Non-surgical repair: Injections for 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 surgery.

The reason you are probably reading this article is that you are exploring all these options and are probably leaning towards finding another way besides surgery. In this article you are going to see a lot of research, the orthopedists will speak up, the physical therapists are going to speak up, and the regenerative therapist, health care providers offering regenerative medicine injections, that would be us, is going to speak up. So let’s look at the different types of meniscus tears and what you can do non-surgically to treat them.

The rush to MRI. Is an MRI really necessary? Whatever your MRI says, you may get surgery anyway.

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

I had an MRI

This is what my MRI says: Radial tear poster medial meniscus, degeneration fraying medial meniscus, moderate bone contusion medial tibial plateau with degenerative changes, moderate bakers cyst. My doctor says I should get a clean-up on my knee.

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 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?

Sometimes we simply get a cut and paste of the person’s MRI report. MRI reports can be helpful but people with “terrible” MRIs have little knee pain. People with good MRIs have terrible pain. It is just as important to understand the person’s full situation, to know how someone feels today, what type of pain did they have when they woke up, what makes it worse as it is to get an MRI report.

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 surgery, get an MRI. What you are going to read below will take this idea one step further, if the MRI cannot tell if you need surgery, you may want to get a surgery to see if you needed surgery. We will show you the studies.

If you want 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) It was written by Dr. Kavyansh Bhan, Department of Trauma and Orthopaedics, Whipps Cross University Hospital, London.

“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 the 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?

(Lack of) “Diagnostic Accuracy of Magnetic Resonance Imaging in the Detection of Type and Location of Meniscus Tears”

That is the title of a February 2021 study published in the Journal of Clinical Medicine. (2) How the study ended was with a suggestion that if you really wanted to know how much damage there was to a patient’s meniscus or their knee capsule, you should go in and see for yourself during an arthroscopic procedure because many times the MRI is not helpful. Let’s let the doctors of the study speak for themselves. First, this is why they did the study:

“Magnetic resonance imaging (MRI) has been widely used for the diagnosis of meniscal tears, but its diagnostic accuracy, depending on the type and location, has not been well investigated. We aimed to evaluate the diagnostic accuracy of MRI by comparing MRI and arthroscopic findings.”

Next, this is what they found out:

What the researchers here did was to compare MRI findings with arthroscopic findings in the same patient to determine if the MRI detected the presence, type, and location of meniscus tears later revealed in an arthroscopic procedure. They also looked at a group of patients who had ACL injury with meniscus tears to see if the meniscus tears showed up on MRI in the same manner that they were discovered during the ACL reconstruction surgery.

The researchers also excluded some patients from the study as not being good study candidates. This would include people who had degenerative arthritis. Degenerative arthritis makes it difficult through imaging, to understand the type and extent of the meniscus tear on MRI.

What the researchers revealed at the end was MRI is limited in understanding the scope of a meniscus injury. To quote: “MRI could be a diagnostic tool for meniscus tears, but has limited accuracy in their classification of the type and location.”

MRI recommendation to arthroscopic surgery should be questioned

In the above study, researchers looked to see if an MRI was as accurate as direct observation in an arthroscopic procedure. The answer was no. Doctors should consider arthroscopic surgery as the best diagnostic tool in some cases of knee pain from a suspected meniscus injury.

A group of physical therapists, based on responses from the patients they see suggest that doctors can be a little too enthusiastic in promoting an arthroscopic surgery where one may not be needed. This is what the physical therapist wrote in the peer-reviewed journal Musculoskeletal Science & Practice (3).

“Current clinical practice guidelines for degenerative meniscal tears recommend conservative management yet patients are frequently referred to the consultant orthopaedic surgeon despite a lack of evidence for the use of arthroscopy.”

Arthroscopic surgery to prove you do not need an arthroscopic surgery?

The lack of clear evidence was that the MRI could not provide definitive or clear evidence that the person needed an arthroscopic meniscus surgery. Basically, because the MRI could not provide this evidence, arthroscopic surgery was recommended. The patient received and probably wanted, surgery to see if they needed surgery.

Back to the researchers:

“Participants described beliefs, strongly influenced by magnetic resonance imaging (MRI) results, that damaged structures were causing their knee problems and expected their knee problems to inevitably worsen over time. Participants were hopeful the orthopedic consultation would clarify their problem and lead to a subsequent definitive intervention. Most participants viewed surgery as “the quick and straightforward solution” necessary to repair faulty cartilage. The exercise was not seen as compatible with the recovery process by most (“Would I make it worse?”). The people in this study feared NOT having surgery.

