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Review
Meniscal Ramp Lesions
Anatomy, Incidence, Diagnosis, and Treatment
Jorge Chahla,* MD, Chase S. Dean,* MD, Gilbert Moatshe,*
†‡
Justin J. Mitchell,*
§
MD,
Tyler R. Cram,* MA, ATC, Carlos Yacuzzi,* MD, and Robert F. LaPrade,*
§||
MD, PhD
Investigation performed at the Steadman Clinic and the Steadman Philippon
Research Institute, Vail, Colorado, USA
Meniscal ramp lesions are more frequently associated with anterior cruciate ligament (ACL) injuries than previously recognized.
Some authors suggest that this entity results from disruption of the meniscotibial ligaments of the posterior horn of the medial
meniscus, whereas others support the idea that it is created by a tear of the peripheral attachment of the posterior horn of the
medial meniscus. Magnetic resonance imaging (MRI) scans have been reported to have a low sensitivity, and consequently, ramp
lesions often go undiagnosed. Therefore, to rule out a ramp lesion, an arthroscopic evaluation with probing of the posterior horn of
the medial meniscus should be performed. Several treatment options have been reported, including nonsurgical management,
inside-out meniscal repair, or all-inside meniscal repair. In cases of isolated ramp lesions, a standard meniscal repair rehabilitation
protocol should be followed. However, when a concomitant ACL reconstruction (ACLR) is performed, the rehabilitation should
follow the designated ACLR postoperative protocol. The purpose of this article was to review the current literature regarding
meniscal ramp lesions and summarize the pertinent anatomy, biomechanics, diagnostic strategies, recommended treatment
options, and postoperative protocol.
Keywords: ramp lesion; meniscus tear; ACL; meniscocapsular; hidden lesion
Concomitant intra-articular lesions are commonly seen
in patients sustaining anterior cruciate ligament (ACL)
rupture.
4,7
Approximately 43%of all ACL-injured
patients have been reported to have an associated lat-
eral or medial meniscal injury.
23
In 1988, Strobel
40
described a particular type of meniscal injury associ-
ated with ACL rupture involving the peripheral attach-
ment of the posterior horn of the medial meniscus.
Currently known as a ramp lesion, this pathology has
historically been under-recognized because it is com-
monly located within a posteromedial ‘‘blind spot’’ when
using standard anterolateral and anteromedial arthro-
scopic portals.
41
This potential difficulty in diagnosis is
clinically important as ramp lesions have been reported
to be present in 9%to 17%of all ACL tears.
5,26
Further-
more, the use of imaging modalities such as magnetic
resonance imaging (MRI) to detect ramp lesions has a
low reported sensitivity.
5
Duetothelimitedutilityof
MRI and the difficulty of identifying ramp lesions
through the standard anterior portals, it is vital to per-
form a systematic arthroscopic exploration to diagnose
these ‘‘hidden’’ lesions.
38
There is no consensus regarding the definition of
meniscal ramp lesions, as different anatomical locations
have been proposed as the site of injury. Originally, a
ramp lesion was defined as a longitudinal tear of the
peripheral attachment of the posterior horn of the medial
meniscus at the meniscocapsular junction of less than
2.5 cm in length.
26
However, recent literature has sug-
gested that ramp lesions are associated with injury to the
meniscotibial ligament attachment of the posterior horn
of the medial meniscus.
38
Regardless of the definition,
these lesions can cause pain, dysfunction, and altered
knee kinematics.
38
Because of the prevalence, potential
importance, and diagnostic challenges associated with
these injuries, we present a review of the currently
available literature on ramp lesions using searches of
PubMed, MEDLINE, and Cochrane databases using the
keywords ramp lesion,ramp tear,meniscocapsular,and
hidden lesion.
||
Address correspondence to Robert F. LaPrade, MD, PhD, Steadman
Philippon Research Institute, The Steadman Clinic, 181 West Meadow
Drive, Suite 400, Vail, CO 81657, USA (email: drlaprade@sprivail.org).
*The Steadman Philippon Research Institute, Vail, Colorado, USA.
†
Department of Orthopedic Surgery, Oslo University Hospital, Oslo,
Norway.
