Knee Mensicus Tears – Accelerate Osteoarthrtis or Bistander?

A Recent Framingham study has demonstrated on MRI:

  • By age 69, 50% have meniscial tears; it is more common in women
  • 61% of these tears were asymptomatic
  • In cases of Osteoarthritis, those with symptoms 63% had cartilage tears, without symptoms were 60%.
  • If no osteoarthritis but symptoms, 32% had cartilage tears; versus 23% tears in those without symptoms.

Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons
Martin Englund, M.D., Ph.D., Ali Guermazi, M.D., Daniel Gale, M.D., David J. Hunter, M.B.,B.S., Ph.D., Piran Aliabadi, M.D., Margaret Clancy, M.P.H., and David T. Felson, M.D., M.P.H.
N Engl J Med 2008;359:1108-15.September 11, 2008

The question is whether the meniscus tear is due to the same process that caused the osteoarthritis or whether the tear accelerated the osteoarthritis. There was a recent review that discussed this issue:

Rheum Dis Clin North Am. 2008 Aug;34(3):573-9. The role of the meniscus in osteoarthritis genesis. Englund M. abstract

The didn’t seem so sure:

“A degenerative lesion in the middle-aged or older patient could suggest early-stage knee osteoarthritis and should be treated accordingly. Surgical resection of nonobstructive degenerate lesions may remove only the evidence of the disorder while the osteoarthritis degradation proceeds. Well-designed randomized, controlled clinical trials are needed.”

His early discussion of this is abtracted here

An earlier article agreed:

J Bone Joint Surg Am. 2003 Jan;85-A(1):4-9.

The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee.
Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, Einhorn TA, Felson DT.

abstract

“CONCLUSIONS: Meniscal tears are highly prevalent in both asymptomatic and clinically osteoarthritic knees of older individuals. However, osteoarthritic knees with a meniscal tear are not more painful than those without a tear, and the meniscal tears do not affect functional status. These data do not support the routine use of magnetic resonance imaging for the evaluation and management of meniscal tears in patients with osteoarthritis of the knee.”

It is also suggested cartilage tear may help accelerate the problem:

1) Am J Sports Med. 2007 Oct;35(10):1756-69. Epub 2007 Aug 29. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Lohmander LS, Englund PM, Dahl LL, Roos EM.
abstract

“Injuries of the anterior cruciate ligament and menisci are common in both athletes and the general population. At 10 to 20 years after the diagnosis, on average, 50% of those with a diagnosed anterior cruciate ligament or meniscus tear have osteoarthritis with associated pain and functional impairment: the young patient with an old knee.”

However they do then say “There is a lack of evidence to support a protective role of repair or reconstructive surgery of the anterior cruciate ligament or meniscus against osteoarthritis development.”

2) A cross-sectional “survey” found OA worse in those with cartilage tears:

J Rheumatol. 2007 Apr;34(4):776-84. Epub 2007 Mar 15. Meniscal tear as an osteoarthritis risk factor in a largely non-osteoarthritic cohort: a cross-sectional study. Ding C, Martel-Pelletier J, Pelletier JP, Abram F, Raynauld JP, Cicuttini F, Jones G. abstract

“Importantly, meniscal tear is associated with cartilage defect, loss of cartilage volume, alteration in bone size, and prevalence of radiographic OA, suggesting that meniscal tear in non-OA subjects appears to be an early event in the disease process, and may be a risk factor for knee cartilage damage and articular structural changes”

3) A followup study found the same:
Arthritis Res Ther. 2007;9(2):R21. Knee meniscal extrusion in a largely non-osteoarthritic cohort: association with greater loss of cartilage volume. Ding C, Martel-Pelletier J, Pelletier JP, Abram F, Raynauld JP, Cicuttini F, Jones G. abstract

They followed people for two years and those without OA but with a tear, deteriorated more rapidly.

“Most importantly, meniscal extrusion at baseline is associated with greater loss of knee cartilage over 2 years, and this seems to be mediated mostly by subchondral bone changes, suggesting extrusion represents one pathway between bone expansion and cartilage loss.”

4) The above was expanded on here by same authors:

Arthritis Res Ther. 2007;9(4):R74. Risk factors associated with the loss of cartilage volume on weight-bearing areas in knee osteoarthritis patients assessed by quantitative magnetic resonance imaging: a longitudinal study. Pelletier JP, Raynauld JP, Berthiaume MJ, Abram F, Choquette D, Haraoui B, Beary JF, Cline GA, Meyer JM, Martel-Pelletier J.

free article here

Comment – there are discordant views on the subject.
It seems to me that if the symptoms are more of one of OA – no real catching on history and no soft end point cartilage flexion or extension restriction, then OA might bve the prime issue and cartilage consideration should be minimal. However is there is a history of catching, there is restriction on flexion/extension , and knee mobilizations techniques temporarily give significant improvement, then the cartilage may need more attention. If there is no OA on xray, then that knee needs scoping.
Any views on the subject? canada goose frauen canada goose frauen

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