THEKNE-02575; No of Pages 6

The Knee xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

The Knee

Comparative postural stability in patients with lateral meniscus versus medial

meniscus tears
Jin-Hyuck Lee a, Jae-Won Heo b, Dae-Hee Lee b,⁎
a
Department of Orthopaedic Surgery, Korea University College of Medicine, Anam Hospital, Seoul, South Korea
b
Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: Types of mechanoreceptors may differ between the medial and lateral menisci, sug-
Received 27 August 2017
gesting that postural stability may differ between patients with medial and lateral meniscus tears.
Received in revised form 15 January 2018
However, to date, postural stability has not been compared in patients with medial and lateral
Accepted 30 January 2018
Available online xxxx meniscus tears. This study used stabilometry to compare postural stability in patients with medial
and lateral meniscus tears.
Methods: Postural stability and thigh muscle strength were assessed in 24 patients with medial and
Keywords:
18 patients with lateral meniscus tears. Postural stability was determined by measuring the
Lateral
Medial
anteroposterior (APSI), mediolateral (MLSI), and overall (OSI) stability indices using stabilometry.
Meniscus tear Maximal torque (60°/s) of the quadriceps and hamstring was evaluated using an isokinetic testing
Postural stability device.
Results: The three stability indices, OSI, APSI, and MLSI, in both involved and uninvolved knees
were all significantly greater in patients with lateral than with medial meniscus tears.
(P b 0.001 for all OSI, APSI, and MLSI in both involved and uninvolved knees, except for P = 0.005
for MLSI of involved knees). In patients with medial meniscus tears, both OSI (1.4 ± 0.4 vs. 1.1 ±
0.4, P = 0.037) and MLSI (0.9 ± 0.3 vs. 0.8 ± 0.3, P = 0.041) were significantly higher on the
injured than the uninjured side. In patients with lateral meniscus tears, none of the stability indices
differed significantly between injured and uninjured knee joints.
Conclusion: Postural stability of both the injured and uninjured knee joints was poorer in patients
with lateral than with medial meniscus tears.
© 2018 Elsevier B.V. All rights reserved.

1. Introduction

The anterior and posterior horns of the meniscus contain numerous mechanoreceptors, including Ruffini endings (slow-adapting
mechanoreceptors) and Pacinian corpuscles (rapidly adapting mechanoreceptors), which provide information on the position and
motion of the joint [1,2]. Because sensory information associated with a patient's conscious perception of joint motion via mechanore-
ceptors in the meniscus may contribute to postural stability [3–6], a reduction in proprioception due to mechanoreceptor damage
resulting from meniscus tears may be associated with a reduction in postural stability.
Altered postural stability has been reported in patients with tears, repair, and/or meniscectomy of the medial meniscus (MM) alone
[7–9]. The incidence of lateral meniscus (LM) tears is comparable to that of MM tears, with several previous studies suggesting that
postural stability may differ between patients with MM and LM tears, due to differences in mechanoreceptor distribution between

⁎ Corresponding author at: Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu,
Seoul 135-710, South Korea.
E-mail addresses: eoak22@empal.com, eoak22@skku.edu (D.-H. Lee).

https://doi.org/10.1016/j.knee.2018.01.012
0968-0160/© 2018 Elsevier B.V. All rights reserved.

Please cite this article as: Lee J-H, et al, Comparative postural stability in patients with lateral meniscus versus medial meniscus
tears, Knee (2018), https://doi.org/10.1016/j.knee.2018.01.012
2 J.-H. Lee et al. / The Knee xxx (2018) xxx–xxx

the MM and LM [10–13]. However, to date, postural stability has not been directly compared in patients with MM and LM tears.
Therefore, the current study compared postural stability in patients with MM and LM tears. It was hypothesized that postural stability
would be similar in these groups of patients.

2. Materials and methods

2.1. Patient enrollment

This prospective longitudinal trial enrolled all patients scheduled to undergo meniscus repair or meniscectomy for isolated MM or
LM tears, as confirmed by magnetic resonance imaging (MRI) and physical examination. Patients with concomitant ligament tears were
excluded, to eliminate bias resulting from torn ligaments. Also excluded were patients with MM and LM tears in the same knee joint,
those with meniscus tears in both knees, prominent signs of knee osteoarthritis (Kellgren–Lawrence grade III or IV) on plain radio-
graphs, a history of previous knee injury and receipt of any rehabilitation protocol, or discoid LM tears. Patients were also excluded if
they were unable to perform the isokinetic muscle strength or postural stability tests due to pain or limited motion of the knee joint
resulting from effusion, vestibular or neurological dysfunction, or visual impairment.

