KidsMD Health Topics

Meniscus (knee) tears

  • "We advise kids not to specialize in just one sport. Multi-sport athletes tend not to get as many meniscal tears and other acute and overuse injuries. And for practicing, we advise kids and coaches to alternate exercises and vary drills. In the long term, your muscle memory is better if you change up your practice exercises."

    --Orthopedic Team, Boston Children's Hospital Orthopedic Center

    With more and more kids playing organized sports, there’s been a rise in the number of overuse injuries, as well as acute injuries like meniscus tears, among children and adolescents.

    If your child or teen has been diagnosed with a torn meniscus, we at Children’s Hospital Boston know that he’s experiencing discomfort, as well as some disappointment at the disruption of his sports training. We’ll approach your child’s treatment with sensitivity and support. We want to get your child back to his normal activities—and back into his game safely.


    About meniscus tears (also called meniscal tears)

    • A meniscus tear is sometimes thought of as an overuse injury, but is more accurately classified as an acute injury, usually from sports.
    • The meniscus is a wedge-shaped structure in the knee that consists of fibrocartilage—a very tough but pliable material.
    • The medial meniscus is located on the inside of the knee (toward the middle of the body) and the lateral meniscus is located on the outside of the knee.
    • In the knee joint, the menisci act primarily as stabilizers and shock absorbers between the thigh bone and the shin bone.
    • Compressing or twisting the knee can tear the meniscus, a common injury in sports such as football.
    • More than 500,000 meniscal tears happen in the United States every year.
    • Meniscal tears are often associated with injuries to the anterior cruciate ligament (ACL).
    • Meniscal tears can lead to early arthritis.


    If a piece of torn meniscus isn't removed and "floats" around the knee, it may cause the joint to lock.


    Signs that your child's knee has a torn meniscus include:

    • a popping sensation
    • swelling or stiffness
    • pain associated with twisting or rotating the knee
    • difficulty in fully straightening the knee, or feeling like the knee is locking


    Meniscus tears can often be prevented with:

    • proper conditioning and training (especially cross-training)
    • sport-appropriate equipment and protective gear
    • adequate rest between exercise sessions

    Common types of tears

    [illustration courtesy of the American Academy of Orthopaedic Surgeons]


    Children’s Hospital Boston’s approach to meniscus tears

    Depending on the severity of your child's meniscus tear, treatment may be non-surgical or surgical. At Boston Children's, our doctors are committed to repairing your child's knee with the least invasive option possible.

    You can have peace of mind knowing that the orthopedic team at Boston Children’s has treated thousands of children, adolescents, adults and professional athletes with injuries ranging from the minor to the highly complex. We can provide your child with expert diagnosis, treatment and care—as well as the benefits of some of the most advanced clinical and scientific research in the world.

    The Orthopedic Center at Boston Children’s has provided care to thousands of young athletes and is the health care choice of professional athletes and world-renowned dancers. We are the official orthopedic caregivers for the internationally famous Boston Marathon and the renowned Boston Ballet.

    We provide comprehensive assessment, treatment and follow-up care to children, adolescents and young adults who have sports-related orthopedic injuries. Our skilled orthopedists and sports medicine experts work with physical therapy staff to develop long-term treatment and activity plans. Our team has also developed innovative evaluation programs and effective injury prevention programs and strategies.

    Our orthopedic team includes 24 orthopedic surgeons, 10 primary care sports medicine specialists, two podiatrists, a nutritionist, a sports psychologist, eight physician assistants, 14 nurses and four certified athletic trainers.

    Besides our busy Boston practice, Children's physicians see 500 to 600 patients every week at our locations in Lexington, Weymouth, Peabody and Waltham.

    Our surgeons perform an over 5,000 surgical procedures each year. And because of the knee joint's limited capacity for self-repair, Boston Children's Sports Medicine Research Laboratory is looking for a way to help jump-start the knee into healing itself.

    Meniscus tears: Reviewed by Yi-Meng Yen, MD, PhD
    © Boston Children's Hospital, 2011

    Boston Children's Orthopedic Center Among Highest in U.S.

    As one of the first comprehensive, multidisciplinary programs, Children’s Orthopedic Center is the nation’s largest and most experienced pediatric orthopedic surgery center, performing more than 6,000 surgical procedures each year. Our program—consistently ranked among the top three by U.S.News & World Report—is the preeminent care center for children and young adults with congenital, neuromuscular, developmental and post-traumatic musculoskeletal problems.

    Boston Children's at the Boston Ballet

    The Sports Medicine Division provides comprehensive medical coverage for the Boston Ballet, one of the leading professional dance companies in North America, with more than 50 full-time, top-trained dancers and an internationally-acclaimed repertoire. In addition, through a unique partnership with the Division of Sports Medicine, students from Boston Ballet’s summer dance program—one of the premier ballet training programs in the nation—receive physical therapy from Children’s specialists with expertise in dance-specific injuries.

