Knee problems, Meniscal Repair

Questions About Meniscus Injury, Surgery, Rehab

Dr. O'Hea's Comments:

 This is an excellent  response  to a  question about knee injuries; specifically about injury to the cartilage pad on the outer sides of the  knee  called the meniscus.  It explains how you can  recover on your own and on  what you can  expect if your injury is too far gone and you need surgery.

 I'm a big believer in letting these injuries heal on their own whenever possible. You will need some guidance from a chiropractor or therapist to assist in your recovery.   This post is from the blog of  Doug Kelsey PT, a great therapist/author in Austin, Tejas.

Hi Doug,

I recently came across your blog while searching for answers on a ACL and meniscus injury. I’m fairly new to this as my wife recently had an injury in her gym where her left knee popped. After the instructed popped it back in, and couple of x-rays, few weeks of physiotherapy, and an MRI, 6 weeks later the orthopedic surgeon told us that she has a torn ACL and tear of medial cartilage (meniscus). He also mentioned that he couldn’t see any ACL fragments so it could be from an earlier injury which happened 18 years ago and we have no record of it as to what happened other than that left knee has been weak.

I have quite a few questions for which I received different responses from different people so will try to compile them here so that others can benefit too.

1)    I’ve read that meniscus can repair/heal itself. To what extent is this true? It seems like outer shell of meniscus has blood flow so there might be a chance of healing a tear on the outside.

2)    In case of a meniscus tear or a fold-in, does it need to be cut in a curved fashion? And if can heal, then can the cut now heal itself?

3)    I’ve heard that if you don’t cut the meniscus away then it might result in degeneration. What would happen if it just degenerates itself without actually cutting it thru a surgery? How long does a cut meniscus take to degenerate?

4)    The ortho advised that the meniscus surgery needs to happen within 6 weeks of the injury… I haven’t been able to find any such reference although people say sooner the better. What’s sooner here and what if it’s not too soon but still sooner than later?

5)    I’ve also read a lot about the rehabilitation programs and trying those first (even one of your blog entry from 2006) so in what cases this is helpful? Can physiotherapy help with my wife’s case?

6)    The full recovery period after an ACL and meniscus surgery has been told to be 3 months to 6 months? Can one fully recover to 100% in six months (playing soccer, doing gym etc).. assuming they are within 80-90% of the cases who recover fully. Even though they recover, I’d assume that they have more chances of subsequent injury as compared to a other people. Right?

7)     How long to absorbable bioscrews take to dissolve? There are people with partially dissolved screws after 2 years.

I really appreciate your knowledge and time to respond to this and I’d be willing to add more information to the blog so others might find it informative and useful.

Best Regards,

-H

****

Thanks for reading and for the questions. I'll do my best.

Ok, first off H, the best answers come following an interview and exam. Everything else is guesswork really. There's just no substitute for the process. The internet is the great democratizer of information. What it lacks however is judgment; wisdom. We all have the same bones, muscles, cartilage, etc. yet we're different people with different needs. Clinicians use the data from the history and exam and run that through an "experience filter" to arrive at an answer for you (or your wife). So, my advice is meet with several clinicians and ask the same questions you listed above.

Meniscus tears that are in the more vascular part of the tissue, generally the outer 1/3, have a better chance for healing. If a surgeon can repair the tissue, he or she will usually try. Whenever you remove part or certainly all of the meniscus, you increase the chance for early onset of osteoarthritis due to a change in contact pressures in the knee. The meniscus gets some of its nutrients via the synovial fluid and responds to mechanical pressure in a similar way to articular cartilage so movement and controlled loading usually help.

As far as a surgery time line, I have noticed, and the literature tends to support this, that surgeries go better when the knee is not swollen at the time of surgery. So, if you tear the ACL and your knee swells, which it usually does, most surgeons will wait for the swelling to go down. If you don't, the risk of arthrofibrosis or scarring in the joint, goes up.

We've had clients with partial meniscal tears, some operated on and some not, who have done quite well in rehab as well as folks with meniscal repairs. But, as I mentioned earlier, this is very case dependent. The rehab programs are all custom built based on the person's unique mix of needs, problems, and goals.

Your question about full recovery is a good one and I think what you're asking about is the physical recovery.  But, there's recovery and then there's restoration. The difference is that recovery is a physical process. Tissues heal. Motion returns. Strength increases. But restoration is a mental-emotional-physical process and for some this takes a long time. When you have an injury that sends you to surgery, disrupts your life, perhaps even your livelihood, you have to make some adjustments; accept reality and do things you basically don't want to do. And you usually need a coach or someone to help you through it. Some people are restored to a place of wholeness in months; some years; some I suspect never really make it (for example, their leg is strong but they don't totally trust it).

But, back to your question about physical recovery, the record holder at Sports Center returned to sport level activity in 61 days. But, most people reach athletic capability in 6 to 9 months. However, if you've had articular surface damage, it usually takes longer - 12 to 18 months or more. There are a number of factors that come into play - the type of procedure used, the extent of damage to your knee, how your body responds to surgery or how rapidly you form scar tissue, how adherent you are to post-op instructions (and how thorough the instructions are), your pain tolerance, how your knee responds to load and the type of rehab you go through as well. Tiger Woods was out for 8 months and more than one surgeon believed at the time of surgery that it would take him 24 months to get back into his pre-surgery condition (of course, that's been interrupted due to his personal problems).

And for your last question, bioabsorbable screws are not something we have much to do with but from what I've read, those usually take 18 to 24 months to be absorbed.