Introduction
- Frank R. Noyes, MD
Epidemiology
- •
Meniscus tears are among the most common injuries treated by orthopaedic surgeons.
- •
Approximately 1 million meniscal surgeries are performed each year, with more than 50% done in patients 45 years of age or older.
- •
It has been estimated that the incidence of meniscus tears in athletes is 61 in 100,000.
- •
Although early studies reported a male-female ratio of this injury of 3 : 1, more recent data suggest a fairly even distribution according to gender.
- •
Approximately 60% of meniscus tears occur in patients aged 20 to 49.
- •
Meniscus tears usually occur in two demographic populations: young, active patients who sustain a specific knee injury (usually during sports) and patients who are greater than 50 years of age who never had an injury, but develop degenerative tears
- •
Asymptomatic degenerative tears are common in middle-aged and older adult patients.
- •
Common sports associated with meniscus tears are soccer, skiing, handball, basketball, wrestling, football, gymnastics, and tennis.
Pathophysiology
Intrinsic Factors
- •
Acute ACL rupture: associated meniscus tears in approximately 60%
- •
Chronic ACL deficiency: increased shear forces, risk of giving-way
- •
Varus (medial meniscus) or valgus (lateral meniscus) malalignment
Traumatic Factors
- •
Common mechanisms include a sudden twist, change in direction, jumping, pivoting, or deep knee flexion.
- •
Commonly occurs with other knee injuries such as an ACL rupture.
Classic Pathological Findings
- •
Tibiofemoral joint line pain
- •
Locking or clicking medial or lateral tibiofemoral compartment
- •
Posterior knee pain with flexion greater than 90°
- •
Knee effusion
- •
Lack of pain-free extension
Clinical Presentation
History
- •
Knee injury involving sudden twist, change in direction, jumping, pivoting, or deep knee flexion
- •
Frequently encountered in knees with ACL ruptures
- •
Tibiofemoral joint line pain, swelling, locking, catching
Physical Examination
Abnormal Findings
- •
Tibiofemoral joint line pain on palpation
- •
Pain with full flexion
- •
Lack of pain-free full knee extension
- •
Positive McMurray test: internal or external rotation knee flexion produces pain, clicking, crepitus
- •
Meniscal displacement during joint compression indicated by popping, clicking, catching
- •
Tenderness on palpation at the posterolateral aspect of the joint at the anatomic site of the popliteomeniscal attachments
Pertinent Normal Findings
- •
Symptoms: lack of pain with activities, rotational knee movements
- •
No joint line tenderness
- •
Negative provocative meniscus tests (McMurray)
- •
Full knee motion without pain
Imaging
- •
Radiographs: lateral 30° of flexion, patellofemoral axial, weight bearing posteroanterior 45° of flexion
- •
Knees with varus or valgus malalignment: full standing hip-knee-ankle weight-bearing radiographs to measure weight-bearing line, mechanical axis
- •
MRI using a proton-density weighted, high-resolution, fast-spin echo sequence or similar techniques for enhanced articular cartilage resolution
Differential Diagnosis
- •
Medial or lateral ligament acute tear producing tibiofemoral joint pain
- •
Saphenous neuritis, complex regional pain syndrome producing medial pain, tenderness to palpation
- •
Lateral patellofemoral subluxation syndrome producing pain in medial retinacular structures, medial patellar-meniscal ligament attachments (pain anterior to superficial medial collateral ligament)
- •
Medial tibial stress fracture, pes tendonitis with pain along anteromedial tibial region just distal to joint line
- •
Lateral iliotibial band friction syndrome with pain, tenderness just proximal to lateral tibiofemoral joint
Treatment
Nonoperative Management
- •
Rest, activity modification
- •
Oral nonsteroidal antiinflammatory medications
- •
Physical therapy
Guidelines for Choosing Among Nonoperative Treatments
- •
Degenerative meniscus tears with positive MRI, often asymptomatic; do not require surgery ( Figure 30-1 )
FIGURE 30-1
A degenerative longitudinal medial meniscus tear in a 55 year-old woman.
(Reprinted with permission from Noyes FR, Barber-Westin SD: Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-3-G.)
- •
Degenerative meniscus tears with episodic pain, clicking in sedentary patient
- •
Patient willing to modify activities
- •
Patient unwilling to undergo arthroscopy
- •
Patient unwilling or unable to follow postoperative rehabilitation program
- •
Severe loss tibiofemoral joint space, majority of symptoms related to arthritis
Surgical Indications
- •
Unstable meniscus tear (locking, pain, giving way), particularly in younger or active patient who will usually require meniscectomy if intervention not performed using meniscus repair
- •
Unresolved tibiofemoral joint pain
- •
Giving way, recurrent joint effusion
- •
Associated painful meniscus cyst
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Patient requires functional, pain-free knee as soon as possible for occupation or sports activities.
- •
Failed conservative treatment, unresolved tibiofemoral joint pain more than 2 months
- •
Patient willing to comply with postoperative rehabilitation, activity restrictions
- •
Degenerative tears, delay surgery if symptoms are episodic, livable
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Tear must be classified according to type, location, quality of tissue, damage to meniscus tissue and remaining meniscus bed in order to decide on repair versus excision ( Figure 30-2 ).
FIGURE 30-2
Illustrations of the common complex and avascular meniscus tear patterns. Note the single-plane configuration of the single longitudinal and radial tears and the multiplane (complex) configuration of the double longitudinal and flap tears.
(Redrawn with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-1.)
- •
Peripheral single longitudinal tears: repairable in all cases, high success rate ( Figure 30-3 )
FIGURE 30-3
Double-stacked vertical suture pattern used in the repair of longitudinal meniscus tears. A, The superior sutures are placed first to close the superior gap and to reduce the meniscus to its bed. B, Then, the inferior suture is placed through the tear to close the inferior gap.
(Redrawn with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-10.)
- •
Middle third region, complex tears (horizontal, flap, radial, double and triple longitudinal) often repairable, evaluate individual basis ( Figures 30-4, 30-5, 30-6 )
FIGURE 30-4
Double-stacked repair technique for double longitudinal tears. The peripheral tear is repaired first with superior and inferior vertical divergent sutures ( A ), followed by repair of the inner tear in the same fashion ( B ).
(Redrawn with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-12.)
