Historically misunderstood even by sports medicine specialists, meniscus tears are a range of conditions best managed by considering specifics of both the injury and the patient, explains orthopedic surgeon Nicholas Colyvas, MD. He describes his initial evaluation process, notes key elements of conservative treatment (usually the best option) and reveals which tears may require timely surgery. Bonus: how PRP injections can actually help and how to keep patients’ expectations of biologics in line with reality.
Well, good afternoon everybody. And um I wanna thank you all for uh for um inviting me to talk today about one of my favorite subjects, which is Meniscuses Meni. I'm not sure how you say it yet. Uh But um I think this is something uh you will probably see at some point in time and I think there's a, a fair amount of confusion around it and maybe I'll find help you find a path um to um uh sort of clear a uh uh clear the thoughts a little bit at least. Um So I'm an orthopedic surgeon. I grew up in Zimbabwe, we went to medical school in South Africa and then did my training at U CS F. Um they went into private practice for many years and then actually rejoined U CS F uh as faculty in 2019. And I, I practice out of the uh Mission Bay office, uh 1500 Owens. And so it's sort of the primary location and also see patients at um excuse me at Mount Zion. So that's more convenient for the sort of patients in the north of the city and, and in Marin. Um and in addition to all of the things I like to do with the meniscus and orthopedic surgery, um I'm also uh spending time with my family is really important and I have one bad habits and that's that I like to race cars. So, but meniscus is, is a, is, is a passion of mine and it is even amongst us, uh orthopedic surgeons still a fairly misunderstood entity. Um, and something that I think is um uh continues to shift around in terms of treatment. Uh um choices, um even even the diagnosis of meniscus tears has evolved over the time that I've been in practice. So, um let's see if we can sort some of this out. So I think, you know, from an overall point of view, a take home message uh for, you know, uh today maybe is the majority of meniscus tears. Um I think there's a perception that they need surgery and the reality is it's, it's mostly physical therapy. Most of the meniscus tears we're gonna see are gonna be in older patients, younger patients. It's always or often surgery, but the, the majority of meniscus tears you see are typically gonna be treated conservatively. So that's just the overall theme of today's uh talk. Um Part of the problem with meniscus tears is they come in all sizes and shapes. There's all different types of tears and they occur in different situations and they occur in different patient settings, whether it's age, whether it's weight, whether it's the degree of arthritis. And so there are multiple different types of, uh, injuries to the meniscus, um, listed here. But I think for the purposes of simplifying things, the ones that really need surgery, um, and the ones that should be referred urgently are the bucket handle, tears and the root teas and I'll talk a little bit more about these. Um, and I think a flat tear is sort of a relative indication um for a um uh urgent or um uh less than elective surgery. Um Part of the reason that we have worries about the ministers is its blood supply. Um It really only supplies the outer third very well. So that changes how we manage things. So understanding that's important. Um but there's lots of different classification systems because again, nobody has a really good handle on what's the most important. So they're stable versus unstable terror. That's a, that's a uh an important feature. Um acute versus chronic, we treat very differently, degenerative versus traumatic, we treat differently. So you're gonna hear all of these terms applied to meniscus tears and trying to sort through them is uh is sometimes a bit uh a bit of an effort. Um And they don't occur in isolation. It's not just the meniscus that tears us most of the time. There are other issues around age around the gender, um particularly issues around the knee alignment and knee stil knee stability um and then there's the general health issues that will play into um the, the um uh the, the, the sort of diagnosis and treatment for a meniscus tear. So it's a little, it's a little bit more complicated than you just got a meniscus tear and this is how we treat it. So I'm gonna go through with some case uh examples just to sort of highlight what I'm talking about. First one is, this is a player. This is a patient of mine. He's, he was the star football player uh for his high school. Um and he twisted his injury when he was tackling in football, he had a woollen knee and difficulty putting it down his knee down. But when you examine him, he has a stable knee, his, his ac L seems to be intact, but he's very tender in the lateral joint line. Um and he has a positive mcmurray sign all suggesting a meniscus tear. We get x-rays and they're negative. But when we get this MRI, there's a tear in the lateral meniscus with a fragment that's actually flipped underneath. So what we're looking now at is an unstable flap type tear. Um And we have to take into consideration this is a young patient highly active, wants to get back to all these sports and