What does the following MRI report for tear in laeral meniscal root indicate?

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Posted on Tue, 9 Jun 2015 in X-ray, Lab tests and Scans
Question: **PLEASE READ: I would like for this question to be answered by Dr. XXXXXXX Chail**

I was diagnosed with a partial tear of the left lateral meniscal root at the posterior horn in early March of 2015. I previously uploaded my original MRI study (performed on March 4th) and received advice from you on this website regarding the severity of the tear. Yesterday (May 20th), I had a follow-up MRI study performed to assess whether the injury has healed or gotten worse. I have included a link to the follow-up MRI study below; I have also included a link to the original MRI study for the purpose of comparison.

Based on the follow-up MRI study, does the injury look like it has healed to any degree, or has it gotten worse? Also, is any meniscal extrusion present?

Thanks...

Link to original MRI study (March 4th, 2015):

https://docs.google.com/file/d/0B4peHkrULoWbNEV0WmVzSlRDTFU/edit?pli=1

Link to follow-up MRI study (May 20th, 2015):

https://drive.google.com/file/d/0B4peHkrULoWbdG9aeHJISzdteFE/view?usp=sharing

Thanks...
doctor
Answered by Dr. Vivek Chail 55 minutes later
Brief Answer:
Healing changes are taking place in the injured area

Detailed Answer:
Hi XXXX,
Thanks for writing in to us.

I have read through your query in detail.
Please find my observations below.

Hoping that you have found relief in the rehab measures provided to you.

1. The posterior horn of lateral meniscus root tear is showing healing changes in the area. Complete healing will take time. It is clearly seen to be healing but how much strength will be regained is the question that is to be answered.

2. It has not worsened and there is no meniscal extrusion.

3. The problem with your tear is that there is a high chance of repetitive injury which will further cause worsening if you start with your regular locomotion and physical activities.

4. At your age, one will always like to participate in activities like running and doing fitness regimes. Tears in this region need to be stabilized and then this will provide adequate strength and surgery which will prevent worsening.

5. In a young individual at your age, maximum mobility is required without any risk to further injury.

I would like to hear how you feel about the discomfort and pain right now? Have you been clinically assessed for knee pain and discomfort by your therapist regularly?

I wish to continue with further discussion based on your present problems and try to discuss ways in which they can be solved.

Hope this answers your question. Please feel free to correct any oversight in my interpretation of your problems and discuss them in detail as per your requirements.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Vivek Chail 40 minutes later
Dr. XXXXXXX thanks for the information. Regarding pain/discomfort, it doesn't hurt as badly as it did several months ago when I posted the original MRI, but there is still some pain. I mostly feel it when I stand and put weight on the knee and bend it downward and inward (I.e., medially). It's not really a "severe" pain.

I will be seeing my local orthopedic surgeon within the next few weeks to review my MRI and current symptoms.

Can I ask you to provide more details about the healing changes that have occurred? For example, has scar tissue completely filled-in the site of the tear? Or has it only partially healed with scar tissue, with some of the torn portion remaining unhealed?

You mentioned that I risk making the tear worse with repetitive injury if I start engaging in physical activities (such as running) too soon. Do you think it's a bad idea to use the elliptical? The reason I ask is because I have continued to use the elliptical on almost every day of the week since I was diagnosed with the root tear in early March, so I'm wondering if my use of the elliptical may be preventing the tear from healing fully. Do you think that the elliptical could cause the tear to get worse? I feel mild/moderate pain and stiffness when using the elliptical, but it is more widespread and not sharp or acute.

Thanks....
doctor
Answered by Dr. Vivek Chail 7 hours later
Brief Answer:
Elliptical is fine for short duration exercise and without increase in pain, pending clinical examination

Detailed Answer:
Hi XXXX,
Thanks for writing back with an update.

1. Glad to know that the pain is less and is mild in nature. This further confirms that the healing is occurring though at a slow pace. Usually ligaments and menisci take at least 6 weeks and because the knee is a large weight bearing joint, therefore the healing might take a more gradual and steady course.

