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©Meniscal Injuries of the Knee

Edward P. Mulligan, MS, PT, SCS, ATCVP, National Director of Clinical Education HealthSouth Corporation Grapevine, TX

Clinical Instructor University of Texas Southwestern PT DeptDallas, TX

The contents of this presentation are copyrighted © 2004 by continuing ED. They may not be utilized, reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, or by any information storage or

retrieval system, without permission in writing from Edward P. Mulligan.

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Learning Objectives

Following the completion of the inservice the participant will be able to:

1. identify meniscal anatomy and vascular penetration2. describe meniscal biomechanics, pathomechanics,

and mechanisms of injury3. explain common meniscal mechanisms and

resultant classification of injury4. describe relevant orthopedic examination

procedures relevant to the meniscus5. define indications for surgical excision, repair,

and allograft replacement6. design and effective post-operative rehab program

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Meniscal Anatomy

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Semilunar wedgesof fibrocartilageinterposed betweenthe femoral condyles and tibial plateau

General Overview of Left Knee anatomy from a cross-sectional perspective.

The menisci are semilunar wedges of fibrocartilage interposed between the femoral condyles above and the tibial plateau below.

On the lateral meniscus note the anterior and posterior horns; posterior meniscofemoral ligament (Ligament of Wrisberg); and popliteal muscle’s (not the tendon’s ) attachment

The medial Meniscus also has anterior and posterior horns

The origins of the anterior and posterior cruciate ligament are evident. The anterior cruciate ligament courses in a superior, posterior, and lateral direction to insert on the medial wall of the lateral femoral condyle. The much larger PCL moves in a superior and anterior direction towards its insertion on the femur.

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Medial Meniscus

"C" shapedBroader posteriorly than anteriorlyPeripheral Attachments:

• entire peripheral border is firmly attached to the medial capsule

• semimembranosus tendon slip attaches to posterior horn

• fibers of ACL attach to anterior horn• meniscopatellar fibers attach to

medial border of meniscus

The medical meniscus is shaped like a "C" and is broader posteriorly than anteriorly. It is firmly attached to the tibial plateua by a number of structures.

Peripheral Attachments:

•The entire peripheral border is firmly attached to the medial capsule via the coronary ligaments•A slip of the semimembranosus tendon attaches to posterior horn•The fibers of ACL blend into the anterior horn of the medial meniscus•The meniscopatellar fibers attach to medial border of meniscus

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Lateral Meniscus

"O" shaped covering 2/3 of tibial plateau

Smaller in diameter, thicker in periphery, and wider in body than the medial meniscus

More mobile than medial meniscus

Peripheral Attachments:• popliteus muscle (not tendon) sends

fibrous slip to posterior border• ligament of Wrisberg (meniscofemoral ligament)

attaches to posterior horn• anterior horn to ACL

The peripheral attachments on the lateral side are not a seucre or significant as on the medial side. Peripheral attachments include:•The popliteus muscle (not tendon) sends a fibrous slip to posterior border•The ligament of Wrisberg (posterior meniscofemoral ligament) attaches to posterior horn and is intimate with the posterior cruciate ligament•The ligament of Humphry (anteior meniscofemoral ligament) also courses obliquely form the lateral aspect of the medial femoral condyle to attach to the central portion of the posterior horn of the lateral meniscus.•The anterior horn tof the lateral mensicus terminates in in the area of the origin of the anterior cruciate lgiament. •The small, anterior, transverse intermeniscal ligament connects the anterior horns of the medial and lateral menisci

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Chock Block Shape

Frontal and sagittal x-sections show the triangular wedge shape (thick on periphery and thin centrally)

Chock block function promotes congruency between two relatively incongruent joint surfaces ( the round, convex distal femoral condyleand the flat, concave proximal tibial plateau)

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Meniscal Vascularity

Blood supply comes from the genicular arteries with vascular penetration to the peripheral 10-30%

The popliteal artery is a continuation of the femoral artery and it splitsinto superior lateral, middle, and superior medial branches thatterminate as inferior lateral and medial branches. The menisci’s blood supply comes from these genicular structures and penetrate the outer 10-30% of the meniscus.

