Fox et al Jul • Aug 2012

[ Orthopaedic Surgery ]

The Basic Science of Human Knee

Menisci: Structure, Composition, and
Function
Alice J. S. Fox, MSc,*† Asheesh Bedi, MD,‡ and Scott A. Rodeo, MD†

Context: Information regarding the structure, composition, and function of the knee menisci has been scattered across
multiple sources and fields. This review contains a concise, detailed description of the knee menisci—including anatomy,
etymology, phylogeny, ultrastructure and biochemistry, vascular anatomy and neuroanatomy, biomechanical function, matu-
ration and aging, and imaging modalities.
Evidence Acquisition: A literature search was performed by a review of PubMed and OVID articles published from 1858
to 2011.
Results: This study highlights the structural, compositional, and functional characteristics of the menisci, which may be
relevant to clinical presentations, diagnosis, and surgical repairs.
Conclusions: An understanding of the normal anatomy and biomechanics of the menisci is a necessary prerequisite to
understanding the pathogenesis of disorders involving the knee.
Keywords: knee; meniscus; anatomy; function

O
nce described as a functionless embryonic remnant,162 Meniscal Phylogeny and Comparative Anatomy
the menisci are now known to be vital for the normal
Hominids exhibit similar anatomic and functional
function and long-term health of the knee joint.§ The
characteristics, including a bicondylar distal femur, intra-
menisci increase stability for femorotibial articulation, distribute
articular cruciate ligaments, menisci, and asymmetrical
axial load, absorb shock, and provide lubrication and nutrition
collateral.40,66 These similar morphologic characteristics reflect a
to the knee joint.4,91,152,153
shared genetic lineage that can be traced back more than 300
Injuries to the menisci are recognized as a cause of significant
million years.40,66,119
musculoskeletal morbidity. The unique and complex structure
In the primate lineage leading to humans, hominids evolved
of menisci makes treatment and repair challenging for the
to bipedal stance approximately 3 to 4 million years ago,
patient, surgeon, and physical therapist. Furthermore, long-
and by 1.3 million years ago, the modern patellofemoral
term damage may lead to degenerative joint changes such
joint was established (with a longer lateral patellar facet and
as osteophyte formation, articular cartilage degeneration,
matching lateral femoral trochlea).164 Tardieu investigated
joint space narrowing, and symptomatic osteoarthritis.36,45,92
the transition from occasional bipedalism to permanent
Preservation of the menisci depends on maintaining their
bipedalism and observed that primates contain a medial and
distinctive composition and organization.
lateral fibrocartilaginous meniscus, with the medial meniscus
Anatomy of Menisci being morphologically similar in all primates (crescent shaped
with 2 tibial insertions).163 By contrast, the lateral meniscus
Meniscal Etymology was observed to be more variable in shape. Unique in Homo
The word meniscus comes from the Greek word me-niskos, sapiens is the presence of 2 tibial insertions—1 anterior and
meaning “crescent,” diminutive of me-ne-, meaning “moon.” 1 posterior—indicating a habitual practice of full extension
movements of the knee joint during the stance and swing
References 9, 13, 29, 45, 144, 160, 161.
§
phases of bipedal walking.20,134,142,163,168

From the †Hospital for Special Surgery, New York, New York, and the ‡Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
*Address correspondence to Asheesh Bedi, MD, Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48105 (e-mail:
[email protected]).
DOI: 10.1177/1941738111429419
© 2012 The Author(s)
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Figure 1. Gross photograph of human tibial plateau

demonstrating the relative size and attachments of
the medial and lateral menisci. The medial and lateral
menisci (left side and right side of image, respectively)
are connected by a transverse ligament (TL). 1, anterior
insertional ligament of the medial meniscus; 2, posterior
insertional ligament of the medial meniscus; 3, anterior
insertional ligament of the lateral meniscus; 4, posterior
insertional ligament of the lateral meniscus. ACL, anterior
cruciate ligament; PCL, posterior cruciate ligament.
Reprinted with permission from Messner and Gao.115