    Orthopedic Center
    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 2
    Boston MA 02115
    617-355-6021

  • If your child or teen has sustained a meniscus tear, it will comfort you to know that Children’s Hospital Boston’s Orthopedic Center has a tremendous amount of experience treating this injury, developing therapies for healing and conducting research that leads to better care.

    What is the meniscus?

    One of the most commonly injured parts of the knee, the meniscus is a wedge-like rubbery cushion where the major bones of your leg connect. Meniscal cartilage curves like the letter “C” at the inside (medial) and outside (lateral) of each knee. A strong stabilizing tissue, the meniscus helps the knee joint to carry weight, glide and turn in many directions. It also keeps your femur (thigh bone) and tibia (shin bone) from grinding against each other.

    How do meniscus tears occur?

    Football players and others in contact sports can tear a meniscus when twisting the knee, pivoting, cutting or decelerating. In athletes, meniscus tears often happen in combination with other injuries such as a torn ACL (anterior cruciate ligament).

    Are there different kinds of meniscal tears?

    In young athletes, the meniscus can tear in a number of different ways: 

    • Young athletes often get longitudinal or “bucket handle” tears if the femur and tibia trap the meniscus when the knee turns.
    • Less often, young athletes get a combination of tears called radial or “parrot beak,” in which the meniscus splits in two directions due to repetitive stress activities, such as running.

    Common types of tears

    [illustration courtesy of the American Academy of Orthopaedic Surgeons]


    What should I do if I think my child has torn his meniscus?

    If you think your child has a meniscal tear, see his doctor right away for diagnosis and treatment. Without treatment, a loosened fragment of the meniscus may drift into the knee joint, causing it to slip, pop or lock; if this happens, the knee can get stuck, often at a 45-degree angle, until it’s moved manually or otherwise manipulated.


    What are the signs and symptoms of a torn meniscus?

    When a child or teen tears his meniscus, he might experience a “popping” sensation. Most people can still walk on the injured knee, and many athletes keep playing. When symptoms of inflammation set in, the knee feels painful and tight. Your child may experience:

    • stiffness and swelling
    • tenderness in the joint line
    • collection of fluid (“water on the knee”)
    •  pain when twisting or rotating the knee
    • difficulty in fully straightening the knee, or feeling like the knee is locking


    How are meniscal tears diagnosed?

    Your child’s doctor can usually diagnose an injury to the meniscus based on a physical exam of the knee (see McMurray Test in Tests). The orthopedic surgeon may also require further diagnostic studies, including:

    • MRI (magnetic resonance imaging): a diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body
    • arthroscopy: a minimally invasive outpatient procedure that inserts a small camera into the joint for the doctor to inspect


    How is a meniscus tear treated?

    Initial treatment follows the basic “R.I.C.E.” formula: rest, ice, compression and elevation, combined with non-steroidal anti-inflammatory medications for pain. If the knee is stable and doesn’t lock, this conservative treatment may be all that’s needed. Blood vessels feed the outer edges of the meniscus, giving that part the potential to heal on its own. So, small tears on the outer edges often heal themselves with rest.

    Additional measures to support this conservative approach to treatment can be:

    • crutches to take pressure off the knee
    • exercises to strengthen and stabilize the muscles around the knee
    • arch supports or other shoe inserts to redistribute weight while walking


    If the tear doesn’t heal on its own, surgery or other techniques may be needed.
     

    Why are there more meniscal tears and overuse injuries in kids these days?

    Youth and adolescent participation in organized sports has grown to about 35 to 40 million kids across the United States. Not surprisingly, the incidence of sports injuries is rising—statistics suggest that 30 to 60 percent of student athletes will have an overuse injury at some point in time. In one Sports Medicine practice at Children’s, for example, at least half of the young patients have an overuse injury.
     

    Aren’t organized sports supposed to be good for kids?

    Organized sports are very important and help kids—not just in the sports themselves, but in academics and social situations—and they’re good for children’s overall development and growth. The downside is that “overuse syndrome,” where the kids repeat the same drill over and over, causes overuse injuries.
     

    How can parents and coaches help kids avoid meniscal tears and overuse injuries?

    Parents and coaches have a great deal of influence—for better or for worse. They should stress moderation in training and should restrain the zeal with which they push youth and teens.

    Coaches themselves should learn and use proper training techniques and should avoid too many repetitive drills, since these are the overwhelming reason for overuse injuries. Coaches should also teach proper running mechanics and other sports-motion techniques.

    Physical education departments should make sure that the surfaces of a track or field are in good shape, and that proper equipment, footwear and protective gear are used for each sport.

    Our orthopedic specialists advise:

    • warming up and stretching before practice
    • resting at least one day a week
    • cross-training/alternating sports: It is usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to get fewer overuse injuries than those who specialize in just one sport.
    • alternating exercises during practice: An athlete less likely to experience an injury—and  over the long term, his muscle memory actually improves—if one varies practice drills.
       