‡
OSRTC, The Norwegian School of Sports Sciences, Oslo, Norway.
§
The Steadman Clinic, Vail, Colorado, USA.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: R.F.L. is a consultant for and receives
royalties from Arthrex, Ossur, and Smith & Nephew.
The Orthopaedic Journal of Sports Medicine, 4(7), 2325967116657815
DOI: 10.1177/2325967116657815
ªThe Author(s) 2016
1
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/3.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For reprints and permission queries, please visit SAGE’s Web site
at http://www.sagepub.com/journalsPermissions.nav.
by guest on July 27, 2016ojs.sagepub.comDownloaded from
ANATOMY
The medial meniscus is a semilunar fibrocartilage struc-
ture that covers approximately 50%of the medial tibial
plateau.
11
It is broader posteriorly, measuring approxi-
mately 11 mm in width, and becoming narrower anteriorly
toward the anterior meniscal root. Some authors divide the
meniscus into 3 segments (anterior horn, body, and poste-
rior horn) while others divide it into 5 zones that are dis-
tinguishable on an anatomical basis (anterior root [zone 1],
anteromedial zone [zone 2], medial zone [zone 3], posterior
zone [zone 4], and the posterior root [zone 5]).
41
The anterior and posterior roots anchor the meniscus to
the tibial plateau,
22
and the body of the meniscus is
attached to the adjacent joint capsule and to the tibia by
the meniscotibial ligaments. These attachments are impor-
tant for kinematics and injury patterns of the medial
meniscus as tibial and femoral attachments in the poster-
omedial aspect of the medial meniscus make it less mobile
compared with the lateral meniscus.
44
The reduced mobil-
ity of the medial meniscus makes it susceptible to injuries,
especially in deep flexion and with rotational trauma when
the pressure is increased in the posterior horn of the medial
meniscus.
Despite a recent increase in the awareness of tears near
the posterior aspect of the medial meniscus,
18,25,38
clear
anatomic descriptions of meniscal ramp lesions remain
elusive. For the purpose of this review, ramp lesions are
defined as those that involve a tear or disruption of the
peripheral meniscocapsular attachments of the posterior
horn of the medial meniscus (Figure 1).
EPIDEMIOLOGY
A review of the literature demonstrated that lateral menis-
cal tears occur slightly more frequently than medial tears
in knees with acute ACL injuries, with a mean distribution
of 56%lateral to 44%medial.
8,37
However, in the setting of
chronic ACL deficiency, medial meniscal tears are more
common.
8,37
Despite these trends in the available litera-
ture, 2 recent studies noted a high prevalence of medial
meniscal ramp lesions in both acutely and chronically
ACL-injured patients. In a prospective descriptive study,
Bollen
5
found a 9.3%prevalence of medial meniscal ramp
lesions in 183 consecutive patients undergoing ACL recon-
struction (ACLR). However, this study was limited in its
relatively small sample size. In an attempt to further clas-
sify these lesions, Liu et al
26
performed an extensive study
by arthroscopically evaluating for meniscal ramp lesions in
868 patients undergoing ACLR. They found an even higher
prevalence of ramp lesions, noting that 16.6%of patients
had this lesion. Both of these studies defined a ramp lesion
as a tear of the peripheral attachment of the posterior horn
of the junction between the medial meniscus and the syno-
vium or capsule.
These studies build upon earlier literature suggesting
an association between ACL injury and medial meniscal
tears. Smith and Barrett
37
performed a prospective study
on the location of 575 meniscal tears associated with ACL
injuries. They reported that peripheral posterior horn
tears of the medial meniscus were the most common type
of tear, comprising 40%of medial meniscus tears. Further-
more, more than 75%of medial meniscal tears in the ACL-
deficient knee occurred in the peripheral posterior horn.
However, they did not define whether those lesions were
located at the posterior meniscocapsular junction. Regard-
less of the specific descriptors used to report such tears,
these studies are important in demonstrating the injury
risk to the medial meniscus in association with ACL
rupture.
While ramp lesions are associated with ACL injury, other
known risk factors have also been reported in the litera-
ture. Reported associated risk factors for sustaining a ramp
lesion are age, sex, and time from ACL injury to surgery.
