Medial meniscus partial removal

[arbitrage]

I tore my ACL and MCL in 2000. When they repaired it, they removed about 1/3 of my medial meniscus. My acl is fine, it's the meniscus I'm concerned about.

I've been lifting since the injury and all my strength is back, but I'm wondering if I'm doing further damage to the joint. I've asked 3 different Physical therapists about it and have gotten 3 different answers. The question was, "is it ok for me to do squats?"

PT #1 "Yes you can squat all you want, I've have the same procedure done and I deep squat weekly"

PT #2 "You can squat, but only with body weight or weight light enough to do 25 reps. Any higher and you'll wear out your knee joint."

PT #3 "You should never ever under any circumstance squat. You will already have to have a knee replacement in a few years, and squating will drastically speed that up."

So my question is, should I squat, are front squats or back squats easier on the knees, or should I just do pistols, etc..... Basically, I want to lift as much as possible, as heavy as possible, but do the least damage. Any suggestions?

[UConnJulie]

I honestly don't think that there is enough evidence one way or another ... 1/3 of the medial meniscus could be problematic (depending upon which 1/3) or not. As a physical therapist, I find that many of my colleagues are poorly educated when it comes to strength training, and many are taught a bias against full ATG squats.

The truth is that a squat is a completely natural movement (watch any toddler), but because of compensations we acquire along the way (lazy glutes, tight hip rotators, limited ankle mobility, etc) it alters the normal easy toddler squat into something that looks atrocious with many many people.

If you have good hip and ankle mobility and good gluteal activation, I do not see any reason why you cannot perform loaded squats like any other person. Obviously listen to your body, and if you have pain or limited range of motion, then those need to be addressed. You might get arthritis, but you might not ... and again you might get it (or not) whether you squat or not.

[arbitrage]

I assumed that there was no definite right answer, as the responses I got were so different. If you could will you answer this for me.

In the past year I've only done front squats or pistols, because I can't do quite as much weight as with back squats. Do you feel these exercises would be easier on my knee or does it really not matter?

Also, is the supposed damage I'm doing because of increased load on the joint? It seems damage done from the impact of running would be higher on the joint than squating with 315, but thats my guess.

[UConnJulie]

Well, one of the main functions of the meniscus is to provide a better contact between a rounded bone (the femur) and a flat bone (the tibia). It therefore distributes forces more evenly across the entire joint surface. Here is a good schematic.



Back 75+/- years ago when the meniscus was injured, surgeons would remeove the whole thing and the result was severe arthritis from the loss of force distribution. The hyaline cartilege which lines the bone would get worn away, and the body would lay down more bone to compensate (spurs).

Now they just trim away whatever they have to, keeping as much of the meniscus intact as possible. Depending upon the part removed, it may have a big impact on force distribution, or a small impact.

I personally believe that any type of ballistic movement (like running) puts much more compressive force through the joint(s) than squatting. Front squats and pistols will tend to load your quads more than back squats ... is that good or bad? Well, again it depends. In a knee injury I don't personally see back squats as being more injurious than front squats. In fact, in an ACL-deficient athlete, I prefer to get the posterior chain as strong as possible, and that includes back squats.

[Kaiser]

What Julie said.

Adding my own personal experience: I'm missing all of my right lateral mensicus, and 75% of my left lateral meniscus. I can ride a bike all day long, but running, as Julie mentioned, is too much for what little cushioning I have left from the articular cartilage. In my case, I used to be able to squat decently after the operation, but not much beyond parallel - when the femur rotates past a certain point, the pain is very intense for me. The joint moves to a point where it creates a bone-on-bone pressure point. It hurts and swells up, so I don't do it despite many trainers online trying to tell me to. As Julie said, let your personal situation dictate what you can and cannot do. The only thing I would add is that since you have a preexisting condition, try to proceed as carefully as you can. Because of what they have done, it is very possible that your biomechanics have changed - in my case, it was definitely true that I pronated much more (and I already did some) with no lateral meniscus - I didn't correct for this and, oila, I tore my plantar fascia after not correcting for this and having it stretched over time. Oh yeah, when it tore, it simultaneously put too much pressure on my calcaneous (heel bone) and that literally fractured in a very bad way. So... it is all connected. Be careful and make sure you build up the strength around the knee.

