What is a saddle tear?

What is a Saddle Tear?

A saddle tear is a specific type of meniscal tear pattern where the tear extends along the inner free edge of the meniscus, resembling the shape of a saddle draped over the meniscal rim.

Anatomical Description

• The tear follows the curved contour of the meniscus along its inner margin, creating a configuration that looks like a saddle when viewed arthroscopically 1
• This pattern represents a horizontal or oblique tear that tracks along the free edge rather than extending radially or longitudinally through the meniscal substance 2
• Saddle tears can occur in either the medial or lateral meniscus, though the medial meniscus is more vulnerable to injury due to its intimate attachment to the medial collateral ligament 3

Clinical Significance

• The location along the inner free edge typically places saddle tears in the avascular white-white zone, which has poor healing potential and makes conservative management less likely to succeed 2
• These tears may present with mechanical symptoms including clicking, catching, or pain along the joint line, though mechanical symptoms alone should not automatically indicate surgery in degenerative cases 4, 5
• Physical examination findings include joint line tenderness, knee effusion, and positive McMurray or Apley tests 5, 3

Diagnostic Approach

• MRI is the test of choice for confirming meniscal tears and defining the type, location, and severity of injury 3, 6
• Plain radiographs should be obtained first to assess for osteoarthritis, as this significantly impacts treatment decisions 5
• The presence of bone marrow lesions on MRI in combination with meniscal tears may indicate the origin of knee pain in patients with osteoarthritis 7

Treatment Considerations

• For young patients with traumatic saddle tears: surgical repair or partial meniscectomy is typically indicated, as conservative management is generally not recommended as first-line treatment for acute traumatic tears in this population 8
• For patients over 35 with degenerative meniscal tears (including saddle tears): conservative management with physical therapy is recommended as first-line treatment, as arthroscopic surgery provides no significant benefit over conservative management 4, 5
• The only clear indication for arthroscopy in degenerative knee disease is patients who are objectively unable to fully extend their knee (true locked knee) 5
• Meniscal repair is superior to partial meniscectomy when feasible, with better functional outcomes and less severe degenerative changes over time 2

Important Clinical Pitfall

• Do not confuse saddle tears with bucket handle tears—bucket handle tears are longitudinal tears where a large fragment displaces into the intercondylar notch and can cause true mechanical locking, while saddle tears remain along the inner edge without displacement 3, 1