26
Liu et al
26
reported an 18.56%prevalence of ramp lesions in
males compared with 11.97%in females (P¼.01). Patients
younger than 30 years (P< .01) also had a considerably
higher prevalence of ramp lesions. However, there was no
significant difference in the prevalence of ramp lesion
between patients aged 10 to 20 years and 20 to 30 years,
as well as between patients between 30 to 40 years and
older than 40 years.
26
Additionally, the prevalence of
ramp lesions significantly increased as time since injury
increased until 24 months after a nonsurgical ACL injury.
After 24 months, the prevalence plateaued.
26
Thus, a sig-
nificantly higher prevalence of ramp tears was reported in
patients with chronic ACL tears compared with patients
with acute ACL tears.
26
BIOMECHANICS
Biomechanical studies have demonstrated the importance
of the menisci, as they contribute to load transmission and
distribution, joint lubrication, proprioception, cartilage
nutrition, and act as a secondary stabilizing structure.
2
This is especially true for the medial meniscus, which has
Figure 1. Schematic diagram of a left knee (disarticulated
from the femur) demonstrating the location of a ramp lesion
in the posteromedial meniscocapsular junction of the medial
meniscus.
2Chahla et al The Orthopaedic Journal of Sports Medicine
by guest on July 27, 2016ojs.sagepub.comDownloaded from
been reported to play a key role in stabilizing the knee joint
in chronically ACL-deficient knees.
6,36
Hughston and
Eilers
20
described the close relationship that exists
between the meniscus, the joint capsule, the posterior
oblique ligament, and the semimembranosus tendon and
how the capsular arm of the semimembranosus tendon
insertion translates the posterior horn of the meniscus
posteriorly during knee flexion. Moreover, Hughston and
Eilers
20
suggested that a contraction of the semimembra-
nosus muscle that occurs while the medial meniscus is
‘‘wedged’’ between the femur and tibia would expose and
stress the meniscocapsular interface and potentially result
in a peripheral meniscal tear. This tear can occur in knees
with either acute or chronic ACL tears.
20,37
Papageorgiou
et al
29
reported that the forces on the medial meniscus were
increased by 200%in response to anterior tibial loads with
a transected ACL. Likewise, deficiency of the medial menis-
cus has been associated with ACLR failure.
29
When a
medial meniscectomy is performed with an ACLR, the in
situ forces in the reconstructed ACL graft increase between
33%and 50%.
29
In a human cadaveric study by Peltier
et al,
30
the authors reinforced the concept that the posterior
horn of the medial meniscus is a secondary restraint to
anterior tibial translation.
Currently, the available literature discussing the bio-
mechanical consequences of ramp lesions is limited. It
is not clear whether these lesions affect joint kinematics
and loading in the medial compartment of the knee
similar to ACL deficiency
15,28
or posterior root lesions
and complete radial tears.
24
However, ramp lesions are
reported to increase forces on the ACL, and lesions of
the meniscotibial ligaments may increase rotatory
instability of the knee.
30
A recent cadaveric study by
Stephen et al
39
demonstrated that anterior tibial transla-
tion and external rotational laxities were significantly
increased after sectioning of the posteromedial menisco-
capsular junction (equivalent to a ramp lesion) in an ACL-
deficient knee. Moreover, anterior and external rotational
instabilities were not restored after ACLR alone but were
restored with ACLR combined with posterior meniscocap-
sular repair.
39
IMAGING
While MRI is a reliable diagnostic modality for most menis-
cal pathologies, studies have reported low sensitivity of
MRI to detect ramp lesions. Edgar et al
13
reported detection
of ramp lesions in 33 of 43 patients using MRI, resulting in
a sensitivity of 77%. However, a prospective case series by
Bollen
5
reported 0 of 11 arthroscopically confirmed ramp
lesions were detected on MRI. Bollen
5
theorized that MRI
identification of ramp lesions was limited due to the knee
being in near full extension at the moment of the study,
which reduces the meniscocapsular separation. This is sim-
ilar to how a reduced bucket-handle tear may not be
detected on MRI.