it's the type of tear that we're looking at that is unstable because there's a flap that's broken off and is sitting um underneath the meniscus the underlying condition of the knee is excellent. He's 17 years old, he's got pristine cartilage. So, you know, we're not worried about this being an older arthritic knee, that's probably gonna need a knee replacement anyway. And we always worry about the associated injuries because many meniscus injuries occur with AC L injuries or with other types of injuries in the knee, in this case. Not so. And so when we look at a treatment plan here, we can consider all of these physical therapy, um injections, ice antiinflammatories, but realistically in a, in a, in a patient like this surgery is probably gonna be where we go. So this is a sort of uh textbook meniscus tear needs surgery. Fix. That patient does very well is return to all of his sports. But that's the young patient. What about the 46 year old? Now, this patient's got a history with his knees already had uh AC L reconstruction. He doesn't have a traumatic injury. He's got this sort of mostly progressive medial pain. Um and he doesn't have any instability. His AC L was done really well and this is a lot of what you're gonna see. The 40 50 60 year old patients with slow progressive medial pain, sometimes lateral pain. Their exam is kind of straightforward. Um They might have an effusion or not, the knee is typically stable. They have tenderness in the joint lines and their meniscus signs are probably positive. Um And you get an x-ray and there's degenerative changes here. You know, you've got thinning of the, of the medial joint line. There's osteophytes, there's even calcification within the joint space there suggesting that, that meniscus has some degenerative changes. Um And what are you gonna do? Are you gonna get an MRI here? I'll tell you lots of patients end up getting MRI S, lots of patients demand MRI S. Um And this patient got an MRI, but I'm not sure that it changes your management here. The MRI S sure enough show medial and narrow meniscus tears, but these are really degenerative tears, they're not acute traumatic tears. And so we're faced with the same considerations. This is a different type of patient, older patient, their type of tear really is more degenerative than an acute type of tear. And you know, the underlying condition of the knees, this is an arthritic joint. This patient is ultimately gonna get a knee replacement. Um you know, in five years, 10 years, somewhere in that zone. Um And, and so this, we, we treat these differently and this is probably the majority of what we see the degenerative meniscus tear in the middle aged or older patient. So when we look at the treatment plan, physical therapy and load of brace injections um and surgery instead of surgery being the first. And, and I will say that in the past, I think that that has been um oftentimes the first line of treatment for these. Um, today, I think that we really are pushing this far more into the conservative management realm with physical therapy first and maybe a brace and then cortisone injections if those don't work and then maybe surgery for those that, that, um, that fail conservative management. And all of this goes back to, um, this, uh, this series of papers that, uh, came out in the, in Jama and the New England Journal of Medicine that, you know, looked at what we were doing a lot of, I mean, we're talking about hundreds of thousands of surgeries a year, um for cleaning out of joints and that included cleaning out meniscuses, um, and doing, you know, partial mest and all of this, um, you know, you know, was, was looked at and these studies started coming out showing that there's really no difference for surgery with the, with the mastectomy. Um, if you do physical therapy or if you do surgery for patients with arthritis and, you know, the, the we know that taking out that meniscus, there's lots of studies that show that, that accelerates the arthritis. Um And often most of these studies in 2002, multiple, in 2002, multiple studies started coming out showing that there's really no benefit from doing a partial menotomy, an arthroscopy and partial menotomy on these knees that have degenerative change. So, man, so surgery is not the first line of treatment. Um and the, you know, the data still keeps coming out. This is, um, you know, this is from 2016. Um There's, there's no, um uh you know, there's, there's no reason to go straight to surgery. Definitely consider physical therapy as the first treatment option. Um Big studies now starting to show, you know, meta analysis starting to show the same thing, um, lack of level and e e evidence to guide the management surgical management of meniscus tears in these degenerative knees. Um And so, you know, starting from about 2012, we're starting to see this sort of pushback on doing surgery for knees and all of these other other companies now really sort of heavily marketing the regenerative medicine uh angle for this where, um you know, they're, they're saying actually, not only is it not doing it not helping, but it's doing harm. And I think, you know, that is not entirely a fair accusation. Um and this just cannot lump all of these together, but, you know, the writing is on the wall here. They, the, the surgery for these degenerative tears is not the ideal