Tunnel syndromes - causes of occurrence, symptoms of the disease, diagnosis and treatment methods

Symptoms

The most commonly used symptoms of a knee meniscus injury are:

Constant pain at the level of the knee joint gap.

Atrophy of the muscles of the thigh, and sometimes the lower leg.

Baykov's symptom

Baikov's symptom: the knee joint is bent to an angle of 90°, a finger is pressed on the corresponding part of the joint space and the lower leg is passively extended, while the pain sharply increases.

Chaklin's symptoms

Chaklin's sartorius symptom : with active raising of the straight leg, atrophy of the internal portion of the quadriceps femoris muscle is visible and against this background the tension of the sartorius muscle is sharply contoured;

Chaklin's "click" symptom when moving the knee joint.

Turner's symptom

Turner's symptom: increased local pain and temperature sensitivity in the n.saphenus innervation zone, along the inner surface of the knee joint (if the internal meniscus is damaged)

Perelman's "staircase" symptom

Pain when going down stairs.

Landau's symptom

Pain in the area of injury when trying to sit cross-legged.

Shteiman's symptoms

When the leg is bent at the knee joint at an angle of 90°, rotational movements are accompanied by pain, if the internal meniscus is damaged

Steimann's symptom Ⅰ the appearance of pain on the inside of the knee joint during external rotation of the leg;

Steimann's symptom Ⅱ when bending the knee, the pain shifts posteriorly, since when bending the meniscus stretches posteriorly;

flexion contracture of the knee joint;
painful cushion at the level of the joint space in the damaged area;
arrhythmic gait (the result of muscle atrophy); with internal rotation, with damage to the external meniscus during external rotation;
galosh symptom: pain when putting on galoshes;
Rauber's symptom (develops in the first 2-3 months after the onset of the disease): on radiography, spine-like growths on one or two condyles;
symptom of lateral meniscus dysplasia: bevel of the contour of the lateral condyle, widening of the external gap of the knee joint;
Polyakov's symptom: the patient, in a supine position, lifts his healthy straight leg up and raises his torso, leaning on the shoulder blades and heel of the injured leg, pain occurs in the area of the damaged meniscus (menisci);
Bragard's symptom Ⅰ pain during internal rotation;
Bragard's symptom Ⅱ pain moves posteriorly with continued flexion of the knee;

McMurray's sign

Symptom Mac Murray or Mac Murray, in English the surname is written as Mc. Murray, with the knee bent and the patient lying on his stomach, turning and abducting the leg with a fixed foot causes a sensation of pain and cracking.

How the test is carried out:

McMurray test The patient lies on his back with the knee fully bent. The surgeon holds the foot by the heel. The leg rotates on the hip with the knee in full flexion. The leg is rotated until a right angle is achieved while the foot is supported first in full internal rotation and then rotated in full external rotation. In patients with a torn meniscus, a clicking sound occurs and the patient complains of pain.

Source: Meniscal tears by Nicola Maffulli, Umile Giuseppe Longo, Stefano Campi, and Vincenzo Denaro

McMurray lateral tear test. Image by fpnotebook.com

The McMurray test, also known as the McMurray conduction test, is used to evaluate individuals for tears in the knee meniscus. A meniscal tear can result in a meniscus mark on the pedicle, which can become lodged between the surfaces of the joint.

To perform the test, the knee is held with one hand, which is positioned along the line of the joint, and bent to full flexion, while the foot is supported by the sole of the foot with the other hand.

The examiner then internally rotates the leg, extending the knee to 90 degrees of flexion. If a “thumping” or “popping” sensation is felt along with the pain, this represents a “positive McMurray test” for a tear in the posterior portion of the lateral meniscus. Likewise, external rotation of the leg can be used to test the posterior portion of the medial meniscus.

You can watch how the tests are carried out on video here

McMurray test for medial tear. Image by fpnotebook.com

The McMurray test is named after Thomas Porter McMurray, a British orthopedic surgeon of the late nineteenth and early twentieth centuries who first described the test.

The description of the test has since been modified by various authors. Most often, varus-valgus load is added to the knee.

These variations are different tests with different statistical performance and should not be confused with the original.

