Meniscal Injury

Lower Limb

Overview

Meniscal injuries are common knee conditions involving tear or degeneration of the fibrocartilage menisci, occurring through acute traumatic mechanisms or chronic degenerative processes. These injuries can significantly impair knee stability and mobility, leading to pain, swelling, and functional limitation. Early recognition and appropriate management are essential to prevent secondary osteoarthritic changes.

Pathophysiology

The menisci are C-shaped fibrocartilage structures that act as shock absorbers and load distributors within the knee joint. Acute injuries typically result from combined flexion-rotation mechanisms (commonly twisting on a planted foot), while degenerative tears occur due to cumulative microtrauma and age-related changes in tissue quality. Meniscal tears disrupt the normal load distribution, increase abnormal shear forces on articular cartilage, and can cause mechanical symptoms such as locking or catching. The medial meniscus is more frequently injured than the lateral meniscus due to its firm peripheral attachments limiting mobility during rotation.

Typical Presentation

Site

Knee joint, typically medial or lateral joint line; pain may be localized to the affected meniscus or diffuse across the knee

Quality

Sharp, catching, or stabbing pain with mechanical symptoms; may feel like knee 'giving way' or locking; aching quality with degenerative tears

Intensity

Variable from mild to severe; acute traumatic injuries often present with significant acute pain; degenerative tears may present with intermittent mild-to-moderate pain

Aggravating

Deep flexion activities (squatting, lunging), rotational movements, weight-bearing on flexed knee, prolonged walking, ascending/descending stairs, twisting or pivoting motions

Relieving

Rest, ice application, knee extension, reduced weight-bearing, anti-inflammatory medication, compression

Associated

Joint swelling (effusion), stiffness particularly after rest, reduced range of motion, sensation of instability, crepitus, positive McMurray test, positive Thessaly test, possible knee buckling or giving way

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade A
A+ABCDStrong clinical value: substantially changes the diagnosis (LR ≥10 or ≤0.1)
useful both to rule in and rule out.

Lachman Test (for concurrent ACL assessment)

Procedure

Patient supine, knee bent to 20–30°. Stabilise the lower femur with one hand and pull the upper tibia forwards with the other, comparing movement and end-feel with the other knee.

Positive Finding

More forward movement than on the other side, with a soft or absent end-point.

Sensitivity / Specificity

85%/94%

Reference: Benjaminse A et al., J Orthop Sports Phys Ther 2006; PMID 16715828

Interpretation

Tests the anterior cruciate ligament. Meniscal tears often occur with ACL tears, so check it in every twisting injury. Note: the Lachman test assesses anterior cruciate ligament integrity; its figures derive from ACL-rupture populations (Benjaminse 2006) and it appears here only to screen for a concomitant ACL injury, not a meniscal tear itself.

Sources

Grade B
A+ABCDGood clinical value: meaningfully changes the diagnosis in one direction (LR 5–10 or 0.1–0.2)
best for ruling IN (confirmation).

Thessaly Test

Procedure

Patient stands on the affected leg, holding your hands for balance, knee bent to 5°. Ask the patient to rotate the body and knee in and out three times. Repeat with the knee bent to 20°. Test the good knee first.

Positive Finding

Joint line pain, locking or catching during rotation, especially at 20° of flexion.

Sensitivity / Specificity

75%/87%

Reference: Smith BE et al., Evid Based Med 2015; PMID 25724195

Interpretation

A positive test supports a meniscal tear. Avoid it when the knee is acutely painful or unstable, as it is a weight-bearing twisting test. Thessaly test at 20° of knee flexion for meniscal tears: pooled sensitivity 75%, specificity 87% (Smith 2015 meta-analysis). The previously shown 94%/96% were the diagnostic-ACCURACY figures from Karachalios 2005 (JBJS Am, not "Arthroscopy") mislabelled as a sensitivity/specificity pair; that single-centre study is widely regarded as spectrum-biased, so the pooled meta estimate is used.

Sources

Grade B
A+ABCDGood clinical value: meaningfully changes the diagnosis in one direction (LR 5–10 or 0.1–0.2)
useful both to rule in and rule out.

MRI (Magnetic Resonance Imaging)

Procedure

Arranged by the treating doctor: MRI of the knee.

Positive Finding

A tear line reaching the meniscal surface, or a displaced fragment.

