2014 Rehabilitation of Meniscal Injury and Surgery

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Rehabilitation of Meniscal Injury and Surgery

John T. Cavanaugh, PT, MEd, ATC, SCS1

1 Sports Rehabilitation and Performance Center, Hospital for Special

Surgery, New York, New York

J Knee Surg 2014 ;27: 459–478.

Address for correspondence John T. Cavanaugh, PT, MEd, ATC, SCS,

Sports Rehabilitation and Performance Center, Hospital for Special

Surgery, 535 East 70th Street, New York, NY 10021(e-mail: [email protected]).

Meniscal cartilage plays an essential role in the function and

biomechanics of the knee joint. The meniscus functions inload bearing, load transmission, shock absorption, joint sta-

bility, joint lubrication, and joint congruity.1–3 Individuals

today are increasingly more active in later decades of life.

Although the incidence of meniscal pathology is dif cult to

estimate, this increased exposure to athletic activityincreases

the risk of injury to these structures. Hede and coworkers 4

reported the mean annual incidence of meniscus tears as 9.0

in males and 4.2 in females per 10,000 inhabitants.

Tears were found to be more common in the third, fourth,

and fth decades of life. It has become clearer in recent

decades that meniscal excision leads to articular cartilage

degeneration.5–7 Degenerative changes havebeen found to be

directly proportional to the amount of meniscus removed.8

Therefore, it has been generally recognized that the amount

of meniscal tissue removed should be minimized, repaired, or

replaced.9–11 Whether a meniscal lesion is treated conserva-

tively or surgically, the rehabilitation program will play an

important role in the functional outcome. This article will

discuss these programs and the various treatment strategies

employed.

Mechanism of Injury/Presentation

Meniscal lesions can occur from either mechanical or bio-

chemical (degenerative) causes.12 Noncontact forces are the

most frequent mechanism of injury to the menisci.2 Typically,

these stresses result from a sudden acceleration or decelera-

tion in conjunction with a change of direction (rotation force)

that traps the menisci between the tibia and femur, resulting

in a tear. In jumping sports such as basketball and volleyball,

the additional element of a vertical force with angular mo-

mentum (varus or valgus) on landing can contribute to a

meniscal injury. Contact injuries involving valgus or varusforces can contribute to meniscal pathology. Ligament inju-

ries to theanterior cruciate ligament (ACL) or medialcollateral

ligament, or both in which increased tibial displacement

occurs, can displace the menisci from its peripheral attach-

ments and result in a tear. In chronic ACL insuf ciency, the

Keywords

► meniscus

► rehabilitation

► surgery

Abstract Meniscal cartilage plays an essential role in the function and biomechanics of the knee joint. The meniscus functions in load bearing, load transmission, shock absorption, joint

stability, joint lubrication, and joint congruity. Individuals today are increasingly more

activein later decades of life. Although theincidence of meniscal pathologyis dif cult to

estimate, this increased exposure to athletic activity increases the risk of injury to these

structures. Hede and coworkers reported the mean annual incidence of meniscus tears

as 9.0 in males and 4.2 in females per 10,000 inhabitants. Tears were found to be more

common in the third, fourth, and fth decades of life. It has become clearer in recent

decades that meniscal excision leads to articular cartilage degeneration. Degenerative

changes have been found to be directly proportional to the amount of meniscus

removed. Therefore, it has been generally recognized that the amount of meniscal

tissue removed should be minimized, repaired, or replaced. Whether a meniscal lesion is

treated conservatively or surgically, the rehabilitation program will play an important

role in the functional outcome. This article will discuss these programs and the various

treatment strategies employed.

received

May 5, 2014

accepted after revision

September 1, 2014

published online

November 12, 2014

Copyright © 2014 by Thieme Medical

Publishers, Inc., 333 Seventh Avenue,

New York, NY 10001, USA.

Tel: +1(212) 584-4662.

DOI http://dx.doi.org/

10.1055/s-0034-1394299.

ISSN 1538-8506.

Special Focus Section 459

mailto:[email protected]://dx.doi.org/10.1055/s-0034-1394299http://dx.doi.org/10.1055/s-0034-1394299http://dx.doi.org/10.1055/s-0034-1394299http://dx.doi.org/10.1055/s-0034-1394299mailto:[email protected]


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incidence of meniscal pathology can approach 98%.13 The

medial meniscus injury rate has been found to be higher than

that for the lateral side (86.9 vs. 28.9%) in this population.14

Degenerative lesions are not uncommon in older individ-

uals. As we age, the menisci become stiffer and are less

compliant.15 Mesiha et al16 observed that meniscal tissue

from patients older than 40 years has a lesser cellularity and a

decreased healing response than tissue from younger pa-tients. The most common types of meniscal tears are vertical,

longitudinal, oblique, degenerative, radial, and horizontal.17

Meniscal tears present with varied clinical symptoms such

as pain, effusion, locking, and persistent focal joint line

tenderness. Displaced tears, such as bucket handle tears,

canproduce locking and“giving way” episodes. Nondisplaced

tears can alter meniscus mobility and produce abnormal

traction stresses on the capsule and synovium, which result

in pain and swelling.18

Management (Overview)

Meniscal tears may be treated conservatively based on loca-tion within the meniscus, type of lesion, and associated

symptoms. The natural history of longitudinal tears less

than 1 cm is either spontaneous healing or resolution of

symptoms. Stable tears with less than 3- to 5-mm displace-

ment, peripheral tears less than 1 cm that displace less than

3 mm, degenerative tears in arthritic knees, and partial tears

may not require surgical intervention.19,20 Surgical options

include partial meniscectomy, meniscal repair, or meniscus

transplantation. Meniscal tear pattern, geometry, site, vascu-

larity, size, stability, tissue viability or quality, and associated

pathology are all taken into account when determining

whether to resect or repair a meniscal lesion.

21

Consideration must also be given to the underlying artic-

ular cartilage. Seedhom and Gardreanes22 demonstrated that

removal of 16 to 34% of the meniscus resulted in a 350%

increase in contact forces. Therefore, attempts to preserve the

injured meniscus are made whenever possible.