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Meniscal Vascularity

Vascular Zones• Red Zone - peripheral capsular

attachment area; outer 3 mm rim•• Pink ZonePink Zone -junction of vascular

and avascular zone; blood supply on periphery, but not centrally

Avascular Zone• - inner 2/3 of meniscus without blood supply

Red “Vascular” Zone: with 3 mm of rim – red/redPink or Gray “Junction” Zone: 3-5 mm from periphery – red/whiteWhite “Avascular” Zone : greater than 5 mm from periphery – white/white

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Meniscal Function

Joint StabilitySmall but significant role in resisting varus, valgus, rotational, and AP stresses

If ACL intact, menisectomy does not significantly increase AP laxity

If ACL deficient, menisci play a more important role in stability

– After menisectomy there is a significant increase (3 mm) in AP laxity

– Removal of posterior horn of medial meniscus alone will destabilize the meniscus

Functions of the Menisci1. Stability2. Shock Absorption3. Nutrition/Lubrication4. Promote congruency

Removal of the posterior horn of the medial meniscus will destabilize the knee because the posterior oblique ligament no longer maintains orstabilizes the wedging effect of the meniscus

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Meniscal Function

Shock Absorption and Load TransmissionMenisci the tibiofemoral contact area by 75%

• Loss of menisci results in smaller areas of tibio-femoral contact

• Partial menisectomies peak local contact stress by 65%; total menisectomy by 235%

Menisci transfer centrally applied stresses radially

• Loss of menisci function through menisectomy or radial tear will result in increased load transfer to articular cartilage and subchondral bone

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Meniscal Function

Nutrition and Joint Lubrication

The menisci help distribute a thin film of synovial fluid over the surface of the articular cartilage

Joint CongruencyTapered ring geometry promotes the mating of two incongruent surfaces

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Meniscal Passive Biomechanics

Femoral condyles displace menisci as a result of compression and translation• the conjoint internal rotation of the tibia during flexion occurs about an axis medial to

the knee joint • menisci move posterior with flexion and anterior with extension• medial meniscus moves about 6 mm and the lateral meniscus about 12 mm

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Meniscal Active Biomechanics

FlexionMedial Meniscus - posterior glide is assisted by semimembranosus and counteracted by the pull of the meniscopatellar fibers and the ACL which attach to the anterior horn

Lateral Meniscus - posterior glide is assisted by the fibers of the popliteus

SMBPOP

ExtensionMedial Meniscus -assisted by menisco-patellar fibers and influenced by the active contraction of the quadsLateral Meniscus - posterior horn is pulled anteriorly by the increased tension on the meniscofemoral ligaments from the PCL

Tibial Rotationinfluenced by meniscopatellar fiber tension and the larger articulating femoral condyle

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Part 2: Mechanisms, Classification, and Examination

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Meniscal Tears: Mechanism of Injury

Youthful Trauma

Rotational and Compressive forces with the knee partially flexed

menisci are torn (usually longitudinal tears) when they

are caught, pinched, or impaled between the condyles

Meniscal injury generally has a different mechanism in younger vs. older patients.

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Meniscal Tears: Mechanism of Injury

Elderly DegenerationNon-specific trauma with slow, insidious onset60% likelihood of degenerative tear after 60menisci degenerate as they become less pliable and complex or radial tearing is generally irreparable

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Meniscal Injury Predisposing Factors

Abnormal mechanical axes – genu varus/valgus

Congenital anomalies – Discoid menisci

Degenerative menisciLigamentous laxity

discoid lateral meniscus

DISCOID MENISCUSIncidence is only 1.5-5% in the West , but 15% in Japan; the lateral is much more commonly discoid than the medial

EtiologyThe congenital cause is a failure of the fetal discoid form of the meniscus to involute.

ClassificationI - Stable, CompleteII - Stable, IncompleteIII - Unstable, crescent-shaped, except for a thickened posterior horn. Its instability is due to congenital absence of the meniscotibial (Wrisberg) ligament

Clinical FeaturesSymptoms of snapping and popping usually occur between the ages of 6 to 12 years.Patients with type III discoid menisci may present with complaints of instability.

