Key points
In children, repair the meniscus whenever possible. Meniscectomy, even partial, should be exceptional. [Geffroy 2021; Asokan 2023]
- Two groups: traumatic tears in a normal meniscus (adolescents, often with ACL injury) and atraumatic lesions in an abnormal (usually discoid) meniscus (often under 10).
- Paediatric menisci are more vascular, so repair indications extend into the red-white and even white-white zones.
- Clinical tests are specific but much less sensitive than in adults. MRI is the key investigation.
- Beware MRI false positives (vascular signal in the posterior medial meniscus) and false negatives (ramp lesions, lateral tears).
- Every ACL-injured knee needs MRI and arthroscopic screening for meniscal tears, including ramp lesions.
- Repair in a stable or stabilised knee. Repair the meniscus at the same time as ACL reconstruction.
- Master all three techniques: all-inside, inside-out and outside-in.
- Repair failure ranges from 0% to 42% across series, about 9% to 17% in larger cohorts and pooled data. Risk is highest in the first year and with complex and bucket-handle tears. Failure is often partial.
- Return to pivoting sport at 4 to 6 months after isolated repair.
- The evidence is almost all level IV retrospective series. There are no randomised trials in children.
Discoid meniscus has its own trainee page.
Anatomy, function and vascularity
The menisci distribute load across the tibiofemoral joint. Circumferential collagen fibres convert axial load into hoop stress, with radial and random fibres in addition. [Asokan 2023]
Other functions: shock absorption, stability, proprioception, cartilage nutrition and joint lubrication. [Liechti 2019]
Vascularity changes with age
Blood supply comes from a perimeniscal capillary plexus arising from the geniculate arteries.
| Age | Vascularised portion |
|---|---|
| Birth | Whole meniscus |
| About 9 months | Peripheral two-thirds |
| About 10 to 12 years onward | Peripheral 10% to 30% (adult pattern) |
Sources differ on timing: Asokan 2023 gives age 10, Geffroy 2021 gives after age 12.
Zones: red-red (vascular), red-white (watershed) and white-white (avascular). Better vascularity is a key reason children heal repairs better than adults.
Why a radial tear matters
A complete radial tear cuts the circumferential fibres. The meniscus can no longer generate hoop stress, contact pressures rise, and osteoarthritis is accelerated. A root tear has the same effect and leads to extrusion (a "phantom" meniscus).
Epidemiology and risk factors
Paediatric meniscal injury is becoming more common, driven by earlier, more intense and year-round sport, and by better MRI access. True prevalence is unknown, partly because many discoid menisci are never diagnosed. [Asokan 2023]
| Study | Population | Key findings |
|---|---|---|
| Jackson 2019 | 880 children having arthroscopy, single centre, 16 years | 63% male. Only 38% isolated tears. ACL rupture in 46% (50% of males, 40% of females). 53% repaired, 91% of those all-inside. 25% discoid. |
| Mitchell 2016 | 1,082 injuries in US high-school athletes | Injury rate 5.1 per 100,000. Higher in matches than practice. 68% male, but girls higher in sex-comparable sports such as soccer. ACL injury in 36.9%. |
| Rohde 2023 (SCORE) | 1,185 repairs, multicentre, mean age 15.3 | 68.9% had concurrent ACL surgery. Boys had more lateral repairs (54.3% vs 40.9%), girls more medial (41.4% vs 32.1%). Higher BMI linked with complex and radial lateral tears. |
Asokan 2023 reports Mitchell's rate as 5.1 per 100,000. Check the original for the denominator before quoting it.
Risk factors
- Adolescent male sex (greater body mass and momentum through the knee)
- Contact and pivoting sport: football, netball, rugby, skiing
- ACL injury, especially if instability persists
- Discoid meniscus (younger children, atraumatic)
- Over 80% of tears in normal menisci follow high-intensity sport. They are rare under age 10. [Geffroy 2021]
Tear patterns in the normal meniscus
Tears in children are the same types as in adults, but in different proportions. Three things guide treatment: tear type, vascularity at the tear, and knee stability. [Geffroy 2021]
| Pattern | Features in children | Notes |
|---|---|---|
| Vertical longitudinal | Most common traumatic tear. Up to 80% in stable knees. | Follows collagen orientation, so heals well after repair |
| Bucket-handle | A vertical tear that propagates and displaces, especially in an unstable knee | Can be asymptomatic in children. Flexion contracture suggests it. |
| Ramp lesion | Peripheral tear of the posterior medial meniscus, from red-zone tear to meniscotibial ligament detachment | Found in 23% of paediatric ACL reconstructions. Often missed on MRI and anterior arthroscopy. |
| Root tear or avulsion | Radial tear at the posterior horn, or bony avulsion, mainly with an unstable knee | Defunctions the meniscus and causes extrusion |
| Radial | Rare. Middle or anterior segment after hyperextension. | Disrupts hoop stresses |
| Horizontal | Rare, often microtraumatic rather than from one injury | Can cause a lateral meniscal cyst, palpable anterior to the LCL in flexion. Not degenerative, unlike in adults. |
| Complex | Mixed patterns | Most common pattern in one series (28%), then vertical (16%) [Shieh 2016, via Asokan 2023] |
The two reviews differ on which pattern is most common. Geffroy reports vertical tears, while Asokan cites complex tears from a revision-surgery series, which may over-represent complex patterns.
