Meniscus injury

[fixmeplease]

Hello,
I supsect a 30 year old male patient of mine has a minor tear on the medial aspect of the meniscus of his left knee and would like a bit of info regarding possible treatment and outcomes.
He used to be very active in his early 20's doing lots of sports and martial arts and thinks he remembers hurting it, limping for a few days/weeks but then just getting on with things.
About a year ago he use to cycle 3 miles a day to and from work and noticed very minor pain slightly inside the medial aspect of his left knee that he just ignored.
Recently he's beeing doing a lot of cycling to and from work (15km each way) and has noticed the pain. He's carried on with cycling for a few weeks but the pain has gotten worse and he now catches the train. The pain occurs when he's pushing down with the leg when it's bent at 90 degrees. After cycling he'll notice a dull ache. There's no locking. All ligament tests are -ve. Full flexion and extension with no pain, but does feel a small clunk when coming to near full extension in weight bearing. No joint line tenderness when examined. +ve McMurrays. He's also able to happily run on his knee without any pain, it's just the cycling (and any knee flexion activities after cycling).

Should the patient be reffered to have an MRI scan? If this shows a tear then would a surgeon be happy to operate if the patient only struggles with cycling? As it seems to be a chronic injury going back at least a year I don't think conservative treatment will improve him to the level of cycling long distances which he wants to be at. Should the patient be advised to stop all cycling to prevent further damage?
Any advice would be appreciated. Thanks!

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[thomas bibu]

hi pal,

from you post I understand your patient is
* a 30-year-old male patient - young adult
* very active in his early 20's - fairly active
* limping for a few days/weeks - obvious injury
* a year ago noticed very minor pain - long history
* cycling 15 km each way - constant stress/strain
* worse when bent at 90 degrees - symptomatic now
* feel a small clunk extending in weight bearing - supportive signs

should the patient be reffered to have an MRI scan?

well, from my point of view and experience I would definitely state "yes".

the underlying cause should be ascertained and follow up treatment coz the patient is young and should enjoy a good quality of life.

cheers,

thomas

[sanagupta1]

Hi,

did u check his Knee Flexors and extensors strength.
I would definately want to check the strength of lower limb as a whole...Before sending for MRI and Any sort of surgery.

Sana

[Physio Dace]

It doesn't sound like a meniscus tear that would require surgery - if it is the meniscus (you should always be able to find an area of joint line pain though) its probably minor fraying/degen changes that if rested/managed adequately would not need a clean-up. I'd ensure the hams/popliteus, patellofemoral joint and slump/SLR tests were clear before sending for imaging - and would typically trial treatment for 2-3 weeks and if no appreciable change then refer on.

[Hallamshire Physiotherapy]

I agree that is sounds like a meniscal injury, but I would have thought surgery is not necessary. Look very carefully at their cycling position (alter seat hight?) and change the loading to the medial joint especially in the symptomatic position. If they can run without pain the meniscus must fundamentally okay from my experience. I agree with Dace that fully SLR and slump testing is needed and even check the saphenous nerve over as it passes over the medial aspect of the knee. Look at the hip rotation/control especially at ninety degree flexion and change the loading pattern across the knee.

Steve
Hallamshire Physiotherapy

[ginger]

Protective responses at L3 with hypomobility and inflammatory involvement of the nerve root will commonly give rise to medial knee pain. Check L3 with mobs. If irritated , keep mobing unilateraly till improvement is noted ( may take ten minutes ) there , then re check for knee pain. Medial knee pain is commonly referred in this way and often mistaken for other "pathology".