A tear of the meniscus is the breakup of one or more fibrocartilage strips on the knee called menisci. When doctors and patients refer to "torn cartilage" in the knee, they may actually refer to injuries to the meniscus at the top of one of the tibiae. Menisci can be torn during non-hazardous activities such as walking or squatting. They can also be torn by the traumatic powers encountered in sports or other forms of physical activity. The traumatic action is most often a twisting motion on the knee while the leg is bent. In older adults, meniscus can be damaged by prolonged 'wear and tear' called degenerative tears.
Tears can cause pain and/or swelling of the knee joint. Especially acute injuries (usually in younger and more active patients) can cause excessive tears that can cause mechanical symptoms such as clicking, capturing, or locking during knee joint motion. The joint will hurt when used, but when there is no load, the pain is gone.
A medial meniscal tear may occur as part of an unhappy triad, along with anterior cruciate ligaments and medial collateral ligaments.
Video Tear of meniscus
Signs and symptoms
The common signs and symptoms of torn meniscus are knee pain, especially along joint lines, and swelling. This is worse when the knee bears more weight (eg, when running). Another typical complaint is locking the joints, when the affected person can not straighten the leg completely. This can be accompanied by a feeling of clicking. Sometimes, a tear of the meniscus also causes the sensation that the knee gives way.
A person with a torn meniscus can sometimes remember certain activities during the injury. Tearing of the meniscus usually occurs after a trauma involving the turning of the knee when slightly flexed. These maneuvers also exacerbate pain after injury; for example, getting out of the car is often reported to be painful.
Maps Tear of meniscus
Cause
There are two menisci in the knee. They sit between the femur and the shins. While the ends of the femur and shin have a thin layer of soft hyaline cartilage, the menisci is made of hard fibrocartilage and corresponds to the surface of the bone they are sandari. One meniscus rests on the medial tibial plateau; this is the medial meniscus. The other Meniscus rests on the lateral tibial plateau; this is the lateral meniscus.
This Menisci acts to distribute weight throughout the knee joint. Without menisci, body weight will be unevenly applied to the bone in the leg (femur and tibia). This uneven distribution of weight will lead to the development of abnormal excessive force that causes early damage to the knee joint. Menisci also contributes to joint stability.
Menisci is maintained by small blood vessels but has a large area at the center without direct blood supply (avascular). This poses a problem when there is an injury to the meniscus, as the avascular area is less likely to heal. Without the essential nutrients provided by the blood vessels, healing can not occur.
The two most common causes of meniscus tears are traumatic injury (commonly seen in athletes) and degenerative processes, which are the most common ruptures seen at all patient ages. Meniscal tears can occur in all age groups. A traumatic tear is most common in active people aged 10-45 years. A traumatic tear is usually radial or vertical in the meniscus and is more likely to produce movable fragments that can be captured in the knee and therefore require surgical treatment.
A meniscus can be torn because the knee is rotated internally or externally in a flexion position, with the leg in a bent position. It is not unusual for a meniscal tear to occur along with an injury to the anterior ligaments of the ACL ligaments and medial medial ligament ligaments - these three problems occur together known as the "happy triads", which are seen in sports such as football when the player is struck on the outside of the knee. Individuals who experience a meniscus tear usually experience pain and swelling as their main symptoms. The other common complaint is locking the joints, or the inability to completely straighten joints. This is due to a piece of torn cartilage preventing the normal functioning of the knee joint.
The degenerative tears are most common in people from the age of 40 up but can be found at any age, especially with obesity. Meniscal degenerative tears are considered to occur as part of the aging process when collagen fibers in the meniscus begin to break down and less support the meniscal structure. The degenerative tears are usually horizontal, producing the upper and lower segments of the meniscus. These segments usually do not move out of place and therefore are less likely to produce mechanical symptoms of capture or locking.
Risk factors
Meniskus is made of cartilage, viscoelastic material, which makes it more susceptible to the degree of injury loading. Repeated loading can also cause injury. Recent studies have shown people who experience rapid loading and/or recurrent loading rates to be most vulnerable to meniscus tears. People over the age of 60 who have working conditions where squatting and kneeling are more commonly susceptible to degenerative meniscal tears. Athletes who are constantly experiencing high loading levels (ie soccer, rugby) are also susceptible to tearing meniscus. The study also showed that with increasing time between ACL injury and ACL reconstruction, there was an increased likelihood of a meniscus tear. This study shows meniscus tears occurring at a rate of 50-70% depending on how long after an ACL injury surgery occurs.
