rehabilitation protocol for meniscus repair · rehabilitation protocol for meniscus repair this...

RehabilitationProtocolforMeniscusRepairThisprotocolisintendedtoguidecliniciansandpatientsthroughthepost-operativecourseforameniscusrepair.Specificinterventionshouldbebasedontheneedsoftheindividualandshouldconsiderexamfindingsandclinicaldecisionmaking.Ifyouhavequestions,contactthereferringphysician.ConsiderationsforthePost-operativeMeniscalRepairProgramManydifferentfactorsinfluencethepost-operativemeniscalrepairrehabilitationoutcomes,includingtypeandlocationofthemeniscaltearandrepair.Considertakingamoreconservativeapproachtorangeofmotion,weightbearing,andrehabprogressionwithmorecomplextears,all-insidemeniscalrepairs,andmeniscaltransplants.Itisrecommendedthatclinicianscollaboratecloselywiththereferringphysicianregardingintra-operativefindingsandsatisfactionwiththestrengthoftherepair.Post-operativeconsiderationsIfyoudevelopafever,intensecalfpain,excessivedrainagefromtheincision,uncontrolledpainoranyothersymptomsyouhaveconcernsaboutyoushouldcallyourdoctor.PHASEI:IMMEDIATEPOST-OP(0-2WEEKSAFTERSURGERY)RehabilitationGoals

• Protectrepair• Reduceswelling,minimizepain• Restorepatellarmobility• Restorefullextension• Flexion<90degrees• Minimizearthrogenicmuscleinhibition,re-establishquadcontrol,regainfullactiveextension• Patienteducation

• Keepyourkneestraightandelevatedwhensittingorlyingdown.Donotrestwithatowelplacedundertheknee

• Donotactivelybendyourknee;supportyoursurgicalsidewhenperformingtransfers(i.e.sittingtolayingdown)

• DonotpivotonyoursurgicalsideWeightBearing Walking

• Bracelocked,crutches• Partialweightbearing• Whenclimbingstairs,makesureyouareleadingwiththenon-surgicalsidewhengoingupthe

stairs,makesureyouareleadingwiththecrutchesandsurgicalsidewhengoingdownthestairsIntervention SwellingManagement

• Ice,compression,elevation(checkwithMDre:coldtherapy)• Retrogrademassage• AnklepumpsRangeofmotion/Mobility• Patellarmobilizations:superior/inferiorandmedial/lateral• Seatedassistedkneeflexionextensionandheelslideswithtowel

o ***Avoidactivekneeflexiontopreventhamstringstraintotheposteromedialjoint• Lowintensity,longdurationextensionstretches:pronehang,heelprop• Supinepassivehamstringstretch

MassachusettsGeneralHospitalSportsMedicine

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Strengthening• Quadsets• NMEShighintensity(2500Hz,75bursts)supinekneeextended10sec/50sec,10contractions,

2x/wkduringsessions—useofclinicalstimulatorduringsession,considerhomeunitsdistributedimmediatepostop

• Straightlegraiseo **Donotperformstraightlegraiseifyouhaveakneeextensionlag

• Hipabduction• Multi-angleisometrics90and60degkneeextension

CriteriatoProgress

• KneeextensionROM0deg• KneeflexionROM90degrees• Quadcontractionwithsuperiorpatellaglideandfullactiveextension• Abletoperformstraightlegraisewithoutlag

PHASEII:INTERMEDIATEPOST-OP(3-5WEEKSAFTERSURGERY)RehabilitationGoals

• Continuetoprotectrepair• Reducepain,minimizeswelling• Maintainfullextension• Flexion<120degrees

WeightBearing Walking• Continuepartialweightbearing• ConsultwithreferringMDregardingunlockingbrace

AdditionalIntervention*ContinuewithPhaseIinterventions

Rangeofmotion/Mobility• Stationarybicycle:gentlerangeofmotiononly(seePhaseIIIforconditioning)Cardio• UpperbodyergometerStrengthening• Calfraises• Lumbopelvicstrengthening:sidelyinghipexternalrotation-clamshell,plankBalance/proprioception• Doublelimbstandingbalanceutilizingunevensurface(wobbleboard)• Jointpositionre-training