2.2. Postural stability test for proprioception

Postural stability and isokinetic thigh muscle strength in all patients were assessed by a single rater blinded to the side of injury.
Postural stability tests were performed on both injured and uninjured knees using the Biodex Stability System (BSS) (Biodex Medical
Systems, Shirley, NY), with a movable balance platform that provided up to 20° of surface tilt in a 360° range of motion. This platform,
which interfaced with computer software (Biodex, Version 1.32), enabled the device to objectively assess balance. Participants were
instructed to: stand with one bare foot on the BSS locked platform; keep the other foot off the ground in a comfortable position;
keep their arms at their sides; and look straight ahead at a point on the wall approximately one meter away at eye level. As soon as
the subject was able to maintain this point, indicating that his/her location was on the center of pressure, the examiner recorded the
foot location using a coordinate system consisting of the lateral malleolus and the heel cord on the foot plate. After positioning, subjects
were instructed to maintain the same position of their feet until the end of each test. Subjects unable to maintain balance during testing
were allowed to briefly touch their toes with the opposite foot or grasp the handrails for a short time to re-establish balance as soon as
possible. If a subject was unable to quickly re-establish balance, that test was canceled. Each test consisted of two trials, starting at level
12 (most stable) and gradually decreasing to level one (least stable), with the stability level automatically declining every 1.66 s. Two
test evaluations of 20 s each were performed, with 10 s between each pair of tests.
The mean and standard deviation of the two trials were calculated by the stability system. The measures of balance and postural
stability included anteroposterior (APSI), mediolateral (MLSI), and overall stability index (OSI) scores. A lower stability index was
associated with a more stable platform, indicating greater dynamic balance or postural stability of the subject.

2.3. Assessment of isokinetic strength

Isokinetic knee extension/flexion (concentric/concentric muscle contraction) strength was measured with each subject seated on a
Biodex multi-joint system 4 (Biodex Medical Systems) with his/her trunk perpendicular to the floor, and hips and knees flexed to 90°. A
strap was used to immobilize each subject's thigh, and the dynamometer attachment was aligned to the lateral malleolus of the lower
leg of the knee being tested. Before each test session, each individual performed a set of five warm-up submaximal knee flexions and
extensions of each leg at 60°/s. Each test session consisted of five isokinetic knee extensions and flexions (range of motion, 80–0°) of
each leg at 60°/s, with a rest time of 30 s between tests. Peak flexion and extension torques were recorded (N·m/kg). Extensor strength
was regarded as quadriceps strength, and flexor strength was regarded as hamstring muscle strength. The mean value of two trials was
regarded as the maximal peak torque of the hamstring and quadriceps.

2.4. Statistical analysis

Based on a previous study for postural stability in patients with knee joint injuries [14], an OSI difference N 0.5 between groups with
MM and LM tears was regarded as clinically important. A priori power analysis was performed to determine sample size, using a
two-sided hypothesis test at an alpha level of 0.05 and a power of 0.8. The results of a pilot study involving five knees in each group
indicated that 15 knees would be required to detect a significant between-group difference in OSI N0.5, which was the primary outcome
measure. The overall power of this study for detecting a significant between-group difference in OSI was 0.932.
To quantify the test–retest reliability of isokinetic strength and postural stability, intraclass correlation coefficients (ICCs) were
calculated for two trials of maximal peak torques of the quadriceps and hamstring. ICCs were also calculated for two measurements
of each stability index. ICC values N0.75, between 0.4–0.75, and b 0.4 were regarded as representing good, fair, and poor reliability/
accuracy, respectively.
The mean values of stability indices, the strength of the hamstring and quadriceps muscles, and their ratio were compared between
the MM and LM tear groups, and on the uninvolved and involved sides, using Student's t-tests. A P-value b0.05 was regarded as statis-
tically significant. Data were analyzed using SPSS software version 12 (SPSS Inc., Chicago, IL, USA).

