On this episode of the #AskMikeReinold show we talk about how we diagnose meniscus and articular cartilage lesions in the knee, and how we would treat them different. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 224: Diagnosing Meniscus Versus Articular Cartilage Lesions in the Knee
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Show Notes
- Meniscus Repair Rehabilitation: Why Are We Still Stuck in the 90’s?
- Clinical Examination for Meniscus
Transcript
Mike Reinold:
Today we have Evan from Philadelphia. He asks, “Hey, Mike, love the show. How do you and your team diagnose meniscus versus articular cartilage lesions in the knee? Based on that, how would your treatment change?”
Mike Reinold:
I thought that was a pretty good question. I got a bunch of thoughts, but who wants to jump in on this? How do you start? Somebody comes in maybe with some knee pain, it sure seems internal. Is that the right word? Deep or something like that, it’s not something you can touch. How do you diagnose between meniscus and articular cartilage lesions? Who wants to start.
Lenny Macrina:
I can give it a shot. To me, it’s getting a good history, obviously, and sometimes the person will tell you what’s going on in their knee if you ask the right questions. They’ll divulge some good information. Now, what that is, I don’t know, you just got to work around their history. But I think location is a good starting point. Meniscus is going to be a little bit more posterior, I think, kind of joint line posterior. I would say cartilage might be, especially if it’s patellofemoral, it’s going to be anterior. But if it’s more condyle, it’s going to be, I’d say, relatively more anterior than the posterior meniscus, which is more commonly torn in most people, is that posterior horn. I think that’s one thing. Definitely swelling. They may have some chronic swelling that might be more articular cartilage, unless they had an acute knee injury, then you start thinking more meniscus, but they could also have an acute cartilage injury, so you got to be careful there.
Mike Reinold:
They could go together.
Lenny Macrina:
And they could go together. Correct. Those are my starting points. What was the mechanism? How’d this come on? What was their onset? Did they have a twisting injury? Did the swelling delay? I think it was hours later or the next day, that’s a good clue for a meniscus, typically. I think having location of symptoms, being able to palpate the symptoms, I think if you can palpate right on the joint line, especially the posterior aspect of the joint line, that’s going to be a good indication that it’s probably a little bit more meniscus, obviously locking, catching, kind of a bucket handle type thing. That’s going to be the obvious thing, too.
Lenny Macrina:
For PT, if you’re not seeing a doctor and they’re not considering surgery, you oftentimes treat in the same way, generally speaking. I think we’ll go a little deeper into that because there are some differences that we would consider, including how you load them and the ranges of motion, how you load them. But obviously MRI is going to be the big answer, is it a lesion of the cartilage or is it a lesion of the meniscus? That’s mine, is location, palpation, and how are their symptoms? When do they get the symptoms? Do they get the symptoms every time they squat at a 50 degree angle, you can judge that? Or is it a little bit more mechanical when they are trying to load the joint? That’s my generalisms without having the person in front of me.
Mike Reinold:
I like that. I like that It makes sense, right? The subjective is going to tell you a lot, like how did this happen and when does it bother you? And that starts telling you, because there’s different structures. Mike, what do you got?
Mike Scaduto:
I was just going to throw out there, I think, at least in my experience, maybe an articular cartilage lesions tends to be more consistent within the range of motion. I think that’s what Lenny was saying, pain in a certain range of motion where that articular lesion is articulating. That’s like going over the pothole. They have a symptom right at that point, and then the range above and below may be asymptomatic, it may not be painful for them. Maybe in a meniscus, that could be a little bit different, even in a bucket handle meniscus tear, maybe the knee locks, but it could be a little more inconsistent as to where that happens. I don’t know. That’d be one of my thoughts.
Mike Reinold:
What about special tests? Are there special tests that differentiate between these two? What do you guys think?
Lenny Macrina:
Yeah, you could do a McMurray’s, you could do joint line palpation, pain and end range, my big three for a meniscus. If they don’t check those boxes and I’m like, “Well, it’s inconsistent. Things aren’t really making sense with your history,” then you start thinking the other stuff. You know what I mean?
Mike Reinold:
Right.
Lenny Macrina:
You got to check the boxes first.
Mike Scaduto:
It would be more ruling out a meniscus tear and then considering an articular cartilage tear.
Lenny Macrina:
That’s going to be the easiest, I think, for us to be able to diagnose without imaging or x-ray or an MRI, especially an MRI, is going to be all right. It’s meniscus until it’s not a meniscus, I guess. You know what I mean? Like we said earlier, it could be both. It oftentimes is both. If you have an injury to the meniscus, especially an acute injury where you have some kind of maybe a compression with a little rotation, not enough to tear the ACL, you oftentimes get some kind of bruising or cartilage injury to the joint and you get meniscus issues. They sometimes go hand in hand, depending on the amount of energy that went into the knee during that acute issue.
