Melanie McNeal, PT, CSCS, CFT
for patients of
DAVID LINTNER, MD
The fibrocartilaginous menisci act as shock absorbers, force distributors, and aid in knee stabilization. Meniscal tears are the most common of all knee injuries. The most common mechanism of injury is twisting the knee with a planted foot. A “pop” is often audible followed by severe pain and swelling. With the next few days, the patient may notice a “catching” feeling or feel that the knee is “locked up” and gives way. Stairs may be difficulty and painful as well as squatting and kneeling activities.
If conservative treatment fails and the tear is in a location in which healing can occur, a meniscal repair is indicated. If at all possible, it is beneficial to repair a tear rather than remove part of the meniscus because 70-90% of people who undergo total menisectomies have OA in the knee joint within 10 years. The greater the amount of meniscus that can be saved, the more stability and the less chance of arthritis down the road.
Following surgery, it is important to consult with Dr. Lintner regarding the size of the tear and subsequent repair. This will affect the time frame for limiting ROM and weight bearing. If the repair was made at the outer third or periphery of the meniscus, where ample blood supply exists, faster healing can be expected and rehab should progress accordingly.
The following protocol should be followed unless otherwise instructed following a meniscal repair.
Rehab for the first 6 weeks following a repair is critical but boring. Limited exercises can be done due to the ROM and WB’ing precautions. These exercises are critical however. It is important to allow the repair to heal and to avoid stress to the meniscus during this time frame. Squatting or kneeling is contra-indicated.
- The hamstrings attach to the posterior portion of the meniscus and therefore, active and resistive hamstring activity should be avoided for at least 6 weeks post-op!
- A home exercise program is critical and should be emphasized heavily to the patient, especially initially. The more the patient does at home, the faster recovery will be.
MENISCAL REPAIR PROTOCOL
Following surgery, the patient will be placed in an immobilizer which will be worn for at least 3 weeks.
Dr. Lintner’s belief is that the patient can weight-bear and bend the knee but not at the same time.
PWB is allowed for the first 3 weeks.
PROM and AAROM 0-90° for 3 weeks.
STRENGTH AND NM CONTROL
- Quad sets with EMS or biofeedback –the more the better; 100X/day
- SLR – 4 way
- Seated hip flexion
- Heel slides – follow precautions!!!!
- Hamstring and calf stretch – hold 30 sec
- Prone hangs to gain full knee extension
- EMS or EGS if needed for quad facilitation or swelling, respectively
- Ice following exercise and initially, every hour for 20 minutes
*The hamstrings attach to the posterior portion of the meniscus and therefore, active and resistive hamstring activity should be avoided for at least 6 weeks post-op!
*Pt should perform HEP 3X/day
- ROM can now be progressed slowly as tolerated.
- Deep flexion in a weight bearing position should NOT be performed.
- Limit closed chain exercises to 90°.
- The patient can d/c immobilizer and work towards a N gait pattern. *Crutches can be discharged when a N gait is achieved.
- Quad sets are continued until swelling is gone and quad tone is good
- SLR (4 way) add ankle weights when ready
- Weight shifting – lateral; forward/backward
- Shuttle/Total gym – (limit to 90°) bilateral and unilateral- focus on weight distribution more on heel than toes to avoid overload on Patella tendon
- Multi-hip – increase intensity as able
- Leg Press (limit to 90°)
- Step-ups – forward
- Wall slides (limit to 90°)
- Mini-squats – focus on even distribution of weight
- Calf raises
- Goal is 0-125°
- Patella mobilization – manual – especially superior and inferior
- Perform scar massage aggressively at portals and incision
- Heel slides – seated and/or supine at wall
- Continue with HS and calf stretching
- Bicycle – do not perform until 110° of flexion are achieved – do NOT use bike to gain ROM. Perform daily and increase resistance as able to work quad.
- Single leg stance – even and uneven surface – focus on knee flexion
- Plyoball – toss
- Lateral cone walking with single leg balance between each cone
- Cone walking – forward and lateral
- D/C crutches when N gait
- Continue to use ice following exercise
*Continue with HEP daily
By end of this phase, the patient should ambulate with N gait I, have good quad control, controlled swelling, and be able to ascend/descend stairs.
Goals for this phase are full quad control, good quad tone, and full ROM; patient should be able to perform N ADLs without difficulty.
Exercises will be advanced in intensity based on quad tone – a patient who continues to have poor quad tone must not be advanced to activities that require high quad strength such as squats and lunges
- Continue with above exercises, increasing intensity as able
- Step-ups – forward and lateral; add dumbbells to increase I; focus on slow and controlled movement during the ascent and descent
- Squats – Smith press or standing
- Lunges – forward and reverse; add dumbbells or med ball
- Hamstring curls (not until wk 7)
- Single leg squats
- Russian dead lifts – bilateral and unilateral
- Single leg wall squats
- Cycle – increase intensity; single leg cycle maintaining 80 RPM
- Full ROM should be achieved
- Continue with hamstring and calf stretch
- Initiate quad stretch
- Plyoball – toss – even and uneven surface
- Squats on balance board/foam roll/airex
- Steamboats – 4 way; even and uneven surface
- Strength activities such as step-ups and lunges on airex
- Continue to use ice after exercise
*Continue with HEP at least 3X/week
- Continue with above strengthening program 3X/week focusing on increasing intensity and decreasing reps (6-10) for increased strength
- Initiate lateral movements and sports cord: lunges – forward, backward, or side step with sports cord, lat step-ups with sports cord, step over hurdles.
- Plyometric program – bilateral progressing to unilateral
- Plyos can include squat jumps, tuck jumps, box jumps, depth jumps, 180 jumps, cone jumps, broad jumps, scissor hops
- Leg circuit: squats, lunges, scissor jumps on step, squat jumps
- Power skipping
- Bounding in place and for distance
- Quick feet on step – forward and side-to-side – use sports cord
- Progress lateral movements – shuffles with sports cord; slide board
- Ladder drills
- Swimming – all styles
Focus should be on quality, NOT quantity
Landing from jumps is critical – knees should flex to 30° and should be aligned over second toe. Controlling valgus will initially be a challenge and unilateral hops should not be performed until this is achieved.
Initiate sprints and cutting drills.
Progression: Straight line, figure 8, circles, 45° turns, 90° cuts
Sports specific drills
Single leg hop test
Peak Torque/BW Males Pk T/BS females
60°/s (%) 110-115 80-95
180°/s (%) 60-75 50-65
300°/s (%) 30-40 30-45