Improvements in surgical techniques along with advanced

instrumentation and repair methods have enabled orthope-

dic surgeons to repair menisci that were once thought of

being unrepairable. Meniscal allograft transplantation has

emerged as a treatment option for selected meniscus-de-

cient patients to decrease the articular contact stress, provide

pain relief, and restore normal knee kinematics. The health,

activity level, and aspirations of the patient are taken intoconsideration during the decision-making process. Comor-

bidities, such as heart disease, obesity, axial alignment, and

degenerative joint disease, are considered in the decision

process to excise, repair, replace, or even avoid surgery.

Rehabilitation Principles

Individualize Program: Consider Preinjury Status

The most important principle guiding a rehabilitation pro-

gram following meniscal injury or surgery is individualiza-

tion.23 The preinjury status of the patient needs to be taken

under serious consideration, as different patients present

with diverse physical condition at the time of their initial

evaluation. The patient may be an elite athlete, a recreational

athlete, or a nonathlete in weak physical condition. Media

reports of professional athletes returning quickly to their

sport after arthroscopic meniscal surgery often frustrate

nonathletes or recreational athletes, who may take longer

to achieve their postsurgical goals. The professional athlete’s

condition and lower extremity strength enable them toprogress through the rehabilitative process at a faster rate

(► Table 1).

Apply a Working Knowledge of the Basic Sciences to

the Rehabilitation Program

An understanding of the anatomy, function, and biomechan-

ics of the knee joint, as well as the pathophysiology of knee

joint injuries, is needed to provide a quality rehabilitative

experience to individuals who have sustained a meniscal

injury. Knowing how and when these structures are placed

under stress during activities of daily living and specic

exercises will assist the rehabilitation specialist in safely

advancing the patient through the rehabilitative course andoptimize functional outcome.

The menisci consist of approximately 75% of type I colla-

gen.24 Collagen types II, III, IV, and V are also present. Most of

the collagen bers are oriented circumferentially to resist

tensile forces and contain hoop stresses which are generated

while weight bearing.25 Radially oriented “ties” hold circum-

ferential bers together and provide resistance to shear.26

Each meniscus is divided anatomically into horizontal thirds:

the posterior horn, the mid-body, and the anterior horn.

When looking at blood supply the menisci are divided into

vertical thirds. The most peripheral 20 to 30% of the medial

meniscus and the peripheral 10 to 25%of thelateral meniscusreceive a rich blood supply from the medial and lateral

genicular arteries.27

Vascularization decreases approaching the inner portion

of the meniscus and becomes dependent on diffusion.28

Meniscal tears that extend to the inner avascular area have

a more dif cult time with healing. Free nerve endings (no-

ciceptors) and three different mechanoreceptors (Ruf ni

corpuscles, Pacinian corpuscles, and Golgi tendon organs)

can be found in the horns and in the outer two-thirds of the

body of the menisci, thus supporting the role of menisci in

knee joint proprioception.28–32 Karahan et al32 demonstrated

that partial meniscectomy patients had a signicant loss of

Table 1 Rehabilitation principles for the meniscal patient

1. Individualize program: consider preinjury status

2. Apply a working knowledge of the basic sciences to therehabilitation program

3. Team approach to rehab: responsibilities andcommunication

4. Adhere to the rules of rehabilitation

5. Follow a functional progression

6. Follow evaluation/criteria-based guidelines

The Journal of Knee Surgery Vol. 27 No. 6/2014

Rehabilitation of Meniscal Injury and Surgery Cavanaugh460


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An early goal in rehabilitation after meniscus injury or

surgery is to have the patient establish quadriceps control.

This can be demonstrated by having the patient perform a

straight leg raise without pain or an extensor lag. Once

established, the functional progression can be advanced as

long as knee ROM and lower extremity muscle strength

display improvement. The next criterion in the progression

is to have the patient reestablish a normal nonantalgic gaitpattern. Consider that “every step is therapy” and encourage

the patient to ambulate with a heel-toe gait pattern while

progressively weight bearing with crutches. Additional strat-

egies used include decreasing stride length, emphasizing

quality ambulation over quantity, and utilizing water (e.g.,

underwater treadmill) for ambulation training so as to grad-

ually apply increased load through the knee joint. Walking in

chest-deep water results in a 60 to 75% reduction in weight

bearing, while walking in waist-deep water results in a 40 to

50% reduction in weight bearing.41,42 Normalizing a gait

pattern facilitates gains in ROM.

The patient is then asked to exhibit the ability to ascend

stairs, followed by the ability to descend stairs. After demon-strating the ability to eccentrically control body weight

descending stairs,the patient mayinitiate a running program

if not contraindicated. As lower extremity and core muscle

strength, balance, and exibility demonstrate improvement,

higher-level activities including agility-promoting, plyomet-

ric, and sport-specic activities are introduced as therapeutic

interventions.

Follow Evaluation-Based Guidelines

Modern rehabilitation programs following meniscal injury

and/or surgery should followa plan that is not asstructured

as the protocols of yesteryear. Each patient will progress ata different pace. Protocols can accelerate a program too

quickly for the patient whose progress is delayed and can

hold back the patient who is progressing very well. The

rehabilitation specialist should refrain from following a

“cookbook” approach to treatment. Instead, he/she should

combine basic scientic knowledge and physical examina-

tion skills to guide the patient through the rehabilitative

course. Clinical guidelines can and should be developed by

treating clinicians and the referring physicians. These

guidelines should incorporate exible time frames in the

progression to allow for individualization, for example:

“weeks 3 to 5—discontinue crutches when nonantalgic

gait is demonstrated”—versus “week 4—discontinuecrutches for ambulation.” Continual reassessment of the

patient is vital to ensure a consistent and safe progression

of the program. Too rapid a progression in therapy or

normal functional activities of daily living is demonstrated

by increased effusion and pain. This is most likely related to

muscular fatigue, which leaves the articular surfaces un-

protected against compressive forces. Therapeutic exercise

programs, therefore, often must be modied based on

changes in subjective and objective ndings.

A comprehensive evaluation establishes the baseline from

which progress is measured. A comprehensive history reveals

the mechanism of injury, how the injury was initially man-

aged, medical diagnosis including workup (radiographs, MRI

scans, etc.), surgery date, and postsurgical management.