5
In accordance with Bollen
5
, Liu et al
26
concluded that preoperative confirmation of a ramp lesion
was difficult, and MRI patient data did not correlate with
the diagnosis of a ramp lesion.
Hash
17
reported that the most specific sign of a ramp
lesion on MRI was the visualization of a thin fluid signal
completely interposed between the posterior horn of the
medial meniscus and the posteromedial capsule (Figure 2).
When evaluating the medial meniscus it may be difficult
to distinguish a meniscocapsular separation from a
peripheral vertical tear of the posterior horn, especially
when there is incomplete fluid filling adjacent to the
peripheral margin of the meniscus, as would be seen with
a peripheral vertical tear.
17
Hatayama et al
18
reported the characteristic MRI find-
ing of ramp lesions to be high signal irregularity of the
capsular margin of the medial meniscus posterior horn
on T2*-weighted gradient-echo sagittal images. Among all
reports, there is a general consensus that arthroscopic
evaluation is necessary to completely rule out a ramp
lesion.
5,17,26,38
SURGICAL ALGORITHM
A thorough arthroscopic evaluation is important to iden-
tify and treat intra-articular pathology associated with
ACL injury. Sonnery-Cottet et al
38
reported that among
125 tears of the medial meniscus associated with an ACL
rupture, 40%were ramp lesions. Of these, 29 (23.2%)were
detected during exploration of the posteromedial compart-
ment through a standard anterior portal, while 21 (16.8%)
were not found through the anterior portals and were only
Figure 2. Sagittal T2 magnetic resonance image of the medial
compartment of a right knee demonstrating subtle separation
in the posteromedial meniscocapsular junction consistent
with a ramp lesion (yellow arrow).
The Orthopaedic Journal of Sports Medicine Meniscal Ramp Lesions: A Review 3
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discovered by probing the tear through a posteromedial
portal after minimal debridement of a superficial soft tis-
sue layer with a motorized shaver. Therefore, they sug-
gested a systematic arthroscopic exploration
38
and repair
consisting of 4 steps: (1) standard arthroscopic evaluation
through the anterolateral portal and probing of the menis-
cal tissue (Figure 3), (2) exploration of the posteromedial
compartment by advancing the arthroscope through the
notch and medial to the posterior cruciate ligament (PCL),
(3) creation of a viewing posteromedial portal to assess for
hidden lesions if necessary, and (4) medial meniscal repair
(Figure 4).
When a ramp lesion is discovered, no clear consensus
exists on the appropriate treatment of meniscal ramp
lesions. Based on the available literature, there is discrep-
ancy among authors as to the need for surgical intervention
to address a ramp lesion in the setting of an acute ACLR.
While there is little disagreement that ramp lesions should
be repaired in the setting of chronic ACL deficiency,
38
some
authors suggest that a ramp lesion constitutes a stable tear
pattern located in a highly vascular zone with a favorable
biological environment to heal, especially in the setting of
acute ACLR.
26
Furthermore, previous studies have
reported reasonable outcomes with similar longitudinal
meniscal tear patterns left in situ without repair at the time
of ACLR.
12,31,35
These studies suggest that nonsurgical
management may be reasonable. However, Ahn et al
1
hypothesized that during knee flexion and extension, the
hypermobility of the detached meniscocapsular structure in
ramp lesions is dissimilar from other peripheral tears and
would not allow for spontaneous healing. Their study sug-
gests that repairing the lesion would be the most effective
approach.
REPAIR PROCEDURE
As previously mentioned, the available literature suggests
that nonsurgical management of ramp lesions may be
appropriate. However, when repair is chosen as the treat-
ment option, the anatomic location of a meniscal ramp
lesion creates a technical challenge. The posteromedial
location of the ramp lesion places the saphenous neurovas-
cular bundle at increased risk when attempting the menis-
cus repair.
32
Therefore, to avoid iatrogenic injury of the
saphenous nerve during placement of meniscal fixation
devices, needle passing, or suture tying, techniques that
allow for direct visualization of the posterior capsule are
recommended for ramp lesion repair, and outside-in repair
techniques should be undertaken with caution.
