Non-surgical repair of the different types of meniscus tears

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Non-surgical repair of the different types of meniscus tears

If you are reading this article you have likely been diagnosed with a meniscus tear and have just had, or are waiting for an MRI to determine the extent of your knee damage. Depending on your MRI results you will be offered one of three choices:

1. Do nothing.
2. Do something non-surgically.
3. Get a surgery.

So let’s look at the different types of meniscus tears and what you can do non-surgically to treat them.

In this article, we present background information on the many types of meniscus tears and how they can be treated non-surgically. If you have questions about your meniscus injury, get help and information from our Caring Medical staff

The rush to MRI. Is it really necessary? One study suggests a physical examination is just as good. Is MRI just a justification for surgery?

We probably cannot even count the number of emails we received in the last few years that begin like this:

I had an MRI

I had an MRI, I have a torn meniscus, trying to do anything to avoid surgery.

I had an MRI I have another tear

I had arthroscopic knee surgery for a torn meniscus. I just had an MRI and I have another tear of in my meniscus. Now they tell me I am developing arthritis as well. I need more surgery. I am not sure I want or even need more surgery. Are non-surgical options available to me?

I had an MRI, I had surgery, now I have more pain

I had a meniscus repair surgery about six months ago. Soon after the surgery, I started experiencing terrible pain. I cannot work like this. I had another MRI and I am being told to have more surgery. Are non-surgical options available to me?

For most people, you cannot get a surgical recommendation for a meniscus tear without an MRI justifying a meniscus tear significant enough to get a surgical recommendation.

For most people, you cannot get a surgical recommendation for a meniscus tear without an MRI justifying a meniscus tear significant enough to get a surgical recommendation. It is often said that if you want a surgery, get an MRI.

A June 2020 paper suggests that if you want a surgery that may not help you at all, it begins with getting an MRI.

In fact, a June 2020 paper suggests that if you want a surgery that may not help you at all, it begins with getting an MRI. Here is a quotation from that study published in the medical journal Cureus. (1)

“MRI continues to be the imaging modality of choice, and surgical management is the mainstay of treatment for meniscal tears. Arthroscopic partial meniscectomy is currently the most performed orthopedic procedure around the globe. However, recent studies have conclusively shown that outcomes after an Arthroscopic partial meniscectomy are no better than the outcomes after a sham/placebo surgery. “

So the question is, why rush to get an MRI if it is going to send you to meniscus surgery that may not help you? This question is discussed at length in our article Should I have surgery for my meniscus tear?

Another study: A physical examination just as good as an MRI. So is it important to have an MRI report relating the different types of meniscus tears you may have? No, not if you are trying to avoid surgery.

If you have decided to try to avoid surgery, an MRI may not be needed. In a May 2020 study in the journal Advances in Orthopedics,(2) one of the advances doctors were looking for ways to best diagnosis a meniscus tear. To find this answer the researchers of this study looked at patients who were already deemed surgical candidates because of meniscal or cruciate ligament tears. Just before these patients had a knee surgery the patients had an MRI and a physical examination. The researchers then wanted to compare the MRI reading interpretation and the results of the physical examination to what they saw during the surgery.

• What they found was: “Clinical (physical) examination, performed by an experienced examiner, can have equal or even more diagnostic accuracy compared to MRI to evaluate meniscal lesions.”

So what is it that a doctor should look for in a physical examination?

If you decide to forego the MRI because you want to avoid a surgical recommendation, then what is it that your doctor should be looking for in a physical examination?

• For one, how much pain does a patient have and where is this pain coming from.
  • If you have little pain but clear problems with function, that may be a hint that the pain is coming from the center two-thirds of the knee or the “white zone” of the meniscus.
  • Tears of the white zone meniscus and the thought that these meniscus tears do not have the ability to heal is explained below. Briefly, the white zone is called the white zone because it has no direct blood supply and no nerve endings. So while you do not feel pain from a white zone tear, it is thought that you also do not have the ability to heal this injury because there is no blood supply to bring healing factors and elements to the injury site.
• In a situation of chronic knee pain, how much swelling is there? If the knee is constantly swelled, this may be an indication of knee instability. This means you have a lot more going on than just a meniscus tear.

We are going to present a brief video that explains the concept of knee instability and how it impacts your pain and function in a meniscus damaged knee.

A brief video on knee instability and a bulging meniscus – the many types of meniscus tears may have ligament damage as a common factor

• In this video, knee instability is easily documented by stressing the knee (bending it and flexing it) and observing the knee’s function and motion under ultrasound examination. Ultrasound is a real-time, motion-based image that differs from static MRI images where a snapshot is taken of the knee is various static poses.
• (At 0:15 of the video) In a BEFORE ultrasound, here the meniscus can be seen bulging in and out of the knee because of excessive motion from ligament laxity and injury. In other words, the meniscus is moving in and out of its proper place in the knee joint because the supportive knee ligaments that help hold the meniscus in place are damaged. The whole knee is unstable.
• In the AFTER ultrasound and after Prolotherapy injections, (which is how this patient was treated, the treatment is explained below) the ligaments were strengthened and tightened. The meniscus is now is in its proper alignment and no longer subject to degenerative contact stress.