Figure 2. (A) Anatomy of the meniscus viewed from above

(adapted image reprinted with permission from Greis
Embryology and Development et al63; original from Pagnani et al129). (B) Axial view of a
right tibial plateau showing sections of the meniscus and
The characteristic shape of the lateral and medial menisci
their relationship to the cruciate ligaments. AL, anterior
is attained between the 8th and 10th week of gestation.53,60
horn lateral meniscus; AM, anterior horn medial meniscus;
They arise from a condensation of the intermediate layer of
PCL, posterior cruciate ligament; PL, posterior horn lateral
mesenchymal tissue to form attachments to the surrounding
meniscus; PM, posterior horn medial meniscus. Reprinted
joint capsule.31,87,110 The developing menisci are highly
with permission from Johnson et al.83
cellular and vascular, with the blood supply entering from
the periphery and extending through the entire width
of the menisci.31 As the fetus continues to develop, there
is a gradual decrease in the cellularity of the menisci the knee joint (Figure 2A). The peripheral, vascular border
with a concomitant increase in the collagen content in a (also known as the red zone) of each meniscus is thick,
circumferential arrangement.30,31 Joint motion and the postnatal convex, and attached to the joint capsule. The innermost
stress of weightbearing are important factors in determining border (also known as the white zone) tapers to a thin free
the orientation of collagen fibers. By adulthood, only the edge. The superior surfaces of menisci are concave, enabling
peripheral 10% to 30% have a blood supply.12,31 effective articulation with their respective convex femoral
Despite these histologic changes, the proportion of tibial condyles. The inferior surfaces are flat to accommodate the
plateau covered by the corresponding meniscus is relatively
tibial plateau (Figure 1).28,175
constant throughout fetal development, with the medial and
lateral menisci covering approximately 60% and 80% of the
Medial meniscus. The semicircular medial meniscus measures
surface areas, respectively.31
approximately 35 mm in diameter (anterior to posterior)
and is significantly broader posteriorly than it is anteriorly.175
Gross Anatomy
The anterior horn is attached to the tibia plateau near the
Gross examination of the knee menisci reveals a smooth, intercondylar fossa anterior to the anterior cruciate ligament
lubricated tissue (Figure 1). They are crescent-shaped wedges (ACL). There is significant variability in the attachment location
of fibrocartilage located on the medial and lateral aspects of of the anterior horn of the medial meniscus. The posterior

