Discharge Instructions - Meniscus Injury

As discussed in the Emergency Department prior to discharge, based on our evaluation you may have a meniscus tear.  A meniscal tear is a condition that causes knee pain and other knee symptoms.  It happens when a part of the knee joint called the "meniscus" tears.  The meniscus is the cushion of rubbery material (cartilage) between the thigh bone and shin bone.

There are different kinds of meniscal tears, depending on the part of the cartilage that tears and how it tears.  A meniscal tear can happen suddenly, such as during a sports injury.  It can also happen slowly over time.  This is more common in older adults.

Symptoms of a meniscal tear can include: knee pain, knee swelling (from a collection of fluid around the knee), the knee locking, not straightening all the way, or feeling like it "catches" on something as it straightens, the knee giving out, feeling unstable, or feeling like it won't support you, an knee stiffness.

You may have had x-rays of the affected knee in the Emergency Department and the results have been discussed with you prior to discharge.  Many people are curious about whether they will need more advanced imaging such as an MRI or magnetic resonance imaging.  These studies can only be obtained in the Emergency Department when there is a chance that an emergency surgery needs to be done.  It is possible you will need additional imaging, including an MRI, but this will need to be ordered by your primary care provider.  This is because this study will usually require referral to physical therapy and possibly to Orthopedics for surgery.

In some cases, the MRI is inconclusive, and patients suspected of having a meniscal tear are referred for a surgical procedure called an arthroscopy.  This lets the doctor look inside your knee at the meniscus.  During arthroscopy, the doctor makes a few small cuts around the knee.  Then he or she inserts long, thin tools into the knee joint.  One tool has a camera on the end that sends pictures to a TV screen that the doctor sees.  If you have a meniscal tear, the doctor can use the other tools to treat it.

There are several ways to reduce swelling in the injured knee and to help the healing process:

-Elevate the injured knee.  This can be done by putting your leg up on a chair when sitting down (watching TV, reading, eating dinner, etc.).

-If the knee is swollen or painful, apply ice wrapped in a towel (or a bag of frozen peas wrapped in a thin towel) on the knee for about 10 minutes at a time.  Then remove the ice pack and allow the skin to return to normal temperature before re-applying the ice pack (to avoid frostbite).  Continue this while the knee is still swollen; do not apply heat while the knee is swollen.

-A tensor bandage can be wrapped around the knee to provide more support over the lengthy healing period.  This bandage can be removed when applying ice to the knee.

-If the sprain was severe, you may have been provided with a splint or immobilizer during your visit to the Emergency Department.  Use the splint as directed by the emergency physician.

You can take Acetaminophen (also known as Tylenol), Ibuprofen (also known as Advil or Motrin), or Naproxen (also known as Aleve) for the pain.

https://orthoinfo.org/en/diseases--conditions/meniscus-tears/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

MDM - Knee Meniscus Injury

[##]-year-old [male/female] with [right/left] knee pain with history and exam consistent with likely patellofemoral pain syndrome (“runner’s knee”).

Initial consideration in this patient included medial and lateral meniscus injury, ligamentous injury to the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL), knee dislocation, patellar and other knee fractures, patellar and quadriceps tendon injury or rupture, arthritis, pes anserine and prepatellar bursitis, and septic arthritis among others.

Patient present with [right/left] knee pain in the setting of [describe injury] concerning for ligamentous and meniscal injury to the knee.  Patient [reported/denied] episodes of locking and clicking of the [right/left] knee.  Patient noted to have tenderness to palpation [over the medial/lateral joint line concerning for ligamentous injury] on exam.  Specialized testing performed on the [right/left] knee as noted above with [positive McMurray test suggestive of medial meniscus injury].  Imaging of the [right/left] knee [felt to not be indicated in a patient meeting all Ottawa Knee Rules/with no evidence suggestive of bony injury on exam/obtained with plain films noted to be unremarkable/ findings].  The patient was noted to have no evidence of associated [collateral/cruciate ligament/any other] injuries.  Patient provided with [compression sleeve/knee immobilizer/crutches] in the ED prior to discharge [and noted to have improved pain after treatment with Toradol/etc.].

Prior to discharge, we discussed return precautions, symptomatic treatment with rest, ice, compression, and exercises as described in the handout provided at time of discharge, and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.  We specifically discussed that while additional imaging, including MRI, may ultimately be a part of the management of this condition, it is not part of the emergent management of this condition.  We recommended close follow up with their primary care provider for further discussion of additional imaging, and the patient demonstrated understanding and agreement.

https://orthoinfo.org/en/diseases--conditions/meniscus-tears/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

Physical Exam - Orthopedic Knee Exam

[No/Minimal/Moderate] isolated tenderness to palpation over the patella of the [right/left] knee.  [No/Minimal/Moderate] tenderness to palpation at the head of the [right/left] fibula.  [Limited/full] active range of motion of the [right/left] knee to [90/##]°.  [Limited/full] passive range of motion of the [right/left] knee to [90/##]°.  Patient [not able/able] to ambulate 4 steps in the ED [despite pain/due to pain]. 

[No/Mild/Moderate] instability on valgus (medial) stress of the [right/left] knee.  [No/Mild/Moderate] instability on varus (lateral) stress of the [right/left] knee.  [Negative/Positive] Lachman's test (instability with anterior stress on the knee in 15-30° flexion).  [Negative/Positive] anterior drawer test (instability with anterior stress on the knee in 90° flexion).  [Negative/Positive] posterior drawer test (instability with posterior stress on the knee in 90° flexion).  [Negative/Positive] McMurray's test of lateral meniscus (pain when knee is brought from full to 90° flexion while leg is externally rotated with compression over the medial joint line).  [Negative/Positive] McMurray's test of medial meniscus (pain when knee is brought from full to 90° flexion while leg is internally rotated with compression over the lateral joint line). 

[Remainder of extremity exam unremarkable.]

https://www.orthobullets.com/recon/12755/knee-physical-exam--adult