Pathophysiology
The force distribution across the knee joint increases the concentration of strength in cartilage and other joint structures.
Damage to the meniscus because the rotational force directed to the bent knee (as is the case with tortuous exercise) is the underlying mechanism of injury. The valgus force applied to the flexed knee with the planted leg and the external thigh bone may cause a lateral meniscal tear. The varus force is applied to the bent knee when the foot is planted and the incandescent bone is rotated internally resulting in a medial meniscal tear.
Tears produce a rough surface inside the knee, causing the capture, locking, bending, pain, or a combination of these symptoms. Abnormal loading patterns and rough surfaces inside the knee, especially when coupled with a return to exercise, significantly increase the risk of developing arthritis if not present.
Anatomy
Menisci is a C-shaped fibrocartilage slab located between the tibia plateau and the femoral condyl. Menisci contains 70% collagen type I. Menucus a larger semilunar medial attaches stronger than loose, lateral meniscus. The anterior and posterior horns of both meniscus are secured to tibial plains. Anterior, the transverse ligament connects 2 meniscus; posterior, menisccofemoral ligaments help stabilize lateral posterior horn meniscus into the femoral condylus. The coronary ligament connects the peripheral edge of the perercious loose to the tibia. Although lateral collateral ligament (LCL) passes in close proximity, lateral meniscus has no attachment to this structure.
The joint capsule attaches to the periphery of each meniscus but is attached more firmly to the medial meniscus. Disorders of the attachment of the joint capsule to the lateral meniscus, forming popliteal hiatus, allow the popliteal tendons to pass through to its femoral attachment site. Contraction by popliteus during the flexural knee draws the posterior lateral meniscus, avoiding the trap within the joint space. The medial meniscus has no direct muscle relationship. The medial meniscus may displace several millimeters, whereas the less stable lateral meniscus may move at least 1 cm.
In 1978, Shrive et al. reported that the menisci collagen fibers are oriented in circumferential patterns. When a compressive force is applied to the knee joint, the attraction is transmitted to the meniscus. The thigh bone tries to spread the anterior meniscus in the extension and is mediolateral in flexion. Shrive et al. further study the effects of radial cutting on the periphery of the menisci edge during loading. In joints with intact meniscus, force is applied through the meniscus and articular cartilage; However, peripheral peripheral lesions interfere with the normal mechanism of menisci and allow it to spread when the load is applied. Loads are now distributed directly to articular cartilage. Given these findings, it is important to maintain peripheral edges during partial menisectomy to avoid irreversible interference from the ability of circular tension structures.
Diagnosis
Physical exam
After recording the symptoms, the doctor can perform a clinical test to determine whether the pain is caused by compression and torn meniscus impingement. The knee is examined for swelling. In meniscal tears, pressing the joint line on the affected side usually produces tenderness. The McMurray test involves emphasis on the joint line while emphasizing the meniscus (using flexion-extension and varus or valgus stress movements). Similar tests are the Steinmann test (with sitting patients) and the Apley grinding test (grinding maneuver while the person lying on his stomach and knee bent 90 Â °). Bending the knee (being hyperflexion if tolerated), and especially squatting, is usually a painful maneuver if the meniscus is torn. The range of motion of the joints is often restricted.
Cooper signs are present in more than 92% of tears. It is a subjective symptom of pain in the affected knee when it reverses in bed at night. Osteoarthritic pain is present with body weight, but meniscal tears cause pain with knee twisting movements as encrusted meniscal fragments, and capsular attachment will stretch causing pain complaints.
Radiology
X-ray images (usually during weighting) can be obtained to rule out other conditions or to see if the patient also has osteoarthritis. Menisci alone can not be visualized with plain radiography. If the diagnosis is not clear from history and examination, menisci can be imaged with magnetic resonance imaging (MRI scan). This technique has replaced the previous arthrography, which involves injecting contrast media into the joint space. In immediate cases, knee arthroscopy enables rapid diagnosis and simultaneous treatment. Recent clinical data suggest that MRI and clinical trials are comparable in sensitivity and specificity when looking for meniscal tears.
Classification
Meniscal tears can be classified in various ways, such as with anatomic location or close to the blood supply. A variety of tear patterns and configurations have been described. These include:
- Radial tears
- Flap or parrot-beak tears
- Peripheral, longitudinal tears
- Bucket-tear grip
- Horizontal cleavage tears
- Complex, degenerative tears
These tears can then be further classified by their proximity to the meniscus blood supply, ie whether they are in the "red-red", "red-white", or "white-and-white" zones.