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 Fox et al Jul • Aug 2012

horn is attached to the posterior intercondylar fossa of the to increase the congruity of the meniscotibial fossa and the
tibia between the lateral meniscus and the posterior cruciate lateral femoral condyle.75
ligament (PCL; Figures 1 and 2B). Johnson et al reexamined
the tibial insertion sites of the menisci and their topographic Ultrastructure and Biochemistry
relationships to surrounding anatomic landmarks of the knee.82 Extracellular Matrix
They found that the anterior and posterior horn insertion sites
of the medial meniscus were larger than those of the lateral The meniscus is a dense extracellular matrix (ECM) composed
meniscus. The area of the anterior horn insertion site of the primarily of water (72%) and collagen (22%), interposed
medial meniscus was the largest overall, measuring 61.4 mm2, with cells.9,55,56,77 Proteoglycans, noncollagenous proteins, and
whereas the posterior horn of the lateral meniscus was the glycoproteins account for the remaining dry weight.¶ Meniscal
smallest, at 28.5 mm2.82 cells synthesize and maintain the ECM, which determines the
The tibial portion of the capsular attachment is the coronary material properties of the tissue.
ligament. At its midpoint, the medial meniscus is more firmly The cells of the menisci are referred to as fibrochondrocytes
attached to the femur through a condensation in the joint because they appear to be a mixture of fibroblasts and
capsule known as the deep medial collateral ligament.175 The chondrocytes.111,177 The cells in the more superficial layer of
transverse, or “intermeniscal,” ligament is a fibrous band of the menisci are fusiform or spindle shaped (more fibroblastic),
tissue that connects the anterior horn of the medial meniscus whereas the cells located deeper in the meniscus are ovoid or
to the anterior horn of the lateral meniscus (Figures 1 and 2A). polygonal (more chondrocytic).55,56,178 Cell morphology does
not differ between the peripheral and central locations in the
Lateral meniscus. The lateral meniscus is almost circular, menisci.56
with an approximately uniform width from anterior to posterior Both cell types contain abundant endoplasmic reticulum and
(Figures 1 and 2A). It occupies a larger portion (~80%) of the Golgi complex. Mitochondria are only occasionally visualized,
articular surface than the medial meniscus (~60%) and is more suggesting that the major pathway for energy production
mobile.10,31,165 Both horns of the lateral meniscus are attached of fibrochondrocytes in their avascular milieu is probably
to the tibia. The insertion of the anterior horn of the lateral anaerobic glycolysis.112
meniscus lies anterior to the intercondylar eminence and
adjacent to the broad attachment site of the ACL (Figure 2B).9,83 Water
The posterior horn of the lateral meniscus inserts posterior In normal, healthy menisci, tissue fluid represents 65% to
to the lateral tibial spine and just anterior to the insertion of 70% of the total weight. Most of the water is retained within
the posterior horn of the medial meniscus (Figure 2B).83 The the tissue in the solvent domains of proteoglycans. The water
lateral meniscus is loosely attached to the capsular ligament; content of meniscal tissue is higher in the posterior areas than
however, these fibers do not attach to the lateral collateral in the central or anterior areas; tissue samples from surface and
ligament. The posterior horn of the lateral meniscus attaches to deeper layers had similar contents.135
the inner aspect of the medial femoral condyle via the anterior Large hydraulic pressures are required to overcome the
and posterior meniscofemoral ligaments of Humphrey and drag of frictional resistance of forcing fluid flow through
Wrisberg, respectively, which originate near the origin of the meniscal tissue. Thus, interactions between water and the
PCL (Figures 1 and 2).75 matrix macromolecular framework significantly influence the
viscoelastic properties of the tissue.
Meniscofemoral ligaments. The literature reports significant
inconsistencies in the presence and size of meniscofemoral Collagens
ligaments of the lateral meniscus. There may be none, 1, 2, or
4.|| When present, these accessory ligaments transverse from the Collagens are primarily responsible for the tensile strength of
posterior horn of the lateral meniscus to the lateral aspect of the menisci; they contribute up to 75% of the dry weight of the
medial femoral condyle. They insert immediately adjacent to the ECM.77 The ECM is composed primarily of type I collagen
femoral attachment of the PCL (Figures 1 and 2). (90% dry weight) with variable amounts of types II, III,
In a series of studies, Harner et al measured the cross- V, and VI.43,44,80,112,181 The predominance of type I collagen
sectional area of the ligaments and found that the distinguishes the fibrocartilage of menisci from articular
meniscofemoral ligament averaged 20% of the size of the PCL (hyaline) cartilage. The collagens are heavily cross-linked by
(range, 7%-35%).69,70 However, the size of the insertional area hydroxylpyridinium aldehydes.44
alone without knowledge of the insertional angle or collagen The collagen fiber arrangement is ideal for transferring
density does not indicate their relative strength.115 The function a vertical compressive load into circumferential “hoop”
of these ligaments remains unknown; they may pull the stresses (Figure 3).57 Type I collagen fibers are oriented
posterior horn of the lateral meniscus in an anterior direction circumferentially in the deeper layers of the meniscus, parallel

References 11, 75, 79, 93, 98, 133, 173, 185.

