ANATOMY AND BIOMECHANICS OF
THE MENISCUS
ANSWORTH A. ALLEN, MD, GEORGE L. CALDWELL, JR, MD, and
FREDDIE H. FU, MD
The menisci appear at approximately the 8th to 10th week of fetal development. They are discernible in the
adult knee joint as crescent-shaped fibrocartilagenous wedges between the femoral and tibial condyles. Their
unique design, structure, composition, and anatomic attachments allow the menisci to play an integral role in
normal knee joint function. The primary biomechanical function of the meniscus is load transmission. Other
functions include shock absorption, joint stability and congruity, and joint lubrication and nutrition.
KEY WORDS: menisci, fibrocartilagenous structure, composition, anatomic, biomechanical, load
transmission
Our understanding of the meniscus has evolved significantly during this century Initially regarded as functionless remains of leg muscle, 1 the meniscus is now recognized as an important component of the functional
anatomy and biomechanics of the knee joint. Meniscal
injury is one of the more common injuries sustained by
athletes. 2 Although Fairbanks 3 noted changes in the
joints consistent with degenerative arthritis after total
meniscectomy, this relationship was not clearly appreciated, and it was not until the mid-1960s that the wisdom
of total meniscectomy was questioned. 4
As recently as 1971, Smillie s advocated total meniscectomy during anterior arthrotomy if damage to the posterior horn of the meniscus was even suspected. Over the
past two decades, tremendous strides have been made in
our understanding of the basic anatomy and biomechanics of the meniscus. It is now recognized that total meniscectomy is not a benign procedure. The surgical philosophy today is to preserve as much of the healthy meniscus as possible and to repair the meniscus w h e n
feasible. Meniscal replacement with allograft tissue is
also possible. 6-s This article reviews the anatomy and
biomechanics of the meniscus.
ANATOMY
Embryology
The menisci are discernible as distinct structures between
the 8th and 10th week of fetal development. 9 They arise
from a condensation of the intermediate layer of mesenFrom the Hospital for Special Surgery, New York; the Department
of Orthopaedics, Cornell Medical College, New York, NY; the Cleveland Clinic, Fort Lauderdale, FL; Department of Orthopaedic Surgery, Blue Cross of Western Pennsylvania, Pittsburgh; and the Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA.
Address reprint requests to Freddie H. Fu, MD, Blue Cross of Western Pennsylvania, Universityof Pittsburgh, Craig Ave and Baum Blvd,
Pittsburgh, PA 15213.
Copyright © 1995 by W. B. Saunders Company
1048-6666/95/0501-0002505.00/0
2
chymal tissue and form attachments to the surrounding
joint capsule and the cruciate ligaments. 10 The developing menisci are highly cellular and vascular. There is a
gradual decrease in the cellularity of the meniscus with a
concomitant increase in the collagen content, and the
blood vessels retract to the outer region of the meniscus. 11 This transition occurs from the prenatal to the
postnatal stages of development. These histological
changes seem to be a reflection of the meniscal response
to joint motion and the stress of weight bearing. These
changes are most significant between 1 to 3 years of age,
when a child becomes ambulatory. 11
FUNCTIONAL ANATOMY
Although the menisci are distinct structures, they act as a
functional extension of the tibial plateau to increase the
relative depth of the tibial articular surface.12-15 The menisci are located on the peripheral rim of the tibial
condyles, from which they extend into the middle of the
joint. They are triangular in cross-section, with a
thicker, more convex region peripherally that tapers into
a thin, free edge centrally (Figs 1 and 2). 16
The proximal meniscal surfaces articulate with the femoral condyles. They are concave to accommodate the
convexity of the femoral condyles. The inferior or distal
surface is flat and articulates with the convex tibial
condyle laterally and the concave tibial condyle medially
to form the meniscotibial socket. This socket may contribute to the stability of the knee joint, Although the
medial and lateral menisci are histologically similar, they
are unique structures with different shapes, sizes, and
attachments.
