Thanks, Ed, and thanks for the invitation to come today. These are my disclosures. The meniscus we're all familiar with. We're familiar with its anatomy, its role, and its importance in terms of maintaining the health of the knee. It is a commonly injured structure. We're familiar with that. We're familiar with some of the treatment options. But for this, we're going to talk mostly about the young athlete with a traumatic tear as opposed to a degenerative tear. And we're going to focus a little bit on tear pattern, which has some relevance in terms of vertical, radial, parrot beak, horizontal, and complex tears and how that plays into decision making. In terms of treatment of meniscal injury in athletes, we have a number of options. You can treat these non-operatively. Typically that's more for a short period of time. The vast majority of tears are resected if they undergo surgery, although there is growing interest in repair, both in athletes and non-athletes. And that is supported by an increasing number of repairs that we're seeing in the literature. Historically, we thought of vertical tears as being the optimal tear for repair. That was really the very limited indication. But people are starting to think more and more about repairing more of these tears, including root tears, radial tears, and even some horizontal tears. And so that is coming into play in athletes as well as in the non-athletic population. Return to play after meniscus tears in athletes will obviously depend on the treatment. This was a nice algorithm presented by McCarty, Marks, and Wikowitz about 20 years ago. Sadly, there's not much newer in the literature. But you can think about non-surgical management. Again, usually that's sort of short term. Usually surgery will become part of the treatment algorithm at some point. And then the big decision will be whether to debride or resect the tear versus trying to repair it and maintain the integrity of the meniscus. So return to play after non-operative is really trying to minimize symptoms. Again, usually short term. Typically you want to get the swelling down in the knee. You can use a variety of modalities to achieve that. You're trying to maintain range of motion, strength, and functional capacity in the athlete. Again, you're usually trying to do that for a short term goal, whether that's a game, a season, a particular competition. Usually this is not going to be the long term solution. Usually this is managing a situation and then you're going to typically have to progress to some surgical management at some point with the athlete. But you can try to maintain them in competition for at least a period of time, typically. So return to play after meniscectomy will be relatively rapid compared to repair. Can be much more aggressive in terms of the rehabilitation protocol, though it will still depend to some extent on the location of the tear, the age of the athlete, and the level of competition. In terms of the rehabilitation protocol, usually postoperatively we'll begin with a couple weeks of rest, easing into weight bearing and range of motion, starting to get some of the larger muscle groups back online. I mean we've all heard about very rapid return to play in some extreme situations, but usually a week or two of kind of recovering from the surgery and then starting to transition back to activity, usually starting with low impact cardio, starting to ease into some sports specific activities, typically around two to four, six weeks after surgery. Usually within four to eight weeks the athlete can progress with strengthening, start to advance sports specific training in terms of getting ready to get back to sport. Return to play is fairly high after meniscectomy, typically in the one to two month range, although again we can see some situations where it's accelerated. There are a number of factors in the literature shown to influence return to play. So there was one study with soccer players where it was typically two weeks delayed in lateral meniscus tears as opposed to medial meniscus tears. Although there was another study which looked at athletes across a number of sports and showed a slightly later return after partial medial compared to partial lateral. So a little bit of conflicting data in sports specific. In terms of age, it's shown to be quicker in younger athletes within a couple of months as it closed to closer to three months in athletes over 30. And there was some stratification by level of competition as well. Three months roughly in the recreational athlete, under two months in the elite athlete, and the competitive athlete. So level of the athlete will also impact typical return to play after meniscectomy. There is a risk, however, of recurrent or persistent symptoms and additional surgery in the athlete who gets back to sport after partial meniscectomy. This in soccer players, it was shown to be worse after partial lateral meniscectomy as opposed to partial medial meniscectomy with a higher rate of persistent or recurrent pain and swelling and a higher rate of repeat arthroscopy. In professional American football players, about one in 20 underwent a second arthroscopy after partial lateral meniscectomy. So again, beware with the lateral meniscus tear in your athletes. It will probably give you a little more challenge after surgery. And finally, wrestlers who have a very high rate of difficulty after meniscal surgery had a 3% rate published for second arthroscopy after partial meniscectomy. So it's a good surgery. You can get back fairly quickly, but it's not necessarily the perfect long-term solution either. In terms of meniscal repair, obviously there will be a delayed return to play compared to a meniscectomy. The rehabilitation protocols that have been described are variable, depends on the tear in terms of its location, size, as well as the repair technique. There's variability in terms of immobilization or bracing of the joint, as well as the degree to which weight bearing is protected and for how long. Typically people can think of a protective delayed approach rather compared to a more accelerated rapid approach, depending on a number of these factors. So in terms of a protective phase, typically some extent of protecting weight bearing and or range of motion for some period of time up to as much as six weeks, again, depending on tear, age, athlete, and a number of other factors. Typically people recommend avoiding deep flexion up to four to six months. The accelerated phase will include earlier weight bearing and unrestricted range of motion. And again, it will vary by type of tear, but you can have more aggressive protocols depending on the tear that's been repaired. So I think that's the most important thing, thinking about the degree to which you're confident in the repair, the rapidity with which it will heal, and the degree to which you're worried about a re-tear will kind of impact how aggressive you may be after surgery. Again, thinking about the phases of rehabilitation, there's a few studies in the literature. So the first six weeks will typically be protective, to some extent limiting weight bearing and range of motion. People may avoid hamstring strengthening, particularly for posterior tears. Then moves into more of a restorative phase in terms of range of motion, starting to do some strengthening and some proprioception or balance activities in that phase, typically out to about three months. And then typically return to activity in sports starts to progress over three to four months, obviously