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TC(997).(05).Orthopedics Case No 75. Meniscus Tear

Meniscus Tear — বাংলায় ক্লিনিক্যাল নোট

Meniscus tear হলো হাঁটুর ভিতরে থাকা C-shaped fibrocartilage — medial meniscus বা lateral meniscus — ছিঁড়ে যাওয়া। Meniscus হাঁটুর shock absorber, joint congruity, load distribution, stability ও proprioception বজায় রাখে। তাই tear হলে pain, swelling, locking/clicking এবং knee instability হতে পারে। Traumatic tear সাধারণত twisting/pivoting injury থেকে হয়, আর degenerative tear বয়স, osteoarthritis ও repetitive microtrauma থেকে ধীরে ধীরে হয়।

1. Definition — সংজ্ঞা

Meniscus tear = হাঁটুর medial বা lateral meniscus-এর partial বা complete rupture/tear, যার ফলে হাঁটুর pain, swelling, mechanical symptoms এবং movement limitation হতে পারে।

Core meaning:
হাঁটুর ভিতরের “cartilage cushion” ছিঁড়ে গেলে সেটাই meniscus tear।

2. Causes / Etiology — কারণগুলো

  1. Twisting injury / pivoting movement
    ফুটবল, ক্রিকেট, basketball, badminton, sudden turn, squatting থেকে হাঁটু rotate হলে meniscus tear হতে পারে।
  2. Deep squat থেকে উঠা
    squat অবস্থায় knee flexion + rotation হলে posterior horn medial meniscus বেশি vulnerable।
  3. Sports injury
    sudden stop, cutting movement, jump landing, tackle বা direct blow।
  4. ACL injury-এর সাথে meniscus tear
    acute ACL tear থাকলে lateral meniscus tear বেশি দেখা যায়; chronic ACL-deficient knee-তে medial meniscus বেশি ক্ষতিগ্রস্ত হতে পারে।
  5. Degenerative meniscal lesion
    বয়স বাড়া, osteoarthritis, obesity, varus knee, repetitive microtrauma—এগুলোতে meniscus দুর্বল হয়ে সামান্য movement-এও tear হতে পারে। ESSKA traumatic tear ও degenerative lesion আলাদা করে দেখে, কারণ management ভিন্ন।
  6. Occupational kneeling / heavy work
    যারা বারবার kneel/squat করেন, heavy lifting করেন, তাদের risk বেশি।
  7. Previous knee injury or surgery
    আগের ligament injury, meniscal repair/meniscectomy, malalignment থাকলে recurrence বা degeneration হতে পারে।

3. Symptoms — লক্ষণগুলো

  1. Joint-line pain
    হাঁটুর ভেতরের পাশে ব্যথা হলে medial meniscus, বাইরের পাশে হলে lateral meniscus suspected।
  2. Swelling / effusion
    injury-এর কয়েক ঘণ্টা থেকে ২৪–৪৮ ঘণ্টার মধ্যে swelling হতে পারে; meniscus tear-এ delayed/intermittent swelling common।
  3. Locking
    হাঁটু পুরোপুরি সোজা করতে না পারা—especially bucket-handle tear-এ urgent orthopedic review দরকার।
  4. Clicking / popping / catching
    হাঁটু বাঁকানো, সিঁড়ি ওঠা, squat করার সময় click/catch অনুভূত হয়।
  5. Giving way / instability feeling
    রোগী বলে: “হাঁটু ভেঙে যাচ্ছে/সাপোর্ট দিচ্ছে না।”
  6. Pain with squatting or twisting
    নামাজের বসা, squat toilet, নিচু হয়ে কাজ, খেলাধুলায় pain বাড়ে।
  7. Reduced range of motion
    flexion/extension painful বা limited হতে পারে।
  8. Recurrent pain after activity
    হাঁটা বা খেলাধুলার পরে swelling ও pain ফিরে আসে।

4. Clinically Diagnosis — ক্লিনিক্যাল ডায়াগনোসিস

AAOS 2024 guideline অনুযায়ী joint-line tenderness, McMurray test ও Thessaly test একসাথে করলে acute meniscal tear diagnose করতে clinically helpful; MRI preferred imaging modality।

History

  1. Injury mechanism: twisting, pivoting, squatting, sports trauma
  2. Pain site: medial/lateral joint line
  3. Swelling timing: immediate হলে ACL/fracture ভাবতে হবে; delayed হলে meniscus বেশি likely
  4. Mechanical symptoms: locking, catching, clicking
  5. Functional limitation: stairs, squat, walking, sports
  6. Previous knee injury/OA history

