Common Mistakes in Meniscal Injury

Abstract

The menisci are essential for knee joint stability and function. Magnetic resonance imaging (MRI) has proven to be an invaluable tool for evaluating a wide range of meniscal injuries, yet various injury patterns are underdiagnosed or misdiagnosed, potentially leading to persistent clinical symptoms and early joint degeneration. Additionally, these pathologies may be difficult to recognize both clinically and during arthroscopy.

This review highlights commonly missed diagnoses, arranged in descending order of how frequently they are misinterpreted in routine practice: medial meniscocapsular junction tears, posterior root tears of the lateral meniscus, posterior horn tears of the lateral meniscus, lateral meniscocapsular junction tears, and posterior root tears of the medial meniscus. We also delve into relevant anatomy, normal MRI appearances, injury findings and patterns, differential diagnoses, and tips for image interpretation. By understanding these commonly missed injuries and using a targeted search strategy, radiologists can enhance diagnostic accuracy and improve patient care.

Keywords

meniscocapsular junction tears - ramp lesion - posterior root tear - meniscus - magnetic resonance imaging interpretation

Publication History

Article published online:
07 October 2025

• References

• 1 Crawford MD, Hellwinkel JE, Aman Z. et al. Microvascular anatomy and intrinsic gene expression of menisci from young adults. Am J Sports Med 2020; 48 (13) 3147-3153
• 2 Cooper DE, Arnoczky SP, Warren RF. Meniscal repair. Clin Sports Med 1991; 10 (03) 529-548
• 3 Sayegh ET, Matzkin E. Classifications in brief: The International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine classification of meniscal tears. Clin Orthop Relat Res 2022; 480 (01) 39-44
• 4 Sharif B, Ashraf T, Saifuddin A. Magnetic resonance imaging of the meniscal roots. Skeletal Radiol 2020; 49 (05) 661-676
• 5 Tomsan H, Gorbachova T, Fritz RC. et al. Knee MRI: meniscus roots, ramps, repairs, and repercussions. Radiographics 2023; 43 (07) e220208
• 6 Griffith JF. Five overlooked injuries on knee MRI. AJR Am J Roentgenol 2021; 217 (05) 1165-1174
• 7 Cavaignac E, Sylvie R, Teulières M. et al. What is the relationship between the distal semimembranosus tendon and the medial meniscus? A gross and microscopic analysis from the SANTI study group. Am J Sports Med 2021; 49 (02) 459-466
• 8 DePhillipo NN, Moatshe G, Chahla J. et al. Quantitative and qualitative assessment of the posterior medial meniscus anatomy: defining meniscal ramp lesions. Am J Sports Med 2019; 47 (02) 372-378
• 9 Mouton C, Magosch A, Pape D, Hoffmann A, Nührenbörger C, Seil R. Ramp lesions of the medial meniscus are associated with a higher grade of dynamic rotatory laxity in ACL-injured patients in comparison to patients with an isolated injury. Knee Surg Sports Traumatol Arthrosc 2020; 28 (04) 1023-1028
• 10 LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am 2007; 89 (09) 2000-2010
• 11 Thaunat M, Ingale P, Penet A. et al. Ramp lesion subtypes: prevalence, imaging, and arthroscopic findings in 2156 anterior cruciate ligament reconstructions. Am J Sports Med 2021; 49 (07) 1813-1821
• 12 Seil R, Mouton C, Coquay J. et al. Ramp lesions associated with ACL injuries are more likely to be present in contact injuries and complete ACL tears. Knee Surg Sports Traumatol Arthrosc 2018; 26 (04) 1080-1085
• 13 Sonnery-Cottet B, Praz C, Rosenstiel N. et al. Epidemiological evaluation of meniscal ramp lesions in 3214 anterior cruciate ligament-injured knees from the SANTI study group database: a risk factor analysis and study of secondary meniscectomy rates following 769 ramp repairs. Am J Sports Med 2018; 46 (13) 3189-3197
• 14 Brophy RH, Steinmetz RG, Smith MV, Matava MJ. Meniscal ramp lesions: anatomy, epidemiology, diagnosis, and treatment. J Am Acad Orthop Surg 2022; 30 (06) 255-262
• 15 Lambrey PJ, Fayard JM, Graveleau N. et al; Francophone Society of Arthroscopy ACL Registry Study Group. Risk factors and prevalence of ramp lesions in ACL ruptures: an analysis from the registry of the Francophone Arthroscopic Society. Knee Surg Sports Traumatol Arthrosc 2024; 32 (07) 1700-1709
• 16 Vieira TD, Pioger C, Frank F. et al. Arthroscopic dissection of the distal semimembranosus tendon: an anatomical perspective on posteromedial instability and ramp lesions. Arthrosc Tech 2019; 8 (09) e987-e991
