Save the Meniscus: Why I Repair Root and Ramp Tears Instead of Trimming Them Out
Root tears make the knee behave as if the whole meniscus is gone, and ramp tears hide behind ACL injuries. Why I repair them whenever the tissue allows.
A patient comes in with a twisted knee that catches when she squats, a nagging ache along the inside joint line, and an MRI that reads "medial meniscus root tear." On paper it sounds minor. But when I look closely at the imaging and then get inside the knee at surgery, the story is often bigger than the report suggests — a tear at the meniscus root, or a hidden tear where the meniscus meets the capsule that the MRI never called.
How I handle those tears in the operating room has more to do with whether that knee develops arthritis in ten years than almost anything else I do.
The days of removing most meniscus tears are long in the rearview mirror. My philosophy, and where the best evidence has landed, is straightforward: whenever the tear and the tissue allow it, I repair the meniscus rather than remove it.
Why the meniscus is worth saving
The meniscus is a C-shaped wedge of cartilage that acts as the shock absorber between your thighbone and shinbone. It spreads load across the joint so the smooth cartilage on the ends of the bones doesn't take a pounding with every step. When it works, you never think about it. When it's gone, the cartilage underneath starts wearing out.
The numbers make the case. A meniscus tear roughly triples the risk of developing knee arthritis down the road, and taking meniscus tissue out only accelerates that.1 That's why I treat the meniscus as tissue to protect, not tissue to discard.
Two tears people have never heard of: root and ramp
Root tears
The "root" is where the back of the meniscus anchors to the bone. That anchor is what lets the meniscus do its job — it holds the wedge in place so it can spread load instead of squirting out to the side.
When the root tears, the meniscus is still physically there, but biomechanically the knee behaves as if the entire meniscus is gone. This is the one that scares me the most, because an untreated root tear can take a normal-looking joint to bone-on-bone arthritis within a year.2,3
Ramp lesions
A ramp lesion is a tear at the very back of the medial meniscus, where it blends into the joint capsule. It travels with ACL injuries — somewhere between 9% and 24% of ACL tears have one4 — and it's notoriously easy to miss. MRI catches it only about 70% of the time5, so a meaningful share are found only when I look directly into the back of the knee during surgery.
Because I perform approximately 85 ACL reconstructions a year, I've made a habit of deliberately inspecting that hidden corner every single time, rather than trusting the MRI report to have found everything.
Repair vs. remove: the real tradeoff
I want to be honest about this, because repairing a meniscus is not a free lunch. It asks more of the patient. When I repair a tear, the stitches need time to heal to living tissue, which means a more protected recovery — restricted weightbearing and limits on deep bending for several weeks. Trimming a tear out lets someone walk out faster.
The reason I still push toward repair whenever the tissue supports it is that the short-term convenience of removal is paid back with interest in the long-term health of the knee.
| Trim it out (meniscectomy) | Repair it | |
|---|---|---|
| Recovery speed | Faster — back to activity in weeks | Slower — protected for ~4–6 months |
| Cartilage protection | Reduced — removes the cushion | Preserved |
| Long-term arthritis risk | Higher over time | Lower |
| Best suited for | Small, frayed, unrepairable tears | Root, ramp, and peripheral tears with blood supply |
| The knee at 10 years | More wear | Better protected |
Who I recommend repair for
Not every tear can be saved, and I won't pretend otherwise. A small, degenerative flap in poor tissue with no blood supply won't heal no matter how carefully I stitch it, and forcing a repair there just means a second surgery. But the tears that genuinely benefit from repair — root tears, ramp lesions, and peripheral tears in the well-vascularized outer zone — are exactly the ones I want to catch and fix.
My training at the Hospital for Special Surgery and my years as an assistant team physician with the New York Giants drilled the same lesson: in an active knee, meniscus tissue is worth fighting for. I lean toward repair for younger and active patients, for anyone with a root or ramp tear, and especially for the meniscus tears I find alongside an ACL reconstruction, where fixing both at once gives the knee its best long-term shot.
Frequently asked questions
Can every meniscus tear be repaired?
No. Repair works when the tear is in tissue with a good blood supply and the fibers are healthy enough to hold stitches. Small, frayed, or degenerative tears in poor tissue often can't heal, and in those cases a careful trim is the better choice. I make that call based on what the tear actually looks like at surgery.
Why is a root tear such a big deal?
The root anchors the meniscus to bone. When it tears, the meniscus can no longer spread load — so even though it's still there, the knee acts as if the whole meniscus is gone. That's why an untreated root tear can lead to rapid arthritis, and why I prioritize repairing them.
Will a repair really slow down my recovery?
Somewhat, yes. A repair needs to heal to living tissue, so I protect it with limited weightbearing and restricted deep bending for several weeks — often four to six months before full return to sport. Trimming a tear out is faster in the short term, but the repair pays off in the long-term health of your knee.
Do you check the meniscus during ACL surgery?
Every time. Ramp lesions ride along with ACL tears and are frequently missed on MRI, so I directly inspect the back of the knee during every reconstruction. If I find a ramp or root tear, I repair it in the same operation — fixing both together gives the knee its best long-term outcome.
If you've been told you have a meniscus tear — or you're facing ACL surgery and want to understand what else might be going on inside the knee — I'm always happy to walk through your imaging with you and talk honestly about whether your tear is one we can save. The decision we make in the operating room today is really a decision about the knee you'll be walking on decades from now.
References
- Poulsen E, Goncalves GH, Bricca A, et al. Knee osteoarthritis risk is increased 4-6 fold after knee injury: a systematic review and meta-analysis. Br J Sports Med. 2019;53(23):1454-1463. doi:10.1136/bjsports-2018-100022
- Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus: similar to total meniscectomy. J Bone Joint Surg Am. 2008;90(9):1922-1931. doi:10.2106/JBJS.G.00748
- Krych AJ, Reardon PJ, Johnson NR, et al. Non-operative management of medial meniscus posterior horn root tears is associated with worsening arthritis and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):383-389. doi:10.1007/s00167-016-4359-8
- 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. Am J Sports Med. 2018;46(13):3189-3197. doi:10.1177/0363546518800717
- Moteshakereh SM, Zarei H, Nosratpour M, et al. Evaluating the diagnostic performance of MRI for identification of meniscal ramp lesions in ACL-deficient knees: a systematic review and meta-analysis. J Bone Joint Surg Am. 2024;106(12):1117-1127. doi:10.2106/JBJS.23.00501
- DePhillipo NN, Cinque ME, Chahla J, et al. Incidence and detection of meniscal ramp lesions on magnetic resonance imaging in patients with anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(10):2233-2237. doi:10.1177/0363546517704426
- Englund M, Guermazi A, Roemer FW, et al. Meniscal tear in knees without surgery and the development of radiographic osteoarthritis among middle-aged and elderly persons: the Multicenter Osteoarthritis Study. Arthritis Rheum. 2009;60(3):831-839. doi:10.1002/art.24383
This article is general education, not medical advice for your situation. Every knee and hip is different — talk with your own doctor about your care.