Your knee just locked on you; what do you do? (the fickleness of the meniscus)

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Four years ago I had an ACL reconstruction. That topic has proven to be one of the more popular on this site. What’s been lost in that with regards to my own surgery, is I also had a meniscus repair procedure.

My ACL recovery has gone very well. My meniscus recovery hasn’t been as smooth.

20% seems to be in the ballpark for how many meniscal repairs will fail. That’s a pretty damn high percentage. I knew that going in, but if you can have a repair done, you want one. A repaired meniscus does better long term, particularly when it comes to very active people. (I’ll write about this in another post.) One of the trade offs is, compared to taking the torn part of the meniscus out -a partial meniscectomy- there is an increased chance you will be back in the operating room with a repair, and even more so if the repair doesn’t hold. (Again, we’re talking active people here, usually of the running kind. The less you “pound the pavement,” or pivot your knees (football / futbol / etc.), the less this matters.)

18 months after my ACL and meniscus surgery, I was walking through a bar and my knee gave way a little bit, with a small pop, right on the inside. “Fuck fuck fuck fuck fuck. I just tore my meniscus again.” I was pretty much positive the repair didn’t hold, but I was in some denial. I’d been doing very well. Feeling as good as I’d felt in nearly two years. (It was almost that long since I had the initial injury.) At the time, I couldn’t deal with going through another surgery. I avoided going back to see my surgeon.

Furthermore, after about a week, I was fine. I then went two years, only having issues maybe every few months. By issues I mean I’d have some discomfort, but it was rarely anything more than that. I was working on my legs up to 10 hours a day, with no problems.

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First takeaway regarding the meniscus

You can go a long time with a meniscus tear, and be fine. I even trained for and ran a 10k during this time! With no issues either. Some people can go decades and not worry about it. Maybe they modify their activity some, but few need surgery for such a thing.

After I’d been running longer distances for six months, I started having some odd sensations in my knee, and they were becoming more regular. I decided to take a break from the running, and just try and get rid of these sensations.

Six months after that, I start running again, and after a week I get a strong sensation of my leg locking up on me. It was not a fun one. I was sore for a few days afterwards, then fine, but it prompted me to go back to my surgeon.

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Second takeaway regarding the meniscus

You can have a huge tear in your meniscus, my initial tear was very large and this was the tear that had reopened, and it still might not make itself known to an orthopedist.

My original tear-

The unfortunate truth is clinical assessments, like when an orthopedist manipulates your leg, are often not that accurate. Testing the ACL is actually pretty solid; testing the meniscus is not at all. My experience with these has been a negative test doesn’t mean you don’t have something going on, but a positive test typically means you do. Personally, I often test negative when it comes to the meniscus, despite having very large tears.

I talk to the surgeon and he’s again not sure about the meniscus. I have some tissue that I can actually manipulate, which is eerily reminiscent of a plica. I mention this to him, and he’s pretty damn sure I have a plica issue going on, and that could be giving me meniscal-esque symptoms. I’m still at the point I’d rather accept that than the stronger potential for surgery with a meniscal issue. With a plica band, you can often handle things conservatively.

We both agree a MRI is the next step.

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Third takeaway regarding the meniscus

You can have a huge tear in your meniscus, and it still might not show up on a MRI. My radiology report came back as “possible medial meniscal tear.” Neither the radiologist or orthopedist saw anything that stood out.

They couldn’t see this big chunk of tissue moving around!

I decide alright, let me just take it easy on the leg for like a year. No running, nothing intense, just leave the thing alone and try to avoid any scenario which I know can give me problems.

A few months after this, a few months of not a single knee problem, which brings us to August 2015, I’m laying on my side moving my leg up and down, and I feel a slight movement in my knee. Nothing painful, but I stop. I go to stand up, and my leg won’t extend. I can then feel a nice bulge right at the inside and front portion of my knee. Below and medial to the knee cap.

I had something similar to this happen before, but it went away after a minute. I thought that might have been the plica getting locked for a second. This wasn’t going away though. I couldn’t stand on the leg. Not from pain, but because it literally couldn’t straighten.

A few hours later, this is still going on.

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Fourth takeaway regarding the meniscus

When your knee locks on you like this, and it’s not improving, it’s time to kick into urgency mode.

1. Get off the leg
2. Get into a doctor, preferably an orthopedic surgeon, ASAP

I got on crutches the next day, and went to the emergency room. My hope was I could expedite getting this taken care of, once they saw how limited my range of motion was.

The reason you want to take care of this so quickly is you do not want to be walking on a bent leg, especially one which has an object in-between the joint, blocking normal range of motion. That object can cause further damage. I went to the ER to see what the possibility of getting into surgery that day could be. Getting into my own orthopedist can take some time as he’s often very busy. Rather than wait another day to get a hold of him, I wanted to see what else could be done.

(I found out the quickest the ER could do something would be in a few days, as they rarely will call the on call orthopedist for something of that nature. They instead refer you out. I’ve seen reports of other hospitals moving to surgery right away though.)

Crutches help get off the leg, but the next step is getting that object out of the way.

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Fifth takeaway regarding the meniscus

I’m not a fan of surgery as much as anyone. It’s expensive, the recovery sucks, anesthesia is terrifying, the fact you have to sign “risk of death” as being ok is as disturbing as it gets.

There is some solid research that has come out, and I believe more will come out, illustrating the futility of knee surgery. Meniscal surgeries being potentially number one on the futility list.

But once a meniscus, or part of it, displaces into the joint and range of motion is being blocked, short of manipulating the leg to where it will reduce back into place, which really seems to be a lot of pure luck, surgery is the only option.