Please cite this article as: Lee J-H, et al, Comparative postural stability in patients with lateral meniscus versus medial meniscus
tears, Knee (2018), https://doi.org/10.1016/j.knee.2018.01.012
 J.-H. Lee et al. / The Knee xxx (2018) xxx–xxx 3

Table 1
Demographic characteristics of subjects in the medial and lateral meniscus tear groups.

MM tear LM tear P

Sample size (number) 24 20

Gender (male/female) 17/7 14/6
Age (years)a 32.6 ± 11.9 33.6 ± 11.9 0.783
Height (cm)a 172.7 ± 8.0 172.4 ± 8.0 0.922
Weight (kg)a 70.3 ± 11.1 74.8 ± 12.7 0.228
Body mass index (kg/m2)a 23.5 ± 3.0 25 ± 3.5 0.127
Time interval from injury to stability measurement (months) 4.1 ± 3.1 3.7 ± 2.9 0.125

MM, medial meniscus; LM, lateral meniscus.

a
Values expressed as mean ± standard deviation.

3. Results

Of the 53 patients (53 knees) who were approached, 50 agreed to take part in the study. After assessments for eligibility, 44 patients,
24 with MM and 20 with LM tears, were enrolled. Baseline demographic characteristics and time intervals from injury to measurement
of postural stability were similar in the two groups (Table 1). In all subjects, the test–retest reliabilities of isokinetic peak torque were
acceptable for the quadriceps (ICC = 0.82) and hamstring (ICC = 0.79) muscles. The test–retest reliabilities for postural stability were
also good for OSI (ICC = 0.77), APSI (ICC = 0.83), and MLSI (ICC = 0.81). All three stability indices of both involved and uninvolved
knees were significantly higher in patients with LM than with MM tears (Table 2), indicating that postural stability of both injured
and uninjured knees was lower in patients with LM than with MM tears.
The two groups showed similar isokinetic maximal peak torques in the quadriceps and hamstring muscles at 60°/s on both the in-
volved and uninvolved sides, as well as similar hamstring to quadriceps ratios on both sides (Table 3). Muscle strength of the quadriceps
and hamstring muscles did not correlate with OSI, APSI, or MLSI on either injured or uninjured knees of patients with LM and MM tears
(Table 4).
In the MM tear group, both OSI (1.4 ± 0.4 vs. 1.1 ± 0.4, P = 0.037) and MLSI (0.9 ± 0.3 vs. 0.8 ± 0.3, P = 0.041) were significantly
higher on the injured than on the uninjured side, whereas their APSIs were similar on the two sides (0.9 ± 0.3 vs. 0.9 ± 0.3, P = 0.570).
In contrast, OSI, APSI, and MLSI on the injured and uninjured knee joints did not differ significantly in the LM tear group (Figure 1).

4. Discussion

This study directly compared postural stability in patients with MM and LM tears. The most important finding was that postural
instability of both the injured and uninjured knee joints was more severe after LM than after MM tears. Although the reason for this
difference is unclear, it may be explained by the distribution of mechanoreceptors around the MM and LM. Animal studies showed
the presence of mechanoreceptors within the meniscus of cat and dog knee joints [15,16], with Ruffini corpuscles (type I mechanore-
ceptors) located mainly in the posterior horn of the MM, and Pacinian corpuscles (type II mechanoreceptors) located mainly near blood
vessels at the posterior horn of the LM [17]. Mechanoreceptors were also detected in the peri-meniscal connective tissue of human knee
joints [1,18]. An assessment in 23 fresh cadaveric human knees found that Pacinian corpuscles were detected only in the LM, not in the
MM [19]. Pacinian corpuscles adapt rapidly to changes in dynamic joint motion, whereas Ruffini corpuscles respond slowly to changes
in static joint position and intraarticular joint pressure [20]. Postural stability is more dependent on input of information from rapidly
adapting mechanoreceptors like Pacinian corpuscles than from slowly adapting mechanoreceptors like Ruffini corpuscles [6]. Therefore,
the poorer postural stability observed following LM tears, not MM tears, may have been due to greater predominance of Pacinian cor-
puscles in the LM than in the MM, as damage to Pacinian corpuscles is likely greater in LM than MM tears. The poorer postural stability
observed after LM tears may have also been due to differences in anatomical structures adjacent to the LM and MM. Excursion of the LM
is greater than excursion of the MM, due to reduced peripheral capsular attachment around the popliteal hiatus of the LM [21]. There-
fore, LM instability due to LM tears may be greater than MM instability due to MM tears. This, in turn, may result in a greater decrement
in postural stability following LM than MM tears. Furthermore, the LM contains a characteristic anatomical structure usually absent
from the MM. This structure, the meniscofemoral ligament, connects the posterior horn of the LM with the intercondylar notch of

Table 2
Parameters of postural stability in patients with medial and lateral meniscus tear.

