Episode 115 | How Does a Meniscus Injury Impact Your ACL Rehab and Recovery?

What is up guys, and welcome back to another episode on the ACL Athlete Podcast. Today, we are diving into meniscus injuries in ACL rehab. We want to answer the question: How does a meniscus injury impact your ACL recovery, your rehab, especially that post-op process? I know a lot of you are thinking, well, am I going to be non-weightbearing? Am I weight-bearing? What does this mean exactly when I have a meniscus issue? Let’s kind of dive into this, and the goal today is not to get into very specifics of the type of meniscus injuries or the nuances of those. But it’s more so to just cover a general guide and a general way of looking at this, so you have a good idea of what category or maybe one bucket that you fall into if you’re approaching ACL surgery or if you are in that process of going through post-op, what can you expect? Let’s get right into it. 

Let’s say somebody’s injured their knee, they got an MRI, they have a torn ACL that’s right on it. They also see that there’s a torn medial meniscus, something that is pretty common with ACL tears. But lots of variations can happen, right? Other ligaments: MCL, maybe LCL, maybe both menisci (that’s plural for meniscus, I think). But what I want to focus on is mainly an ACL tear and a meniscus. Sure, there are other ligaments that could play into it. But if a meniscus is involved, what is that process going to look like?

And like I had said, tons of different variations. We’re going to speak in a general sense here to get a good grasp of meniscus involvement with an ACL tear. You’re approaching reconstruction, how can we look at this? First, I do want to back up for a second and talk about the meniscus because I think it’s important to understand what it is. It’s basically two C-shaped pieces of what we call fibrocartilage, that act as shock absorbers between your femur and your tibia, between that shin bone and between that thigh bone. There’re these two C-like structures and you can’t see me, although I’m doing this. If you take your index finger and your thumb and make a C on one hand and an opposite C on the other, and you put those two hands together, that’s how your meniscus sits on top of your tibia, which is your shin bone. And then you have your femur or your thigh bone which is the thing that is connecting to create the knee joint. 

Of course, you got the patella there as well. But they are these two C-shaped pieces of that fibrocartilage, basically, those cushions that are sitting there. And they help to reduce the friction and to help with shock absorption as the knee hits impact-related activities, or just going through motions. Those are the main pieces here. And you have many different types of tears and their locations. Some can heal, some can’t. Based on those locations and the types of tears, you have your medial and your lateral meniscus. Medial is typically towards your midline, to the inside of the knee. And then you have your lateral, which is to the outside of the knee. A lot of times people will have these types of injuries whenever they have an ACL injury due to the nature of the trauma to the knee. And so it’s important to understand what these are and then what you could expect potentially for the road ahead.

Let’s say you’re going through this process. You are having the ACL reconstruction. And there’s a meniscus injury that has shown up. Hopefully, you’ve consulted with a surgeon about what those potential options are. And we are saying that you are going through ACL reconstructive surgery. Then, therefore, there is going to be an intervention or a process to reconstruct that ACL ligament. And then there’s also potentially some intervention to be able to help with whatever the meniscus is happening. 

Typically, one of two things happens. You either repair the meniscus, that’s by stitching it down. They’ll literally go in there and they’ll anchor some stitches down to it, and that’ll help it to heal and mend down. The other second option is a meniscectomy which basically just means that they’re going to cut part of it away. And usually, it’s a percentage based on how they see it looks in the knee and they will estimate and see, okay, is the knee going to generally function? And usually, the goal is to preserve as much as possible but to make sure that it is not going to get in the way or mechanically get in the way of preventing your knee from bending and moving, or potentially causing any irritation or pain down the road.

And then there’s this small little subcategory that I’m going to include here that you’ll hear about sometimes. This is the third option which is where they might just not mess with it. And it’s a very small percentage of people, but they might see a little bit of a tear or something like that. They know that it’ll heal down or they might not feel like it’s necessary when they get in there, and so they might leave it alone. And there’s some athletes that we see who go through this process as well and do totally fine. But this always comes back to the surgeon. What do they see when they get in there and the route that they potentially want to take with it?