Personally, I've had good success keeping the inevitable osteoarthritis at bay by using glucosamine+chondroitin for the last decade. Clinical trials are all over the board on the product's efficacy - you can find a ton of subjective assessment trials that say it does or doesn't work, and a trial in Belgium (I believe) that showed actual radiograph confirmed improvement in the joint space of those who took G+C. Now, later studies have shown no significant improvement, or that the chondroitin itself doesn't do anything (in contrary to other studies that show the combined effect of G+C is greater than the individual effects of either component). If they took out that much of your medial, you might want to consider it if you start showing any symptoms of OA (there is no proof that it will prevent OA, only hints that it will remediate it once it has started).

My experience, fwiw....

[Lisa~]

Kaiser, very interesting post. I was actually considering adding to this thread to suggest that he might try not squatting below parallel. Below parallel the angle of the femur on the tibia requires more cushioning by the meniscus. So this is one of those times when modifications make sense.

I think glucosamine/chondroitin is a good idea too.

[Kaiser]

Originally Posted by Lisa~

Kaiser, very interesting post. I was actually considering adding to this thread to suggest that he might try not squatting below parallel. Below parallel the angle of the femur on the tibia requires more cushioning by the meniscus. So this is one of those times when modifications make sense.

I think glucosamine/chondroitin is a good idea too.

Lisa, I wish you were around when the 'experts' were telling me that there was no reason I shouldn't be able to go ATG (or even beyond parallel), even while I would have pain and subsequent swelling.

From what I've read, G+C is supposed to help create an environment where you can keep your articular cartilage better. There is a lot of debate as to whether it is useful apparently. All I know is, when I first started with it, they said it would take 6-8 weeks to start noticing results - I was already skeptical about the product and ready to give up when I didn't notice anything after 6 weeks, and then at 8 I started noticing it seemed to be getting better. I'm guessing in my case it was not a placebo effect, but even if it is, it would be hard to tell me that at this point, right?

[Lisa~]

Originally Posted by Kaiser

Lisa, I wish you were around when the 'experts' were telling me that there was no reason I shouldn't be able to go ATG (or even beyond parallel), even while I would have pain and subsequent swelling.

I want to clarify my position on full squatting just a bit. There have been many studies that show that full squatting creates no greater forces at the knee than shallower knee angles. The most unstable position to change direction is at a 90 degree knee bend. And for tendinitis or tendinosis issues, the goal is to work the client's way back to full squatting (or to whatever depth the client can achieve with good spine mechanics). Tendons heal. (And that information is/was probably the source of much of the advice given to you.)

But if part of the meniscus has been removed, its ability to regrow is very, very limited. This is a situation you have to work around from here forward. Much of the same recommendations would still apply. Improve technique and mobility issues (something got you injured in the first place and if it wasn't a car wreck or something then there is probably an imbalance that needs to be addressed). Research and apply ways to maximize your regenerative abilities, medically and/or nutritionally. Continue unloaded full ROM movement for the knee joint, even if that means lying on your back and moving the knee through full ROM as a starting point. But for loaded movement you'll have to find the right choices on an individual basis. Each knee will be altered in a slightly different way and each client will differ in their abilities and determination. Once we get to an altered joint, there are no blanket answers to every situation.

There are, however, steps or progression you can use to help you find your own best solutions. I'm going to recommend Mike Robertson's Bulletproof Knees manual here because I think his information applies to your situation. He includes very practical sections on exactly what steps to take and in what order to progress.

[UConnJulie]

As usual Lisa states it with elegance ...

[Kaiser]

Thanks for sharing your expertise Lisa.

Quick question:

Originally Posted by Lisa~

But if part of the meniscus has been removed, its ability to regrow is very, very limited.

I haven't been on top of this subject for the last five or six years; is there something new that I am not aware of? I know there have been some in vitro studies on regrowing meniscal cartilage, but nothing substantial has occured with it. Synthetic and bovine replacement research has been a bust. I am not aware of any ability of meniscal cartilage cells to regrow on their own, certainly not in any patterned an useful way. If you have something, please let me know!

[Lisa~]

That's what I was trying to say, without being dogmatic.