2. In the MRI, the lateral meniscus posterior horn appears more regular and clear. At the time of injury the margins were slightly hazy and presently it appears with regularity. The scan does not show the scar in detail but there is some amount of structural order noted as compared to the scan immediately after the injury was detected.

3. The elliptical is a good exercise method and does not allow much pressure on the knee. From the biomechanics of the knee, the elliptical there is less amount of stress on the legs and meniscal tears usually happen due to twisting injury. Elliptical has been recommended for those with minor meniscal tears with no or minimal pain. Joint mobility and stabilization of the knee joint are prerequisite before using elliptical and I hope that your joint mobility and stabilization are normal.

Running is a scale higher than elliptical and is recommended only after your pain level is made comfortable. There is also a small chance of degenerative changes happening earlier in your knee and therefore using a combination of elliptical and running for shorter distances might be a better option than running alone.

4. If your surgeon recommends surgery, it is to reinforce strength at the injured meniscal root area. The healing of the posterior horn lateral meniscal tear is not adversely affected by the elliptical however under light exercise schedules, however, should there be increase in pain even by a bit then the duration of time on the elliptical requires to be decreased. There are other structures like the patellar tendon that might be under stress when using an elliptical but I don’t think you have any such risk presently.

5. You might try wearing a knee support or comfort when working on the elliptical and watch if the stiffness and moderate pain are under control. Please do discuss this at the next appointment with your orthopedician and he might do certain leg maneuvers to examine the stability, muscle strength and mobility at the joint. Further continuation of your physical activities depends on these three factors.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Vivek Chail 4 hours later
Dr. XXXXXXX thanks for the additional information. At this point, do you think the tear will undergo any further healing? The tear probably occurred sometime in February (there wasn't an acute twisting/pivoting injury, so I don't have an exact date of when the injury occurred), so I wasn't sure if further healing was possible since it has already been almost 10 weeks or more.

Do you think it is a bad sign if there is still catching/popping? Is this unlikely to heal on its own?

Also, I have read that meniscal tears heal back with tissue that is not as capable of bearing weight as the original meniscal tissue.... do you know if this is true?

In general, is it possible for you to tell how much of the tear has healed as compared to how much of the tear is still present (e.g., "60% of the tear has healed, 40% of the injury is still torn")?
doctor
Answered by Dr. Vivek Chail 11 hours later
Brief Answer:
It might be possible that 40 percent of your injury has healed

Detailed Answer:
Hi XXXX,
Welcome and thanks for writing back with an update.

1. The features I observe are distinctly showing that healing has progressed from the earlier scan and I am certainly hopeful that it will continue.
2. I do agree that the exact date of your injury is difficult to recall, however I request some more insight in to your injury to know what exactly made you to consult the orthopedician?

Was there sudden sharp pain one fine day in the knee and restriction of movements occurred or was is a slow dull pain which was under control but increased on running?

This is in context to know that if you have a chronic tear or there was weakness and laxity and an acute partial tear. It is quite difficult to make out if a tear is acute or chronic purely on MRI scan but since there is no other injury associated with the lateral meniscus posterior horn root tear therefore I am guessing that it must be a long duration chronic tear which you experienced as increased pain on doing running exercises. Usually patients having acute lateral meniscus posterior root tears also present with injury to the anterior cruciate ligament and this is a complex injury, requiring surgical manipulation in most cases.
In case of meniscal injuries, a few months can be accepted as healing progresses. If we agree to the fact that you have been running long distance for few years then it might be possible that the injury first started appearing more than over 6 months ago, probably you might remember any particular day when you first felt little discomfort in your knee and that is the day the meniscal injury might have surfaced.

In the above setting, 10 weeks is not sufficient time for complete healing.

3. The symptoms of catching and popping might signify meniscal locking and if this persists then many doctors advise surgery. If allowed to stay, locking injuries cause significant pain, discomfort and restrict proper knee movements.

4. There are certain areas of the menisci which have good blood supply and rest of it might have less blood supply which limits regain of strength. In this case the weight bearing is reduced. This is the reason surgeries are becoming more common in meniscal injuries and wherever possible reinforcement of the meniscal tear is also done.