CriteriatoProgress

• Noswelling(ModifiedStrokeTest)• FlexionROM120degrees• ExtensionROMequaltocontralateralside

PHASEIII:LATEPOST-OP(6-8WEEKSAFTERSURGERY)RehabilitationGoals

• Continuetoprotectrepair• Maintainfullextension• Normalizegait• Flexionwithin10degreesofcontralateralside• Safelyprogressstrengthening• Promotepropermovementpatterns• Avoidpostexercisepain/swelling

WeightBearing • Maydiscontinueuseofbrace/crutchesafter6wksperMDandonceadequatequadcontrolisachieved

AdditionalIntervention*ContinuewithPhaseI-IIInterventions

Rangeofmotion/Mobility• Supineactivehamstringstretch• Standinggastrocstretchandsoleusstretch• Gentlestretchingallmusclegroups:pronequadstretch,standingquadstretch,kneelinghip

flexorstretch• RotationaltibialmobilizationsiflimitedROM


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Cardio• Stationarybicycle,flutterkickswimming,pooljoggingStrengthening• Partialsquatexercise0-60degrees• Ballsquats,wallslides,minisquatsfrom0-60deg• Hamstringstrengthening:pronehamstringcurls• Lumbopelvicstrengthening:bridgesonphysioball,bridgeonphysioballwithroll-in,bridgeon

physioballalternating,hiphike• Gymequipment:legpressmachine,hipabductorandadductormachine,hipextensionmachine,

romanchair,seatedcalfmachine• Progressintensity(strength)andduration(endurance)ofexercisesBalance/proprioception• Singlelimbbalanceprogresstounevensurfaceincludingperturbationtraining

CriteriatoProgress

• Noswelling/painafterexercise• Normalgait• ROMequaltocontralateralside• Jointpositionsensesymmetrical(<5degreemarginoferror)

PHASEIV:TRANSITIONAL(9-12WEEKSAFTERSURGERY)RehabilitationGoals

• MaintainfullROM• Safelyprogressstrengthening• Promotepropermovementpatterns• Avoidpostexercisepain/swelling

AdditionalIntervention*ContinuewithPhaseI-IIIinterventions

Cardio• Elliptical,stairclimberStrengthening

o **Thefollowingexercisestofocusonpropercontrolwithemphasisongoodproximalstability

• Squattochair• Laterallunges• Singlelegprogression:partialweightbearingsinglelegpress,slideboardlunges:retroand

lateral,stepupsandstepupswithmarch,lateralstep-ups,stepdowns,singlelegsquats,singlelegwallslides

• KneeExercisesforadditionalexercisesanddescriptions• Gymequipment:seatedhamstringcurlmachineandhamstringcurlmachine• Romaniandeadlift

CriteriatoProgress

• Noepisodesofinstability• Maintainquadstrength• 10repetitionssinglelegsquatproperformthroughatleast60degkneeflexion• KOOS-sportsquestionnaire>70%• FunctionalAssessment

o Quadricepsindex>80%;HHDmeanpreferred(isokinetictestingifavailable)o Hamstring,glutmed,glutmaxindex≥80%;HHDmeanpreferred(isokinetictestingfor

HSifavailable)o Singleleghoptest≥75%comparedtocontralateralside(earliest12wks)

• Return-to-sporttestingcanbeperformedatMGHSportsPhysicalTherapy,ifnecessary


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PHASEV:EARLYRETURNTOSPORT(3-5MONTHSAFTERSURGERY)RehabilitationGoals

• Safelyprogressstrengthening• Safelyinitiatesportspecifictrainingprogram• Promotepropermovementpatterns• Avoidpostexercisepain/swelling