Diagnosed viaX-Rays & MRI

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Meniscal Injury Incidence

Medial meniscus is torn 5-7 times more often than lateral meniscus

Medial meniscus is injured more often because it is far less mobile

The least mobile portion of the menisci is the medial posterior horn

Posterior horn tears most common medially and transverse tears most common laterally

The medial meniscus is most commonly injured in the stable knee or in the chronic ACL deficient knee

The lateral meniscus is most commonly injured with an acute ACL tear.

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Meniscal Injury Classifications

ShapeComplete vs. IncompleteStable vs. UnstablePeripheral vs. Central

– Red - blood supply on both sidesGood potential to heal

–– Pink Pink - blood supply on periphery, but not centrally

– - within the avascular zonePoor potential to heal

Shape: nature of the tearComplete vs. incomplete: full vs partial thicknessStable vs. Unstable: susceptible to displacement or notPeripheral vs. Central: vascular supply surrounding the tear

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Vertical Tears (also called longitudinal) can be partial and confined to the posterior horn or can progress to the anterior compartment to become a complete vertical or longitudinal tear. These complete vertical tears can become a displaced or peripheral bucket handle tear

The parrot-beak tear occurs in the thicker portion of the lateral meniscus.

Flap tears are often complex, oblique anteriorly based tears of the posterior horn of the medial meniscus. Because they are prone to displacement (inverted flap) and cause a loss of the integrity of the circumferential fibers – these tears usually have to be excised.

The radial tear of the lateral meniscus is usually a traumatic tear of youth and is almost always located in the middle segment of the lateral meniscus. Usually it is associated with previous pathology and is actually a combination of tears.

Radial tears have a lower incidence of successful healing following repair, but tears at the posterior horn origin heal better than those in the middle third owing to improved vascularity in that region. The poor function is due to the disruption of the circumferential fibers of the meniscus.

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Meniscal Injury Clinical Features

HistoryTrauma - twisting injuryDegenerative - no history of specific injury; often in middle age

Mechanical Symptoms locking, catching, clicking, snapping, giving waySwelling and Pain

Physical Exam1. Joint line tenderness2. Effusion3. + McMurray's, Apley's, Squat Test4. Quad Shutdown or atrophy

The Four Hallmark objective exam findings are:

1. Joint Line tenderness – good sensitivity2. Mild to Moderate Effusion that occurs over 1st day or two following trauma3. Positive entrapment test – McMurray’s, Apley’s, or Squat – good specificity4. Relatively quick quad shutdown and atrophy over first week or two following

injury

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subjective factors to differentiate meniscal and patellar pathology

MENISCAL• Twisting, traumatic onset• Joint line symptoms• Locking• Sharp pain with loaded

cutting maneuvers

PATELLOFEMORAL• Gradual, insidious onset• Diffuse, anterior symptoms• Grating, Aching, Crepitation• Pain coming into or out of

squat

Classical subjective and functional factors that may differentiate meniscal from patellofemoral pathology.

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Objective Exam: Special Tests

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Meniscal Entrapment Testing

Specific combinations of motion to identify symptomatic meniscal injury

Flexion to extension with tibia:externally rotated and valgus stress internally rotated and valgus stress externally rotated and varus stress

internally rotated and varus stress

As you move through the range of motion,note where and when the patient notes pain or catching-clicking sensations.

Extension from a hyperflexed position in varus and internal rotation = posteromedial meniscal injury

Extension from a hyperflexed position in valgus and external rotation = posterolateral meniscal injury

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meniscal entrapment test Rationale

Flexion – compresses the posterior portion of the menisci. Catching or locking

in flexed positions indicates damage to the posterior meniscal elements.

Extension – compresses the anterior portion of the menisci. Catching or locking

in extended positions indicates damage to the anterior meniscal elements.

Tibial Rotation – used to distort the menisci & assist in identifying the area of the

meniscal lesion

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meniscal entrapment test Rationale

Varus Stress– compresses the medial compartment to increase – catching, clicking, or locking symptoms– may cause stretch pain of meniscal attachments

on the lateral side of the joint

Valgus Stress– compresses the lateral compartment to increase

catching, clicking, or locking symptoms– may cause stretch pain of meniscal

attachments on medial side of the joint

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meniscal entrapment test Interpretation

Meniscal tears/lesions do not hurt (they are aneural) - they click, catch, or lock

The pain produced from the entrapment tests occurs at the site of meniscal tissue attachments.