||
References 8, 16, 49, 77, 80, 112, 131, 166, 180.
¶

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hyaluronic acid.67,72 The amount of proteoglycans in the

meniscus is one-eighth that of articular cartilage,2,3 and there
may be considerable variation depending on the site of the
sample and the age of the patient.49
By virtue of their specialized structure, high fixed-charge
density, and charge-charge repulsion forces, proteoglycans
in the ECM are responsible for hydration and provide the
tissue with a high capacity to resist compressive loads.‡ The
glycosaminoglycan profile of the normal adult human meniscus
consists of chondroitin-6-sulfate (40%), chondroitin-4-sulfate
(10% to 20%), dermatan sulfate (20% to 30%), and keratin
sulfate (15%; Figure 4).65,77,99,159 The highest glycosaminoglycan
concentrations are found in the meniscal horns and the inner
Figure 3. Schematic diagram demonstrating the collagen half of the menisci in the primary weightbearing areas.58,77
fiber ultrastructure and orientation within the meniscus: Aggrecan is the major proteoglycan found in the human
1, superficial network; 2, lamellar layer; 3, central main menisci and is largely responsible for their viscoelastic
layer. Arrowheads, radial interwoven fibers; arrow, loose compressive properties (Figure 5). Smaller proteoglycans,
connective tissue. Reprinted with permission from Petersen such as decorin, biglycan, and fibromodulin, are found in
and Tillmann.132 smaller amounts.124,151 Hexosamine contributes 1% to the dry
weight of ECM.57,74 The precise functions of each of these small
proteoglycans on the meniscus have yet to be fully elucidated.

to the peripheral border. These fibers blend the ligamentous Matrix Glycoproteins
connections of the meniscal horns to the tibial articular Meniscal cartilage contains a range of matrix glycoproteins, the
surface (Figure 3).10,27,49,156 In the most superficial region of identities and functions of which have yet to be determined.
the menisci, the type I fibers are oriented in a more radial Electrophoresis and subsequent staining of the polyacrylamide
direction. Radially oriented “tie” fibers are also present in gels reveals bands with molecular weights varying from
the deep zone and are interspersed or woven between the a few kilodaltons to more than 200 kDa.112 These matrix
circumferential fibers to provide structural integrity (Figure 3).# molecules include the link proteins that stabilize proteoglycan–
There is lipid debris and calcified bodies in the ECM of human hyaluronic acid aggregates and a 116-kDa protein of unknown
menisci.54 The calcified bodies contain long, slender crystals function.46 This protein resides in the matrix in the form
of phosphorous, calcium, and magnesium on electron-probe of disulfide-bonded complex of high molecular weight.46
roentgenographic analysis.54 The function of these crystals Immunolocalization studies suggest that it is predominantly
in not completely understood, but it is believed that they located around the collagen bundles in the interterritorial
may play a role in acute joint inflammation and destructive matrix.47
arthropathies. The adhesive glycoproteins constitute a subgroup of the
Noncollagenous matrix proteins, such as fibronectin, matrix glycoproteins. These macromolecules are partly
contribute 8% to 13% of the organic dry weight. Fibronectin responsible for binding with other matrix molecules and/or
is involved in many cellular processes, including tissue repair, cells. Such intermolecular adhesion molecules are therefore
embryogenesis, blood clotting, and cell migration/adhesion. important components in the supramolecular organization of
Elastin forms less than 0.6% of the meniscus dry weight; its the extracellular molecules of the meniscus.150 Three molecules
ultrastructural localization is not clear. It likely interacts directly have been identified within the meniscus: type VI collagen,
with collagen to provide resiliency to the tissue.** fibronectin, and thrombospondin.112,118,181
Proteoglycans
Vascular Anatomy
Located within a fine meshwork of collagen fibrils,
The meniscus is a relatively avascular structure with a limited
proteoglycans are large, negatively charged hydrophilic
peripheral blood supply. The medial, lateral, and middle
molecules, contributing 1% to 2% of dry weight.58 They are
geniculate arteries (which branch off the popliteal artery)
formed by a core protein with 1 or more covalently attached
provide the major vascularization to the inferior and superior
glycosaminoglycan chains (Figure 4).122 The size of these
aspects of each meniscus (Figure 5).9,12,33-35,148 The middle
molecules is further increased by specific interaction with
geniculate artery is a small posterior branch that perforates
the oblique popliteal ligament at the posteromedial corner of
#
References 13, 14, 21, 27, 49, 59, 114, 156, 171, 182.
References 13, 49, 73, 78, 80, 112, 131.
** References 1, 10, 71, 89, 116, 121, 145.
‡