The importance of this classification function, however, is ultimately determining whether the meniscus can be improved. Meniscus reparation depends on a number of factors. These include:
- Age/strength
- Activity level
- Tear pattern
- Chronicity of tears
- Related injury (anterior cranial ligament injury)
- Healing potential
Prevention
Torn meniscus is a common injury in many sports. Menisci holds 30-50% of the body weight in standing position. Some sports where common meniscus tears are American soccer, soccer associations, ice hockey and tennis. Regardless of what its activities are, it is important to take proper precautions to prevent torn meniscus from occurring.
Clothing
There are three main ways to prevent meniscus tears. The first is wearing the correct footwear for the sport and the surface where the activity takes place. This means that if the sport played is association football, cleats are an important item in reducing the risk of a meniscus tear. Appropriate footwear is very important when engaging in physical activity because an unbalanced step can mean a tear of the meniscus. It is strongly recommended that the cleats contain soles that form around the legs, not less than fourteen cleats per shoe, not lower than half the diameter of the cleat tip, and at most, the cleat lengths three-thirds of an inch.
Stretching
The second way to prevent a meniscus tear is to strengthen and stretch the major leg muscles. The muscles include the hamstrings, thighs, and calves. One popular exercise used to strengthen the hamstrings is curved. It is also important to stretch the hamstrings properly; doing a toe touch can do this. Sitting leg extensions strengthen the quads and stretching the quads will help relax the muscles. Toe raises are used to strengthen and stretch the calves. Muscle mass and sufficient strength can also help maintain knee health. The use of a parallel squat increases the much needed stability in the knee if done correctly. The parallel squat execution will develop the lower body muscles that will strengthen the hips, knees, and ankles.
Technique
The last major way to prevent tears in the meniscus is to learn the right techniques for ongoing movement. For a sport that involves fast, fast moves, it is important to learn how to cut, turn, land from a leap, and stop correctly. It is important to take the time to perfect this technique when used. These three major techniques will significantly prevent and reduce the risk of meniscus tears.
Treatment
Currently, maintenance allows for faster recovery. If the tear is not serious, physical therapy, compression, elevation and knee icing can cure the meniscus. A more serious tear may require a surgical procedure. However, surgery does not seem to be better than non-surgical treatment.
Conservative care
Initial treatment may include physical therapy, bracing, anti-inflammatory drugs, or corticosteroid injections to improve flexibility, endurance, and strength.
Exercises can strengthen the muscles around the knee, especially the quads. Stronger and larger muscles will protect the meniscus cartilage by absorbing part of its weight. Patients may be given paracetamol or anti-inflammatory drugs.
For patients with non-surgical treatments, physical therapy programs are designed to reduce the symptoms of pain and swelling in affected joints. This type of rehabilitation focuses on maintaining various movements and functional development without exacerbating symptoms. Physical therapists may use modalities such as electrical stimulation, cold therapy, and ultrasound.
Recently, accelerated rehabilitation programs have been used and proven to be as successful as conservative programs. This program reduces the time patients spend using crutches and allows load-pulling activities. A less conservative approach allows patients to apply a small amount of stress and prevent various motion losses. It is possible that patients with peripheral tears may pursue an accelerated program and patients with larger tears will use conservative programs.
Surgery
Arthroscopy is a surgical technique in which the joint is operated using an endoscopic camera as opposed to open surgery on the joint. Meniscus can be repaired or completely removed; these are described in more detail below. It should not be recommended for degenerative meniscus tears, unless there is locking or knee capture, repetitive effusion or persistent pain. Evidence suggests that it is no better than conservative management in those with and without osteoarthritis. There seems to be no benefit in adults with meniscus tears that have mild arthritis.
An independent international guide panel that has no conflict of interest makes a strong recommendation against arthroscopy for a degenerative meniscus tear; This conclusion is reached on the basis that there is high-quality evidence that there is no lasting benefit and less than 15% of people even have small short-term benefits. Artroscopic loss for meniscal tear repair includes two to six weeks recovery time and rare but serious side effects that can occur, including blood clots in the legs, surgical site infection, and nerve damage. BMJ Quick Recommendations include infographics and shared decision-making tools to facilitate conversations between doctors and patients about the risks and benefits of arthroscopic surgery.