AdditionalIntervention*ContinuewithPhaseII-IVinterventions

• Intervalrunningprogramo ReturntoRunningProgram

• Progresstoplyometricandagilityprogram(withfunctionalbraceifprescribed)o AgilityandPlyometricProgram

CriteriatoProgress

• ClearancefromMDandALLmilestonecriteriabelowhavebeenmet• Completionjog/runprogramwithoutpain/swelling• FunctionalAssessment

o Quad/HS/glutindex≥90%;HHDmeanpreferred(isokinetictestingifavailable)o Hamstring/Quadratio≥70%;HHDmeanpreferred(isokinetictestingifavailable)o HopTesting≥90%comparedtocontralateralside

• KOOS-sportsquestionnaire>90%• InternationalKneeCommitteeSubjectiveKneeEvaluation>93• PsychReadinesstoReturntoSport(PRRS)

PHASEVI:UNRESTRICTEDRETURNTOSPORT(6+MONTHSAFTERSURGERY)RehabilitationGoals

• Continuestrengtheningandproprioceptiveexercises• Symmetricalperformancewithsportspecificdrills• Safelyprogresstofullsport

AdditionalIntervention*ContinuewithPhaseII-Vinterventions

• Multi-planesportspecificplyometricsprogram• Multi-planesportspecificagilityprogram• Includehardcuttingandpivotingdependingontheindividuals’goals• Non-contactpractice→Fullpractice→Fullplay

CriteriatoProgress

• Laststage,noadditionalcriteria

RevisedJanuary2019Contact PleaseemailMGHSportsPhysicalTherapy@partners.orgwithquestionsspecifictothisprotocol

ReferencesAdamsD,LogerstedtD,etal.CurrentConceptsforAnteriorCruciateLigamentReconstruction:ACriterion-BasedRehabilitationProgression.JOSPT201242(7):601-614.DeFrodaSF,BokshanSL,etal.Variabilityofonlineavailablephysicaltherapyprotocolsfromacademicorthopedicsurgeryprogramsforarthroscopicmeniscusrepair.ThePhysicianandSportsMedicine.2018.46(3):355-360.GlazerDD.DevelopmentandPreliminaryValidationoftheInjury-PsychologicalReadinesstoReturntoSport(I-PRRS)Scale.JournalofAthleticTraining.2009;44(2):185-189.IrrgangJJ,AndersonAF,BolandAL,etal.DevelopmentandvalidationoftheInternationalKneeDocumentationCommitteeSubjectiveKneeForm.AmJSportsMed.2001;29:600-613.

MandelbaumBR,SilversHJ,WatanabeDS,etal.EffectivenessofaNeuromuscularandProprioceptiveTrainingPrograminPreventingAnteriorCruciateLigamentInjuriesinFemaleAthletes:2-

yearfollow-up.AmJSportsMed.2005;33:1003-1010.

Noyes,FR,HeckmannTP,etal.MeniscusRepairandTransplantation:AComprehensiveUpdate.JOSPT201242(3):274-290.VanderHaveKL,PerkinsC,etal.Weightbearingversusnonweightbearingaftermeniscusrepair.SportsHealth.2015.7(5):399-402.VediV,WilliamsA,etal.Meniscalmovement:anin-vivostudyusingdynamicMRI.JBJS.1999.81:37-41.WilkKE,MacrinaLC,etal.RecentAdvancesintheRehabilitationofAnteriorCruciateLigamentInjuries.JOSPT201242(3):153-171.


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FunctionalAssessmentPatientName: MRN:

DateofSurgery: Surgeon:

GraftType(circle): Autograft Hamstring BPTB Quad

Allograft Achilles BPTB Other

ConcomitantInjuries/Procedures:

Readytojog? YES NO

Readytoreturntosport? YES NO

Recommendations:

Examiner:

OperativeLimb Non-operativeLimb

LimbSymmetryIndex

Rangeofmotion(X-0-X) -

Pain(0-10) -

KneeEffusion -

HamstringStrength(average/3trials)

QuadricepsStrength(average/3trials)