Medial Meniscus
The medial meniscus is more frequently injured than the
lateral meniscus. This is a reflection of its functional
anatomy and its relationship to the surrounding structures in the joint. It is semilunar in shape and is approx-
Operative Techniques in Orthopaedics, Vol 5, No 1 (January), 1995: pp 2-9
gament
.~ral
3iscus
Posterior cruciate ligament
Fig 1. Drawing of the tibial plateau showing the shape and
attachments of the medial and lateral menisci. The transverse ligament and the cruciate ligaments are also shown.
(Reprinted with permission, is)
Fig 2. Photograph of a frontal section through the medial
compartment of a human knee. The meniscal articulation
with the femoral and tibial condyles is shown. The triangular
cross-section of the meniscus is also shown (arrow). (Reprinted with permission, is)
imately 3.5-cm long w h e n measured in the anteriorposterior direction. It is significantly broader posteriorly
and becomes progressively more narrow as the anterior
horn is approached. Ferrer-Roca and Vilalta 17 measured
the width of the meniscus along the radius of the tibial
plateau and showed that the width of the posterior horn
averaged 10.6 mm at its widest point. The midpoint averaged 9.6 mm, and the anterior horn averaged 7.7 m m .
The anterior horn attachment of the medial meniscus is
in the front of the anterior cruciate ligament in the region
of the anterior intercondylar fossa, whereas the posterior
horn attaches to the posterior intercondylar fossa anteromedial to the posterior cruciate ligament. Johnson
et al is recently re-examined the tibial insertion sites of the
menisci a n d their topographical relationships to surrounding anatomical landmarks in the knee. They
found that the anterior- and posterior-horn insertion sites
of the medial meniscus were larger than those of the lateral meniscus. The area of the anterior-horn insertion
site of the medial meniscus was the largest overall and
ANATOMY AND BIOMECHANICS OF THE MENISCUS
measured 1.12 cm 2, whereas that of the posterior horn
was 0.68 cm 2. It was also apparent that the medial meniscai horns were not as close to the anterior cruciate
ligaments as previously thought (Fig 3).
The transverse ligament is a fibrous band of tissue that
connects the anterior horn of the medial meniscus to the
anterior horn of the lateral meniscus (Fig 1). The medial
meniscus is attached through its periphery to the joint
capsule. The deep medial collateral ligament represents
a distinct thickening of the joint capsule. It is attached
to the midportion of the meniscus. The coronary ligament is the inferior portion of the capsule that attaches
the meniscus to the tibial plateau. There is decreased
mobility of the medial meniscus secondary to its capsular
and bony attachments. 19
Lateral Meniscus
The lateral meniscus is almost circular, with the anterior
and posterior horns in relatively close proximity. It has
a more uniform width than the medial meniscus and occupies a larger portion of the tibial articular surface. 12
Ferrer-Roca and Vilalta 17 also showed that the lateral meniscus is 10.6-mm wide at the posterior horn, 11.6 m m at
its midpoint, and 10.2 at the anterior horn. The area of
the anterior horn is 0.76 cm 2, whereas that of the posterior horn is 0.94 cm2.18
The meniscal horns are in close proximity to the anterior cruciate ligament. The anterior horn of the lateral
meniscus is adjacent and parallel to the anterior half of
the anterior cruciate ligament tibial insertion site. The
posterior horn of the lateral meniscus inserts slightly
more medially at the posterior border of the anterior cruciate ligament tibial insertion site. 18
The lateral meniscus is loosely attached to the joint
capsule throughout its periphery, except at the popliteal
hiatus. 2° The posterior convexity of the lateral meniscus
Fig 3. Schematic drawing of an axial view of a right tibial
plateau showing sections of the meniscus and their relationship to the cruciate ligaments. AL, anterior insertion of the
lateral meniscus; PL, posterior insertion of lateral meniscus;
AM, anterior insertion of the medial meniscus; PM, posterior
of medial meniscus.
