Understanding, Treating and Preventing Meniscus Tears

Phelps Health Marketing Director Paige Heitman and Digital Marketing Coordinator Kayla Marsala talk with Sylvester Youlo, MD, an orthopedic surgeon at Phelps Health, about meniscus tears on the Ask the Professionals radio show.

Kayla Marsala: Good morning, everyone, and welcome to the Ask the Professionals radio show with Phelps Health. I'm Kayla Marsala, co-hosting with Paige Heitman.

Paige Heitman: Good morning.

Kayla: Today, we are talking with Dr. Sylvester Youlo, an orthopedic surgeon at Phelps Health who specializes in sports medicine. Welcome back, Dr. Youlo.

Dr. Sylvester Youlo: Thank you, always glad to be here.

Kayla: We are going to talk about what to do when you have a torn meniscus in your knee. So first, what is a meniscus?

Dr. Youlo: If you haven't heard the word meniscus, you will hear it sometime in your life. Either you know somebody who has had a meniscal problem, you will have one or maybe your child will. This is an important topic. In fact, one of the most common surgeries that's performed around the world is meniscus surgery.

So, just follow my logic. The meniscus is inside a knee, and when we think about the knee, we can make two fists. [You have] one fist on the left side, one fist on the right side, and you bring your knuckles together. Then [consider] each fist. One of them is the end of your thigh bone, and the other is the end of your shin bone. The shin and thigh bones sit together. Now, imagine that between a shin and a thigh bone, you have a donut, okay? That doughnut is a meniscus. Continue to follow [my food analogies]. Imagine that doughnut is not the size of a doughnut. It's not that thick; it’s a pancake. So, it's a doughnut that looks like a pancake, but it sits between your thigh and shin bones. That's what the meniscus actually looks like. It's small.

The thickness of the meniscus is about 5 millimeters. The width of the meniscus is about 10 millimeters, but it is an important part of the knee. It serves as a shock absorber for the knee. Now, you may be asking, ‘Why do you need a shock absorber in your knee?’ Well, the end of your thigh bone is covered with a layer, and the end of the shin bone is covered with a layer. That layer is important and is called cartilage. If you lose that layer, you have arthritis, and you don't want those layers banking together too hard. So, the meniscus [serves as a] shock absorber to protect that layer.

Kayla: That is really interesting. I like that analogy. It makes it a little bit easier to understand without using medical terms. Moving on, when someone injures their meniscus, what happens to their knee?

Dr. Youlo: An injury to a meniscus is pretty much a tear. [Using food analogies again,] imagine a pancake that looks like a doughnut. You have a tear in it. That's a meniscal tear, and that pancake, you can tear it any way you want. So, if you have a tear in that pancake that's between your knuckles, it's a torn meniscus. You can tear the meniscus in different ways, either by injury or actually you can tear without doing [much at all].

Kayla: What are some injuries that could cause you to tear your meniscus?

Dr. Youlo: That's a good question. There are two kinds of meniscal tears you can have. There's one we call a degenerative tear, [which is] usually a tear that happens in older patients who aren’t doing anything in particular. You are not playing sports. Rather, you are getting out your car, you're getting out of bed and now your knee hurts. At some point, you have a meniscus tear. When that happens, it's called a degenerative tear. And then we have football players. You are playing football, and somebody hits your knee, [resulting] in a big swollen knee. They find out they have a meniscal tear, which is called a traumatic tear. Those are the two different kinds of tears. So, tears that happen [due to] an injury, and those that happen [as you age].

Kayla: Do these types of tears look different from each other?

Dr. Youlo: Not necessarily. The tears can look the same. [What is important] is how you treat them. [Say you have a] high school or college kid who hurts their meniscus while playing football. [Important factors include] their age, the kind of tear they have and how they developed that tear.

Then, take me, [for example]: I'm 46 years old, eating bonbons, getting out of my bed, and I hurt my meniscus. The treatment is also different. A person’s age and determining what caused the tear are important.

