Meniscus Repair Postop Rehabilitation Protocol

This protocol provides a guideline for rehabilitation following a meniscal repair. It is crucial to tailor the rehabilitation program to the individual patient, considering factors such as age, activity level, type of repair (inside-out, outside-in, all-inside), location of the tear, associated injuries (e.g., ACL, cartilage), and surgeon's recommendations. Close communication with the surgeon is essential. This protocol assumes the surgeon has given clearance to progress.

Pathophysiology

The meniscus is a C-shaped fibrocartilaginous structure located within the knee joint, providing stability, load distribution, shock absorption, and joint lubrication. Meniscal tears are common, often resulting from traumatic twisting injuries or degenerative changes. Repair is preferred over meniscectomy when possible, particularly in younger, active individuals and in cases where the tear is in the vascular zone ("red zone") of the meniscus, which has a greater potential for healing. However, repair requires a period of protected weight-bearing to allow for adequate healing and minimize the risk of re-tear.

Phase I: Protection Phase (Weeks 0-4)

Goals: Protect the repair, reduce pain and swelling, regain quadriceps control, and maintain range of motion (ROM) while avoiding excessive stress on the meniscus.

• Weight Bearing: Non-weight bearing (NWB) or toe-touch weight bearing (TTWB) for the first 2-4 weeks as prescribed by the surgeon. Progress to partial weight bearing (PWB) around week 3-4 if healing is progressing well. Use crutches.
• Bracing: Hinged knee brace locked in full extension for ambulation and sleeping. The brace may be unlocked for gentle exercises, but range of motion limits will be dictated by the surgeon, typically allowing gradually increasing flexion within the brace.
• Range of Motion (ROM):
  • 0-90 degrees of flexion (or as prescribed by the surgeon). Gradual progression towards full ROM as tolerated.
  • Emphasis on passive range of motion (PROM) and active-assisted range of motion (AAROM) early on.
• Exercises:
  • Ankle pumps: Promote circulation and reduce swelling.
  • Quadriceps sets: Focus on regaining voluntary quadriceps contraction.
  • Hamstring sets: Gentle isometric contractions.
  • Gluteal sets: Strengthen hip extensors to assist with ambulation.
  • Heel slides: Start with AAROM and progress to AROM as tolerated.
  • Patellar mobilizations: Maintain patellar mobility to prevent stiffness.
  • Hip abduction and adduction isometrics: Strengthening hip muscles without knee stress.
  • Core stabilization exercises (gentle): Maintain trunk stability.
• Pain Management:
  • Ice: Apply ice packs for 15-20 minutes several times a day to reduce pain and swelling.
  • Elevation: Elevate the leg above the heart to minimize swelling.
  • Pain medication: As prescribed by the surgeon.
• Precautions:
  • Avoid twisting or pivoting on the affected leg.
  • Avoid deep squatting or kneeling.
  • Adhere strictly to weight-bearing restrictions.

Phase II: Loading Phase (Weeks 4-12)

Goals: Gradually increase weight bearing, improve ROM, restore strength and neuromuscular control, and prepare for functional activities.

• Weight Bearing: Progress from PWB to full weight bearing (FWB) as tolerated, typically by week 6-8. Discontinue crutches when FWB is achieved without pain or limping.
• Bracing: Wean from the brace gradually, typically by week 6-8, depending on pain, swelling, and quadriceps control. May continue brace during higher impact activities longer.
• Range of Motion (ROM):
  • Progress towards full ROM (0-135 degrees).
  • Focus on active range of motion (AROM) and stretching exercises.
• Exercises:
  • Stationary cycling: Low resistance, focusing on smooth pedaling motion.
  • Mini-squats (limited range): Focus on proper form and quadriceps activation.
  • Leg press (low weight, limited range): Gradually increase weight and range as tolerated.
  • Hamstring curls (light weight): Controlled movements.
  • Calf raises: Standing or seated.
  • Step-ups (low step height): Focus on controlled descent.
  • Balance exercises: Single-leg stance, wobble board, balance pad.
  • Proprioceptive exercises: Begin with eyes open, progress to eyes closed.
  • Continue core stabilization exercises.
• Pain Management: Continue ice and elevation as needed.
• Precautions:
  • Avoid activities that cause pain or swelling.
  • Avoid twisting or pivoting on the affected leg.
  • Gradually increase exercise intensity and duration.

Phase III: Return to Function Phase (Weeks 12+)

Goals: Restore full strength, power, and endurance; improve agility and coordination; and return to pre-injury activity level.

• Weight Bearing: FWB without limitations.
• Bracing: No brace required for most activities unless specified by the surgeon.
• Range of Motion (ROM): Full and pain-free ROM.
• Exercises:
  • Progressive strengthening exercises: Increase weight and resistance.
  • Plyometric exercises: Jumping, hopping, bounding (start with low-impact activities).
  • Agility drills: Cone drills, shuttle runs, figure-eight runs.
  • Sport-specific training: Gradually introduce activities specific to the patient's sport or occupation.
  • Running program (if applicable): Begin with walk/run intervals and gradually increase running time.
• Criteria for Return to Activity:
  • Full and pain-free ROM.
  • No joint swelling or pain.
  • Symmetrical strength and power compared to the uninjured leg.
  • Successful completion of functional testing (e.g., single-leg hop test, agility tests).
  • Surgeon's clearance.
• Precautions:
  • Continue to avoid activities that cause pain or swelling.
  • Use proper technique and warm-up before exercise.
  • Gradually increase activity level.
  • Consider using a functional brace for high-impact activities or sports.

Common Special Tests

• McMurray's Test: Evaluates for meniscal tears. The knee is flexed, and the tibia is rotated internally and externally while the knee is extended. A click or pain may indicate a meniscal tear.
• Apley's Compression Test: Evaluates for meniscal tears. Patient is prone, knee is flexed to 90 degrees, axial load is applied to the tibia, and the tibia is rotated internally and externally. Pain or clicking suggests a meniscal tear.
• Thessaly Test: Performed weight-bearing. The patient stands on one leg with the knee flexed to 5 degrees and then to 20 degrees and rotates the body internally and externally. Pain or clicking suggests a meniscal tear.
• Joint Line Tenderness: Palpation along the medial and lateral joint lines to assess for pain, which can indicate a meniscal tear.

Disclaimer: This protocol is for informational purposes only and should not be considered medical advice. Consult with your physician or physical therapist to determine the appropriate rehabilitation program for your specific condition.