Pain is located over the specific area of pathology with palpation but may be reported in the opposite corner of the actual pathology during the entrapment tests with these specific entrapment test methods

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what portion of the menisci is under stress?

posteromedial posterolateral

Posteromedial stress because of the flexed and varus posture of the knees.Posterolateral stress because of the flexed and valgus postue of the right knee.

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McMurray Test

Medial Meniscal Testing– Extension from a hyperflexed position in varus and internal rotation =

posteromedial meniscal injury

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McMurray Test

Lateral Meniscal Testing– Extension from a hyperflexed position in valgus - external rotation =

posterolateral meniscal injury

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Apley’s Compression - Distraction Test

Apley’s Compression Test– Hard downward pressure is applied

with rotation– Pain indicates a meniscal injury

Apley’s Distraction Test– Traction is applied with rotation– Pain will occur if there is damage to

the capsule or ligaments– No pain will occur if it is meniscal

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meniscal testing truth

TEST Citation Sensitivity Specificity

MRI Jackson 93% 90%McMurray Evans 20% 91%McMurray Fowler 29% 96%Apley (compression) Fowler 16% 80%Joint Line Tenderness Fowler 85% 30%Pain on Forced Flexion Fowler 51% 70%Block to Extension Fowler 44% 86%

Sensitivity - % patients correctly identified by the test - good at ruling outSpecificity - % patients correctly not identified by the test - good at ruling in

According to Stratford, et al, J Orthop Sports Phys Ther in 1995 – the McMurray test will miss as much as 40% of meniscal tears.

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MRIs are about 90% accurate

uniform black signal at the tip of red arrow

white signal within black signal at the tip of the red arrow

The gold standard for diagnosing is either direct visualization through arthroscopy or MRI.

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Thessaly TestAccuracy Results

Test Accuracy

90%96%94%Thessaly 20°

82%90%86%Thessaly 5°

80%89%81%Joint Line Palpation

59%82%75%Apley’s

72%84%78%McMurray’s

ACL + Meniscus

Lateral Meniscus

Medial Meniscus

Exam

Also reported sensitivity, specificity, false positives and negatives for each test

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Thessaly 20°Test Results

ACL + MeniscusLateral Mensicus

Medial Meniscus

1%1%4%False Negative

90%96%94%Accuracy

9%4%2%False Positive

91%96%97%Specificity

80%92%89%Sensitivity

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Other MeniscalProvocative Maneuvers

Joint Line Tenderness– O’Donohue– Bragard– Steinmann– Payr’s– Cabot’s Popliteal sign

Symptom Reproduction– Apley– Bohler and Kromer– Duck Walking (Childress Sign)– Helfet– Ege

O’Donohue – pain with rotation at 0 and 90 degreesBragard – reproduction of symptoms medially with ER and ext; alleviation of symptoms with flex/IRSteinmann’s – tenderness at joint line that moves posteriorly with flexion, anteriorly with extension, medially with ER and laterally with IR. Payr’s – medial joint line pain in the Figure 4 positionCabot’s Popliteal sing – medial joint line pain while isometrically extending the knee from the Figure 4O’Donohue – pain with rotation at 0 and 90 degreesBragard – reproduction of symptoms medially with ER and ext; alleviation of symptoms with flex/IRSteinmann’s – tenderness at joint line that moves posteriorly with flexion, anteriorly with extension, medially with ER and laterally with IR. Payr’s – medial joint line pain in the Figure 4 positionCabot’s Popliteal sing – medial joint line pain while isometrically extending the knee from the Figure 4 position

Apley – already discussedBohler and Kromer – pain with varus/valgus in compressed compartments and flexion/extensionDucking Walking (Childress Sign)- duck walking causing pain or snapping in posterior hornHelfet – lack of ER (lateralization of tibial tubercle) in full extensionEge – deep squat in full LE ER for medial meniscus and LE IR for lateral meniscus

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Part 3: Surgical Considerations

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Operative vs. Conservative Management

Small, peripheral, stable tears that are not causing functional limitations may respond to non-surgical intervention

Small, peripheral, stable (defined as partial thickness splits or tears that displace less the 3-5 mm when probed) that are not causing functional limitations may respond to non-surgical intervention

The other group of patients that may do better with a non-operative course is the degenerative tear in a severely osteoarthritic knee.

