Arch Orthop Trauma Surg (2010) 130:427431

DOI 10.1007/s00402-009-1018-2

ARTHROSCOPY AND SPORTS MEDICINE

Effect of partial medial meniscectomy on the proprioceptive

function of the knee
Mustafa Karahan Baris Kocaoglu
Cengiz Cabukoglu Umut Akgun Rustu Nuran

Received: 24 May 2009 / Published online: 10 December 2009

Springer-Verlag 2009

Abstract
Introduction The aim of this study was to assess the
proprioception of the partial meniscectomized knee and to
assess if there is an effect on the knee proprioception.
Materials and methods We performed a casecontrol
study involving patients with meniscus tear at the posterior
horn of medial meniscus. Group 1 composed of 19 patients,
with an average age of 26.3 years, who were enrolled after
sustaining an injury to the medial meniscus. Twenty
healthy individuals, with an average age of 25.1, without
history of knee injury, constituted Group 2. In order to
document the proprioceptive capabilities of the knee, angle
reproduction tests were performed.
Results At a mean of 2 years after the surgery, there was
no difference between the meniscectomized and healthy
knee regarding the angle deviations in the lower flexion
angles (15, 30, 45). However, mean knee joint position
sense (KJPS) at 60 reproduction in Group 1 and 2 was
M. Karahan
Department of Orthopedics and Traumatology,
Faculty of Medicine, Marmara University,
Istanbul, Turkey
B. Kocaoglu (&)
Department of Orthopedic Surgery,
Acibadem Kadikoy Hospital, Faculty of Medicine,
Acibadem University, Istanbul, Turkey
e-mail: bariskocaoglu@gmail.com
C. Cabukoglu
Department of Orthopedic Surgery, Pendik Sifa Hospital,
Istanbul, Turkey
U. Akgun
R. Nuran
Department of Orthopedic Surgery,
Acibadem Kozyatagi Hospital, Faculty of Medicine,
Acibadem University, Istanbul, Turkey

64.3 (SD 5.3) and 69.2 (SD 4.9), respectively. Concomitantly, mean KJPS at 75 reproduction in Group 1 and 2
were 80.1 (SD 6.59) and 74.4 (SD 5.6), respectively. Paired
t test showed a statistically significant difference between
Group 1 and 2 when compared to control angle deviations
at 60 and 75 reproductions (P \ 0.05).
Conclusion KJPS of the patients in meniscectomized
group was poorer than the patients in healthy knee group at
60 and 75 knee flexion degrees. Those results indicated
that even a partial absence of menisci causes a deterioration of proprioceptive functions of the knee.
Keywords

Knee
Meniscectomy
Proprioception

Introduction
Proprioception is a sensory modality that encompasses the
sensations of joint position and joint motion [1, 2]. The
afferent signals of proprioception are sensed by peripheral
receptors within joints as well as within the surrounding
musculature and cutaneous structures. In the knee, mechanoreceptors such as Ruffini endings, Pacinian corpuscles and Golgi tendon organs are present in the anterior
cruciate ligament (ACL), posterior cruciate ligament (PCL)
and menisci [39]. Mechanoreceptors and nociceptive free
nerve endings have also been identified in the articular
surface [1, 2]. Quick-adapting mechanoreceptors, such as
the Pacinian corpuscle, are thought to mediate the sensation of joint motion, and slow-adapting receptors, such as
the Ruffini ending and Golgi tendon organ, are believed to
mediate the sensation of joint position [1, 2, 10].
Many studies have been conducted in order to understand the mechanical function of the menisci. The role of
meniscus in chondral protection and joint surface congruity