    Can a meniscal tear be prevented?

    A torn meniscus is not strictly a preventable injury, since sports such as basketball, soccer, skiing, gymnastics, volleyball and football do put athletes at some risk to tear a meniscus. But athletes and active young people can reduce their risk by:

    • maintaining general health and fitness: sport-specific conditioning, diet, exercise, sleep
    • learning/using proper sport-specific movements (form) and techniques
    • wearing/using proper sport-specific gear (see next question)
    • risk awareness: learning which moves cause risks
    • hamstring/leg strengthening (especially for girls)
       

    Are there other guidelines and resources for injury prevention and safer training?

    The American Academy of Orthopaedic Surgeons (AAOS) has issued comprehensive guidelines for helping to prevent sports injuries. Below is an excerpt from the AAOS recommendations:

    • Use proper equipment.
      • Replace athletic shoes as they wear out.
      • Wear loose-fitting clothes that are light enough to release body heat.
      • In cold weather, dress in removable layers.
    • Warm up.
      • Warm up to prepare to exercise, even before stretching.
      • Run in place for a few minutes.
      • Breathe slowly and deeply, or gently rehearse the motions of the exercise to follow.
    • Stretch.
      • Stretch slowly to the point of muscle tension.
      • Hold each stretch for 10 to 20 seconds, then slowly release.
      • Inhale before each stretch, exhale on release.
      • Do each stretch only once.
      • Never bounce on a fully stretched muscle.
    • Drink water.
      • Drink enough water to prevent dehydration, heat exhaustion and heat stroke.
      • Drink 16 ounces (one pint) of water 15 minutes before exercising, another 16 ounces after cool-down.
      • Drink water every 20 minutes or so while exercising.
    • Cool down.
      • Cool down for twice as long as warm-up.
      • Slow down motion and lessen intensity for at least 10 minutes before stopping completely.
    • Rest.
      • Schedule regular days off from exercise, and rest when tired.
      • Fatigue, soreness and pain are good reasons to not exercise.

    Who at Children’s will be caring for my child if he tears his meniscus? 

    Members of our orthopedic team will provide expert care and support for your child. Our staff includes 10 primary care sports medicine specialists, 24 orthopedic surgeons, two podiatrists, a nutritionist, a sports psychologist, eight physician assistants, 14 nurses and four certified athletic trainers.

    Will my child be OK?

    The good news is that 98 percent of patients with simple meniscus tears are able to return to sports and regular activities without knee instability.

    After your child’s knee has healed, and after his strength and stability have returned through physical therapy, he should be able to return to his previous sports and activities—usually within six months. (But his doctor may recommend lifestyle changes for him if he has joint changes, such as arthritis or instability, which couldn’t be corrected even with surgery.)

    Your child’s rehab team will help him relearn normal movements and pain-free activities. After he has successfully eliminated most of his discomfort and has returned to his normal routine, it’s important for him to continue to be involved in some form of orthopedic fitness to ensure continued physical health and well-being.

    What is the Orthopedic Center doing to encourage injury prevention and safer training?

    With Children’s goal of dramatically reducing overuse injuries in youth sports, members of our team often travel to local and regional schools, youth groups and sports clubs to teach leg strengthening and other techniques. We also conduct frequent safe training programs and clinics for coaches. Call 617-355-3501 for details.

    FAQ

    Q: What is a meniscus tear?
    A:
    A meniscus tear is an injury to the meniscus, a wedge-shaped cushion of fibrocartilage located on the inside and outside of the knee in the knee. Compressing or twisting the knee can tear the meniscus, a common injury in sports such as football, basketball and skiing, which involve cutting and pivoting.

    Q: How do meniscus tears happen happen?
    A:
    Football players and others in sports can tear a meniscus by twisting the knee, pivoting, cutting or decelerating. In athletes, meniscus tears often happen in combination with other injuries such as a torn ACL (anterior cruciate ligament).

    Q: What are the signs and symptoms of meniscus tears?
    A:

    • a “popping” sensation in the knee
    • stiffness and swelling
    • pain when twisting or rotating the knee
    • difficulty in fully straightening the knee, or feeling like the knee is locking
    • tenderness in the joint line
    • collection of fluid (“water on the knee”)

    Q: What should we do before we see the doctor for a diagnosis?

    A: If you suspect that your child has torn his meniscus, home care before your child gets to the doctor should include “R.I.C.E.”:

    • rest:Make sure he doesn’t exert in any way that involves the injured area; he can use crutches or a cane, if it helps.
    • ice:Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
    • compression:Wrap a bandage or soft brace (from the drugstore) around his injury.
    • elevation:The child should remain seated or reclining, with his leg elevated, as often as possible before seeing the doctor.