• 17 Thaunat M, Fayard JM, Guimaraes TM, Jan N, Murphy CG, Sonnery-Cottet B. Classification and surgical repair of ramp lesions of the medial meniscus. Arthrosc Tech 2016; 5 (04) e871-e875
• 18 Allende F, Berreta RS, Allahabadi S. et al. Meniscal ramp lesion classification systems: a systematic review. Knee Surg Sports Traumatol Arthrosc 2024; 32 (07) 1710-1724
• 19 Greif DN, Baraga MG, Rizzo MG. et al. MRI appearance of the different meniscal ramp lesion types, with clinical and arthroscopic correlation. Skeletal Radiol 2020; 49 (05) 677-689
• 20 Koo B, Lee SH, Yun SJ, Song JG. Diagnostic performance of magnetic resonance imaging for detecting meniscal ramp lesions in patients with anterior cruciate ligament tears: a systematic review and meta-analysis. Am J Sports Med 2020; 48 (08) 2051-2059
• 21 D'Ambrosi R, Meena A, Raj A. et al. Good results after treatment of RAMP lesions in association with ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31 (01) 358-371
• 22 Albayrak K, Buyukkuscu MO, Kurk MB, Kaya O, Kulduk A, Misir A. Leaving the stable ramp lesion unrepaired does not negatively affect clinical and functional outcomes as well as return to sports rates after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29 (11) 3773-3781
• 23 Li S, Qin Y, Wang H. et al. Repair of ramp lesions of the medial meniscus with ACL reconstruction can better restore knee stability: a cadaveric study. Orthop J Sports Med 2023; 11 (04) 23 259671221140120
• 24 Siboni R, Pioger C, Jacquet C. et al. Meniscal ramp repair: a 2-portal posteromedial approach. Arthrosc Tech 2022; 11 (07) e1163-e1169
• 25 Robinson JR, Sanchez-Ballester J, Bull AM, Thomas RdeW, Amis AA. The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Joint Surg Br 2004; 86 (05) 674-681
• 26 Stevens KJ, Albtoush OM, Lutz AM. The Stieda fracture revisited. Skeletal Radiol 2021; 50 (05) 945-953
• 27 Lundquist RB, Matcuk Jr GR, Schein AJ. et al. Posteromedial corner of the knee: the neglected corner. Radiographics 2015; 35 (04) 1123-1137
• 28 Wang P, Zhang CZ, Zhang D. et al. The imaging features of the meniscal roots on isotropic 3D MRI in young asymptomatic volunteers. Medicine (Baltimore) 2018; 97 (18) e0624
• 29 Krych AJ, Wu IT, Desai VS. et al. High rate of missed lateral meniscus posterior root tears on preoperative magnetic resonance imaging. Orthop J Sports Med 2018; 6 (04) 2325967118765722
• 30 Karpinski K, Forkel P, Häner M, Bierke S, Petersen W. Etiology of posterior meniscus root tears: medial vs. lateral. Arch Orthop Trauma Surg 2023; 143 (01) 429-437
• 31 LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med 2015; 43 (02) 363-369
• 32 Asai K, Nakase J, Oshima T, Shimozaki K, Toyooka K, Tsuchiya H. Lateral meniscus posterior root tear in anterior cruciate ligament injury can be detected using MRI-specific signs in combination but not individually. Knee Surg Sports Traumatol Arthrosc 2020; 28 (10) 3094-3100
• 33 Berthold DP, Muench LN, Herbst E. et al. High prevalence of a deep lateral femoral notch sign in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus. Knee Surg Sports Traumatol Arthrosc 2021; 29 (04) 1018-1024
• 34 Lee DR, Reinholz AK, Till SE. et al. Current reviews in musculoskeletal medicine: current controversies for treatment of meniscus root tears. Curr Rev Musculoskelet Med 2022; 15 (04) 231-243
• 35 LaPrade RF, Ho CP, James E, Crespo B, LaPrade CM, Matheny LM. Diagnostic accuracy of 3.0 T magnetic resonance imaging for the detection of meniscus posterior root pathology. Knee Surg Sports Traumatol Arthrosc 2015; 23 (01) 152-157
• 36 Banovetz MT, Roethke LC, Rodriguez AN, LaPrade RF. Meniscal root tears: a decade of research on their relevant anatomy, biomechanics, diagnosis, and treatment. Arch Bone Jt Surg 2022; 10 (05) 366-380
• 37 Shumborski SJ, Salmon LJ, Monk CI, Pinczewski LA. Stable lateral meniscal posterior root tears left in situ at time of anterior cruciate ligament reconstruction are of minimal long-term clinical detriment. Arthroscopy 2021; 37 (12) 3500-3506
• 38 Khoo JR, Yau WP. Repair of meniscus root tear—is there a difference between medial meniscus root repair and lateral meniscus root repair? A systematic review and meta-analysis. J Orthop Surg (Hong Kong) 2023; 31 (02) 10 225536231175233