MM tear LM tear P

OSI involved 1.39 ± 0.42 2.11 ± 0.59 b0.001

OSI uninvolved 1.13 ± 0.35 2.16 ± 0.73 b0.001
APSI involved 0.88 ± 0.30 1.55 ± 0.46 b0.001
APSI uninvolved 0.91 ± 0.25 1.83 ± 0.48 b0.001
MLSI involved 0.90 ± 0.31 1.19 ± 0.34 0.005
MLSI uninvolved 0.82 ± 0.28 1.36 ± 0.51 b0.001

MM, medial meniscus; LM, lateral meniscus; OSI, overall stability index; APSI, anteroposterior stability index; MLSI, mediolateral stability index.

Please cite this article as: Lee J-H, et al, Comparative postural stability in patients with lateral meniscus versus medial meniscus
tears, Knee (2018), https://doi.org/10.1016/j.knee.2018.01.012
4 J.-H. Lee et al. / The Knee xxx (2018) xxx–xxx

Table 3
Muscle strength (isokinetic peak torque of the quadriceps [Q] and hamstring [H] muscles at 60°/s) and HQ ratio in the medial and lateral meniscus tear groups.

MM tear LM tear P

Quadriceps 60 (uninvolved, N·m) 202.3 ± 47.3 190.3 ± 28.2 0.346

Quadriceps 60 (involved, N·m) 151.6 ± 53.4 136.5 ± 39.2 0.320
Hamstring 60 (uninvolved, N·m) 103.1 ± 24.1 96.8 ± 26.4 0.428
Hamstring 60 (involved, N·m) 78.0 ± 22.6 69.8 ± 15.9 0.199
HQ ratio (uninvolved, %) 53.1 ± 16.5 50.8 ± 10.4 0.592
HQ ratio (involved, %) 55.3 ± 16.3 53.7 ± 14.7 0.746

Muscle strength was calculated as isokinetic peak torque of the quadriceps and hamstring muscles at 60°/s.
MM, medial meniscus; LM, lateral meniscus; H, hamstring; Q, quadriceps.

