My MRI shows I have a meniscus tear. Now, what do I do? Is ice and rest and over the counter medication enough, or will I need surgery? I'm your host Evo Terra. And today to help me answer those questions, I'm joined by Dr. Dustin Briggs, orthopedic surgeon, specializing in hip and knee arthritis. Briggs, welcome to Living Well with Eisenhower Health, Healthcare, As it Should Be. Dr. Dustin Briggs:
Yes, Evo. Thanks for having me. Evo Terra:
So what is the meniscus and what does this thing do? Dr. Dustin Briggs:
Yeah. So, we have patients show up frequently at the clinic having had an MRI and they say that their meniscus is torn. And I have found that the expectations for that visit are all across that board. And so, today we're gonna kind of clarify what the meniscus is and what it does. So, in general there are two types of cartilage in the knee. There's the smooth cartilage that covers the ends of bones. It allows them to rub smoothly together and then particular to the knee, there's a second type of cartilage called the meniscus. And in medicine, we like to compare things to food. I don't know why we do that, but we do it all the time.
And I think the most, close resemblance is calamari. So when I see calamari, it's rubbery, it's a disc shaped and that's kind of what you think about in the meniscus. And we have two meniscus or meniscal in our knee. One on the inside and one on the outside and we call those medial and lateral respectively in medicine. So, briefly that's what the meniscus is and sort of layman terms. Evo Terra:
We got it, makes sense. Now I recall many moons ago when my wife was a hockey player and wound up tearing her meniscus on the ice and I wasn't even there, she had to drive back home. Which was a, a terrible thing and went to the MRI and they said, yeah, sure enough, you have a tear indeed on your meniscus. I know what she did about that, but for the people who have this diagnosis, what should they do about that? Dr. Dustin Briggs:
Yeah. And that's kind of the fun thing about hearing people's stories. Is that just with that story you, learn so much about someone, hearing that your wife is active, she plays hockey. And so, just the story kind of allows you to get a sense of what the expectations are gonna be of that patient. And so, meniscus tears in general, we have to take the context of that tear and that's really what I wanted to talk about today. When we talk about arthritis that for the most part talks about the other kind of cartilage in the knee, the smooth cartilage, when the smooth cartilage starts to wear out in our joints for the most part, that's what we mean when we discuss arthritis.
So a meniscus tear in the context of arthritis, we don't actually address the meniscus directly because the whole knee itself is wearing out. And so addressing just the meniscus, wouldn't resolve the symptoms. I kind of used the analogy, I'm from Iowa and grew up mowing yards and it's kind of like pulling the dandy lions, but leaving the thistles. Your only sort of addressing half of the problem. And so a meniscus tear in the context of arthritis, we tend to treat that more down the arthritis pathway.
Which is inflammation and pain control kind of symptom control, and ultimately more down the road of knee replacement options. Conversely, a meniscus tear in the context of no arthritis the treatment can focus more on a meniscus, if it's appropriate. Evo Terra:
Right. Right. And. I wanna talk about the arthritis in a little bit of knee replacement, because I know exactly where this is headed for me eventually, if I look at my family history, but let's think about more about the tear. I recall what she had done, but it was almost 30 years ago. What are the treatment options today for meniscus tears without arthritis? Dr. Dustin Briggs:
So ISCU stares the thought arthritis. I would say the younger the patient, the more aggressive we are to treat them. And so, especially in like kids or people in their twenties or thirties, there are some types of meniscus tears that are actually repairable. So we go in arthroscopically and try to repair the meniscus tear and get it to heal. Now, as we age the healing potential of the meniscus or the pattern of the meniscus tear kind of dictates if it has much healing, potential or not. And for the most part as we age that goes down.
And so arthroscopic surgery for a torn meniscus, as we age, is more of a trimming, or we get rid of the tear as opposed to trying to repair it. So most often we come in and trim a little bit of the meniscus away and from a long term perspective, the meniscus acts as a shock absorber. So the more volume it has in the knee. In general, the better it functions. So as we're trimming away some of the bulk of the meniscus, we also in a way allow it to be less of a good shock absorber and less of a stabilizer. And so we try to, just to get rid of as little of the meniscus as possible.
