Meniscal Injury Treatment & Management
- Author: Sarjoo M Bhagia, MD; Chief Editor: Consuelo T Lorenzo, MD more...
A study by El Ghazaly et al indicated that in patients with symptomatic unstable meniscal tears, better treatment results can be achieved with arthroscopic partial meniscectomy (APM) than with physical therapy. The study, on 70 patients, found that although pain and swelling were reduced in the physical therapy patients, their injured knees continued to have limited range of motion, with greater knee function and treatment satisfaction found in the APM patients.
On the other hand, a study by Stensrud et al reported that in middle-aged patients with degenerative meniscal tears, a 12-week supervised exercise therapy program can yield similar results to APM. Indeed, isokinetic knee extension peak torque was a mean 16% greater in the exercise group.
The protocols for rehabilitation of a meniscal injury take into consideration biomechanical principles and the results of the physical examination. Factors such as the extent and location of the lesion, the amount of articular cartilage degeneration on weight-bearing surfaces, the duration of injury, and the joint stability affect the pace and aggressiveness of the rehabilitation program. No preset duration for any phase of rehabilitation is described in this section, and phases may overlap, depending upon the patient's progress and symptoms. The protocols should be adjusted to each patient's status, progress, and goals.
Rehabilitation following meniscectomy
When the patient first reports to outpatient physical therapy 4-7 days after surgery, he or she usually is able to bear full weight or as much weight as tolerated on the involved leg. Modalities are used as needed to decrease pain or swelling, including heat/ice contrasts, ice alone, transcutaneous electrical nerve stimulation (TENS), electric galvanic stimulation, and phonophoresis. As needed, the patient should perform flexibility exercises for the lower extremity musculature, including the hamstrings, quadriceps femoris, hip flexors, hip adductors, and calf muscles.
During the initial stage, the emphasis should be placed on overcoming any limitations to ROM. To increase passive flexion ROM, the patient should complete exercises such as wall slides. The patient uses the uninvolved leg to control the speed of descent and to push the involved leg back up into extension. The patient does not have to use the quadriceps muscle of the involved leg for this exercise, but he or she can use it if there is no pain.
After the patient attains 110-115° of flexion, he or she may substitute heel slides for supine wall slides to increase flexion ROM. Isometric exercises for the quadriceps muscle assist in strengthening the quadriceps muscle, especially the VMO segment. Electrical muscle stimulation may be used to help retrain poorly contracting VMO or quadriceps femoris muscles. Short-arc quadriceps femoris muscle exercises strengthen the quadriceps femoris muscle.
Additional exercises to strengthen the lower extremity musculature (eg, hamstrings, hip adductors, hip abductors, calf muscles) are included in the program. The patient can begin isotonic strengthening exercises for the hamstring muscles when he or she can flex the knee to at least 80-90°. Hip abduction strengthening may begin when VMO muscle contraction and strength is adequate. If the patient begins hip abduction exercises before the quadriceps femoris muscle is strong enough, the exercises may contribute to increased lateral tracking of the patella. The tensor fasciae latae muscle inserts into the iliotibial band distally, and contraction of this muscle increases the tightness of the fascial sheath, contributing to lateral patellar tracking.
Depending on weight-bearing ability and other symptoms, the patient can begin toe raise exercises to strengthen the lower leg. Proper foot placement is important, as it influences the stresses at the knee. Supination of the foot causes tibial external rotation and a varus force at the knee joint, resulting in increased pressure in the medial compartment. Pronation causes tibial internal rotation, a valgus force at the knee joint, and increased lateral compartment pressure.
Stationary bicycling may be implemented into the rehabilitation program when the patient attains 115-120° of knee flexion. This exercise increases joint lubrication, which helps to improve ROM. Tension and resistance should be adjusted according to the presence of effusion or the patient's complaints of pain. If the patient's ROM is not adequate, bicycling may cause forced motion and increased pressure, irritating the knee.
The patient should have full ROM to begin this phase. Modalities are continued as indicated by symptoms. Flexibility and strengthening exercises are continued, increasing resistance as tolerated. The patient may progress to isokinetic strength and endurance training.
The patient also may begin closed kinetic chain exercises during this phase. If the quadriceps femoris muscle is strong enough (ie, if the patient can lift 10 lb during short-arc quadriceps femoris muscle exercise), the running program may be initiated. The first stage of the running program is jogging in place on a trampoline. Unless pain or swelling occurs, the patient gradually progresses to jogging for 10-15 minutes.
During the advanced phase, the patient continues to progress in strength-training exercises while beginning to return to sports activities. Track running may begin when the patient is able to run on the treadmill for 10-15 minutes at a pace of 7-8 minutes per mile (depending upon the patient's previous activity level). Once mileage on the track has reached 2-3 miles, agility drills and sport-specific activities may be performed.