    Q: How is a torn meniscus usually diagnosed?
    A:

    • physical exam (see McMurray Test in Tests)
    • MRI (magnetic resonance imaging): a diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body
    • arthroscopy: a minimally invasive outpatient procedure that inserts a small camera into the joint for the doctor to inspect

    Q: How does Children’s treat a torn meniscus?
    A:

    • “R.I.C.E.”: rest, ice, compression and elevation
    • non-steroidal anti-inflammatory pain medications
    • rest from activity that may stress or twist the knee
    • crutches to take pressure off the knee
    • exercises to strengthen and stabilize the muscles around the knee
    • arch supports or other shoe inserts to redistribute weight while walking
    • if tear doesn’t heal, surgery

    Q: Does the location of a meniscal tear matter?

    A: Depending on where in the meniscus a tear occurs, some injuries may be easier to repair than others.

    • Tears at the outer edge of the meniscus heal more easily because the outer edge has a greater blood supply.
    • Tears to the inner two-thirds of the meniscus don't heal as well because this area does not have a rich blood supply.
    • Tears that cross from the outer edge of the meniscus to the inner portion may be easier to repair because of access to the blood supply.

    Q: Will my child be OK?

    A: Most kids with meniscal tears can return to sports and regular activities after a few months of rest and healing time. Your child’s doctor will give you guidance about how long your child’s knee should be rested in order for it to heal.

    During the healing period, it’s important to support your young athlete’s resolve to rest his knee, since he may feel disappointed and frustrated at not being able to play his sport.

    Dr. Stein

    Q: If my child has been injured playing sports, should he go back to sports?

    A:If your child’s doctor has cleared him to go back to sports, the many benefits and life lessons he’ll gain from playing greatly outweigh the risks of injury. These benefits include:

    • physical fitness
    • teamwork, competitive prowess, accomplishment
    • improved body composition—less risk of obesity
    • reduced risk of heart disease and diabetes
    • stronger immune system
    • academic fitness—kids who play sports often academically outperform kids who don’t
    • emotional and psychological fitness—improved self-esteem, self-concept, self-confidence, empowerment and perception of competence

    Q: What is Boston Children’s experience in orthopedics?

    A: Boston Children’s Orthopedic Center is known for our clinical innovations, research and leadership. Ranked among the top three in orthopedics for 2012-2013 by U.S.News & World Report, we provide the most advanced diagnostics and treatments, several of which were pioneered and developed by Children’s researchers and clinicians—including platelet-rich plasma (PRP) treatment for tendon repair and physeal-sparing ACL procedures for children whose growth plates are still open.

    Causes

    As more and more kids play organized sports, there’s been a rise in the number of meniscal tears and other overuse injuries (microtraumas to bones, tendons, ligaments or muscles) among adolescents and children, largely from repetitively using the same parts of the body. Football, tennis and basketball players can tear a meniscus by twisting the knee, pivoting, cutting or decelerating. Meniscus tears often happen in combination with other injuries, especially a torn ACL (anterior cruciate ligament).

    Signs and symptoms

    • a “popping” sensation in the knee
    • stiffness and swelling
    • pain when twisting or rotating the knee
    • difficulty in fully straightening the knee, or feeling like the knee is locking
    • tenderness in the joint line
    • collection of fluid (“water on the knee”)

    When to seek medical advice

    Meniscus tears usually cause enough discomfort that an injured child will seek medical or parental help. Consult your child’s doctor if:

    • your child is in pain
    • his knee is swollen
    • walking and bending his knee are difficult

    Questions to ask your doctor

    You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

    You probably already have some ideas and questions on your mind, but it can be easy to forget the questions you wanted to ask when you’re talking to your child’s doctor. It’s often helpful to jot them down ahead of time to make sure that all your concerns get addressed. You may also suggest that your child write down questions to ask, too. Some of the questions you may want to ask include:

    • What has happened to my child’s knee, and why?
    • Is this a serious injury? Will it do any permanent damage?
    • What tests will you perform to diagnose my child?
    • What actions might you take after you reach a diagnosis?
    • Will my child be OK if he has a meniscal tear?
    • Will there be restrictions on my child’s activities? If so, for how long?
    • What should we do at home?
    • How can we help him understand that he needs to rest the injury?

    Who’s at risk

    At greater risk than some young athletes are those whose sports involve quick pivoting, cutting, decelerating and side-to-side motions, such as football, tennis, skiing and basketball.

    Complications

    Complications after proper treatment for meniscal tears are rare, but can occur if surgical repair has been needed. Complications can include:

    • bleeding or infection (1 percent)
    • nerve or vessel injury
    • retear of the meniscus (5 to 25 percent)
    • knee stiffness (5 to 25 percent)
    • premature arthritis
    • need for further procedures

    Extremely rarely, there can be acute injury to the popliteal artery (0.01 percent), weakness or paralysis of the leg or foot, or a blood clot in the calf veins (0.12 percent).