Hamstring:QuadricepsRatio(asabove) -

HopTesting

Single-legHopforDistance

TripleHopforDistance

CrossoverHopforDistance

VerticalJump

Y-BalanceTest

Calculated1RM(singlelegpress)

Psych.ReadinesstoReturntoSport(PRRS)


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RangeofmotionisrecordedinX-0-Xformat:forexample,ifapatienthas6degreesofhyperextensionand135degreesofflexion,ROMwouldread:6-0-135.Ifthepatientdoesnotachievehyperextension,andislackingfullextensionby5degrees,theROMwouldsimplyread:5-135.Painisrecordedasanaveragevalueoverthepast2weeks,from0-10.0isabsolutelynopain,and10istheworstpaineverexperienced.KneeEffusionistestedusingtheModifiedStrokeTest.Anupstrokeisappliedtomedialsideofknee,followedbydownstrokeonlateralside.Thetherapistobservesformovementoffluidwitheachstroke.

- 0:nowaveproducedwithdownwardstroke- Trace:smallwaveoffluidonmedialsideofknee- 1+:largebulgeoffluidonmedialsideofkneewithdownstroke- 2+:Effusionreturnstomedialsideofkneewithoutdownstroke- 3+:inabilitytomoveeffusionfrommedialsideofknee

Quadricepsstrengthismeasuredusingahandhelddynamometer.Thepatientissecuredin60degreesofkneeflexionandtheHHDisplacedbetweenthepatient’stibiaandtheresistancearm,1inchproximaltothemidlinebetweenthemalleoli.ThepatientisinstructedtoapplyamaximalisometriceffortforcetheHHDandtheaverageof3trialsisrecordedforeachlimb.Hamstringstrengthismeasuredusingahandhelddynamometer.Thepatientissecuredin60degreesofkneeflexionandtheHHDisplacedbetweenthepatient’slowerlegandtheresistancearm,1inchproximaltothemidlinebetweenthemalleoli.ThepatientisinstructedtoapplyamaximalisometricforceagainsttheHHDandtheaverageof3trialsisrecordedforeachlimb.Hamstring:quadricepsratioiscalculatedforeachlimbbasedontheaverageof3trialsforflexionandextension,respectively.Theaverageisometrichamstringstrengthisdividedbytheaveragequadricepsstrength.Hoptestingisperformedperstandardizedtestingguidelines.Theaverageof3trialsisrecordedtothenearestcentimeterforeachlimb.


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ReturntoRunningProgramThisprogramisdesignedasaguideforcliniciansandpatientsthroughaprogressivereturn-to-runprogram.Patientsshoulddemonstrate>80%ontheFunctionalAssessmentpriortoinitiatingthisprogram(afterakneeligamentormeniscusrepair).Specificrecommendationsshouldbebasedontheneedsoftheindividualandshouldconsiderclinicaldecisionmaking.Ifyouhavequestions,contactthereferringphysician. PHASEI:WARMUPWALK15MINUTES,COOLDOWNWALK10MINUTES

Day 1 2 3 4 5 6 7

Week1 W5/J1x5 W5/J1x5 W4/J2x5 W4/J2x5

Week2 W3/J3x5 W3/J3x5 W2/J4x5

Week3 W2/J4x5 W1/J5x5 W1/J5x5 ReturntoRun

Key:W=walk,J=jog**OnlyprogressifthereisnopainorswellingduringoraftertherunPHASEII:WARMUPWALK15MINUTES,COOLDOWNWALK10MINUTES

Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday

1 20min 20min 20min 25min

2 25min 25min 30min


4 35min 40min 40min


6 50min 50min 50min


8 60min 60min

Recommendations• RunsshouldoccuronsoftersurfacesduringPhaseI• Non-impactactivityonoffdays• Goalistoincreasemileageandthenincreasepace;avoidincreasingtwovariablesatonce• 10%rule:nomorethan10%increaseinmileageperweek