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is well presented in the literature [1, 2]. On the other hand,

histological studies showed that meniscal tissues are highly
innervated with free nerve endings that are located mostly
in the middle and outer third of meniscus. But the function
of such rich innervations is still not well known [4, 5, 7, 8].
In one single study, authors mentioned that stimulation
of the posterior horn of the medial meniscus produced
measurable amounts of cerebral cortical-evoked potentials
during arthroscopy [11]. In a recent animal study, they
obtained strong clues to show a reflex arc between medial
meniscus and hamstring muscles [12]. So there should be a
reflex arc like the one in ACL [1, 4]. Those reflex arcs are
related to proprioception of the knee. It has been described
that proprioception is disturbed in patients with an ACLdeficient knee [13, 14]. Thus it can also be true for a
meniscus tear.
Jerosch et al. first mentioned about the proprioception of
the knee joint with an isolated meniscus lesion [15]. But in
this study, there were some shortcomings. The proprioception test was performed with lack of standardization.
Some of the patients were tested before arthroscopy and
some after. Different parameters were used for the testing.
To our knowledge no studies have yet investigated the
short-term outcome of partial medial meniscectomy at the
side of the posterior horn on the knee joint position sense
(KJPS). Therefore, the goal of this study was to assess the
proprioception of the partial meniscectomized knee and to
assess if there is an effect on the knee proprioception.

Materials and methods

We performed a retrospective study involving patients with
meniscus tear at the posterior horn of medial meniscus.
Written informed consent, approved by our institutional
review board, was obtained. The study group was 19
patients composed of 11 men and 8 women, with an
average age of 26.3 years (range 1648), who were
enrolled after sustaining an injury to the medial meniscus.
Twenty healthy individuals, 13 men and 7 women, with an
average age of 25.1 (range 1840), without history of knee
injury, were used as a control group. The physical examination was normal in all patients. The study group was
named as Group 1 and the control group as Group 2. The
exclusion criteria for all patients include diabetes, neurological disorders and use of opiate analgesics.
All patients in Group1 were presented with medialbased knee pain, swelling and catching. Symptoms were
exacerbated by exercise and started approximately a mean
of 2 weeks (range 14 weeks, SD 1.2) before being seen in
the office and had gradually worsened. On clinical examination, all patients had pain localized to the medial joint
line on palpation. There was no instability on any of the

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knee. Plain radiographs of their knees revealed no evidence

of arthritis, loose bodies, fracture or bony pathology.
Magnetic resonance imaging (MRI) was subsequently
ordered and it showed isolated posteromedial partial tear of
the medial meniscus in all patients.
Because of the diagnosis, arthroscopy was recommended. All patients underwent knee arthroscopy (13 left
and 6 right knees) and all had an intact functional ACL as
well as a partial tear of the medial meniscus at the posterior
horn. The rest of the anatomical structures were all normal.
There was no cartilage lesion that needed chondroplasty in
any of the patients. Tears were commonly radial, flep radial
and parrot beak tear. The tears were at white and red-white
zone. Partial meniscectomy was performed to all patients.
All patients had one session physical therapy after the
operation. KJPS was evaluated by a dynamometer, at
2 years after the operation. At the same time, a functional
knee score using the modified Lysholm scoring system was
obtained.
Knee joint position sense
In order to document the proprioceptive capabilities of the
knee, the patients were asked to perform angle reproduction test which is a modified technique according to Barret
[16].
Apparatus is a kind of dynamometer
The dynamometer was a modified CPM machine. A Thomas splint with a Pearson knee-flexion piece was modified
to provide well-padded support to the whole leg, with its
axis of flexion close to the axis of the knee. A protractor
attached to the splint measured the angle (0) subtended by
the Pearson knee piece as it was moved by an observer in
the range. The patient was positioned supine and the knee
joint of the tested leg was aligned with the axis of the
dynamometer and the thigh was secured on the ground with
a fixation strap. A curtain at the level of the pelvis prevented visual control of the hip and knee flexion position
(Fig. 1). During the test each of the patients were asked to
wear shorts in order to minimize the sensory input of
clothes tissue to the skin during testing. The dynamometer
constant velocity was set as 2/s.
First, the leg was moved passively to five different
predetermined positions of flexion to inform the patients
about the angle sense. Those were 15, 30, 45, 60 and
75 of knee flexion. The angles were presented randomly.
After that, the patient was instructed to push a stop button
at the moment he or she thought the test position which was
shown in visual analog model had been reached (Fig. 2).
For both tests the amount of error, in the patients ability to
match the reference angle, was noted (in degrees). The

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429

Statistical analysis
Data were statistically analyzed using the SPSS software
for windows (version 11.5). Student t test was performed to
determine significant differences between the obtained
proprioception and also to determine the differences
between preoperative and postoperative Lysholm scores.
Statistical significance was accepted at the level of
P \ 0.05.