Observations document patient’s weight-bearing status,

gait deviations, joint effusion, muscle atrophy, and joint

alignment. Attention to the patient’s subjective complaints

is of the utmost importance throughout the rehabilitative

process. Reports of pain (location and description), lack of

mobility, andweaknesshavea direct effect on the progressionof a rehabilitation program. The physical examination should

document available active range of motion (AROM) and

passive range of motion (PROM). Girth measurements should

be taken above, at, and below each knee joint for comparison

to assess muscle atrophy. Palpation of joint line tenderness is

a valuable component of the evaluation of a meniscal patient.

Eren43 demonstrated that joint line tenderness as a test for

lateral meniscal tears was 96% accurate, 89% sensitive, and

97% specic. Manual muscle testing may reveal a proximal or

distal weakness or muscle imbalance. Quadriceps testing is

often not appropriate in the immediate postinjury or post-

operative setting. Neurovascular integrity should be evaluat-

ed. Assessment of patellar orientation and tracking whereappropriate can provide valuable information when quadri-

ceps strengthening exercises are implemented at a later date.

Flexibility assessment is important, as tight muscles about

one joint can alter forces at another joint. Gait evaluation

(when applicable) can be useful in assessing the patient ’s

biomechanical prole.

The clinical evaluation would not be complete without

dening goals and a treatment plan to meet these goals. The

information gathered should be reviewed with the patient.

Realistic goals should be discussed and established by the

patient, physician, and rehabilitation specialist. The patient

should be made to understand the magnitude of their injuryor surgery and the timetable for recovery. Goals should be

specic tothe individual needsof the patient.Goals should be

functional and measurable as well. The patient should be

made aware of his or her role in the rehabilitative process. A

treatment plan can only be developed when the clinical

ndings from a comprehensive examination are considered.

The rehabilitation specialist should develop a prioritized

problem list. Specic rehabilitation strategies can then be

used to address each problem. Examples include utilizing

cryotherapy to control or decrease pain and joint effusion,

ROM exercises to address a loss of knee exion or extension,

and gait training to normalize an asymmetrical or antalgic

gait pattern. Throughout the rehabilitative course, a criteria-based functional progression of therapeutic exercises should

be followed.

Conservative Management

When a meniscal lesion is treated conservatively, the refer-

ring physician should communicate with the rehabilitation

specialist and share their prognosis for the patient. As dis-

cussed earlier, concomitant pathology (degenerative joint

disease, chondromalacia, ligament deciency, chondral inju-

ry, etc) should also be identied. Following a comprehensive

examination, the patient should be treated symptomatically,




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addressing pain, swelling, motion loss, weakness and inhibi-

tion, and loss of function.

Following an acute meniscal tear, pain and an ensuing

knee effusion can be expected. Inhibition of the quadriceps

muscle shortlyfollows. Mechanoreceptors in thejoint capsule

respond to changes in tension and in turn inhibit motor

nerves supplying the quadriceps muscles.44

Therefore, controlling posttraumatic effusion leads todecreased quadriceps inhibition and results in a faster return

of muscle function. Early posttraumatic treatment strategies

include cryotherapy, quadriceps setting, straight leg raises in

multiple planes, progressive weight bearing as tolerated gait

training with crutches, active-assisted range of motion

(AAROM) exercises (►Fig. 1), and exibility exercises. The

patient is advised to perform these exercises as part of a

comprehensive home program and to modify one’s activity

level until symptoms subside and ROM and muscle strength

demonstrate improvement. Weight bearing crutch ambula-

tion is encouraged until the patient demonstrates a normal

nonantalgic gait pattern. Therapeutic exercises are advanced

to include closed kinetic chain (CKC) exercises, such as legpress, mini squats, step-ups, step-downs, retro treadmill

ambulation, and balance/proprioception activities. Palmitier

and colleagues45 in a biomechanical model of the lower

extremity demonstrated reduced tibiofemoral shear force

when a compressive force is applied to the knee joint. Co-

contraction of agonist and antagonist muscles during func-

tional CKC movements provide joint stabilization by decreas-

ing shear forces acting on the knee. CKC exercises also reduce

patellofemoral joint reaction force. Hungerford and Barry46

demonstrated greater patellofemoral contact stress per unit

area during open kinetic chain (OKC) knee extension than

during squatting under body weight between full extension

and 53 degrees of exion. Squatting between 53 and 90degrees of exion produced greater patellofemoral contact

stress per unit area than that produced during OKC knee

extension in the same range. Retrograde treadmill ambula-

tion on progressive percentage inclines is used to facilitate

quadriceps strengthening.47 As full ROM is improved and

quadriceps control is demonstrated, OKC knee isotonic ex-

tension exercises are implemented inside a pain-free/crep-

itus-free arc of motion. Bilateral knee extensions are initiated

before unilateral knee extension.

Research suggests that a certain level of deafferentation

occurs after lower extremity joint injury.48 As the central

nervous system receives decreased sensory information,

there is decreased ability to adequately stabilize the lowerextremity.48,49 Efforts to regain proprioception loss begin

with balance activities utilizing bilateral support, advancing

to unilateral support.50 A foam-like cushion or a computer-

ized platform device such as the Biodex BioSway System

(Biodex Medical Systems, Shirley, NY) can be used (►Fig. 2).

A criteria-based functional progression is followed

throughout the rehabilitation course. Upon demonstration

of full ROM and a controlled 8″ step-down (►Fig. 3) (without

Fig. 1 Active-assist ed range of motion exercise. The patient supports

his involved lower extremity with the noninvolved lower extremity as

the patient attempts to ex the involved knee. Upon reaching the

degree of stretch, the noninvolved extremity assists the involved knee

in returning to the fully extended position. Fig. 2 Biodex BioSway System (Biodex Medical Systems, Shirley, NY).


Rehabilitation of Meniscal Injury and Surgery Cavanaugh 463


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pain and good lower extremity control without deviations), arunning program is initiated. Backward running is preceded

by forward running, as retrograde runninghas been shown to

generate lower patellofemoral joint compression forces than

forward running.51 Advanced sport-specic activities such as

deceleration training and plyometrics are added as appropri-

ate to meet the specicity of the individual athlete’s sports

requirements. Before plyometric exercises are incorporated

into a treatment regime, ROM and exibility should be

restored. Static and dynamic balance should be proved to

be within acceptable ranges. The patient should also demon-

strate a lack of apprehension in performing sport-specic

movements. Plyometric training should follow a functional

progression, with the components of speed, intensity, load,volume, and frequency monitored and advanced accordingly.