3
receives an aponeurotic extension from the popliteus
muscle, 21"22 as the popliteus tendon grooves the meniscus. A portion of the arcuate ligament is also attached to
the upper portion of the posterior convexity of the meniscus. The posterior meniscofemoral ligament (ligament of Wrisberg) extends from the posterior horn of the
lateral meniscus to the medial femoral condyle.
There is increased excursion of the lateral meniscus 19'22
during knee motion compared with the medial meniscus.
This occurs because of the lack of a rigid circumferential
attachment and the dynamic contributions from the meniscofemoral ligaments and the popliteus muscle.
Meniscofemoral Ligaments
The meniscofemoral ligaments consist of the anterior ligament, Humphrey's ligament, and the posterior ligament
of Wrisberg (Fig 4). They are accessory knee ligaments
that attach to the medial femoral condyle in the region of
the posterior cruciate ligament. The presence and size
of the meniscofemoral ligaments are variable. Heller
and Langman 23 reported meniscofemoral ligaments in
71% of the knees they dissected; however, their reported
presence has varied, ranging up to 100%.
The posterior meniscofemoral ligament (ligament of
Wrisberg) arises from the posterior horn of the lateral
meniscus, posterior tibia, or posterior capsule and crosses
obliquely, posterior to the posterior cruciate ligament to a
distinct insertion site on the medial femoral condyle.
It may be as large as one half the diameter of the posterior
cruciate ligament. A dominant posterior meniscofemoral ligament was found in 36% of the specimens dissected
by Heller and Langman. 23
The anterior meniscofemoral ligament (Humphrey's
ligament) arises from the posterior horn of the lateral meniscus and passes along the anterior aspect of the posterior cruciate ligament to insert on the medial femoral
condyle. Although the meniscofemoral ligament may
serve as a minor restraint to posterior translation of the
tibia after the posterior cruciate ligament is cut, the ligaments are believed to play an important role in the normal meniscal kinematics. They increase the congruity
between the lateral meniscus and the lateral femoral
condyle during flexion, extension, and rotation of the
knee. In our studies of the cross-sectional areas of the
ligaments, the meniscofemoral ligament averaged 20%
(range, 7% to 35%) of the size of the posterior cruciate
ligament. 24,25
VASCULAR ANATOMY
The menisci have a very limited blood supply and are
essentially avascular structures. Their limited vascularity is confined to the peripheral region.
The blood supply to the menisci comes from the superior and inferior branches of the medial and lateral geniculate arteries. 12"26-3° Branches from these vessels form a
perimeniscal capillary plexus in the synovium and capsular tissues of the knee joint. 26 This network of vessels
supplies the peripheral portions of the menisci throughout their attachment to the joint capsule and the synovium. These vessels are arranged predominantly in a
circumferential pattern, with radial branches directed toward the central portion of the menisci. 26
Arnoczky and Warren have shown that only the pe-
Fig 4. Photograph of a sagittal section of a cadaveric knee-joint specimen showing the anterior meniscofemoral ligament
(Humphrey's ligament) (arrow) and its relationship to the posterior cruciate ligament (A) and the posterior meniscofemoral
ligament (ligament of Wrisberg) (arrow) and its relationship to the posterior cruciate ligament (B), (Reprinted with permission, s)
4
ALLEN, CALDWELL JR, AND FU
ripheral 10% to 30% of the width of the medial meniscus
and 10% to 25% of the width of the lateral meniscus are
penetrated by these vessels (Fig 5). 26 They also described branches [hat arise from the middle geniculate
artery and the terminal branches of the medial and lateral
geniculate arteries that supply the anterior and posterior
horn attachments of the menisci. This occurs through
endoligamentous vessels in the vascular synovium that
covers the meniscal horns.
