Checked: 17-10-2014 by
vicky.ryan Next Review: 21-10-2016
Knee injuries - meniscal tears NS MOM
management of injuries arising from acute trauma to the knee joint, including:
initial assessment and radiologic investigations
soft tissue injuries
red flags and referral criteria
management of soft tissue injuries
Out of scope:
specific management of fractures and dislocations
management of crush injuries and traumatic amputation of the knee joint
Knee injuries :
muscle strain (or 'pull'):
stretching or tearing of muscle fibres
most strains happen because the muscle has:
been stretched beyond its limits; or
been forced to contract too strongly
graded depending on the severity of muscle fibre damage:
first-degree strain − mild strain when only a few muscle fibres are stretched or torn; injured muscle is tender and painful, but has normal strength
second-degree strain − moderate strain, with a greater number of injured fibres and more severe muscle pain and tenderness; swelling present and noticeable loss of strength, sometimes with visible bruising
third-degree strain − muscle is torn all the way through, sometimes producing a 'pop' sensation as the muscle rips into two separate pieces or shears away from its tendon; there is total loss of muscle function
knee ligament injuries :
stretching or tearing of the knee ligaments
can be graded by:
grade I – no increased laxity, pain and tenderness over the course of the ligament, no actual disruption of fibres
grade II – some increased laxity compared with the other knee, usually pain and tenderness over the course of the ligament, some disruption of the fibres
grade III – gross laxity, tenderness over the ligament may or may not be present as there are no 'intact' fibres to stress, complete rupture of the ligament
meniscal tears :
menisci are semi-lunar shaped discs of fibrocartilage located in the medial and lateral aspects of the knee joint, positioned between the articular surfaces of the tibia and femur
meniscal tears typically occur as a result of tibial rotation whilst the weight bearing knee is in flexion
may also occur through repetitive motion such as squatting
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
'Knee ligament tears' and 'Meniscal tears' have been incorporated into this care map, and updated with the following references:
 Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy 2011; 27: 1275-88
 Elattar M, Dhollander A, Verdonk R et al. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc 2011; 19: 147-57.
 Hergan D, Thut D, Sherman O et al. Meniscal allograft transplantation. Arthroscopy 2011; 27: 101-12.
 Delince P, Ghafil D. Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature. Knee Surg Sports Traumatol Arthrosc 2012; 20: 48-61.
 Biau DJ, Katsahian S, Dartus J. Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament: A Meta-Analysis Based on Individual Patient Data. Am J Sports Med 2009; 37: 2470-8.
 Raynor MC, Pietrobon R, Guller U et al. Cryotherapy after ACL reconstruction: a meta-analysis. J Knee Surg 2005; 18: 123-29.
 Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med 2009; 19: 9-12.
 Karachalios T, Hantes M, Zibis AH et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am 2005; 87: 955-62.
 American College of Radiology (ACR). Acute trauma to the knee. VA: ACR; 2011.
 Linko E, Harilainen A, Malmivaara A et al. Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev 2005; 18: CD001356.
 Forster MC, Forster IW. Patellar tendon or four-strand hamstring? A systematic review of autografts for anterior cruciate ligament reconstruction. Knee 2005; 12: 225-30.
 Grant JA, Tannenbaum E, Miller BS et al. Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments. Arthroscopy 2012; 28: 110-22.
 National Institute for Health and Clinical Excellence (NICE). Partial replacement of the meniscus of the knee using a biodegradable scaffold. London: NICE; 2012.
Date of publication: 30-Apr-2012
This care map has been drafted using the Map of Medicine editorial methodology and represents best clinical practice according to the highest quality evidence available, including the following guidelines:
 PRODIGY. Sprains and strains. Version 1.4. Newcastle upon Tyne: PRODIGY; 2008.
 New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue knee injuries: internal derangements. Wellington, NZ: NZGG; 2003.
Further information was provided by the following references including practice-based knowledge: [3-6].
Local administrative information
Knee Arthroscopy Policy
Criteria Based Access
Date Adopted: 1st June 2016
The CCG will fund knee arthroscopy in adults only where:
1. The patient has been assessed (including paper based triage where appropriate) by Musculoskeletal Services and diagnosed as suffering from end-stage osteoarthritis suitable for referral for consideration of surgery.
2a. Clinical examination (or MRI scan) has demonstrated clear evidence of an internal joint derangement (i.e. ligament rupture or loose body within the knee)
2b. The patient is suffering confirmed knee osteoarthritis with regular clinically significant mechanical symptoms such as true knee locking or the knee is unstable i.e. giving way
3. Conservative management over a period of at least 3 months has been fully explored, and complied with, but treatment has failed. Conservative management can include advice, physio and support from the intermediate musculoskeletal services and pain management with non-steroidal anti-inflammatory drug (NSAID) painkillers. A trial of conservative management should be the first-line treatment for all patients with degenerative meniscal tears. (Khan M, 2014)
Note: Evidence of symptoms and compliance with conservative management must be documented in the patient’s clinical records and demonstrated in any referral to secondary care.
Knee arthroscopy is not routinely commissioned for the following indications and funding approval with supporting clinical evidence will need to be sought via the IFR route where there are exceptional circumstances present:
1. Debridement of meniscal tears either with or without Osteoarthritis or other degenerative meniscal injury (Khan M, 2014),
2. The patient has previously had an arthroscopy to treat the affected knee.
3. Intractable knee pain even if considered likely the patient has the potential to benefit from arthroscopic treatment according to assessment by a Consultant Knee Surgeon.
