Physiotherapy and rehabilitation after meniscal repair surgery - Henry AtkinsonPhysiotherapy and Rehabilitation following meniscal repair surgeryHenry Dushan Edward Atkinson, Jennifer Michelle Laver, Elizabeth Sharp Mr Henry D.E.Atkinson, MBChB, BSc Med Sci, MRCS, FRCS Tr & Orth Consultant Trauma and Orthopaedic Surgeon North Middlesex University Hospital, Sterling Way, London N18 1QX North London Sports Orthopaedics Miss Jennifer Michelle Laver, B App Sc (Physio)(Hons) Senior Lower Limb Sports Physiotherapist SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia Mrs Elizabeth Sharp MSc (Man Ther) MCSP Grad Dip Phys Clinical Director ESPH ESPH ES Physical Health, 116 Lordship Lane, London, SE22 8HD ESPH, 22 Harley Street, London W1G 9PL It takes approximately 3 months for the meniscal repair to heal(64). The aim of rehabilitation is to protect the healing meniscus while supporting a graduated RTS as the scar tissue matures(65). The functional rehabilitation follows a similar progression to ACL protocols, but with different time-frames. Ankle pumps are performed immediately after surgery until normal mobility is restored. Patients commence SLR, IRQ, passive and active assisted knee flexion in a seated position on the bed (to 90 degrees only) and passive knee extension (in sit with a ?phone-book?) from day one(66). General postoperative advice is given as for arthroscopic menisectomy(66). Multi-angle isometric quadriceps should be used for the first 2 weeks, rather than CKC exercises, as they do not stress the meniscal repair18. Gym is started from 4-6 weeks (66), and patients typically RTS from 12 to 16 weeks(65,67). Most patients FWB without the routine use of crutches(67), and patients do not require bracing(68). Weight bearing in full extension assists quadriceps activation and helps to prevent loss of knee extension range(18), and may also promote meniscal healing through early physiological loading(67). However, excessive weight bearing is discouraged as compressive and shear forces on the joint can damage the healing meniscal repair(66). Patients must avoid knee flexion past 90 degrees and deep knee bends while weight bearing for 6 weeks(65). Caution should be exercised with leg presses (low loads or double legs are recommended) and low chairs should be avoided. Increased knee flexion increases the compressive loads transmitted through the posterior horns of the menisci, with 85% of load transmitted at 90 degrees knee flexion compared with approximately 50% in extension(69). Posterior horn meniscal tears can be seen arthroscopically to separate from the capsule in knee flexion and reduce into place in extension(70). Squats should be avoided for 3 months(65). Interestingly, Barber et al found that an ARP consisting of FWB without bracing, without restrictions in ROM or pivoting activity, and a RTS as early as 3-4 months post-operatively, did not result in any significant differences in rates of healing or re-injury when compared with standard meniscal repair protocol involving immobilization, restricted weight bearing and later RTS(68). Conversely, Tenuta et al found that a similar ARP that placed no restrictions on ROM or weight bearing had a significantly higher number of incompletely healed meniscal repairs(71). In summary: Week 1-4 - May involve partial weight bearing with crutches, or FWB without crutches - Control of swelling with ice, elevation and compression - Soft tissue mobilization and reduction of scar tissue - ROM 0?-90? - Activation of VMO in isometric exercises, IRQ - Passive and active knee exercises - Hydrotherapy from week 2 Week 4-6 - 0-90- range of motion - Gradual increase to full weight bearing walking gait, if previously partial weight bearing - Pilates based exercises partial weight bearing to maintain range of motion and strengthen quadriceps - Closed chain exercise. Wall squats, lunges, steps - Stretch programme for quadriceps, hamstring, ITB, calf, hip rotators Week 6-12 - Isokinetic closed and open chain quadriceps and hamstring rehabilitation - Cardiovascular and sport specific exercise - Closed and open chain resisted exercise in gym using treadmill, bike and leg press - Balance, strength and stability exercises on the gym ball - Swimming Week 12 - One might consider performing isokinetic open chain quadriceps and hamstring tests on the KIN-COM. Final rehabilitation programme - Specific strength and stability training to overcome any residual deficits shown up in the Isokinetic test - Return to full sporting activities by week 12-16 Acknowledgements John R Camens B App Sc Physio Grad Dip Physio (Orthopaedics), SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia. Glenn Withers B.Physio. MCSP Cert. Pilates Instructor MIAPI, Pilates Art Physiotherapy / London Sports Medicine 50-52 Kilburn High Road, London, NW6 4HJ, UK References 1. 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Knee Surgery, Sports Traumatology, Arthroscopy 10: 284-288. 65 Boyd KT and Myers PT (2003): Meniscus preservation: rationale, repair techniques and results. Knee 10: 1-11 66 Heckmann TP, Barber-Westin SD and Noyes FR (2006): Meniscal Repair and Transplantation: Indications,Techniques, Rehabilitation, and Clinical Outcomes. Journal of Orthopaedic and Sports Physical Therapy 36 (10): 795-814 67 Kocabey Y, Nyland J, Isbell WM and Caborn DNM (2004): Patient outcomes following T-Fix meniscal repair and a modifiable, progressive rehabilitation program, a retrospective study. Arch Orthop Trauma Surg 124: 592-596 68 Barber FA (1994): Accelerated Rehabilitation for Meniscus Repairs. Arthroscopy: The Journal of Arthroscopic and Related Surgery 10 (2): 206-210 69 Wilk KE, Briem K, Reinold MM, Devine KM, Dugas JR and Andrews JR (2006): Rehabilitation of Articular Lesions in the Athlete?s Knee. Journal of Orthopaedic and Sports Physical Therapy 36 (10): 815-827 70 Morgan CD, Wojtys EM, Casscells CD and Casscells SW (1991): Arthroscopic meniscal repair evaluated by second-look arthroscopy. American Journal of Sports Medicine 19 (6): 632-637 71 Tenuta JJ and Arciero RA (1994): Arthroscopic Evaluation of Meniscal Repairs: Factors That Effect Healing. American Journal of Sports Medicine 22 (6): 797-802 Keywords Rehabilitation, Physiotherapy, Pilates, Knee surgery, Anterior cruciate ligament reconstruction, Menisectomy, Meniscal repair. Abstract Soft-tissue knee surgery is performed for a multitude of conditions and encompasses a large number of procedures. The postoperative management of these conditions is constantly evolving as a result of advances in technology and a better understanding of human physiology, however there remains no consensus on the ideal timeframe over which loading can be progressed. Rehabilitation protocols provide basic guidelines through which effective outcomes can be achieved. However, the rate and extent of recovery will depend on many patient and external factors, and it is questionable whether full recovery or a return to normality is ever complete. The complex neuromuscular motor patterning, strength and control which are affected by the injury and the surgery is very difficult to gauge, and difficult to recreate. Isokinetic testing affords a validated, reliable and reproducible method of evaluating muscle strength, endurance and antagonist/agonist balance. It may be utilised at the earliest safe opportunity to establish the efficacy of any functional rehabilitation programme and can allow adjustments to be made to optimise outcomes. Future studies into the use of pilates programmes and their effects on earlier muscle pattern retraining may also allow for safer and earlier returns to sporting activity. This review establishes an evidence-based approach to the postoperative rehabilitation of the knee following anterior cruciate ligament reconstruction, arthroscopic menisectomy, and meniscal repair surgery. Volume 24 , Issue 2 , Pages 129-138 (April 2010) http://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327%2810%2900031-X/abstract www.sportsortho.co.uk Please log in to view the content of this page. If you are having problems logging in, please refer to the login help page. |
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