5. Meniscal tears healing is difficult to assess on regular scans. Technically there are certain sequences which show healing better and these are still under research and exploration. If you ask me to give an independent opinion based on the scan then my score will be 40 percent healed and 60 percent healing in progress. Please note that my opinion is subjective in nature and an approximation and provided at your request. In reports we usually do not mention amount of healing due the delicate nature of the entire healing process.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 1 hour later
Dr. XXXXXXX thanks for providing the additional information. To answer your question, the local orthopedic surgeon I have consulted thinks the tear is chronic/degenerative, not acute. The symptoms originally began in early-to-mid January with mild stiffness of the knee that was noticed during the 2-4 hours after running, but there was no pain at that point. However, during the last week of February, my knee actually started hurting during running. On the Monday of that week, the knee only hurt a little bit... the next day, the pain was worse... on Wednesday (the next day), the pain was even worse... and then the following day (Thursday), the pain was so severe that I had to stop running about halfway through my route. I have not run since that day.

In your opinion, do chronic/degenerative root tears heal better than acute root tears?

Also, based on my MRI studies, does the tear look like it is in the red (healing) zone?

To provide more information on the catching/popping, I don't think it is actual locking of the knee, because (so far) there have not been any instances in which I have been unable to bend/unbend the knee. Also, this is hard to describe, but it feels as if a smaller "piece" is popping/catching as compared to 1-2 months ago. I usually feel/hear it pop/catch when I place the medial portion of my foot/toe against the ground and twist the foot laterally while moving the leg forward at the same time (at the end of this movement, the medial portion of the foot is almost perpendicular to the opposite foot).
doctor
Answered by Dr. Vivek Chail 8 hours later
Brief Answer:
There is chronic tear without destruction of joint cartilage surface

Detailed Answer:
Hi XXXX,
Welcome and thanks for writing back with an update.

1. It appears that your situation might have been a acute on chronic injury. By this I mean that the injury was progressing slowly through January and then in a week it worsened with continued stress. For practical purposes, it is a chronic tear which has happened over weeks.

2. When we consider acute and chronic or degenerative tears, there are few things that require to be discussed.

Among acute and chronic tears, there is a distinctive pattern of acute tear seen in younger patients and chronic tear seen in older patients. In this setting, repair of acute tears is more effective than that of a chronic tear in which case there are many other degenerative changes that are also present and require attention. There is also a middle group including patients like you who are probably in the younger age group and have a chronic tear without any cartilage destruction and joint degenerative changes.

In the above cases, an acute tear patient does well with repair while in the chronic tear with degenerative changes group, partial meniscectomy shows better outcome.

Coming back to the surgical treatment algorithm to be followed in your case, you are in the middle group where there is chronic tear with no significant cartilaginous changes. In this group, the treatment offered is repair.

3. The meniscus root is a vascular area and therefore heals well following surgical treatment in most patients, concerning any tear in the area.

4. To address the clicking popping and other areas of discomfort, I suggest you mark yourself based on a popular scoring method called Lysholm score.

Please find the link to such a scoring chart below

http://alaska XXXXXXX org/locations/pvmc/Documents/Lysholm%20Knee%20Scale.pdf

Using the above link you can give yourself points with reference to the activities you are comfortable in participating and the amount of associated discomfort. The scores to be calculated under each heading is mentioned in brackets and the total score is to be considered. The higher the score, the more comfortable is the patient. This scoring is followed by many doctors and I would like to know your score to get an objective idea of your discomfort.

You might also score yourself at present and at the time when the injury surfaced. Comparison between both scores will give us an idea on your pain improvement and recovery.

5. If you choose to get operated then this includes a very slow recovery and rehabilitation. The first 6 weeks after surgery are very important and to be carefully monitored by the rehab team. Complete weight bearing is allowed only after two months from surgery.

Please do write back with your Lysholm score and we can discuss various outcomes and finer points which you might have in your mind.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 1 hour later
Dr. XXXXXXX thanks for the information. I looked at the chart, and my Lysholm score seems to be somewhere between 83-88.

