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MENSICUS TEARS AFTER FORTY…a treatise

 

I could talk generally about meniscus tears, but not all meniscus tears are created equal. There are meniscus tears and then there are degenerative meniscus tears, and it’s the latter I’m talking about now. And the two types of meniscus tears are almost entirely different entities.

DEFINITION OF MENISCUS TEARS

But for starters, let’s just define the two types of tears, and to do this, it’s easiest to define acute meniscus tears and then just about everything else is degenerative. That way it will be easier for you to figure out which kind you have.

Just about any meniscus tear in a person under forty who injures their knee, is an acute tear…and NOT a degenerative tear. On the flip side, just about any meniscus tear in a person over forty who experiences the more or less spontaneous onset of knee pain, is a degenerative meniscus tear.

Now there is everything in between, with the exception of a young person having a degenerative tear. I don’t think I’ve ever seen that. Of course there are always exceptions, but in general, the youthful meniscus is a very resilient structure and tears only as a result of an injury: twisting the knee in a football game, falling off a bicycle, landing bad on a trampoline, etc. There are a few young people out there with naturally loose ligaments, who can tear their meniscus cartilage with only a minor injury, but those are rare circumstances.

My focus now is the degenerative meniscus tear…everybody else’s meniscus tear. I often see elderly patients who come to me with an MRI which demonstrates a meniscus tear. The patient may or may not have had X-rays which show signs of arthritis, sometimes advanced arthritis. They think the cause of their pain is the meniscus tear itself, and many have the expectation that surgical repair is what they need.

Sometimes surgery is an alternative, but not most of the time. Degenerative meniscus tears are simply a sign of the development of arthritis. In simple terms, arthritis is the result of the gradual wearing out of the joint cartilage and the subsequent inflammation triggered by this process. It just so happens that in the knee, we have two kinds of cartilage: the shiny white stuff on the ends of the bones (just like on the end of a chicken bone), and the meniscus cartilage.

As we age, our articular cartilage and our meniscus cartilages begin to wear out. Unfortunately, in some of us, they begin to wear out quite early in life, and we’re seeing younger and younger patients with early-onset arthritis, especially in the knees.

Conditions and activities associated with degenerative meniscus tears and early knee arthritis include:

-a genetic predisposition to arthritis (and it doesn’t matter whether or not your folks actually complained)

-obesity

-previous history of a knee injury

-activities involving a lot of squatting and climbing, cutting and high impact

If you experience the gradual onset of arthritis after the age of sixty, then you are likely just genetically “scheduled” to have arthritis. Your knees are just wearing out, and it doesn’t seem like such an unreasonable time in life to get it. But when you’re young, sometimes it just doesn’t make sense.

SIGNS & SYMPTOMS OF A DEGENERATIVE MENISCUS TEAR

Sometimes patients experience the gradual onset of an aching sensation in the knee, perhaps even in both. They notice swelling after standing for long periods of time. Their knees hurt when they abruptly stand up from a seated position, especially if they’ve been sitting for a while. The knees ache in the morning, after mowing the lawn, or after staying with grandchildren and having to walk up and down stairs or squat to the ground to change diapers. Sound familiar?

But almost as frequently, I see older patients who have the fairly acute onset of knee pain, most commonly on the inside or in the back of the knee. They might not recall a specific injury. But they might recall some activity, perhaps an exercise program, during or after which they noted the onset of pain. Or sometimes they might remember the onset of pain after slightly twisting their knee, doing something as simple as turning from the refrigerator. Perhaps a bad step off a curb. Maybe even after a fall. But often they can’t recall any injury. They just woke up one day with pain in the knee.

They started taking some anti-inflammatories, like Advil or Aleve. They iced their knee or applied heat. Maybe that helped a little. They often try to work through the pain. Many people think that doing more exercise might help the pain. Most of the time it just makes it worse.

Their knee might swell. It might feel stiff. It hurts to stand up after they’ve been sitting for a while. The knee hurts at night, especially if it’s resting against the other knee and it feels better to put a pillow between the legs.

Sometimes the pain is severe and constant. Other times it’s mild and intermittent. And everything in between!