Kayla: What happens in your knee when your meniscus is damaged? How does that affect your knee and how you walk?

Dr. Youlo: There are a couple of things that happen. Your meniscus is a shock absorber; you don't want to lose it. If you lose it, you lose that effect of a shock absorber. But if you have a tear, what happens? Well, it hurts. Why does it hurt? Well, if you have a tear in the meniscus, the meniscal tear itself is not the thing that is hurting, but the meniscal pattern. The pattern is torn; it flips and moves around. If it falls over, it hurts. If it flips in the different corner of your knee, it hurts. That's what most people [experience]. So, when an older person with a torn meniscus comes in with knee pain, it's because that piece is flipping around. We call these mechanical symptoms, [where it] feels like something got stuck in your knee. Sometimes, it stops hurting because it flips back to where it needs to be, but then it moves again. In younger patients, when they have a tear, they also [experience] similar pain, but you notice they have a traumatic tear, and the treatment will be different.

Kayla: Are there any other signs and symptoms of a meniscus injury aside from pain?

Dr. Youlo: Yes. Besides pain, you can get swelling in the knee.

Kayla: If you suspect you might have a meniscus tear, should you go to your primary care provider first, or should you go straight to an orthopedic doctor? What does that process look like?

Dr. Youlo: If you're an older person with knee pain, you [could possibly] have a meniscus tear without a specific injury. It's OK to see your primary care doctor first. They can treat you and give you medicine, but the tear is not going to go away. If your pain gets better, people may try to ignore the tear, but that’s difficult to do. [In the event of a] traumatic injury – for example, your high school football player hurts their knee, and you suspect a meniscus tear, please don't wait. We have some of the best orthopedic surgeons in the world, right here at Phelps Health. Don't keep your child at home, hoping their knee is going to get better. Come see us.

Kayla: Whenever you do decide that you need to go to an orthopedic surgeon or doctor to check out your meniscus, what does that appointment look like? How is a torn meniscus diagnosed?

Dr. Youlo: First, we will ask you what happened. For example, a football player may have been trying to block another person, and an opponent hits their knee. [Or maybe someone else] was running, and their knee gave out. The next step is an exam. [In this initial exam], we only examine places of the knee we can touch. How does the knee look? Is it swollen? [If we suspect] a patient has a torn meniscus, they should get an MRI scan [a noninvasive medical imaging test], to see if it really is a torn meniscus. Sometimes with a knee injury, a ligament might also be involved, in addition to a torn meniscus. [This is] especially true for young patients who play sports. So, [when a young athlete] has a knee injury, you can't rub dirt on it. You need to come in, so that we can see it. They may have a major injury that will affect them later on in life.

Now, for an older person [with a confirmed or suspected meniscus tear], it's not an emergency situation where you have to see an orthopedic surgeon right away. Again, you can go to your primary care doctor, but if you are not satisfied, we can see you as well. There are things we can do, short of any kind of major procedures, to treat that meniscus tear.

Kayla: Say a parent doesn't bring their child in, and they do end up having a torn meniscus. Can that affect their quality of life?

Dr. Youlo: If you have a torn meniscus, and you're young, [it’s important to] remember the meniscus is a shock absorber that protects the knee. If you tear your meniscus, it may be possible to repair that tear. [Imagine the scenario where you choose not to repair the tear], and your child plays football in that tear all season. [This is comparable to having] a small tear in a piece of paper, and then you start squishing the paper and just tearing and tearing. Eventually you can tear that paper into pieces, where it’s almost impossible to put the pieces back together. So, if a young patient has a torn meniscus, it's better to be seen to make that diagnosis, so that we can fix the meniscus and allow it to heal. But if it [the meniscus] is torn into shreds, it becomes too damaged where it can't be healed. And if the patient is having pain after a torn meniscus, they may need surgery to get rid of the pain. But in this case, you can actually lose your meniscus, so a young patient needs to be evaluated quicker than an older person [with the same issue.] We want to be able to repair that meniscus.

