Objective: This guideline provides recommendations regarding diagnosis, evaluation, and assessment of meniscus and articular cartilage lesions, and non-operative treatment interventions following post-surgical care of the lesions.

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Target population: 

• Adults with knee pain and mobility impairments/ knee meniscal/ articular cartilage lesions.

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Classification:

• International Classification of Diseases (ICD-10) codes and conditions associated with knee pain and mobility disorders are:

  • S83.2 Tear of meniscus, current;​

  • M23.2 Derangement of meniscus due to old tear or injury; and 

  • S83.3 Tear of articular cartilage of knee, current.

Title of guideline: Knee pain and mobility impairments: meniscal and articular cartilage lesions

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Author(s): Logerstedt DS., et al. 

Year of publication: 2018

Link to full guideline: Link

Target Users:

• Physical therapists (CCGI Note: the guideline explicitly states physical therapists as the target users. However, this information is valuable for all rehabilitation healthcare professionals).

Levels of Evidence

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I: Evidence obtained from systematic reviews, high-quality diagnostic studies, prospective studies, or randomized controlled trials

II: Evidence obtained from systematic reviews, lesser-quality diagnostic studies, prospective studies, or randomized controlled trials (e.g., weaker diagnostic criteria and reference standards, improper randomization, no blinding, less than 80% follow-up)

III: Case-control studies or retrospective studies

IV: Case series

V: Expert opinion

Grades of Recommendation

A: Strong Evidence: A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I study

B: Moderate Evidence: A single high-quality randomized controlled trial or a preponderance of level II studies support the recommendation

C: Weak Evidence: A single level II study or a preponderance of level III and IV studies, including statements of consensus by content experts, support the recommendation

D: Conflicting Evidence: Higher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies

E: Theoretical/ foundational Evidence: A preponderance of evidence from animal or cadaver studies, from conceptual models/ principles, or from basic science/bench research support this conclusion

F: Expert Opinion: Best practice based on the clinical experience of the guideline development team

1. Self-reported outcome measures: activity limitations/ self-reported measures

• Knee-specific outcomes:

  • International Knee Documentation Committee 2000 Subjective Knee Evaluation Form (IKDC 2000); or

  • Knee injury and Osteoarthritis Outcome Score (KOOS); or

  • Lysholm scale (with removal of swelling item, and using unweighted scores)​

• Activity level*

  • Tegner scale​

  • Marx activity rating 

• General health

  • Medical Outcomes Study 36-Item Short Form Health Survey (SF-36)

  • European Quality of Life-5 Dimensions (EQ-5D)​

• Knee-related quality of life

  • Knee Quality of Life 26-item questionnaire (KQoL-26)​

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*Clinicians may use the Tegner scale or Marx activity rating scale to assess activity level before and after interventions intended to alleviate the physical impairments, activity limitations, and participation restrictions associated with meniscus or articular cartilage lesions; however, these have less evidence support regarding measurement properties

2. ​Physical performance measures

• Clinicians may administer appropriate clinical or field tests that can identify a patient’s baseline status relative to pain, function, and disability; detect side-to-side asymmetries; assess global knee function; determine a patient’s readiness to return to activities; and monitor changes in the patient’s status throughout the course of treatment.

  • Early rehabilitation time period:

    • 30-second chair-stand test

    • Stair-climb test

    • Timed up-and-go test

    • 6-minute walk test

  • Return to activity or sports:

    • Single-leg hop tests​

3. Physical impairment measures

• Clinicians should administer appropriate physical impairment assessments of body structure and function, at least at baseline and at discharge or 1 other follow-up point, for all patients with meniscus tears to support standardization for quality improvement in clinical care and research.

  • ​Modified stroke test for effusion assessment

  • Assessment of knee active range of motion

  • Maximum voluntary isometric or isokinetic quadriceps strength testing

  • Maximum passive knee flexion

  • McMurray’s maneuver

  • Palpation for joint-line tenderness

• Clinicians may administer the appropriate physical impairment assessments of body structure and function, at least at baseline and at discharge or 1 other follow-up point, for all patients with articular cartilage lesions to support standardization for quality improvement in clinical care and research.

  • Modified stroke test for effusion assessment

  • Assessment of knee active range of motion

  • Maximum voluntary isometric or isokinetic quadriceps strength testing

  • Palpation for joint-line tenderness​

​Meniscal Lesions

• Prevalence of 12-14%​

• A high incidence of meniscal tears occurs with injury to the Anterior Cruciate Ligament (ACL).

• Tear patterns of the knee meniscus can be classified as either traumatic tears or degenerative tears.

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Clinical findings of knee pain, history of twisting knee mechanism injury, history of “catching” or “locking,” delayed onset of effusion, and a Meniscal Pathology Composite Score greater than 3 positive findings may be used to classify patients with knee pain and mobility disorders into the ICD category of tear of the meniscus and the associated ICF impairment-based categories of knee pain (b28016 Pain in joint) and mobility impairments (b7100 Mobility of a single joint).

