Meniscus tear/ lesion

Degenerative meniscus -marked by slow progression of tissue degeneration without a history of acute trauma (Abram et al., 2018) 

Meniscal tears- a defect or split in the meniscocapsular complex; can occur in a degenerative or non-degenerative meniscus (Abram et al., 2018); onset might sometimes be associated with twisting, kneeling or deep squatting activities 

Traumatic meniscal tears -usually sudden onset of knee pain with a sufficient knee injury mechanism- often cutting, pivoting, landing from height or jump (Kopf et al., 2020) 

Differentiation should be distinguished clinically based on aetiology and usual age range (see demographics section) (Kopf et al., 2020) 

Many meniscal tears are asymptomatic (Kopf et al, 2020) 

Wide age range for meniscal presentations (Abram et al., 2018):  

Traumatic tears: often sports related- therefore often associated with younger individuals (< 40) (Dawson et al, 2017).  Certain patterns of meniscal tear are thought more likely to cause symptoms (Abrams et al, 2018) 

Degenerative lesions/ tears:  

• Tend to occur in people > 40 years due to changes in the menisci (loss of elasticity, drier, more brittle) (Dawson et al, 2017). 

•  > 1/3 of people over 50 with no radiographic OA have meniscal pathology on MRI imaging (increases to 70% in those with OA) (Abram et al, 2018).   

• In symptomatic knees with degenerative lesions (usually > 40 years of age) there may be a history of minor or repeated trauma  (Dawson et al, 2017) 

Meniscal tear:  

• Mechanism: Typically report twisting of the affected knee (Tekeda, 2023); higher forces usually involved with younger individual vs lower forces required in patient with likely degenerative meniscal tissue 

• Swelling: may describe delayed swelling (hours following onset of symptoms) but not always present 

• Catching/ locking (mechanical symptoms) may be present (Tekeda, 2023; Abrams et al, 2018)- presence / absence should always be documented if meniscal pathology is expected and escalation considered- see escalation section  

• New clicking / painful clicking when moving knee- may or may not be present (Abrams et al., 2018)  

• Pain- very variable- can be localised or more diffuse (Tekeda, 2023); meniscal tear often characterised by sharp, localised, intermittent pain (Abrams et al, 2018) 

• Aggs: classically twisting and squatting activities 

Effusion: may or may not be present 

ROM: may be reduced 

Joint line palpation: Point tenderness at joint line +/- discrete palpable lump suggestive of possible swelling or extrusion 

Options for provocation tests: 

McMurrays 

Thessaly 

Apleys                                

                             (Abrams et al. 2018, Tekeda, 2023) 

A 2025 study comparing 2 orthopaedic surgeons' usage of Joint line tenderness, McMurray's, Apley, Thessaly, Ege, and Hyper-flexion tests in a group of 255 patients (188 of whom had arthroscopically confirmed meniscal tears) found that no single clinical test was sufficiently reliable for independent diagnosis but combining McMurray and Apley testing yielded the best accuracy.  Apply this finding with caution as this is not based on systematic review and the preferences of the assessors could have influenced their accuracy in utilizing specific tests (Rinonapoli et al., 2025) 

XR should be considered dependent on forces involved and pain levels to exclude fracture or osteochondral lesion; XR should also be considered in patients where OA could be a likely differential 

MRI is gold standard for imaging option for diagnosis of a treatable meniscal tear (and should be first line investigation where OA is not suspected) (Abrams et al., 2018). 

Within IRMER guidance for GGC (from IRMER guidance document IAP-2017-005) certain APP groups can arrange MRI imaging whereby there is a clinical scenario indicating meniscal tear or instability; patient has been symptomatic for ≥ 4 weeks; there is no XR evidence of OA (mandatory XR between 40-60 years).   

Types of tears: different terminology is often used- from consensus article around recommended terminology: 

Vertical (longitudinal/ radial/ bucket handle longitudinal); 

Horizontal (usually degenerative in nature) 

Radial tears (including flap) 

Posterolateral root tears 

Note. Ramp lesions are generally accepted to occur at the ligamentous connection between posterior horn or medial meniscus and tibial plateau and therefore do not affect actual meniscal tissue.                           (Kopf et al, 2020) 

Picture available of some tear types at https://bestpractice.bmj.com/topics/en-gb/826/aetiology  (you need to login to knowledge network with email and password- follow links to 'Open Athens' to do this)

(Tekeda, 2023) 

Risk Factors 

Participation in repetitive cutting, pivoting and landing activities (especially with rough or uneven playing surface and poor weather conditions) increases risk of meniscal injury in athletes.   