Sensitivity / Specificity

89%/88%

Reference: Phelan N et al., Knee Surg Sports Traumatol Arthrosc 2016; PMID 26614425

Interpretation

Confirms the tear and its type, and shows other injuries. Meniscal changes on MRI are common in people over 40 without symptoms, so findings must match the clinical picture. MRI is most useful when the result will change management. MRI against arthroscopy for medial meniscal tears: pooled sensitivity 89%, specificity 88% (Phelan 2016 meta-analysis, KSSTA); lateral meniscal tears 78%/95%. MRI is the imaging reference standard short of arthroscopy.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

McMurray's Test

Procedure

Patient supine. Fully bend the knee, then rotate the tibia out and straighten the knee while pressing on the inner side (medial meniscus); repeat with the tibia rotated in and pressure on the outer side (lateral meniscus). Keep a hand on the joint line.

Positive Finding

A painful click or clunk felt at the joint line, reproducing the familiar symptoms. Pain alone without a click is less meaningful.

Sensitivity / Specificity

61%/84%

Reference: Smith BE et al., Evid Based Med 2015; PMID 25724195

Interpretation

A positive test supports a meniscal tear; a negative test does not exclude one. Combine it with joint line tenderness, the Thessaly test and the history (twisting injury, delayed swelling, catching or locking). McMurray's test for meniscal tears: pooled sensitivity 61%, specificity 84% (Smith 2015 meta-analysis, BMJ Evid Based Med). Methodological quality of the pooled studies was poor; interpret alongside history and other findings. (The previously shown 58%/95% was attributed to the fabricated 'Hegedus 2015 BJSM' citation.)

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Joint Line Tenderness

Procedure

Patient supine, knee bent to 90°. Palpate along the medial and lateral joint lines from front to back, and compare with the other knee.

Positive Finding

Focal tenderness at the joint line that reproduces the familiar pain.

Sensitivity / Specificity

83%/83%

Reference: Smith BE et al., Evid Based Med 2015; PMID 25724195

Interpretation

Supports a meniscal tear, but joint line tenderness also occurs with osteoarthritis, ligament sprains and synovitis. Combine it with the other meniscal tests and the history. Joint line tenderness for meniscal tears: pooled sensitivity 83%, specificity 83% (Smith 2015 meta-analysis). Low evidence quality. (The previously shown 70%/72% was attributed to the fabricated "Hegedus 2015 BJSM" citation.)

Sources

No accuracy study

Ege's Test

Procedure

Patient standing with feet about 30–40 cm apart. For the medial meniscus, the feet are turned out; for the lateral meniscus, turned in. Ask the patient to squat slowly as far as possible and stand up again.

Positive Finding

Joint line pain or a click on the relevant side during the squat.

Interpretation

A weight-bearing version of McMurray's test. A positive result supports a meniscal tear on the painful side; many people cannot squat fully for other reasons, so interpret pain alone with caution. Not suitable for an acutely painful knee. Ege's test (weight-bearing McMurray) has limited independent validation and was not included in the Smith 2015 pooled meta-analysis; the figures previously shown are not traceable to a confirmed diagnostic-accuracy source.

Sources

⚠ Red Flags

  • •Signs of acute ligamentous instability (positive Lachman or anterior drawer tests suggesting ACL injury)
  • •Severe acute swelling suggesting hemarthrosis or significant inflammatory response
  • •Locked knee that cannot be passively extended, suggesting mechanical block
  • •Significant trauma with multi-ligamentous injury pattern
  • •Signs of infection (warmth, erythema, fever) suggesting septic joint
  • •Chronic symptoms with progressive functional deterioration despite conservative management
  • •Neurovascular compromise (diminished pulses, sensation changes, motor weakness)

⚡ Yellow Flags

  • •High kinesiophobia or fear-avoidance beliefs limiting rehabilitation engagement
  • •Catastrophizing about knee function and prognosis
  • •Significant mood disturbance or depression related to functional limitations
  • •Excessive reliance on healthcare provider reassurance
  • •Workplace or sport-specific distress affecting coping
  • •Previous unsuccessful treatment experiences creating negative expectations
  • •Social isolation due to activity limitation

Osteopathic Techniques

For degenerative meniscal tears, a home exercise programme is the base. In a large trial, adding in-clinic physical therapy (exercise plus manual therapy) gave no extra pain relief.

Region

Knee joint capsule and surrounding tissues

Technique

Soft tissue, knee and quadriceps
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of soft tissue technique alone in meniscal tears. In a large trial, physical therapy that included manual therapy added nothing to home exercise.

