Dr. Pomeranz's Ultimate Guide to :

MRI of the Knee

Vertical Tear

A vertical tear (or longitudinal vertical meniscal tear) progresses in a vertical or craniocaudal orientation parallel to the meniscal edge.3




Vertical Tear: Injury

Injuries are more common in younger patients post knee trauma3, and in the posterior horns1 especially in the meniscus outer third with a pivot shift. Injuries are typically associated with significant traumas such as ACL tears.3




Vertical Tear: MRI

Increased signal intensity of a vertical line that makes contact with superior and/or inferior surfaces.3 Length varies.




Vertical Tear: Differentials and Pitfalls

A vertical tear may be longitudinal or radial, as both demonstrate vertical signal. However, a radial tear typically aligns perpendicular to the longitudinal axis of the C-shaped meniscus and thus demonstrates corresponding signal on coronal images seen as a "gap" defect or area of truncation. Mimics include the normal popliteal hiatus, the normal meniscofemoral ligament (Wrisberg and Humphrey) attachment, abnormal meniscocapsular separation, and a normal vascular pedicle in the outer meniscal third (seen in children).
The meniscofemoral ligament is called the Humphrey ligament if it passes anterior to PCL, and the Wrisberg ligament if it passes posterior to PCL. Both may coexist in less than 20 percent of the population. The meniscofemoral ligaments extend between the lateral meniscus posterior horn and intercondylar notch aspect of the medial femoral condyle. The vertical signal between the posterior horn of the lateral meniscus and the Wrisberg ligament may persist on one or two slices depending on the slice thickness and gap, and may be mistaken for a vertical tear. Vertical signal persisting for more than 1-2 slices from the posterosuperior meniscus attachment is a variant of a vertical tear seen with pivot shift inquiries called a "Wrisberg rip tear".
Normal vascular pedicle is seen as prominent signal in the posterior horn of the medial meniscus and does not communicate with the articular surface.




Vertical Tear: Treatment

Small, nondisplaced red zone tears usually heal spontaneously. Meniscal suture repair is the preferred treatment. Meniscectomy may be required for unstable or large radial tears, but meniscectomy should be avoided when possible.




Vertical Tear: References

  1. Nguyen JC, De Smet AA, Graf BK et-al. MR imaging-based diagnosis and classification of meniscal tears. Radiographics. 2014;34 (4): 981-99.
  2. Pomeranz SJ. Gamuts & Pearls in MRI & Orthopedics. Ohio, The Merten Company, 1997.
  3. Weerakkody Y., et-al. Meniscal Root Tear: Radiopaedia (sourced 10Jan2018):



Vertical Tear: Example

A 16-year-old male with football injury to the knee. MRI study demonstrated concomitant typical pivot-shift bone injuries (green arrows), complete ACL tear (not shown), and vertical tear of the medial meniscus (orange arrow).
Image 1 - Sagittal PD NEW SPIR
Vertical meniscus tears are most commonly seen in adolescents and active young people and usually caused by trauma, such as shear force during pivot-shift injuries; as the tibia translates anteriorly, the femur will "rip" the posterior horn outer third segment vertically, and as the tibia returns to its usual position, the meniscal fragment will resume its position. Vertical tears usually start in the posterior horn, but may propagate to body and eventually anterior horn. They involve the outer (red) zone. Inner edge (white zone) involvement is very rare unless radial subtype. Vertical tears demonstrate parallel course along the length of the meniscus, and, if long enough and gapped, may progress to unstable bucket-handle tears. This type of tear demonstrates high incidence of concomitant ACL tear. Vertical tears are best seen on sagittal images, as vertical high signal communicating with one or two intra articular surfaces on short TE sequences. So, vertical longitudinal tears may be partial or full thickness if one or both superior and inferior surfaces are involved.