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Figure 4. Extracellular matrix. (A) Electron micrograph of an aggrecan aggregate shadowed by platinum. Many free aggrecan
molecules are also seen. (B) Schematic drawing of an aggrecan aggregate shown in part A. Reprinted with permission from Alberts
et al.6

Figure 6. Microvasculature of the medial meniscus

(superior aspect), following vascular perfusion with
India ink and tissue clearing using a modified Spälteholz
Figure 5. Confluence of geniculate arteries (anterior view). technique. Perimeniscal capillary plexus (PCP) can be seen
Reprinted with permission from Brindle et al.26 penetrating the peripheral border of the medial meniscus.
F, femur; T, tibia. Reprinted with permission from Arnoczky
and Warren.12

the tibiofemoral joint. A premeniscal capillary network arising

from the branches of these arteries originates within the
synovial and capsular tissues of the knee along the periphery for meniscus healing (Figure 6).12,33,68 Endoligamentous vessels
of the menisci. The peripheral 10% to 30% of the medial from the anterior and posterior horns travel a short distance
meniscus border and 10% to 25% of the lateral meniscus are into the substance of the menisci and form terminal loops,
relatively well vascularized, which has important implications providing a direct route for nourishment.33 The remaining

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portion of each meniscus (65% to 75%) receives nourishment

from synovial fluid via diffusion or mechanical pumping (ie,
joint motion).116,120
Bird and Sweet examined the menisci of animals and
humans using scanning electron and light microscopy.23,24 They
observed canal-like structures opening deep into the surface
of the menisci. These canals may play a role in the transport
of fluid within the meniscus and may carry nutrients from the
synovial fluid and blood vessels to the avascular sections of
the meniscus.23,24 However, further study is needed to elucidate
the exact mechanism by which mechanical motion supplies
nutrition to the avascular portion of the menisci.