Diagnostic Classification Criteria

Meniscus

• Twisting injury

• Tearing sensation at time of injury

• Delayed effusion (6-24 hours post injury)

• History of “catching” or “locking”

• Pain with forced hyperextension

• Pain with maximum passive knee flexion

• Pain or audible click with McMurray’s maneuver

• Joint-line tenderness

• Discomfort or a sense of locking or catching in the knee over either the medial or lateral joint line during the Thessaly test when performed at 20° of knee flexion

• Meniscal Pathology Composite Score: the combination of history of “catching” or “locking,” pain with forced hyper- extension, pain with maximum passive knee flexion, joint- line tenderness, and pain or audible click with McMurray’s maneuver

Articular Cartilage

• Acute trauma with hemarthrosis (0-2 hours) (associated with osteochondral fracture)

• Insidious onset aggravated by repetitive impact

• Intermittent pain and swelling

• History of “catching” or “locking”

• Joint-line tenderness

Meniscal Pathology Composite Score (MPCS)

​Articular Cartilage Lesions

• Prevalence of 60-70%​

• The most frequent localizations of cartilage lesions were to the medial femoral condyle and the patellar articular surface.

• Medial meniscal tears (37%) and ACL ruptures (36%) were the most common injuries occurring concomitantly with articular cartilage injuries.

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The clinical findings of intermittent knee pain, history of acute trauma to the knee, history of “catching” or “locking,” effusion, and joint-line tenderness may classify patients with knee pain and mobility disorders into the ICD category of tear of the articular cartilage and the associated ICF impairment- based categories of knee pain (b28016 Pain in joint) and mobility impairments (b7100 Mobility of a single joint).

1. Knee pain and mobility impairments associated with meniscal and articular cartilage tears can be the result of a contact or noncontact incident which can result in damage to one or more structures. Clinicians should assess for impairments in range of motion, motor control, strength, and endurance of the limb associated with the identified meniscal or articular cartilage pathology or following meniscal or chondral surgery.

Summary

• The clinical course for most patients after meniscus injury managed with or without surgery is satisfactory, though these patients will report lower knee function compared to the general population.

• Patients who have nonoperative management for meniscus tear have similar to better outcomes in terms of strength and perceived knee function in the short term and intermediate term compared to those who had arthroscopic partial meniscectomy.

• Impairments in proprioception and muscle strength and poor patient-reported outcomes are present early after meniscal injury and in the short-term time period (less than 6 months) after arthroscopic partial meniscectomy.

• Young patients who have meniscus repair have similar to better perceived knee function, less activity loss, and higher rates of return to activity compared to those who have arthroscopic partial meniscectomy (APM). Elite and competitive athletes or athletes younger than 30 years are likely to return to sport less than 2 months after APM, and athletes older than 30 years are likely to return by 3 months after APM.

1. Progressive knee motion 

• Clinicians may use early progressive active and passive knee motion with patients after knee meniscal and articular cartilage surgery.

2. Progressive weight bearing 

• Clinicians may consider early progressive weight bearing in patients with meniscal repairs.

• Clinicians should use a stepwise progression of weight bearing to reach full weight bearing by 6 to 8 weeks after matrix-supported autologous chondrocyte implantation (MACI) for articular cartilage lesions.

3. Progressive return to activity 

• Clinicians may utilize early progressive return to activity following knee meniscal repair surgery.

• Clinicians may need to delay return to activity depending on the type of articular cartilage surgery.

4. Supervised rehabilitation

• Clinicians should use exercises as part of the in-clinic supervised rehabilitation program after arthroscopic meniscectomy and should provide and supervise the progression of a home-based exercise program, providing education to ensure independent performance.

5. Therapeutic exercises

• Clinicians should provide supervised, progressive range-of-motion exercises, progressive strength training of the knee and hip muscles, and neuromuscular training to patients with knee meniscus tears and articular cartilage lesions and after meniscus or articular cartilage surgery.

6. Neuromuscular electrical stimulation/biofeedback

• Clinicians should provide neuromuscular stimulation/re-education to patients following meniscus procedures to increase quadriceps strength, functional performance, and knee function.

​Radiography

• The Ottawa knee rule should be used to determine when to order radiographs in individuals with acute knee injury. A knee radiograph series is required in patients with any one of the following criteria:

  • Aged 55 or older;

  • Isolated tenderness of patella (no bone tenderness of knee other than patella)

  • Tenderness of head of the fibula;

  • Inability to flex knee to 90 degrees;

  • Inability to bear weight both immediately and in the emergency department for 4 steps regardless of limping.

MRI

• Clinical examination by well-trained clinicians appears to be as accurate as MRI in regard to the diagnosis of meniscal lesions.

• A lower threshold of suspicion of a meniscal tear is warranted in middle-aged and elderly patients.

• MRI may be reserved for more complicated or confusing cases and may assist an orthopaedic surgeon in preoperative planning and prognosis.

• Imaging may be used to monitor the status of meniscus repair or articular cartilage repair or restoration procedures.