A run, a bad knee ache and a difficult-to-diagnose problem
DOROTHY Beckett has been a runner for decades and knows her body well, so the 61-yearold biochemistry professor was puzzled when her knee hobbled for no apparent reason after a routine run.
Beckett took two weeks off to let it rest and then tried an easy run. She was met with excruciating pain and decided it was time to visit a doctor.
What Beckett never expected was that she was about to begin a long, seemingly endless journey to figure out and properly treat her injury. In the end, Beckett learned that she had torn her medial meniscus root - not all that uncommon in someone her age. The trouble is, many physicians misdiagnose the condition.
While less common than a tear of the meniscus, the rubbery cartilage that works like a shock absorber in your knee, a root tear is more devastating, as the root holding the meniscus to the bone tears away, causing a loss of all meniscal function. If a patient is unlucky, by the time of a proper diagnosis, it’s too late - osteoarthritis may have set in, rendering the patient ineligible for repair surgery.
Luckily for Beckett, lots of knocking on doors finally led her to Scott Faucett, a sports medicine and hip preservation orthopedist at George Washington Hospital. He was able to give her a diagnosis and follow it up with a repair surgery.
Today, two years later, Beckett is back to her normal running mileage, feeling thankful she dodged a bullet.
The meniscus root, attached to the tibia, or shin bone, plays a vital role in knee stabilization, Faucett says.
“Tears to the root typically happen in a noncontact situation, often twisting or skiing,” he says. “You’ll generally see them in 40- to 70-year old patients and non-athletes who spend a lot of time kneeling.”
Typically, a patient will feel a “pop” upon standing or twisting. “Most patients know when it happens, as opposed to those injuries that creep in over time, Faucett says. “It’s a catastrophic injury.”
Without the root, the knee essentially loses the benefits of a meniscus, resulting in bone-onbone contact and a fairly rapid descent to osteoarthritis, Faucett says.
While Beckett missed the popping sensation with her tear, she did feel its impact within hours of the injury.
When her first line of attack - rest - didn’t work, she headed to a local sports medicine doctor who sent her for an MRI. “But the radiologist missed it on the film,” Beckett says, “so my physician sent me on to physical therapy for six weeks.”
This mis- or missed diagnosis is common with root tears because they are present without some of the typical hallmarks of meniscus injury: locking or catching of the knee or a sudden giving way. As a result, physicians and radiologists don’t necessarily look for meniscus injury, Faucett says.
“It’s not that hard to find the injury, but until the past few years, there’s been little awareness of it, so physicians don’t look for it,” he says.
Recent research and educational efforts are bringing more light to the issue, however.
To dodge such a misdiagnosis, Faucett recommends getting an MRI immediately if a popping sensation is present. If not, and if after six weeks the pain is still present, an MRI is appropriate before more damage occurs.
Root tears account for up to 21 per cent of all meniscus tears, and affecting about 100,000 patients annually, according to a recent study. The chief problem with a missed diagnosis with this condition is that it can rapidly deteriorate to osteoarthritis, with bones too damaged to support reattachment surgery, Faucett says. “At that point, surgery to reattach the root is generally not successful,” he says.
Traditional approaches to root tears have involved either removing the entire meniscus, or taking a “wait and watch” approach, says Laith Jazrawi, orthopedic surgeon and chief of the division of sports medicine at NYU Longone Health.
“Historically, surgeons would take the entire meniscus out, and 20 years on the patients would progress to very bad arthritis,” he says. “Waiting to see if would heal on its own didn’t work either, as the root doesn’t reattach to the bone.”
This could be life altering for patients with years of potential activity ahead of them, according to a 2018 meta-analysis. Of more than 350 patients, it found that over 10 years the repair, removal or nonoperative treatment of meniscal root tears led to rates of osteoarthritis of 53 per cent, 99.3 per cent and 95.1 per cent, respectively, and total knee replacement rates of 33.5 per cent, 51.5 per cent and 45.5 per cent, respectively.
“Without the root, a knee will simply behave like it has no meniscus,which is why that approach fails,” Jazrawi says.
With more research, surgeons have increasingly begun to treat root tears by reattaching the root to the tibia, rather than removing the meniscus or leaving it be in hopes of eventual self healing.
Faucett has pioneered a technique that involves drilling tunnels into the affected tibia and sewing the meniscus root back onto the bone and fastening it arthroscopically with a surgical “button.” That avoids cutting into the back of the knee, which can slow recovery. He said patients tend to be on crutches for six weeks - with a slow ramp up to full activity.
“The main goal is to get the meniscus reattached,” he says. “I recently repaired the knee of a 77-year-old, and she was back to full activity six months out.”
Jazrawi also performs root repair surgery. He says that as long as arthritis isn’t present, the outcomes are promising.
“There’s a population of patients with advanced arthritis that really won’t be helped by the surgery,” he says. “They are probably headed toward total (knee) replacement eventually.”
For a patient with arthritis in place, says Faucett, a root repair won’t prevent pain and a partial or total knee replacement is probably inevitable if pain worsens.
Faucett says that the success rate for the repair is high - he said he has seen retearing in about 5 per cent of the 250 surgeries he has preformed. “Eventual development of arthritis is also low,” he adds.
As for Beckett, she considers herself lucky.
“There was no arthritis,” she says. “In addition to being able to run again, I am in great physical shape and, most importantly, able to live an active life without pain.” — The Washington Post