Kayla: How do you decide if a patient needs surgery for their torn meniscus?

Dr. Youlo: Young patients almost always need surgery for a torn meniscus, so the meniscus can be saved. For an older person, we can try nonsurgical methods. But if their knee continues to catch, is swelling and feels like something is locked in it, they may also need surgery to resolve their symptoms.

Paige: We’ve talked a lot about athletes who may have torn their meniscus, and even older people who just get out of bed after eating those bonbons, right? Are meniscal tears associated with any other injuries? Let’s say I’m in my mid-40s, I get out of bed, and I have this sharp pain in my knee. Could I only have torn my meniscus, or are there other things that could be happening?

Dr. Youlo: It would be very unlikely to just get out of bed without an injury, to have any other major injury to your knee, in the presence of a torn meniscus. For most older patients, who have torn their meniscus, it’s an isolated injury. There's nothing else [going on]. However, it’s also common to have arthritis, [which is the swelling and tenderness of one or more joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age]. So, people can have arthritis and a torn meniscus. You could have knee pain because you have arthritis, and you also happen to tear your meniscus, but to have a major ligament or anything else torn in your knee without an injury, is almost unheard of.

Paige: For those older patients who have a torn meniscus, is surgery always the best option, and if not why?

Dr. Youlo: Not necessarily. If you have a torn meniscus, but your symptoms are manageable, you don't have to have surgery. Remember, the meniscus is not going to heal itself. It’s something that can fold over and cause pain. For other patients, it doesn’t fold over or cause pain. You can ignore it and live with it. But, if you have situations where the knee hurts, it’s most likely folding over and hurting no matter what you do. [At this point], you need surgery to relieve your pain and to live a more functional life.

Kayla: When the doctor and the patient decide that surgery is the best option, can you walk us through what that surgery looks like?

Dr. Youlo: So, we have two people. Let’s talk first about the older person, with a torn meniscus that flips back and forth, causing them pain. What we do most of the time is called a partial meniscectomy – big words. It just means we go in there and shave the piece that is torn out and then smooth out the rest of the meniscus. A partial meniscectomy is the most common surgery that is performed around the world. Once you shave that piece off and smooth out the rest of it, pain gets better.

Now, for a young patient who has had a traumatic injury and tore their meniscus, we try everything we can to repair it. And this is why it's so important to bring your child in early, because you don't want them to lose it. [However,] there are times when a young person’s meniscus gets torn into shreds, [rendering it] irreparable. [In this case], we shave out that part. It's really rare to lose the entire meniscus, though. Usually, just part of it is torn and is either repairable, or you have to tear out that piece that is causing the pain.

Kayla: Can you live without a meniscus? Are there instances where you would have to remove someone’s meniscus altogether?

Dr. Youlo: Yes, you don't want to lose your entire meniscus. Remember, it is a shock absorber for the end of the bone, which is covered with a layer. That layer acts as a cushion. If you lose that layer, you have arthritis. If you lose your meniscus, you lose that shock absorber effect. And then it puts you on a path to develop arthritis in your knee. If you’ve heard somebody talk about knee arthritis, [you’re aware] that it’s pretty painful. And the only treatment for knee arthritis is an artificial knee, a knee replacement. If you are young, you don't want to have a knee replacement, because it's not a normal knee. That's why young patients with a torn meniscus should have it repaired. Now, if you're older and have a torn meniscus without an injury, taking out a piece usually doesn't put you on a fast path to arthritis. There was a study done years ago that showed the more of the meniscus that you lose, the higher your chances are of getting arthritis. Losing a small piece doesn't necessarily put you on the path to develop arthritis right away. But if you lose the whole thing, it increases your chances dramatically to develop arthritis within 5 years.

Kayla: What does recovery look like after a meniscus surgery? Is it a long process?