getting back range of motion, getting back balance, strength, making sure the inflammation is down, and sort of progressing the intensity and duration of activity. So these are the things to think about as you're bringing the athlete back after meniscal repair. The time for return to play really depends on the anatomy, the function. People do think a little bit about tear characteristics, depending on how the location of the tear and the pattern of the tear in terms of whether and when you can be more aggressive. The other important factor is to think about that many of these occur with concomitant ACL reconstructions, and obviously that tends to be the rate limiting step in terms of return to sport rather than the meniscus repair itself when you have athletes undergoing the concomitant surgeries. So these are the things to think about in return to play after the meniscal repair. The literature shows still very good results. Not quite as high as the meniscectomy, but still in the 80% to 95% range. There's not any well-established guidelines in terms of what are the criteria to meet for return to play. Again, typically in the four to six month range, and now longer with concomitant ACL reconstructions, as Kurt was talking about. There is evidence that the MRI signal of repair matures for at least six months. So clinical healing kind of progresses from about 45% at three months to two-thirds at six months. The MRI healing progresses not quite as quickly. So even though athletes are going back at six months, it's not clear that they've had a complete return to normal signal on the MRI. There's probably still some work to figure out to what degree that should be taken into account in returning to athletes to play. Right now, that's not considered a necessary criteria. Again, there is a risk of recurrent or persistent symptoms, and the need for additional surgery after meniscal repair can be up to about one in three. There is some limited sport-specific data, about 7% in elite soccer players after meniscal repair, and up to 21% in wrestlers. Again, some conflicting evidence regarding the rate of re-tear with concomitant ACL reconstruction. Probably conventional wisdom would lean towards a lower rate of re-tear with concomitant ACL reconstruction, but there's not good evidence in the literature yet that really provides a convincing answer. So comparing partial meniscectomy to repair, as you might expect, obviously a higher rate, a quicker return after partial meniscectomy versus repair. Of course, it is a heterogeneous population. It's a little bit of apples to oranges. It's different tears. They may have different concomitant injuries. There's obviously patient and surgeon bias that goes into terms of selecting which surgery is chosen. There's still a lot to be learned about long-term outcomes in terms of, do athletes stay at their sport? How do they do over long-term between the two approaches? And I think right now, it's mostly general principles rather than strict or specific guidelines in terms of saying what to do on whom and when. So I think it's still a little bit of judgment rather than evidence. So in summary, meniscus tears, we all know, are a common injury in athletes. The treatment is almost always surgical at some point, although it may not be surgical initially. Obviously, athletes get back quicker after partial meniscectomy than repair. There seems to be a little higher rate of issues after partial lateral than partial medial meniscus. And there is a high rate of subsequent surgery after meniscal repair in athletes. So these are things to keep in mind in terms of counseling athletes going forward. And I think there's still evolving evidence in terms of the optimal indications for repair. What are the actual criteria for return to play? And what are really the long-term outcomes in terms of the athlete's longevity and long-term knee health? Thank you very much. Well, I'm just going to have to leave us. We won't be here for the discussion. So we're just going to quiz him a little bit now. Any questions from the audience right now about meniscus repairs? Yeah. About post-meniscectomy surgery in general, our top tennis player finished the French Open and had a meniscectomy. And two weeks later was at Wimbledon. And he actually did very, very well. Is there a danger? Again, I wasn't at the surgery, so I really don't know the terror pattern. But is there a danger to coming back too soon in terms of stresses on the knee, the tibial plateau, things like that? I mean, is there a second ward? So, again, I think it is anecdotal, case-by-case, athlete, surgeon, tear-specific. I think it's more of a short-term risk than a long-term risk, i.e., if you've got great control of inflammation, they're able to bounce back in terms of their conditioning, obviously, in an optimal condition, and obviously, it depends on the athlete. They can do very well. I don't think there's a high long-term difference in terms of outcomes. But obviously, if they go back too quick and it blows up on them, then it becomes a challenge. So, again, I think that is always an opportunity with some exceptional athletes to be able to do that. The problem, as you know, is then every kid in every league is the next Wimbledon winner, and they're trying to get back a little too quick. So, I think it's more of a short-term challenge in terms of rehab. Scott? So, great question, Scott. I think it's probably a little bit of a combination of both, right, and maybe a little combination of how quickly the athlete goes back. It may not be a confirmed re-tear, it may be persistent swelling, pain, issues that are challenging. So, I think that touches on the big question mark, which we still don't understand that well, which is the biology of it, right? So, is it truly a traumatic tear in an intact, healthy meniscus, or, to your point, is it early degeneration and it's just collapsing, and then, you know, probably many of those that fail early are probably more of the latter. So, Rob, after your repairs, how many MRIs actually do look normal? Well, I think the MRIs rarely look normal. There's always a question of MR or MR arthrogram as well, and yeah, I don't think you're restoring the meniscus to its perfect health by any stretch. Even with a good-looking MRI, you're probably not. Okay. I have a question. In a teenage athlete, say, a 16-year-old soccer player, stable knee, no ligament injury, meniscus repair, what would be your preference, a device for repair or suture, and does alignment make a difference in terms of getting them back, in terms of medial versus lateral, valgus versus varus? So, I think two or three questions in there. I mean, in terms of device, and I will pun a little bit, I think it depends on the tear pattern and location. So, I think there are some, if not many, that can be well done with many of the newer inside devices. I still think the gold standard is inside-out. Nothing's been shown to be better with more and more techniques. Suture repair. Yes, right. And so, I mean, that's kind of where I would take that. In terms of alignment, there's no doubt that that's important. I don't know that that's being checked as frequently as, say, with chondral defects. I think that's probably an area of opportunity as well, and it might be interesting. That may be one of the things that plays into a lot of the persistent pain, swelling, and other symptoms, maybe alignment as much as the meniscus itself. Okay. Thanks, Rob.

meniscus injuries

treatment options

tear patterns

surgery

return to play