• 39 Park LS, Jacobson JA, Jamadar DA, Caoili E, Kalume-Brigido M, Wojtys E. Posterior horn lateral meniscal tears simulating meniscofemoral ligament attachment in the setting of ACL tear: MRI findings. Skeletal Radiol 2007; 36 (05) 399-403
• 40 Savoye PY, Ravey JN, Dubois C. et al. Magnetic resonance diagnosis of posterior horn tears of the lateral meniscus using a thin axial plane: the zip sign–a preliminary study. Eur Radiol 2011; 21 (01) 151-159
• 41 Krych AJ, LaPrade MD, Cook CS. et al. Lateral meniscal oblique radial tears are common with ACL injury: a classification system based on arthroscopic tear patterns in 600 consecutive patients. Orthop J Sports Med 2020; 8 (05) 2325967120921737
• 42 Jeon YS, Alsomali K, Yang SW, Lee OJ, Kang B, Wang JH. Posterior horn lateral meniscal oblique radial tear in acute anterior cruciate ligament reconstruction incidence and outcomes after all-inside repair: clinical and second-look arthroscopic evaluation. Am J Sports Med 2022; 50 (14) 3796-3804
• 43 Aman ZS, DePhillipo NN, Storaci HW. et al. Quantitative and qualitative assessment of posterolateral meniscal anatomy: defining the popliteal hiatus, popliteomeniscal fascicles, and the lateral meniscotibial ligament. Am J Sports Med 2019; 47 (08) 1797-1803
• 44 Peduto AJ, Nguyen A, Trudell DJ, Resnick DL. Popliteomeniscal fascicles: anatomic considerations using MR arthrography in cadavers. AJR Am J Roentgenol 2008; 190 (02) 442-448
• 45 Masferrer-Pino A, Saenz-Navarro I, Rojas G. et al. The menisco-tibio-popliteus-fibular complex: anatomic description of the structures that could avoid lateral meniscal extrusion. Arthroscopy 2020; 36 (07) 1917-1925
• 46 Toyooka S, Shimazaki N, Masuda H. et al. Preoperative magnetic resonance imaging as a diagnostic aid for hypermobile lateral meniscus. Diagnostics (Basel) 2021; 11 (12) 2276
• 47 Suganuma J, Mochizuki R, Inoue Y, Yamabe E, Ueda Y, Kanauchi T. Magnetic resonance imaging and arthroscopic findings of the popliteomeniscal fascicles with and without recurrent subluxation of the lateral meniscus. Arthroscopy 2012; 28 (04) 507-516
• 48 Nair R, Dubey N. MR imaging of the hypermobile lateral meniscus of the knee: a case report. Acta Med Acad 2019; 48 (02) 225-229
• 49 Heaton DJ, Collins MS, Johnson AC, Krych AJ, Dancy ME, Tiegs-Heiden CA. Retrospective evaluation of MRI findings in arthroscopically confirmed cases of hypermobile lateral meniscus. Skeletal Radiol 2024; 53 (03) 465-472
• 50 Dancy ME, Tagliero AJ, Till SE. et al. Surgical repair of hypermobile lateral meniscus secondary to popliteomeniscal fascicle tears improves pain and mechanical symptoms. Arthrosc Sports Med Rehabil 2023; 5 (06) 100802
• 51 Moon HS, Choi CH, Jung M. et al. Medial meniscus posterior root tear: how far have we come and what remains?. Medicina (Kaunas) 2023; 59 (07) 1181
• 52 Kaiser JT, Damodar D, Udine MJ. et al. Meniscal extrusion: a critical analysis review. jBJS Rev 2022; 10 (07)
• 53 Kaneko S, Hashimoto S, Honda A. et al. The usefulness of posterior shiny corner lesions in the early diagnosis of medial meniscus posterior root tears. Cureus 2024; 16 (05) e60605
• 54 Krych AJ, Bernard CD, Kennedy NI. et al. Medial versus lateral meniscus root tears: is there a difference in injury presentation, treatment decisions, and surgical repair outcomes?. Arthroscopy 2020; 36 (04) 1135-1141
• 55 Hwang BY, Kim SJ, Lee SW. et al. Risk factors for medial meniscus posterior root tear. Am J Sports Med 2012; 40 (07) 1606-1610
• 56 Wang J, Peng K, Gu J, Gao S. A larger radius of the medial femoral posterior condyle is a risk factor for medial meniscus posterior root tears. BMC Musculoskelet Disord 2024; 25 (01) 616
• 57 Krych AJ, LaPrade MD, Hevesi M. et al. Investigating the chronology of meniscus root tears: do medial meniscus posterior root tears cause extrusion or the other way around?. Orthop J Sports Med 2020; 8 (11) 2325967120961368
• 58 Bernard CD, McGauvran AM, Desai VS. et al. Understanding the implications of the meniscal ossicle: patient presentation, treatment, and outcomes. J Knee Surg 2021; 34 (02) 155-163
• 59 Perry AK, Lavoie-Gagne O, Knapik DM. et al. Examining the efficacy of medial meniscus posterior root repair: a meta-analysis and systematic review of biomechanical and clinical outcomes. Am J Sports Med 2023; 51 (07) 1914-1926
• 60 Moore M, Levitt S, Lin CC. et al. Clinical outcomes following transtibial medial meniscal root repair are maintained at long-term follow-up. Knee Surg Sports Traumatol Arthrosc 2024; 32 (11) 2959-2966