situation. And, you know, there are just multiple um inputs now from all over the place this is from, uh this is from yesterday. Actually, something I saw talking about knee arthroscopy is no better than sham or placebo surgery, stop the harm. You know, all of these, these messaging this messaging that sort of is very anti arthroscopy, um, for these meniscus tears. And again, I think that this has a basis in truth, but it's probably pushing the envelope a little bit too far. So, you know, we're talking about, uh AAA procedure that's done a lot. This is 750,000 year. That's a lot of procedures. And the reality is that not all of them are not, are either, you know, not all of them are, are not doing any good and certainly not, all of them are harming people. Uh And there is a, a place, a limited place for doing a, a mastectomy in these cases. And there are some papers that identify that the bottom line is if you have that patient that comes in with progressive knee pain, they're, they're older, they have some degenerative change on the x-rays. You do end up getting an MRI and it shows a meniscus tear. Um It's not, it's something that we would, um, we would determine on a case by case basis if they needed surgery. Most of those, it's very safe. It's very reasonable to send that patient to physical therapy. Maybe use an unloaded brace, consider doing some injections before considering surgery. So here's an example, 61 year old, um, no prior knee problems, he stepped off the ladder, he twisted his knee, he had some medial pain, mild swelling and some meniscus signs and you get an x-ray and he's got a little medial joint line narrowing, you know, he's got the earliest signs of degenerate change in his knee. Um And his meniscus on MRI shows a tear. Um and this kind of tear looks to be, you know, possibly acute, possibly chronic or possibly more likely acute or chronic. And again, you go through these considerations, this is an older patient, he's had an acute injury, but it's in a more of a degenerative knee and go ahead and go through your determination list here. And this patient for me, starts with physical therapy. I think that you might find other or orthopedic surgeons would consider surgery for this patient. But this is again, start with physical therapy and eventually, if they don't improve like this patient, ultimately, after I think it was three or six months of conservative management, then you can go to surgery and they go on to do well. And that is, um, uh, you know, that, that patient that crosses over, in other words, you've tried the Conservative management and, and, and they, they fail and they end up getting the surgery. So how many patients is that? Well, I think that if you look at the, the literature, it's about somewhere around 25% of patients will, will, um, sp conservative management. We're talking again about these degenerative tear tears in older patients, conservative management and end up getting surgery. But that means about 75% of patients do not get surgery So that's a, you know, that's a significant number. And what you see is this um area right here where there's a break at the root of the meniscus. And when you look at it on the Sagittal, there's a, there's a gap there and there's a gap on the axial and this is sort of a classic root tea. Um And, you know, they really do happen in somewhat overweight a little bit older patients. And um they usually have some degenerative changes. But it's very clear that these actually the answer for this question is not physical therapy, not partial mastectomy, but meniscus repair, trying to repair that meniscus. Um And that surgery is something that I think we've only recognized more recently. I started than doing them in like 2012. Before that, we didn't recognize root teas and they're almost like a separate entity that we feel urgently need surgery. Um Because the, this is what they look like. This is the, this is the meniscus over here and there's a gap where it's supposed to attach, it's essentially a detachment of the meniscus. And when that happens, you lose all of the function of the meniscus. It's almost like taking the meniscus out. Um And that really is um uh a setup for developing early arthritis. So it's a functional total menotomy when you have that there's good data now to support repairing those surgically as soon as possible, the clinical data, this is the early studies. There's now better studies that show that when you do repair these roots, you actually put them back down where they belong. Um Then you essentially are um um returning the normal stresses to that knee and that you are um you're saving this patient. This is an example. The patient has a root tear, they go on to a knee replacement within five years. This is a patient that gets a uh root repair and seven years later still has a very functional, normal looking knee. So root tears, I wouldn't call them an emergency, but I would say that they are the types of tears that we wanna see urgently. Um And the problem is, you know, if you have a patient who comes in to see you and has, is older and has um uh knee pain, you don't know until you get an MRI if that knee pain is coming from a root tea or if it's just a general knee tear. So you have to go by a high clinical suspicion. You have to think does this patient have a history where they had a relatively low