Neuroanatomy
Figure 7. Diagrams showing the mean movement (mm)
The knee joint is innervated by the posterior articular branch in each meniscus during flexion (shaded) and extension
of the posterior tibial nerve and the terminal branches of (hashed). ANT, anterior; POST, posterior; mme, mean
the obturator and femoral nerves. The lateral portion of the meniscal excursion; P/A, ratio of posterior to anterior
capsule is innervated by the recurrent peroneal branch of meniscal translation during flexion. Reproduced with
the common peroneal nerve. These nerve fibers penetrate permission from Thomspon et al.165
the capsule and follow the vascular supply to the peripheral *
P < 0.05 (Student t test analysis).
portion of the menisci and the anterior and posterior horns,
where most of the nerve fibers are concentrated.52,90 The outer
third of the body of the meniscus is more densely innervated
than the middle third.183,184 During extremes of flexion and Biomechanical Function
extension of the knee, the meniscal horns are stressed, and the
The biomechanical function of the meniscus is a reflection of
afferent input is likely greatest at these extreme positions.183,184
the gross and ultrastructural anatomy and of its relationship
The mechanoreceptors within the menisci function as
to the surrounding intra-articular and extra-articular
transducers, converting the physical stimulus of tension and
structures. The menisci serve many important biomechanical
compression into a specific electrical nerve impulse. Studies
functions. They contribute to load transmission,¶¶ shock
of human menisci have identified 3 morphologically distinct
absorption,10,49,94,96,170 stability,51,100,101,109,155 nutrition,23,24,84,141 joint
mechanoreceptors: Ruffini endings, Pacinian corpuscles, and
lubrication,102-104,141 and proprioception.5,15,81,88,115,147 They also
Golgi tendon organs.‡‡ Type I (Ruffini) mechanoreceptors are
serve to decrease contact stresses and increase contact area
low threshold and slowly adapting to the changes in joint
and congruity of the knee.91,172
deformation and pressure. Type II (Pacinian) mechanoreceptors
are low threshold and fast adapting to tension changes.§§ Type
Meniscal Kinematics
III (Golgi) are high-threshold mechanoreceptors, which signal
when the knee joint approaches the terminal range of motion In a study on ligamentous function, Brantigan and Voshell
and are associated with neuromuscular inhibition. These neural reported the medial meniscus to move an average 2 mm,
elements were found in greater concentration in the meniscal while the lateral meniscus was markedly more mobile with
horns, particularly the posterior horn. approximately 10 mm of anterior-posterior displacement during
The asymmetrical components of the knee act in concert as flexion.25 Similarly, DePalma reported that the medial meniscus
a type of biological transmission that accepts, transfers, and undergoes 3 mm of anterior-posterior displacement, while the
dissipates loads along the femur, tibia, patella, and femur.41 lateral meniscus moves 9 mm during flexion.37 In a study using
Ligaments act as an adaptive linkage, with the menisci 5 cadaveric knees, Thompson et al reported the mean medial
representing mobile bearings. Several studies have reported excursion to be 5.1 mm (average of anterior and posterior
that various intra-articular components of the knee are sensate, horns) and the mean lateral excursion, 11.2 mm, along the
capable of generating neurosensory signals that reach spinal, tibial articular surface (Figure 7).165 The findings from these
cerebellar, and higher central nervous system levels.|||| It is studies confirm a significant difference in segmental motion
believed that these neurosensory signals result in conscious between the medial and lateral menisci. The anterior and
perception and are important for normal knee joint function posterior horn lateral meniscus ratio is smaller and indicates
and maintenance of tissue homeostasis.42 that the meniscus moves more as a single unit.165 Alternatively,
the medial meniscus (as a whole) moves less than the lateral
‡‡
References 15, 35, 52, 64, 90, 126, 127, 149, 183. meniscus, displaying a greater anterior to posterior horn
§§
References 15, 52, 90, 126, 127, 149, 183.
||||
References 19,32,42,125,136,157,174. References 4, 10, 45, 50, 152, 153, 172.
¶¶