    For teens

    Many teens who have a meniscal tear are not only high-performing, determined athletes, but also high-performing, determined students. If you approach your healing period with that same spirit of determination, you should be back to sports and your active lifestyle within a few months, depending on how severe your tear was in the first place.

    The most important thing you can do to get back into your sport is to give your knee a total rest. But even though you know the importance of rest to your recovery, you may still find this to be a tough time. If you feel frustrated, depressed or angry during this important time, speak to your doctor, parent or counselor—they’re all on your team, and they all want to help.

    For parents

    If your teen is like many young athletes who’ve sustained a meniscal tear, he’s not only a high-performing, determined athlete—he’s also a high-performing, determined student. Encourage him to approach his recovery period with the same spirit of determination that he applies to other areas of his life. With patience and perseverance, he’ll probably be back to sports and his active lifestyle within a few months.

    Even though you and your teen know the importance of resting his knee, you both might experience his healing period as a difficult time. Parents who identify with their children’s success can feel frustrated or depressed along with their children, so speak to your doctor or counselor if you need help.

    Prevention

    Our Sports Medicine specialists advise young athletes to:

    • warm up and stretch before practice
    • rest at least one day a week
    • cross-train/alternate sports: It’s usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to get fewer overuse injuries than those who specialize in just one sport.
    • alternate exercises during practice: An athlete less likely to experience an injury—and  over the long term, his muscle memory actually improves—if one varies practice drills.

    Long-term outlook after surgery

    If your child needed surgery, his long-term outlook is excellent. Most patients who’ve had surgery for meniscus tears can return to sports and regular activities without knee instability. Some patients do complain of stiffness and pain after surgery, but current surgical and physical therapy techniques have minimized these problems.

    Meniscus tears glossary

    • ACL (anterior cruciate ligament): a major ligament in the knee that connects the tibia to the femur at the center of the knee; helps stabilize the knee,limiting rotation and forward motion of the tibia; often becomes injured in association with a meniscal tear
    • arthroscope: a thin, fiberoptic scope introduced into a joint for diagnostic and treatment procedures inside the joint; used in ACL diagnosis and repair
    • brace or cast: a custom-made protection worn around your child’s knee while it heals
      after surgery for a meniscus tear
    • cartilage: a smooth, rubbery tissue that cushions the bones at the knee joint, and allows the knee to move easily without pain
    • The Center for Families at Children’s: dedicated to helping families find the information, services and resources they need to understand their child’s medical condition and take part in their care
    • diagnosis, diagnostics: identifying disease or injury through examination, testing and observation
    • femur: thigh bone
    • knee: the largest and most complex joint in your child’s body, joining the thigh bone and shin bone and covered by the patella. It depends on four ligaments, as well as other muscles and tendons, to function properly. Menisci on both sides of the knee help cushion the knee and keep the femur and tibia from grinding against each other.
    • lateral: side
    • laxity (in the knee): looseness, instability
    • ligament: elastic band of tissue connecting bone to bone
    • medial: inside
    • meniscus (lateral meniscus, medial meniscus): a pad of cartilage that contains thick bundles of collagen fibersand cushions the knee joint. Menisci can be found on both the lateral (outside) and medial (middle, inside) sides of the knee.
    • meniscal tear: an injury to the meniscus; often treated with rest, but occasionally needing surgical repair
    • meniscal repair: procedure undertaken if the meniscus has been torn, often at the same time as ACL surgery
    • microtrauma: a small injury to the body, such as microtears to muscle fibers, stress to the tendon, bruising of the bone; can occur to bone, muscle, tendon or ligament. If not allowed rest in order to heal, microtraumas can lead to overuse injuries, such as meniscus tears.
    • MRI (magnetic resonance imaging): produces detailed images of organs and structures within the body; shows the amount of damage to the meniscus, ACL and any other parts of the knee, such as cartilage and/or other ligaments
    • non-surgical (non-operative) treatments: alternatives to surgery; most treatments for overuse injury are non-surgical
    • orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
    • orthopedist/orthopedic surgeon: a physician concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
    • overuse injuries: sports-related microtraumas that result from repetitively using the same parts of the body, usually by overtraining; can occur to muscle, tendon, ligament or bone
    • physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
    • post-operative (post-op): occurring after surgery
    • premature arthritis: inflammation of a child’s (knee) joint caused by trauma to the joint, as in a meniscal or ACL tear; often accompanied by pain and swelling
    • pre-operative (pre-op): occurring before surgery
    • tibia: shin bone

    Boston Children's Orthopedic Care in Lots of Places

    Boston Children's physicians provide orthopedic care at Boston Children's locations in Lexington, Peabody, Weymouth and Waltham, as well as at our main campus in Boston.