Results
Fig. 1 The patient lay supine on a couch with one leg supported in
the splint; a screen prevented any visual clues as to the position of the
limb

Group 1

Group 2
Trial

Trial
1

15
60

30
75

Angle

Angle
0

45
90

15
60

30
75

45
90

Fig. 2 The test angle was given in visual analog model. The patient
was instructed to push a stop button at the moment he or she thought
the test position which was shown had been reached

No cases of postoperative extra-articular or intra-articular

complications were encountered and this includes the
absence of extra-articular irritation and neurovascular
incidents.
At a mean of 2 years after the surgery, there was no
difference between the meniscectomized and healthy knee
regarding the angle deviations in the lower flexion angles
(15, 30, 45). The detailed data are given in Table 1.
However, mean KJPS at 60 reproduction in Group 1 and 2
was 64.3 (SD 5.3) and 69.2 (SD 4.9), respectively. Concomitantly mean KJPS at 75 reproduction in Group 1 and
2 was 80.1 (SD 6.59) and 74.4 (SD 5.6), respectively.
Paired t test showed that there was a statistically significant
difference between Group 1 and 2 when compared to
control angle deviations at 60 and 75 reproductions
(P \ 0.05). KJPS of the patients in meniscectomized group
was poorer than the patients in healthy knee group.

Discussion
Proprioception, is responsible for sensations of joint
movement and joint position sense, and may contribute to
functional joint stability. Unconscious proprioception is
believed to modulate muscle function and initiate reflex
stabilization [1, 12]. In addition, clinical experience

Fig. 3 The knee was moved passively toward extension by the

dynamometer at a constant velocity of 2/s. The patient was instructed
to push a stop button at the moment he or she thought the test
positions (15, 30, 45, 60 and 75) had been reached

measurement of inaccuracy was the difference between the

perceived angle and the actual angle of flexion.
During the test, patients were blindfolded (Fig. 3). Both
knees were tested three times. A total of 585 measurements
were performed. For each leg, the mean result of the three
trials was calculated and used for statistical analysis.

Table 1 Mean, standard deviation (SD) and P values of the knee

joint position sense at five different degrees of knee flexion in both
groups
Knee joint
position sense (KJPS)

Group 1

Group 2

P value

KJPS 15

14.56 4.025

15.14 4.286

0.285

KJPS 30

32.28 4.326

30.45 4.435

0.118

KJPS 45

48.56 3.995

45.62 3.834

0.104

KJPS 60

64.27 5.326

69.17 4.867

0.036

KJPS 75

80.12 6.589

74.39 5.625

0.022

Values are mean SD

Bold values indicate statistically significant

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indicates that proprioceptive skills may play a major role in

protecting the knee, especially at the extreme ranges of
movement identified by the presence of three types of
mechanoreceptors in anterior and posterior horns of the
human menisci: Ruffini endings, Pacinian corpuscles and
Golgi tendon organs [1, 11, 12].
Quick-adapting mechanoreceptors, such as the Pacinian
corpuscles, are thought to mediate the sensation of joint
motion, and slow-adapting receptors, such as the Ruffini
endings and Golgi tendon organs, are believed to mediate
the sensation of joint position [17]. The presence of these
indicate that the menisci detect proprioceptive information
in the knee joint and therefore play an important role in the
joint position sense of the knee. The neural information
coming from these mechanoreceptors possibly determines
the degree of anterior and posterior translation of the
femoral condyles on the tibial platform [18]. In this way
the contribution of the meniscus to the stability of the knee
may not only be mechanical but also be proprioceptive.
In one single study, Saygi et al. [11] addressed electrophysiological function of the medial meniscus; they
stimulated intact medial menisci of human volunteers with
a monopolar probe. They mentioned that stimulation of the
posterior horn of the medial meniscus produced measurable amounts of cerebral cortical-evoked potentials during
arthroscopy [11]. In other recent study, Akgun et al. [12]
got strong clues of the existence of medial meniscushamstring reflex arc in rabbits. This was important because
any event interfering with the mechanoreceptor mechanism
may alter the meniscus mobility and this proved the
importance of meniscus for proprioception.
Reider et al. [17] mentioned that the loss of proprioception after an ACL rupture could be due to altered knee
kinematics following disruption of the ligament. The same
was thought for a total meniscectomy. Investigations had
indicated that total meniscectomy had a significant effect
on the kinematics of the knee joint [9]. Thijs et al. prospectively analyzed knee proprioception after the meniscal
transplantation. The meniscal allograft transplantation
seems to have a significant positive effect on the joint
position sense of the previously total meniscectomized
knee [19]. According to Thijs et al. [19], changes in knee
kinematics following a total meniscectomy could lead to
possible changes in the tension on the capsular structures of
the knee joint, so that their input was disrupted.
In fact, Jerosch et al. [15] first mentioned about the
proprioception of the knee joint with an isolated meniscus
lesion. He concluded that meniscectomy had a significant
effect on knee proprioception. This may disprove the
hypothesis of Thijs et al. about the capsular tension
because some of his cases had a partial meniscectomy. But
in the study of Jerosch et al., there were some shortcomings. The proprioception test was performed without