According to some sources, the sensitivity of the McMurray test for medial meniscal tears is 53% and the specificity is 59%. A recent study compared the results of clinical trials with those of arthroscopy and/or arthrotomy. The clinical test had a sensitivity of 58.5%, a specificity of 93.4%, and a positive predictive value of 82.6%. A more recent study showed 97% specificity for meniscal tears.

Source: wikipedia

Symptoms of damage to the internal meniscus of the knee joint:

pain on the inside of the knee joint;
point sensitivity over the place of attachment of the ligament to the meniscus;
painful shooting when tense;
"block" of the knee;
pain along the tibial collateral ligament when hyperextending and turning the tibia outward with the leg bent at the knee;
pain when bending the leg too much;
synovitis;
weakness of the muscles of the anterior thigh. Symptoms of damage to the lateral meniscus of the knee joint:
pain with tension, pain along the fibular collateral ligament, radiating to the outer part of the knee joint;
"block" of the knee;
pain along the fibular collateral ligament with hyperextension and excessive flexion and internal rotation of the leg;
synovitis;
weakness of the muscles of the front of the thigh.

Anatomy of the meniscus

The menisci of the knee joint are cartilage pads that act as shock absorbers in the joint, as well as stabilize the knee joint and increase the congruence of the articular surfaces in the knee joint.

When moving in the knee joint, the menisci are compressed and their shape changes. There are two menisci in the knee joint - external (lateral) and internal (medial). In front of the joint they are connected by a transverse ligament.

The external meniscus is more mobile than the internal one, so traumatic injuries occur less frequently.

The internal meniscus is less mobile and is connected to the internal collateral ligament of the knee joint, so the injury is often combined with damage to this ligament.

Lateral to the joint, the menisci are fused to the joint capsule and have a blood supply from the arteries of the capsule. The internal parts are located deep in the joint and do not have their own blood supply, and their tissues are nourished by the circulation of intra-articular fluid.

Therefore, damage to the meniscus near the joint capsule heals well, but tears in the inner part, deep in the knee joint, do not heal at all. Prevalence of meniscus injuries

Among internal injuries of the knee joint, meniscal injuries occupy the first place. According to the CITO Sports and Ballet Injury Clinic, where mainly athletes, in whom this injury occurs most often, are treated, meniscal injuries account for 60.4% of 3019 people, of which 75% are patients with injuries to the internal meniscus, 21% with injuries and diseases of the external meniscus and 4% - with damage to both menisci.

The proportion of meniscus damage is correspondingly 4:1. This is due to the patient population and improved diagnostics (arthroscopy and other methods). Thus, the menisci are most often damaged in athletes and physical workers aged 18 to 40 years.

In children under 14 years of age, meniscus rupture occurs relatively rarely due to anatomical and physiological characteristics. Damage to the menisci is more common in men than in women - in a ratio of 3:2, the right and left are affected equally.

Diagram of a damaged meniscus

Surgery

Indications for surgery for a torn meniscus of the knee joint are:

Meniscus tear and displacement.
Blood in the cavity.
Crushing meniscal tissue.
Separation of the body and horns of the meniscus.
Lack of effect from drug treatment for several weeks.

In such situations, surgical intervention may be prescribed, which is carried out using different methods:

Meniscectomy or meniscus removal

This operation is indicated when a large part of the meniscus is torn off, cartilage tissue decomposes, and complications develop. This procedure is quite traumatic and leads to the elimination of pain only in 50-70% of cases.

Meniscus repair

If possible, surgeons try to preserve the meniscus as much as possible. Recovery is possible in the following situations:

separation of the meniscus from the capsule;
longitudinal vertical gap;
peripheral meniscus tear;
absence of degenerative processes in cartilage tissue;
young age.

The success of the operation depends on the age and location of the rupture. Localization of the damage in the red or intermediate region and the patient's age under 40 years increase the likelihood of a successful outcome.

Arthroscopy

The photo shows an MRI of a damaged meniscus of the knee joint

This method is considered the most modern and least traumatic. During the procedure, the site of injury is visualized using an arthroscope and surgery is performed. This method can be used for tears of the body or anterior horn of the meniscus. Read more about it.

In approximately 70-85% of cases, the cartilage tissue completely heals, and the knee joint restores its functions.

Meniscus transplantation

Indications for such surgery for a torn meniscus of the knee joint are considered to be crushing of the meniscus and a significant deterioration in a person’s quality of life. In this case, contraindications to transplantation are: old age, knee instability, degenerative processes, general somatic diseases.

