Maggie McKay (Host): Our knees are hard workers, and we probably don't give them much thought until they give way and they don't work. So today, we're going to find out about meniscus tears and how to treat them non-surgically as well as surgically with orthopedic surgeon, Dr. James Friedman.

Welcome to Hello Healthy, a Dignity Health podcast presented by Dignity Health. I'm Maggie McKay. Welcome, Dr. Friedman. Thank you so much for being here and making the time.

James Friedman, MD: Yes, of course. Thank you for having me.

Host: So just to start, what is the meniscus, first of all? Is it cartilage?

James Friedman, MD: That's a good question. Yes and no. So, there's a couple of different types of cartilage. So, it can be a little bit confusing when we talk about cartilage in general. Essentially within our knees at the ends of our bones, we have a cartilage layer that's more like a marshmallow layer, and that's usually what we talk about when we're referring to cartilage. The meniscus is a type of cartilage. But unlike the marshmallow layer, it's more like rubber and it acts like a shock absorber that sits in between the two cartilaginous layers at the end of the bone. The role of the meniscus is therefore to act as a shock absorber to protect the softer cartilage from damage when we're walking and running and doing all the things we do with our knees.

Host: What are the most common causes of tears?

James Friedman, MD: So in my mind, there's three things that cause meniscus to tear. The first is traumatic. So, that would be like your 18-year-old football player that gets tackled on the field and the knee gets hit so hard that it causes this rubber meniscus to just tear. The second one is associated with arthritis. And so, arthritis is the wearing down of that softer cartilage that we were talking about, the marshmallow layer. And as it wears down, it acts like a sandpaper and it sort of grinds into our meniscus. And as it grinds into the meniscus, it causes that meniscus to tear. The third kind, which is more recently been understood, comes from the stretching of the meniscus or basically where the meniscus is overworked. So, you can imagine if you put a thousand-pound backpack on your back today and walked around with it for the next 10 years, the meniscus would start to stretch and even tear under that strain.

Host: What's the worst habit we do that harms our knees? Would it be running or something like that?

James Friedman, MD: Actually, running has not been associated with meniscus tears. There's two things that I think is the most common reason to cause meniscus tears. One is folks who are doing high intensity exercises with poor form. So, for example, box jumping at a gym. If you're landing and your knees are twisting under you, that's putting a lot of stress on your meniscus. And so, it's really important when we're doing these high level activities that we really make sure that our legs are strong, that our muscles are strong, and that we're using good technique.

The other one is weight. So, every pound on your body is about seven pounds on the knees. And so even being a little bit overweight can put a lot of stress on our knees. And more and more what we're seeing in our population is people in their 40s and even 30s are getting that third type of meniscus tear where the prolonged excess weight is starting to cause stretching and tearing of the meniscus.

Host: So, are we talking about like obese people or...?

James Friedman, MD: Obese, yes. Obviously, it's a spectrum. But even being overweight can start to affect your meniscus and cause early wear.

Host: Wow. So, what are the symptoms? How do you know that that's what's going on when your knees hurt?

James Friedman, MD: So usually with meniscus tears, if it happens after an acute injury, or if it's this stretching and tearing from too much weight, usually there's an acute event. You twisted just the wrong way, you were standing from a chair, you got tackled in football. Most people describe feeling a pop or a sudden pain followed by a little bit of swelling in the knee. Usually following that, they'll just have an achy pain in the knee, that sometimes is accompanied with a feeling of locking or catching or popping.

Host: How common a problem are meniscus tears?

James Friedman, MD: They're extremely common. The reason for that is because knee arthritis is very common. Now, most of what we've been talking about so far are those first two kinds where either you get tackled in football or you have a lot of weight going down on the knee. But the most common meniscus tear actually happens with the folks with arthritis. Almost everybody with arthritis in their knee will have meniscus tears, because that arthritis grinds into the meniscus, it will tear.

Host: So, take us through how you would treat it with surgery and without.

James Friedman, MD: Sure. So if we want to make the decision between surgery and non-surgery, we first have to understand what the meniscus is doing, which is that, as I said, was to protect the cartilage. If you're an 18-year-old who has perfect cartilage, but you've torn your meniscus, we wanted to do surgery to try and repair the function of that meniscus to protect your cartilage. That's very different than somebody with, say, arthritis, where the cartilage has ground into the meniscus and caused it to tear. Then, we need to make the decision, is the pain coming from the meniscus? Or is it coming from the cartilage wearing down? And that sometimes can be very difficult to figure out.

You'll get a lot of different opinions from different doctors, but the literature more and more is showing that cleaning out a meniscus in somebody with arthritis, usually only provides short-term benefit at best, no longer than anywhere from six months to two years.

Host: So, it sounds like they can reoccur, meniscus tears?