4. For diagnostic purposes only.
5. To provide arthroscopic washout alone as a treatment for chronic knee pain due to osteoarthritis. Current evidence suggests that arthroscopic knee washout alone should not be used as a treatment for osteoarthritis because it cannot demonstrate clinically useful benefit in the short or long term. (NICE)
Clinical tests for the diagnosis of soft tissue knee injuries are most useful in the context of an appropriate history .
are common, occurring most frequently in sports including football, basketball, and baseball 
the medial meniscus is injured more frequently than the lateral meniscus as it is less mobile 
the types of movement typically associated with meniscal injuries are :
in younger people – twisting, squatting, or cutting manoeuvres
in middle-aged and older people – more trivial movements
a history of the following are strongly suggestive of a meniscal tear:
pain along the joint line 
giving way 
clinical tests which strongly suggest a meniscal tear are :
tenderness specific to the joint line; and
Thessaly test :
can be used as first-line clinical screening test for meniscal tears 
support patient by holding their outstretched hands while the patient stands flat-footed
keeping the knee flexed at 20 degrees, ask patient to rotate knee and body, internally and externally three times
patients with suspected meniscal tears will experience joint-line discomfort
the McMurray test is no longer recommended 
NB: A lack of extension is also suggestive of a meniscal tear .
The following management options are common to all knee injuries :
RICE protocol :
avoid activity in the first 48-72 hours to prevent further damage 
crutches may be necessary if weight-bearing is too painful 
a brace may be helpful to support the joint but gentle movement should be encouraged 
wrap ice in a damp towel (direct application onto bare skin can result in an ice burn)
apply ice for 20 minutes every two hours during the day for the first 48-72 hours
tubigrip or a simple elastic bandage can be applied between ice treatments to reduce swelling
avoid firm bandages and tubigrip at night as these can constrict circulation
Elevation − raise the leg on a pillow during the day as much as possible to help reduce the swelling
avoid HARM :
Heat − avoid hot baths, showers, saunas, heat packs, and liniments
Alcohol − alcohol increases bleeding and swelling and delays healing
Running − any form of exercise will cause further damage
Massage − avoid massage which causes increased bleeding and swelling
paracetamol is probably the most cost-effective and potentially least harmful choice of analgesia for soft tissue knee injuries 
non-steroidal anti-inflammatory drugs (NSAIDs) may be beneficial for treating a persistent effusion that has not responded to the 'RICE protocol' :
consider prescribing an oral NSAID, eg ibuprofen, 48 hours after the initial injury 
topical NSAIDs are effective and safe for acute sprains, strains, and sports injuries 
bracing – medial collateral ligament (MCL) only
Surgical treatment (meniscal repair or partial or total meniscectomy) is the only reparative treatment for meniscal tears; however a conservative approach may achieve resolution of symptoms and restoration of knee function in selected patients :
if a clinically stable isolated meniscal injury is suspected in the absence of associated injury or pathology, a trial of conservative treatment may be appropriate
if a conservative approach is taken, rehabilitation with appropriate physiotherapy is usually considered, with subsequent orthopaedic referral if symptoms persist beyond 6-8 weeks
however, when considering conservative treatment, take the following factors into account:
sport and activity commitments
if the patient is young and active, this may indicate that earlier referral for consideration of surgical intervention might be more appropriate
if patient presents with locking or giving way symptoms that are indicative of a meniscal problem 
Local administrative information
Weston General Hospital - Fracture Clinic
Telephone: 01934 881022
Southmead hospital - Orthopaedics
Telephone: 0117 323 5105
Bristol Royal Infirmary - Trauma & Orthopaedics department
Telephone: 0117 342 0302 / 0303
(Ward A609 was Ward 14)
The standard RSS referral form is available as an EMIS template
The standard RSS referral form is available as an EMIS template
Consider the following in rehabilitative treatment :
the aim of rehabilitation is to maximise function of the affected knee joint, maintain proprioception and prevent muscle wasting
there is currently limited evidence for the:
effectiveness of the conservative approach in comparison to meniscal surgery; or
use of individual physiotherapy approaches to meniscal injuries
a variety of general approaches that may be considered depending upon the clinical scenario include:
a carefully considered home exercise programme such as gentle weight-bearing and quadriceps strengthening exercises
proprioceptive training to retain protection and stability of the joint
close kinetic chain exercise 
modalities of electrotherapy, eg ultrasound, laser, transcutaneous electric nerve stimulation (TENS), biofeedback, neuromuscular electrical stimulation (NMES)
It is important that the patient undergoing physiotherapy for acute knee injury has their progress assessed regularly, ideally at weekly intervals .
Suggested goals of therapy are :
a return to normal gait and full weight-bearing, passive flexion and extension at 1-3 weeks
full active flexion within 8 weeks
full return to sport within 6-9 months
Refer to orthopaedics after 6-8 weeks if there is deterioration or minimal improvement in :
joint function and stability
range of knee movement
ability to bear weight
pain and swelling
Local administrative information
All GP practices north of the patch excluding Wrington should send patients to Clevedon for physiotherapy – use the NSCP community referral form (ensure you tick physiotherapy box)
All GP practices south of the patch including Wrington should send patients to Weston general hospital for physiotherapy – use the BNSSG physiotherapy referral form