Non-Surgical treatment options for the different types of Meniscus tears

In the illustrations below we describe the various types of meniscus tears. These illustrations will help give you an anatomical bearing and help you understand each tear. Some people have more than one meniscus tear at a time or the tear they suffer may be a “complex” tear.

Meniscus bucket handle tear – Longitudinal Tears

You may have had your MRI, went to an orthopedist, and learned you have a bucket handle meniscus tear. A look at an MRI convinces the doctor to offer a recommendation to have suture repair surgery (the doctor will stitch up the tear) as opposed to meniscus tissue removal surgery.

A bucket handle tear is considered a full-thickness tear. For most patients, as soon as they hear “full-thickness,” they will next hear a surgical recommendation. Your doctor may have explained to you that you have suffered a bucket handle meniscus tear. It is called a bucket handle because the flap of tissue the tear causes assumes the shape of the handle of a bucket, a crescent moon shape or letter “C” shape. Then your doctor may explain:

• The meniscus bucket handle tear is a tear that tears vertically in either zone. It does not cut across the meniscus, but rather tears so that the curve looks like a bucket handle. Sometimes a bucket handle tear will turn into a “flipped meniscus” where the meniscus fragment folds backward.
• Next, your doctor will give you your treatment options. If you are reading this article you have probably tried “conservative,” care because you have chronic knee swelling and you can’t seem to straighten out your leg because your knee is stuck or locked in a bent position, and, your knee is very noisy, making a popping or clicking sound. So rest, knee brace, medications, and physical therapy or exercise programs are recommended. When these do not work, then you get the surgical recommendation.
• In your own research and perhaps as suggested by your doctor, you may have been told about Platelet rich Plasma injections or simply PRP.  PRP is an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint deterioration.
• Your doctor may suggest to you that this may work for you and that this may be considered as it is an in office non-surgical repair. If this is a route you would like to explore we present research in which doctors presented case studies of three patients where Platelet Rich Plasma Therapy treatments were able to completely repair a bucket handle meniscus tear 7 months after diagnosis of the injury.(3) Also, see our article Bucket handle meniscus tear repair and treatment options.

Your MRI report may include tags such as:

• • Posterior (back) horn medial meniscus tear,
  • transverse tear, radial tear of the medial meniscus
    • Is a tear that extends across both zones, starting at the red zone and then extending downward into the white zone.
    • Of note, a new study in the Orthopaedic Journal of Sports Medicine examined different surgical techniques for meniscus radial tears. The researchers concluded: “Radial tears of the meniscus are difficult to repair (surgically). Further research into more stable constructs (surgical techniques) is necessary”(4)
  • horizontal medial meniscus tear,
    • Of note O.Şahap Atik, MD, Professor of Orthopedic Surgery, Turkish Joint Diseases Foundation wrote an editorial “Should degenerative horizontal tear of the medial meniscus be treated with surgery?” where he could not suggest surgery provided any extra benefit to patients over non-surgical treatments.(5)

Red zone tear, white zone tear. When non-surgical options can work and when surgery will be the “only” choice

We are now going to expand on our discussion of the White Zone Tear, the Red Zone Tear, and the tear that goes across the red zone and the white zone.

Menisci have two zones. The red zone is the meniscus’ outside zone the white zone is the inside zone. Meniscus tears are characterized by their placement within these two zones. In your many doctor visits, you probably received a pretty good education in what red zone tears and white zone tears are of the menisci.

A red zone tear lies within the blood-rich portion of the meniscus. Where there is a blood supply there is healing as blood brings the healing and growth factors needed for wound repair.

• The white zone meniscal tear is thought to be non-healing because there is no direct blood supply. 
• Many doctors do not believe the white zone meniscus tear can be repaired because of this.
• This is typically the part of the meniscus removed in meniscus surgery.

If you have a red zone tear, there is a chance arthroscopic surgery can go in and sew it up. If you have a white zone tear, it is most likely that your meniscus will be removed. That would be all or some of it. The great majority of meniscus arthroscopic surgeries are to REMOVE some amount of meniscus tissue.

Many patients at this point, exploring non-surgical options will look into stem cell therapy.

The reality of stem cell therapy

• Stem cell therapy can be an effective treatment for meniscus damage. We have seen excellent results in many patients. However, stem cell therapy needs to be understood within the reality of what this treatment can and cannot do and how this treatment should be used.