  • knee exam at Boston Children's Hospital

    At Boston Children's Hospital, we know that the first step to treating your child is forming an accurate, timely diagnosis.


    The exam

    To diagnose a torn meniscus, your child’s orthopedic specialist will take a medical history and perform a physical exam on your child. The doctor will check for pain along the joint line, where the meniscus lies. He or she will conduct what’s called the McMurray Test, in which the knee is bent, then straightened and rotated. The tension on a torn meniscus from this manipulation will cause a clicking sound.


    The tests

    To confirm the diagnosis with detailed images of the injury, the doctor may also use:

    • MRI (magnetic resonance imaging): a diagnostic procedure that uses a combination of large magnets, radio frequencies and a computer to produce detailed images of organs and structures within the body
    • arthroscopy: a minimally invasive outpatient procedure that inserts a small camera into the joint for the doctor to inspect

    If you live far from Boston, we can help

    As an international pediatric orthopedics center, Children’s treats young patients from all over the world. Our International Center assists families residing outside the United States: We facilitate the medical review of patient records; coordinate appointment scheduling; and help families with customs and immigration, transportation, hotel and housing accommodations. 

    Our Orthopedic Clinical Effectiveness Research Center (CERC)

    The Orthopedic Clinical Effectiveness Research Center (CERC) was established by Children’s Orthopedic Center to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and is playing an instrumental role in establishing, for the first time, evidence-based standards of care for pediatric orthopedic patients throughout the world. 

  • Boston Children's Hospital's Orthopedic Center provides patients with comprehensive care—including evaluation, diagnosis, consultation, non-surgical therapies, surgery and follow-up care.

    Initial self-aid for a torn meniscus usually involves “R.I.C.E.” (rest, ice, compression and elevation), as well as medications to help control pain and swelling:

    • rest: Make sure your child doesn't exert in any way that involves the injured knee; he can use crutches or a cane, if it helps.
    • ice: Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
    • compression: Wrap a bandage or soft brace (from the drugstore) around his injury.
    • elevation: Your child should remain seated or reclining, with his leg elevated, as often as possible before and after seeing the doctor.


    Non-operative treatment

    If your child's knee is stable and does not lock, the R.I.C.E. formula combined with nonsteroidal anti-inflammatory pain medication may be all that's needed to treat his torn meniscus. Blood vessels feed the outer edges of the meniscus, giving that part the potential to heal on its own. So, small tears on the outer edges often heal themselves with rest.

    Additional measures to support this conservative approach to treatment can be:

    • crutches to take pressure off the knee
    • exercises to strengthen and stabilize the muscles around the knee
    • arch supports or other shoe inserts to redistribute weight while walking


    Surgical repair

    If your child's meniscus tear doesn't heal on its own and his knee becomes painful, stiff or locked, it may need surgical repair. The goal of meniscal surgery is to obtain a stable, smooth rim of meniscal tissue that doesn't rub abnormally on the cartilage surfaces of the knee. (Patients may still have an increased risk of arthritis in the knee after a meniscal tear, even if surgery is performed.)

    Depending on …

    • the type of meniscal tear
    • whether your child also has an injured ACL
    • your child's age, general health and other variables

    … the surgeon may recommend surgery using an arthroscope to:

    • place sutures to repair the meniscus, or
    • use small instruments to trim off damaged pieces of meniscal cartilage


    Arthroscopic surgical techniques

    Children's orthopedic surgeons have spent many years developing highly specialized arthroscopic techniques to repair meniscus tears. Our deep experience allows us to repair not only small “simple” tears—but also complex, multi-component tears, which most physicians elect to remove.

    Arthroscopic treatment of meniscal tears

     [photo courtesy of the American Academy of Orthopaedic Surgeons]

    Because many of our patients are young, we emphasize trying to repair not only small meniscal tears, but also large, complex tears. Although the success rate is lower for complex tears (80 percent) compared to simple tears (98 percent), we feel that it's worth the time and effort to try to save the meniscus—in order to keep as much of the normal shock absorber in the knee as possible.

    In some cases, the torn part of the meniscus is either so small that it's impractical to repair, or so damaged that the repair is likely to fail. In these cases, this tissue is simply trimmed out to leave a stable rim of meniscus and to minimize further damage within the knee.


    Alternatives to surgery

    Surgical treatment is usually advised for patients with symptoms of unstable meniscal tears, including pain, locking, giving way or catching in the knee. But non-operative management of isolated meniscal tears may be indicated for patients:

    • with small, stable tears located in the outer one-third of the meniscus
    • with low-demand lifestyles
    • with no effusion (“water on the knee”) or swelling of the knee and no symptoms of locking or catching in the knee


    Care before surgery

    If your child is to have arthroscopic surgery to treat his meniscal tear, he may need a complete physical with his pediatrician before surgery to assess his health and rule out any conditions that could interfere with his surgery.

