Meniscal Tears And ‘Mechanical Symptoms’ – An Unsolved Puzzle
Mechanical symptoms in combination with a meniscal tear on MRI is currently a strong indication for arthroscopic meniscal surgery. We recently conducted several studies that challenge our current understanding of what may cause mechanical knee symptoms. We also explored if patients with mechanical knee symptoms have a particular favorable outcome after meniscal surgery.
The use of arthroscopic surgery to treat degenerative meniscal tears, a very common surgical procedure, has been much debated during the last decade. Despite a series of randomized trials showing no better effect of arthroscopic partial meniscectomy (APM) compared with placebo surgery or exercise therapy to treat patient-reported pain and function,1,2 there is a strong belief among clinicians that subgroups of patients exist that have a particular favorable effect of surgery.3,4 One such subgroup is patients with meniscal tears and mechanical symptoms.
Definition of ‘mechanical symptoms’
Symptoms of ‘catching’ and/or ‘locking’ of the knee are typically considered to be of mechanical origin, caused by something being trapped or stuck inside the knee that can be removed with surgery. If mechanical symptoms are present in combination with a meniscal tear confirmed on MRI the symptoms are generally considered to originate from the tear, providing a strong rationale for meniscal surgery.
Similar to other types of symptoms, mechanical symptoms are often fluctuating, and a chronically locked knee is a rare finding. In the clinic the presence/absence of such symptoms are typically determined from the patients’ medical history supplemented with objective tests. The definition and understanding of symptoms of ‘catching’ and ‘locking’ are associated with variation both among patients and clinicians. In the research literature mechanical symptoms are typically patient-reported and determined by asking patients about presence and/or frequency of ‘catching’ and/or ‘locking’ in their symptomatic knee.
Symptoms and outcome after meniscal surgery
Surgery is considered to be particularly beneficial for relieving mechanical knee symptoms.4 However, a secondary analysis of the FIDELITY trial comparing APM with placebo surgery in the subgroup of patients with preoperative mechanical symptoms reported no better effect of APM compared with placebo surgery in relieving mechanical symptoms in patients with degenerative meniscal tear.5
In addition, observational data from a large Finnish cohort reported no difference after APM in improvement in patient-reported pain and function between patients with degenerative meniscal tears, with and without preoperative mechanical symptoms.6 A finding we have recently confirmed.7 However, it appears that younger patients (under 40 years of age) with mechanical symptoms improve more in patient-reported pain and function than patients without these symptoms after meniscal surgery.7 The reason for this is unclear. It may speculate that this is caused by a larger proportion of patients in the younger population having tear types such as longitudinal-vertical (i.e., bucket-handle) tears that theoretically are more likely to cause mechanical symptoms.8
Relationship between ‘mechanical symptoms’ and meniscal tears
We recently conducted a study to investigate if certain meniscal tear types such as ‘unstable’ tears (i.e. vertical or longitudinal-vertical tears)8 are more likely to cause ‘mechanical symptoms’ or if other concurrent knee pathologies could explain these symptoms. In the study we included a wide range of meniscal tear characteristics (i.e. tear pattern, location of tear, size of tear, etc.) but also other knee pathologies (i.e. cartilage damage, ACL status, etc.) identified at arthroscopy, that could potentially cause mechanical symptoms. We found no important relationship between any of the included factors and patient-reported ‘catching and/or locking’ of the knee or ‘inability to straighten knee’ (i.e. extension deficit).9 These results question the intuitive logic that mechanical symptoms are caused by specific joint pathologies. To further elucidate if mechanical symptoms indeed are a specific symptom of meniscal tears we conducted a second study, comparing the frequency of mechanical symptoms between patients with and without a meniscal tear at knee arthroscopy. We found that about half of all patients reported catching and/or locking and inability to straighten their knee fully. Surprisingly, these mechanical symptoms were equally common among patients with and without a meniscal tear.10
What does all this mean?
Taken together, these findings suggest that patient-reported mechanical symptoms are not a specific symptom of meniscal tears, but common in patients with knee problems in general. Furthermore, the results do not support a simple cause—effect link between structural knee joint pathologies, including meniscal tears, and patient-reported mechanical symptoms, often suggested to exist. Thus, when encountering a patient reporting mechanical symptoms in the clinic in combination with a confirmed meniscal tear on MRI, one should be very cautious to consider these symptoms to be attributable to the meniscal tear.