Activities should begin with simple drills and advance to

more complex exercises (e.g., double leg in-place jumping vs.

box drills). Dynamic stretching exercises should be included

to develop sport-specic exibility and to enhance perfor-

mance. This form of stretching incorporates the actual range

of movement about a joint, with the patient overcoming

resistance to movement while performing an activity at the

normal speed.52 To ensure that an athlete is prepared to

return to sport, the rehabilitation specialist should be able to

objectively demonstrate that the athlete has met the criteria

(ROM, exibility, strength, power, endurance) to meet the

demands of that particular sport. These criteria must be met

to decrease the possibility of reinjury.

Testing provides evidence of progress in a rehabilitation

program and is a vital tool of criteria-based rehabilitation

guidelines. Lower extremity strength and power assessment

is accomplished via isokinetic and functional testing. Testing

can provide a bilateral comparison (involved vs. noninvolved

extremities), represented as limb symmetry (100%) or as apercentage decit. Isokinetic testing of the knee involves

assessment of the quadriceps and hamstring muscles during

a testing regime in which speed is constant and resistance is

variable and accommodating. Isokinetic testing has been

shown to be both reliable and valid.53,54 Testing velocities

should be determined for the individual patient. Slower-

velocity testing (30, 60, and 90 degrees) is avoided in many

meniscal patients, as joint compressive, shear, and tibial

displacement forces are greater at these speeds than at

intermediate (120, 150, and 180 degrees) and fast (240,

300 degrees þ per second) test velocities.55,56 Faster-velocity

testing can also replicate knee velocity during functional

activity. Wyatt and Edwards57 have reported the angularvelocity of the tibiofemoral joint during walking to be 233

degrees. Data interpretation can include, among other

parameters, peak torque, peak torque to body weight ratio,

total work, average power, quadriceps to hamstring ratio,

force decay rate, and torque curve analysis. Many clinicians

strive for more than 85% limb symmetry in the affected limb

compared with those in the contralateral limb as acceptable

level for a return to sports activities.58 Functional testing

allows a more functional approach to strength assessment by

using a CKC environment during measurement. Functional

testing links specic components of function with the actual

task and provides direct evidence to prove functional status.Observation during testing can assist the rehabilitation spe-

cialist in ascertaining the athlete’s apprehension or lack

thereof in performing a functional task (e.g., landing from a

jump). Limb symmetry tests include hop tests, vertical jumps,

and leg-press tests. Daniel et al59 introduced the one legged

hop test for distance in 1982 (►Fig. 4). Barber et al60 de-

scribed four hop tests to assess lower extremity functional

limitations: single-legged hop for distance, timed hop, triple

hop for distance, and crossover triple hop for distance. The

single-legged hop for time and the crossover hop have been

reported to be the most sensitive and best indicators of

function.60,61 Normal limb symmetry was identied as

limb values within 85% of one another for both men andwomen regardless of limb dominance or sports activity level.

Decits demonstrated in these tests as well as observed

dif culty in stabilization on landing, apprehension, or com-

plaints of pain indicate the need for continued therapeutic

interventions in the areas of strength, power, and balance

development. Information obtained, whether subjective or

objective, can be presented to the referring physician for

consideration. The patient/athlete is then advised regarding

the level of sports participation, with or without modica-

tions, to which he or she can return. On discharge from a

formal rehabilitation program, the rehabilitation specialist

should provide the patient with a comprehensive home or

Fig. 3 Step-down exercise. The patient descends an 8″ step leading

with his noninvolved lower extremity. The patient is cued to perform

his decent in a slow, controlled manner. The rehabilitation specialist

monitors complaints of knee pain and observes asymmetry.




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gym therapeutic exercise program to maintain and advancethe present level of function.

Rehabilitation Strategies after ArthroscopicPartial Meniscectomy

Surgery of the meniscus is a common orthopedic procedure,

constituting 10 to 20% of surgeries performed in some

practices.62 With the advancement of arthroscopic surgery

in the last three decades, total meniscectomy is less com-

monly performed. McGinity et al63 have reported diminished

morbidity when partial meniscectomy is performed over

total meniscectomy. Early proper management after surgery

is vital in ensuring a fast and safe recovery. Postoperativeeffusion and pain are controlled byencouraging the patient to

use axillary crutches in the immediate postoperative period.

A progressive weight-bearing gait is advised. The rehabilita-

tion specialist needs to encouragethe patient to monitor load

and volume of activity in the days following surgery. This

advice is particularly important when dealing with patients

with degenerative joint disease and/or a high body mass

index (BMI). Increased BMI makes surgery more challenging

and subjects the knee to increased contact forces.64,65

As the patient develops a more normal, nonantalgic gait,

use of crutches is discontinued. Cold and compression is

applied postsurgically using a commercial cryotherapy de-

vice, for example, Game Ready Cold Therapy Compression

System (CoolSystems, Inc., Concord, CA) (►Fig. 5) to controlpain and inammation. Nonsteroidal anti-inammatory

drugs are recommended by some surgeons. Rasmussen et

al66 reported on 120 patients, randomized to either naproxen

twice a day or placebo for 10 days after arthroscopy. At

20 days after surgery, patients in the naproxen group had

less effusion and pain and more ROM and walking activity.

Quadriceps setting and straight leg raises in multiple

planes are encouraged immediately after surgery to regain

motor control and inhibit atrophy. AROM and AAROM exer-

cises are started to improve motion. Initiation of postopera-

tive outpatient rehabilitation is recommended as soon as

possible. A comprehensive evaluation is performed, postop-erative exercises reviewed, and activity modications identi-

ed. Gait is assessed and an appropriate assistive device

(crutches or cane) is recommended. When ROM reaches

approximately 85 degrees, a short crank ergometer can be

used to develop strength, ROM, and cardiovascular condition-

ing. Schwartz et al67 have demonstrated that these therapeu-

tic effects of stationary cycling can be attained early in the

postoperative course by changing the ergometer crank from a

standard 170 mm to smaller crank lengths (140–80 mm). As

knee exion ROM approaches 110 degrees, the patient is

progressed to a standard ergometer. The rehabilitation pro-

gram is then advanced in a similar fashion following the

criteria-based functional progression as described earlier inthis article. The guidelines for post–partial meniscectomy are

found in ► Table 2.