Hypermobile lateral meniscus
Rare, with mainly case reports. The posterior lateral meniscus has normal shape but is hypermobile, probably from a defect in its posterior attachment. It causes locking in forced flexion. MRI is normal or shows a slightly wide popliteal hiatus. MRI in flexion can help. [Geffroy 2021]
Assessment
Clinical signs of an isolated traumatic tear are poor in children. A low threshold for MRI is justified. [Geffroy 2021]
History
- Twisting injury with the knee loaded in flexion, often with haemarthrosis
- Joint line pain, catching, clicking, locking
- Earlier unreported injuries or giving-way episodes, which suggest ACL insufficiency
Examination
- Effusion and joint line tenderness
- McMurray, Apley grind and grinding tests are specific but much less sensitive than in adults. Use the provocative Apley test sparingly in children. [Asokan 2023]
- Flexion contracture suggests a displaced bucket-handle tear, but these can be asymptomatic
- Painful swelling anterior to the LCL in flexion suggests a meniscal cyst
- Always perform comparative ligament examination
MRI
MRI is the investigation of choice. Request it for post-traumatic joint line pain, especially with haemarthrosis, and in every ACL tear to screen for associated meniscal injury. Ideally a paediatric musculoskeletal radiologist reports it.
| Pitfall | Detail | How to handle it |
|---|---|---|
| False positive | Horizontal high signal in the posterior medial meniscus, from normal vascularity | Without trauma or haemarthrosis, doubt the diagnosis. Only Crues grade 3 signal reaching the articular surface suggests a true tear. |
| False negative | Ramp lesions ("hidden lesions") | Look for bone oedema in the posterior medial tibia beneath the meniscus, a reliable sign. Normal signal in the posterior meniscosynovial fold can confuse. |
| Under-calling | Lateral meniscal tears | Inspect the lateral meniscus systematically at arthroscopy |
| Normal MRI | Hypermobile lateral meniscus | Consider MRI in flexion |
Key diagnostic accuracy data for children (Kocher 2001) are summarised on the ACL trainee page: MRI sensitivity 79% and specificity 92% for medial tears, and 67% and 83% for lateral tears.
Management: the four Rs
Preserve as much meniscal tissue as possible. Asokan 2023 groups management into retention, repair, resection and replacement.
| Option | Indications | Notes |
|---|---|---|
| Retention (no surgery) | Asymptomatic tears. Asymptomatic discoid meniscus, even if found at arthroscopy. Small radial tears 3 mm or less. Stable, undisplaced red-red peripheral tears. | Avoid pivoting sport for 12 weeks |
| Repair | Most paediatric tears, including white-white zone, complex and long-standing tears. All tears with ACL injury. | Better results if repaired within 8 weeks [Asokan 2023]. Delay alone is not a reason to resect [Geffroy 2021]. |
| Resection | Chronic displaced tears with degenerate tissue that will not reduce or hold sutures. Complex tears that cannot be stabilised. | Partial meniscectomy should be exceptional. Remove only unstable fragments. |
| Replacement (meniscal allograft transplantation) | Symptomatic knee after major meniscal loss, without arthritis | Rarely indicated. Do not operate on asymptomatic knees. |
Where the two reviews differ
- White-zone tears. Geffroy 2021 repairs them in children and expects good results. Asokan 2023 suggests limited resection may be better for avascular-zone tears.
- Discoid meniscus. Both favour saucerization plus repair over total meniscectomy. See the discoid trainee page.
Meniscal allograft transplantation in children
- Middleton 2019: 23 children, single centre, 5 years. Lysholm 57.9 to 87.6, Tegner 2 to 5, IKDC 40.6 to 78.6. No graft failures.
- Riboh 2016: 36 adolescents at 2 years. Improved function. Meniscal reoperation 6%.