32
Figure 3. Arthroscopic evaluation of the meniscocapsular junction as viewed through the anteromedial portal with the probe
inserted through the anterolateral portal. The scope and probe are passed medial to the posterior cruciate ligament and lateral to
the medial femoral condyle. (A) Identification of the meniscocapsular junction with the arthroscopic probe. (B) Dynamic evaluation
of the meniscocapsular junction revealing a ramp lesion.
Figure 4. Inside-out meniscal repair of a meniscal ramp lesion
in a left knee. Double-loaded nonabsorbable sutures were
placed through the meniscal body and the posteromedial
capsule. Sutures were retrieved and tied against the extra-
articular aspect of the capsule.
4Chahla et al The Orthopaedic Journal of Sports Medicine
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All-inside techniques and inside-out techniques have
demonstrated success in the literature to treat this con-
dition.
25
Although technically demanding, the inside-out
repair technique allows for a greater versatility in suture
placement and increased number of sutures, thereby
potentially creating a stronger construct.
27
For an
inside-out repair, a posteromedial approach is per-
formed. An oblique vertical incision is made from approx-
imately the adductor tubercle to the posterior aspect of
the tibial plateau. Subcutaneous sharp dissection is per-
formed down to the sartorius fascia, which should be
incised as proximal as possible with preservation of the
pes anserine tendons. An anatomic ‘‘triangle’’ can be
observed at this point. This ‘‘triangle’’ is formed by the
posteromedial joint capsule anteriorly, the medial gas-
trocnemius posteriorly, and the direct arm of the semi-
membranosus inferiorly. A retractor is placed in this
interval to protect the posterior neurovascular structures
during the repair procedure.
9
To initiate the ramp lesion repair, an arthroscopic self-
delivery gun fitted with a cannula (single or double lumen
cannulas) is used to pass double-loaded nonabsorbable
sutures into the meniscus in a vertical mattress fashion.
To begin passing the sutures, the knee is positioned in
20to 30of flexion and the meniscal needle is advanced
through the superior or inferior aspect of the posterior horn
of the medial meniscus. The corresponding portion of the
meniscofemoral or meniscotibial capsule is then penetrated
with the second needle of the suture. To help the assistant
retrieve the needle, the knee can be flexed to 70to 90after
the meniscal needle is advanced a few millimeters. The
assistant then retrieves the needles through the posterome-
dial surgical interval, the needles are cut from the sutures,
and the suture ends are clamped while maintaining slight
tension. The same process is repeated with sutures both in
the superior and inferior borders of the posterior horn of the
medial meniscus placed between 3 to 5 mm apart. The
meniscal sutures are tied with the knee at 90of flexion,
being careful not to overtighten the posteromedial
structures.
9
A similar procedure can be performed using all-inside
devices. The steps of the repair will depend on the device
used. Overall, advantages of all-inside sutures include the
ease of use, less neurovascular risks, and no additional inci-
sions. However, the all-inside technique is not exempt from
complications such as irritation from anchors, meniscal
body tears resulting from bigger holes created from device
insertion, and implant failure.
16
BIOLOGICAL AUGMENTATION
Regardless of the treatment option chosen, improved over-
all outcomes have been reported for meniscus tears associ-
ated with ACL injury that were repaired at the time of
ACLR. These findings have been hypothesized to be related
to the biological augmentation of the repair from factors in
the bone marrow released within the joint.
21
Moreover, a
recent study reported that the local release of vascular
endothelial growth factor (VEGF) and its angiogenetic
receptor vascular endothelial growth factor receptor
2 (VEGFR2) were significantly higher after ACLR than
after partial meniscectomy, indicating a better vasculo-
genic potential for enhanced meniscus healing capabilities
associated with ACLR tunnel reaming.
14
Because of this,
it may be reasonable to consider biological augmentation
such as the addition of platelet-rich plasma (PRP) or per-
forming a bone marrow stimulation technique by using a
pick to create holes into the notch, releasing similar fac-
tors as when treating ramp lesions not associated with
ACL injury. However, it is unclear whether this is neces-
sary as a ramp lesion has a favorable eccentric and periph-
eral location in the red-red zone that enhances the
biological potential.