    Before surgery, tell your child's doctor about any medications that he's taking. You will be informed which medications he should stop taking before surgery. This typically includes aspirin and anti-inflammatory medications, which should be stopped 10 days before surgery.

    Your doctor may also order tests, such as blood samples or an echocardiogram, to help prepare for your child's procedure.


    Care after surgery

    After surgery, you and your child will be given written instructions, pictures of his surgery, a prescription for therapy and a copy of our rehabilitation guidelines. A cast or brace will immobilize the knee for a period of time after surgery, and your child will use crutches for four to six weeks.

    Your child will need to complete a course of rehabilitation exercises before gradually resuming his activity. He'll meet with the physical therapist, who will instruct your child in exercises, wound care and how much weight he should place on the operated knee. The therapist will work with your child to help set goals for rehabilitation; the entire rehab process will probably take four to six months.

    Throughout the rehab period, your Children's team will be available for questions, concerns and help.


    Caring for your child after treatment or surgery

    Your child's doctor will give you guidance regarding how long your child's knee should be rested in order for it to heal. The good news is that 98 percent of patients with simple meniscus tears are able to return to sports and regular activities without knee instability.

    After your child's knee has healed, and after his strength and stability have returned through physical therapy, he should be able to return to his previous sports and activities—usually within six months. (But his doctor may recommend lifestyle changes for him if he has joint changes such as arthritis or instability that couldn't be corrected even with surgery.)

    Your child's rehab team will help him relearn normal movements and pain-free activities. After he has successfully eliminated most of his discomfort and has returned to his normal routine, it's important for him to continue to be involved in some form of orthopedic fitness to ensure continued good physical health and well-being.

    Coping and support

    At Boston Children's Hospital, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Our Center for Families staff will give you all the information you need regarding:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family


    In particular, we understand that you may have a lot of questions when your child is diagnosed with a meniscal tear. Will this affect my child long term? When can he return to his sports and activities? Children's can connect you with extensive resources to help you and your family through this stressful time, including:

    • patient education: From the first doctor's appointment to treatment and recovery, our staff will be on hand to walk you through your child's treatment and help answer questions you may have—How long will his recovery take? Will he need home exercises and physical therapy? We'll help you coordinate and continue the care and support your child received while at Children's.
    • parent-to-parent: Want to talk with someone whose child has been treated for a meniscus tear? We can often put you in touch with other families who've been through the same process that you and your child are facing, and who will share their experience at Children's.
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy— representing Protestant, Jewish, Muslim, Roman Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your Children's experience.
    • social work: Our clinical social workers have helped many families in your situation. Your Children's social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to dealing with a child's injury, changing family dynamics and financial issues.

    A Long Line of Orthopedic Firsts

    With a long history of excellence and innovation and a team of clinicians and researchers at the forefront of orthopedic research and care, Children's is home to many treatment breakthroughs:

    • advanced techniques and microsurgery care for complex fractures and soft tissue injuries to the hand and upper extremity
    • one of the first pediatric sports medicine clinics in the nation
    • a hip program that has performed more than 7,000 periacetabular osteotomies
    • advances in our spinal program, such as video-assisted thorascopic surgery

    We are also:

    • the oldest and largest comprehensive center for the care of spina bifida
    • one of the first scoliosis clinics in the nation
    • one of the first centers in the nation to use adjuvant chemotherapy and perform limb salvage surgery for patients with osteosarcoma

     

    We Care for Professional Athletes and Dancers
    The Division of Sports Medicine has provided care to thousands of young athletes and is the health care choice of world-renowned dancers and professional athletes. We are the orthopedic caregivers for the Boston Ballet and the Boston Marathon.
  • For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research—pioneering approaches and major advances in the care and treatment of trauma to the joint, scoliosis, polio, TB, hip dysplasias and traumas to the hand and upper extremities.

    Our advanced research helps answer the most pressing questions in pediatric orthopedics today—providing the children we treat with the most innovative care available.

    Boston Children’s research shows that too much high-impact training can lead to stress fractures in pre-teen and teen girls

    Today’s kids are urged to participate in sports at younger and younger ages and at greater levels of intensity. While weight-bearing activity is generally thought to increase bone density, a Children's study found that for preadolescent and adolescent girls, too much high-impact activity can lead to stress fractures.

    If stress fractures are detected too late in children and adolescent athletes, they pose a risk of true fracture, deformity or growth disturbance requiring surgical treatment, say the researchers, led by Alison Field, ScD, of Children's Division of Adolescent Medicine, and Mininder S. Kocher, MD, MPH, associate director of Sports Medicine at Children's.

    Their study, published online on April 4, 2011, by the Archives of Pediatric and Adolescent Medicine, followed 6,831 girls aged 9 to 15 participating in the large national Growing Up Today study, co-founded by Field. During the seven years after enrollment, 4 percent of the girls developed a stress fracture. The most significant predictors were high-impact activities—particularly running, basketball, cheerleading and gymnastics.