There are no paediatric studies of synthetic meniscal substitutes. [Geffroy 2021]
Repair technique principles
Choose the technique by where the tear lies from front to back. A surgeon treating children should be competent in all three. [Geffroy 2021]
| Technique | Best for | Advantages | Drawbacks |
|---|---|---|---|
| All-inside | Posterior segment and posterior half of the middle segment | No extra incision. Quicker and simpler. | Needs a peripheral rim. Implant migration, iatrogenic meniscal damage. Avoid an anterolateral portal for posterior lateral repairs (use anteromedial). |
| Inside-out | Posterior segment to mid-body, bucket-handle tears | Gold standard for many surgeons | Counter-incision, neurovascular risk |
| Outside-in | Anterior half of the meniscus, radial tears, ramp lesions | Reaches anterior tears | Short incision to tie the knot |
General principles
- Arthroscopy is feasible from age 3 to 4 using a standard 4.5 mm, 30-degree scope.
- Prepare (freshen) the tear edges with a rasp, shaver or basket. Poor preparation risks failure. An extra portal may be needed.
- Use non-absorbable UHMWPE or slow-absorbing suture (for example PDS 2-0).
- Prefer vertical sutures, perpendicular to the tear, every 5 to 7 mm. Alternate superior and inferior stitches if possible. Do not over-tighten.
- In a tight medial compartment, needle pie-crusting of the MCL opens the space for posterior repairs.
- No reliable evidence supports adding platelet-rich plasma.
By tear type
| Tear | Technique |
|---|---|
| Vertical posterior | Inside-out and/or all-inside vertical sutures, with meniscal and adjacent synovial bites |
| Bucket-handle | Good-quality debridement, reduction (inside-out traction helps). Outside-in if it extends anterior to mid-body. |
| Ramp | Accessory posteromedial portal, curved suture hook through meniscotibial ligament then meniscus. Inspect via the notch between MFC and PCL. |
| Horizontal | Freshen, then outside-in sutures that sandwich the cleavage. Excise a large cyst through a lateral pre-ligamentous portal. |
| Radial | Outside-in horizontal stitches. Delay weight-bearing 3 to 4 weeks. |
| Root | All-inside horizontal mattress if tissue remains at the root. Transosseous tibial fixation for root detachment. |
Meniscal injury with ACL rupture
Repair only in a stable or stabilised knee. Reconstruct the ACL and repair the meniscus in the same procedure. [Geffroy 2021]
- Meniscal tears occur with 47% to 61% of paediatric ACL tears, mainly posterior vertical tears. [Geffroy 2021]
- In pooled repair series, tears with ACL injury were 42% medial, 37% lateral and 21% both. [Liechti 2019]
- Chronic instability causes new tears, especially medial, and extends existing ones. Delayed ACL reconstruction increases meniscal tears.
- Ramp lesions occur in 23% of paediatric ACL reconstructions. Look for them systematically through the notch.
- Repair results were better when done with ACL reconstruction. One series found longer return to activity and lower Tegner scores with concurrent ACLR. [Liechti 2019]
- Some authors add an anterolateral procedure to ACL reconstruction to protect a medial meniscal repair. [Sonnery-Cottet 2018, via Geffroy 2021]
For ACL timing and technique in children, see the paediatric ACL trainee page.
Rehabilitation and return to sport
There is no consensus on post-operative protocols. Tailor them to the tear type and the quality of the repair. [Geffroy 2021]
| Phase | Typical guidance |
|---|---|
| Weeks 0 to 4 to 6 | Partial weight-bearing and no deep flexion [Asokan 2023]. Some authors allow immediate weight-bearing after stable vertical repairs. Limit flexion for a month after posterior repairs. |
| Radial and root repairs | Delay weight-bearing for 3 to 4 weeks |
| From 4 to 6 weeks | Non-weight-bearing activities, if the knee is dry and pain-free |
| About 3 to 4 months | Running |
| 4 to 6 months | Pivoting and contact sport. Average healing time after repair is about 6 months. |
- Strict immobilisation is not needed mechanically, but can help pain in children under 10, especially after discoid surgery.
- The need for formal physiotherapy is debated. It may help after discoid surgery with multiple sutures.
- With concurrent ACL reconstruction, the ACL timeline applies.
- Immediate versus protected weight-bearing after peripheral vertical repairs gave similar failure rates in one study. [Perkins 2018, via Geffroy 2021]
Assessing healing
No non-invasive test reliably confirms healing. Absence of symptoms is not proof. MRI shows persistent signal that is hard to interpret. CT arthrography can show sealing, and may be considered before revision surgery.