If an injury to the meniscus is isolated, then the knee will be relatively stable. However, if other injuries such as anterior cruciate ligament injury (torn ACL) coupled with torn meniscus, then arthroscopy will be performed. Meniscal repair has a higher success rate if there is sufficient blood supply to the peripheral edge. The inside of the meniscus is avascular, but the blood supply can penetrate up to about 6 millimeters or a quarter of an inch. Therefore, a meniscus tear that occurs near the peripheral edge is able to heal after meniscal repair. A study conducted by Heckman, Barber-Westin & amp; Noyes finds that it's better to fix the meniscus than to throw it away (menisectomy). The amount of rehabilitation time required for repair is longer than menisectomy, but lifting the meniscus can cause osteoarthritis problems. If the meniscus is removed, the patient will be rehabilitated for about four to six weeks. If the repair is done, then the patient will need four to six months. If physical therapy does not resolve symptoms, or in locked knee cases, surgical intervention may be necessary. Depending on the location of the tear, repairs can be made. Outside a third of meniscus, a sufficient blood supply exists and improvement is likely to heal. Usually younger patients are more resilient and respond well to these treatments, while older and more sedentary patients do not have good results after repair.
Meniscus transplant
Meniscus transplantation is done on a regular basis, although the procedure is rare and there are many questions about its use. Side effects of menisectomy include:
- The knee loses its ability to send and distribute loads and absorb mechanical shocks.
- Continuous swelling and stiffness in the knee.
- The knee may not be fully moving; there may be a knee locking sensation or bending on the knee.
- The full knee may move full after the meniscus rips.
- Increases arthritis progression and time for knee replacement.
Meniscus implants
Other treatment approaches in development are meniscus implants or "artificial meniscus." While many artificial joints and bionic body parts are available to patients, including arms, legs, joints and other body parts, prosthetic replacements for the meniscus have avoided modern medicine. Several initiatives are underway.
The first implanted in humans is called the Meniscus NUsurface Implant. The operation took place in January 2015 at the Wexner Health Center of The Ohio State University. NUsurface implants are made of medical grade plastics and are designed to require no fixation of bone or soft tissue. Implants are currently being tested in two FDA-approved clinical trials that are expected to be completed by mid to late 2018. If approved by the FDA, implants can be a good option for active young patients, who are considered too young for knee replacement because the operation only takes place about 10 years.
Other early-stage meniscus implants include TRAMMPOLIN and Orthonic.
Scientists are also working to grow artificial meniscus in the laboratory. Scientists from Cornell University and Columbia grow new meniscuses in sheep knee joints using 3-D printers and body stem cells themselves. Similarly, researchers at Scripps Clinic's Shiley Center for Orthopedic Research and Education also reported growing the entire peniscus. Animal testing will be required before meniscus replacement can be used in people, and then clinical trials will follow to determine its effectiveness. Currently, there is no time for clinical trials, but it is estimated that it will take years to determine whether the laboratory-grown meniscus is safe and effective.
Post surgical rehabilitation
After successful surgery to treat the crushed part of the meniscus, the patient must follow a rehabilitation program to get the best results. Rehabilitation after meniscus surgery depends on whether the entire meniscus is removed or repaired.
If the crushed meniscus part is removed, the patient can usually start walking using crutches one or two days after surgery. Although each case is different, the patient returns to normal activity on average after a few weeks (2 or 3). However, a perfectly normal path will resume gradually, and it is not unusual to take 2-3 months for recovery to reach the level at which the patient will run smoothly. Many menisectomy patients never experience 100% functional recovery, but even years after the procedure, sometimes they feel a pull or strain on their knees. There is little medical follow-up after menisectomy and official medical documentation tends to ignore the imperfections and side effects of this procedure.
If the meniscus is improved, the following rehabilitation programs are much more intensive. After surgery, the hinged support of the knee is occasionally placed in the patient. This brace allows controlled knee motion. Patients are encouraged to walk using crutches from day one, and most of the time can put partial weight on the knee.
Fixing symptoms, restoring function, and preventing further injury are the main goals when rehabilitating. At the end of rehabilitation, normal range of motion, muscle function and body coordination are restored. Personal rehabilitation programs are designed to take into account the patient's operation type, improved location (medial or lateral), simultaneous knee injury, type of meniscus tear, patient age, knee condition, loss of strength and ROM, and hope and motivation from patient.