The inner 65% to 75% of the menisci is avascular and
probably receives most of its nutrition from the synovial
fluid by diffusion or mechanical pumping. 3~'32 A system
of microcanals in the menisci, which may also play a role
in the transport of nutrients, has been described by Bird
and Sweet. 33"34
NEUROANATOMY
Several different types of neurological receptors have
been identified within meniscal tissue. 29'35"36 According
to Hilton's law, any nerve that crosses a given joint will
send branches to that joint. Nerve supplies to the knee
joint come from the posterior articular branch of the posterior tibial nerve, the terminal portion of the obturator
nerve, and the terminal branches of the femoral nerve to
the quadriceps muscles. Nerve supplies to the lateral
portion of the capsule arises from the recurrent peroneal
branch of the common peroneal nerve. These nerve fibers penetrate the capsule and follow the vascular supply
to the peripheral portion of the menisci and the anterior
and posterior horns, where most of the nerve fibers are
concentrated. 3s'37 This concentration of sensory receptors in the meniscal horns may implicate the meniscus in
some kind of a proprioceptive function in the knee joint.
According to Wilson et a136 there are also free-standing
nerve fibers in the menisci that are not surrounded by
vessels. These fibers are present predominantly in the
middle third of the menisci, an area that is devoid of
Fig 5. Frontal section 5-mm thick of the medial compartment
of the knee (Spalteholz preparation, original magnification
x65, x 1.65). Branchiing radial vessels from the perimeniscal
capillary plexus (PCP) penetrate the peripheral border of the
medial meniscus. F, femur; T, tibia. (Reprinted with permission. 26)
ANATOMY AND BIOMECHANICS OF THE MENISCUS
penetrating vessels.
pain conduction. 36
They have been implicated in slow
MICROANATOMY
Composition and Structure
The meniscus is fibrocartilagenous tissue composed of
collagen, with interposed cells. These cells are either
fibrochondrocytes or a mixture of fibroblasts and chondrocytes. There are two types of cells: the more superficial fusiform cells and the deeper ovoid cells. These
cells synthesize and maintain the extra cellular matrix,
which is primarily collagen. 12
Approximately 74% of the normal meniscus is water.
The dry organic matrix is composed of 75% collagen, with
8% to 13% n o n c o l l a g e n o u s p r o t e i n s a n d 1% hexosamines. Type I collagen predominates and is approximately 90% of the total collagen. Smaller amounts of
types II, III, V, and VI collagens are also present. 3s
The predominance of type I collagen distinguishes the
fibrocartilage of the menisci from the hyaline cartilage of
the joint surface, where type II cartilage predominates.
The type V collagen seems to be concentrated on the
articular surfaces of the menisci. 12
As previously stated, the collagen content of the menisci increases from the prenatal to the postnatal stages in
response to the stress of weight bearing and joint motion} 1 According to Ghosh et a139 the collagen content
increases until approximately age 30 and remains fairly
constant until it begins to decrease at around age 80.
The crimping pattern of collagen fibers observed in tendons is also present in the menisci. This pattern disappears when stress is applied to the tissue. 39
The collagen fiber arrangement is ideal for transferring
a vertical compressive load into circumferential stresses. 39
Type I collagen fibers are oriented circumferentially in the
deeper layers of the meniscus, parallel to the peripheral
border. These fibers blend into the ligamentous connections of the meniscal horns to the tibial articular surface. 12"4°-42 In the most superficial region of the menisci,
the type I fibers are oriented in a more radial direction.
Some radially oriented fibers are also present in the
deeper layers. The radial fibers come in from the periphery and are interspersed or woven between the circumferential fibers to provide structural rigidity. 4°-43
This arrangement of the fibers is important in resisting
large hoop or circumferential stresses that are produced
at the periphery of the menisci during weight bearing (Fig
6).12,40-42
Proteoglycans are located between the collagen fibers.