FIGURE 30-5
Repair technique for radial meniscus tears. The inner sutures ( A ) are placed first, followed by the peripheral sutures ( B ). The first suture needle is placed midway through the meniscus body, then used to apply a circumferential tension to reduce the tear gap, and then advanced through the posterior meniscus bed. The second suture needle is placed in a similar manner. This reduces the radial gap, allowing subsequent sutures to be placed. Usually 3 to 4 sutures are placed superiorly and two sutures, inferiorly. C, Occasionally superior vertical divergent sutures are placed along the tear site to help stabilize the repair.
(Redrawn with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-14.)
FIGURE 30-6
Repair technique for flap tears. A, the tear is identified and reduced. B, Horizontal tension sutures are placed to anchor the radial component of the tear. C, The longitudinal component is sutured using the double-stacked suture technique.
(Redrawn with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes, Saunders, Philadelphia, 2009, pp. 733–771. Fig. 28-17.)
- •
Special cases considered for repair include lateral meniscus tear with a meniscal cyst ( Figure 30-7 ), posterior horn popliteomeniscal attachment tear ( Figure 30-8 ), and posterior meniscus root attachment tear ( Figure 30-9 ).
FIGURE 30-7
Demonstration of repair of lateral meniscus horizontal tear with a meniscal cyst. A, A 3-cm lateral joint incision placed directly over cyst shows the iliotibial band and an obvious protruding cyst. B, Iliotibial band is split in a line of fibers over the cyst and retracted, the cyst is removed, and repair is performed of the remaining meniscus to the attachments. C, Closure of the iliotibial band over the meniscus. Vertical sutures placed through the peripheral meniscus and iliotibial band help stabilize the repair. Then the arthroscopic inside-out repair of the meniscus body tear is performed.
(Reprinted with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-15.)
FIGURE 30-8
An athlete who had a prior negative arthroscopic examination and MRI and continued posterolateral joint pain shows a posterior horn popliteomeniscal attachment tear that required suture repair. A, Enlarged popliteal hiatus and laxity of the meniscotibial attachments is shown. B, Multiple vertical divergent superior and inferior inside-out sutures.
(Reprinted with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-4.)
FIGURE 30-9
Posterior meniscus root attachment tear. A, Placement of two mattress sutures; the meniscus suture-passing device (Arthrex, Naples, FL) may be passed in and out of the portal to place higher-holding strength mattress sutures over a single suture. B, Final placement of sutures brought out through a 4-mm transtibial tunnel and tied over a post to restore the meniscus attachment.
(Reprinted with permission from Noyes FR, Barber-Westin SD. Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-16.)
- •
Small longitudinal tears (less than 10 mm in length) left in situ
- •
Inner third region and chronic degenerative tears resected
- •
Use vertical divergent sutures to anatomically appose the tear site. This suture technique has superior tensile strength compared with horizontal sutures and meniscus fixators.
- •
Complex tears are usually repaired with the vertical divergent suture technique. The other option, all-inside suture devices, is not preferred because only 2 to 4 sutures are placed, which does not provide an adequate repair for sufficient healing, especially with immediate range of motion programs.
- •
Evidence
Multiple-Choice Questions
- QUESTION 1.
Meniscus tears frequently accompany which other knee injury?
- A.
Patellar subluxation
- B.
Saphenous neuritis
- C.
Anterior cruciate ligament rupture
- D.
Tibial stress fracture
- A.
- QUESTION 2.
Which of the following findings may be misdiagnosed as a meniscus tear?
- A.
Pain with full flexion
- B.
Pain anterior to superficial medial collateral ligament
- C.
Lack of pain-free full extension
- D.
Tibiofemoral compartment clicking
- A.
- QUESTION 3.
Full standing radiographs should be performed under which circumstances?
- A.
Positive Lachman test
- B.
Patient walks with severe limp
- C.
Older patient with potential for arthritis
- D.
Knee with varus or valgus malalignment
- A.
- QUESTION 4.
Which type of meniscus tear should always be treated by resection and not by repair?
- A.
Longitudinal tears less than 10 mm in length
- B.
Posterior root attachment
- C.
Flap
- D.
Triple longitudinal
- A.
- QUESTION 5.
One of the factors that significantly increases healing rates and the ability to repair complex meniscus tears is:
- A.
Horizontal suture technique
- B.
All-inside suture technique
- C.
Vertical divergent suture technique
- D.
Meniscus fixators
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Clinical Presentation )
- QUESTION 2.
Correct answer: B (see Differential Diagnosis )
- QUESTION 3.
Correct answer: D (see Imaging Studies)
- QUESTION 4.
Correct answer: A (see Aspects of Clinical Decision Making When Surgery Is Indicated )
- QUESTION 5.
Correct answer: C (see Aspects of Clinical Decision Making When Surgery Is Indicated )
Nonoperative Rehabilitation of Meniscus Injuries
- K. Donald Shelbourne, MD
- Heather E. Freeman, PT, DHS
- •
When any type of degenerative meniscus tear is accompanied by an effusion and/or any loss of range of motion or strength compared with the opposite knee, rehabilitation to address these impairments is usually effective for reducing or eliminating the patient’s symptoms.
- •
Steroid injections, oral steroids, or nonsteroidal antiinflammatory medications may be used as an adjunct to rehabilitation by decreasing the effusion and pain.
- •
Rehabilitation should be structured into phases based on the following goals:
- •
Reduce the effusion and restore normal knee extension (symmetric to the noninvolved knee).
- •
Restore normal, symmetric knee flexion.
- •
Restore symmetric lower extremity strength.
- •
Gradually re-introduce impact activities/athletics.
- •
Progression of rehabilitation to the next phase is determined by meeting the goals of each phase rather than based on a timeline.
- •
Introduction
- •
Selecting an appropriate course of treatment for meniscus tears needs to be based on an understanding of the type and location of the meniscus tear as well as an assessment of concomitant impairments such as loss of range of motion (ROM), strength, and the presence of an effusion.
- •
It is important for clinicians to recognize that meniscal pathology seen on a magnetic resonance imaging (MRI) scan of a middle-aged patient is frequently an incidental finding.
- •
Clinical correlation of symptoms, physical examination findings, and diagnostic imaging studies is needed to determine whether the patient’s symptoms are related to the meniscal pathology, early osteoarthritis, or other associated impairments.
- •
Even in the presence of a degenerative meniscus tear, a patient with a loss of ROM and/or a knee joint effusion may improve with a well-directed rehabilitation program designed to resolve these deficits.
- •
The knee pain may be a new occurrence, but it is important to consider that the degenerative meniscus tear may have been present for quite some time without causing pain. If the tear is not new, then the pain may be related to stiffness, deconditioning, or a joint effusion.