Outcomes, failure and reoperation
Repair results in children are very good, and better than in adults, whatever the tear type or site. [Geffroy 2021]
Liechti 2019 systematic review
8 level IV studies, 287 patients (301 menisci), mean age 15.1 (range 4 to 18), mean follow-up 51.6 months.
| Outcome | Result |
|---|---|
| Concurrent ACL reconstruction | 52% (158 of 301) |
| Post-operative Lysholm | 85.4 to 96.3 (5 studies) |
| Post-operative Tegner | 6.2 to 8 (7 studies) |
| Failure (revision surgery) | 52 of 301 (17.3%), mean 16.6 months |
| Management of failures | 41 partial meniscectomy, 9 re-repair, 2 non-operative |
| Complications | 2: transient partial peroneal palsy after open lateral repair, and septic arthritis |
| Return to sport | 24 of 26 (Mintzer), 10 of 12 (Accadbled), 11 of 19 (Schmitt) |
Other failure data
| Study | Population | Failure or reoperation |
|---|---|---|
| Patel 2019 | 907 index meniscal procedures in children | 83 (9%) reoperated, mean 23.3 months |
| Jackson 2019 | 880 children | 36% reinjury, highest with medial tear plus ACL injury. Revision surgery 11% of females, 8% of males. |
Factors linked with failure
- Complex horizontal and radial tears heal less well (18% to 65%) than vertical tears (80%). [Krych 2008; Hagmeijer 2019]
- Repaired displaced bucket-handle tears re-tear more often than in-situ vertical tears. [Shieh 2016]
- Failure risk is highest in the first year.
- An unstable knee, or a failed ACL graft, puts the repair at risk.
When a repair fails
In about half of failures, the failure is only partial, which supports trying primary repair. [Pujol 2011] The residual tear is usually resected, but re-repair can be tried, especially for bucket-handle or peripheral tears. Check the ACL graft if the knee is unstable.
Newer evidence (2020 to 2026)
Recent work is mainly large multicentre registries from the SCORE multicentre group. It supports repair as safe, but shows more short-term complications than older series reported.
| Study | Design | Key findings |
|---|---|---|
| Tagliero 2020 | Systematic review, 13 studies, 466 adolescents, 503 repairs | Re-tear 0% to 42% at 22 to 211 months (93 failures). Post-operative Lysholm 85 to 96, IKDC up 24 to 42 points. One level II, one level III and 11 level IV studies. |
| Rohde 2023 (SCORE) | 1,185 repairs, multicentre | See epidemiology: sex, age and BMI differences in tear pattern. 68.9% with ACL surgery. |
| SCORE safety registry 2023 (conference abstract) | 2,375 repairs, mean age 15.1 | Overall complications 12.6% (grade III 5.7%). Stiffness 4.0%, failed repair 2.3%, persistent pain or mechanical symptoms 2.1%. Isolated repairs had the most failures (6.4%). Higher risk with posterior horn medial and longitudinal lateral tears. |
| Agonias 2026 (SCORE registry) | Prospective QI registry, 16 centres, 600 isolated repairs, age 19 or under (mean 15.1), minimum 8 months | Complications 19.2% (grade II 7.2%, grade III 12.0%). Failed repair 9.2%. More complications in females, medial posterior horn and body tears, lateral oblique (parrot-beak) tears, and with either locked-in-extension or unrestricted range of motion. |
| Hiredesai 2026 (PearlDiver database) | 7,555 meniscectomies and 2,797 repairs, age 16 or under, isolated primary surgery, 5 to 10 years | Post-traumatic OA at 10 years 2.3% after meniscectomy vs 1.5% after repair (from billing codes). Risk factors: a later motion-restoring procedure (HR 5 to 6), age 12 or under and obesity (meniscectomy), depression (repair). |
Both 2026 studies were checked against their published abstracts. Hiredesai relies on billing codes, which under-detect early osteoarthritis, and its abstract gives the meniscectomy rate as both 2.3% and 2.2%.
What this adds
- Complications after repair are more common than older series suggested (12% to 19% in recent registries). Stiffness is the main one.
- Isolated repairs may fail more than repairs done with ACL reconstruction. This matches older paediatric series. [Liechti 2019]
- Database data show a low but lower rate of post-traumatic osteoarthritis after repair than after meniscectomy at 10 years (1.5% vs 2.3%). Stiffness needing further surgery was the strongest risk factor after either.