Phase I
There are three phases that follow the meniscal surgery. Each phase consists of the purpose of rehabilitation, training, and criteria to proceed to the next phase. Phase I begins immediately after surgery up to 4-6 weeks or until the patient is able to meet the developmental criteria. The goal is to restore normal knee extension, reduce and eliminate swelling, regain control of the foot, and protect the knee (Fowler, PJ and D. Pompan, 1993). During the first 5 days after surgery, passive continuous motion machines are used to prevent prolonged immobilization periods leading to muscle atrophy and delayed functional recovery. During 4-6 weeks post-surgery, active and passive non-heavy bearing movements that flex the knee up to 90? recommended. For patients with meniscal transplantation, knee flexion may further damage the allograft due to increased shear forces and pressure. If any weight-bearing exercise is applied, a controlled clamp should be worn on the knee to keep the knee close (& lt; 10?) Or full extension. The suggested exercise targets an increase in patient's ROM, muscle strength and neuromuscularity, and cardiovascular endurance. Aquatic therapy, or swimming, can be used to rehabilitate patients because it includes ROM, strength, and cardiovascular exercise while relieving stress on the body. It has also been shown to significantly improve the dependent edema and symptoms of pain. No gait pain without crutches, swelling and 4-6 weeks after surgery are the criteria for starting the next phase (Ulrich G.S., and S Aroncyzk, 1993).
Phase II
The phase of this rehabilitation program is 6 to 14 weeks after surgery. The goals for Phase II include being able to restore full ROM, normal gait, and perform functional movements with control and without pain (Fowler, PJ and D. Pompan, 1993). In addition, muscle strengthening and neuromuscular training are emphasized using progressive load training and balance exercises. Exercises in this phase can increase knee flexion for more than 90 °. Recommended exercises include stationary bicycles, standing on the surface of the foam with two and one legs, strengthening the abdomen and back, and strengthening the quads. The proposed criteria included normal walking force on all surfaces and a single foot balance longer than 15 seconds (Ulrich G.S., and S Aroncyzk, 1993).
Phase III
The patient started the exercise in Phase III 14 to 22 weeks after surgery. The objective and final criteria of Phase III is to exercise/movement certain work without pain or swelling (Fowler, PJ and D. Pompan, 1993). Exercises for maximum muscle control, strength, flexibility, special movements for the work/exercise of the patient, low to high exercise, and abdominal and back strengthening exercises are all recommended exercises (Ulrich G.S., and S Aroncyzk, 1993). Exercises to improve cardiovascular fitness are also applied to fully prepare the patient to return to the desired activity.
If developmental criteria are met, patients may gradually return to "high impact" activities (such as running). However, "heavier activities", such as running, skiing, basketball, etc. Generally any activity where the knee bears a sudden change of direction of movement can cause repetitive injuries. When planning sports activities, it makes sense to consult a physical therapist and check how much exercise affects the knee.
Epidemiology
The meniscal tear is the most common knee injury. These tend to be more frequent in sports that have rough contacts or spinning sports like soccer. This is more common in men than women, with ratios of about two and a half men for one woman. Men between the ages of 31 and 40 tend to tear their meniscus more often than younger men. Women seem more likely to tear their meniscuses between the ages of 11 and 20 years.
People who work in tense jobs such as construction or professional sports are also more likely to have a meniscal tear because of the tension that their knee targets.
According to the National Library of Medicine of the United States, an isolated medial meniscal tear occurs more frequently than other tears associated with the meniscus. The prevalence of meniscus tears is the same for both knees. In several different studies, one's BMI is shown to have a greater effect on the frequency of meniscus tears; having a higher BMI will result in more weight in the joint, which can cause the knee to be out of sync, which causes more muscle burden, resulting in easier tearing.
In 2008 the Department of Health and Human Services reported a combined total 2,295 disposal for major diagnoses of lateral/meniscus cartilage (836.0), medial/meniscus cartilage tear (836.1), and cartilage/meniscus tear (836.2). ). Women have a total of 53.49% disposal, while men have 45.72%. Individuals between the ages of 45 and 68 had an average of 31.73% release followed by the 65-84 age group, with 28.82%. The average length of stay for patients diagnosed with meniscus tearing was 2.7 days for men and 3.7 days for women. There were reports of 6,941 returning hospitals for knee repair. Individuals between the ages of 18 and 44 were among the highest with 37.37% total discharge, followed by the age group 45-64, with a percentage of 36.34%. Men had a slightly higher amount of dirt (50.78%) than women (48.66%). The average length of hospital stay for male and female patients in the hospital is 3.1.
References
External links
Source of the article : Wikipedia
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