- •
The overall goal of treatment is to regain symmetry. By restoring full, symmetric knee extension first, then knee flexion, and finally strength, the patient often experiences a significant improvement or resolution of symptoms.
- •
The progression of this rehabilitation process should be based on meeting specific goals, rather than based on a timeline.
- •
Patients with tibiofemoral joint space narrowing typically have meniscal abnormalities that are amenable to rehabilitation rather than surgical treatment.
- •
One common type of meniscus tear in the osteoarthritic patient is a posterior horn radial tear that extrudes beyond the tibiofemoral articulation. This occurs when narrowing of the joint space places a compressive force on the meniscus, creating “hoop stress” that eventually causes the meniscus to tear and the peripheral part of the meniscus gets extruded.
- •
The patient often gives a history of feeling a painful “pop,” followed by a joint effusion and decreased ROM. Although this type of tear is very painful initially, a combined treatment approach of medication and rehabilitation is often very effective.
- •
An initial course of nonoperative treatment is most appropriate for degenerative meniscus tears because many patients will improve to a functional level without surgery.
- •
Meniscus tears that are degenerative in nature are not amenable to repair owing to the characteristic horizontal cleavage seen with a degenerative tear, the poor blood supply, and the frayed, degenerative quality of the meniscus at the tear location. These tears often occur in patients who are middle aged or older and are most common in the medial meniscus.
- •
Most meniscus tears in young, competitive athletes are not degenerative in nature and therefore, would not respond as well to nonsurgical intervention.
- •
Hence, the focus on this chapter is on nonsurgical treatment of degenerative meniscus tears in the older, recreational athlete.
Phase I 1
1 The timeframes of each phase of the rehabilitation will vary widely between patients. Progression to the next phase of rehabilitation is criteria based rather than time based.
| PHASE I | PHASE II | PHASE III | PHASE IV |
|---|---|---|---|
|
|
|
|
Goal
- •
To eliminate effusion and restore normal, symmetric knee extension
Protection
- •
No protection required. Encourage the patient to fully weight bear on the affected leg and use the knee normally as soon as possible.
- •
Provide gait training to restore normal gait pattern. By teaching the patient to stop favoring the leg, there will be less strength and range of motion loss owing to disuse.
Management of Pain and Swelling
- •
Over-the-counter nonsteroidal antiinflammatory medications and acetaminophen may be used as needed to help with swelling control and pain.
- •
If additional pain control is needed to allow the patient to tolerate rehabilitation during the early phase, injected or oral steroids may be used.
- •
If a moderate or severe effusion is present, significant relief may also be achieved by draining the knee.
Techniques for Progressive Increase in Range of Motion
- •
First determine what amount of ROM is normal for the patient.
- •
If the opposite knee is normal, use the ROM of that knee as a baseline for determining how much knee extension and flexion is normal for that patient.
- •
Most people have some degree of knee hyperextension, so the goal is not to achieve 0° of extension; rather, the goal is to restore normal knee extension, which may include hyperextension.
- •
In some instances the opposite knee may not be normal and may also have limited ROM, which makes determining the goals for ROM more difficult. When both knees have limited ROM attempts should be made to achieve knee hyperextension, and although the end goal may not be as clearly defined, maximize ROM of both knees until the patient reaches a plateau and do not stop simply because 0° of extension is achieved.
- •
Measure knee extension by having the patient lie supine and prop both heels up on a bolster high enough to allow the knees to fall into hyperextension ( Figure 30-10 ).
FIGURE 30-10
Patient positioning for measurement of knee extension. Patient is lying supine with both heels propped up on a bolster high enough to allow the knees to fall into hyperextension.
- •
Perform a low-load, long duration stretch for knee extension/hyperextension three to five times per day.
- •
Instruct the patient to perform a 10-minute heel prop with an ankle weight placed above and below the knee joint, AND/OR
- •
Use a passive knee extension device for 10 to 15 minutes ( Figure 30-11 ).
FIGURE 30-11
A passive knee extension device is used for a low-load, long duration stretch. The patient controls the intensity of the stretch through a hand-held crank.
- •
- •
Perform towel stretches into maximal extension. Stabilize the thigh with one hand while using a towel to pull the heel upwards ( Figure 30-12 ). Hold for 5 seconds and perform ten repetitions.
FIGURE 30-12
The towel stretch exercise is used to stretch the knee into maximal extension, including hyperextension.
Activation of Primary Muscles Involved
- •
Ensure that good neuromuscular control of the quadriceps is achieved.
- •
Perform active heel lifts. Have the patient sit with the leg extended, contract the quadriceps muscle group, and actively lift the heel up off of the table ( Figure 30-13 ).
FIGURE 30-13
The active heel lift is performed in a long-sitting position. The patient contracts the quadriceps and dorsiflexes the ankle, elevating the heel above the supporting surface.
- •
If the patient cannot achieve an active heel lift, add a short-arc quad exercise to help facilitate activation of the quadriceps muscle group.
- •
Techniques to Reduce Effusion
- •
Instruct patient in use of a cold-compression device.
- •
Advise patient to elevate the knee above the level of the heart while using the cold-compression device and whenever possible.
- •
Advise patient to avoid high impact activities such as running, jumping, and prolonged walking.
Functional Exercises
- •
Teach the patient standing and sitting extension habits.
- •
Stand with body weight shifted onto the involved leg and lock the knee out straight.
- •
Sit with the heel propped and knee straight, allowing the knee to fall into hyperextension.
- •
Milestones for Progression to the Next Phase
- •
Little to no effusion present in the knee
- •
Full, symmetric knee extension equal to the opposite normal knee
Phase II
Goals
- •
To restore normal, symmetric knee flexion and maintain symmetric knee extension
Management of Pain and Swelling
- •
Over-the-counter nonsteroidal antiinflammatory medications and acetaminophen may be used as needed to help with swelling control and pain.
Techniques for Progressive Increase in Range of Motion
- •
First determine what amount of knee flexion is normal for the patient.
- •
If the opposite knee is normal, use the range of motion of that knee as a baseline for determining how much knee flexion is normal for that patient.
- •
Measure knee flexion by having the patient perform a heel slide. Ask the patient to slide the heel toward the buttocks, pulling the knee into as much flexion as possible while in a long-sitting position ( Figure 30-14 ). Compare the involved knee to the non-involved knee.