energy trauma and took a knee that even may have had some degenerative changes, but wasn't particularly symptomatic and they had an acute significant increase in their pain. Um That's a patient who may have a root tear if it's someone who comes into you and says, hey, for the last six months, I've had this progressive slow increase in pain on my medial side of my knee. That's probably not a root tear in this age group. So I don't get MRI S for everybody. I get MRI S where I have a high clinical suspicion. Um, but my clinical suspicion is heightened in anyone who comes in who's over 50 and who has, you know, some early degenerative changes. And I'm, I'm, I'm getting an MRI and anyone who says that, listen, my knee was fine and then I, you know, I stepped off this curb or something like that and I had this sharp, severe pain and it still hurts on the inside that person. I really have a high suspicion of a root tea. So root teas, I think are newer injuries that we recognize and have uh surgical intervention that can actually save them from arthritis. Um uh or at least delay the process, uh or the onset of arthritis in these patients. So we, we find these really important. Um So, you know, I think in, in your practice, if you see a patient that you know, you have, you have a concern has a meniscus tear, you get an MRI and you get a report back that says they have a bucket handle tear or a root tea or a flap tear, which is really an unstable tear with the minister. This is, is flipped on itself and it's flapped off and it's flipped on itself and causing pain. Those don't get better with surgery. Those are the three types of tears that we would say. Ok, look, we need to get to that earlier. Surgically probably doesn't need to go to P T first. We would, we would wanna, we wanna do surgery because they're almost certainly gonna end up with surgery. Even if they get the P T. This is again for the older patient for younger patients. Um, we're, we're more aggressive about getting the P T and we're more aggressive about doing uh, surgery. The other question that I get a lot, um, on a, about all of these, um, um, uh, meniscus tears is really all about biologics. Ok. And everyone sort of has a, an opinion about whether or not Pr P is gonna help, whether or not stem cells are gonna help. Um, and what we can do specifically for meniscus tears, I think is evolving and I think that it's going to change more and more over time. Um, and I'll, I'll, I'll say that I think that a lot of what the way we treat meniscus tears now in, in knees, particularly, again, degenerative knees, um, is really going to evolve over time, uh, from non-surgical to, from surgical to more non-surgical including, um, injections of biologics. But I'm sure you all know that Pr P is the Miracle Wonder drug for absolutely everything. Um, it, you know, it is heavily marketed heavily, um, uh, uh, heavily pushed by, by just about everybody. Um, and if you, if you, um, you know, sort of dig into it deeper, I mean, you know, it's literally used for everything. Um, if you dig it in, dig into a little bit deeper, uh, I think there are valuable and, um, valid places for which it can be used. I think in orthopedics, this is something that we are steadily developing. Um, we're, you know, we're developing indications we're developing uh results uh from studies, I think that, um, the, the reality is we're gonna see more and more of this. It can't be ignored, I think 10 years ago, 15 years ago, it was considered experimental. But now we're seeing that there's really uh AAA significant increase in the use of PR P. We'll, we'll start with that. Um, and it is in older age groups because of course, of the case, uh uh cases. And it's interesting to see here that it's being used in tendons, um, cartilage, meniscus ligament labor, uh in a lot of musculoskeletal uh places. And I think that 25% of meniscus tear, that's, that's a really high number for, for what we know in terms of its value, um in terms of its value and in terms of studies that have been done to show that it actually helps for meniscus nonetheless, that's sort of where it is. And when we look at the cost, of course, that's the, that's the other side of this that um I don't know what one medical charges we charge at U CS F around 1000 or I think it's gone up to 11 100 per injection at this stage. Um And then the majority of them are not covered by the, the vast majority are not covered by insurance. Um I have had some workers comp insurance, approve it sometimes but um I think that, um you know, the cost has to be weighed against the value of the uh of the injection. Um What evidence we have I think is that for early arthritis, so not late stage arthritis, but early arthritis in the knee. Uh There is some evidence to show that PR P can help. And the reason I bring this up in terms of meniscus is that any degenerative knee with early o A probably has some degeneration of the meniscus. So indirectly, you're treating both the cartilage problem and the meniscus problem. Um And so I, I think that there is a place for these degenerative knees to consider PR P. And certainly that's part of the long discussion that I have with these patients is, you know, what other than physical therapy and unloaded braces can we use uh to help reduce the pain, change the homeostasis of the knee so that the knee tolerates