The absent relationship between meniscal tears and mechanical symptoms may explain why surgery does not relieve these symptoms better than placebo surgery or result in larger improvements in pain and function compared to patients without mechanical symptoms and degenerative meniscal tears. Importantly, data from two recent randomized trials on patients with degenerative meniscal tears highlight that the subgroup of patients with preoperative mechanical symptoms have the same benefit from exercise therapy as APM. One study found that mechanical symptoms were relieved to the same extent in the exercise as in the APM group.11 In the other study, no differences in pain were observed at 3 years follow-up time between the exercise group and the surgery group.12
Arguably patients with meniscal tears exist that present in the clinic with a chronically locked knee or a knee that will catch or lock during objective testing, where surgery may be indicated to relieve these symptoms. These patients likely represent the subgroup for which meniscal surgery were intended in the first place, but may now represent a minority due to subsequent ‘indication drift’? For younger patients (i.e. 40 years or younger) with meniscal tears evidence from randomized trials on best treatment is still lacking. Despite the absence of relationship between mechanical symptoms and meniscal tears our observational data indicate that younger patients with mechanical symptoms experience greater improvements after surgery than those without these symptoms. Future randomized trials will need to confirm this finding and investigate if exercise therapy can also address mechanical symptoms in the younger population with meniscal tears.
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- Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014;186:1057-64
- Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ2015; 350:h2747.
- Jevsevar DS, Yates AJ, Jr., Sanders JO. Arthroscopic partial meniscectomy for degenerative meniscal tear. N Engl J Med2014; 370:1260.
- Beaufils P, Becker R, Kopf S, Englund M, Verdonk R, Ollivier Met al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc2017; 25:335-46.
- Sihvonen R, Englund M, Turkiewicz A, Jarvinen TL, Finnish Degenerative Meniscal Lesion Study G. Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial. Ann Intern Med2016; 164:449-55.
- Sihvonen R, Englund M, Turkiewicz A, Jarvinen TL. Mechanical Symptoms as an Indication for Knee Arthroscopy in Patients with Degenerative Meniscus Tear: A Prospective Cohort Study. Osteoarthritis Cartilage2016;24:1367-75
- Pihl K, Turkiewicz A, Englund M, Lohmander LS, Jorgensen U, Nissen Net al. Change in patient-reported outcomes in patients with and without mechanical symptoms undergoing arthroscopic meniscal surgery: A prospective cohort study. Osteoarthritis Cartilage2018; 26:1008-16.
- Mordecai SC, Al-Hadithy N, Ware HE, Gupte CM. Treatment of meniscal tears: An evidence based approach. World J Orthop2014; 5:233-41.
- Pihl K, Turkiewicz A, Englund M, Lohmander LS, Jorgensen U, Nissen Net al. Association of specific meniscal pathologies and other structural pathologies with self-reported mechanical symptoms: A cross-sectional study of 566 patients undergoing meniscal surgery. J Sci Med Sport2018 [Epub ahead of print]
- Thorlund JB, Pihl K, Nissen N, Jorgensen U, Fristed JV, Lohmander LSet al. Conundrum of mechanical knee symptoms: signifying feature of a meniscal tear? Br J Sports Med2018 [Epub ahead of print]
- Kise NJ, Risberg MA, Stensrud S, Engebretsen L, Roos E: Treningsterapi versus artroskopisk meniskreseksjon; Hva skjer med mekaniske symptomer? In: Høstmøte 2016, Norsk Ortopedisk Forening.vol. 2016. Oslo: Norsk Ortopedisk Forening; 2016:203
- Gauffin H, Sonesson S, Meunier A, Magnusson H, Kvist J. Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 3-Year Follow-up of a Prospective, Randomized Study. Am J Sports Med2017;45:2077-84
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I see people after arthroscopic surgery with no improvement or worsening of the symptoms. When I examine them I am confident their symptoms are driven by the patella femoral joint. I do not have a lot of success with making these people happy. They have had surgery and still have a grumbling knee. Being promised that the surgery will fix their pain, and it doesn’t, is not good for the CNS.
Your conclusions are confirmed with my work in biomechanics and human movement.
Weak and Collapsed feet, mainly in the forefoot, that have primary knee pains and complaints respond well to corrective foot pads, kinesiology taping of the feet and knees and dynamic foot braces as both primary and concomitant care
Dr Shav – The Biomechanical Watchdog
the mechanical symptoms are genuine, but they are happening at the patellofemoral joint & thus transient. whenever the quadriceps gets fatigued or feels overworked, it can momentarily lose control on the patella, which gives the feeling of “giving way” that recovers spontaneously. the locked knee is also because the patella is malaligned & tilted laterally secondary to Q stiffness. A period of rest (underloading) & some knee extension relieves those symptoms, but pain will persist. the problem is extra-articular (as there is no synovial effusion or haemarthrosis) and we are treating intra-articular pathology which is in effect reflection of the loading that is influenced by hip muscl strength.