But this is a guess really before you get into the knee, based on the MRI, the clinical testing that’s done. So where they move your knee around. And then some of the symptoms, like some of them are a little bit more obvious, there’s clearly catching and clicking. Maybe the knee locks up at a certain range of motion, and that could be the meniscus folding. There could be certain other symptoms that come along with it that can lead us to think that there’s a meniscus that’s involved. It’s really tough to say with 100% certainty. And you really won’t know, and the surgeon won’t know until they get into the knee for sure. And this is where it’s important to share having clients who have gone through this, myself have gone through this. And we’ve had people where they go into the surgery and they thought it was just going to be an ACL, and turns out it was a meniscus. And they either had to cut away some of the menisci or maybe they repaired it. And then they come out thinking, oh, I was just going to have an ACL tear and reconstruction after that. But they came out with a meniscus repair which impacted probably the initial parts of their rehab process which we will get into. 

And for myself, for my first ACL, I actually had a meniscus tear on MRI. And they were planning to go in and repair that. But after I got out of surgery, it turned out they didn’t need to mess with it. From what I remember, they thought that the ACL looked pretty good, so they didn’t need to repair it or do a meniscectomy. Thank God, because we want to save that if we can. So that was a really cool, positive outcome from my first ACL. It’s not uncommon for people to go into the surgery and potentially have a different outcome prior to before. 

Now, some are a little bit more clear than others based on the MRI or the clinical testing or symptoms or what that might be. And then some, it’s a little bit more gray and vague. We always communicate with our athletes and let them know. You never know what is going to be going on 100% in that knee until they get in there. Of course, some are a bit clearer than others. But I would say, plan the worst-case scenario, especially if there is some conversation about meniscus. So that way you’re not surprised when you wake up and have to be on crutches for maybe four or six weeks and can’t put your weight down on your foot.

I think that’s important from an expectation standpoint. We’re always trying to manage that in this process. If you’re dealing with a meniscus issue with your ACL injury and you’re having surgery or planning to have surgery, then it’s just something to consider. And no matter what, it’s probably best to just kind of think of worst-case scenarios. I think that that helps us prepare for life in general. But also for something like this, just to make sure that we come out and if it’s better than what your worst-case scenario was. Awesome. That doesn’t mean to think very negatively. But it’s good to set expectations when there’s a lot of unknowns in the process.

 Now, let’s piggyback on that topic of expectations, which is going to be the main thing we focus on here. If you are having a repair versus a meniscectomy, if they go in and repair it, often you’ll see a surgeon’s guidelines of non-weightbearing for anywhere from two to six weeks. I’ve seen up to eight weeks before which is rough, but that’s very rare. On average, I will say most surgeons, if you’re going to have a meniscus repair of some sort, it’s somewhere around the four-week mark. Sometimes the surgeon will allow some weight-bearing earlier. And some are pretty hardcore about the four-week mark or that six-week mark, wherever they’re at. It really depends on the surgeon. It depends on the type of repair that they do. Some are more conservative, some are more aggressive with ACLs. It just really depends. You guys would be so surprised by the range and variety that we see and even the types of ACL procedures that would actually blow your minds.

But with that said, we’re going to stick with what we see the most and what the research also supports for us to be doing. But usually that two to six-week mark is what we’re looking at an average of four weeks. And then a lot of times people will be restricted to how much they can bend their knee, usually somewhere around the 90-degree mark, to not put as much stress on certain parts of the meniscus as they bend the knee. And then some surgeons I know don’t restrict anything and treat it the same as if they repaired it or not, which we see a lot of positive outcomes from. But again, it’s going to come back to the surgeon and what the preferences are, what they see in the knee, and you just got to respect it. 

And then let’s say that they are going to do a meniscectomy. They’re going in and they’re planning to cut away some of that meniscus. Now, how much percentage? Will be dependent on the tear and what they see fit for it. Ideally, preserving as much as possible is key here. But it’s often the same recovery as if it was just an ACL rehab or an ACL reconstruction by itself. Typically, most people are weight-bearing as tolerated if they just had a menisectomy. Usually no restrictions in the range of motion. And again, it makes sense because people don’t have anything like healing at that meniscus level or stitching down or anything to really protect. It’s just been cut away so you can continue on as much as possible because it’s not just going to magically regrow or reheal. So that’s how the meniscectomy works with that. It’s not always this way with meniscus repairs and with meniscectomies. But I’d say 80% to 90% of the time, this is how it’s going to go. And we see that with all of our ACLers, we work with. A lot of them come in with some type of meniscus-related issue. This is usually the two directions that most people go with the exception of sometimes just letting it heal if there’s a meniscus issue involved. 