We don’t treat everyone with stem cell therapy

• It is important to note that we do not use stem cell therapy on every patient. In fact, we use stem cell therapy in very few of our patients. We find that other simpler and less costly regenerative medicine injection treatments can work just as well. This is explained below.

Over expectation of what stem cell therapy can do may lead to patient disappointment

• In many people who reach out to our office, we find that they have an unrealistic expectation of what stem cell therapy can offer them. For some people, stem cell therapy cannot, in one simple injection, repair, and reverse years of degenerative damage. Many treatments may be necessary. Patient should be aware of what stem cell therapy can really do.
• For example, stem cell therapy cannot generate a meniscus from nothing. If you do not have a meniscus, stem cell therapy as an injection will not make a new one. If you have a meniscus tear, lesion, or hole in cartilage, stem cell therapy may help create a natural healing patch, but, the treatment, like any medical treatment, has its limitations. Stem cell therapy can patch a hole, but without supportive treatments to address what caused the degenerative knee condition  and what caused the hole in the cartilage in the first place, (knee instability and degenerative wear and tear motion from damaged and weakened knee ligaments), stem cell therapy will not be the single-shot cure a patient will hope for.

If you are exploring stem cell therapy for a meniscus tear, the great likelihood that you are doing this research is that you are looking to an option for surgery. Please see our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work?

Partial-thickness tears or full-thickness tears: The other classification of the meniscus tear is related to the depth of the tear.

• Tears are considered to either be partial-thickness tears or full-thickness tears.
• Partial-thickness tears are tears that only extend part way across the meniscus, while full thickness tears extend fully across. So, if you have a full thickness flap tear, then it is a tear that cuts across the meniscus completely.

No matter the tear, partial meniscectomy and physical therapy may not work or may work. It is hard to tell.

This is a study from orthopedic surgeons writing in the medical journal Arthroscopy. (6) If ever there were to be a favorable study on surgery you would think this was it. Not so. In this study, doctors suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy. The studies evaluated in this research is not robust enough at this time to support claims of superiority for either alternative, and both arthroscopic partial meniscectomy or physical therapy could be considered reasonable treatment options for this condition.

They may work, one may or may not work better than the other. The research is not sure.

Two studies – seven years apart 2013 – 2020

We are going to look at two studies on physical therapy, surgical avoidance and meniscus tears. Both lead by Jeffrey N. Katz, MD.  The first study, considered by many a landmark study, was published in the New England Journal of Medicine. (7)

• Here the research team studied 351 patients with either a torn meniscus or knee osteoarthritis for 12 months.
• They randomly assigned the patients to either a physical therapy group or an arthroscopic surgery group.
• They evaluated each patient’s pain and knee function at six and 12 months and discovered that after one year the results were about the same: both had some improvement with no significant difference between the two treatment options.
• The one interesting fact is that patients had the option to crossover into the other treatment group. 51 patients in the physical therapy group decided to go ahead with surgery, whereas only 9 patients in the surgery group chose to switch to physical therapy. No reasons were given as to why the patients decided to switch.

Did the physical therapy group or the surgery group have more pain or less pain 5 years down the road?

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There seems to be a connection between meniscus removal and the need for total knee replacement.

In February 2020, (8) a study lead by Harvard Medical School, the Cleveland Clinic, the Hospital for Special Surgery, Weill Cornell Medicine and the Mayo Clinic examined the patient records of people who had physical therapy or arthroscopic partial meniscectomy for their meniscus problems over a 5-year follow-up period.

• The primary comparison the researchers were looking at was pain in the two groups. Did the physical therapy group or the surgery group have more pain or less pain 5 years down the road?
• Secondary comparison was, how many people went on to have a total knee replacement?

Results:

• Pain scores improved substantially in both groups over the first 3 months, continued to improve through the next 24 months and were stable at 24-60 months. Both groups did just as well.
• Greater frequency of total knee replacement in those undergoing arthroscopic partial meniscectomy merits further study. There seems to be a connection between meniscus removal and the need for total knee replacement.

You don’t have to search long on this website to see find research citing the dangers of surgery for a torn meniscus. The meniscus is an essential part of the knee and surgery usually entails removing part of this essential structure. A compete or partial menisectomy leads to further degeneration in the knee and puts the patient at risk for long-term knee osteoarthritis. For the knee osteoarthritis patient, “shaving” or “scoping” loose cartilage is detrimental to the knee. Knee surgery often does more harm than good and has repercussions adverse long-term effects.  A more conservative and effective option is to receive Prolotherapy for the torn meniscus and knee osteoarthritis so that the tissue can be rebuilt and full knee function can be restored.