FIGURE 30-14
A heel slide is performed by having the patient use the hands or a towel to slide the heel toward the buttocks as far as possible.
- •
Perform a heel slide exercise. Hold the stretch for 5 seconds, then pull the knee into slightly more flexion and hold for an additional 5 seconds.
- •
If knee flexion is more severely limited, begin with a wall slide exercise ( Figure 30-15 )
FIGURE 30-15
In cases of more severe knee flexion loss, the wall slide is an effective exercise to improve knee flexion. The patient uses the foot of the noninvolved leg to apply gentle, downward pressure on the foot of the involved leg, increasing the knee flexion of the involved leg.
Other Therapeutic Exercises
- •
Perform towel stretches to monitor knee extension (see Figure 30-12 ).
- •
If any loss of knee extension is detected, back off from flexion exercises and return to focusing on knee extension.
- •
Begin a low impact exercise program using a bike, elliptical, or stair climber. Begin with light resistance and gradually increase time from 5 minutes to 30 minutes. Then slowly increase the resistance.
Functional Exercises
- •
Continue with standing and sitting extension habits to encourage full knee extension and normal use of the involved leg.
Milestones for Progression to the Next Phase
- •
Full, symmetric knee range of motion compared to the opposite, normal knee
- •
No effusion
- •
Good neuromuscular control of the quadriceps muscle group
Phase III
Goals
- •
To restore symmetric lower extremity strength
Management of Pain and Swelling
- •
Although some activity-related soreness and swelling may occur, pain and swelling should mostly be under control during this phase.
- •
Patients are advised to use a cold-compression device as needed for swelling and pain control.
- •
Over-the-counter nonsteroidal antiinflammatory medications and acetaminophen may also be used as needed.
Techniques for Progressive Increase in Range of Motion
- •
Range of motion should be maximized prior to the beginning of Phase III. Monitor range of motion by performing towel stretch and heel slide and comparing with the opposite, normal knee.
- •
If any loss of range of motion occurs as the strengthening program is underway, discontinue strengthening exercises and focus on Phase I and II exercises until symmetric range of motion is restored.
Other Therapeutic Exercises
- •
Objectively measure strength of the quadriceps and hamstring muscle groups for both the involved and noninvolved legs (Cybex, Biodex, etc.)
- •
If a side-to-side deficit is detected (greater than or equal to 10%), begin single-leg strengthening program 5 to 7 times per week. Reevaluate strength testing on a regular basis and transition to bilateral strengthening exercises once full strength symmetry has been restored.
- •
Single leg press
- •
Single knee extension
- •
Step-down
- •
- •
Continue to progress the low impact exercise program (bike, elliptical, or stair climber) by increasing resistance and/or increasing workout time.
Sport-Specific Exercises
- •
Patients involved in low impact sports (nonrunning or jumping) activities may gradually return to these activities at this time.
- •
Participation in sports requiring running or jumping should be delayed until full strength and range of motion symmetry has been regained.
Milestones for Progression to the Next Phase
- •
Quadriceps and hamstring muscle group strength at least 90% (involved knee/non-involved knee)
- •
Full, symmetric knee range of motion compared to the opposite, normal knee.
- •
No effusion
Phase IV
Goal
- •
Return to sports
Management of Pain and Swelling
- •
Some soreness and swelling may occur during this phase as the patient’s activity level is increased and should be treated with use of a cold-compression device as needed.
Techniques for Progressive Increase in Range of Motion
- •
Range of motion should be maximized prior to the beginning of Phase IV. Monitor range of motion by performing towel stretch and heel slide and comparing with the opposite, normal knee.
- •
If any loss of range of motion occurs during the return to sport phase, discontinue impact activities and focus on Phase I and II exercises until symmetric range of motion is restored.
Other Therapeutic Exercises
- •
Continue with the low impact exercise program for cardiovascular conditioning and as a form of cross-training.
- •
Once symmetric strength has been achieved, begin doing lower extremity strengthening program for both legs.
Functional Exercises
- •
For patients returning to sports requiring change of direction, gradually progress through a functional progression to introduce jumping, planting, and pivoting.
- •
Add increased speed and multidirectional components to the movement patterns throughout the progression.
Sport-Specific Exercises
- •
When introducing impact activities (running, jumping, etc.) begin with an every-other-day schedule to allow the knee to adjust to the new level of activity without increasing amounts of soreness or swelling.
- •
Begin with structured drills to allow the patient to work through each component skill of the sport individually.
- •
Progress into “scrimmage” situations where skills are combined together in a non-competitive situation.
- •
Finally, progress to full competition.
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Symmetric ROM, symmetric strength, no effusion
- •
Completion of functional progression
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Continued pain that is isolated to the medial or lateral joint line and limits activity despite attempts to regain symmetry
- •
Patient is unable to tolerate rehabilitation because of pain that is not controlled with the pain control measures described previously.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Full, symmetric knee range of motion compared with the opposite, normal knee
- •
No effusion
- •
Quadriceps and hamstring muscle group strength at least 90% (involved knee/noninvolved knee)
- •
Completion of functional progression
Evidence
Multiple-Choice Questions
- QUESTION 1.
The first phase of rehabilitation should focus on swelling control and regaining symmetric ______.
- A.
strength
- B.
knee extension
- C.
thigh girth
- D.
knee flexion
- A.
- QUESTION 2.
Nonoperative treatment of meniscus tears is most appropriate for which type of tear?
- A.
Medial meniscus
- B.
Nondisplaced bucket handle
- C.
Degenerative
- D.
Meniscus tears associated with ACL tears
- A.
- QUESTION 3.
Normal knee range of motion is defined as:
- A.
whatever the range of motion of the opposite, normal knee is.
- B.
0° of extension to 135° of flexion.
- C.
0° of extension to 145° of flexion.
- D.
5° of hyperextension to 145° of flexion.
- A.
- QUESTION 4.
When measured objectively, symmetric strength is defined as being within ___% of the opposite knee.
- A.
5
- B.
10
- C.
15
- D.
20
- A.
- QUESTION 5.
Forms of lower impact exercise are:
- A.
Bike
- B.
Stair climber
- C.
Elliptical
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Phase I )
- QUESTION 2.
Correct answer: C (see Introduction )
- QUESTION 3.
Correct answer: A (see Phase I )
- QUESTION 4.
Correct answer: B (see phase III )
- QUESTION 5.