Rehabilitation Strategies after ArthroscopicMeniscal Repair

The rst reported meniscal repair was presented by Annan-

dale in 1885.68 Surgical techniques to repair the meniscus

have evolved from the placement of sutures across the torn

meniscus through arthrotomy to using arthroscopy. Pub-

lished meniscal repair results have supported favorable suc-

cess at extended follow-up in over 70 to 90% of patients.69–73

Fig. 5 Game Ready Cold Therapy Compression System (CoolSystems,

Inc., Concord, CA).

Fig.4 Single-leg hoptest. Thepatientattempts to jumpforward as far

as he can rst with the noninvolved and then the involved lower

extremity. Three attempts are recorded and averaged. Limb symmetry

is then calculated.




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Table 2 Partial meniscectomy rehabilitation guidelines

Postoperative phase 1 (wk 0–3)

Goals

• Control postoperative pain/swelling

• Range of motion 0 ! 130 degrees

• Prevent quadriceps inhibition

• Restore normal gait

• Normalize proximal musculature muscle strength

• Independence in home therapeutic exercise program

Precautions

• Progressive weight bearing with crutches

• Activity modications

Treatment strategies

• Active— assistive range of motion exercises (pain-free ROM)

• Towel extensions

• Patella mobilization

• Progressive weight bearing as tolerated with crutches

D/C crutches when gait is nonantalgic

• Computerized force plate (Biodex) for weight bearing progression/patient education

• Underwater treadmill system (gait training) if incision benign

• Quadriceps reeducation (Quad Sets with EMS or EMG)

• Multiple angle quadriceps isometrics (bilaterally — submaximal)

• Short crank ergometry ! standard ergometry

• SLRs (all planes)

• Hip progressive-resisted exercises

• Leg press (80 ! 0 degrees arc) bilaterally

• Initiate forward step-down program

• Mini-squats

• Proprioception/Balance training: bilateral support

Proprioception board/Balance systems

• Lower extremity exibility exercises

• Upper extremity cardiovascular exercises as tolerated

• Cryotherapy

• Home therapeutic exercise program: evaluation based

• Emphasize patient compliance to home therapeutic exercise program and weight bearing progression

Criteria for advancement

• Normalized gait pattern

• ROM 0 ! 130 degrees

• Proximal muscle strength 5/5

• SLR (supine) without extension lag


Goals

• ROM 0 degrees ! WNL

• Normal patella mobility




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Table 2 (Continued )


• Ascend and descend 8″ stairs with good control without pain

Precautions

• Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment is demonstrated

• Avoid pain with therapeutic exercise and functional activities


• AAROM exercises

• Patella mobilizations

• Leg press (90 ! 0 degrees arc) bilateral ! eccentric

• Progress squat program

• Retrograde treadmill ambulation/running

• Proprioception/balance training: bilateral ! unilateral support

Proprioception board/contralateral Theraband exercises/balance systems

• Progress forward step-up program

• Initiate forward step-down program

• Stairmaster

• Elliptical trainer

• SLRs (progressive resistance)

• Lower extremity exibility exercises

• OKC knee extension: Bilaterally (pain/crepitus-free arc)



• ROM 0 degrees ! WNL

• Demonstrate ability to ascend and descend 8″ step

• Normal patella mobility

Postoperative phase 3 (wk 6-?)

Goals

• Demonstrate ability to descend 8″ stairs with good leg control without pain

• 85% limb symmetry on Isokinetic testing

• Return to normal ADL

• Improve lower extremity exibility

Precautions


• Avoid running till adequate strength development and MD clearance



• Leg press (90 ! 0 degrees emphasizing eccentrics)

• OKC knee extensions 90 ! 0 degrees ( pain/crepitus-free arc )

• Advanced proprioception training (perturbations)

• Agility exercises (sport cord)

• Elliptical trainer

• Forward treadmill running

• Hamstring curls/proximal strengthening

• Lower extremity stretching

(Continued )




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The postoperative management of a meniscal repair takes on

a more conservative approach as compared with partial

meniscectomy to allow for successful healing of the repair.

Rehabilitation guidelines differ among surgeons and re-

main controversial.74–77 Discrepancies exist in the amount of

weight bearing and knee exion allowed in the early post-

operative time frame as well as the time frame for return tosports activity. Barber74 reported no differences in healing

rates between patients who followed a more conservative

and protective program and patients who participated in a

more accelerated program (weight bearing, ROM exercises,

and early return to sports activity). Programs should be

individualized to the type of surgical procedure performed,

the type of meniscal tear repaired, and the basic science

information that is currently available. Therefore,information

from the surgeon regarding the classication of the tear, the

anatomic site of the repair (vascular vs. nonvascular), and

location within the meniscus (anterior or posterior) should

directly affect the postoperative regimen.During weight bearing, compressive forces are loaded

across the menisci.These tensile forces create hoop stresses

which expand the menisci in extension.75 Morgan et al78

demonstrated that extension appears to reduce the menis-

cus to the capsule, whereas exion causes tears in the

posterior horn to displace from the capsule. Becker et al79

have reported that weight bearing from full extension to

90-degree exion increases the pressure on the posterior

horn by, roughly a factor of four. The compressive loads

applied while weight bearing in full extension following a

vertical, longitudinal repair or bucket-handle repair can

reduce the meniscus and stabilize the tear.74–82 In complete

transactions of circumferential ber bundles of the menis-cus, such as radial tears that comprise the whole cross

section or posterior root tears, weight bearing should be

delayed because the hoop stresses would distract the tear

margins and compromise healing.83 The surgeon and reha-

bilitation specialist should take into consideration the axial

alignment of the patient. Habata et al84 reported an associ-

ation between atraumatic tears of the medial meniscus and

varus deformity. Medial meniscus repair patients with a

varus deformity and lateral meniscus repair patients with a

valgus deformity may need a more conservative approach

in their rehabilitation, as the compressive loads in the

respective involved compartment are higher. Surgeons

may elect to delay weight bearing and/or place these

individuals in an unloader brace.