Fastening the meniscus with special clamps

This procedure can secure the meniscus without making additional incisions. For this purpose, absorbable fixatives of the first or second generation are used.

Causes of meniscus injuries

Knee joint in extended (right) and bent (left) positions. The contact surfaces of the femoral condyles (red line) with the menisci in the extended position of the leg are significantly larger than in the bent position.

As a result, the body weight on the tibia in the first case is distributed over a larger area than in the second, and the articular cartilage does not experience a one-sided, clearly limited area load. When the knee is bent, the menisci are moved slightly back, the collateral ligaments are relaxed, and the lower leg can rotate relative to the thigh.

In a bent position, the condyles are held together by the cruciate ligaments. If the knee joint is forced to rotate while the leg is straightened, such as when playing football or skiing, the result can be damage to the meniscus or even rupture of the ligaments.

The cause of a meniscus tear is an indirect or combined injury, accompanied by rotation of the tibia outward (for the medial meniscus), inward (for the external meniscus). In addition, damage to the menisci is possible with sudden excessive extension of the joint from a bent position, abduction and adduction of the lower leg, and less often when exposed to direct trauma (hitting the joint on the edge of a step or being hit by some moving object). Repeated direct trauma (bruises) can lead to chronic trauma to the menisci (meniscopathy) and subsequently to its rupture (after squatting or a sharp turn).

Degenerative changes in the meniscus can develop as a result of chronic microtrauma, after rheumatism, gout, chronic intoxication, especially if the latter are present in people who have to walk a lot or work while standing. With a combined mechanism of injury, in addition to the menisci, the capsule, ligamentous apparatus, fat body, cartilage and other internal components of the joint are usually damaged.

Types of meniscus damage

The following types of meniscus injury are distinguished: separation of the meniscus from its attachment sites in the area of the posterior and anterior horns and the body of the meniscus in the paracapsular zone;

ruptures of the posterior and anterior horns and the body of the meniscus in the transchondral zone;

various combinations of the listed damages;

excessive mobility of the menisci (rupture of the intermeniscal ligaments, meniscal degeneration);

chronic trauma and degeneration of the menisci (meniscopathy of a post-traumatic and static nature - varus or valgus knee (see varus and valgus);

cystic degeneration of the menisci (mainly external). Types of meniscus tears

Types of meniscus tears. Image kolenzo.ru

Nature of meniscus damage

Meniscal tears can be complete, incomplete, longitudinal (“watering can handle”), transverse, flap-like, or fragmented.

More often, the body of the meniscus is damaged with the damage transferring to the posterior or anterior horn (“handle of the watering can”). Isolated damage to the posterior horn is less common (25-30%)

Damage to the posterior horn. Image nogostop.ru

and even less often the anterior horn is injured (9%). Tears can be with or without displacement of the torn part.

Types of meniscus tears. Image osustave.com

Tears of the medial meniscus are often combined with damage to the lateral capsuloligamentous apparatus. With repeated blockades with displacement of the torn part of the meniscus, the anterior cruciate ligament and the cartilage of the internal femoral condyle are injured (chondromalacia).

Symptoms of meniscus damage

In the clinical picture of meniscus damage, acute and chronic periods are distinguished. Diagnosis of meniscus injuries in the acute period is difficult due to the presence of symptoms of reactive nonspecific inflammation, which also occur with other internal injuries of the joint. Characterized by local pain along the joint space corresponding to the area of damage (body, anterior, posterior horn), severe limitation of movements, especially extension, the presence of hemarthrosis or effusion.

With a single injury, bruises, tears, pinching, and even crushing of the meniscus often occur without tearing it off or separating it from the capsule. Predisposing factors for complete rupture of a previously undamaged meniscus are degenerative phenomena and inflammatory processes in it. With proper conservative treatment of such damage, complete recovery can be achieved.

After the reactive phenomena subside (after 2-3 weeks - the subacute period), the true picture of the damage is revealed, which is characterized by a number of typical clinical symptoms in the presence of an appropriate history and mechanism of injury: local pain and infiltration of the capsule at the level of the joint space, often effusion and joint blockade.

