This is a sidebar article to our main article: Should I have meniscus surgery? Reviews of Surgical and Nonsurgical Treatments for Meniscus Tears.

A meniscus injury can come in many types, sizes, and unfortunately may not be properly diagnosed. See below where we discuss diagnosing a meniscus tear.

Since this is a young population, preservation of the meniscus is critical to prevent early onset knee osteoarthritis. Therefore conservative non-surgical care should be first explored.

Typical of non-surgical treatment recommendations will be:

• Rest, ice, compression (knee brace) and elevation to immobilize the joint. Better known by the acronym R.I.C.E. this treatment plan has recently fallen upon harsh criticism, even from the doctor who conceived this treatment plan. Please see our article: Rest Ice Compression Elevation RICE Treatment Are Rest And Immobilization Not Good Practice?
• Non-steroidal anti-inflammatory drugs (NSAIDs) as anti-inflammatory  and pain medication. The use of NSAIDs have also fallen under recent criticism. Please see our article:
  When NSAIDs Make Pain Worse And Other Side-Effects.
• Physical therapy maybe prescribed depending on the athletic activity of the younger patient.

If conservative care does not help, a surgery may be recommended. This will be discussed below.

Surgery based on incorrect MRI? The problem of MRI misdiagnosis in adolescent soccer players.

You have a superstar soccer player. He or she has been complaining about knee pain. You go to the doctor who orders an MRI that suggests a meniscus tear. You may not want to lose any more of the soccer season so you may decide on a quick arthroscopic surgery for your player. Now let’s look at a recent paper. An August 2022 case history in The Journal of the Canadian Chiropractic Association (3) opens with the question of accuracy in diagnosis in adolescent soccer players. Here, Antonio Petrolo, a Sports Sciences Resident, at the Canadian Memorial Chiropractic College writes:

“Injuries to the meniscus are particularly prevalent in soccer players . . .However, in the adolescent soccer player population, it has been reported that up to 63% of asymptomatic knees may demonstrate horizontal or oblique tears on MRI. These results may negatively influence clinical decision-making and plans of management for adolescent soccer players with knee problems.

A case of a 15-year-old soccer player is presented after having been diagnosed by his family physician with a left lateral meniscus tear as per MRI, following a 10-week period of anterior knee pain. He presented to a chiropractor for a second opinion before consulting with the orthopedic surgeon. . . Recommendations for progressive rehabilitation owing to the lack of clinical evidence for meniscal abnormality were made. A primary diagnosis of left patellar tendinopathy was determined and after a 6-week comprehensive rehabilitation program, the patient made a complete recovery.”

Summary: “A thorough history, physical examination, and understanding of the patient’s injury mechanism are suggested before confirming/refuting suspicions of meniscal abnormalities via MRI. This will help to inform better clinical decision-making as well as decrease the occurrence of unnecessary imaging.”

In a May 2020 (4) study of patients with an average age of about 14 years old, 70% girls and 30% boys with mainly medial meniscus damage, with a pain scale of 7.7 on a scale of 0 – 10 with 10 being unbearable, platelet-rich plasma was found effective in improving the clinical outcomes of adolescent patients with intramural meniscus tears, for whom conservative management with physical therapy has failed to achieve pain relief. These young patients who received PRP injections reported a great reduction in pain, down to a 2 on a scale of 10 with 76.7% of the patients having “excellent” and “good” outcomes, while before injection, just 3% of the patients had a “good” score.

After the surgery

An April 2024 study in the journal Clinics and practice (5) asked if MRIs show true functional outcomes following arthroscopic repair of an isolated meniscus tear in a young patient.

Results: MRI assessment revealed:

• 4 cases of grade 1 (11.4%). This is considered a fully healed repaired meniscus.
• 14 cases of grade 2 (40.8%). This is considered a partially healed meniscus.
• and 17 cases of grade 3 (48.0%) lesions, classified as unhealed.

