Cartilage tears 101: A conversation with Michael D. Milligan, M.D., CAQSM

April 12, 2016

Topic: Cartilage tears 101: A conversation with Michael D. Milligan, M.D., CAQSM

To learn more about cartilage tears and how to treat them, we chatted with Andrews Institute physician Michael D. Milligan, M.D., CAQSM, an expert in primary care sports medicine.

One of the most common forms of knee injury are cartilage tears, which typically tend to impact the area of meniscus cartilage. But what exactly is the meniscus cartilage? According to Healthline, the meniscus is the area of cartilage that provides a protective layer between the thighbone and shinbone - it essentially acts as a shock absorbing cushion. The menisci can be found in every knee joint and come in pairs.

Meniscus tears can be caused by a number of things. Perhaps the most usual cause is a sports injury, but other accidents that put too much pressure on the knee joint, such as standing too quickly or breaking a fall, can also engender a tear.

Articular cartilage is another area of the joint that can be involved in a tear, although this kind of injury is less common that a meniscus tear. The articular cartilage is a smooth covering that can be found on the end of the bones. It's purpose is to allow the bones of the joint to move seamlessly against each other, without friction and strain.

To learn more about cartilage tears and how to treat them, we chatted with Andrews Institute physician Michael D. Milligan, M.D., CAQSM, an expert in primary care sports medicine:

1. What happens during a cartilage tear?
A tear of the meniscus cartilage of the knee is an injury to the wedge like cushion between the joints. Such tears can be acute traumatic injuries frequently from a twisting injury. The tears can also occur as degenerative or "wear and tear" injuries. In this case the tears occur due to natural attrition of the cartilage related to many factors associated with the natural aging of the body.

2. What are typical symptoms that a patient may experience with this kind of injury?
We often tell patients that a meniscus injury acts like a rock in your shoe. Sometimes it can be quite irritating and bothersome and at other times you may not even know it is there. For the patient there is the potential for periods when the meniscus injury is bothersome and periods when it is not noticeable. Unfortunately, this is unpredictable and varies from patient to patient and injury to injury.

Most commonly patients with meniscus tears present for evaluation because of swelling and stiffness in the knee joint. Pain within the knee may also occur.

In some instances the patient may experience catching and locking of the knee. I tell patients to think of this as sticking something in the door hinge. This is quite bothersome to patients and is an important factor in our decision making process. From time to time we will see patients with what we call a "locked knee."  These patients have a piece of meniscus cartilage that is torn and positioned in the joint in a manner that prevents the joint from moving.  We can sometimes move the knee in the office to realign this piece of cartilage into a better position to permit movement. However, more commonly this patient must be taken to surgery to remove the lodged piece of meniscus.

3. Can you describe some of the most common reasons why this injury may occur?
Most meniscus tears fall into two categories. One category are meniscus tears that occur as a result of a traumatic injury such as a severe twisting of the knee, as might occur from stepping in a hole or being hit by another player on the field.  The other category is degenerative meniscus tears, which can occur as result of an injury but may also occur without any recognized injury preceding.

Injuries to the articular cartilage are often the result of traumatic accidents. They may occur at the same time as a meniscus injury due to the forceful contact between two articular (joint) surfaces. Articular cartilage injuries may also occur as an after effect of the altered mechanics of the knee from a prior injury. Articular cartilage injuries can also be a part of the natural degeneration of a joint and are the underlying problem in patients with knee osteoarthritis.  

"Injuries to the articular cartilage are often the result of traumatic accidents."

4. Soccer players in particular seem vulnerable to this kind of injury - why do you think that is?
In my experience all athletes, and for that matter, all patients are at risk for developing cartilage injuries.

In regards to soccer, these athletes certainly are running and cutting on their legs as part of their sport, frequently on uneven surfaces (grass fields). They may also be hit by opposing players such as during a slide tackle. These activities do pose some risk but I have not seen anything in my experience that suggests that soccer athletes are any more prone to these injuries than athletes in any other sport. 

5. What is the standard recovery procedure for a cartilage tear?
Treatment is variable and should be tailored to an individual patient. A variety of factors go into the evaluation and decision process on what is the best method of treatment for the patient, as well as the timing of that treatment.

6. Is surgery always necessary? Are there alternative treatments?
Surgery, particularly arthroscopic surgery, is a common treatment for symptomatic meniscus tears in patients with otherwise healthy knees. The decision on if and when surgery is warranted remains case by case.

It is not uncommon that a patient may be able to function at a high level with minimal or ultimately no symptoms with a meniscus tear.  Research has shown that many people go through life with tears in their meniscus that never bother them. By the same token, patients who have a symptomatic meniscus tear may be able to regain normal function despite the ongoing presence of the tear. However, this certainly is not the case with every patient.

In patients with a locked knee surgery is necessary and typically done quickly to regain motion of the joint.

In other patients we base decision making on their symptoms, the demands their job or sport place on their joint, the overall health of their knee, and the patient's feelings about surgery, among other factors.

In 2016, we do have other treatment options, though, surgery remains the gold standard for patients who remain adversely impacted by meniscus injury. In the physically mature individual many physicians offer corticosteroids injections as an acute treatment to reduce pain, inflammation, and swelling related to a meniscus or articular cartilage injury.  The decision on use of corticosteroid injections for these circumstances are very much case-by-case. Treatments under investigation that have shown promise are PRP (Platelet Rich Plasma) and Stem Cell injections. The Andrews Institute is a leader in research on these products for treatment of cartilage injuries. Though research is ongoing current studies suggest there may be a benefit for certain patients. For the patient interested in these procedures we will talk through the option including the benefits and risks.

Michael D. Milligan, M.D., CAQSM, is an expert in primary care sports medicine at Andrews Institute.Michael D. Milligan, M.D., CAQSM, is an expert in primary care sports medicine at Andrews Institute.

7. Is exercise advised after a cartilage tear? Or can it hinder recovery?
This is another case in which we must tailor the treatment plan and recommendations to the individual patient. We frequently prescribed Physical Therapy as part of the treatment plan for the patient with a meniscus or articular cartilage injury that we are opting to treat in a nonsurgical manner.  It is also not uncommon to hear through the news of a college or professional athlete that is playing with torn cartilage in the knee. As a physician who was responsible for the medical care of Division I athletes for the last decade, I certainly have seen many athletes play with meniscus tears. In these athletes ultimately the injury is managed with surgery at a time that is less impactful on their season. This decision is based on a lot of factors and is certainly highly individualized.

8. How long does it typically take to recover from a cartilage tear?
Each situation is unique and requires a conversation between the patient and the physician taking into account the patient's medical history, their physical exam performed by the physician, a review of the imaging studies, and consideration of the physical demands placed on the joint.

9. In terms of prevention, especially for athletes, what steps can be taken to avoid a cartilage tear?
This is a good question and we don't have all of the answers yet. Certainly we know that the same things that are important for our general health are beneficial to our joint health. In particular, remaining physically active, maintaining a healthy body weight, not smoking, and addressing other factors that impact cardiovascular health contribute to healthy joints.

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