Physical examination

  1. Joint line tenderness
    সবচেয়ে sensitive clinical signগুলোর একটি; medial/lateral joint line palpation করলে pain।
  2. McMurray test
    Knee flexion → tibial rotation → extension; pain/click হলে positive। medial meniscus test করতে tibia externally rotate করা হয়।
  3. Thessaly test at 20° knee flexion
    রোগী affected leg-এ দাঁড়িয়ে body rotate করবে; pain/click/locking হলে positive।
  4. Apley compression test
    Prone position, knee 90° flexion, tibial compression + rotation; pain হলে meniscal pathology suspect।
  5. Effusion test
    Patellar tap / bulge sign।
  6. ROM test
    Full extension block থাকলে displaced bucket-handle tear suspect।
  7. Ligament test must be done
    Lachman, anterior drawer, pivot shift — ACL associated injury exclude করার জন্য।

5. Investigations — নির্দিষ্টভাবে কী কী করবেন

  1. X-ray knee — AP, lateral, skyline/merchant, weight-bearing view
    Meniscus directly দেখা যায় না; fracture, osteoarthritis, loose body, chondrocalcinosis exclude করার জন্য। Young acute meniscal injury-তে X-ray normal থাকতে পারে।
  2. MRI knee without contrast — best imaging
    Meniscus tear, ACL/PCL injury, cartilage injury, bone bruise, root tear, bucket-handle tear দেখতে best। AAOS guideline MRI-কে preferred imaging modality বলেছে; CT arthrography/US MRI unavailable বা contraindicated হলে বিকল্প।
  3. MRI findings
    Grade III signal extending to superior/inferior articular surface = tear; bucket-handle tear-এ double PCL sign; root tear-এ meniscal extrusion/ghost sign দেখা যেতে পারে।
  4. Ultrasound
    Effusion, parameniscal cyst দেখতে সাহায্য করতে পারে; meniscal tear diagnosis-এর জন্য MRI-এর substitute নয়, তবে MRI contraindicated হলে adjunct।
  5. Diagnostic arthroscopy
    Purely diagnostic হিসেবে এখন কম করা হয়; usually therapeutic arthroscopy—repair/partial meniscectomy করতে হলে।
  6. Lab test
    Routine দরকার নেই। Fever, hot swollen knee, severe inflammatory picture থাকলে CBC, ESR/CRP, serum uric acid, joint aspiration for Gram stain/culture/crystal analysis করা উচিত।

6. Differential Diagnosis — কোন রোগগুলো exclude করবেন

  1. ACL tear
  2. MCL/LCL sprain
  3. Osteoarthritis flare
  4. Patellofemoral pain syndrome
  5. Plica syndrome
  6. Osteochondral lesion / loose body
  7. Tibial plateau fracture
  8. Septic arthritis
  9. Gout / pseudogout
  10. Pes anserine bursitis

7. Complications — জটিলতা

  1. Chronic pain and recurrent swelling
    Tear untreated থাকলে knee effusion বারবার হতে পারে।
  2. Mechanical locking
    Displaced bucket-handle tear knee extension block করতে পারে।
  3. Quadriceps wasting
    pain ও disuse-এর কারণে thigh muscle দুর্বল হয়।
  4. Cartilage damage
    torn fragment joint surface ঘষে cartilage injury করতে পারে।
  5. Early osteoarthritis
    Meniscal tear ও meniscectomy—দুটিই knee joint degeneration/OA risk বাড়াতে পারে; তাই surgery করলে যতটা সম্ভব meniscus preserve করা guideline-based।
  6. Meniscal cyst
    Horizontal tear-এর সাথে parameniscal cyst হতে পারে।
  7. Reduced sports/work performance
    pivoting, kneeling, squatting, long walking সীমিত হয়।

