mensci repair rehabilitation protocol

Rehabilitation ProtocolAfter Menisci Repair

Key factors determining progression

• Anatomic site of tear.• Suture fixation • location of tear

(anterior or posterior).• Other pathology (PCl,

MCl, or ACl injury).

(too vigorous rehabilitation can lead to failure).

REHAB CONSIDERATIONS

Weight-bearing and Motion Rehabilitation Considerations

• Although weight-bearing has little effect on displacement patterns of the meniscus and may be beneficial in approximating longitudinal tears, • weight-bearing may place a

displacing force across radial tears.

EARLY MOTION

• Several studies have confirmed the benefits of early motion by demonstrating meniscal atrophy and decreased collagen content in menisci after immobilization.

• ROM of the knee before 60 degrees of flexion has little effect on menisci displacement, but flexion angles greater than 60 degrees translate the menisci posteriorly. This increased translation may place detrimental stresses across a healing meniscus.

Rehabilitation Considerations

• Weight-bearing and Motion• EARLY MOTION• As knee flexion increases, compressive loads across

the meniscus also increase. • The combination of weight-bearing and increasing

knee flexion must be carefully balanced in the development of a rehabilitation protocol.

Axial Limb Alignment

• Varus malalignment tends to overload the medial compartment of the knee, with increased stress placed on the meniscus, and valgus malalignment has the same effect on the lateral compartment and lateral meniscus.

Axial Limb Alignment

• These increased stresses may interfere

or disrupt meniscal healing after repair.

The use of an "unloader" brace has

been recommended to help protect the

healing meniscus, although no scientific

data exist to support this approach.

Rehabilitation after Meniscal Repair

• Current studies support the use of unmodified accelerated ACL rehabilitation protocols after combined ACL reconstruction and menisci repair.

• In tears with decreased healing potential (such as white-white tears, radial tears, or complex pattern tears), limiting weight bearing and limiting flexion to 60 degrees for the first 4 weeks have been suggested to better protect the repair and increase the healing potential of these difficult tears.

• However, we are unaware of any published studies that support these measures.

Rehabilitation after Meniscal Repair

• Rehabilitation after isolated menisci repair remains controversial.

• The healing environment clearly is inferior to that with concomitant ACL reconstruction, but good results have been obtained with accelerated rehabilitation protocols after isolated meniscal repairs.

Phase 1: Maximum Protection-Weeks 1-6

Stage 1: Immediate Postoperative Day 1-Week 3• Ice, compression, elevation.• Electrical muscle stimulation.• Brace locked at 0 degrees. • ROM 0-90 degrees.• Motion is limited for the first 7- 21 days, depending on the development of scar tissue around the repair site. Gradual increase in flexion ROM is based on assessment of pain (0-30, 0-50, 0-70, 0-90 degrees).

Phase 1: Maximum Protection-Weeks 1-6• Stage 1: Immediate Postoperative Day

1-Week 3• Patellar mobilization.• Scar tissue mobilization.• Passive ROM.• Exercises• Quadriceps isometrics.• Hamstring isometric!t\ if posterior hom

repair, no hamstring exercises for 6 wk).• Hip abduction and adduction.• Weight-bearing as tolerated with

crutches and brace locked at 0 degrees.• Proprioception training.

Phase 1: Maximum Protection-Weeks 1-6

• Stage 2: Weeks 4-6• Progressive resistance exercises

(PREs) -1-5 pounds.• Limited-range knee extension (in

range less likely to impingeor pull on repair).• Toe raises.• Mini-squats.• Cycling (no resistance).• Surgical tubing exercises (diagonal

patterns).• Flexibility exercises.

Phase 2: Moderate Protection-Weeks 6-10• Criteria for Progression to Phase II• • ROM 0-90 degrees.• • No change in pain or effusion.• • Quadriceps control ("Good MMT").• Goals• • Increase strength, power, endurance.• • Normalize ROM of knee.• • Prepare patients for advanced exercises.• Exercises• • Strength- PRE progression.• • Flexibility exercises.• Lateral step-ups (30 sec X 5 sets --> 60 sec X

5 sets).• • Mini-squats.• • Isokinetic exercises.

Phase 2: Moderate Protection-Weeks 6-10

• Endurance Program• • Swimming (no frog kick).• • Cycling.• • Nordic-Trac.• • Stair machine.• • Pool running.

Phase 2: Moderate Protection-Weeks 6-10

• Coordination Program • Balance board. • High-speed bands. • Pool sprinting. • Backward walking.• Plyometric Program

Phase 3: Advanced Phase-Weeks 11-15• Criteria for Progression to Phase 3• • Full, nonpainful ROM.• • No pain or tenderness.• • Satisfactory isokinetic test.• • Satisfactory clinical examination.• Goals• • Increase power and endurance.• • Emphasize return-to-skill activities.• • Prepare for return to full untestricted activities.• Exercises• • Continue all exercises.• • Increase tubing program, plyometrics, pool program.• • Initiate running program.• Return to Activity: Criteria• • Full, nonpainful ROM.• • Satisfactory clinical examination.• • Satisfactory isokinetic test.

ACCELERATED REHAB FOR MENISCAL REPAIR

PHASE 1 0-2 WEEKS

• Phase 1: Weeks 0-2Goals• • Full motion.• • No effusion.• • Full weight-bearing./Weight-bearing As tolerated.Treatment• • ROM as tolerated (0-90

degrees).• • Cryotherapy.• • Electrical stimulation as needed.• • Isometric quadriceps sets.

Phase 2: Weeks 2-4

• Criteria for Progression to Phase 2• • Full motion.• • No effusion.• • Full weight-bearing.• Goals• • Improved quadriceps strength.• • Normal gait.• Therapeutic Exercises• • Closed-kinetic chain resistance exercises 0-90 degrees.• • Bike and swim as tolerated.• • Early-phase functional training

Phase 3: Weeks 4-8

Criteria for Progression to Phase 3• • Normal gait.• • Sufficient strength and proprioception for advanced• functional training.Goals• • Strength and functional testing at least 85% of contralateral

side.• • Discharge from physical therapy to full activity.Therapeutic Exercises• • Strength work as needed.• • Sport-specific functional progression.• • Advanced-phase functional training.

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