Rationale

Hands-on work to the quadriceps and the tissues around the knee to ease tension and pain.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the quadriceps, the patellar and quadriceps tendons, the iliotibial band near the knee and the tissues around the joint. Transverse friction massage across a tendon is one form. In trials it was given alongside exercise.

Evidence in Meniscal Injury

Searched 24 Oct 2026: no trials of soft tissue technique alone in meniscal tears. Indirect: Katz 2025 (n=879, degenerative meniscal tear with knee pain): standard physical therapy (supervised exercise plus manual therapy) added to home exercise did not reduce pain more at 3 months.

Region

Tibiofemoral and patellofemoral joints

Technique

Articulation, knee (tibiofemoral and patellofemoral)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of knee mobilisation alone in meniscal tears. In a large trial, physical therapy that included manual therapy added nothing to home exercise.

Rationale

Gentle, rhythmic glides of the knee and kneecap within their range to ease pain and stiffness.

How it's done, cautions & evidence

How it's done

Passive, low-velocity glides of the knee within its range, with no thrust: distraction and front-to-back glides of the tibia on the femur, and glides of the kneecap in each direction, usually 2–3 oscillations a second for 1–2 minutes. A Mulligan variant holds a sustained glide of the tibia while the patient actively bends and straightens the knee.

Cautions

In knee osteoarthritis trials, no serious adverse events were reported with manual therapy.

Evidence in Meniscal Injury

Searched 24 Oct 2026: no trials of knee mobilisation alone in meniscal tears. Indirect: Katz 2025 (n=879, degenerative meniscal tear with knee pain): standard physical therapy (supervised exercise plus manual therapy) added to home exercise did not reduce pain more at 3 months.

Region

Gastrocnemius and soleus

Technique

Muscle energy, calf (gastrocnemius and soleus)No trials found

Rationale

Low-force, patient-powered stretch for a tight calf.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Meniscal Injury

Searched 24 Oct 2026: no trials of calf muscle energy technique in meniscal tears.

Region

Lateral thigh: iliotibial band and vastus lateralis

Technique

Soft tissue, hip and thighNo trials found

Rationale

Eases tension in the hip and thigh muscles that help control knee alignment.

How it's done & evidence

How it's done

Hands-on kneading, stretching and sustained pressure to the muscles around the hip and thigh: the hip flexors, adductors and hamstrings, and tensor fasciae latae with the iliotibial band.

Evidence in Meniscal Injury

Searched 24 Oct 2026: no trials of lateral thigh soft tissue technique in meniscal tears.

Sources

Rehabilitation Exercises

Seated knee flexion-extension (active-assisted)

Range of MotionBeginner

Supine heel slides with towel on low-friction surface

Range of MotionBeginner

Quadriceps stretching (standing or supine)

StretchingBeginner

Hamstring stretching (supine, using strap or towel)

StretchingBeginner

Gastrocnemius and soleus calf stretching

StretchingBeginner

Quadriceps sets with vastus medialis obliquus (VMO) focus (isometric)

StrengtheningBeginner

Glute bridges (bilateral, progressing to single-leg)

StrengtheningBeginner-Intermediate

Side-lying hip abduction for gluteus medius

StrengtheningIntermediate

Clamshells for hip external rotators

StrengtheningIntermediate

Step-ups onto low platform (4-6 inches)

StrengtheningIntermediate

Single-leg stance on stable surface, progressing to eyes closed

BalanceIntermediate

Tandem stance and tandem walking for proprioceptive training

BalanceIntermediate-Advanced

Referral Criteria

  • •MRI or imaging findings confirming complex meniscal tear anatomy or extensive degenerative changes requiring surgical evaluation
  • •Persistent mechanical locking that does not resolve with conservative management, suggesting free fragment or unstable tear
  • •Failure to improve after 6-8 weeks of appropriate conservative care and structured rehabilitation
  • •Development of significant knee instability or repeated 'giving way' episodes suggesting associated ligamentous injury (ACL/MCL/PCL)
  • •Progressive functional deterioration or loss of range of motion despite compliance with rehabilitation
  • •Symptoms consistent with concurrent osteoarthritis requiring rheumatology or orthopedic specialist input
  • •Suspected associated injuries (osteochondral lesion, significant effusion, ligamentous damage) identified through clinical testing or imaging
  • •Patient goals requiring early return to high-level sport or work, potentially benefiting from surgical consultation
  • •Signs of complex regional pain syndrome or chronic pain presentations requiring multidisciplinary pain management
  • •Diagnostic uncertainty after thorough clinical assessment