The menisci translate dorsally with knee exion. This

motion depends not only on the exion angle but also on

the weight bearing condition.85 Walker and Erkman34 dem-

onstrated that progressive knee exion subjects the menisci

to greater stress. Thompson et al86 demonstrated that themeniscus translates posteriorly with exion; however, me-

niscal movement was ata minimum at less than 60 degrees of

exion. Thus, consideration is given to limiting exion to 60

degrees during the early period of healing. Tibial rotation

causes large excursions of the meniscus within the rst 30

degrees of exion.87 Terminal exion is accompanied by a

large dorsal translation of the condyles and causes increased

compressive stress of the meniscus.76,85 Therefore, deep

squats and tibial rotation are avoided in the early phases of

rehabilitation following meniscal repair. There is evidence in

a canine model that the maximum tensile strength of menis-

cus repairs reaches 80% by 12 weeks, which suggests that thesuture/scar combination provides enough stability for clinical

function.88 However, many surgeons defer their patients

from returning to pivoting sports until 4 or more months

postoperatively.

Meniscal Repair Guidelines PostoperativePhase I (Weeks 0–6)

Rehabilitation guidelines following meniscal repair are divid-

ed into three phases and are outlined in ► Table 3.

The rst phase is designed to protect the repair and allow

for maximal healing. Rehabilitation is initiated immediately

postoperatively. The patient is placed in a double-uprightknee brace that is locked in full extension. This brace is used

exclusively for ambulation and sleeping for the rst 4 to 6

postoperative weeks. A progressive program of weight bear-

ing as tolerated is initiated for bucket-handle and vertical,

longitudinal tears. Weight bearing will be limited to toe-

touch for radial or more complex repairs for 4 to 6 weeks as

compressive loading may cause distraction of these repairs.

Weight bearing with the knee in progressive exion is

avoided for 4 to 6 weeks, as the meniscus is subjected to

greater stress in this position.

The patient is instructed in ROM exercises to attain full

extension and the recommended degree of exion AAROM



• Isokinetic test

• Functional hop test



• Ability to descend 8″ stairs with good leg control without pain

• 85% limb symmetry on Isokinetic testing

Source: © Hospital for Special Surgery Sports Rehabilitation and Performance Center.




11/20

Table 3 Meniscal repair rehabilitation guideline

Meniscal repair guideline postoperative phase 1 (wk 0–6)

Goals

• Emphasis on full passive extension


• Range of motion ! 90-degree exion

• Regain quadriceps control


Precautions

• Avoid active knee exion

• Avoid ambulation without brace locked at 0 degrees before 4 wk

• Avoid prolonged standing/walking


• Towel extensions, prone hangs, etc.

• Quadriceps re-education (Quad Sets with EMS or EMG)

• Progressive weight bearing PWB ! WBAT with brace locked at 0 degrees with crutches

Toe-touch weight bearing for complex or radial tears


• Active-assisted exion/extension 90 ! 0 degrees exercise



• Proprioception board (bilateral weight bearing)

• Aquatic therapy — pool ambulation or underwater treadmill (wk 4–6)

• Short crank ergometry (if ROM > 85 degrees)

• Leg press (bilateral/60 ! 0-degree arc) (if ROM > 85 degrees)

• OKC quadriceps isometrics (submaximal/bilateral at 60 degrees) (if ROM > 85 degrees)


• Hamstring and calf stretching

• Cryotherapy

• Emphasize patient compliance to home therapeutic exercise program and weight bearing and range of motion precautions/progression


• Ability to SLR without quadriceps lag


• Demonstrate ability to unilateral (involved extremity) weight bear without pain


Goals• Restore full ROM

• Restore normal gait (nonantalgic)

• Demonstrate ability to ascend and descend 8″ stairs with good leg control without pain

• Improve ADL endurance



Precautions

• Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment


(Continued )




12/20



• Avoid running and sport activity


• Progressive weight bearing/WBAT with crutches/cane (brace opened 0 ! 60 degrees), if good quadriceps control(good quad set/ability to SLR without lag or pain)

• Aquatic therapy — pool ambulation or underwater treadmill

• D/C crutches/cane when gait is nonantalgic

• Brace changed to MD preference (unloader brace, patella sleeve, etc.)

• Active-assistive range of motion exercises


• SLRs (all planes) with weights

• Proximal progressive-resisted exercises

• Neuromuscular training (bilateral ! unilateral support)

Balance apparatus, foam surface, perturbations

• Short crank ergometry ! standard ergometry (if knee ROM > 115 degrees)

• Leg press (bilateral/eccentric/unilateral progression)

• Squat program (PRE) 0 ! 60 degrees

• OKC quadriceps isotonics (pain-free arc of motion)

• Initiate forward step-up and step-down programs

• Stairmaster

• Retrograde treadmill ambulation

• Quadriceps stretching

• Elliptical machine


• Cryotherapy

• Emphasize patient compliance to home therapeutic exercise program


• ROM to WNL

• Ability to descend 8″ stairs with good leg control without pain


Goals

• Demonstrate ability to run pain free

• Maximize strength and exibility as to meet demands of activities of daily living

• Hop test 85% limb symmetry

• Isokinetic test > 85% limb symmetry

• Lack of apprehension with sport-specic movements

• Flexibility to accepted levels of sport performance

• Independence with gym program for maintenance and progression of therapeutic exercise program at discharge

Precautions


• Avoid sport activity till adequate strength development and MD clearance




13/20

exercises are performed with exion restricted to 90 degrees

during the initial (4–6 weeks) protectionphase. Repairs to the

posterior horn are limited to 70 degrees for the rst 4 weeks,

and then progressed as tolerated. Active or resisted knee

exion is avoided during this phase due to the attachment of

the semimembranosus muscle on the medial meniscus andthe popliteus muscle on the lateral meniscus.89

At 4 to 6 weekspostoperatively, thehinged brace is opened

to 60 degreesto allow for ROM during gait. Gait training using

a pool or underwater treadmill is utilized to unload the

involved extremity. Crutches are discharged when a non-

antalgic gait is demonstrated. Quadriceps reeducation is

addressed post-op day 1 with the patient instructed to

perform quadriceps setting exercises with a rolled towel

under their surgical knee. Electrical stimulation and/or bio-

feedback can be used should the patient demonstrate quad-

riceps inhibition. Straight leg raising in multiple planes is

encouraged for the development of proximal strength.