If this sounds familiar…you might have a degenerative meniscus tear.

 

UNDERSTANDING YOUR MENISCUS TEAR

 The meniscus is a tough, rubbery cartilage in between the two bones of the knee. It’s attached to the lining of the joint and has a very poor blood supply, so when it tears, it won’t heal on its own. If you’re young and have a tear that’s close to the ridiculously poor blood supply, sometimes it can be fixed. But frankly, most meniscus tears can’t be fixed, and that goes double for degenerative tears. Sorry. We can’t treat forty-plussers like high school basketball players.

Many patients come to me with MRI scans, showing a degenerative tear of the meniscus, thinking that the tear can be fixed and put back together…just like new. They’re often surprised and dismayed to find out that not only can the meniscus not be repaired, in most cases it doesn’t even need an operation. There’s something very disheartening about a condition you have to live with! But many of you have other conditions like this! Take hypertension, for example. It can be treated, but not cured. And there’s no surgery for it.  Patients often think surgery can cure their problem. Certainly in many cases, that might be true. We can “cure” a broken femur with an operation. We can “cure” carpal tunnel syndrome with one, but not the degenerative meniscus tear. We can only “treat” it. An operation for it simply removes the offending piece of meniscus, leaving an empty void where it used to be. More on that later.

In general, when a patient over forty is diagnosed with a meniscus tear, it is usually a degenerative meniscus tear. I say “in general,” because occasionally a forty or fifty-year-old will sustain a meniscus tear during a game of soccer. But even in these instances, the quality of the meniscus is still poor, and they are usually not amenable to repair.

But this discussion is about degenerative meniscus tears, and it applies to most of my readers. These tears are a symptom of the development of arthritis. If you are diagnosed with a meniscus tear, and you’re over forty, then you are likely developing arthritis. It’s complicated, because most patients will say they’ve never had arthritis before, or they’ve never had knee pain before. They don’t understand how they could be developing arthritis. Many associate the onset of their pain with an injury, and in fact may have sustained an injury at work, so it’s hard to understand how that meniscus was already in a damaged or degenerated state. It’s a big dilemma with regard to workers’ compensation, because even though most insurers will accept the tear as a “compensable injury,” they won’t accept the ensuing symptoms of arthritis as part of the injury. It’s complicated.

 

WHAT DO MENISCUS CARTILAGES AND PANTS HAVE IN COMMON?

So if your meniscus is so tough, how did it tear so easily? I like to compare the meniscus to a pair of pants. When you buy a new pair of pants, the only way they tear is to catch them on something and rip them. That’s like the meniscus in a twenty-year-old. A twenty-year-old has to have an injury in order to tear their meniscus. They have to twist it playing soccer, or get hit from the side in a football game. They’re often associated with anterior cruciate ligament tears. But as the pants age, the seams begin wearing out. They get threadbare. Every day, you get in and out of chairs the same way. But one day you stand up from that chair, and the seam tears apart. And you can’t sew that seam back like it was when the pants were brand new because the fabric is all worn out. Sadly, unlike your pants, we can’t just go get a new meniscus.

 

 SO WHAT’S NEXT?

So what can we do with that worn out, torn meniscus? Well first of all, we can live with it. There’s no rule that says if you tear your old, beat up meniscus, you must have an operation on it. That’s right. Most people think that if they have a torn meniscus, it needs a surgery, just like the professional ball players. This is not the case. Sometimes if you can modify some aggravating activities like squatting, lunging, and running, you can get along with that tear. What did we do with degenerative tears before MRI scans and knee arthroscopy? People lived with aching knees and figured out how to modify the way they did things in order to decrease their pain. Of course, we’re much less tolerant of pain now, because we think there’s always a treatment…an operation.

 

NO SURGERY?

But wait. Even before that operation, there are other things to do. Sometimes all it takes is some relief of the inflammation. Remember, arthritis is the combination of the wearing out of cartilage (in the knee that’s the surface cartilage and the meniscus cartilages) and the inflammation it stirs up. A lot of your pain comes from the inflammation and by decreasing it, you just might be able to avoid surgery and get along with your aging knee!