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differential excursion. Thompson et al found that the area of knees that have undergone meniscectomy.170 As the inability
least meniscal motion is the posterior medial corner, where the of a joint system to absorb shock has been implicated in the
meniscus is constrained by its attachment to the tibial plateau development of osteoarthritis, the meniscus would appear to
by the meniscotibial portion of the posterior oblique ligament, play an important role in maintaining the health of the knee
which has been reported to be more prone to injury.143,165 A joint.138
reduction in the motion of the posterior horn of the medial
meniscus is a potential mechanism for meniscal tears, with a Joint Stability
resultant “trapping” of the fibrocartilage between the femoral
The geometric structure of the menisci provides an important
condyle and the tibial plateau during full flexion. The greater
role in maintaining joint congruity and stability.## The superior
differential between anterior and posterior horn excursion may
surface of each meniscus is concave, enabling effective
place the medial meniscus at a greater risk of injury.165
articulation between the convex femoral condyles and flat
The differential of anterior horn to posterior horn motion
tibial plateau. When the meniscus is intact, axial loading of the
allows the menisci to assume a decreasing radius with flexion,
knee has a multidirectional stabilizing function, limiting excess
which correlates to the decreased radius of curvature of the
motion in all directions.9
posterior femoral condyles.165 This change of radius allows the
Markolf and colleagues have addressed the effect of
meniscus to maintain contact with the articulating surface of
meniscectomy on anterior-posterior and rotational knee laxity.
both the femur and the tibia throughout flexion.
Medial meniscectomy in the ACL-intact knee has little effect
on anterior-posterior motion, but in the ACL-deficient knee,
Load Transmission
it results in an increase in anterior-posterior tibial translation
The function of the menisci has been clinically inferred of up to 58% at 90o of flexion.109 Shoemaker and Markolf
by the degenerative changes that accompany its removal. demonstrated that the posterior horn of the medial meniscus
Fairbank described the increased incidence and predictable is the most important structure resisting an anterior tibial
degenerative changes of the articular surfaces in completely force in the ACL-deficient knee.155 Allen et al showed that the
meniscectomized knees.45 Since this early work, numerous resultant force in the medial meniscus of the ACL-deficient
studies have confirmed these findings and have further knee increased by 52% in full extension and by 197% at 60° of
established the important role of the meniscus as a protective, flexion under a 134-N anterior tibial load.7 The large changes
load-bearing structure. in kinematics due to medial meniscectomy in the ACL-deficient
Weightbearing produces axial forces across the knee, which knee confirm the important role of the medial meniscus in
compress the menisci, resulting in “hoop” (circumferential) knee stability. Recently, Musahl et al reported that the lateral
stresses.170 Hoop stresses are generated as axial forces and meniscus plays a role in anterior tibial translation during the
converted to tensile stresses along the circumferential collagen pivot-shift maneuver.123
fibers of the meniscus (Figure 8). Firm attachments by the
anterior and posterior insertional ligaments prevent the meniscus Joint Nutrition and Lubrication
from extruding peripherally during load bearing.94 Studies by
The menisci may also play a role in the nutrition and
Seedhom and Hargreaves reported that 70% of the load in
lubrication of the knee joint. The mechanics of this lubrication
the lateral compartment and 50% of the load in the medial
remains unknown; the menisci may compress synovial fluid
compartment is transmitted through the menisci.153 The menisci
into the articular cartilage, which reduces frictional forces
transmit 50% of compressive load through the posterior horns
during weightbearing.13
in extension, with 85% transmission at 90° flexion.172 Radin et
There is a system of microcanals within the meniscus located
al demonstrated that these loads are well distributed when the
close to the blood vessels, which communicates with the
menisci are intact.137 However, removal of the medial meniscus
synovial cavity; these may provide fluid transport for nutrition
results in a 50% to 70% reduction in femoral condyle contact
and joint lubrication.23,24
area and a 100% increase in contact stress.4,50,91 Total lateral
meniscectomy results in a 40% to 50% decrease in contact area
Proprioception
and increases contact stress in the lateral component to 200% to
300% of normal.18,50,76,91 This significantly increases the load per The perception of joint motion and position (proprioception)
unit area and may contribute to accelerated articular cartilage is mediated by mechanoreceptors that transduce mechanical
damage and degeneration.45,85 deformation into electric neural signals. Mechanoreceptors
have been identified in the anterior and posterior horns of
Shock Absorption the menisci.*** Quick-adapting mechanoreceptors, such as
Pacinian corpuscles, are thought to mediate the sensation of
The menisci play a vital role in attenuating the intermittent
joint motion, and slow-adapting receptors, such as Ruffini
shock waves generated by impulse loading of the knee with
normal gait.94,96,153 Voloshin and Wosk showed that the normal ##
References 7, 25, 51, 101, 108, 109, 128, 155.
knee has a shock-absorbing capacity about 20% higher than References 5, 15, 81, 88, 147, 179, 184.
***

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Figure 8. Free body diagram of forces acting on the meniscus during loading. As the femur presses down on the meniscus during
normal loading, the meniscus deforms radially but is anchored by its anterior and posterior horns (Fant and Fpost). During loading,
tensile, compressive, and shear forces are generated. A tensile hoop stress (Fcir) results from the radial deformation, while vertical
and horizontal forces (Fv and Fh) result from the femur pressing on the curved superior surface of the tissue. A radial reaction force
(Frad) balances the femoral horizontal force (Fh). Reprinted with permission from Athanasiou and Sanchez-Adams.17