Work related lifting and carrying (over 4.5kg), kneeling, deep squatting, and a high volume of climbing all increase the risk. (Prill et al., 2025) 

Structural/ Other 

Discoid meniscus – normal variant of meniscal morphology; nearly always affects lateral meniscus.  Not common; highly susceptible to tear in early life (Trunz and Morrison, 2022) 

More Common incidence/ risk: 

Traumatic tears: can have other associated diagnoses including Bakers cyst; Ligament injury; Osteochondral defect; (Tekeda 2023) 

Degenerative lesion: Bakers cyst; OA; Gout; Pseudogout  

Less Common 

Traumatic tear: Medial synovial plica syndrome; Osteochondritis dissecans (Tekeda, 2023) 

Degenerative lesion: DISH (Diffuse Idiopathic Skeletal Hyperostosis)- more common in spine but can also affect peripheral joints including the knee with/ without OA changes (more common in males, overweight, HTN, DM) (Janneke et al., 2020) 

Fracture if traumatic (including osteochondral defect (Kim, 2019; Tekeda, 2023)) and SIFK (Subchondral Insufficiency fractures- previously known as SONK- Spontaneous Osteonecrosis of the Knee);  

DVT or Peripheral Arteria Disease if any risk factors/ lower leg involvement (Kim, 2019) 

Infective/ Septic arthritis 

Reactive arthritis 

Osteosarcoma/ other cancers

Intervention should be guided on the information below but also based on shared decision-making models with consideration given to mechanical symptoms, general knee pain, and knee pain during activity (including squat/ stairs/ twisting bending tasks) (Damsted et al., 2023) 

No clear guidelines on educational intervention in patients with meniscal related concerns. The DREAM trial (involving young patients with meniscal tears) involved education around the following:  

• Meniscal tears- pathoanatomy 

• Making sense of symptoms  

• treatments and prognosis 

• Structuring rehab around individual goals 

• Sustaining the motivation for continuous exercise  

• Return to sports and other activities and future goals  

                                       (Damsted et al., 2023)  

Interventions to resolve effusion, reduce pain, restore quads strengthen and regain joint specific motor control (hip/ knee/ core) may be advantageous in treating meniscus tears. 

Traumatic tears: Analysis of the DREAM trial RCT reported that early meniscal surgery did not appear superior to exercise and education in improving pain, function and quality of life after 12 months following a traumatic/ non traumatic meniscal tear in a group of patients aged 18-40 (Damsted et al., 2024).   

However, where significant pain or mechanical symptoms predominate this should be taken into account. 

Degenerative lesions: Robust evidence from multiple high-quality studies and consensus of expert reviews of comparable results with conservative or surgical management.   

Conservative management including physical therapy is recommended as first approach (provided no mechanical symptoms of concern) with escalation for consideration of surgery only where there has not been a satisfactory outcome (see escalation section for more info) (Lee et al., 2018; Zhang et al., 2021; Prill et al., 2025) 

Degenerative lesions: Manual therapy and joint mobilisation techniques may be applied (In addition to exercise training). (Prill et al., 2025)

Platelet rich plasma injections (Akkawi et al., 2022) 

Hyaluronic acid injections (Akkawi et al., 2022) 

Factors that influence response to rehab for traumatic meniscus tears is unclear.  Possible factors might include: biomechanics, BMI, co-morbidities, psychosocial factors, smoking status, age, occupations, levels of physical activity and engagement with physio (Prill et al., 2025) 

Middle aged and older patients with a meniscal tear seem to overestimate the effectiveness of surgery in terms of participation in daily life activities such as walking and sports activities.  (Noorduyn et al., 2020) 

Predictive factors of poor results after arthroscopic partial meniscectomy for degenerative meniscal lesions include age at surgery, obesity, meniscal extrusion, duration of clinical symptoms, bone marrow oedema, complex or large tears, lateral meniscal lesions and misalignment (Akkawi et al., 2022) 

Joint contact mechanics are altered in the meniscal deficient knee- this may contribute to the progression of degenerative changes.  The risk of developing OA after partial meniscectomy is variable.  In 30-40% of patient radiographic OA-like changes are present within 5 years and > 50% of partial meniscectomy patients will develop OA within 10-20 years

Traumatic tear/ younger 

• Urgent referral if knee locked (True Locking - passively block in to extension; consider urgent SCI referral -which could be vetted to acute knee clinic where available; or attendance at Minor Injuries may be appropriate if acute, for escalation to fracture clinic- discuss with senior clinician if unsure)

• Surgery considered if mechanical symptoms are significant or persist despite rehabilitation, subject to further imaging 

• Consider early referral for those less than 25 years of age as may be suitable for meniscal repair. 

Degenerative 

• Mechanical symptoms following appropriate rehabilitation, such as locking or instability, inability to return to work/usual activities of daily living; in the absence of any significant OA. 