Correct answer: D (see Phase III )
Postoperative Rehabilitation after Meniscus Repair
- Frank R. Noyes, MD
- Timothy P. Heckmann, PT, ATC
- Sue D. Barber-Westin, BS
- Timothy P. Heckmann, PT, ATC
Indications for Surgical Treatment
- •
Meniscus tear with unresolved tibiofemoral joint pain
- •
Patient less than 50 years of age or in 50s and physically active
- •
Meniscus tear reducible with good tissue integrity affirmed at surgery
- •
Meniscus tear classified at surgery according to location, type, size, integrity of tissue, and remaining meniscus bed
- •
Peripheral single longitudinal tears (red-red, one plane)—repairable in all cases, high success rates
- •
Middle third region (red-white or white-white—often repairable with reasonable success rates
- •
Outer-third and middle-third regions (red-white, one plane) longitudinal, radial horizontal tears—decision on repair versus excision made at surgery
- •
Patients willing to comply with postoperative rehabilitation program
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
Diagnostic arthroscopy
- •
Meniscus tissue and synovial junction rasped, loose unstable meniscus fragments removed
- •
Preferred procedure uses multiple vertical divergent sutures
- •
Neurovascular structures protected throughout procedure with posterolateral or posteromedial exposure and Henning retractor ( Figure 30-16 )
FIGURE 30-16
Cross-section showing popliteal retractor between the posterior capsule and the medial gastrocnemius for a medial meniscus repair. The suture cannula is placed through the lateral or medial portal with care taken to angle the needle away from the neurovascular structures.
(Reprinted with permission from Noyes FR, Barber-Westin SD: Meniscus tears: Diagnosis, repair techniques, and clinical outcomes. In Noyes FR, Barber-Westin SD, editors: Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 733–771. Fig. 28-7.)
- •
Placement of sutures depends on tear pattern.
- •
Single longitudinal tears: vertical divergent sutures placed 3- to 4-mm intervals along the length of the tear in alternating fashion; first on the superior surface to reduce the meniscus and then on the inferior surface to close the inferior tear (see Figure 30-3 )
- •
Sutures are brought out through posterolateral or posteromedial accessory incision and tied directly over the posterior meniscal attachment and capsule.
- •
Tension in each suture is confirmed arthroscopically after the knot is tied
- •
Double-longitudinal meniscus tears require an additional set of sutures ( Figure 30-17 ; see also Figure 30-4 )
FIGURE 30-17
A longitudinal meniscal tear site demonstrating some fragmentation inferiorly. This tear required multiple superior and inferior vertical divergent sutures to achieve an anatomic reduction.
(Reprinted with permission from Noyes FR, Barber-Westin SD: Arthroscopic repair of meniscal tears extending into the avascular zone in patients younger than twenty years of age. Am J Sports Med 30:589–600, 2002.)
- •
Radial tears are repaired with horizontal sutures placed at 2- to 4-mm intervals along the tear site (see Figure 30-5 ).
- •
Flap tears require two sets of sutures (see Figure 30-6 ).
Factors That May Affect Rehabilitation
- •
Classification of meniscus tear according to location, type and size of tear, and integrity of meniscal tissue
- •
Meniscus repairs located in the periphery (outer one-third region) heal rapidly, complex multiplanar repairs that extend into central one-third region require greater caution with rehabilitation
- •
Type of repair: inside-out multiple vertical sutures versus all-inside
- •
All-inside repairs use only a few sutures, require delay in full weight bearing and added protection
- •
Presence of articular cartilage damage, 2-B or 3-A, B (Cincinnati Knee Rating classification)
- •
Concurrent procedures such as knee ligament reconstruction, high tibial osteotomy, articular cartilage restorative procedures
- •
Understand type and location of meniscus tear and repair technique.
- •
Knowledge of concurrent operative procedures and condition of articular cartilage throughout knee joint
- •
Early return (within 4 to 6 months) to strenuous activities, high impact loading, deep knee flexion, sudden pivoting or twisting carries definite risk of repeat meniscus tear.
- •
Supervised rehabilitation program is supplemented with home exercises performed daily.
- •
Be aware of potential complications, signs, symptoms requiring prompt treatment
- •
Continued pain in involved tibiofemoral compartment
- •
Failure to achieve knee extension and flexion goals according to protocol
- •
Decreased patellar mobility (early arthrofibrosis)
- •
Decreased voluntary quadriceps contraction and muscle tone
- •
Persistent joint effusion, inflammation
- •
Phase I (days 0–14): Immediate Postoperative Period
Important early postoperative signs for the therapist to monitor are effusion, pain, gait, knee flexion and extension, patellar mobility, strength and control of the lower extremity, lower extremity flexibility, and tibiofemoral compartment symptoms. Use modalities such as electrical muscle stimulation, biofeedback, and cryotherapy as required. The patient’s response to surgery and progression during the first 14 days sets the tone for the initial phases of rehabilitation. Monitor for posteromedial or infrapatellar burning, posteromedial tenderness along the distal pes anserine tendons, tenderness of Hunter’s canal along the medial thigh, hypersensitivity to light pressure or temperature change, abnormal pain response, quadriceps shutdown, and inability to achieve knee motion goals as designated by protocol.
Goals
- •
Range of motion (ROM) minimum: 0° to 90° first 2 weeks postop
- •
Weight bearing: toe-touch to half body weight (BW) for peripheral repairs; toe-touch to quarter BW for complex or all-inside repairs; none to toe-touch for radial repairs
- •
Pain, hemarthrosis controlled
- •
Good patellar mobility
- •
Adequate quadriceps contraction
Protection
- •
Long-leg postoperative brace for complex or all-inside meniscus repairs. Brace is opened from 0° to 90°, but is locked at 0° at night. Brace not routinely used for peripheral repairs.
- •
Crutches. Toe-touch to half BW for peripheral repairs. Toe-touch to quarter BW for complex and all-inside repairs. None to toe-touch weight bearing for radial repairs. “Sponge (very light) pressure” allowed during toe-touch weight bearing.
Management of Pain and Swelling
- •
Oral medications as required
- •
Therapeutic modalities: electrical muscle stimulation, cryotherapy
- •
Elevate lower limb as frequently as possible.
Techniques for Progressive Increase in Range of Motion
- •
Begin first day postoperative
- •
Passive knee flexion and passive and active/active-assisted knee extension exercises
- •
Seated position, 0° to 90°, three to four times a day in 10-minute sessions
- •
Active knee flexion is limited to avoid hamstring strain to the posteromedial joint.
- •
Hyperextension avoided in anterior horn meniscus repairs.