8. Treatment / Management

A. Non-pharmacological management

  1. Acute phase: PRICE
    Protection, Rest, Ice 15–20 min, Compression bandage, Elevation — প্রথম 48–72 ঘণ্টা।
  2. Activity modification
    squat, kneeling, running, pivoting, jump landing বন্ধ।
  3. Physiotherapy
    quadriceps strengthening, hamstring strengthening, hip abductor strengthening, ROM exercise, proprioception/balance training।
  4. Brace / crutch
    painful walking হলে short-term crutch; locking থাকলে urgent ortho referral।
  5. Weight reduction
    degenerative meniscal lesion/OA থাকলে weight control pain কমায়।
  6. Surgery
    Traumatic repairable tear-এ meniscus repair preferred, কারণ preservation করলে long-term OA risk কমতে পারে। Partial meniscectomy শুধু irreparable complex/degenerative/flap/non-reducible bucket-handle tear-এ বিবেচনা।
  7. Degenerative meniscal tear
    Exercise-based rehab first-line; degenerative knee disease/meniscal tear-এ arthroscopic surgery প্রায় সব রোগীর জন্য routine recommended নয়—BMJ guideline strong recommendation against arthroscopy দিয়েছে।

9. Pharmacological Treatment — Bangladesh Brand সহ

Important: নিচের dose adult general dose. CKD, peptic ulcer, anticoagulant use, uncontrolled HTN, IHD, pregnancy, asthma, liver disease, elderly patient—এসব ক্ষেত্রে dose/choice পরিবর্তন হবে। Meniscus tear-এ drug tear heal করে না; pain ও inflammation control করে rehab সম্ভব করে।

9.1 Pain control: mild to moderate pain

DrugDetails
Generic name: ParacetamolTherapeutic category: Analgesic + antipyretic. Pharmacological class: Para-aminophenol derivative / non-opioid analgesic.
Bangladesh available brand examplesNapa 500 mg/665 ER/1000 mg, Ace 500 mg, Renova 500 mg, Fast 500 mg, Xpa 500 mg — MedEx-listed brands.
Dose & duration500 mg–1 g PO every 6 hours PRN; max 4 g/day. Usually 3–5 days. Low body weight, chronic alcohol use, liver disease, elderly: safer max often 2–3 g/day. NICE BNF adult dose: 0.5–1 g every 4–6 h, max 4 g/day.
কেন used হয়First-line pain relief; gastric ulcer/CKD risk থাকলে NSAID-এর তুলনায় safer, কিন্তু anti-inflammatory effect weak।
Side effectsUsually safe; overdose → hepatotoxicity, acute liver failure. Rare rash, thrombocytopenia।
InteractionsAlcohol, enzyme-inducing antiepileptics, rifampicin → hepatotoxicity risk; long-term regular high-dose paracetamol warfarin effect বাড়াতে পারে।

9.2 NSAIDs — pain + inflammation

Ibuprofen

DrugDetails
Generic name: Ibuprofen
Therapeutic categoryNSAID; drugs for pain/inflammation, OA/RA pain.
Pharmacological classPropionic acid derivative NSAID; COX inhibition → prostaglandin synthesis কমায়।
Bangladesh available brand examplesProfen 400 mg, Flamex 400 mg, Reumafen 400 mg, Neurofen 400 mg, Intaflam 400 mg — MedEx-listed.
Dose & duration400 mg PO TDS after food for 3–5 days; use lowest effective dose. NICE/NHS adult pain dose commonly 200–400 mg up to 3 times/day.
কেন used হয়Acute knee pain + inflammatory swelling কমাতে।
Side effectsDyspepsia, gastritis, peptic ulcer/GI bleed, renal impairment, fluid retention, BP increase, bronchospasm in NSAID-sensitive asthma।
InteractionsWarfarin/DOAC/aspirin/clopidogrel/steroid/SSRI → GI bleed risk; ACEi/ARB + diuretic → AKI risk; lithium, methotrexate, cyclosporine toxicity; অন্য NSAID-এর সাথে combine করবেন না।

Naproxen

DrugDetails
Generic name: Naproxen / Naproxen sodium
Therapeutic categoryNSAID; drugs for osteoarthritis/rheumatoid arthritis/pain.
Pharmacological classPropionic acid derivative NSAID.
Bangladesh available brand examplesNaprox 500 mg, Naproxen 500 mg, Naproson 250 mg; Naprox Plus/Naxin Plus 500 mg + Esomeprazole 20 mg combination exists.
Dose & duration250–500 mg PO BD after food for 5–7 days; max usually 1000 mg/day for musculoskeletal pain. NHS mentions joint conditions 500–1000 mg/day.
কেন used হয়Longer duration NSAID; inflammatory knee painে useful।
Side effectsGastritis, ulcer, GI bleed, renal injury, edema, BP increase.
InteractionsSame NSAID interactions; anticoagulants, antiplatelets, steroid, SSRI, ACEi/ARB + diuretic, lithium, methotrexate।