Dr. Youlo: It depends who is counting…. For an older person with a torn meniscus, I make two small poke holes in front of your knee, put small instruments in the knee and then trim out that piece. So, there are tiny poke holes. The knee will be sore, but you don't have any real restrictions. [Of course,] you wouldn’t want to go running right away, because it's going to be sore. So, the recovery is pretty easy in that case.

Now, if you are a laborer on your feet all day long – for example, a nurse – it's going to be difficult to [return to work right away]. For these types of laborers, they can typically return to work in about 6 weeks. If you're somebody [with an office job], you can go back whenever you want.

For an athlete with a torn meniscus, that's different. In that case, we are not taking out the meniscus; we are repairing it. So, you have to let it heal. Athletes will get restrictions on how much weight they can put on [their knee]. At 6 weeks, we will increase the weight, and then around 3 months, we start having them get back to sports. So, an athlete with a torn meniscus might need a minimum of 3 months [before resuming sports].

Kayla: Backing up for a second: I’ve heard that people can receive a meniscal transplant. Is that something that's commonly done? How do you decide if you're going to do that or not?

Dr. Youlo: So, the success rate of a meniscal transplant is pretty low. We would use a cadaver, a young person who is close in age and take the meniscus and surgically place it in there. And then hopefully it heals. But the success rate is pretty low. [In order for this to even be considered, a patient would need to meet a few criteria.] The only time we do that is if you lose your whole meniscus. [Secondly], you need a good exam with several tests to make sure you still can use a meniscus. If you have arthritis already, then you don't need a meniscus, because the meniscus is to protect the knee from arthritis.

Now, let’s say you have a 20-year-old who tore their whole meniscus (which is not common). Their knee itself is healthy, and they don't have arthritis. [In this case], they would need a meniscal transplant. The recovery for a meniscal transplant can be up to a year. So, it's a big deal, and the success rate is not great. That's why you don't want to lose your whole meniscus. If a young athlete has a torn meniscus, bring them in. Let's see them; let's check them. Let's make a diagnosis so we can help them.

Paige: Let’s talk about long-term success rates for meniscus surgeries in general. What are those success rates? Is the surgery usually pretty successful? And if somebody does have to get that type of surgery, do they ever have to get it repaired? Like with a hip replacement, for example? At what point would you also have to get a meniscus repaired for normal wear and tear?

Dr. Youlo: Remember there are two kinds of patient populations we are talking about. For the older patient that has a partial meniscectomy, you're done. You don't need any further meniscal surgery. But remember the whole meniscus is not out. You still have it. If you have another tear, you might need surgery again to take another piece out.

If the meniscus is repaired in a young patient, the success rate varies. Remember that the meniscus [is made up of different parts]. Depending on where your tear is, the chance of that tear healing is different. For some young patients who have had the surgery, their meniscus retears because it never healed. In that case, they might need a second surgery. [With this second surgery], we don’t usually repair it a second time. We just remove a piece because it didn't heal the first time, and it’s not going to heal again.

But if you have a successful meniscal repair that has healed, your knee should be fine. You shouldn't need another surgery. It’s completely different than a hip or knee replacement. Knee and hip replacements are metal and plastic. They can wear out, and you may have to have them done again. [With a meniscal repair,] this is your normal knee. It's almost like you had a cut on your leg, I put stitches across it and it healed. When the meniscus heals, that's it; the knee is good. [You can resume normal activities.]

Paige: Go back to sports, right?

Dr. Youlo: That's correct.

Paige: Can the recovery period for meniscal-type surgeries vary? Sometimes it takes people a little bit longer. If they are really gung-ho with their therapy, maybe it takes a little less time. Just how important are physical therapy and rehab to these types of surgeries?