“The negative role of MRI in promoting surgical expectations needs further consideration.”

This is the conclusion: “How participants understand their knee problem contributes to surgical expectations and perceptions that it is not amenable to conservative management. Findings suggest a need to educate both patients and primary care clinicians about the safety and efficacy of exercise as first-line therapy for degenerative meniscal tears. The negative role of MRI in promoting surgical expectations needs further consideration.”

The problem of pseudotears

A February 2021 study in the medical journal Arthroscopy (4) examined why MRI readings were often inaccurate when it came to interpreting whether there was an actual tear or not of the anterior horn of the lateral and medial meniscus. What these researchers examined was the phenomena of pseudotear, the appearance of a meniscus tear that is not there.

Peter R. Kurzweil, M.D. is an orthopedic surgeon. He is an editorial reviewer for the journal Arthroscopy. This is what he wrote in response to this study’s observations: (5)

Editorial Commentary: False-Positive Meniscus Pseudotear on Magnetic Resonance Imaging: A False Sign That Rings True

“The false-positive finding of anterior horn meniscus (pseudo)tear on magnetic resonance imaging (MRI) is an important finding of which to be aware. We have recently seen awareness similarly raised regarding root tears of the meniscus, which, if overlooked, could have detrimental consequences. Manifestations of the MRI finding of meniscus pseudotear arise from the variability of the insertion of the transverse geniculate ligament into the anterior horn of the lateral meniscus. Bearing in mind that anterior knee pain is a common reason that patients present for an orthopaedic and sports medicine evaluation, the understanding that this MRI finding does not represent a true meniscus tear may save patients from unnecessary arthroscopic surgery.”

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,(6) one of the advances doctors were looking for ways to best diagnose 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.

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?

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

The hard to find Ramp Lesion in an ACL deficient knee

For those of you reading this article, and you had an acute ACL tear or you had previous ACL surgical repair and were diagnosed with a “ramp lesion” you should an understanding that ramp lesions are vertical or longitudinal tears of the peripheral capsular attachment (the meniscus’ outer edge attachment) of the posterior horn of the medial meniscus at the meniscocapsular junction. (Simply an anchor that keeps the meniscus from floating around in the knee). It is often consider a minor injury and is especially suspected in ACL deficient or compromised knees.

This injury is often difficult to detect on MRI. 

A July 2021 study in the journal Skeletal radiology (7) suggests MRIs can only offer “moderate accuracy.” Here are the summary learning points:

This next part sounds like an MRI report. If you had a suspected meniscus tear it may sound like your MRI report.

Here is a point. This MRI report sounding description appears detailed and in-depth. It is giving a picture of what is happening in the knee. Or is it?

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.

What are we seeing in this image?

In this illustration, 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.

In this illustration 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. This illustration describes a bucket handle tear, radial tears, horizontal tears, oblique tears and complex tears.

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:

Your MRI report may include tags such as:

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.

What are we seeing in this image?

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. All or some of it. The great majority of meniscus arthroscopic surgeries are to REMOVE meniscus tissue. In this image, we note that the meniscus has a poor healing ability because approximately 70% of the meniscus gets no direct blood supply. This is why the meniscus has a white zone. In the other 30% of the meniscus that gets a blood supply, this creates the “red zone.”

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. All or some of it. The great majority of meniscus arthroscopic surgeries are to REMOVE meniscus tissue.

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.

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

What are we seeing in this image?

Meniscus tears can be considered to either be partial-thickness tears or full-thickness tears. Partial-thickness tears are tears that only extend partway 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.

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.

Above we cited a study from a group of physical therapists discussing how their patients perceived arthroscopic surgery and their (the patients) relative disappointment that they did not get surgery. The physical therapists wrote that these people need to be educated on the reality of the success of arthroscopic knee surgery.

This is a study from orthopedic surgeons writing in the medical journal Arthroscopy. (11) If ever there were to be a favorable study on the 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 are 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. (12)

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

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

In February 2020, (13) 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.

Results:

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 complete or partial meniscectomy 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 for 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, 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 lead 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 (14). 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:

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

The point of this study is that the surgeons are looking at 20 patient profiles. The 20 people already had either 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 meniscus surgery prediction and a coin toss. The chance was equal.

Typically when patients decide whether to have 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 surgery or exercise 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:

Conclusions: Surgeons’ criteria for deciding that surgery was indicated did not pass the 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.

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

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

The reality of stem cell therapy

We don’t treat everyone with stem cell therapy

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

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 for an option for surgery. Please see our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work?

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your knee problems and knee instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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This article was updated July 11, 2021

 

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