that meniscus tear or that cartage to um change any uh somewhat differently. Um And I think there is some evidence for Pr P. So we use this uh I would say a fair amount for these um degenerative meniscus tears. Um And there is differences in the types of PR P you use. Um I think Drew Lansdowne from our department and uh Bill Berrigan, we have excellent talks on, on all the details on how to do these. Needless to say. I think we do use PR P um for uh for these patients and it seems like the, the um improvement is uh relatively um relatively good and lasts for a reasonable amount of time longer than a cortisone injection does, which is of course, maybe the older treatment that we would use in this type of situation. Um So I think there is a valuable, valuable enough place for PR P that it should be included in the discussion. Um but there is no evidence to support the fact that it might regrow the meniscus or regrow your cartilage. And we don't know what happens in the long term with these. Um There is data. Now again, if we're sticking mostly to the meniscus, there is some data to show that um when, when we're talking about these PR P injections um that had all of the data that's been done has been on intraarticular injections. Uh what's being done now for the last few years. Um Mostly on a sort of trial basis at this point is actually under ultrasound viewing that meniscus and trying to trephinating and inject, uh PR P actually directly into the degenerative meniscus with the hope that that will somehow change whatever healing cascade. Um, is there, um, uh, in the, in the knee and, um, or in the meniscus itself, it's hard for me to imagine that we're actually healing a degenerative meniscus. What we see even in those patients who have degenerative meniscus and don't get surgery over time, is that the, if we get a follow up, MRI the meniscus looks more or less the same, but the knee is more or less accommodated to what that uh what that knee, what that meniscus is providing in terms, in terms of structural support. So, you know, if you fly on any plane and get the air, the aircraft magazine, you'll see all of these um advertisements about injecting uh uh stem cells. Uh But the reality is that it's not gonna reach, we have nothing that we know of today that regenerates your meniscus or your cartilage and none of this seems to stop people in the long run getting arthritis bad enough that they're gonna need a, a knee replacement. Um So it's, it's, it's still an evolving field. How does it work when we discuss this with the patient? Um I think I do not, I do not talk about these uh providing really a um uh a regrowth of their cartilage or healing the meniscus tear. Um More about just that it changes the anti amatory cascade or mediators and it's not gonna change any structure, but that doesn't mean that it doesn't, uh the knee doesn't feel better after a series of treatment with perhaps a combination of the unloaded brace and physical therapy. Probably the physical therapy is the most important of a lot um, costs and then you always have to discuss the costs with the patients. Um, when we're talking about this, I think, um, this is a topic that of course deserves its own conference and, and talk in itself. But um I always think I always thought and I actually um uh send this, I give this link to this uh treatment, this um sorry um article from the New York Times. Um because I think it, it provides a pretty balanced account of what we're looking at. Um And this is now 2019, but even 2023 23 I think we're in a similar place. So, so um just as a summary, I think that we are talking about um a group of diseases, not necessarily just one single uh type of disease. And that really is um uh the, the crux of the problem is you can't just say one minute, this is a meniscus tear. Um And we're gonna fix it this way. AC L tears for the most part are simple and easy. You know, if you have an AC L tear, you treat, you treat them more or less sold the same way. Um But, but meniscus tears, a meniscus tear in a young patient is a completely different entity. And then to, to a meniscus tear in an older patient, there are different types of tears. There are different types of um patients that you find the tears and it's not just about the meniscus, it's the whole knee joint and the whole, the whole body, you know, and the whole of the alignment of the leg and everything all of that goes into, um, into it. Um, as I said, from the beginning, I think that the majority of meniscus tears when you look at them in older patients, they are, you know, almost always gonna be, um, conservatively treated first. They may end up getting surgery later, but conservative treatment is sort of the primary method, uh, to treat these patients. Um I think, you know, highlighting the recognizing root tears, I think in the older patient is important. Um, and something to think about whenever you see these patients. And the other thing is what I found is a lot of times you, you have a patient who you send for physical therapy and sometimes that makes it worse and just doesn't fit the clinical picture. Uh, and in those cases, you, you know, you want to think about maybe either if you haven't got an MRI, get an MRI or referring them out to, to, to us to take a look at because oftentimes there's more going on there than just a meniscus tear.