eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Meniscal Injury: Treatment & Medication
Updated: Jun 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Rehabilitation Program
Physical Therapy
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
Initial phase
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.
Intermediate phase
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.
Advanced phase
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.
Nonoperative rehabilitation
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.
Surgical Intervention
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.
Operative management
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 and Images 3, 4). Intraoperatively, a decision has to be made whether to repair, excise, or leave the tear in the meniscus alone.
Arthroscopic probing of a posterior horn complex meniscal tear with multiple flaps.
Arthroscopic view of medial meniscus after excision of flap tear.
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.11
Other Treatment
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.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained injuries.
Acetaminophen (Tylenol, Feverall, Tempra, Aspirin-Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible following various dose levels in those with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
Nonsteroidal anti-inflammatory drugs
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprelan, Anaprox, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of COX, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Diclofenac (Voltaren, Cataflam)
Designated chemically as 2-[(2,6-dichlorophenyl)amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA. One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. Believed to inhibit COX, which is essential in biosynthesis of prostaglandins. Can cause hepatotoxicity; hence, monitor liver enzyme levels in first 8 wk of treatment.
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Delayed-release, enteric-coated form is diclofenac sodium, and immediate release form is diclofenac potassium. Has relatively low risk for bleeding GI ulcers.
Adult
25 mg PO bid/tid
If well tolerated, increase by 25 or 50 mg qwk until satisfactory response is obtained or total daily dose of 150-200 mg PO is reached
Higher doses generally do not increase effectiveness
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and by inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; severe heart failure and hyponatremia may occur because celecoxib may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction
More on Meniscal Injury |
| Overview: Meniscal Injury |
| Differential Diagnoses & Workup: Meniscal Injury |
 Treatment & Medication: Meniscal Injury |
| Follow-up: Meniscal Injury |
| Multimedia: Meniscal Injury |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Further Reading
Related eMedicine topics:
Anterior Cruciate Ligament Injury [Physical Medicine and Rehabilitation]
Anterior Cruciate Ligament Injury [Sports Medicine]
Anterior Cruciate Ligament Pathology
Knee, Anterior Cruciate Ligament Injuries (MRI)
Knee Injury, Soft Tissue
Knee, Meniscal Tears (MRI)
Meniscus Injuries
Clinical guidelines:
ACR Appropriateness Criteria® nontraumatic knee pain. American College of Radiology - Medical Specialty Society. 1995 (revised 2005). 9 pages. [NGC Update Pending] NGC:004631
Knee & leg (acute & chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 May 7). 289 pages. NGC:006561
Clinical trials:
Chondrocyte Maturation and Cartilage Loss Following Meniscal Injury
Comparing Knee Cartilage Surgery Versus Standard Physical Therapy in Treating People With a Meniscal Tear and Osteoarthritis
Meniscal Repair: A Randomized Prospective Trial of FAST-FIX vs. Meniscal Suturing
Keywords
meniscal injury, meniscus, knee surgery, knee injury, knee injuries, meniscus tear, torn meniscus, medial meniscus, lateral meniscus, meniscus surgery, knee meniscus, medial meniscus tear, meniscus injury, meniscus repair, meniscus treatment, meniscal tear, menisci, lateral meniscus tear