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Meniscal Surgical Options

Partial MenisectomyMeniscal RepairMeniscal Allograft

Menisectomy = excisionRepair = mend, fix, restorationAllograft = transplantation

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Meniscal Surgical Indications

Partial Menisectomies– complex tears in avascular zone– Large flap or radial tears– degenerative tears– irreparable tears

Meniscal Repair– young patients - all tears except inner 4-6 mm– stable knees– complete longitudinal tears greater than 1 cm

in length

Excision Indications•Complex tears in the white, avascular zone •Flap and radial tears measuring more than 5 mm in length •Degenerative or irreparable tears

Radial split tears are more frequently noted in the lateral meniscus; if they extend to the periphery, they have the potential to heal.

Indications for Repair•Young patients – all tears except inner 4-6 mm•Stable knees or knees undergoing concurrent ACL reconstruction•Complete longitudinal tears greater than 1 cm in length but within 3-4 mm or peripheral rim

Vascular channels or fibrin clots may be used on white zone tears

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Meniscal Repair Techniques

High % of success– Seems to be independent of age, length of tear, or time

since injury– 90% success in ACL reconstructions; 30-40% failure in

ACL deficient knees

Complications: 5% failure; 2% have neurovascular injury

Medial repairs – at risk for entrapment of the sartorial branch of the saphenousnerve resulting in a painful neuroma

Lateral repairs – possible peroneal nerve or popliteal artery injury from suture passing

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Meniscal Repair Techniques

Sutures– Inside Out: middle and posterior tears– Outside In: anterior tears

Arrows– All inside barbs, harpoons, darts

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Outside-In Meniscal Repair

No longer done routinely other than on some anterior tears

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Inside-Out Meniscal Repair

A cannula (curved guide tube) is used to direct needles and firmly tie sutures on the outside of the capsule. This does require a small, 1-2”, incision in the area where the sutures need to be tied.

General Indications

1. Peripheral, unstable longitudinal tears greater than 1 cm (shorter than 8 mm may heal on own)

2. Longitudinal tears with 3mm of periphery (red-white zone)3. Tears 4-6 mm from the capsule (white zone) are sometimes repaired in young

ACLs and with the assistance of a fibrin clot

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All Inside Meniscal Arrow Repair

Meniscal arrows or darts aretiny biodegradable polymer harpoons that hold togetherthe torn portions of ameniscal tear until the fragments join together and the arrow dissolves.

Another popular all inside repair is the T-Fix system which are sutures that act like wall anchors

Are arrows and darts beginning to loose popularity? Recent studies seem to indicate the suture strength is superior to barbs, darts, and arrows.

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Meniscal Healing Prognosis

GOOD PROGNOSISYounger Patient (under 35)

Peripheral DamageLongitudinal TearShort TearAcute Injury (bloody effusion)

Stable Knee

POOR PROGNOSISOlder PatientCentral DamageComplete TearBucket Handle TearChronic InjuryUnstable Knee

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Part 4: Post-Operative Rehabilitation

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Pro-Active Post-Arthroscopic Knee Rehab

BOTH the surgical procedure and subsequent clinical rehabilitation influences the rate and extent of recoveryHughston, 1980

The earlier AROM is allowed, the earlier full ROM is achievedSherman, 1983

Patients need post-operative physical therapy to normalize motor control, muscular strength, and gaitDurand, 1991 and 1993

Supervised rehab facilitates successful outcomesMoffett, APMR, 1994

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Pro-Active Post-Arthroscopic Knee Rehab

Timm, 1988 retrospective study on 5,000+ post-op knee cases

POST-OPERATIVE CARE SUCCESS RATE

No exercise 0%Home exercise instruction only 9%Supervised isotonic exercise program 48%Supervised isokinetic and comprehensive rehab 92%

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Physical Therapy Efficacy

No differences between home program and HEP with six weeks of supervised physical therapy according to a varietyof outcome measures