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AgilityandPlyometricProgramThisprogramisdesignedasaguideforcliniciansandpatientsthroughaprogressiveseriesofagilityandplyometricexercisestopromotesuccessfulreturntosportandreduceinjuryrisk.Patientsshoulddemonstrate>80%ontheFunctionalAssessmentpriortoinitiatingthisprogram.Specificinterventionshouldbebasedontheneedsoftheindividualandshouldconsiderclinicaldecisionmaking.Ifyouhavequestions,contactthereferringphysician. PHASEI:ANTERIORPROGRESSIONRehabilitationGoals

• Safelyreconditiontheknee• Providealogicalsequenceofprogressivedrillsforpre-sportsconditioning

Agility • Forwardrun• Backwardrun• Forwardleanintoarun• Forwardrunwith3-stepdeceleration• Figure8run• Circlerun• Ladder

Plyometrics • Shuttlepress:Doubleleg!alternatingleg!singlelegjumps• Doubleleg:

o Jumpsontoabox!jumpoffofabox!jumpson/offboxo Forwardjumps,forwardjumptobroadjumpo Tuckjumpso Backward/forwardhopsoverline/cone

• Singleleg(theseexercisesarechallengingandshouldbeconsideredformoreadvancedathletes):o Progressivesinglelegjumptaskso Boundingruno Scissorjumpso Backward/forwardhopsoverline/cone

CriteriatoProgress

• Noincreaseinpainorswelling• Pain-freeduringloadingactivities• Demonstratespropermovementpatterns

PHASEII:LATERALPROGRESSIONRehabilitationGoals

• Safelyreconditiontheknee• ProvidealogicalsequenceofprogressivedrillsfortheLevel1sportathlete

Agility*ContinuewithPhaseIinterventions

• Sideshuffle• Carioca• Crossoversteps• Shuttlerun• Zig-zagrun• Ladder

Plyometrics*ContinuewithPhaseIinterventions

• Doubleleg:o Lateraljumpsoverline/coneo Lateraltuckjumpsovercone

• Singleleg(theseexercisesarechallengingandshouldbeconsideredformoreadvancedathletes):o Lateraljumpsoverline/coneo Lateraljumpswithsportcord

CriteriatoProgress

• Noincreaseinpainorswelling• Pain-freeduringloadingactivities• Demonstratespropermovementpatterns


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PHASEIII:MULTI-PLANARPROGRESSIONRehabilitationGoals

• ChallengetheLevel1sportathleteinpreparationforfinalclearanceforreturntosport

Agility*ContinuewithPhaseI-IIinterventions

• Boxdrill• Stardrill• Sideshufflewithhurdles

Plyometrics*ContinuewithPhaseI-IIinterventions

• Boxjumpswithquickchangeofdirection• 90and180degreejumps

CriteriatoProgress

• ClearancefromMD• FunctionalAssessment

o Quad/HS/glutindex≥90%contralateralside(isokinetictestingifavailable)o Hamstring/Quadratio≥70%o HopTesting≥90%contralateralside

• KOOS-sportsquestionnaire>90%• InternationalKneeCommitteeSubjectiveKneeEvaluation>93• PsychReadinesstoReturntoSport(PRRS)


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PsychologicalReadinesstoReturntoSport

PatientName: MRN:

Surgery: DateofSurgery:

Surgeon: Pleaserateyourconfidencetoreturntoyoursportonascalefrom0–100Example: 0=Noconfidenceatall 50=Moderateconfidence 100=Completeconfidence

1. Myoverallconfidencetoplayis_____

2. Myconfidencetoplaywithoutpainis_____

3. Myconfidencetogive100%effortis_____

4. Myconfidencetonotconcentrateontheinjuryis_____

5. Myconfidenceintheinjuredbodyparttohandledemandsofthesituationis_____

6. Myconfidenceinmyskilllevel/abilityis_____

Total:_____

Score:_____

Examiner:________________________________

GlazerDD.DevelopmentandPreliminaryValidationoftheInjury-PsychologicalReadinesstoReturntoSport(I-PRRS)Scale.JournalofAthleticTraining.2009;44(2):185-18

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