- •
- •
Patellar mobilization in superior, inferior, medial, and lateral directions
- •
Hamstring and gastrocnemius-soleus flexibility
- •
If 0° to 90° not achieved by seventh day postoperative, begin overpressure exercises.
- •
Hanging weights for extension ( Figure 30-18 )
FIGURE 30-18
Extension overpressure hanging-weight exercise.
(Reprinted with permission from Heckmann TP, Noyes FR, Barber-Westin SD: Rehabilitation of meniscus repair and transplantation procedures. In Noyes FR, Barber-Westin SD, editors: Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 806–817, Figure 30-3.)
- •
Rolling stool, wall-sliding for flexion ( Figures 30-19 , 30-20 )
FIGURE 30-19
Rolling stool overpressure exercise for knee flexion.
(Reprinted with permission from Heckmann TP, Noyes FR, Barber-Westin SD: Rehabilitation of primary and revision anterior cruciate ligament reconstructions. In Noyes FR, Barber-Westin SD, editors: Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 306–336, Figure 13-7A.)
FIGURE 30-20
Wall slide overpressure exercise for knee flexion.
(Reprinted with permission from Heckmann TP, Noyes FR, Barber-Westin SD: Rehabilitation of primary and revision anterior cruciate ligament reconstructions. In Noyes FR, Barber-Westin SD, editors: Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 306–336, Fig. 13-7C.)
- •
Commercially available ROM devices
- •
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Activation of the quadriceps, hamstrings, gastrocnemius-soleus, and hip musculature is accomplished immediately postoperatively with the exercises described in this time frame.
Sensorimotor Exercises
- •
Begin first week postoperative during partial weight-bearing period.
- •
Weight shifting side-to-side and front-to-back with crutch support
- •
Cup walking to develop symmetry between limbs, hip and knee flexion, quadriceps control during midstance, hip and pelvic control during midstance, and gastrocnemius-soleus control during pushoff ( Figure 30-21 ).
FIGURE 30-21
Cup walking.
(Reprinted with permission from Heckmann TP, Noyes FR, Barber-Westin SD: Rehabilitation of meniscus repair and transplantation procedures. In Noyes FR, Barber-Westin SD, editors: Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders, pp. 806–817, Figure 30-6A.)
- •
Open and Closed Kinetic Chain Exercises
- •
Begin first day postoperative.
- •
Quadriceps isometrics: one set × 10 repetitions every hour patient is awake
- •
Straight leg raises, flexion plane only initially: three sets × 10 repetitions
- •
Add leg raises in extension, abduction, adduction planes when patient has sufficient quadriceps control to prevent an extensor lag during flexion plane leg raises.
- •
- •
Active-assisted knee extension 90° to 0°: three sets × 10 repetitions. Limit to 90° to 30° for anterior horn repairs.
- •
Milestones for Progression to the Next Phase
- •
ROM 0° to 90°
- •
Adequate quadriceps contraction, exhibited by no extensor lag on supine straight leg raise
- •
Pain, inflammation controlled
- •
Good patellar mobility: patient or therapist is able to move the patella medial-lateral and inferior-superior directions without problems.
Phase II (weeks 3 to 6)
By 6 weeks postoperative, the patient should have at least 0° to 135° of knee motion and a normal gait pattern.
Goals
- •
ROM 0° to 135°
- •
Gradually resume full weight bearing with a normal gait pattern.
- •
Begin closed-chain exercises.
- •
Progress balance, proprioceptive training.
- •
Progress lower extremity strength exercises.
Protection
- •
Brace discontinued week 6 for complex and all-inside meniscus repairs; 6 to 8 weeks for radial repairs.
- •
Crutches discontinued week 4 for peripheral repairs.
- •
Half to full weight bearing for complex and all-inside repairs
Management of Pain and Swelling
- •
Continue cryotherapy following all exercise sessions.
- •
Oral medications if required
Techniques for Progressive Increase in Range of Motion
- •
ROM is increased to 120° by weeks 3 to 4 and 135° by weeks 5 to 6.
- •
Patients who fail to achieve these goals are placed into the overpressure program and should be evaluated by the surgeon.
- •
Gentle manipulation under anesthesia may be indicated for noteworthy limitations of knee motion by week 6.
- •
Other Therapeutic Exercises
- •
Upper body ergometer at 3 to 4 weeks if available
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Activation of the quadriceps, hamstrings, gastrocnemius-soleus, and hip musculature is accomplished with the exercises described in this time frame.
Sensorimotor Exercises
- •
Double-leg balance exercises: The patient should point the feet straight ahead in tandem (heel/toe), flex the knee 20° to 30°, extend the arms outward to horizontal, and position the torso upright with the shoulders above the hips and the hips above the ankles. Stand in this position until balance is disturbed.
- •
Balance exercises may be done on a minitrampoline for greater challenge.
- •
- •
Walk on Styrofoam half rolls and whole rolls
- •
Balance board
Open and Closed Kinetic Chain Exercises
- •
Multiangle quadriceps isometrics (active), 0°, 30°, 60°, 90°: 1 set × 10 repetitions each
- •
Straight leg raises in flexion, extension, abduction, and adduction: 3 sets × 10 repetitions. Add ankle weights at 5 to 6 weeks of less than 10% of body weight.
- •
Knee extension (active/ active-assisted) 90 to 0°: three sets × 10 repetitions. Limit to 90° to 30° for anterior horn repairs
- •
Toe raises: three sets × 20 repetitions
- •
Heel raises begin at 5 to 6 weeks: three sets × 10 repetitions
- •
Wall sits (above 60°) to fatigue: three sets
- •
Minisquats: 3 sets
- •
At 5 to 6 weeks, peripheral meniscus repairs, hamstring curls, 0° to 90°: three sets × 10 repetitions
- •
At 5 to 6 weeks, peripheral meniscus repairs, leg press, 70 to 10°: three sets × 10 repetitions
- •
At 5 to 6 weeks, all repairs, multi-hip machine (flexion, extension, abduction, adduction): three sets × 10 repetitions
- •
5 to 6 weeks, all repairs, knee extension (resisted), 90° to 30°: three sets × 10 repetitions
Milestones for Progression to the Next Phase
- •
ROM 0° to 135°
- •
Normal gait
- •
Normal patellar mobility: patient or therapist able to move the patella in all directions without resistance
- •
Pain, effusion controlled
- •
Muscle control throughout ROM as observed by therapist as patient performs exercises
Phase III (weeks 7 to 12)
Full return to activities of daily living by 8 to 12 weeks postoperative. Precautions include no impact loading, no pivoting or twisting, no deep squatting.
