s13244-016-0472-y
DIAS, MAZUQUIN, B. F., MOSTAGI, F. Q. R. C., LIMA, T. B., SILVA, M. A. C., RESENDE, B. N., BORGES DA SILVA, R. M., LAVADO, E. L. & CARDOSO, J. R., 2013. The effectiveness of postoperative physical therapy treatment in patients who have undergone arthroscopic partial meniscectomy: systematic review with meta-analysis. The Journal of Orthopaedic and Sports Physical Therapy [online]. 43(8), pp. 560–576. Available from: https://doi.org/10.2519/jospt.2013.4255
DORAL, M. N, BILGE, O., HURI, G., TURHAN, E. & VERDONK, R., 2018. Modern treatment of meniscal tears. EFORT Open Rev [online]. 3(5), pp. 260–268. Available from: https://doi.org/10.1302/2058-5241.3.170067
FOX, A. J., BEDI, A. & RODEO, S. A., 2012. The basic science of human knee menisci: structure, composition, and function. Sports health [online]. 4(4), pp. 340–351. Available from: https://doi.org/10.1177/1941738111429419
JAZRAWI & STRAUSS, E. J., 2020. The management of meniscal pathology: from meniscectomy to repair and transplantation. Springer [online]. Available from: https://doi.org/10.1007/978-3-030-49488-9
SKOU, S. T., HOLMICH, P., MARTIN, L., ET AL., 2022. Early Surgery or Exercise and Education for Meniscal Tears in Young Adults. NEJM Evid [online]. 1(2). Available from: https://doi.org/10.1056/EVIDoa2100038