Diclofenac sodium — oral/topical

DrugDetails
Generic name: Diclofenac sodium
Therapeutic categoryNSAID; drugs for OA/RA, musculoskeletal inflammation.
Pharmacological classPhenylacetic/acetic acid derivative NSAID.
Bangladesh available brand examplesDiclofen 50 mg, A-Fenac 50 mg, Difenac 50 mg, G-Diclofenac 50 mg; topical Voligel 1% gel 50 g.
Dose & durationOral: 50 mg PO BD/TDS after food for 3–5 days; max 150 mg/day. Topical gel: 2–4 g over painful area TDS/QID for 7–14 days. MedEx lists adult oral 75–150 mg/day and gel 2–4 g 3–4 times/day.
কেন used হয়Pain + inflammation; topical form localized painে systemic side effect কম।
Side effectsGI bleed, dyspepsia, renal injury, edema, BP/CV risk; topical: skin irritation।
InteractionsLithium/digoxin level increase, anticoagulant bleeding risk, cyclosporine nephrotoxicity, methotrexate toxicity—MedEx notes these interactions.

Aceclofenac

DrugDetails
Generic name: Aceclofenac
Therapeutic categoryNSAID; pain and inflammation in OA/RA/trauma.
Pharmacological classPhenylacetic acid derivative NSAID; COX/prostaglandin inhibition.
Bangladesh available brand examplesDolonac 100 mg, Flexi 100 mg, Reservix SR 200 mg, Xerifen 100 mg.
Dose & duration100 mg PO BD after food for 3–5 days; BNF adult dose 100 mg twice daily.
কেন used হয়Knee trauma/inflammation pain control; BD prescriptions-এ common NSAID।
Side effectsGastritis, nausea, abdominal pain, ulcer/GI bleed, renal impairment, liver enzyme rise, rash।
InteractionsLithium/digoxin, diuretics, anticoagulants, methotrexate—MedEx lists close monitoring.

Etoricoxib

DrugDetails
Generic name: Etoricoxib
Therapeutic categoryNSAID / selective COX-2 inhibitor.
Pharmacological classCOX-2 selective inhibitor.
Bangladesh available brand examplesTory 60/90/120 mg, Etorix 90/120 mg, Setorib 60/90/120 mg, Ribox 60/90/120 mg, E-coxib 60/90/120 mg.
Dose & durationOA-type pain: 30–60 mg OD; severe acute inflammatory pain: 90 mg OD short course by physician. BNF OA dose: 30 mg OD, increased to 60 mg OD if needed.
কেন used হয়GI intolerance risk থাকলে selected patient-এ NSAID alternative; once daily।
Side effectsBP increase, edema, renal impairment, dyspepsia; CV risk—uncontrolled HTN/IHD/stroke historyে avoid।
InteractionsWarfarin/anticoagulants bleeding risk, ACEi/ARB + diuretic renal risk, lithium, methotrexate; alcohol unsafe noted in MedEx result.

9.3 Gastroprotection with NSAID

DrugDetails
Generic name: Pantoprazole
Therapeutic category:Anti-ulcerant / PPI
Pharmacological class:Proton pump inhibitor; gastric H+/K+ ATPase inhibition
Bangladesh available brand examplesPantolok 20/40 mg, Protocid 40 mg, Trupan 40 mg injection.
Dose & duration20–40 mg PO OD 30 min before breakfast while NSAID is used; high GI-risk patientে 20 mg OD prophylaxis. MedEx lists NSAID-associated gastric/duodenal ulcer prophylaxis 20 mg daily.
কেন used হয়NSAID-induced gastritis/ulcer/GI bleed risk কমাতে।
Side effectsHeadache, diarrhea/constipation; long-term: hypomagnesemia, B12 deficiency, fracture risk, C. difficile risk।
InteractionsWarfarin/INR monitoring; clopidogrel interaction omeprazole-এর চেয়ে pantoprazole কম problematic, তবু caution।