The amount of proteoglycans in the meniscus is significantly less than that of hyaline articular cartilage, 12 and
there may be considerable variation, depending on the
site from which the sample was taken and the age of the
specimenY This may contribute to the regional variation of the stiffness and strength of the normal meniscus. 44 Proteoglycans provide a function in the menisci
similar to the function they provide in articular cartilage:
they give the menisci the ability to resist large compressive loads} 2
5
Fig 6. Schematic drawing of the meniscus showing the collagen fiber orientation (Modified and reprinted with permission. 4°)
Meniscal Motion
Normal knee kinematics is an intricate combination of
flexion, extension, rolling, and gliding motion within 6°
of freedom. Meniscal motion was recently demonstrated in a study by Thompson et a1.19 They used human cadaveric knees and a 3-dimensional magnetic resonance imaging reconstruction technique to demonstrate
motion of the menisci as the knee was moved through 0°
to 120° of flexion. The images were shown in a cinematic format to demonstrate meniscal deformation (Figs 7
and 8).
The quantitative excursion of the menisci was also assessed. Excursion of the medial meniscus averaged 5.1
+ 0.96 m m as compared with 11.2 --- 3.27 mm mean lateral meniscal excursion. On both sides, the mean excursion of the posterior horn was less than that of the anterior horn. The ratio of mean posterior- to anterior-horn
excursion was 1:2.4 --- 0.8 medially and 1:1.13 --- 0.23 laterally (Fig 9). 19
Thompson et al demonstrated the limitation of medial
meniscal excursion in the posteromedial corner caused by
the meniscocapsular attachments and the articular geometry in this region. The increased excursion of the lateral
meniscus was attributed t o its unconstrained popliteal
margin and close central tibial attachments. They also
pointed out that the menisci deform and change their
radii to remain congruent to the tibiofemoral articular surface throughout range of knee motion. The increased
excursion of the lateral meniscus relative to the medial
meniscus was confirmed. This presumably is because of
the greater soft tissue and bony constraints of the medial
meniscus. 19
BIOMECHANICS
The biomechanical function of the meniscus is a reflection
of its gross and ultra structural anatomy and of its relationship to the surrounding intra-articular and extraarticular structures. Biomechanical functions performed
by the menisci include load transmission, 12"45-48shock ab6
Fig 7. (A-C) Superior 3-dimensional meniscal images in 60 °
increments from 0 ° to 120 ° of flexion (A, anterior; P, posterior; M, medial; L, lateral). (Reprinted with permission. 19)
sorption, 12'41"49 joint stability, 5°'52 joint lubrication, 53"55
and joint nutrition. 33'56'57
Load Transmission
Although Kings8 was the first to imply that the meniscus
may have a role in load transmission across the knee
joint, it was Fairbanks 3 who first hypothesized that the
meniscus may have some load-bearing function. His
hypothesis was based on the changes he observed in
postmeniscectomy knees. A number of clinical and biomechanical studies have supported Fairbanks hypothesis. 34,45-48,51,59-68
One of the more attractive models of load transmission
was put forth by Shrive et al. 62"67 They proposed that
because of the wedge shape of the meniscus, a net resultant force is generated in response to an applied load,
which tends to extrude the menisci from the joint. This
ALLEN, CALDWELL JR, AND FU
P/A 1:1.3"x"
P/A 1:2.4 "X"
7.0
~m
ANT ,,ss,.-" 1' " ' ~ . .
I
12.8
%
.....,~,~%~:~
t
5.1
mme
11.2
rome
"~:.~ %%
POST
LATERAL
MEDIAL
I
I
1:2.3"
Fig 9. Diagram of mean meniscal along t h e tibial plateau
(ANT, anterior; POST, posterior; MME, mean meniscal excursion; P/A, ratio of posterior to anterior meniscal translation
during flexion; *, P < 0.05 by Student's t-test analysis). (Reprinted with permission. TM)
knee ranges of motion from 0° to 90 °, with more load
transmission at full extension.
