Medial Meniscus Injury and Medial Collateral Ligament of Knee: Analysis of Traumatic Meniscus Tears

Mr. White, a 32-year-old football player claimed that his right medial knee was painful and was unable to get off the field after being tackled during his practice 4 months ago. The next day of injury, he visited the chiropractic clinic due to pain and inability to bend or straighten his right knee fully. The aggravating factors are putting pressure over the outside of his knee and walking was increasing the pain; nature of pain was dull with occasional sharpness associated with certain movements such as walking or pivoting, up and down stairs, or quick movements. There was no referred pain or any paraesthesia. On Verbal Rating Scale, he rated the pain as 2/10 in the office and worst is 7/10. The clinical practitioner observed that he had mild edema around the right knee and no bruising and limitations of at last ten degrees of flexion and final degrees of extension of right knee due to severe pain. He said the tackle was from the right side level below the thigh and knee with feet were planted on the ground and he had difficulty to stand up due to knee pain, his coach applied a compression bandage. The neurological screening was unremarkable bilaterally for the upper and lower extremities.

Based on Mr. White’s condition, he is suspected to have medial meniscus injury which is particularly sports-related injury and usually involves damage due to rotational force. When the foot is planted and the femur is internally rotated, a valgus force directed to a flexed knee may cause a tear of the medial meniscus. (Bhagia, 2018) This mechanism is shown in his history of falls. Anatomically, the semilunar medial meniscus is attached to tibia plateau more firmly than the relatively mobile, more circular lateral meniscus, and this may result in a greater incidence of medial meniscus injury. (Bhagia, 2018) This injury can happen in all age groups either caused by traumatic injury or degeneration of meniscus. (UW Medicine, 2019) Mr. White has a risk factor at it because the traumatic meniscus tears are most common in sporty people from age 10-45. (UW Medicine, 2019) He experienced the symptoms of medial meniscus injury like initial localized pain on the medial knee and the pain increases during twisting or squatting, putting weight on knee, and affected daily activities like going up and down stairs. (UW Medicine, 2019) The swelling often does not occur until the day after the injury, therefore he did not complain of swelling until the medical giver observed mild swelling on the next day. (UW Medicine, 2019) There is a chance for the catching or locking to happen in knee, the knee may stuck in midrange as the torn fragment has been displaced and trapped within the joint, extension may feel limited against a rubbery resistance, cause the limited range of motion (ROM) of knee movement. (Bhagia, 2018) They had carry out the tests to confirm this injury on his right knee like McMurray test showed positive, the specificity is 94%, and sensitivity is 64.7% for medial; and the positive Apley’s test which is specificity 93% and sensitivity 41%. (Magee, 2014)

Besides, Mr. White is also injured his right knee medial collateral ligament (MCL) as it occurs commonly in athletes of contact sports, either through trauma or sudden changes in speed or direction during performing activities and the mechanism of injury is typically the valgus knee loading, external rotation of tibia, or a combined force vector both that occurs in sports require knee flexion. (Laprade, 2012) Running and turning actions contracting the muscle can also increase stress on the MCL to sprain or tear it. (Andrews, 2017) There was no popping sound noticed by Mr. White when being tackled, so the MCL is not completely tear, other signs and symptoms are local swelling which may not happen immediately, limited ROM of knee motion, difficulty in climbing the stairs, the knee may be instability and feeling like give way or kneecap feels loose. (Martel, 2017) The weak positive valgus stress testing of the right knee at zero and thirty degrees flexion resulted as weak positive shown laxity with sensitivity of 86-96% indicates the MCL injury. (Magee, 2014)

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The physical assessment of medial meniscus injury is more challenging as it is avascular and has no nerve supply on their inner two-thirds, cause a little or no pain or swelling at the medial aspect. (Malanga, 2003) First, joint line palpation is providing useful information to detect meniscal tears with palpation along the joint line will advocate tenderness, especially in flexion and internal rotation of tibia. (Malanga, 2004) The literatures of Fowler and Lubliner, Kurosaka et al resulted as sensitivity for joint line tenderness of 55% to 85%, with a specificity range of 29% to 67%, this examination is prefer to be detect the meniscal tears. (Malanga, 2004) Secondly, the Mc Murray test is among the primary examination to detect the meniscal tear, by external rotation of the flexed knee, the medial meniscus is tested and produce a click, Mr. White can feel that the sensation of right knee gave way same as previous experience. (Malanga, 2004) The test is resulted with sensitivities (16%–58%) and specificities (77%–98%) so it is advised a combination with other physical assessments and related with patients’ history that is suspected of meniscal injury. (Malanga, 2004) Next, the Thessaly test is introduced to improve to accuracy of detecting the meniscal tear. (Goossens, 2015) Mr. White will feel discomfort in his right medial knee joint line when right foot is planted and at 20° of flexion with external rotating knee and body. (Harrison, 2009) The literature showed results of sensitivity of 90.3%, specificity of 97.7%, and concluded the test is easily performed, valid, and reproducible physical assessment for predicting meniscal tears. (Harrison, 2009) Besides, muscle girth assessment can be used as atrophy of the vastus medialis obliquus portion of the quadriceps muscle also may be noticeable. (Calmbach, 2003) The quadriceps circumference should be evaluated bilaterally to determine the severity of the problem and rehabilitation potential and passive and active range of motion should be checked and compared bilaterally. (Rao, 2015) In order to test Mr. White’s knee muscle strength, Manual Muscle Testing can be done on knee flexion and extension; the range of motion assessment can be done to check the degree of lack of knee movement.