– Outcomes questionnaires– Days return to work– Gait kinematics– Hop/Jump tests

Goodwin PC et al, Phys Ther 83:520-535, 2003

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Physical Therapy Efficacy

Vervest AM, et al. Effectiveness of physiotherapy after menisectomy. Knee Surg Sports Traumatol Arthrosc. 1999; 7(6):360-364

Physiotherapy group showed significantly better results than the control group in regards to patient satisfaction and functional outcomes

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post-op meniscal rehab considerations

Proactive approachProtected arcs of motionVarus-valgus stressRotational torqueOKC vs. CKCTime to Return– Excisions: 4-6 weeks– Repairs: 4-6 months

Proactive Approach – supervised rehab begins immediately and patient is discharged when they demonstrate no evidence of complications and independence in their exercise program and symptom management

Protected Arcs of Motion – limit flexion range for posterior mensical injuries

Varus-Valgus Stress – avoidance of varus compression activities with medial meniscal injury and valgus compression activities with lateral meniscal injury.

Rotational Torque – avoidance of rotational movemets, particularly in weight bearing postures

CKC (weight bearing) activities may be avoided initially in rehab because of the potential compressive forces. Patients tend to do better early in their rehab with non-weight bearing activities that do not cause compression or co-contraction. They need to be progressed to weight bearing, functional activities as their surgical discomfort decreases and their gait pattern normalizes.

Meniscal excisions can progress as their symptoms allow. The offending lesion has been removed and there is no tissue of signifcance to protect during the course of rehabilitation.

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post-op menisectomy rehabilitation considerations

Control post-op pain/swelling FWB when gait normalizesROM and strengthening to toleranceReturn to activity typically takes 3-6 weeks

Prevent Common Complications:

1. Quad neural disassociation – reflex inhibition – address through early quad facilitation and strengthening techniques

2. Portal neuromas – address through early soft tissue and incisional management3. Flexion (or extension) contracture – address with early joint mobilization and

encouragement of AROM

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post-op meniscal repair rehab considerations

General Considerations and Influences– Site of repair

Red vs. whiteComplex vs. peripheral

– Associated pathologies

Patients with a fibrin clot in to fix a white zone tear may need longer a longer immobilization time to maintain the clot’s integrity and position

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post-op meniscal repair rehab considerations

General Considerations and Influences– Age – Athletic or ADL goals– Surgeon Philosophy

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post-op meniscal repair rehab considerations

Immediate protected motion post-op (0-90° for 4 wks)

Locked in full extension if early weight bearing; FWB at 4-6 wks

Neoprene compression sleeve to minimize swelling and provide support

Slow, gradual progressions based on objective status

No resistive flexion for 2 months

No squats, twisting, or “heel-to-butt” stretching activities for 3-6 months

4-6 month restriction on return to athletics

Locked in full extension during weight bearing because there are decreased compressive loads transmitted through the menisci (50%) as compared to when in 90 degrees of flexion (85% )

May progress more slowly with lateral repairs secondary to higher % of load transmission of weight distribution in this compartment

Resistive flexion activities are delayed because of the strain that contractions of the semimembranosis and popliteus may place on the healing menisci during the first couple of months.

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Post-operative Rehab Protocol

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POST-OPERATIVE MENISCAL REPAIR REHABILATION

A. General Considerations1. Rehabilitation program is based on the site of tear/repair (vascular/avascular zone; anterior or posterior

location); associated pathologies (ligamentous injuries); age; athletic/occupational goals; and physician philosophy and preference

B. Initial Maximum Protection Phase: (roughly first month post-op)1. Modality Care for Pain and Effusion (must prevent quad shutdown)

ice - compression - elevationhigh frequency electrical stimulation to quadriceps

2. Brace Range of Motion: 0-90° passive ROM allowed within confines of brace. Some surgeons maylimit ROM based on site of repair

peripheral mid zone 10-80°peripheral posterior zone 20-90°peripheral anterior zone 20-90° } can increase to 10 degreesavascular zones 20-70° at 10 days post-op

3. Weight Bearing Status: (some may have patient remain NWB for first few weeks)toe touch to PWB for first 3 weeks with knee locked in brace in full extension