endings and Golgi tendon organs, are believed to mediate the McNicol and Roughley studied the variation of meniscal
sensation of joint position.140 The identification of these neural proteoglycans in aging113; small differences in extractability and
elements (located mostly in the middle and outer third of the hydrodynamic size were observed. The proportions of keratin
meniscus) indicates that the menisci are capable of detecting sulfate relative to chondroitin-6-sulfate increased with aging.146
proprioceptive information in the knee joint, thus playing an Petersen and Tillmann immunohistochemically investigated
important afferent role in the sensory feedback mechanism of human menisci (ranging from 22 weeks of gestation to 80
the knee.61,88,90,158,169 years), observing the differentiation of blood vessels and
lymphatics in 20 human cadavers. At the time of birth, nearly
Maturation and Aging of The the entire meniscus was vascularized. In the second year of
Meniscus life, an avascular area developed in the inner circumference.
In the second decade, blood vessels were present in the
The microanatomy of the meniscus is complex and certainly
peripheral third. After 50 years of age, only the peripheral
demonstrates senescent changes. With advancing age, the
quarter of the meniscal base was vascularized. The dense
meniscus becomes stiffer, loses elasticity, and becomes
connective tissue of the insertion was vascularized but not the
yellow.78,95 Microscopically, there is a gradual loss of cellular
fibrocartilage of the insertion. Blood vessels were accompanied
elements with empty spaces and an increase in fibrous
by lymphatics in all areas.†††
tissue in comparison with elastic tissue.74 These cystic areas
Arnoczky suggested that body weight and knee joint motion
can initiate a tear, and with a torsional force by the femoral
may eliminate blood vessels in the inner and middle aspects of
condyle, the superficial layers of the meniscus may shear off
the menisci.9 Nutrition of meniscal tissue occurs via perfusion
from the deep layer at the interface of the cystic degenerative
from blood vessels and via diffusion from synovial fluid.
change, producing a horizontal cleavage tear. Shear between
A requirement for nutrition via diffusion is the intermittent
these layers may cause pain. The torn meniscus may directly
loading and release on the articular surfaces, stressed by body
injure the overlying articular cartilage.74,95
weight and muscle forces.130 The mechanism is comparable
Ghosh and Taylor found that collagen concentration
with the nutrition of articular cartilage.22
increased from birth to 30 years and remained constant
until 80 years of age, after which a decline occurred.58 The
noncollagenous matrix proteins showed the most profound Magnetic Resonance Imaging of The
Meniscus
changes, decreasing from 21.9% ± 1.0% (dry weight) in
neonates to 8.1% ± 0.8% between the ages of 30 to 70 years.80 Magnetic resonance imaging (MRI) is a noninvasive diagnostic
After 70 years of age, the noncollagenous matrix protein levels tool used in the evaluation, diagnosis, and monitoring of
increased to 11.6% ± 1.3%. Peters and Smillie observed an
increase in hexosamine and uronic acid with age.131 References 9, 12, 31, 33, 35, 61, 132, 139, 140, 148, 167.
†††

347
 Fox et al Jul • Aug 2012

single-blind prospective study comparing clinical examinations

and MRI in 57 knee examinations.117 He found no significant
difference in sensitivity between the clinical examination and
MRI (80.7% and 73.7%, respectively). Shepard et al assessed the
accuracy of MRI in detecting clinically significant lesions of the
anterior horn of the meniscus in 947 consecutive knee MRI154
and found a 74% false-positive rate. Increased signal intensity
in the anterior horn does not necessarily indicate a clinically
significant lesion.154

Conclusions
The menisci of the knee joint are crescent-shaped wedges of
fibrocartilage that provide increased stability to the femorotibial
articulation, distribute axial load, absorb shock, and provide
lubrication to the knee joint. Injuries to the menisci are
recognized as a cause of significant musculoskeletal morbidity.
Preservation of the menisci is highly dependent on maintaining
its distinctive composition and organization.

Figure 9. A sagittal magnetic resonance (proton-density) ACKNOWLEDGMENT

image of a healthy knee depicting the medial menisci We wish to thank Tom Cichonski for his assistance in the
(arrows). The concave superior meniscal surface formatting of this manuscript.
improves contact with the femoral epicondyles, and a flat
undersurface improves contact with the tibial plateau. The
periphery is thicker than the central portion, allowing for References
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