Weights (progressive resistive exercise) are added to theseexercises when tolerated along with exercise machines to

further advance proximal strengthening. Proprioceptive and

balance training are started as soon as the patient demon-

strates the ability to bear 50% of their weight. A rocker board

is utilized starting in a sagittal plane and is then progressed to

a more challenging coronal plane. A computerized balance

platform can be utilized for patient feedback.

As exion ROM improves to greater than 85 degrees, select

OKC and CKC exercises are introduced to the therapeutic

exercise program. Bilateral leg press and mini-squats are

performed inside a 60- to 0-degree arc of motion. Quadriceps

isometrics are performed submaximally at 60 degrees of

exion. Stationary bicycling is added to the rehabilitation

program by utilizing a short crank (90 mm) ergometer.

Hamstring and calf stretching exercises are added into both

formal and home therapeutic exercise programs. Cryotherapy

and electrical stimulation (TENS) may be utilized for pain

control. Home therapeutic exercise programs are continuallyupdated.

Meniscal Repair Guidelines PostoperativePhase 2 (Weeks 6–14)

The second postoperative phase following meniscal repair is

dedicated to restoring normal ROM to the involved knee and

improving muscle strength to the level needed to perform

activities of daily living. The demonstration of a normal gait

pattern is an early goal of this phase. AAROM exercises are

progressed as tolerated with the goal of attaining full ROM by

the end of thisphase. As ROM improvesto 110! 115 degrees,

cycling is advanced to a standard 170 mm ergometer. Quad-riceps stretching is added as ROM increases to greater than

120 degrees. Leg press exercise will progress to eccentric and

eventually to unilateral training utilizing greater ROM (< 90

degrees). A squat program with progressive resistance is

initiated utilizing a physioball for support and comfort inside

a 60 ! 0-degree arc of motion. A forward step-up program is

begun on successive step heights (4″, 6″, and 8″). Stairmaster

and elliptical machine are incorporated as symptoms allow.

Retrograde treadmill ambulation on continual progressive

percentage inclines is utilized to facilitate quadriceps

strengthening. A forward step-down program is initiated

on successive height increments (4″, 6″, and 8″). The



• Start forward running (treadmill) program at 4 mo post-op if 8 ″ step-down satisfactory

• Continue LE strengthening and exibility programs

• Agility program/sport specic (sport cord)

• Start plyometric program when suf cient strength base demonstrated

• Isotonic knee exion/extension (pain and crepitus-free arc)

• Isokinetic training (fast ! moderate ! slow velocities)

• Functional testing (hop test)

• Isokinetic testing



• Symptom-free running and sport-specic agility

• Hop test 85% limb symmetry


• Lack of apprehension with sport-specic movements

• Flexibility to accepted levels of sport performance

• Independence with gym program for maintenance and progression of therapeutic





14/20

functional strength goal at the end of this phase is for the

patient to demonstrate pain-free descentfrom an 8″ stepwith

adequate lower extremity control without deviations.90

Neuromuscular training is advanced to include unilateral

balance activities, such as contralateral elastic band exercises

and balance systems training. As these activities are mas-

tered, the rehabilitation specialist can incorporate less stable

surfaces (foam rollers, rocker boards, etc.) as well as pertur-bation training to these activities to further enhance neuro-

muscular development. The patient’s home therapeutic

exercise program is continually updated based on evaluative

ndings and functional level.

Meniscal Repair Guidelines PostoperativePhase 3 (Weeks 14–22)

The focus of the nal phase of rehabilitation following

meniscal repair is directed at optimizing functional capabili-

tiesand preparing thepatient/athlete for a safe return to sport

activities.

At 4 months postoperatively, given symmetrical ROM anddemonstrated quadriceps control, a running program on a

treadmill is initiated. Retrograde running is preceded by

forward running. An initial emphasis on speed over shorter

distances versus slower distance running is recommended.

Lower extremity strengthening and exibility programs are

continued. Advanced strengthening activities including iso-

kinetic and plyometric training are introduced. Plyometric

training should follow a functional sequence with the com-

ponents of speed, intensity, load, volume, and frequency

being monitored and progressed accordingly. Activities begin

with simple drills and advance to more complex exercises (e.

g., double-leg jumping vs. box drills) (►

Fig. 6). Agility ex-ercises are introduced with the demands of the individual’s

sport taken into consideration, for example, deceleration,

cutting, sprinting. The rehabilitation specialist should be

certain to observe any apprehension during the agility activi-

ty progression.

To quantify strength and power, both isokinetic and

functional testing are performed. The goals of isokinetic

testing include a less than 15% decit for quadriceps and

hamstring average peak torque and total work at test veloci-

ties of 180 and 300 degrees. Functional testing links specic

components of function and the actual task and provides

direct evidence to prove functional status. Single-leg hop

test59 and crossover hop test60 are performed with the goalof achieving an 85% limb symmetryscore. The results of these

tests along with any other pertinent clinical ndings includ-

ing the lack of apprehension with sport-specic movements

are presented to the referring orthopedic surgeon for thenal

determination of sports participation.

Rehabilitation Strategies following Meniscal Transplantation

The meniscal transplantation procedure wasrst described by

Milachowski in 1984.91 The procedure has evolved into a

primarily arthroscopic technique in which a cadaveric menis-

cusis inserted into a meniscus-decient knee. Ideal candidates

for this procedure include patients whose knees are normallyaligned, stable, and demonstrate little degenerative changes.

Meniscal transplantation may also be indicated during con-

comitant ACL reconstruction, as the absence of the meniscus

could preclude satisfactory stabilization.21,92,93 Numerous

studies have demonstrated statistically signicant improve-

ments in pain and function using various clinical outcome

measures following meniscal transplantation.26,93–98 Rehabil-

itation programs following meniscal transplantation are de-

pendent on surgical technique, concomitant procedures, and

pathology, as well as surgeon’s preference.