Historically, partial meniscectomy has been the primary treatment option for meniscus injuries in young, elite athletes

An August 2024 study (6) leady by doctors at the Department of Orthopedic Surgery, Mayo Clinic Florida and the Hospital for Special Surgery in New York, reviewed research on the the management of meniscal injuries in the elite athlete. They write: “Historically, partial meniscectomy has been the primary treatment option for meniscus injuries. However, in recent years there has been an increased emphasis on meniscus preservation due to the increased risk of cartilage degeneration over time. Moreover, while partial meniscectomy still provides a quicker return to sport, recent literature has demonstrated similar rates of return to sport and return to pre-injury levels between partial meniscectomy and meniscus repair.” In looking for the “best” meniscus surgery the researchers also added while meniscus allograft transplantation has become an increasingly utilized salvage procedure (a last chance to return to sport for many) there is limited evidence to suggest that the procedure could return and withstand the demands of elite competition. Finally the conclude: “Currently, there is no uniform approach to treating meniscal injuries in elite athletes.”

The hard to find Meniscus Ramp Lesion in an ACL deficient knee

For those of you reading this article, where it’s you, or your son or daughter, and have had an acute ACL tear or previous ACL surgical repair and were diagnosed with a “ramp lesion” you should understand 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 considered 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 (1) suggests MRIs can only offer “moderate accuracy.” Here are the summary learning points:

• There were 57 patients in this study, all had surgical repair of the ACL between January and May 2019. None of these patients had previous knee surgery.
• A comparison in identifying the ramp lesion was made between arthroscopic evaluation and two trained radiologists with 5 and 14 years of experience who did a “blinded review” (the radiologists were not told that they were supposed to be looking for a ramp lesion.)

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

• The following pathological signs were studied: complete fluid filling between the capsule and the posterior horn of the medial meniscus (fluid indicating tear or injury), the irregular appearance of the posterior wall of the medial meniscus (typically something that is torn away leaving behind evidence of tearing), edema (edema – swelling) of the (knee) capsule, fluid hyperintensity in contact with the medial meniscus and anterior subluxation of the medial meniscus. (Damage displayed by fluid buildup surrounding the medial meniscus and subluxation or dislocation of the meniscus at the front of the knee.

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

• Results: Twelve of the 57 patients had a ramp lesion diagnosed by arthroscopy (21%).
• Only complete fluid hyperintensity between the posterior horn of the medial meniscus and the capsule was significantly associated with ramp lesions. (Even so) the diagnostic accuracy of this specific sign was moderate.

An August 2022 paper in the journal Knee Surgery, Sports Traumatology, Arthroscopy (2) writes: “The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). . . Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries.

Long-term pain after meniscus surgery and accelerated osteoarthritis

References

1 Laurens M, Cavaignac E, Fayolle H, Sylvie R, Lapègue F, Sans N, Faruch M. The accuracy of MRI for the diagnosis of ramp lesions. Skeletal Radiology. 2021 Jul 3:1-9. [Google Scholar]
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3 Petrolo A. Meniscal lesion or patellar tendinopathy? A case report of an adolescent soccer player with knee pain. The Journal of the Canadian Chiropractic Association. 2022 Aug;66(2):157. [Google Scholar]
4 Popescu MB, Carp M, Tevanov I, Nahoi CA, Stratila MA, Haram OM, Ulici A. Isolated meniscus tears in adolescent patients treated with platelet‐rich plasma intra‐articular injections: 3‐month clinical outcome. BioMed Research International. 2020;2020(1):8282460. [Google Scholar]
5 Martinkėnienė VB, Austys D, Šaikus A, Brazaitis A, Bernotavičius G, Makulavičius A, Sveikata T, Verkauskas G. Do MRI Results Represent Functional Outcomes Following Arthroscopic Repair of an Isolated Meniscus Tear in Young Patients?—A Prospective Comparative Cohort Study. Clinics and Practice. 2024 Apr 1;14(2):602-13. [Google Scholar]
6 Marigi EM, Davies MR, Marx RG, Rodeo SA, Williams RJ. Meniscus Tears in Elite Athletes: Treatment Considerations, Clinical Outcomes, and Return to Play. Current Reviews in Musculoskeletal Medicine. 2024 Jun 4:1-8. [Google Scholar]