Also, regarding surgery, I should point-out that even though my doctor originally recommended surgery, I haven't had a follow-up appointment with him based on my new MRI, so his recommendation may have changed. Since my tear seems to be healing based on my latest MRI, do you think surgery will be necessary for me? In other words, should I continue to let it heal for at least 2-3 more months and only then consider surgery?

Thanks....
doctor
Answered by Dr. Vivek Chail 9 hours later
Brief Answer:
Your Lysholm score is on the better side

Detailed Answer:
Hi XXXX,
Welcome and thanks for writing back with an update.

1. If your scoring based on Lysholm system is 83 to 88 then it is very good. In some research studies, the meniscal repair surgery target groups have had Lysholm score of about 53 pre operatively which subsequently increased to 67 after surgery. In this context, your symptoms are minimal in nature and not a serious concern for surgery.

2. Referring back to the earlier part of our discussion yesterday, the irregularity in the lateral meniscus posterior in the first MRI measured about 6.1 mm in its widest portion and 5.1 mm in the narrowest portion. In the second MRI the measurements are 4.1 mm in the widest portion and 3.1 mm in the narrowest position as seen on the sagittal PD sequence. Therefore my estimation of the healing process is 40 percent and 60 percent is ongoing.

3. In most of the medical literature relating to lateral meniscus posterior root tears, surgery is recommended if there is meniscal extrusion more than 3 mm and if there are associated injuries. Since you are in the safe zone and the Lysholm score is high therefore it appears that surgery can be thought of at a later date, should your symptoms worsen or healing get delayed.

4. Since it is healing, I suggest you discuss the time to be spent on the elliptical with a trainer and maintain a shorter exercise schedule.

It is important to note that once you have recovered and are planning to continue with your exercises, running 8 miles a day might not be the best thing for you. You can divide your time between the elliptical, running and also discuss other forms of exercise with your trainer. While running, a knee support is advised and the pace may be suited to your comfort level. Undue pressure and stress on the affected knee might be avoided.

5. Were I to be in your position, I would have taken it slow for the next 3 months to promote adequate healing and watched for the healing in progress. I am optimistic about the repeat MRI after 3 months and that it might show a better outcome.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Vivek Chail 1 hour later
Dr. XXXXXXX thanks for the additional advice. So in other words, it would probably be a good idea to get another follow-up MRI perhaps in August?

Also, I am generally curious about the healing process of meniscal tears. Of the 4.1mm and 3.1mm tear portions that are still present, do you think these portions are also in the red zone, or could it be that they are in the white zone? In other words, do you think that there could be a residual ~1-2 mm that will never heal and could therefore present the long-term risk of re-tearing?
doctor
Answered by Dr. Vivek Chail 9 hours later
Brief Answer:
The root is a vascular zone and let us give it a chance to heal itself

Detailed Answer:
Hi XXXX,
Welcome and thanks for writing back with an update.

1. Since the tear is partial and shows healing from the earlier scan, allowing time for more healing is suggested. Let us give nature a chance and your injury to heal by itself. Surgery also has its limitations, though by and large it is successful. In one of the researches, one out of 10 patients had a repair which did not heal well. Non healing after repair is more of a post operative complication at advanced age.

2. The root of meniscus is a well vascularized area and in most likelihood there will be healing. Please avoid unnecessary stress on the affected knee and take is cautiously with your workouts and elliptical.

3. With continued stress, it is not just the injured area which is at risk but the other ligaments might also be under stress. This cannot be easily predicted and that is why we have scoring systems that enable us to understand the degree of discomfort and treat based on the findings. There have been cases that the first injury has healed but newer areas have developed tears and then a more comprehensive solution is provided.

4. At your age, there is not much risk of developing severe complications arising from a root tear. However, being cautious and avoiding deliberate knee injury is something that you have to be concerned about.

5. The fibers are small and the healing is occurring gradually. You might imagine that there is a bridge which is being repaired with minimum vehicular traffic flowing through it. A little more traffic and there is a risk of the bridge collapsing under the load. Finally we have to depend on the next MRI and watch for the healing. Please take good care for the next three months and then we can see if complete healing has occurred. In my opinion, unless surgery is an emergency, better to give a chance to heal naturally.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Vivek Chail

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