Mike Reinold:
Right. Especially if you have a big compressive, like if you have a big valgus stress, maybe to your MCL and your lateral meniscus, lateral [inaudible 00:05:39] back. If you have something that’s a plant pivot twist, that’s less compression, maybe a little bit more meniscus without cartilage, for example, lot’s of different things. Yeah, special test wise, it’s probably more to rule in a meniscus tear than to rule anything out. That’s the weird part. Meniscus tests aren’t perfect. Unless you get a huge meniscus tear, sometimes those tests aren’t completely positive. Again, you’re probably trying to rule in not rule out. I think that’s good. I think we nailed what’s the difference in how we would detect that or something. Now let’s talk about does anything change? I don’t know. What do you guys think? Lisa, concept wise, would you treat somebody different between cartilage and meniscus?
Lisa Russell:
Not entirely, I guess. Just in terms of, I feel like no matter what there painful range is and their painful activities are your guide and then helping them find their way through that and add some strengthening. To me, no, I haven’t treated a ton of articular cartilage injury to have experienced what happens when you work with it.
Mike Reinold:
Usually, when you have somebody with a big articular cartilage defect, it’s usually like a mechanism that occurred. There’s probably other issues going on, too. If it’s degenerative, that’s different than articular cartilage, it’s more OA. What’s that Dan? Did you have something?
Dan Pope:
I guess I had a question for you guys. Again, I don’t have as much experience with articular cartilage problems, but I think, from a PT perspective, we probably have to potentially be careful in terms of when is the right time to refer to a surgeon. If they do have something that needs to be surgically repaired, potentially like a meniscus that could be repaired, I know if we wait longer and longer outcomes are usually a bit worse, so I would agree with Lisa, potentially trying to treat that individual, figuring out things that, obviously doing their evaluation, figuring out what’s wrong and try to address the issues you find, but potentially sending back to a surgeon if things aren’t improving just to make sure that we’re not missing something big or more important.
Mike Reinold:
That makes sense.
Lenny Macrina:
I think we’re in a very fortunate… Our facility is, I think, a little different, though. We get a lot of, especially our state as well, we get a lot of direct access type people. So we get people with an injury and they come right in to see us because they have a history with us, they trust us, and then we can be a referral source for the doc. So I think the general population and the typical way people get into physical therapy with a knee injury is they go through a doctor’s office. And so they go to a doctor, they get an x-ray, and it turns out to be patellofemoral pain syndrome, and then we dive deeper into the injury and the history and we realize that maybe it might be more than that. But they also go to the doc and the doctor notices and can recognize that it’s more of an issue, and then they’ll just get an x-ray. But maybe they can’t get an MRI until insurance sees that they went through a course of physical therapy, so now we need to be able to adjust our plan of care based off of the person’s presentation.
Lenny Macrina:
Like Mike Scaduto said, if they have pain every time they squat to 50 degrees, well, we’re going to stay at 45 degrees. We’re not going to blow through that range of motion where they feel the pain, and hopefully, as we develop, strengthen their leg by loading them from 0 to 45, for example, the quads can take up more of the forces through the knee and maybe we can get through that range of motion so they can squat a little deeper and get a little bit more of a functional squat. Again, we talked about in previous episodes do we need to get that deep squat? Probably not. In people with a range of motion that has specific lesion, you’ve got to try to work them in that pain-free range of motion and then hopefully get carryover that pain goes away and the deeper ranges of motion that they typically have the pain, and we can build that capacity, then score, we avoided hopefully a surgery. But if we can’t, that’s when they fail PT, which is a term that’s all over social media right now, and we have to send them back and now an MRI can happen, and now they go down the rabbit hole of microfracture, osteochondral, autograft, allograft, or meniscus. Now you got this whole world of surgeries that that person has to go through now. It’s a tough outcome for many people.
Mike Reinold:
All right. I’ll wrap it up by just saying, piggybacking off a little bit what Mike and Lisa said, we’re working around it, probably not a ton of differences at the beginning phase of that, but early phase. I think the only thing I would add here is that maybe my return to activity progressions might be a little bit more cautious, a little bit differently if it’s meniscus, maybe I’m a little bit more cautious with agility-based things and change of direction and little sorts of things if it’s an articular cartilage thing. Again, we won’t get into this, but patellofemoral, tibiofemoral, let’s assume it’s tibiofemoral if we’re talking about meniscus, but I would probably be a little bit more gradual with my application of compression. Maybe things like jumping and bounding and even running and sprinting might go a little bit slower with an articular cartilage procedure, while things like agility and change of direction and sheer forces would go slower with a meniscus.
Mike Reinold:
Early on, I think you’re right, we’ll work around it, everything’s pretty similar, it’s an internal derangement of the knee. It is what it is, but as we gradually get them back to activity, maybe we’ll be a touch more progressive with those things depending on the structure.
Mike Reinold:
Awesome. Another great question. Thank you so much, Evan. We appreciate it. Thank you so much for listening and we appreciate it. Please head to iTunes and Spotify and rate and review us. We love to see those comments and we actually learn from them and tweak things with the show, so we appreciate it. The more the better. Keep them coming. We’ll appreciate it, and keep going. See you on the next episode. Thank you so much.