James Friedman, MD: Yes. In all scenarios, they can recur. So, starting with the 18-year-old who got tackled during football, we can do a repair, but it may not completely heal, or they may have another injury that just causes it to re-tear. When we do repairs in athletes, there's a fail rate of anywhere between 10 and 20%, depending on the size of the tear. So, those can absolutely recur. For that second type that we talked about where the meniscus stretches out over time, that has actually a much higher healing rate. But that can also fail as high as 5%$ to 10%. And then, when we're talking about the tears that come from arthritis, the meniscus will just continue to shred and tear as that arthritis progresses.

Host: When you say repair, does that mean surgery?

James Friedman, MD: Yes. Thank you for asking. Yes. So, anytime we do a cleanup of the meniscus where we cut out the torn portion, or if we repair it, that is arthroscopic and sometimes even open surgery. To repair it, we use suture to essentially tie the meniscus back to itself.

Host: And what about non-surgically?

James Friedman, MD: So, non-surgically is usually treated with a combination of rest to allow the inflammation in the knee to go down, anti-inflammatory medications like ibuprofen or Tylenol. We use physical therapy to work on strengthening the muscles around the knee to help support the knee. And finally, just time. So oftentimes, if you have a meniscus tear, that tear will sort of settle back into its original spot, and the pain will go away.

Host: That's amazing. I opt for that option. The one time I had a knee issue, they gave me a cortisone shot, does that make sense, in the knee.

James Friedman, MD: Yeah. So, corticosteroids are also very good. That's another form of anti-inflammatory. Those injections do help get rid of the inflammation in the knee. And oftentimes, we do that for meniscal tears as well, usually in the population with arthritis. We try to avoid those in the younger athletes.

Host: What about recovery? How long is physical therapy? Is it always mandatory?

James Friedman, MD: If we're not doing surgery, recovery is really as long as it takes for the pain to go away. Occasionally, the pain doesn't go away with nonoperative treatment and then we can decide is the soft cartilage intact enough that we want to try a meniscus cleanup? Or sometimes, we discuss going straight to a total knee replacement. So, non-operative doesn't have a set time for recovery. Hopefully though, people start to see results within six weeks.

Host: That's pretty fast.

James Friedman, MD: Yes. So usually, after a tear, people do recover quite quickly if they're going to recover without surgery. With surgery, if you just cut out the torn part of the meniscus, the recovery is quite quick, people should be seeing results within two to six weeks. If they're not seeing results, then oftentimes the pain wasn't coming from the meniscus tear and it's coming from cartilage degeneration. And then finally, if we do a meniscus repair, recovery is much longer because it takes a long time for that meniscus to heal. And so oftentimes, people aren't returning to their activities for up to four to six months.

Host: So, let's say you have a patient who put it off, put it off and said, "Oh, it just hurts. It'll get better on its own," and then It didn't. What happens when you put that off and you don't even know you have a meniscus tear?

James Friedman, MD: It depends on what caused the tear. If this is your 18-year-old football player, who waited because they didn't want to take the time off for surgery, it makes the repair much more difficult and much less likely to heal. And so for the 18-year-old football player, it's a big deal to put off that surgery, much different than somebody with arthritis with the tear. So, for somebody who puts off the surgery, they haven't actually caused necessarily any more damage by waiting. So, oftentimes, we will wait in somebody who has arthritis with a meniscus tear to see if they get better on their own. If they don't get better, like I said, then we can decide whether or not we want to go in and try and trim the meniscus or take out the torn portion, or if we need to talk about a total knee replacement.

Host: So, is there a way to prevent meniscus tears? Obviously if you have arthritis, you can't do anything about that, but are there things we can do to prevent getting them?

James Friedman, MD: I think a balance of controlling weight and exercise. It's sort of the cure-all for everything these days, but that does help with the meniscus. So, controlling your weight does take a lot of the pressure off of the meniscus and will help prevent tears. And then, keeping up with exercise, so keeping your legs strong, keeping your quadriceps strong does help stabilize the knee and helps prevent injury to the meniscus.

Host: My trainer was saying that It's a myth. Tell me if that's accurate, like we were talking about earlier, that running is bad for your knees. He said it's actually pretty good for it because it keeps them moving. Is that right?

James Friedman, MD: It's controversial. There was actually a study that came out of the New England Journal of Medicine that found that long distance runners do not have higher incidences of arthritis in the knees. However, that being said, folks who intermittently run or who aren't doing a lot of exercise but then go out and run a hundred miles in a day probably are putting themselves at higher risk just because their muscles aren't strong enough to support the knee during that increase in activity.

Host: Is there anything else you'd like to add in closing that we didn't cover that you'd like people to know about meniscus tears?

James Friedman, MD: I think it's important to understand that just because you have a meniscus tear doesn't mean that you have to have surgery. And I think that especially as we get older, meniscus tears are quite common, and many people do just fine without surgical management.

Host: Well, that's very encouraging. Thank you so much for sharing your expertise and talking with us today.

James Friedman, MD: Of course. My pleasure.

Host: Again, that's Dr. James Friedman. And if you'd like to find out more, please visit dignityhealth.org/stockton/ortho. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. This is Hello Healthy, a Dignity Health podcast presented by Dignity Health. Thanks for listening.