OUTCOMES
There are few short- or long-term outcomes studies after
the identification and treatment of ramp lesions. Because
of this, treatment recommendations and the decision for
surgical or nonsurgical management is based on a limited
number of studies. While there are no reported outcomes
after nonsurgical treatment, Choi et al
10
previously demon-
strated that both all-inside and inside-out repair
approaches to medial meniscal lesions can provide similar
results. Li et al
25
specifically reported on 23 ramp lesions
treated with an all-inside device with a mean follow-up of
14 months. In their study, the mean Lysholm score
improved from 64.4 ±4.5 preoperatively to 91.2 ±4.6 post-
operatively.
25
These studies reinforce aforementioned stud-
ies, suggesting that repair can be performed by means of an
inside-out repair
38
or with all-inside devices
25
depending
on the surgeon’s preference, as either may provide appro-
priate outcomes for patients.
REHABILITATION
Currently, there is no universal consensus on the postoper-
ative rehabilitation protocol regarding meniscal ramp
lesions. Therefore, general principles of rehabilitation after
meniscal repair are typically utilized. Currently, there are
no evidence-based protocols available, and therefore, ther-
apy programs should be applied and individualized on a
case-by-case basis. Furthermore, when a concomitant knee
injury occurs with a meniscal ramp lesion, the rehabilita-
tion will be partially dictated by the concurrent operative
procedure.
43
Rehabilitation after a ramp lesion repair depends on
whether the repair is isolated or performed concurrently
with ACLR.
3
When performed with an ACLR, the rehabil-
itation is followed according to the ACL rehabilitation pro-
tocol. Weightbearing is initiated as tolerated, and patients
may wean off crutches as soon as they can ambulate with-
out a limp. No limits on knee motion are prescribed, and
knee motion is increased as tolerated.
Goals for isolated meniscal ramp repair include
edema control, knee range of motion, and quadriceps-
activation exercises, which are initiated on the first day
The Orthopaedic Journal of Sports Medicine Meniscal Ramp Lesions: A Review 5
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postoperatively.
19
Primarily, the focus is to prevent exces-
sive weightbearing and joint compressive forces that
could lead to undue traction and shearing stress, result-
ing in disruption of meniscal healing.
19,33
Stress is
believed to increase 10-fold during knee flexion exceed-
ing 90. Therefore, it is recommended to restrict passive
flexion to 90for the first 2 weeks postoperatively and to
avoid all active flexion.
33
The medial meniscus has been
shown to be highly mobile during knee rotation in the
first 30of flexion; therefore, patients with ramp lesions
should avoid knee rotation during the first 3 postopera-
tive weeks.
42
Pivot and contact activities, as well as
squatting and lifting exercises involving maximum knee
flexion while weightbearing, should not be performed for
at least 4 to 6 months.
33
Patients who have repairs of peripheral meniscus tears,
such as ramp lesions, are generally progressed more rap-
idly than those who have repairs of tears extending in the
central one-third region or those who undergo meniscal
transplantation.
19
Most authors agree that patients can
return to sports or strenuous activities when the clinical
examination reveals a nontender joint line, absence of pain
and effusion, restored muscle strength, and full range of
motion, particularly full extension.
34,45
CONCLUSION
Ramp lesions constitute a common but often missed entity
in ACL-deficient knees, both in an acute and chronic set-
ting. Biomechanical studies have reported that a ramp
lesion produces significant anterior tibial translation and
external rotational instability in ACL-deficient knees that
is not reestablished with an isolated ACLR but with a con-
comitant meniscal repair. MRIs have been reported to have
low sensitivity to detect ramp lesions; therefore, a system-
atic arthroscopic algorithm should be utilized to fully iden-
tify these lesions. If present, it is highly recommended to
repair these lesions to avoid the previously mentioned
unwanted biomechanical consequences. In cases of isolated
ramp lesions, a standard meniscal repair rehabilitation
protocol should be followed. However, when a concomitant
ACLR is performed, the rehabilitation should follow the
designated ACLR postoperative protocol. Meniscal ramp
tears are more common than previously thought; as a
result, it is important to be vigilant regarding the high
prevalence of these lesions, especially in the setting of an
ACL tear.
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