Goals
- •
Progress lower extremity strength
- •
Progress balance, proprioception
- •
Increase endurance
Protection
- •
Crutches discontinued weeks 8 to 12 for complex, all-inside, and radial repairs
- •
Weight bearing advanced per gait pattern and change in knee symptoms
Management of Pain and Swelling
- •
Cryotherapy as required
Techniques for Progressive Increase in Range of Motion
- •
If knee motion is still limited during this time period, a gentle manipulation under anesthesia may be indicated. Severe limitations may be treated with arthroscopic debridement. The program for treatment of knee motion problems has been described in detail.
- •
Flexibility: hamstring, gastrocnemius-soleus, quadriceps, iliotibial band
Other Therapeutic Exercises
- •
Weeks 7 to 8: stationary bicycling, 15 minutes, one to two times a day
- •
Weeks 9 to 12 (select one activity a day for 15 minutes)
- •
Stationary bicycling
- •
Water walking
- •
Swimming with straight leg kicking
- •
Walking
- •
Stair climbing machine, low resistance, low stroke
- •
Ski machine, short stride, level, low resistance
- •
Elliptical cross-trainer
- •
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Activation of the quadriceps, hamstrings, gastrocnemius-soleus, and hip musculature is accomplished with the exercises described in this time frame.
Sensorimotor Exercises
- •
Balance board: two-legged, three times per day for 5 minutes
- •
Lateral step-ups: 5- to 10-cm block, three times per day, three sets × 10 repetitions
- •
Resisted gait training: resisted band marching and elastic band resistance to terminal single leg standing balance
Open and Closed Kinetic Chain Exercises
- •
Straight leg raises flexion, extension, adduction, abduction: three sets × 10 repetitions
- •
Add rubber tubing, three sets × 30 repetitions
- •
- •
Toe and heel raises: three sets × 10 repetitions
- •
Wall sits, to fatigue: three sets
- •
Minisquats: three sets
- •
Weeks 9 to 12: add rubber tubing, 0° to 40°: three sets × 20 repetitions
- •
- •
Hamstring curls all meniscus repairs, active: three sets × 10 repetitions
- •
Knee extension, active, 90° to 30°: three sets × 10 repetitions
- •
Multihip: three sets × 10 repetitions
- •
Leg press, 70° to 10°: three sets × 10 repetitions
- •
Start weeks 9 to 12 for complex repairs.
- •
Techniques to Increase Muscle Strength, Power, and Endurance
- •
See Open and Closed Kinetic Chain Exercises described above.
Neuromuscular Dynamic Stability Exercises
- •
See Sensorimotor Exercises described above.
Milestones for Progression to the Next Phase
- •
No effusion, painless ROM
- •
Performs daily activities without problems
- •
Can walk 20 minutes without pain
- •
Normal range of motion
Phase IV (weeks 13 to 26)
Primary focus during this phase is developing lower extremity muscle strength and cross-training for cardiovascular endurance.
Goals
- •
Increase strength and endurance.
- •
Peripheral repairs may begin running program 20 weeks postoperative if tolerated ( Box 30-1 )
Box 30-1
Running Program for Rehabilitation of Meniscus Injuries
A running program is begun at approximately 20 weeks postoperative in patients who had peripheral meniscus repairs and who have no more than a 30% deficit in average peak torque for the quadriceps and hamstrings on isometric testing performed on a Biodex dynamometer (Biodex Corp., Shirley, NY). This program is delayed until approximately 30 weeks postoperative in patients who had complex meniscus repairs and until at least 1 year postoperative in patients who had a meniscus transplant.
Isometric muscle testing is initially performed at an angle of 60° of knee flexion, which places the knee in a protected position for both the meniscus and the patella. Progression to isokinetic testing at high speeds is important, but the initial goal is to test the integrity of the quadriceps and hamstring musculatures. Other testing parameters worth evaluating include peak torque to body-weight ratios, agonist-to-antagonist ratios, and time to peak torque values.
Patients begin with a walk/run combination program, using running distances of 18, 37, 55, and 91 meters. Initially, patients run at 25% to 50% of their normal speed. Once patients can run straight ahead at full speed, lateral and crossover maneuvers are added. Short distances (such as 18 m) are used to work on speed and agility. Side-to-side running over cups may be used to facilitate agility and proprioception. Figure-eight and carioca running drills are also useful.
Running, Begin
- •
20 wk postoperative peripheral meniscus repairs
- •
30 wk postoperative complex meniscus repairs
- •
Minimum 1 yr postoperative meniscus transplants
Patient must demonstrate no more than 30% deficit in quadriceps and hamstrings peak torque on isometric testing.
Use Walk/Run Program Initially
- •
18, 37, 55, 91 m
- •
25%–50% normal running speed, straight
- •
Progress to 100% speed
Add lateral, crossover, side-to-side, figure eights, carioca drills for agility
(From Heckmann TP, Noyes FR, Barber-Westin SD: Rehabilitation of meniscus repair and transplantation procedures. In Noyes FR, Barber-Westin SD, editors: Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes , Philadelphia, 2009, Saunders, pp. 806–817 .)
- •
Management of Pain and Swelling
- •
Cryotherapy as required
Therapeutic Exercises
- •
Patients encouraged to perform upper body and core strengthening according to future desired activity level.
- •
Aerobic conditioning, three times a week for 20 minutes; select one activity per session
- •
Stationary bicycle
- •
Water walking
- •
Swimming, straight-leg kicking
- •
Walking
- •
Stair climbing machine
- •
Ski machine
- •
Elliptical cross-trainer
- •
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Activation of the quadriceps, hamstrings, gastrocnemius-soleus, and hip musculature is accomplished with the exercises described in this time frame.
Sensorimotor Exercises
- •
Balance board, two-legged, three times a day for 5 minutes
- •
Single-leg stance, unstable platform, three times a day for 5 minutes
- •
Perturbation training
- •
Ball toss on plyoback, single-leg stance
Open and Closed Kinetic Chain Exercises
- •
Straight leg raises with rubber tubing, high speed: three sets × 30 repetitions
- •
Minisquats, rubber tubing, 0° to 40°: three sets × 20 repetitions
- •
Hamstring curls, with resistance, 0° to 90°: three sets × 10 repetitions
- •
Knee extension, active with resistance, 90° to 30°: three sets × 10 repetitions
- •
Multi-hip: three sets × 10 repetitions
- •
Leg press, 70° to 10°: three sets × 10 repetitions
Techniques to Increase Muscle Strength, Power, and Endurance
- •
See Open and Closed Kinetic Chain Exercises.