Dr. Youlo: It’s important. In my practice, for most of my patients, I encourage them to go to therapy. When you have knee surgery, the most common thing that happens is the knee gets weak. Secondly, the knee can get stiff, and that's what we need therapy for, to make that knee stronger and to prevent it from getting stiff. Now, the question is, how long do I do therapy? It's different for different people. Therapy is twice a week in most cases. [Physical therapists] are like a coach. They work with you and give you exercises to do at home. If you [follow all of their recommendations], your therapy might be a little shorter, but for most people, it will be 6 weeks of therapy.

Paige: I think it's really important, too. I tore my ACL [anterior cruciate ligament] when I was in college, and I'm the kind of person who was trying to walk 2 days after surgery. But I actually finished therapy and rehab early because I was so consistent with it. I think people often forget how important that part is. Surgery itself is important, as the repair needs to happen. But taking the time to retrain your knee or meniscus, whatever it is, is also really valuable.

Dr. Youlo: Absolutely essential. [You can compare it to] going to a dentist. You have a cavity filled, and you say, ‘I already saw a dentist; I'm never brushing my teeth again.’ You can't do that. You have to maintain dental hygiene. Well, you also need hygiene for your knee following a surgery. You need to work your knee and make it stronger. And the way you do that is through therapy. Therapists will guide you. Then, once your sessions are over, I tell my patients to treat their knee the same way they would brushing their teeth. You have to train your knee to stay strong. It's going to help you in the long term.

Paige: Yes, one of the things I notice is that if I don't exercise or stretch X times per week, my knee will get stiff and sore.

Dr. Youlo: That's correct.

Kayla: Let’s rewind a little: How can we prevent meniscal tears? I’m thinking of athletes in particular. Is there anything they can do to stop that from happening? Or is it just going to happen?

Dr. Youlo: It is difficult, because it is an injury. For an athlete, one way to prevent knee injury is to be ready for the season. You can't get off your couch and go play football. You need to prepare for the season. The stronger your knee is, the stronger the muscles around your knee are, the lower the chance of having knee injury. For young girls who play sports, your knee has to be strong, and your hips have to be strong. It decreases the chance of having knee injuries.

A meniscal tear is just one of the injuries you can have around your knee. There are a bunch of ligaments around your knee. There is a bunch of damage you can do to your knee, if your knee is not ready to play sports. The off-season is not off-season if you want to be an athlete; the off-season is when you get ready for the next season. [In the off-season], you can’t say, ‘I'm going to sit on the couch and play video games all the time.’ Yes, it's OK to do fun things, but you still have to be ready for the next season if you want to be an athlete. If you consistently prepare in the off-season, the risk of having an injury that next season decreases.

Kayla: Dr. Youlo, how can a patient make an appointment with you if they think they have a torn meniscus or any other related injury?

Dr. Youlo: They can call Phelps Health Orthopedics at (573) 364-5633 (KNEE) or visit phelpshealth.org. Every provider in our practice is fellowship trained and board certified.

Paige: What does fellowship trained mean? Let's talk about that.

Dr. Youlo: After medical school, you have to go to orthopedic training, which is 5 more years. After orthopedic training, you can decide to do an extra year of training, to be a specialist. That's what a fellowship is. You complete that year, and all you do is focus on one thing. In my case, my fellowship was in sports medicine at the University of Kentucky, taking care of student athletes and their injuries. [It’s an intense year] of studying and performing surgeries over and over again. And then you finish with this extra qualification.

[If you’re not familiar] with the University of Kentucky basketball, just Google it. We took care of those kids, through all of their sports. So, a fellowship gives you an extra edge to take care of people.

Kayla: That's perfect. Dr. Youlo, you are always a wealth of knowledge, and we enjoy having you on our show. Thank you for being here today.

Dr. Youlo: Thank you for having me. Phelps Health is a great place. If you ever need to see an orthopedic doctor, just come see us. We are always willing to help you. We have great doctors, all of whom are board certified.

Kayla: Yes, definitely. We have been speaking today with Dr. Sylvester Youlo, an orthopedic surgeon at Phelps Health. If you missed part of the show or would like to listen to it again, please visit phelpshealth.org.