In the olden days, we would do full miniscectomies where we removed the entire thing. And we found that rapidly leads to arthritis because there's just too much pressure on the cartilage. So, I'd say it's limited debridement where we call it where you just trim away the tear and leave as much back as possible. Evo Terra:
Yeah. And that's exactly what she had done. They just repaired the tear itself, which well they trimmed the tear, which to me that's when I hear tear, I think something has been torn us under it was ripped apart and I'm not sure how just trimming off the part that was ripped, solves the problem. Can you help me understand? Dr. Dustin Briggs:
Yeah, that's a great question. And we use kind of buzzwords in medicine to describe the tear and the radiologist and we kinda read it accordingly. So if it's a really simple tear, kind of only in one direction near where it attaches to like the joint capsule, those are kind of the ones where we can repair. But if there's a multi-directional repair kind of afraid rope, if you will. Then that's just too hard to repair. We can't put those ends back together and have 'em heal predictably. And so those are the tears that we tend to trim away and that, you know, a miniscectomy, we call that Evo Terra:
And so in trimming that section, it's trimmed now, so that the meniscus can just heal together on its own. Is that the idea? Dr. Dustin Briggs:
Yeah, that's a good question. And that relates to the indication of the operation. And so, if you have a meniscus tear and pain is the only presenting factor most often, we'll try to treat that without doing any surgery. So that can be physical therapy or injections or oral anti-inflammatories. So there are lots of options to address a meniscus stare if pain is the presenting symptom. And a lot of how we think about meniscus stares actually changed in 2013 when there was a study in the New England Journal of Medicine.
And this was out of a VA and it's pretty well known study within medicine where they did an arthroscopic partial miniscectomy, like discussed versus sham surgery. So actually just made incisions, but didn't do the surgery. So it'd be very hard to get a study like this approved now. But when pain was the only presentation and in otherwise non arthritic knee, the immediate result was no difference over the next 12 months. And so, we kind of stopped using pain as the indication in more mechanical symptoms. So when that tear is loose in the knee and it's causing problems, kind of getting. Pinched between the femur and the tibia, it causes some catching and grinding and popping and a sense of instability. And like you're gonna fall, those mechanical symptoms are the best indication for arthroscopy. Evo Terra:
And we've got a lot of options, it sounds like that, that you've just mentioned right here. So let's think about prevention worth an ounce of cure, I believe is the something along those lines. I may mixing a metaphor up just a little bit here. What can people do to prevent themselves from getting a meniscus tear? Dr. Dustin Briggs:
It's a good, it's a good question. And so a lot of people come in and I shouldn't have been so active as a kid, and it was all that weight lifting, all that football and in a sense that's true, but also there hasn't really been any literature to support that activity level, even high impact activity level leads to arthritis in the knee and indirectly, we kind of associate that with the meniscus tears. So marathon runners haven't really necessarily been shown to have any higher rate of arthritis than a couch potato.
And in fact it might be opposite. The more adipose tissue we have, the higher inflammation we have in our bodies and inflammation is pretty directly associated with arthritis in the knee. So I try to encourage people to stay as active as possible. Having said that we don't want to get hurt. So avoid. Injury is really the best way to do it. So pickle ball is just, it's all the rage. Now my parents are just totally into pickle ball. It's huge where I live here in Pacella Valley. So, I encourage people to be as active as they possibly can, but there's a lot of points in pickle ball.
So don't go diving for balls and don't put your injury at risk. You know, weighted pivoting type movements in the knee are a risk for meniscus tear. So you wanna move your feet a lot. You don't just wanna keep your feet planted and pivot on your knees. You want to keep your knees moving, take small steps. And I think those kind of things can help protect against injury, which is really what leads to most of arthritis. Evo Terra:
Right. Yeah. We definitely want to want to keep our knees as healthy as we possibly can. For a moment, let's talk about some non-surgical interventions that can happen. I know that, you know, my mom's had a knee replacement and so she gets some sort of shot. I don't know what the shot is. She calls it chicken fat. I don't know if it's a cortisone shot or gel injection, perhaps stem cells. What is out there that doesn't require surgery? Dr. Dustin Briggs:
Yeah. So yeah, the chicken comb, that's kinda what people they come and ask for the chicken comb. And that was kind of the first available formulation for a gel injection, which we call the hyaluronic acid. And so a lot of patients ask for hyaluronic acid. The literature's a little mixed on its efficacy. I usually say it's kind of a rule of third. A third of patients have a great result. A third of patients have some marginal relief and unfortunately, a third of patients just don't really notice much difference. Rarely do patients get worse from that injection. Cortisone injection is kind of the bread and butter.