Neuromuscular Dynamic Stability Exercises
- •
See Sensorimotor Exercises.
Plyometrics
- •
Week 24 for peripheral meniscus repairs only. Must have completed running program.
- •
Level surface box hops on 4-square grid. Double-legged hops, land in knee flexion. 4 levels.
- •
Single-leg hops
- •
Vertical box hops
Functional Exercises
- •
Week 16 to 20: peripheral meniscus repairs allowed to begin running program if tolerated. Patient must have less than 30% deficit in quadriceps and hamstrings peak torque on isometric and/or isokinetic testing to begin running.
- •
Week 24: peripheral meniscus repairs allowed to begin cutting, carioca, figure 8 agility, plyometrics (box hops, level, double-leg) if tolerated. Must have less than 20% deficit for quadriceps/hamstrings peak torque on isometric and/or isokinetic testing to begin plyometrics.
Sport-Specific Exercises
- •
Begin week 20 to 24 for peripheral meniscus repairs.
Milestones for Progression to the Next Phase
- •
No pain, effusion
- •
Can perform ADL, walk for 20 minutes without pain
Phase V (weeks 27 and beyond)
Return to activity at 6 to 9 months for peripheral repairs, 9 to 12 months for complex, all-inside and radial repairs.
Condition of the articular cartilage may also be a determining factor for functional progressions.
Goals
- •
Increase strength, endurance, lower extremity function.
- •
Return to previous or desired activity level.
Management of Pain and Swelling
- •
Cryotherapy as required
Therapeutic Exercises
- •
Patients encouraged to perform upper body and core strengthening according to future desired activity level.
- •
Aerobic conditioning, three times a week for 20 to 30 minutes; select one activity per session
- •
Stationary bicycle
- •
Water walking
- •
Swimming, straight-leg kicking
- •
Walking
- •
Stair climbing machine
- •
Ski machine
- •
Elliptical cross-trainer
- •
Sensorimotor Exercises
- •
Balance board, two-legged, three times a day for 5 minutes
- •
Single-leg stance, unstable platform, three times a day for 5 minutes. Progress from 2-legged to 1-legged activity.
- •
Perturbation training
- •
Ball toss on plyoback, single-leg stance
Open and Closed Kinetic Chain Exercises
- •
Straight-leg raises with rubber tubing, high speed: 3 sets × 30 repetitions
- •
Minisquats, rubber tubing, 0° to 40°: three sets × 20 repetitions
- •
Knee extension, active with resistance, 90° to 30°: three sets × 10 repetitions
- •
Hamstring curls, with resistance, 0° to 90°: three sets × 10 repetitions
- •
Multihip: three sets × 10 repetitions
- •
Leg press, 70° to 10°: three sets × 10 repetitions
Techniques to Increase Muscle Strength, Power, and Endurance
- •
See Open and Closed Kinetic Chain Exercises.
Neuromuscular Dynamic Stability Exercises
- •
See Sensorimotor Exercises.
Plyometrics
- •
Week 30 for complex meniscus repairs. Must have completed running program.
- •
Level surface box hops on 4-square grid. Double-legged hops, land in knee flexion. 4 levels.
- •
Single-leg hops
- •
Vertical box hops
Functional Exercises
- •
Week 24: complex meniscus repairs allowed to begin running program if tolerated. Patient must have less than 30% deficit in quadriceps and hamstrings peak torque on isometric and/or isokinetic testing to begin running.
- •
Week 30: complex meniscus repairs allowed to begin cutting, carioca, figure 8 agility, plyometrics (box hops, level, double-leg) if tolerated. Patient must have less than 20% deficit in quadriceps and hamstrings peak torque on isometric and/or isokinetic testing to advance to cutting.
Sport-Specific Exercises
- •
Begin week 30 for complex meniscus repairs.
Criteria for Return to Sport
- •
No knee joint pain or swelling
- •
Full range of knee motion
- •
Less than or equal to 10% deficit quadriceps and hamstrings strength isokinetic testing
- •
Less than or equal to 15% deficit lower limb symmetry single-leg hop testing
- •
Successful completion running and functional training
- •
Complete trial of function by returning to sport, monitor for overuse symptoms
- •
Patient education for re-evaluation if any future knee problems occur
After Return to Sport
Continuing Fitness or Rehabilitation Exercises
- •
Aerobic conditioning recommended according to patient activity levels.
- •
Lower extremity strengthening to be advanced or maintained as required.
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is not considered as part of the criteria for classifying meniscus tears?
- A.
Type of tear
- B.
Location of tear
- C.
Degree of articular cartilage damage
- D.
Size of tear
- A.
- QUESTION 2.
Which of the following meniscal repairs requires the greatest degree of protection in the postoperative recovery phase?
- A.
Peripheral repair
- B.
Radial repair
- C.
Complex repair
- D.
All inside repair
- A.
- QUESTION 3.
Which of the following is not considered an important precaution during the postoperative rehabilitation when attempting to minimize risk for reinjury?
- A.
High impact loading
- B.
Sudden pivoting or twisting
- C.
Deep weight bearing knee flexion
- D.
Resisted knee extension
- A.
- QUESTION 4.
Which of the following is not considered to be a possible early postsurgical complication of meniscus repair?
- A.
Delayed return to running
- B.
Limitation of knee motion
- C.
Quadriceps inhibition
- D.
Hypersensitivity and/or burning
- A.
- QUESTION 5.
Return to activity after a meniscus repair requires careful consideration of both subjective and objective measurements. Which of the following factors would not be considered acceptable in allowing the patient to return to full activity?
- A.
Successful completion of running/functional training
- B.
No knee pain and/or swelling
- C.
Greater than 30% deficit of quadriceps and hamstrings on an isokinetic strength test
- D.
Full range of motion
- A.
Answer Key
- Question 1.
Correct answer: C (see Indications for Surgery)
- Question 2.
Correct answer: B (see Immediate Postop Period):
- Question 3.
Correct answer: D (see Principles of Postop Rehab Box)
- Question 4.
Correct answer: A (see Clinical Pearls section, Phase 1)
- Question 5.
Correct answer: C (see criteria for Return to Sport , Week 27)
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