Let me tell you a personal experience. When my mom was 60 years old, she came to see me as a patient! Yes, I made her make an appointment. Based on her symptoms: pain on the inside of her knee and a little swelling, I figured she was developing a little arthritis and maybe she had a degenerative meniscus tear. At the time she was doing a lot of yoga, and her program included a lot of squatting. I guess she didn’t read my Do Not Do Squats! blog! I told her to stop doing the squats. An X-ray was normal, and later an MRI demonstrated a torn meniscus…a degenerative meniscus tear. Because her knee kept swelling despite use of anti-inflammatories like Advil and Aleve, I gave her a cortisone injection. Her pain and swelling completely resolved. She also stopped all squatting exercises. I didn’t see her as a patient (we did see each other for other mother/daughter reasons) again until she was 81! I recently X-rayed her knee again. Her arthritis had advanced a little, and she had a puffy knee. I gave her another cortisone injection and then a Synvisc (hyaluronic acid) injection, and haven’t heard a peep from of her for over a year (other than the usual mother/daughter peeping). She and my dad are walkers, ballroom dancers and they travel all over the world! But they don’t squat because their orthopedic surgeon-daughter says not to!

 

WHAT ABOUT SURGERY?

Suffice it to say to stay out of the operating room unless it’s absolutely necessary. At 60 years of age, had my mom continued to complain of pain, despite conservative treatment, I probably would have recommended a knee arthroscopy in order to remove the offending cartilage. I would have counseled her that the surgery would not “cure” the meniscus. The cartilage would not be repaired, and nothing could be put back in its place. We could only remove part or all of the meniscus, depending on how much of it was torn. We might clean up some of the surface cartilage. Maybe remove loose fragments of cartilage floating around in her knee. But the arthritis could not be cured. It would persist, and over time it would progressively worsen. And someday she might need to have a total knee replacement.

I would have also told her that there were potential risks and complications of that surgery, like blood clots and infections, but that complications were very rare. The main thing I would have told her was that the surgery might not help her at all, and that occasionally people resume having the same pain within a short period of time. But I would have focused on the fact that most people actually do pretty well for quite a while. Knee arthroscopy is just a treatment for degenerative meniscus tears. It’s just one of the things we can do for a patient with a tear if it doesn’t get better with non-operative treatment. And it’s a good option when all else fails.

And so I say “baloney” to the experts who say that the operation “doesn’t work.” They use semantics to try to convince insurance companies not to pay for knee arthroscopy. Many of them are retired orthopedic surgeons, who don’t have a dog in the hunt anymore. Some are academicians, who might not be following these patients for long periods of time. Many of my patients have grown old with me. And some of these surgeons espouse this rhetoric, but in their practice, they continue to scope knees with degenerative meniscus tears! Why? Because it helps with the pain. Of course this surgery doesn’t “work.” That means, it doesn’t “cure” the condition of arthritis. But it helps, just like anti-inflammatories, and cortisone and hyaluronic acid injections help. It helps, just like hot and cold compresses, and knee sleeves and walking aides help. It helps, like rest and avoidance of squats and high impact exercises help. Once you have a degenerative meniscus tear, there is NO cure for what ails you. There is only treatment. And then there is total knee replacement.

It is incumbent upon your orthopedic surgeon to inform you of the difference between your degenerative meniscus tear and a college quarterback’s meniscus tear, so that you’re not disappointed when after the surgery, you aren’t exactly like you were the day before the onset of your pain. Your expectations have to be different. I often see patients for a second opinion, after they failed to achieve their expected goals following a meniscectomy for a degenerative meniscus tear. Their expectation was that the surgery would “cure” their condition…the condition of a degenerative meniscus tear, perhaps in the same way a meniscectomy would cure a 20-year-old football player, allowing him to return to the game in a few months or by the next season.

Of course, anyone who follows football or basketball knows that surgery after a torn meniscus doesn’t always cure those athletes either. You only hear about the ones who come back, but you never hear about the ones who don’t. Let’s face it. Your meniscus is a very important structure, and the loss of it is devastating no matter when a tear occurs.

