What is the recommended treatment for severe meniscal extrusion?

Treatment for Severe Meniscal Extrusion

For severe meniscal extrusion, surgical intervention with arthroscopic repair is recommended, specifically targeting the underlying pathology—whether meniscal root tear or meniscotibial ligament injury—as conservative management alone is unlikely to adequately address severe extrusion that compromises meniscal biomechanics. 1, 2

Critical Distinction: Degenerative vs. Traumatic Pathology

The treatment approach fundamentally depends on the underlying cause of extrusion:

• Traumatic meniscal root tears with severe extrusion require surgical repair to restore meniscal anatomy and function, as the meniscus loses its hoop stress mechanism when the root is detached 3, 1
• Meniscotibial ligament injuries causing extrusion also warrant surgical repair, as biomechanical studies demonstrate that isolated meniscotibial ligament lesions directly cause meniscal extrusion (increasing from 1.5mm to 3.4mm), and repair significantly reduces extrusion 2
• Degenerative extrusion in older patients without mechanical locking should initially be managed conservatively, as this represents a different pathophysiologic process 4, 5

Surgical Management for Severe Extrusion

When surgery is indicated, the technique must specifically address the extrusion:

• Meniscal root repair alone may not adequately reduce severe extrusion, requiring additional techniques such as arthroscopic direct meniscal extrusion reduction 3
• Peripheral stabilization sutures should be added to standard root repair when severe extrusion persists, particularly in revision cases 1
• Meniscotibial ligament repair using knotless anchors (typically 3 anchors) achieves approximately 48% reduction in absolute meniscal extrusion clinically 2
• The goal is to restore meniscal position within 3mm of the tibial margin, as extrusion beyond this threshold compromises biomechanical function 3, 2

Conservative Management: Limited Role in Severe Extrusion

While physical therapy can reduce mild meniscal extrusion in degenerative osteoarthritis:

• Stretching of the semimembranosus tendon and passive ROM exercises reduced extrusion from 4.3mm to 3.8mm in weight-bearing position over 8 weeks in one study 6
• This approach improved knee extension ROM and re-established medial collateral ligament tension 6
• However, this conservative approach is appropriate only for degenerative extrusion in older patients without traumatic root tears or ligament injuries 4, 6

Treatment Algorithm

For severe meniscal extrusion (>3mm beyond tibial margin):

1. Identify the underlying pathology through MRI and clinical examination:

   • Meniscal root tear (particularly posterior root)
   • Meniscotibial ligament injury
   • Degenerative changes with osteoarthritis

2. If traumatic root tear or ligament injury in younger patients:

   • Proceed with arthroscopic repair
   • Add peripheral stabilization sutures if severe extrusion persists
   • Consider direct meniscal extrusion reduction techniques 3, 1

3. If degenerative extrusion in patients >35 years without mechanical locking:

   • Trial conservative management with structured physical therapy for 3-6 months 4, 6
   • Focus on semimembranosus stretching and passive ROM exercises 6
   • Reassess extrusion with ultrasound after 8 weeks 6

Post-Surgical Rehabilitation

• Bracing and non-weight bearing for 4-6 weeks is required after meniscal repair to allow healing 7
• Early mobilization after this protected period reduces pain and improves function 8
• Structured physical therapy focusing on quadriceps and hamstring strengthening is essential 8, 5
• Recovery from arthroscopic procedures typically requires 2-6 weeks with 1-2 weeks off work 8, 4

Critical Pitfalls to Avoid

• Do not assume standard meniscal root repair will adequately address severe extrusion—additional peripheral stabilization or direct reduction techniques are often necessary 3, 1
• Do not apply degenerative meniscal tear guidelines to traumatic extrusion cases—these represent fundamentally different pathologies requiring different treatment approaches 8, 5
• Do not delay surgical treatment for true mechanical locking or severe extrusion from root tears, as this can lead to progressive cartilage damage 8
• Careful patient selection is crucial—repair techniques require good compliance with post-operative rehabilitation protocols 7