Critical appraisal
The paediatric meniscus literature is almost entirely retrospective case series without comparison groups. Firm recommendations are not possible. [Liechti 2019]
Common flaws
- Small, single-centre series with mixed tear types and techniques.
- Isolated and ACL-associated repairs often pooled, though they behave differently.
- Failure usually defined as reoperation, which misses asymptomatic non-healing.
- Healing rarely confirmed on imaging or second-look arthroscopy.
- Short follow-up for an outcome (osteoarthritis) that appears over decades.
Appraisal points from the sources
| Source | What to notice |
|---|---|
| Liechti 2019 | All 8 studies level IV. No quantitative synthesis. Search to March 2018. Follow-up is given as 22.3 to 96 months in one place and 2.5 months to 19 years in another. Two authors report industry educational support. |
| Geffroy 2021 | Narrative expert review from one surgeon. Strong pro-repair position, including white-zone tears, based largely on older series. |
| Asokan 2023 | Narrative current concepts review. Some figures are secondary citations, such as the high-school injury rate and the tear pattern distribution from a revision series. |
| SCORE registry data | Large and multicentre, but some results so far are conference abstracts only. |
Research gaps
- No paediatric RCTs of technique, rehabilitation or weight-bearing.
- Few long-term data on osteoarthritis after repair vs meniscectomy in children.
- No validated non-invasive test of meniscal healing.
References
- Written by: [author name, role]
- Reviewed by: [clinical reviewer, role]
- Next review due: Oct 4, 2027
Core sources
- Liechti DJ, Constantinescu DS, Ridley TJ et al. Meniscal repair in pediatric populations: a systematic review of outcomes. Orthop J Sports Med 2019;7(5):2325967119843355
- Geffroy L. Meniscal pathology in children and adolescents. Orthop Traumatol Surg Res 2021;107:102775
- Asokan A, Ayub A, Ramachandran M. Pediatric meniscal injuries: current concepts. J Child Orthop 2023;17(1):70-75
Newer evidence
- Tagliero AJ, Kennedy NI, Leland DP et al. Meniscus repairs in the adolescent population: safe and reliable outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 2020;28:3587-3596
- Rohde MS, Shea KG, Dawson T et al. Age, sex, and BMI differences related to repairable meniscal tears in pediatric and adolescent patients. Am J Sports Med 2023;51(2):389-397
- SCORE Quality Improvement Registry, Ellis H. Pediatric meniscus repair: safety profile based on more than 2000 arthroscopic meniscus repairs (Poster 256). Orthop J Sports Med 2023;11(7 suppl 3)
- Agonias et al. Isolated meniscus repairs in youth have a 19% complication rate and 9% failure rate with variations by tear type, location, range of motion protocol, and sex at 8 months. Arthroscopy 2026
- Hiredesai et al. Ten-year post-traumatic osteoarthritis incidence is low after pediatric isolated meniscal surgery but lower after meniscal repair than meniscectomy. Arthrosc Sports Med Rehabil 2026
Cited within the core sources
- Jackson T, Fabricant PD, Beck N et al. Epidemiology, injury patterns, and treatment of meniscal tears in pediatric patients: a 16-year experience of a single center. Orthop J Sports Med 2019;7(12):2325967119890325
- Mitchell J, Graham W, Best TM et al. Epidemiology of meniscal injuries in US high school athletes between 2007 and 2013. Knee Surg Sports Traumatol Arthrosc 2016;24(3):715-722
- Patel NM, Mundluru SN, Beck NA et al. Which factors increase the risk of reoperation after meniscal surgery in children? Orthop J Sports Med 2019;7(5):2325967119842885
- Shieh AK, Edmonds EW, Pennock AT. Revision meniscal surgery in children and adolescents. Am J Sports Med 2016;44:838-843
- Krych AJ et al. Arthroscopic repair of isolated meniscal tears in patients 18 years and younger. Am J Sports Med 2008;36:1283-1289
- Hagmeijer MH et al. Long-term results after repair of isolated meniscal tears among patients aged 18 years and younger: an 18-year follow-up study. Am J Sports Med 2019;47:799-806
- Pujol N et al. Amount of meniscal resection after failed meniscal repair. Am J Sports Med 2011;39:1648-1652
- Middleton S et al. Meniscal allograft transplantation in the paediatric population. Knee Surg Sports Traumatol Arthrosc 2019;27(6):1908-1913
- Riboh JC et al. Meniscal allograft transplantation in the adolescent population. Arthroscopy 2016;32(6):1133-1140
- Kocher MS et al. Am J Sports Med 2001;29:292-296 (diagnostic accuracy, see ACL page)