 

MORE UNDERSTANDING

Let’s mention that football player briefly, if not to demonstrate how your meniscus tear is different from his, but to clarify some long term similarities as well. In a 20-year-old, you are dealing with a fresh and youthful knee. Other than the strain of the injury on muscles, tendons, cartilage and bone, that knee is otherwise normal. Once those supportive structures heal, even though the meniscus is torn, removed or repaired, the knee is kind of back to normal. The player returns to sport whenever his knee feels good or his orthopedic surgeon releases him to play.

The knee of a 50-year-old with a degenerative meniscus tear is not that otherwise normal knee. It is a knee which has been damaged repetitively by over forty-plus years of high impact exercise, squats, standing, taking stairs and gravity and weight and living, not to mention a gene pool of who-knows-what in terms of predisposition to arthritis, deformity, gait abnormality and inflammation! Your expectation for returning to what was hurting you when you started having knee pain should be different now.

Frankly, the twenty-year-old football player’s expectation should be changed as well. Once having torn that meniscus, he will likely develop arthritis within a ten-year period of time. I wish they would stop playing sports, doing squats and participating in high impact exercises immediately. We should be giving our athletes that information and asking them to consider that option. I do! And every once in a while, they listen. They get it. But that’s usually in athletes who are done with participation in interscholastic and collegiate level sports. Most sports medicine docs don’t even try to dissuade young athletes from returning to sports, because it falls on deaf ears. It often falls on the deaf ears of forty-year-old weekend warriors too!

But sadly, a large number of high-level athletes find it impossible to ever return to sports, either because the knee cannot sustain the beating, once it recovers from the injury and surgery, or because something is missing upstairs. They lack the pain tolerance or the will to persevere. And it’s not because they’re wimps. It’s because in many there is a natural protective intuition. “This is not good for me! Stop!”

But more often than not, they don’t stop. You see them out there.  The J.J. Watts of the world. There is some element of pain tolerance, work ethic, adrenaline, hardheadedness and love of the game that keeps them coming back. There’s the money and the glory too, but that’s not all of it because I see weekend softball players like this. And there’s no money in that. Just a little glory and camaraderie. So we make our choices, and we will suffer. Because there is no question about this. You will eventually suffer if you have a meniscus tear.

 

TREATMENT OF DEGENERATIVE MENISCUS TEARS

Other than the patient who is a candidate for arthroscopy and meniscectomy, the treatment for degenerative meniscus tears is the same as the treatment of arthritis. Because that’s what degenerative meniscus tears are: a sign…a symptom…a part of having arthritis. And when you understand this, you can begin to understand what you and I need to do!

So who’s a candidate for knee arthroscopy, remembering that this is only a treatment and not a cure for the degenerative meniscus tear and some early degrees of arthritis? The people who are candidates for arthroscopic meniscectomies include:

Relatively young patients. And I say “relative” because there are forty-year-olds and there are forty-year-olds, and so on and so forth. Occasionally a seventy-year-old shows up with a degenerative meniscus tear which he sustained while exercising and it has locked up his knee! But truthfully, age is a factor. Allow your doctor to tell you that, even though you don’t want to hear it.

-Patients with fairly normal looking X-rays. There are early X-ray signs of arthritis, like little spurs on the edges of the bone or narrowing of the space between the femur and the tibia. As those X-ray findings become more apparent (large spurs which appear to flatten and spread the bone, or bone-on-bone arthritis) the likelihood that you will benefit from surgery lessens because these are just signs that the arthritis is advanced and the meniscus tear is not your only painful problem.

-Patients who have a fairly normal MRI. The MRI is a much more sensitive test and will show not only meniscus tears but also damage to the articular cartilage. Often a patient with a relatively normal looking knee on an X-ray will have MRI evidence of advanced arthritic changes.

-Patients who are active in their leisure time as well as in the workplace, and for whatever reason, cannot modify their activities. This can be particularly difficult for folks in their fifties and sixties, who are manual laborers or stand all day at their job. This is not a time when they can easily modify their job description, and it’s too early to retire.

Patients who have failed a course of conservative treatment, and rest, anti-inflammatories, physical therapy, cortisone or hyaluronic acid injections have failed to result in improvement.