Various characteristic pain tests confirm the damage. The number of these tests is large. The most informative of them are the following: symptoms of extension (Roche, Baikov, Landa, etc.); rotational (Shteiman - Bragarda); compression symptoms and mediolateral test.

Diagnosis of meniscus injuries

The so-called voiced tests, i.e., symptoms of sliding and movement of the menisci and clicking during passive movements, are also of great importance in the diagnosis of meniscal injuries. The most typical and easiest to recognize a medial meniscus tear is a true joint block (a “watering can handle” meniscus tear). In this case, the joint is fixed at an angle of 150-170°, depending on the size of the displaced part of the meniscus.

True blockade of the meniscus must be differentiated from reflex muscle contracture, which often occurs with bruises, damage to the capsular-ligamentous apparatus and entrapment of intra-articular bodies (chondromalacia, chondromatosis, Koenig's disease, Hoffa's disease, etc.). We must not forget about the possibility of pinching the hypertrophied pterygoid fold. Unlike blockade of the joint by the meniscus, these infringements are short-term, easily eliminated, harmless, but are often accompanied by effusions.

In case of damage to the outer meniscus, joint blockades occur much less frequently, since the meniscus, due to its mobility, is more often subject to compression than to tearing.

External meniscus tear. Image naul.ru

In this case, the meniscus is crushed by the articular condyles, which with repeated injuries leads to degeneration and often cystic degeneration. Discoid menisci are especially often cystic.

The most characteristic symptoms of damage to the external meniscus are local pain in the outer part of the joint space, aggravated by internal rotation of the leg, swelling and infiltration in this area; a symptom of a click or roll and, less often, a symptom of blockade.

Many of the listed symptoms of meniscal damage also occur with other injuries and diseases of the knee joint, so timely recognition of a meniscal tear in some cases presents significant difficulties. A carefully collected anamnesis is the main diagnostic criterion. Pain tests, as a rule, are not detected, there is no irritation of the synovium. There is only a positive Chaklin's symptom (tailor's test), sometimes a sound phenomenon (clicking, rolling, friction).

A plain radiograph reveals a narrowing of the corresponding parts of the joint space with signs of deforming arthrosis. In such cases, paraclinical methods help. Great difficulties are encountered with atypical forms of the meniscus (discoid or continuous meniscus), with chronic trauma (meniscopathy), rupture of the ligamentous apparatus of the meniscus (hypermobile meniscus), and damage to both menisci.

A discoid, predominantly external, meniscus is characterized by a rolling symptom (clicking knee). Due to its massiveness, it is more often subject to crushing by articular surfaces, which leads to degeneration or cystic degeneration.

There are three degrees of cystic degeneration of the external meniscus (according to I. R. Voronovich). Grade I is characterized by cystic degeneration of meniscus tissue (cysts are detected only histologically). Clinically, moderate pain and infiltration of the capsule are determined. In grade II, cystic changes spread to the meniscus tissue and the pericapsular zone. Clinically, in addition to the indicated symptoms, a small painless protrusion is detected in the anteromedial part of the external joint space, which decreases or disappears when the knee joint is extended (due to movement of the meniscus deep into the joint). In grade III, the cyst involves parameniscal tissue; mucous degeneration occurs with the formation of cystic cavities not only in the meniscus tissue, but also in the surrounding capsule and ligaments. The tumor-like formation reaches a significant size and does not disappear when the joint is extended. Diagnosis of degrees II and III is not difficult.

Chronic microtrauma of the menisci is characterized by poor anamnestic and clinical data. With meniscopathy, there is usually no history of significant trauma; pain along the joint space, synovitis, and atrophy of the inner head of the quadriceps femoris muscle periodically appear. Meniscopathy also develops when there is a static disorder (valgus, varus knee, flat feet, etc.).

Arthroscopy makes it possible to detect degenerative changes: the meniscus, as a rule, is thinned, lacks shine, has a yellow tint with the presence of cracks and tissue disintegration in the area of the free edge; easily torn, excessively mobile. Histological examination using electron microscopy with a scanning device reveals significant cracks and erosions of the surface layer, and in some places, areas of destruction in deep layers.

Symptomatology for damage to both menisci consists of the sum of the symptoms inherent in each of them. Simultaneous damage to both menisci is rare. A predisposing factor is rupture of the intermeniscal ligament, which leads to pathological mobility of the menisci and contributes to their damage. Diagnosis of a rupture of both menisci is difficult, since the clinical picture of damage to the internal meniscus usually predominates. Errors in recognizing meniscal injuries are 10-21%.

