The patient suffered from a distortion trauma to the right knee around 4 months prior to report. In the following days he suffered from intense right side gonalgia which was treated with Voltaren tablets and local application of ice in the evening. The pain lessened after a few days; however, the sense of “discomfort” continued.

The articular pain started to grow around the time of the summer holidays, while - during his habitual walks in the mountains - the patient realized that he found it very difficult to walk because of intense arthralgia.

When the patient returned from his holidays he took diagnostic tests whose results are quoted below.

- X-rays of right knee on (one month later): “Normal bone trophism. Initial arthrosic irregularities to the tibial plate with maintained articular relationships. Regular soft tissues”.

- MRI of right knee on (3 days after x-ray):

o “At the anterior compartment, reduced depth of the hyaline cartilage coverings of the patella where small foci of chondromalcia are identified. Moderate reactive thickening of the connectival septa at the level of the infrapatellar fat pad. The patellar tendon and m. quadriceps femoris tendon result to be within their normal limits as regards morphology and signal.

o At the medial compartment, the meniscal fibro cartilage presents an inhomogeneous aspect in the posterior horn in relation to degenerative facts. There coexist small areas of an altered signal which are compatible with chondromalcia in the above articular surface of the femoral condyle. Moreover, there appear to be aspects of meniscal extrusion compatible with degenerative phenomena. The collateral ligament is in the norm.

o At the collateral compartment, no signal alteration in the meniscus that indicates a slight extrusion aspect in the body. The collateral ligament is in the norm is. There are no osteochondral lesions.

o At the central compatment, hypo plastic aspect with inhomogeneous aspect of the anterior cross ligament as a result of partial lesion. No signal alteration in the posterior cross ligament. No significant signal alteration at the bone spongiosa of the explored ends. A small endosynovial fluid layer is placed in the articular cavities, with an accentuation in the super patellar recess in the external side”.

The patient also had a specialist orthopedic visit on (approx. 2 months after injury), whose report states:

“Right side gonalgia due to degenerative meniscopathy. Arthroscopy is recommended”.

Medical questions

1) Is arthroscopy necessary?

2) Are there any therapies other than arthroscopy which could nonetheless guarantee recovery?

3) What is the best therapy that can be suggested?

4) What is the prognosis?

Medical Report

A remote consultation based upon an MRI scan, without interviewing or examining the patient, is of limited clinical value.

The x-ray shows mild compartment degenerative arthritis, with small intra-articular loose bodies, and inflammatory entisopathy of the quadriceps insertion at the patella.

The MRI scan reviewed shows a degenerative tear of the posterior horn of the medial meniscus, chrondomalacie of the medial femoral condyle, and a partial tear of the ACL.

A tear in the degenerative meniscus is a typical clinical presentation of early degenerative arthritis of the knee.

The best initial treatment is rest, anti-inflammatory medication, physiotherapy and modified daily activity when symptoms subside. Modified activity means reducing walking distance or other physical exercise. It is important not to stop exercise.

Arthroscopy is necessary only if there is no symptomatic improvement after the above non-surgical treatment.

Arthroscopic excision of a torn degenerative meniscus is best indicated in cases where the onset of symptoms followed minimal trauma.

Arthroscopic surgery may not necessarily improve a symptomatic arthritic knee with a torn degenerative meniscus, especially if the symptoms were of spontaneous onset. In such cases, the degenerative arthritis could progress despite the arthroscopic meniscal excision. Arthroscopic meniscal excision without a history of minimal trauma has been associated with exacerbation of knee symptoms due to a vascular necrosis of the bone.

-----, MD

Head of Sports Injury and Arthroscopic Unit