Now, let’s talk about swelling and pain for a second. I think that sometimes people expect that an ACL injury by itself is going to produce the same amount of pain and swelling no matter what happens. You have a knee injury and the swelling and the pain is the same. I beg to differ. And that’s because the type of injury, the trauma of it, how intense it was, what happened, non-contact versus contact, all of these things are going to play into it. Usually, contact-based injuries are a little bit more traumatic, if you will, or there’s more damage to the knee than a non-contact injury, usually in most cases. And that’s because of the forces that are happening. Usually, non-contact is when you take that step for the most part or land awkwardly, and the knee shifts. Versus contact, there is a blunt force that hits the knee which causes the knee to shift. You can tell that there’s more force going through that knee.

When there is an injury to the knee, the swelling and pain vary because of not only the ACL tearing but also because there are typically additional injuries to the knee. There could be a bone fracture, there could be bone bruising, there could be meniscus involvement, there could be other ligament involvement, and there could be tendon involvement. You name anything in there, and it could be affected by that. So that’s going to vary the swelling and pain which is why we can’t say across the board, hey, this person should resolve to this type of baseline based on just an ACL injury alone. 

The details are important, so post-injury. If you have an ACL injury by itself versus ACL plus meniscus, there might be more swelling and pain. It’s very possible. Same thing with post-surgery. You can have more swelling and pain, so don’t be thrown off by this. Usually, what I see a lot of times is that especially if there’s any type of bone bruising, which is often accompanied by the ACL injury, that a lot of times people have a sensitive joint. And if it’s sensitive, it’s going to be more susceptible to pain and to swelling. Just be aware of that. And I think it’s important from the expectation standpoint in terms of knowing, all right if you’re dealing with some of that stuff, it’s normal. And it might take a little bit longer to go down and that’s okay. 

Now, let’s talk timelines and protocols. Do you think someone who was non-weightbearing for four to six weeks, who had the meniscus repair is going to be back to running in 12 weeks? Then why in all the protocols do we have running back at 12 weeks? I’ve seen this in so many different protocols where they expect the athlete to start running in 12 weeks. That’s the frame or the time that most use. And it doesn’t matter if they have meniscectomy or meniscus repair, they’re just like, yeah, 12 weeks. They’re good to start running even though they weren’t putting weight on their foot for a third to half of it. And I think this comes back to asking the question, does this make sense? No.

And this is where I also want to caution you guys of what is it going to look like if you did have a meniscus repair and you were non-weightbearing for four weeks, or maybe it was six weeks? I have an athlete right now who had it in their head from a surgeon, they were like, yeah, you’ll be running in 12 weeks. Well, guess what? They set a target to run in 12 weeks because they’re also a youth athlete and they’re ready to get rolling. They do not want to rehab. They do not want to train. They just want to get back to what they love doing. And so that’s when they think they’ll be running. Well, they had a meniscus repair and they couldn’t get off crutches for four weeks, couldn’t put weight on it, and weren’t allowed to bend past 90 degrees. We had a lot of stiffness coming out of that. 

And this set them up for failure even though we were sure, we were educated on the front end of things and they didn’t necessarily come in immediately after their surgery. A lot of factors play into it. But with that said, I think this is coming back to what is communicated to us and setting expectations. And for us to assume that we’re going to start running at the same level as someone who, let’s say just had ACL cadaver graft. The starting line for that person is a little different than the starting line for the person who had a meniscus repair and they got an autograft from their patellar tendon. That’s going to look a little different. And so that’s one of the things that I want you guys to look at is don’t get stuck on protocols, especially if they’re built on time and don’t account for these individual differences in this process.

And I’m always trying to think of ways of how can we relate this or use analogies to help anchor this. And I don’t know why this one came to mind, but it’s like assuming that a kid with a learning disability is going to learn at the same rate as a kid who doesn’t have one. And sure it’s possible, but there might be some differences in the timeline or when they get up to speed or maybe even the grades that they like to progress into or whatever that education system is. It would just be silly for us to assume that. These two kids starting with two different starting points are going to get to the same point time-wise. And so that’s just silly. Everyone’s different, I can say that because I’m a husband to a wife who works with kids with special needs. There’s no way that these kids all progress at the same rate. They all have very different experiences and abilities to learn. Our bodies are no different and we’re not perfectly going to adapt every six weeks, every 12 weeks because we’re just different. So that’s important to also understand from a protocol, from a timeline standpoint. Don’t get too beat up if you’re not hitting that.