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standardization. Some of the patients were tested before

arthroscopy and some were just after. In addition, different
parameters were used for the proprioceptive testing.
According to the studies in literature, we know that total
meniscectomy alters the knee proprioception. But there is
no consensus on what happened after a partial meniscectomy. It is known that menisci have receptors at all Cooper
zones. Red and red-white zone contains more receptors
than white zone. Therefore, even a partial meniscectomy
could alter knee proprioception.
To our knowledge, no studies have yet investigated the
long-term influence of partial medial meniscectomy at the
side of the posterior horn on the KJPS. Therefore, we
designed a study to assess the proprioception of the partial
meniscectomized knee and to assess if there is an effect on
the knee proprioception at long-term period. We believed
that joint inflammation and muscle atrophy after both
arthroscopy procedure and meniscus tear (by negative
inhibition) can alter our testing method. Hence, we performed the tests to the patients at 2-year follow-up to get
rid of those biases.
At a mean of 2 years after the surgery, there was no
difference between the meniscectomized and healthy knee
regarding the angle deviations in the lower flexion angles
(15, 30, 45). This finding seems surprising since the
proprioceptive ability of the knee joint was suggested to be
more sensitive moving into further degrees of knee
extension [20]. However, paired t test showed that there
was a statistically significant difference between the meniscectomized knee and the healthy one when compared to
control angle deviations at 60 and 75 reproductions
(P \ 0.05). KJPS of the patients in partial meniscectomized group was poorer than the patients in healthy knee
group into further degrees of flexion (60 and 75).
It seems that there is a higher tension on posterior horn
of medial meniscus at both 60 and 75 than knee extension
degrees (15, 30, 45). When the knee is in extension, it is
stable and also there is not much pressure on posterior horn
of menisci. Thus other inner structures may take the
responsibility of the proprioceptive sense other than
menisci. When the knee is in flexion, there would be more
pressure on the posterior horn of menisci because of the
relative instability. Therefore knee flexion results in a
higher firing frequency of the mechanoreceptors on
meniscus; pressure stimulates the slowly adapting Ruffini
and Golgi receptors, which boost proprioceptive awareness
[20]. This may be the cause of the decreased joint position
sense of the knee in this position because we lose some of
those receptors when we make partial meniscectomy.
A limitation of our study is the absence of the randomization at the extent of the partial meniscectomy. Some
patients had meniscectomy at white zone and the others
had at red-white zone. Consequently, it is not clear to what

Arch Orthop Trauma Surg (2010) 130:427431

extent the proprioceptive training exercises, which patients

performed during rehabilitation, contributed to the
improvement in knee proprioception.
In conclusion, the results of this study showed the
appearance of a significant deficit of knee joint proprioception after a partial meniscectomy at 2-year follow-up.
These results indicated that even a partial absence of
menisci causes a deterioration of proprioceptive functions
of the knee signifying that the osteoarthritic changes seen
after a partial meniscectomy may not be only due to biomechanical disadvantages but proprioceptive disabilities
may contribute to it. Finally, further studies are required in
order to find out whether there is any effect on the contralateral side as well.

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