    "This is the first study to look prospectively at causes of stress fracture among a general sample of adolescent girls," says Field, who is also affiliated with Brigham and Women's Hospital. "Most research has been on specialized groups, such as army recruits or college athletes, making it difficult to figure out if the results apply to average adolescents. Our study was large enough to look at the risk associated not only with hours per week of activity, but also hours per week in a variety of activities."

    When researchers adjusted for other risk factors (age, later onset of menstruation and family history of osteoporosis and low bone density), the association between high-impact sports and fractures only strengthened. Girls engaging in eight or more hours of high-impact activity per week were twice as likely to have a stress fracture as those engaged in such activity for four hours or fewer.

    "We are seeing stress fractures more frequently in our pediatric and adolescent athletes," says Kocher, senior author on the report. "This likely reflects increased intensity and volume of youth sports. Kids are often playing on multiple teams, including town and travel teams, and participating in high-intensity showcases and tournaments. It's not uncommon to see young athletes participating in more than 20 hours of sports per week."

    Each hour of high-impact activity per week increased fracture risk by about 8 percent. Basketball, cheerleading/gymnastics and running were independent predictors.

    "The youth athlete is specializing in a single sport at a younger age," says Kocher. "This does not allow for cross-training or relative rest, as the athlete is constantly doing the same pattern of movement and impact. Small injuries are being made in the bone with greater cumulative frequency than the body can handle."

    The key to the treatment of stress fractures is early recognition, Kocher adds. If recognized early, most stress fractures will heal fully with activity restriction. "Kids should not play through pain," he says. "'No pain-No gain' is not an appropriate adage for the young athlete."

    The study was supported by the Orthopedic Center at Boston Children's Hospital and the National Institutes of Health.


    Sports Medicine Research Laboratory

    Boston Children’s Sports Medicine Research Laboratory, led by principal investigator Martha M. Murray, MD, focuses on sports medicine injuries, including those of the ACL (anterior cruciate ligament), knee meniscus and articular cartilage.

    In conjunction with our collaborators, we are studying these problems on multiple levels: gene, protein, cell, tissue and organism.

    Researchers at Boston Children’s Sports Medicine Research Laboratory

    The Orthopedic Center conducts research into:

    • the mechanisms of sports injuries
    • the techniques of rehabilitation and treatment
    • the physiology of exercise and conditioning


    Ongoing research includes the study of:

    • knee injuries
    • running injuries
    • injuries to pre-adolescent children
    • the psychological impact of sports and sports injuries
    • the treatment and prevention of injuries to dancers


    Sports Medicine director Lyle J. Micheli, MD, is one of the world's leading authorities on sports care. Micheli has treated world-renowned dancers and professional athletes, and is the author of hundreds of published clinical studies and scholarly review articles and books.


    Innovations for tendon and ligament treatment

    Platelet-rich plasma. For tendon repair, as with tennis elbow, the Orthopedic Center is now incorporating the latest in tendon regeneration—the application of platelet-rich plasma (PRP). This treatment has been popular in Europe—and now in the United States—for stimulating tissue regeneration in difficult-to-heal areas such as tendons (including Achilles, elbow and patella) that don’t respond to physical therapy or to limits on activity.

    There are normally many healing growth factors in our platelets. The process involves isolating these growth factors in the patient’s blood platelets, and then injecting them into the affected areas under ultrasound guidance. This special procedure is performed by Children’s Pierre d'Hemecourt, MD.

    Physeal sparing. A series of innovative, age-specific reconstruction techniques for treating the ACL injuries of growing children has been developed by Children’s orthopedic surgeon and director of the Division of Sports Medicine Lyle Micheli, MD. These are classified as physeal sparing procedures—that is, they spare the child’s growth plates (physes) from disruption that would occur in traditional ACL reconstructive surgery.

    These physeal sparing treatment techniques are customized to the growing child’s age: pre-pubescent, adolescent or older adolescent. Originally developed as a temporary procedure until a child reached skeletal maturity, follow-up studies have found that five years after their surgeries, 95 percent of children who’d had physeal sparing procedures were doing so well that they didn’t need ACL reconstructive surgery, after all.

    Children speak about what it's like to be a medical research subject

    View a video of a day in the life of Children’s Clinical and Translational Study Unit, through the eyes of children who are “giving back” to science.

    Centers for Young Women's Health and Young Men's Health 

    Why are my friendships changing? How can I convince my parents that being a vegetarian is right for me? What types of birth control are available to me, and how do I use them? Young men and young women have specific concerns about their physical and emotional health. Children’s Center for Young Women’s Health and Center for Young Men’s Health offer general and gender-specific health information, with a focus on fitness and nutrition, sexuality, development and emotional health.

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The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”
- Sandra L. Fenwick, President and CEO
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