The assessment for MCL tear is Valgus stress test applied to the knee at 20° of knee flexion, Mr. White's medial compartment will show increased gapping compared to the left side; while a valgus stress test performed with the knee at full extension, more gapping would indicate a combined cruciate ligament injury. (Laprade, 2012) The examination of medial compartment gapping at 20° of knee flexion predominantly isolates the superficial MCL, with less importance of the roles of the cruciate ligaments, deep MCL, and posterior oblique ligament. (Laprade, 2012) Feeling for an endpoint during this valgus stress test is important to differentiate between a partial and complete medial knee injury. (Laprade, 2012) For the valgus stress test, the literatures of Harilainen showed sensitivity of 86%, and Garvin et al stated sensitivity of 96%. (Malanga, 2004) Next, Mr. White is observed to have swelling around his right knee, therefore palpation can be very useful, assessor can palpate on the meniscofemoral and meniscotibial divisions of the medial knee structures along their entire lengths to identify the location of injury. (Laprade, 2009)

The meniscus injury usually induces the knee to make extra joint fluid and causes the knee to slightly flex for fluid accumulation, and then hamstring tightness and joint contracture will be develop due to prolong slight bending. (UW Medicine, 2019) Therefore, the treatment plan is focusing on the management of pain and edema, regaining range of motion, and avoiding any forceful stress on healing soft tissue like performing pivoting and squatting and should work on keeping the quadriceps muscles strong. (UW Medicine, 2019) Besides, the grade1 and grade 2 MCL injuries, treatment with early ROM exercise with early joint motion will promote ligament healing, and then progress with strengthening exercises is important, plus weight bearing is encouraged when the pain is subsided. (Andrews, 2017) Initially, the RICE protocol (rest, cryotherapy, compression, and elevation) is practiced to reduce pain and swelling in 72 hours after injury occurred. (Chen, 2007) Follow by the soft tissue manipulation to control the tenderness and swelling, 10 minutes of effleurage and thumb kneading massage techniques are applied to medial aspect of knee near the joint line with consistent depth and rate of massage will increases in blood and lymph flow, enhance removal of pain substrates accumulated in the injured part and reducing edema. (Zainuddin, 2005) Edema circumference is measured and compared pre and post-treatment as well as with contralateral knee. The limitation of knee ROM can improve with active full range of motion exercise of knee flexion and extension, done in 10 repetitions and 3 sets, with outcome measure of goniometer ROM measurement to see effectiveness. According to Neogi, there is strong evidence showed physical training important to reduce the symptom of quadriceps weaken due to knee pain just like the condition of Mr. White which is reduce in knee flexion and extension; so improving muscle strength and flexibility are important to increase quality of life. Passive stretching of hamstrings can improve the flexibility of knee; literature showed holding stretches for 15 seconds and repeating 3 times may get greater improvement in active ROM than the intervention of holding stretches for 5 seconds and repeating 9 times. (Roberts, 1999) The 90-90 straight raise test can used to measure the degree of flexibility of hamstrings. Next, in order to overcome the limitation of knee final degree of flexion and extension, manual resisted exercise for quadriceps is prescribed for 10 repetitions and 3 sets, this can help avoid secondary complications like the sense of buckling or kneecap pain. (UW Medicine, 2019). Nevertheless, bracing can be applied to give support and protection for his right knee and to prevent further valgus injury. Studies show the use of valgus unloading bracing for medial compartment injury gives pain relief, enhance proprioception, and improved function. (Callaghan, 2003) Lastly, Mr. White is being advised to avoid vigorous exercises, especially the activities that involving pivoting like football, some home programs can be done like self-stretching of hamstrings, mechanical resisted exercise by applying weight cuff to strengthen quadriceps, as progression mini-squats with bending knee only to 15 degrees can be practice once the pain subsided, this can avoid giving way and keep the strength of quadriceps. (UW Medicine, 2019)

In conclusion, the treatment plan for Mr. White is focus on the management of pain and edema, regaining range of motion, keeping the quadriceps muscles strong with early joint motion, and avoiding any additional forceful stress on healing soft tissue. Therefore, the RICE protocol, soft tissue manipulation, active range of motion exercise, passive stretching of hamstrings, manual resisted exercise of quadriceps, and valgus unloading bracing are given as treatments for him.

References:

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