The principles used for rehabilitation after meniscal repair

are utilized with some variation. The loads placed on the

healing meniscal allograft during rehabilitation activities areunknown. The failure strength of meniscal horn xation in a

drill tunnel in the tibia is also unknown. As meniscal trans-

plants are thought to be under higher stresses in a joint with

early degenerative changes, a more conservative guideline

(► Table 4) is followedrather than a meniscal repair guideline.

Weight bearing following meniscal transplantation is lim-

ited to toe-touch ambulation with the involved knee main-

tained in full extension for the rst 4 weeks. Gradual

progression to full weight bearing occurs by 6 weeks postop-

eratively. A double upright hinged brace is used during this

designated protection phase. Meniscal transplantation pro-

tectionduring this phase is supported bya rabbit study where

Fig. 6 Plyometric exercise: box jumps. The patient jumps consecu-

tively on both lower extremities inside the þ pattern, rst clockwise,

then counterclockwise.




15/20

Table 4 Meniscal transplantation guideline

Meniscal transplantation guideline postoperative phase 1 (wk 0–6)

Goals

• Emphasis on full passive extension


• Range of motion ! 90-degree exion

• Regain quadriceps control


Precautions

• Avoid active knee exion

• Avoid ambulation without brace locked at 0 degrees before 4 wk

• Avoid prolonged standing/walking


• Towel extensions, prone hangs, etc.

• Quadriceps reeducation (Quad Sets with EMS or EMG)

• Toe-touch weight bearing with brace locked at 0 degrees with crutches for 4 wk

Progressive weight bearing PWB ! WBAT, wk 4–6


• Continuous passive motion (CPM) machine

• Active-assisted exion/extension 90 ! 0 degrees exercise



• Proprioception board (bilateral weight bearing)

• Aquatic therapy — pool ambulation or underwater treadmill (week 4–6)

• Short crank ergometry (if ROM > 85 degrees)

• Leg press (bilateral/60 ! 0 degrees arc) (if ROM > 85 degrees) (wk 4–6)

• OKC quadriceps isometrics (submaximal/bilateral at 60 degrees) (if ROM > 85 degrees)


• Hamstring and calf stretching

• Cryotherapy

• Emphasize patient compliance to home therapeutic exercise program and weight bearing and range of motion precautions/progression


• Ability to SLR without quadriceps lag


• Demonstrate ability to unilateral (involved extremity) weight bear without pain

Meniscal transplantation guideline postoperative phase 2 (wk 6–

14)Goals

• Restore full ROM

• Restore normal gait (nonantalgic)

• Demonstrate ability to ascend 8”stairs with good leg control without pain

• Improve ADL endurance



Precautions

• Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment

(Continued )




16/20




• Avoid running and sport activity


• Progressive weight bearing/WBAT with crutches/cane (brace opened 0 ! 60 degrees), if good quadriceps control (good quadset/ability to SLR without lag or pain)

• Aquatic therapy — pool ambulation or underwater treadmill

• D/C crutches/cane when gait is nonantalgic

• Brace changed to MD preference (OTS brace, patella sleeve, etc.)

• Active-assistive range of motion exercises


• SLRs (all planes) with weights

• Proximal progressive-resisted exercises

• Neuromuscular training (bilateral ! unilateral support)

Balance apparatus, foam surface, perturbations

• Short crank ergometry

• Standard ergometry (if knee ROM > 115 degrees)

• Leg press (bilateral/eccentric/unilateral progression)

• Squat program (PRE) 0 ! 45 degrees

• OKC quadriceps isotonics (pain-free arc of motion) (CKC preferred)

• Initiate forward step-up program

• Stairmaster

• Retrograde treadmill ambulation

• Quadriceps stretching

• Elliptical machine


• Cryotherapy

• Emphasize patient compliance to home therapeutic exercise program


• ROM to WNL

• Ability 8″ stairs with good leg control without pain


Goals

• Maximize strength and exibility as to meet demands of activities of daily living

• Demonstrate ability to descend 8″ stairs with good leg control without pain



Precautions



• Treatment strategies:



17/20

alterations in stiffness and viscoelasticity were found in the

early postoperative period, with gradual recovery over

time.99

Immediate ROM is encouraged. Early motion has been

shown to minimize the deleterious effects of immobilization,

such as articular cartilage degeneration, excessive adverse

collagen formation, and pain.100,101 The goal during the rst

phase is to achieve full extension and 90 degrees of knee

exion. Flexion is limited to 90 degrees for the rst 6 weeks,

as progressive knee exion subjects the meniscus to greater

stress.34,78,82 Continuous passive motion (CPM) machine,

AAROM exercises, andtowel extensions areused as treatment

interventions in the initial phase to achieve these goals. ROM

is progressed as tolerated at 6 weeks with the goal of

achieving full ROM by 14 weeks postoperatively.

Treatment strategies for strengthening and neuromuscu-

lar training, though more conservatively applied, are similar

to those employed following meniscal repair. Squatting islimited to 45 degrees for the rst 3 months, 60 degrees for

5 months, and 90 degrees for 6 months. Running is not

recommended before 6 months. Returnto high-load activities

involving cutting, jumping, and pivoting are not currently

recommended after meniscal transplantation.90

Conclusion

An improved understanding in basic science over the last

three decades has contributed tremendously to our knowl-

edge of the menisci’s function and reparability. Advances in

arthroscopic techniques have enhanced the surgeon’s ability



• Isokinetic training (fast ! moderate ! slow velocities)

• Isokinetic testing




• Ability 8″ stairs with good leg control without pain


Goals

• Demonstrate ability to run pain free

• Maximize strength and exibility as to meet demands of recreational activity


• Lack of apprehension with recreation type sport movements


Precautions



• Treatment strategies:

• Progress squat program 85% limb symmetry

• Flexibility to accepted levels of recreational activity






18/20

to salvage what were once considered irreparable lesions and

to successfully transplant menisci. Clinical research has laid a

foundation for which the rehabilitation following meniscal

repair and transplantation is based. Further research in the

form of laboratory science and clinical outcomes are needed

to substantiate treatment strategies employed during the

rehabilitation of these patients. The rehabilitation specialist

should consider each patient as an individual and progressthe patient along a criteria-based progression to achieve a

safe and satisfactory outcome.

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2014 Rehabilitation of Meniscal Injury and Surgery