the femur and runs in front of (anterior meniscofemoral ligament) or behind (posterior meniscofemoral ligament) the posterior cruci-
ate ligament [22,23]. Because the meniscofemoral ligaments are better developed in animals with a greater degree of knee rotation [24],
this ligament may function during rotation of the knee joint. In addition, Pacinian corpuscles, which are rapid mechanoreceptors that
sense joint motion and are mainly located in the LM posterior horn, have also been detected at the area of insertion of the
meniscofemoral ligament into the LM posterior horn [25]. Thus, LM tears that damage the meniscofemoral ligament may result in
more severe postural instability, resulting from a mechanical disadvantage due to injury to the meniscofemoral ligament itself and
from mechanoreceptor damage within the meniscofemoral ligament.
The results of this study also showed that postural stability was decreased not only on the injured but the uninjured knee joints in
patients with LM tear, resulting in similar stability indices on both sides. This phenomenon may be due to the bilateral postural impair-
ment of proprioception, in that aberrant afferent information in the intra-articular receptors of one limb may also affect proprioception
in the contralateral limb [26]. However, in the MM tear group, the OSI and MLSI, but not APSI, were better on the uninjured than on the
injured side, indicating that postural stability on the uninjured side did not decrease as much as that on the injured side in patients with
MM than LM tears. These findings suggest that bilateral impairment of proprioception tended to be more severe in patients with LM
than with MM tears. Therefore, especially in patients with LM tears, postoperative rehabilitation to improve postural stability should
include both the uninjured and injured sides.
To measure postural stability, the current study used stabilometry of BSS. The traditional method of measuring postural stability was
the use of a fixed force platform, with or without a certain degree of tilting. However, this tool did not reflect dynamic conditions during
real activities of daily living because there was no motion of the platform, such that the test conditions were relatively static. Further-
more, the results obtained using a fixed platform have varied widely, preventing comparisons among studies. BSS stabilometry uses a
multiaxial motion platform that can measure an individual's ability to maintain postural stability under dynamic stress conditions. In
addition, this system can objectively quantify the results by calculation of stability indices. These indices have already been validated
with high reliability, thus facilitating comparisons of results with previous studies [27,28].
Several limitations should be considered when interpreting the results of the current study. Measuring postural stability may not be
adequate for determining changes in proprioception. Other tests are more frequently used to measure proprioception, including
determining the threshold of passive motion for detecting knee joint movement, and passive or active positioning of the knee joint
for measuring knee joint position sense [29]. However, previous studies have evaluated postural stability using stabilometry, which
measures changes in proprioception in patients with ligament or meniscus tears [6,9,30]. The decrease in proprioception due to mech-
anoreceptor damage by ligament or meniscus tears may be associated with a reduction in postural stability.
Another limitation was the inability to ensure that the difference in postural stability between the MM and LM tear groups resulted
only from damage to mechanoreceptors in the meniscus. Mechanoreceptors can also be located in muscle spindles and knee joint
capsules other than the meniscus [31]. Thigh muscle strength may also affect postural stability [32,33], although the current study
found no significant differences in peak torques of the quadriceps and hamstring muscles, nor in their ratio (the HQ ratio) between
the MM and LM tear groups. The current study also showed no association between muscle strength and postural stability on both

Table 4
Correlations between muscle strength and postural stability of MM and LM tear patients on both the injured and uninjured sides.

Quadriceps (involved) Hamstring (involved)

r P r P

OSI (involved) 0.056 0.724 0.030 0.849

APSI (involved) 0.014 0.930 0.041 0.794
MLSI (involved) 0.036 0.822 0.084 0.596

Quadriceps (uninvolved) Hamstring (uninvolved)

r P r P

OSI (uninvolved) 0.024 0.878 0.202 0.199

APSI (uninvolved) 0.048 0.765 0.216 0.170
MLSI (uninvolved) 0.022 0.889 0.147 0.351

r, Pearson's correlation coefficient; OSI, overall stability index; APSI, anteroposterior stability index; MLSI, mediolateral stability index.

Please cite this article as: Lee J-H, et al, Comparative postural stability in patients with lateral meniscus versus medial meniscus
tears, Knee (2018), https://doi.org/10.1016/j.knee.2018.01.012
 J.-H. Lee et al. / The Knee xxx (2018) xxx–xxx 5

Figure 1. Stability indices on the involved and uninvolved sides in patients with medial and lateral meniscus tears: A. overall stability index (OSI); B. anteroposterior
stability index (APSI); C. mediolateral stability index (MLSI) (*P b 0.05).

the injured and uninjured sides of meniscus tear patients. Because subjects kept their eyes open, they could visually compensate for
reduced postural stability. However, the control screen of the dynamometer was covered, eliminating visual feedback regarding
their performance during postural stability tests. Finally, the current study could not entirely exclude the influence on postural stability
of differences in the size, location, and type of meniscal tears, because the red and red–white zones of the meniscus contain more than
the white zones [9].

5. Conclusions

In conclusion, postural stability was poorer in patients with LM tears than in those with MM tears, not only for injured but also
for uninjured knee joints. These findings indicate the importance of postoperative rehabilitation for improving postural stability
on both the injured and uninjured sides, particularly in patients with LM tears.

Please cite this article as: Lee J-H, et al, Comparative postural stability in patients with lateral meniscus versus medial meniscus
tears, Knee (2018), https://doi.org/10.1016/j.knee.2018.01.012
6 J.-H. Lee et al. / The Knee xxx (2018) xxx–xxx

Acknowledgments

This study was supported by SMC-Ottogi Research Fund (SMX1162171)

Conflict of interest statement

The authors have no conflicts of interest to disclose.

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Please cite this article as: Lee J-H, et al, Comparative postural stability in patients with lateral meniscus versus medial meniscus
tears, Knee (2018), https://doi.org/10.1016/j.knee.2018.01.012