References

Traumatology and orthopedics / Guide for doctors. In 3 volumes / ed. Shaposhnik Yu.G. - M.: “Medicine”, 1997.

Clinical Sports Medicine / Peter Brukner and Kharim Khan - Third edition, "McGraw

Prevention

To prevent a meniscus tear , it is necessary to use special knee pads during sports - this will help minimize the risk of injury.

It is also recommended to perform special exercises that will help strengthen muscle strength, take chondoprotectors and drugs that improve peripheral circulation.

A torn meniscus is a fairly common knee injury that significantly affects a person’s quality of life. Therefore, in case of any damage, it is worth contacting an experienced traumatologist - he will be able to make the correct diagnosis and select treatment.

Treatment of meniscus damage

Treatment for meniscus injuries depends on the severity of the condition. At one extreme, small tears or degenerative changes in the meniscus should be initially treated conservatively.

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At the opposite extreme, a large, painful watering can-handle tear causes blockage of the knee joint and requires immediate arthroscopic surgery.

Most actual meniscus injuries fall somewhere between these two extremes and the resulting treatment decisions. Therefore, the decision for immediate surgery should be made based on the severity of symptoms and signs, while taking into account the athletic level and workload of the athlete.

Surgery

Arthroscopic knee surgery

Patients whose condition does not improve with conservative treatment require surgery. The purpose of the operation is to preserve the body of the meniscus as much as possible.

Some meniscal lesions are suitable for fusion by surgical suture, which can be performed arthroscopy.

The decision as to whether to attempt repair of a tear is based on several factors, including the recency of the injury, the age of the patient, the stability of the knee, the location of the tear, and its orientation.

The outer third of the meniscus rim has a blood supply, and a tear in this area can heal.

A tear with an increased chance of successful healing is a fresh longitudinal tear in the peripheral third of the meniscus in a young patient with simultaneous anterior cruciate ligament reconstruction. Degenerative processes, displaced tears, horizontal dissections, and complex lesions are poor candidates for healing.

Young patients have a greater likelihood of success. Displaced tears may require removal of the torn portion of the meniscus (meniscectomy).

Meniscus surgery in modern clinics is done by arthroscopy, which is performed through several small surgical holes and takes approximately 1-2 hours. Through these holes, the surgeon inserts surgical instruments into the joint cavity, including a small video camera that allows you to see the joint from the inside.

Rehabilitation after meniscus injuries

Rehabilitation after surgery varies for different people and depends on a number of conditions, so the rehabilitation period is determined by the doctor individually. Patients whose meniscus has been partially or completely removed should prepare to walk on crutches for 4 to 7 days.

Small swelling may persist for 3 to 6 weeks. After 4-6 weeks, and maybe even earlier, the patient will be able to return to normal physical activity. If a torn meniscus has been repaired, crutches must be used for much longer (4-6 weeks) and no stress must be placed on the injured knee to allow the meniscus to heal completely.

Compared to outdated open knee surgery and large surgical incisions, arthroscopic surgery minimizes the necessary tissue disruption, which, of course, greatly reduces recovery time after surgery and allows you to quickly return to work and sports.

A frequent companion to meniscus surgery is arthritis, as in the photo below.

For comparison, a model of a joint without arthritis:

Rehabilitation

The period of rehabilitation after injury is of no small importance. It includes :

Performing special exercises to develop the knee joint.
The use of chondoprotectors and non-steroidal anti-inflammatory drugs.
Massage, physiotherapy.
No loads throughout the year.

Rehabilitation after such an injury includes five stages:

Stage 1 – its duration is 4-8 weeks. At this stage, you need to try to maximize the range of motion in the injured joint and reduce swelling.
Stage 2 – lasts about 2.5 months. It is necessary to completely restore motor activity, eliminate swelling, and begin to train weakened muscles.
Stage 3 – it is necessary to completely restore motor activity when playing sports, to restore muscle strength. At this stage, they actively engage in physical therapy and return to normal life.
Stage 4 – it is necessary to achieve the ability to actively engage in sports without pain, as well as to increase the strength of the muscles of the injured leg.
Stage 5 – all functions of the joint should be restored.