Abram, S.G.F., Beard, D.J., Price A.J. (2018) National consensus on the definition, investigation, and classification of meniscal lesions of the knee. The Knee.  Vol 25(5); pp. 834- 840. Available at https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0968016018303934.pdf?locale=en_US&searchIndex= [Last accessed 13/03/26]  

Akkawi I, Draghetti M, Zmerly H. Degenerative meniscal lesions: Conservative versus surgical management. Acta Biomed. 2022 Jan 19;92(6):e2021354. doi: 10.23750/abm.v92i6.11195. PMID: 35075086; PMCID: PMC8823549.  

Damsted C, Thorlund JB, Hölmich P, et al. Effect of exercise therapy versus surgery on mechanical symptoms in young patients with a meniscal tear: a secondary analysis of the DREAM trial. British Journal of Sports Medicine 2023;57:521-527.  

Damsted, C., Skou, S.T., Holmich, P. et al. Early Surgery Versus Exercise Therapy and Patient Education for Traumatic and Nontraumatic Meniscal Tears in Young Adults—An Exploratory Analysis From the DREAM Trial. J Orthop Sports Phys Ther 2024;54(5):340-349. Epub 22 February 2024. doi:10.2519/jospt.2024.12245  

Dawson LJ, Howe TE, Syme G, Chimimba LA, Roche JJW. Surgical versus conservative interventions for treating meniscal tears of the knee in adults. Cochrane Database Syst Rev. 2017 Sep 7;2017(9); Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6483631/ [Last accessed 16/04/26]  

Jonneke S. Kuperus, Firdaus A.A. Mohamed Hoesein, Pim A. de Jong, Jorrit Jan Verlaan,  Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance, Best Practice & Research Clinical Rheumatology, Volume 34, Issue 3, 2020, https://doi.org/10.1016/j.berh.2020.101527. 

Kopf, S., Beaufils, P., Hirschmann, M.T. et al. (2020) Management of traumatic meniscus tears: 2019 ESSKA meniscus consensus. Knee Surgery, Sports Traumatology, Arthroscopy.  Vol 28. pp 1177- 1194; available at https://pmc.ncbi.nlm.nih.gov/articles/PMC7148286/pdf/167_2020_Article_5847.pdf [Last accessed 12/03/26]  

Kim YJ. Red flag rules for knee and lower leg differential diagnosis. Ann Transl Med. 2019 Oct;7(Suppl 7):S250. doi: 10.21037/atm.2019.07.62. PMID: 31728374; PMCID: PMC6828998 

Lee, DY., Park, YJ., Kim, HJ. et al. Athroscopic meniscal surgery versus conservative management in patients aged 40 years and older: a meta-analysis. Arch Orthop Trauma Surg 138, 1731–1739 (2018). https://doi.org/10.1007/s00402-018-2991-0  

Noorduyn JCA, Glastra van Loon T, van de Graaf VA  et al. Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial. Orthop J Sports Med. 2020 Oct 29;8(10):2325967120954392. doi: 10.1177/2325967120954392. PMID: 33195707; PMCID: PMC7607803.  

Prill, R., Ma, C.B., Wong, S.E. et al. (2025) The formal EU-US Meniscus Rehabilitation 2024 Consensus: An ESSKA-AOSSM-AASPT initiative.  Part II- Prevention, non-operative treatment and return to sport. Knee SUrgery Sports Traumatology Arthroscopy. Vol 33(8), pp. 3014- 3024.  Available from https://esskajournals.onlinelibrary.wiley.com/doi/10.1002/ksa.12689 [Last accessed 06/05/26]  

Rinonapoli, G., Luchetta, L., Ancillai, G. (2025) Clinical reliability of 6 meniscal tests: a diagnostic accuracy study of 255 patients. Acta Orthopaedica. DOI 10.2340/17453674.2025.43906 [Last Accessed 19/05/26] 

Tekeda, H. (2023) BMJ Best Practice Meniscal tear). Meniscal tear - Diagnosis Approach | BMJ Best Practice [Last accessed 29/04/26)  

Trunz, L., Morison, W. (2022) MRI of the knee meniscus. Magentic Resonance Imaging Clinics. Vol 30. Pp 307- 24.  Available at https://www.mri.theclinics.com/article/S1064-9689(21)00734-0/fulltext [Last accessed 16/04/26]  

Zhang Y, Cao W, Cao Q, Zhu Y. Comparative effects on pain arising from injury to the knee meniscus in adults: A systematic review and network meta-analysis. Clin Rehabil. 2021 Jun;35(6):801-811. doi: 10.1177/0269215520976649. Epub 2020 Nov 30. PMID: 33256428.