9.4 Severe pain / short-term rescue analgesic

Tramadol

DrugDetails
Generic name: Tramadol hydrochloride
Therapeutic categoryOpioid analgesic / centrally acting analgesic
Pharmacological classμ-opioid agonist + serotonin/noradrenaline reuptake inhibition
Bangladesh available brand examplesAnadol 50 mg capsule, Trado 50 mg capsule / 100 mg/2 ml injection, Utramal 50 mg capsule / 100 mg suppository / 100 mg/2 ml injection, Lucidol 50 mg capsule / 100 mg/2 ml injection.
Dose & duration50 mg PO every 6–8 h PRN; severe painে 50–100 mg every 4–6 h; max 400 mg/day. Use 1–3 days only if needed. BNF/MedEx both max 400 mg/day উল্লেখ করে।
কেন used হয়NSAID contraindicated বা severe acute pain/post-op painে short-term rescue; routine meniscus tear painে first-line নয়।
Side effectsNausea, vomiting, dizziness, sedation, constipation, respiratory depression, seizure, dependence।
InteractionsAlcohol, benzodiazepine, sedatives, other opioids → respiratory depression; SSRI/SNRI/MAOI/linezolid → serotonin syndrome; epilepsyে caution।

Ketorolac

DrugDetails
Generic name: Ketorolac tromethamine
Therapeutic categoryPotent NSAID analgesic
Pharmacological classPyrrolo-pyrrole NSAID; COX inhibition
Bangladesh available brand examplesToroaid 10 mg tablet, Ketorolac 10 mg tablet, Torax 30 mg/ml injection, Todol 30 mg/ml injection.
Dose & duration10 mg PO every 6 h PRN; max 40 mg/day; total duration ≤5 days. Injection only physician/hospital setting.
কেন used হয়Severe acute pain/post-operative pain; chronic knee painে ব্যবহার করা উচিত নয়।
Side effectsHigh GI bleed risk, renal injury, platelet inhibition/bleeding, bronchospasm।
InteractionsOther NSAIDs/aspirin, anticoagulants, antiplatelets, steroid, SSRI, ACEi/ARB + diuretic, lithium/methotrexate।

9.5 Intra-articular steroid — selected cases only

Meniscus tear নিজে steroid দিয়ে heal হয় না। Degenerative meniscal lesion + OA flare/effusion/synovitis থাকলে, infection exclude করে, specialist intra-articular steroid দিতে পারেন।

DrugDetails
Generic name: Triamcinolone acetonide injection
Therapeutic categoryCorticosteroid anti-inflammatory
Pharmacological classSynthetic glucocorticoid
Bangladesh available brand examplesCenolon 40 mg/ml, Alfacort 40 mg/ml, Trialon 40 mg/ml, Triacin 40 mg/ml, Triamon 40 mg/ml.
DoseKnee IA commonly 20–40 mg single injection; BNF allows adult IA 5–40 mg, max 80 mg depending on joint size.
কেন used হয়OA/synovitis-related pain ও effusion কমাতে short-term relief।
Side effectsPost-injection flare, infection, transient hyperglycemia, skin atrophy, repeated injectionে cartilage harm risk।
Interactions/cautionDiabetes, anticoagulant use, active infection, septic arthritis suspicion, uncontrolled hyperglycemia।
DrugDetails
Generic name: Methylprednisolone acetate
Therapeutic categoryCorticosteroid anti-inflammatory
Pharmacological classSynthetic glucocorticoid depot injection
Bangladesh available brand examplesDepo-Medrol 40 mg/ml or 80 mg/2 ml, Depomed 40 mg/ml or 80 mg/2 ml, Depo-pred 40 mg/ml.
DoseKnee large joint IA often 20–40 mg, sometimes up to 80 mg depending on severity/joint size; product guidance lists large joint 20–80 mg.
কেন used হয়Degenerative OA flare/effusionে short-term anti-inflammatory relief।
Side effects/interactionsSame as above; aseptic technique mandatory।

10. Bangladesh doctors commonly use — practical prescription groups

এটি educational list, final prescription নয়। Patient-specific contraindication দেখে prescribe করতে হবে।

