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When Ava, a 13-year-old basketball player, tried to change direction quickly to drive past her opponent, her knee buckled and she developed an acute haemarthrosis. Ava saw a general practitioner and a physiotherapist who advised her to ice her knee and regain her motion. She initially improved, obtained an over-the-counter brace and returned to playing basketball. The full extent of her injury was not recognised. Ava had weekly episodes of knee giving way when playing basketball and stopped playing her favourite sport. She continued to have a feeling of instability, swelling and pain with her daily activities.
Four months after her injury, MRI of Ava’s knee confirmed the ACL rupture and a lateral meniscal tear. By the time she had a surgical appointment and an arthroscopy her lateral meniscus was almost absent; nothing separated the lateral femoral condyle and the adjacent tibial plateau (figure 1). We will never know the extent of the original injury to Ava’s lateral meniscus. However, we might suspect that the lack of early and specific recognition of the problem and the subsequent recurrent giving way episodes aggravated meniscal damage.
Lateral compartment of the knee with only a small remnant of the lateral meniscus (men); normal lateral femoral condyle (Lat FC); normal popliteus tendon (pop) and chondral damage of the lateral tibial plateau (*).
The clinicians involved in Ava’s care did not have the benefit of access to the 2018 IOC consensus statement on prevention, diagnosis and management of paediatric ACL injuries.1 Had the consensus statement been available, it might have helped them to quickly and accurately diagnose the injury. They might have been more confident in guiding Ava and her parents on the best course of treatment, future sports participation, risk of reinjury and long-term prognosis.1
The IOC consensus statement emphasises the need to protect the meniscus.1 With most of the lateral meniscus missing, Ava’s long-term prognosis for knee health is poor.2 It is possible that she will have an osteoarthritic knee by the time she is in her mid-20s.3 The purpose of this editorial is to remind clinicians, coaches and parents and most importantly athlete-patients of the significance of meniscal injuries associated with an ACL tear.
Treatment options
High-quality rehabilitation with or without ACL reconstruction is an appropriate treatment for athletes with isolated ACL tears.4 Meniscal tears often occur alongside an ACL injury.5 Isolated meniscal tears are far more common in middle and older age, and many tears are asymptomatic or respond well to exercise therapy.6 Surgical treatment is usually not indicated.6
In stark contrast, meniscal tears in children and youth are often symptomatic, and challenging to treat. Small tears may heal without surgery, but larger and/or more complex tears (eg, bucket-handle or meniscus root tear) should be repaired.1
What is the big deal then?
One key challenge for clinicians who work with young athletes is how to best manage the patients who have both an ACL-deficient knee and an associated meniscal injury. This leads to a higher risk of wear and tear to the articular cartilage and arthritis at an early age. The only ways to improve long-term outcomes are to prevent reinjury, maintain a healthy weight and repair the meniscus. We cannot change genetics, or modify the disease process. Crucially, an ACL reconstruction does not necessarily change the natural history of the meniscectomised knee in a young person.
We must adapt the culture of youth sport to emphasise injury prevention.1 A knee injury with an acute haemarthrosis is an ACL rupture until proven otherwise.1 There are other causes, but in cases such as Ava’s, we must immediately suspect that the ACL is injured. We must attend to her urgently (to avoid repeat injury), assume the menisci are injured and ideally image her knee with MRI. Understand and recognise that the menisci are just as important as the ACL. We simply cannot let these young athletes go back to play without them fully understanding the severity of the problem (greater risk of osteoarthritis); these young athletes need the highest quality rehabilitation and close follow-up.
Many surgeons will vehemently suggest that an ACL reconstruction is the best way to protect the menisci. There is conflicting evidence to support that contention.7 8 But there is universal agreement on the importance of meniscal preservation.9
Our plea is that young patients who injure their knees should be seen by qualified practitioners in a timely fashion; that is, ‘get the right patient, to the right clinician, for the right treatment at the right time.’
Lately, a great deal of attention has been placed on the degenerative meniscal tear and the role of arthroscopic treatment.8 Let us stop being so concerned about meniscal tears in middle-aged people. We are clearly missing the boat by lumping ‘meniscal tears’ in young patients into the same pot as ‘meniscal tears’ in adults; only the name is the same. A meniscal tear in a young patient is much more critical to the long-term health of the knee and arguably a more important determinant of future health outcomes (including quality of life) than the status of the ACL itself. Our mission is to get this message out; especially to those who are less likely to read our statement. Please share widely the free IOC consensus statement on paediatric ACL injury (and meniscal tears!).
Footnotes
Contributors All authors contributed in an equally important manner to this manuscript.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.
Provenance and peer review Not commissioned; externally peer reviewed.