Rehabilitation following meniscal repair
The program for rehabilitation following meniscus repair is similar in principle to the program that follows meniscectomy; however, more limitations are put on the patient's weight-bearing status, and the duration of each phase of rehabilitation is longer to allow for healing. Full weight bearing is postponed until 4-6 weeks after surgery to reduce the tensile and compressive forces on the repair site. During the initial phase of rehabilitation, more attention should be paid to applying modalities to decrease pain and effusion. ROM exercises are performed with caution so that the healing process is not delayed. Mobilization of the patella may be required to ensure proper mechanics of the patellofemoral joint. Stretching exercises include calf stretches to reduce the possibility of Achilles tendinitis when the patient resumes weight bearing on the involved leg. Ankle ROM exercises also may be required to maintain adequate ankle ROM before weight bearing begins.
Open kinetic chain strengthening exercises may begin during the initial phase, but caution must be used and the exercises must be reduced or suspended if the patient reports pain. Isokinetic training should not begin until the patient is able to lift 10 lb on the short-arc quadriceps muscle exercise. The running program may begin when the quadriceps femoris and hamstring muscles of the involved leg have reached approximately 70% of the strength of the same muscles of the uninvolved leg, as demonstrated by an isokinetic strength test.
The program for nonoperative rehabilitation is similar in principle to the program that follows meniscectomy. Cryotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) play a very important role in the management of nonoperative meniscal injury. These medications help control the amount of swelling and provide some pain relief. Sometimes, aspiration is useful to decrease the effusion, and, rarely, an athlete may need a judicious 1-time corticosteroid injection. Although not routinely advocated, an injection may provide an athlete with a way to control the irritation within the knee so that performance may not falter. Maintenance of ROM of the knee is important, as are muscular strength and endurance.
A reasonable goal before return to athletic activity is strength of the injured lower extremity within 20-30% of the contralateral side. Initially, activity modification is useful, particularly in athletes who are "weekend warriors." The time frame for return to activity depends on a number of factors. Returning to competition depends on the demands and motivation of the athlete, as well as on the severity of the meniscal tear.
Operative versus nonoperative treatment
Multiple factors are involved in making decisions regarding the management of an athlete with a known or suspected meniscal tear. Factors such as the severity of the symptoms, the ability to perform one's activity, and the timing of possible surgery must be taken into account. The need for surgical management is quite evident in an individual with significant symptoms, such as a locked knee or debilitating pain with clinical or MRI evidence of a meniscal tear. A treatment decision may be much more difficult to make on an individual who has relatively mild symptoms of a meniscal tear and who is participating in a sporting event that is in the middle-to-late part of the season.
The severity of the symptoms can vary for different types of meniscal tears. A bucket-handle tear may cause the knee to lock and be quite painful, whereas a small vertical or radial tear that displaces may cause occasional symptoms of giving way and only mild pain. If the symptoms are infrequent and locking does not occur, then an initial period of conservative management may be indicated, depending on the activity level and demands of the athlete. If the athlete's ability to compete is impaired because of the symptoms, then nonoperative management is unlikely to be satisfactory and arthroscopic surgery should be helpful, although it may mean a delay of 1-4 weeks in returning to competition.
An athlete with recurrent mild symptoms but without impairment in the ability to compete may be a suitable candidate for delayed operative management. Thorough consultation between the athlete, the physician, and the athletic trainer must be undertaken before any decision is made. The athlete must be given a clear explanation of what a meniscus tear is and of what the potential ramifications of delaying surgery are. The potential ramifications of delaying surgery include the possibility of propagation of the tear or significant symptoms during a competition, which may preclude further participation at a particular event. Few published studies have examined the results of nonoperative treatment of meniscal tears, and, to the authors' knowledge, none have been performed in a prospective randomized fashion.
A study by Gauffin et al indicated that in middle-aged patients with meniscal injury, arthroscopic knee surgery combined with physical therapy brings greater pain relief than does physical therapy alone. In the prospective, randomized, single-blind trial, 150 patients aged 45-64 years who had been suffering from meniscal symptoms for more than three months were treated with physical therapy, including a three-month exercise program. Within this group, however, some patients were also treated with arthroscopic resection of meniscal injury, performed within four weeks of inclusion in the study. At 12-month follow-up, evaluation using the Knee Injury and Osteoarthritis Outcome Score determined that pain reduction was significantly greater in the patients who had been treated with physical therapy and surgery than in those treated only with physical therapy.
Once a decision has been made to proceed with operative management, further decisions regarding the surgical treatment of the meniscus tear need to be made (see images below). Intraoperatively, a decision has to be made whether to repair, excise, or leave the tear in the meniscus alone.
Numerous factors are involved in the determination of treatment of a meniscal tear. In assessing these factors, the clinician must be cognizant of meniscal biomechanics, including the role in load transmission and congruity of the knee joint, as discussed previously. Because of the importance of intact functional meniscus tissue, the first goal is to preserve as much of the viable tissue as possible. Many factors (eg, the location, length, pattern, stability, and chronicity of the tear; the athlete's age; presence of degenerative changes; concurrent intra-articular injuries; desired timing of return to competition) need to be taken into consideration during the decision-making process.
When a patient is implementing nonoperative rehabilitation, an aspiration of the knee joint sometimes is useful to decrease effusion. Rarely, an athlete may need a judicious 1-time injection of a corticosteroid. Although not routinely advocated, an injection may provide an athlete with a way to control the irritation within the knee so that performance may not falter.
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