This is what happened to me: My old meniscus tear opened up enough, and was moved in just the right way, that part of it moved into the middle of the joint. Here is a good video on this:

I viscerally feel there are too many surgeries done in America. That it’s one of the ways we can clearly reduce healthcare costs. That doing an unnecessary surgery is about as ethically challenged as an endeavor can be. (Remember, “risk of death.”) But there are scenarios where you have to be damn happy surgeons exist. Two years ago, when discussing a study showing the futility of knee surgery, I wrote,

“I’m not ready to say the surgery is useless for everybody. But, I’m ready to say take 1% of 700,000, perform that many partial menisectomies every year, and I bet our society’s knees are no worse off, and we’ll have nearly four billion dollars which can go to something more useful.”

This is why I saved that 1%.

-> Something has to happen with surgeons, particularly orthopedic surgery. Random numbers -> whether it’s something like we get to where we cut the number of surgeries we do in half, so there are half the surgeons, or halve the salary of the current supply (unlikely due to how much debt it takes to become a surgeon), or we dramatically improve the value of surgery. I can’t deny, I have a side mission of helping us get to a point of less, hopefully dramatically less. But that doesn’t mean zero surgeons. Or that all surgeries are without value.

It’s like drinking or smoking to me. Saying “it’s all bad; never do it” doesn’t work. Should there be a lot less smoking and drinking? Probably. Are the occasional few beers or some wine, or a here and there cigar, perfectly fine, if not beneficial? Probably.

As far as surgeries go though, you can take some solace in arthroscopic surgery of this kind, where you’re basically just cutting a little tissue out, is about as easy as it gets from the surgeon’s point of view. It’s like crawling for them.

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Back to urgency mode

Because nothing was done for me at the ER, I called my surgeon’s office even though it was Sunday and I knew he wasn’t in. I got the on-call doctor, explained things, and she said she’d be sure to put a note in with the front desk to get back to me tomorrow. That was nice of her, but I wasn’t going to rely on that.

The next day I’m at the office at 8:30am, when they open, on crutches, explaining my situation and how I went to the ER the day before. I’m polite but firm in that this is fairly urgent. They talk to my surgeon, say he will be in surgery for most of the day, but they can fit me in tomorrow. Great.

The next day I see him, he apologizes he couldn’t see me the day before (illustrating some sense of urgency on his part). I explain things and right away he goes, “Well, I can tell you the diagnosis pretty quickly now!” We both know the meniscus repair has failed, and it’s time to go back in. They start doing my pre-op appointment right then, and schedule me for surgery ASAP, seven days later.

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Reiterating one takeaway

As I said, considering this isn’t life threatening, this is still pretty damn urgent surgery. I’ve never gotten an appointment with his office without a month wait (usually a good sign as you want an ortho who isn’t hurting for business), yet I got into surgery within a week.  I would have had it earlier should my surgeon’s schedule been open. He actually tried to get me in a couple days sooner, but it just didn’t work.

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Tangent: Why will a meniscus repair fail?

This is one of those questions that has no easy answer.

First, regarding the initial injury four years prior, it took a while for me to know I had a meniscus tear (and ACL tear).

Next, it took a while for me to succumb to going in for surgery the first time around. I found out what was really going on in my leg about four months after the initial injury, and by the time I had the surgery, it was seven months out.

The sooner you can get a meniscus tear repaired, the better. This put me at a disadvantage right away, and made me more likely to fit into the 20% failure group. A lot of this was bad luck, as well as me doing everything I could to avoid surgery. By the time I had surgery, it’s possible the tissue that was attempted to be reattached was so far gone it couldn’t be salvaged. That while it could be sewn together, maybe it was dead or not active enough and not going to reattach.

Perhaps it was my fault for waiting too long; perhaps the surgeon shouldn’t have even tried to repair such tissue. But again, if a repair is feasible, you typically go for it.

The other factors nobody likes to admit are factors:

1) Maybe my rehab wasn’t as good as it could have been. Maybe I did something to cause the repair to fail.

I feel very good this wasn’t a factor. Primarily because my repair failed 18 months after my surgery. If the repair failed earlier, then I’d say this could be more likely. At 18 months, I could see this being a timeline in which the sutures on the inside of my knee finally gave way. It wasn’t like a week after surgery I did too much and boom, felt the tear open up. I was walking around 18 months later and it happened.

It also retore exactly where the previous sutures were. You can see them where the torn meniscus was removed:

As well as see a suture or two floating around:

2) Maybe the surgeon didn’t have a great day

Maybe the sutures weren’t as tight as they could be. Or not put together as well as they could be. Again, I don’t believe this is much of s factor due to the timeline. The sutures held together for ~18 months. The tissue should have healed way before then.

More than likely, everyone did a solid job -I don’t think anyone would change anything they did- but the tissue didn’t come together. Whether this is the tissue was dead, the tissue had a lesser blood supply, for some reason it didn’t stick. Think if you had stitches done on your arm, and the skin, while sewn so tightly, just never molded back together. Eventually those sutures break down, and that skin opens up again. Rub that area on and off, and eventually part of the skin may go flapping around. I think this is probably what happened to the inside of my knee.

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How am I doing now?

Very well! I took a day off of work, and then was walking around without crutches 48 hours after surgery. I’m not playing basketball right now or anything -nor would I advise anyone to so soon after this procedure!- but I’m working on my legs hours at a time (personal training), and having no issues getting around or going through activities of daily living.

In the future I’m going to write some more about partial meniscectomy rehab. The biggest aspect of this initially is regaining range of motion, extension range of motion to be specific. I already have a manual on regaining the ability to straighten your knee if interested.

Lastly, if anyone is looking for an orthopedic surgeon in Southern California, I’ve been very happy with the one I’ve used, and his office. His name is Jonathan Myer, and his group is San Diego Sports Medicine.

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