That's a, I call it kind of a turbocharged anti-inflammatory that goes into the knee. So instead of taking like an anti-inflammatory, like ibuprofen or something orally, we inject it into the knee and it's got really strong anti-inflammatory effects. You know, getting those sparingly, if you still have pretty good preservation of the cartilage, I think is a pretty good idea. Once you lose the cartilage completely in your bone on bone, I think it's pretty safe to do pretty routine cortisone injections every three or four months, if it's working. But like I said, while you still have some cartilage, you may want to do that sparingly.
There are some other injections like stem cells and PRP that have, they're not covered by insurance. So they're a little less utilized. Stem cells haven't had much. I would say that, at this point in 2022 the cost of stem cells is kind of prohibitive and I'm not sure that the value, the benefit outweighs the cost. PRP is a platelet, rich plasma, That's where we draw some of your own blood. We spin it down and get all the good healing factors in there. And we can inject that into the knee too. And that does decrease some of the symptoms as well. And that's reasonably well supported in the literature. But again, That does cost quite a bit as well and is not covered by insurance.
So, there's no silver bullet for injections. Otherwise we would do that as opposed to knee replacements. We don't have an injection now, currently that restores the missing cartilage and no injection that can kind of heal or repair a meniscus tear. So there's really no such thing as reversing the arthritis or the cartilage loss in the. Evo Terra:
Right. Well, let's take this to the logical conclusion, arthritis it's set in. We have problems and it's caused a meniscus tear. Does that automatically mean knee replacement? Dr. Dustin Briggs:
Yeah. So, and let's kind of a touch base on that a little bit. I do like to pair an MRI in my clinic with weight bearing x-rays. And so, if I'm doing the workup from start, someone has knee pain, they haven't really been seen by their PCP much and they come straight to me. I'll get weight bearing x-rays first. And if those weight bearing x-rays show more than 50% joint space loss in that knee. And I know there's a little bit of arthritis and I know there's probably a degenerative type meniscus tear. If the x-rays shows bone on bone arthritis, then there really is no need the for an MRI to make the diagnosis.
There may be a role for MRI to determine what surgery to do and the extent of the disease and all that. But to make the diagnosis of just a simple weight bearing x-ray can often save people thousands of dollars in the time of getting an MRI. And so that's good to know, but if the MRI's already been had, and then we pair that with bone on bone arthritis, then a knee replacement is an option. Typically we do wanna wait until the x-rays show severe disease before considering a knee replacement. And so it can be a little frustrating for patients that don't quite meet the criteria for a knee replacement, but clearly have a real problem with their knee.
And I see this frequently, I mean, Multiple patients that are in that exact category. And it's frustrating for me. And it's frustrating for them because the knee is not normal. However, they're not quite yet a candidate for a knee replacement and it can be a very frustrating place to be for patients and the surgeons alike. And so that is why there's such a big market for all these injections and in a wa y, you gotta be careful with those injections because they're kind of targeted at a vulnerable patient population that would like to do anything to get pain relief, but they're not a candidate for surgery. Evo Terra:
well, thank you, Dr. Briggs for all the information. I hate that it's a waiting game for some of us, but now we've got more information and more information is always helpful. Dr. Dustin Briggs:
Yeah, I can't thank you enough for having me today, it can be a, it can be a frustrating diagnosis. It's a confusing diagnosis. And so hopefully we clarified a little bit today kind of what patients can expect when they come to us with a meniscus tear, because it's not quite as straightforward as what what it might seem just based on the MRI. Evo Terra:
And once again, that was Dr. Dustin Briggs orthopedic surgeon, helping us figure out whether or not knee replacement or meniscus tear surgery or other options is right for us. If you have more questions or you'd like to schedule an appointment with Dr. Briggs call 760-773- 4545, or go to Eisenhowerhealth.org/ortho. That's Eisenhower health.org/ortho. And thanks for listening to Living Well with Eisenhower Health, Healthcare, As It Should Be. I'm Evo Terra, stay well.