4. Manual Therapy:patellar mobilizationsscar tissue/soft tissue mobilization to prevent neuroma formation

5. Exercise: (in brace)Quadricep Isometrics4-plane SLRPassive range of motionSingle leg cycling of uninvolved leg and/or UBE

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Post-operative Rehab Protocol

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C. Subacute Initial Mobilization Phase (roughly 2nd month)

General Goals: Gradual return to FWB status and development of muscular endurance (not strength).1. Modality Care prn - ice post activity or exercise; compression and elevation prn2. Weight Bearing Status: (suggested progression)

a. peripheral repairs - begin 25% weight bearing week 3-4 and progress by weight bearing status by 25% per week until FWB by the 6th-7th week post-op without protection of brace.

b. central (avascular repairs) - begin 25% WB during week 4 and progress by 25% per weekuntil FWB in the 8th week post-op without protection of brace

3. Exercise Program: (possibly still in brace)a. gradual increases in resistance to 4 plane SLRs with careful monitoring of varus/valgus stresses.b. Protected Arc Open Chain Knee Extension based on repair sitec. open chain surgical tubing resisted hip, knee, and ankle exercises.d. Initiation of proprioception training:

1. soleus pumps - heel raises progression2. NWB/PWB BAPS Board3. Supine Quad Press with low resistance

e. Lower Extremity Flexibility Program with exception of quadriceps stretchingf. Stationary Cycling with mild pedal tension. Progressively out of brace during cycling.

D. Intermediate Functional Strength Improvement Phase: Months 2-5General Goals: Emphasis on strength, power, endurance, functional activities, and normalizing lower extremity flexibility, This

phase may be delayed if avascular repair or symptoms indicate slow healing.1. Exercise Program: (out of brace)

Quadricep stretching can be initiated slowlyLower Extremity Progressive Resistive Exercise - can now slowly progress towards full arc ranges of

motion.Low intensity, high repetition hamstring curls initiatedWeight Bearing Exercises:

1. Mini-Squats 2. Lateral Step Ups 3. Standing BAPS Board

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Post-operative Rehab Protocol

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e. Isokinetic Exercise - high speed work to avoid compressive and shear forces. May need range limitation dependent upon repair site and stage of healing.

f. Cardiovascular Training:1. Pool Therapy - walking/kicking2. Stationary Bike3. Elliptical Machine4. Stairclimbing device

E. Return to Activity Phase - 5-6 months postGeneral Goals: preparation for return to sport or occupational demands

1. Functional Progression:Progressive Plyometric Program if relevant to patient goalsCoordination Activities - hops, side-steps, crossovers, cariocas, etcWalk-Run Progression Protocol over 4-8 weeksAgility Training

2. Functional and Isokinetic Evaluation Prior to Return to Sport/Occupation

REHABILITATION PROGRAM SUMMARY:• Immediate protected motion post-operatively (0-90° for month)• Locked in full extension if early weight bearing; FWB at 4-6 weeks• Neoprene Compression Knee Sleeve effective to decrease swelling and provide support• Slow, gradual progressions based on healing requirements • Alter program according to objective findings of pain over repair site and/or swelling• Protect meniscal repair by avoiding ROM which stresses the sutures or arrows• No resistive flexion for 2 months• No squats or twisting activities for 3-6 months• 4-6 month restriction on athletic activity

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Remember … a good clinician knows when to ignore the protocol’s suggestions

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meniscal allograft rehabilitation

Locked in full extension first 6-8 weeks

Progressive weight bearing over 6-12 weeks

Slow gradual progression

6-12 months to return to full, unrestricted activity

Fritz JM, Irrgang JJ, Harner CD. Rehabilitation following allograft meniscaltransplantation: a review of the literature and case study. J Orthop Sports Phys Ther. 1996 Aug; 24(2): 98-106.

Allograft - transplantation from a donor or collagen mensical implants (scaffold of collagen hoping to stimulate new collagen growth – currently under FDA investigation)

The bes review of the literature and case study on meniscal allograft transplantation is from Fritz JM, Irrgang JJ, Harner CD. J Orthop Sports Phys Ther. Aug 1996 24(2): 98-106

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References

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