Physical therapy is great in many circumstances, but in the case of a soft tissue injury that is not healing on its own, i.e. a torn meniscus or knee osteoarthritis, a more aggressive treatment is needed. Prolotherapy is able to stimulate the body’s immune system to initiate the natural healing cascade to repair the soft tissue injury.

Please see our article Does arthroscopic meniscus surgery leads to knee replacement?

Is successful meniscus surgery a matter of luck? Do you have the same chance for a successful outcome if you just rehab with exercise?

This is a March 2020 study published in the British Journal of Sports Medicine (9). What this study wanted to do was examine the ability of surgeons to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients.

Here is how the study worked:

• A group of orthopedic surgeons were given 20 patient profiles to examine. These profiles were derived from a randomised clinical trial comparing arthroscopic partial meniscectomy with exercise therapy in middle-aged patients with symptomatic (painful) non-obstructive meniscal tears. From each treatment group (arthroscopic partial meniscectomy and exercise therapy), the researchers selected five patients with the best and five patients with the worst knee function after treatment.

The surgeons of this study make a recommendation for treatment. Was surgery correct?

• Next, the surgeons (unaware of what treatment the 20 patient profiles they were looking at had, surgery or exercise) had to choose between arthroscopic partial meniscectomy and exercise therapy as preferred treatment and subsequently had to estimate the expected change in knee function for both treatments. Finally, surgeons were asked which patient characteristics affected their treatment choice.

The point of this study is that the surgeons are looking at 20 patient profiles. The 20 people already had either a surgery or exercise therapy. The results of how successful the surgery was and how successful the exercise therapy was, was used to determine if the surgeon made the “right call.”

Results: Surgeons making a successful prediction and a coin toss. The chance was equal.

Typically when patients decide whether to have a surgery or not they typically do not toss a coin. Probably some do because they do not have enough information to make a more educated assessment of their chances of having a successful surgery or having equal success with non-surgical options.

So here are the results of this study. Remember a surgeon was asked to look at 20 patient profiles and make a recommendation for surgery or no surgery. The 20 patients had already had a surgery or exerice therapy and the successful results of their treatment had already been recorded. How did the surgeons do? They may as well have flipped a coin.

Here is what the study said:

• Overall, 50.0% of the (surgeon’s) predictions were correct, which equals the proportion expected by chance.
• Experienced knee surgeons were not better in predicting outcome than other orthopaedic surgeons.
• In general, bucket handle tears, knee locking and failed non-operative treatment directed the surgeons’ choice towards arthroscopic partial meniscectomy, while higher level of osteoarthritis, degenerative (problems) and the absence of locking complaints directed the surgeons’ choice towards exercise therapy.

Conclusions: Surgeons’ criteria for deciding that surgery was indicated did not pass statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.

In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue

We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below is an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C.

• Dextrose Prolotherapy is a simple sugar injection into the knee that attracts you own healing repair cells into the area to fix the damaged meniscus
• In some patients, it may not be enough to attract your own cells to this damaged area with Prolotherapy, in this type case we may have to put cells there via injection. Our first option would be Platelet Rich Plasma (PRP) Prolotherapy. This would put the healing factors found in your blood platelets into the damaged joint.
  • WE DO NOT offer PRP as a stand-alone treatment or injection. While PRP brings healing cells into the joint, it acts to repair degenerative damage. In our experience, while PRP addresses damage deep in the such as a meniscus, we must still address the joint instability problem created around the knee. We do this with Prolotherapy. Here damaged or weakened ligaments that are simply “stretched,” can be strengthened with treatment to help restore and maintain normal joint mobility. We discuss the meniscus interaction with the MCL in a moment. Simple PRP on the inside, Prolotherapy on the outside of the joint.
  • PRP is injected at the meniscus with ultrasound guidance
• Most meniscal tears require four to six treatments although that could be less or more depending on the patient.
• What helps our success rate with meniscal tears is our treatment of the MCL or the medial collateral ligament at the same time.
• We will use of ultrasound machine to access the integrity of the MCL

Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, has many advantages over arthroscopy, which include:

• These treatments are considered a much safer and conservative treatment
• the procedure does not take long to administer; an individual is usually in and out of the doctor’s office in less than an hour
• it stimulates the body to help repair the painful area; for example, the new collagen tissue formed is actually stronger than it was before the injury
• it reduces the chance of long-term arthritis; with arthroscopy, the chance of long-term arthritis increases
• in the case of athletes, it increases their chances of being able to play their sports for the rest of their lives; arthroscopy significantly decreases those chances
• exercise is encouraged while getting Prolotherapy treatments; one must be very cautious with exercise after arthroscopy
• the procedure is much less invasive; remember that arthroscopy requires the knee to be blown up with about 100 ml of fluid to fit all the scopes into the knee.

If you have questions about bucket handle meniscus tear repair and treatment options, get help and information from Caring Medical

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