Load transmission may be one of the more important
meniscal functions. The menisci protect the articular
cartilage from excessive stresses and prevent early degenerative changes in the joint.
Joint Stability and Congruity
Fig 8. (A-C) Lateral 3-dimensional meniscal images in 60 °
increments from 0 ° to 120 ° of flexion (A, anterior; P, posterior; M, medial; L, lateral). (Reprinted with permission. 19)
is resisted by the circumferentially oriented collagen fibers and their a t t a c h m e n t s to the meniscal horns.
Therefore, large circumferential hoop stresses are generated to balance this net resultant force. They estimated
that approximately 45% of the knee-joint load is carried
by the meniscus.
Baratz et al 6° have shown that total meniscectomy decreased the tibia-femoral contact area up to 75%, with
increased peak load of up to 235%. Partial meniscectomy decreased the contact area by only 10% and increased
the peak load by 65%. Malalignment of the joint in postmeniscectomy knees can decrease the contact areas and
increase the peak stresses in the knee joint. 69 The posterior horns of the menisci carry more load than the anterior horns, and the load distribution is a function of the
knee flexion angle. Ahmed and Burke 59 used pressure
gradient transducers to show that the menisci transmit at
least 50% of the compression load in the knee joint in
ANATOMY AND BIOMECHANICS OF THE MENISCUS
The role of the menisci in increasing joint congruity and
enhancing stability is conceptually apparent w h e n the articular surfaces of the tibiofemoral joint are examined.
However, a consensus of opinion regarding the stabilizing role of the meniscus in the intact knee has not been
reached. 12 The joint surfaces are noncongruous, and
the proximal surface of the meniscus provides a concave
surface that accommodates the convexity of the femoral
condyles. In doing so, the meniscus not only obliterates
the dead space between the femur and the tibia, but also
increases the congruity of the tibiofemoral joint. 12"15
In essence, the menisci act like wedges to perform the
so-called "socket-forming function" of the meniscus described by Virchow. 7° Joint stability may also be facilitated through the meniscoligamentous and meniscocapsular connections.
The medial meniscus is a secondary stabilizer of the
knee, decreasing anterior knee translation in anterior cruciate-ligament-deficient knees. 71 There is little effect on
anterior-posterior knee translation after medial meniscectomy in anterior cruciate-ligament-intact knees. 69 The
medial meniscus is prone to injury in patients with
chronic anterior cruciate-ligament-deficient knees. 71
As the meniscus attempts to prevent anterior translation
of the anterior cruciate-ligament-deficient knee, it is exposed to increased shear stresses, and meniscal damage
can occur.
Joint Lubrication and Nutrition
The role of the meniscus in joint lubrication has been
extrapolated from the studies that have shown that the
coefficient friction of the joint is increased by 20% after
7
meniscectomy. 53-55 Although fluid is extruded from the
hyaline cartilage of the articular surface during weight
bearing, it is not clear whether this is true of the meniscus. 12
Bird and S w e e t 33'56 have found a system of microcanals
within the meniscus that not only communicates with the
synovial cavity but is also located close to the blood vessels. These canals have been implicated in fluid transport for nutritional purposes and joint lubrication.
It would seem likely that the peripheral portion of the
menisci receives its nutrition from the vasculature at the
periphery of the meniscus. The inner portion of the
meniscus, ie, the remaining 65% to 75%, most likely receives its nutrition from diffusion, the synovial cavity,
or m e c h a n i c a l p u m p i n g s e c o n d a r y to joint motion.12 Microcanals may also serve as a conduit for nutrients. 33,56
CONCLUSION
The menisci are integral to normal knee function. A
fundamental knowledge of meniscal anatomy and biomechanics is necessary to predict the meniscal response to
injury and repair. Although we have made significant
strides in our understanding of the basic science of the
menisci, there are still questions that need to be resolved.
Future studies will focus on the biochemistry, microanatomy, and biomechanics of the menisci.
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