Also, don’t start running at 12 weeks, wait a little longer, and get stronger. Side note: You will think of me later about it. I promise. Part of this podcast is also me just being real with you. I always want to make sure I’m very transparent. In PT school, I did a big research review and lit analysis on ACL recovery and osteoarthritis.

There was a big focus on what are the risk factors related to getting osteoarthritis in the future when you have an ACL injury. Are there any other concomitant injuries such as meniscus or MCL or certain other factors that will play into an increased risk for future arthritis? Well, you already opened the door when you had an ACL injury itself, but this increases those odds when you have a meniscectomy. Yes, it does. 

Now, before you start worrying, you’re probably listening like, oh my god, I’m going to have osteoarthritis. I’m not going to be able to bend my knee. I’m going to have a total knee replacement. Don’t worry. Seriously, you’ll be okay. I promise. I am right there with you. I had a meniscectomy on my left side. On my second ACL, I had a meniscectomy on my lateral meniscus. I am right there with you. I’m going eight years on now. I’m totally fine. Can bend my knee, can function, super strong, we’re good to go. But I do know my risk is increased, and that’s just life. We are just a little susceptible to certain things. We trade off the things that we love to do for potentially these types of injuries and things that can happen. And so that’s just what comes with the territory. Also, most important here is what can we do to control the controllable? I know what I need to do to keep that OA osteoarthritis at bay as much as possible, and that’s to be as strong as possible.

That’s one of the biggest factors that help to reduce the risk of OA put it at bay by limiting your functions and the things you want to do. And even pain is to be strong, to be mobile, all the things that we work on within ACL rehab. When you’re looking at, what can I control with this risk? Well, a lot of it’s going to come back to movement and getting strong and just making sure that you take care of your body.

The last thing before we wrap things up. Why is this important? Well, one, I want you to make sure that you know the expectations for this process. The other thing too is that I’m huge for you guys being advocates of yourself. Making sure that you’re able to feel educated, to feel empowered to ask questions, to make decisions. And I think a lot of this comes back to the educational pieces. And I think that sometimes people look through their own lens and they kind of want to do all the things that maybe they prefer to do without really considering the long term. Sometimes surgeons get cut happy, and sometimes they want to do the meniscectomy because it’s the easier route. Or maybe the repair might be a little harder, maybe they don’t specialize in that type of thing. So that’s the thing that I want you to make sure you’re careful about. Is that if you can preserve your meniscus, if you can somehow really advocate and see if you can avoid the meniscectomy, that’s awesome. I always encourage my athletes to do that and do a repair if possible.

And if you need a second or a third opinion, that’s okay, too. I always recommend that. Field your options. And while you might be like, I don’t want to really be on crutches for four to six weeks, it is going to be really annoying. Take that short-term loss for that long-term gain. I promise you your 70-year-old self will really appreciate it. And there are certain situations where they can’t save it. They won’t. They’ll have to do a menisectomy. I don’t really know in my own case. I didn’t know that that was even an option. I’m sure they were probably going to have to cut it away anyway, but who knows? Maybe it could have been saved, but if it can’t, it’s going to be okay. I promise. But always try to save it if you can. Trust your surgeon. Do your research. Get some other opinions if you need to. And then just roll with it and then be confident in that choice. And whatever ends up being the end result is the end result. You’re going to strength train, you’re going to take care of your body, whether you get one or not is not going to be your problem anyway.

All right, team. That’s going to do it for today. I think a meniscus injury involving ACL rehab is long overdue for this podcast. I apologize for the wait. But I did want to get this over to you guys. I think it’s an important topic. It’s an important decision to make. It’s also important in just manage expectations of this process, which is basically ACL rehab in a nutshell. But be advocates of yourself. Feel educated. If you need any help, if you have any questions, if you’re like, I still won’t get this meniscus thing, send me a message. I’ll send some other resources to you. I’m happy to help in any way that we can. And as a small thank you, can you guys go over and rate this show for me, provide any feedback, and send it our way? We’re always trying to level this thing up, answer questions, and provide value to all of you guys. It would help us out a ton. It helps more exposure to other ACLers who are trying to grab information from other clinicians, coaches, surgeons, and everyone involved in the process, and we all win. Go and do that for me.

Otherwise, I will catch you guys next week. Thank you guys so much for listening. This is your host, Ravi Patel, signing off.