  1. Mild pain, no major swelling
    • Paracetamol 500 mg–1 g PRN
    • Topical diclofenac gel
    • PRICE + physiotherapy
      কেন: pain control, systemic NSAID avoid করা যায়।
  2. Moderate inflammatory knee pain/swelling
    • One NSAID only: Ibuprofen / Naproxen / Aceclofenac / Diclofenac / Etoricoxib
    • Add PPI if GI risk or NSAID course needed
      কেন: prostaglandin-mediated inflammation ও pain কমে; rehab easier হয়।
  3. Severe acute pain / post-trauma pain
    • Paracetamol + short course NSAID
    • Rescue: Tramadol short-term or Ketorolac only selected severe cases
      কেন: severe pain control; তবে dependency/GI-renal risk থাকায় short-term।
  4. Degenerative meniscal lesion + OA flare/effusion
    • Paracetamol/topical NSAID ± short oral NSAID
    • Physiotherapy + weight reduction
    • Selected case: intra-articular steroid by specialist
      কেন: OA/synovitis-driven pain control; meniscus healing নয়।
  5. Locked knee / bucket-handle tear / displaced tear
    • Analgesia only temporary
    • Urgent orthopedic referral for arthroscopic repair/management
      কেন: mechanical block medicine দিয়ে ঠিক হয় না।

11. Prevention — কীভাবে প্রতিরোধ করবেন

  1. Exercise-এর আগে warm-up এবং dynamic stretching।
  2. Quadriceps, hamstring, gluteus medius strengthening।
  3. Sudden twisting/pivoting কমানো; sports technique ঠিক করা।
  4. Squat করলে knee alignment ঠিক রাখা—knee যেন ভিতরে collapse না করে।
  5. Obesity থাকলে weight reduction।
  6. Proper footwear; uneven ground এ running avoid।
  7. ACL injury থাকলে যথাযথ rehab/brace/surgery plan।
  8. Heavy occupational kneeling করলে knee pad ব্যবহার।
  9. Previous meniscus injury থাকলে return-to-sport ধীরে ধীরে, physiotherapist clearance নিয়ে।
  10. Degenerative knee pain থাকলে repeated deep squat, squat toilet, heavy stair climbing কমানো।

12. Overview / Summary

Meniscus tear হলো হাঁটুর fibrocartilage cushion-এর rupture। প্রধান লক্ষণ হলো joint-line pain, swelling, locking/catching, clicking এবং squat/stairs-এ pain। Clinical diagnosis history + joint-line tenderness + McMurray/Thessaly/Apley test দিয়ে করা হয়; MRI হলো preferred investigation। Treatment-এর মূল হলো PRICE, physiotherapy, activity modification, pain control; traumatic repairable tear-এ meniscus preservation/repair preferred, আর degenerative tear-এ conservative rehab first-line।

13. Actionable Plan / Steps

  1. Acute injury হলে: 48–72 ঘণ্টা PRICE, weight-bearing কমানো, painful squat/twist বন্ধ।
  2. Clinical exam করুন: joint line tenderness, McMurray, Thessaly, effusion, ROM, ACL/MCL testing।
  3. X-ray করুন: fracture/OA/loose body exclude করতে।
  4. MRI করুন: locking, persistent swelling/pain, sports injury, suspected ACL/root/bucket-handle tear, surgery planning থাকলে।
  5. Medicine: paracetamol ± one NSAID ± PPI; two NSAID একসাথে নয়।
  6. Physiotherapy: ROM → quadriceps/hamstring strengthening → proprioception → sport-specific training।
  7. Urgent ortho referral: locked knee, extension block, severe swelling, suspected bucket-handle/root tear, ACL-associated injury, failed conservative treatment 4–6 weeks।

14. Reference List

  1. Textbook: Miller MD, Thompson SR. DeLee, Drez & Miller’s Orthopaedic Sports Medicine: Principles and Practice. 5th ed. Elsevier; 2019.
  2. Textbook: Canale ST, Beaty JH, Azar FM. Campbell’s Operative Orthopaedics. 14th ed. Elsevier; 2021.
  3. Guideline: American Academy of Orthopaedic Surgeons. Clinical Practice Guideline: Management of Acute Isolated Meniscal Pathology. Published June 10, 2024.
  4. Consensus / DOI: Kopf S, Beaufils P, Hirschmann MT, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2020;28:1177–1194. DOI: 10.1007/s00167-020-05847-3.
  5. Guideline / DOI: Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017;357:j1982. DOI: 10.1136/bmj.j1982.
  6. Imaging guideline: American College of Radiology. ACR Appropriateness Criteria: Chronic Knee Pain.
  7. Drug reference: NICE BNF: Paracetamol, Ibuprofen, Naproxen, Diclofenac, Aceclofenac, Etoricoxib, Pantoprazole, Tramadol, Triamcinolone dosing pages.
  8. Bangladesh brand reference: MedEx Bangladesh drug index pages for listed brands/generics.

Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday,Time:-03-27-12 Pm

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