The very elderly, those with advanced arthritic changes on X-ray or MRI, those who can modify their activities to the point where the knee no longer hurts, or those who have not yet undergone a course of conservative treatment should consider alternatives to knee arthroscopy. It’s rare for me to scope the knee of a 70-year-old or someone with advanced arthritis. I wouldn’t scope the knee of someone who was no longer complaining of pain after they stopped doing squats or had improvement in their pain after a course of P.T., taking some Aleve or having a cortisone injection. And frankly, this is a large percentage of the folks who come to see me with MRIs demonstrating a degenerative meniscus tear!

 

INSTEAD OF SURGERY

The first line of treatment for degenerative meniscus tears is to try to stop doing the activity or activities which may have caused or exacerbated the pain. Stop running. Stop squatting. Stop playing ball. See if you can have a light duty job modification temporarily or even permanently. Remember, meniscus tears don’t heal, and the most we can do for them surgically is to remove them. You will still have the arthritis.

Meniscus tears cause inflammation or swelling in the knee. So the next line of treatment is to try to decrease inflammation. If there are no contraindications to non-steroidal anti-inflammatories (NSAIDs), then you can try a prescription level NSAID (like meloxicam or Celebrex), or an over-the-counter NSAID (Advil, Aleve). These medications have the potential for side effects, so we don’t want to keep you on them indefinitely, but it’s certainly worth a try for a month or so. If you have liver or kidney disease, stomach ulcers or you’re taking a blood thinner, you should not take prescription or over-the-counter NSAIDs.

Cortisone injections are also an option. There are very few side effects of cortisone injections. Nevertheless, it’s a shot, and many patients don’t like the sharp, pointy object. But if your doctor uses a local anesthetic, and does the injection in a gentle, caring way, it shouldn’t be too terribly painful. Often they result in tremendous pain relief, and can be a part of the long-term treatment for arthritic knees. But for the person suffering from a degenerative meniscus tear, they can also provide temporary relief of pain in addition to giving the doctor an idea as to whether or not your pain is coming from the inside of your knee. There is always bad press out there about cortisone. It can cause significant side effects in people who take them for a long time. There are studies showing that they can be associated with damage to articular cartilage. This has yet to demonstrate clinical significance, and anecdotally, we can all tell you that cortisone helps, and clinically doesn’t seem to cause rapid deterioration of the already deteriorated knee! There are many choices for those of us who are too young or too overweight to have total knee replacements!

Physical therapy can be beneficial. As we age our muscles atrophy and weaken, and our balance deteriorates. These factors can affect your ability to recover from a degenerative meniscus tear. But it’s not a cure, and in some cases, patients have increased pain after PT!

Arthritic knees can also benefit from injections of hyaluronic acid (HA). Synvisc, Euflexxa, and Orthovisc are a few brand names. The reasons why these injections benefit arthritic knees are complex, and there are many theories regarding this issue. But suffice it to say, there are many patients (including some of my own family members) who are benefiting from these injections, which can be given every six months. Most skilled orthopedic surgeons can give these injections in their office, and without the use of ultrasound guidance, which can add to the cost.

There is a lot of controversy regarding cortisone and hyaluronic acid injections. They are not cheap, and insurers (including Medicare) are becoming more and more reluctant to authorize their use. But in some areas where insurers opted not to pay for HA injections, the number of total joint replacements went up an amazing 500%! Given no other options, patients in pain had to turn to joint replacement earlier than they might ordinarily have done when the injections were an option. Suffice it to say that in the hands of thousands of orthopedic surgeons around the country…and frankly, the world…cortisone and hyaluronic acid injections remain an extremely viable option for those suffering from arthritis.

But for the average patient suffering from a simple degenerative meniscus tear, with little arthritic changes on X-ray or MRI, hyaluronic acid injections might not be the mainstay of treatment. They would be indicated for those with more advanced arthritic changes in addition to the tear.

 

KNEE ARTHROSCOPY

And when all else fails, and you continue to experience pain, swelling or locking…there is the knee arthroscopy. It should probably not be the first thing considered when that MRI demonstrates a degenerative tear. The conservative treatment protocol discussed above should at least be offered and discussed as an option. You are not the same as that 20-year-old football player. Knee arthroscopy is the first option for him! He will fail to improve with anti-inflammatories. He will not get better with P.T. and an injection will be ineffective. We will scope his knee and repair or remove the torn cartilage. He’ll get arthritis in that knee eventually, but he does not have it at the time of his injury.

Knee arthroscopy can be very effective for some patients who fail to improve with a conservative course of treatment. It’s not a complicated operation, and you’re not likely to experience a complication. Sure, you’ll have a grand list of potential complications, which can seem daunting when you read it. You could even die from an infection or a blood clot. Blood clots do occasionally occur following knee arthroscopy, but they’re rare, and if caught early, can be treated with blood thinners, to avoid a potentially deadly pulmonary embolism. Infections almost never occur. Persistent swelling and stiffness can result, more from the condition itself than from the surgery. And last but not least…persistent pain! Occasionally, a patient gets NO relief from the surgery at all. This is extremely rare, and not likely if we select the right patients for surgery. If a patient has advanced arthritis, they are unlikely to get long term benefit from the operation, and six months later, might find that their knee is hurting just as much as ever.

Bottom line. It’s an operation. You have to undergo anesthesia. There are potential complications and if you’re the one who has them, you won’t be happy. Which is why, when you decide to sign up for that operation…and frankly, any elective operation…you should make sure you’ve done everything you and your doctor decided on to avoid that operation. Then you can go into that operation knowing that the operation was the best alternative for you at that time.

The good news! If you’re the right patient for a knee arthroscopy, you will get some pain relief and have a good result, with little potential for complications!

Remember, NSAIDs, P.T., injections and arthroscopy are not a “cure” for the arthritis or the meniscus tear. They’re a treatment. We can’t give you back your twenty-year-old knee, and eventually that arthritis is going to catch up with you no matter what. But hopefully with these treatment options, we at least hold off on total knee replacement until you get a little older.

 

TOTAL KNEE REPLACEMENT

When all else fails, and you have advanced arthritis in your knee, which has failed to improve with use of medications, injections, activity modifications and yes, even knee arthroscopy, then you might be a candidate for total knee replacement.

And just for the record…why is it important to hold off on that total knee replacement? People ask me this all the time, because they see more and more neighbors, friends and family members having successful knee replacements at younger and younger ages. Knee replacements are the “cure” for knee arthritis. The problem is that knee replacements don’t last forever. And once they loosen or wear out, they have to be revised. Revision surgery is more complicated, and more likely to result in complications like infection, or fracture, pain and stiffness.  Frankly, the objective is for the original knee replacement to outlive you. Sorry to say it in that course way, but that’s the idea. You don’t want to have to have a revision. So if an average knee replacement lasts around 20 years, you don’t want to be thinking about revision when you’re 90. Or even 80. So it’s ideal to wait to get your knee replaced until your well into your sixties.

Many of you and your docs will say, “Why wait until my quality of life is so poor that I’m miserable?” Because you don’t want a revision.

Additionally, young patients simply aren’t as satisfied with their total knee replacements as older patients. The reasons for that are complex, but take my word for it. If you have a replacement when you’re 50, you just won’t be as happy with it as when you’re 65.

And here’s one more thing. Many of you think that when you have your knee replaced you can just go out and play ball, ski, run, squat and do anything you were doing before the knee went bad. And some of your surgeons will tell you that’s fine. Since I don’t do total joints, it’s easy for me to tell you that you shouldn’t do those things. Knee replacement is a pain relieving operation. It’s not a basketball-enabling operation. It’s not a mogul-skiing-enabling operation. And the more stuff you do to tear it up, the faster it will wear out and get you to…a revision…which we don’t want. So when you start thinking about a total knee replacement, don’t think of it as something which you need to do early so you can get back to playing sports. Think golf, walking, swimming, cycling…maybe doubles tennis with other old folks.

I think I’ve said just about everything there is to say about degenerative meniscus tear, and if you made it this far…then you know what to do!

MENSICUS TEARS AFTER FORTY…a treatise
MENSICUS TEARS AFTER FORTY…a treatise

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