Curr Rev Musculoskelet Med (2012) 5:46–58

DOI 10.1007/s12178-011-9110-y

KNEE REHABILITATION (J CAVANAUGH, SECTION EDITOR)

Rehabilitation following meniscal repair

John T. Cavanaugh & Sarah E. Killian

Published online: 23 March 2012

# Springer Science+Business Media, LLC 2012

Abstract It has become increasingly more evident that the reported the mean annual incidence of meniscus tears as 9.0 in
meniscus plays an important role in contributing to knee joint males and 4.2 in females per 10,000 inhabitants. Tears were
longevity. Advances in surgical techniques by orthopaedic found to be more common in the third, fourth and fifth
surgeons to repair traumatized menisci have led to better long decades of life.
term outcomes, decreasing the incidence of articular cartilage It has become more and more clearer in recent decades that
degeneration. Advances have also been made in rehabilitative meniscal excision leads to articular cartilage degeneration
techniques following meniscal repair. These techniques along [3–5]. Degenerative changes have been found to be directly
with sound rehabilitation principles to include a criteria based proportional to the amount of meniscus removed [6]. Even
progression have contributed to excellent outcomes and earlier partial meniscectomy results in higher than normal stress on
return to function and sport. The role of the meniscus, recent the underlying articular cartilage [6–10]. An vitro study by
advances in surgical repair and the current post-operative Seedhom and Hargreaves demonstrated that removal of 16%
rehabilitation techniques employed by sports rehabilitation to 34% of the meniscus resulted in a 350% increase in contact
specialists today are discussed. forces [10].
Therefore it has been generally recognized that the amount
Keywords Knee . Meniscus . Surgery . Rehabilitation of meniscal tissue removed should be minimized, repaired or
replaced [7–9]. This article will focus on the current treatment
strategies employed in the rehabilitation of individuals who
Introduction have undergone a meniscal repair procedure.

The population, in general has become more athletically active

and individuals are staying active longer. Meniscal injuries Basic science
have become very common among professional and amateur
athletes and are one of the most common indications for knee Meniscal cartilage plays a crucial role in the function and
surgery [1]. biomechanics of the knee joint. The meniscus functions in
Although the incidence of meniscal pathology is difficult to load bearing, load transmission, shock absorption, joint
estimate, the increased exposure to athletic activity increases stability, joint lubrication, and joint congruity [11–13].
the risk of injury to these structures. Hede and coworkers [2], The knee menisci (medial and lateral) are wedge-shaped
semilunar disks made of fibrocartilage interposed between
J. T. Cavanaugh (*) : S. E. Killian the tibia and the condyles of the femur. The lateral meniscus
Sports Rehabilitation & Performance Center, is O-shaped while the medial meniscus is C-shaped with a
Hospital for Special Surgery,
larger posterior horn.
535 East 70th Street,
New York, NY 10021, USA The menisci are attached to the tibia by the coronary
e-mail: cavanaughj@hss.edu ligaments and by direct insertion of the anterior and posterior
S. E. Killian horns into the bone. The menisci also attach to the joint
e-mail: killians@hss.edu capsule. The medial meniscus attaches to the deep layer of
Curr Rev Musculoskelet Med (2012) 5:46–58 47

the medial collateral ligament and the lateral meniscus The medial meniscus has been shown to be a significant
attaches loosely to the lateral joint capsule. The posterior horn restraint to anterior tibial displacement [12]. The lateral
of the lateral meniscus is attached to the femur via the menis- meniscus is more mobile than the medial meniscus and
cofemoral ligament. The capsular attachments of the medial may rotate as much as 15–20° [32].
meniscus are more secure than the lateral meniscus [14, 15]. The function of the meniscus is reflected in its anatomy
The menisci consist of approximately 75% type I collagen because its cells and extracellular matrix are arranged in such a
[16]. Collagen types II, III, IV and V are also present. Most of way that compressive forces, shear stresses, circumferentially
the collagen fibers are oriented circumferentially to resist directed forces, and tensile hoop stresses can be endured and
tensile forces and contain hoop stresses which are generated redirected optimally [31, 33, 34].
while weight bearing [17]. Radially oriented “ties” hold cir-
cumferential fibers together and provide resistance to shear
[18]. Mechanism of injury
Each meniscus is divided anatomically into horizontal
thirds: the posterior horn, the mid-body, and the anterior The meniscus can fail from either mechanical or biochemical
horn. Menisci are divided into vertical thirds when looking (degenerative) causes [35]. Noncontact forces are the most
at blood supply. The most peripheral 20% to 30% of the frequent mechanism of injury to the menisci [12]. These
medial meniscus and the peripheral 10–25% of the lateral stresses result from a sudden acceleration or deceleration in
meniscus receive a rich blood supply from the medial and conjunction with a change of direction (rotation force) that
lateral genicular arteries [19]. traps the menisci between the tibia and femur, which results in
Vascularization decreases approaching the inner portion a tear. In jumping sports such as basketball and volleyball, the
of the meniscus and becomes dependent upon diffusion additional element of a vertical force with angular momentum
[20]. Because of the poor blood supply, tears that extend (varus or valgus) on landing can contribute to a meniscal
to the inner avascular area have a more difficult time with injury. This scenario can increase the likelihood of a tear when
healing. Arnoczky and Warren have reported that in order hyperextension or hyperflexion forces accompany significant
for meniscus tears to heal, the tear needs to be in contact rotation between the joint surfaces.
with the peripheral vascular area [19]. Contact injuries involving valgus or varus forces have
Free nerve endings (nociceptors) and 3 different mechanor- contributed to meniscal pathology. Ligament injuries to the
eceptors (Ruffini corpuscles, Pacinian corpuscles, and Golgi ACL or MCL or both in which increased tibial displacement
tendon organs) can be found in the horns and in the outer two- occurs can displace the menisci from its peripheral attachments
thirds of the body of the menisci [20–23]. The menisci therefore and result in a tear. In chronic ACL insufficiency, the incidence
may serve as proprioceptive structures, providing a feedback of meniscal pathology can approach 98% [36]. The medial
mechanism for joint position sense [24•, 25]. Karahan, et al. meniscus injury rate has been found to be higher than that for
demonstrated that partial meniscectomy patients had a signifi- the lateral side (86.9% vs. 28.9%) in this population [37].
cant loss of knee joint position sense at knee flexion angles of Degenerative meniscal lesions are common in older individ-
60 and 75° at a mean 2 year follow-up [24•]. uals. The menisci become stiffer and less compliant with age
The distal surface of the femur is convex and rests on a [38]. It has been observed that meniscal tissue from patients
relatively flat tibial plateau, whereas the concave proximal over 40 years of age has a lesser cellularity and a decreased
surface of the meniscus deepens the articular fossae of the tibia healing response than tissue from younger patients [39].
to create more congruity with the femoral condyles [26, 27]. To The most common types of meniscal tears are vertical
retain this congruity during knee joint flexion, the whole longitudinal, oblique, degenerative, radial and horizontal
meniscus moves posteriorly on the tibial plateau to accommo- [40]. Meniscal lesions present with varied clinical symp-
date the femoral rollback on the tibial plateau, and, in particu- toms such as pain, effusion, locking, and persistent focal
lar, the anterior horn shows great displacements to stay in close joint line tenderness. Displaced tears, such as bucket handle
contact with the declining diameter of the femoral condyles tears, can produce locking and “giving way” episodes. Non-
[26, 28•, 29]. In this manner, the meniscus stabilizes the knee displaced tears can alter meniscus mobility and produce
joint and contributes to load bearing and shock absorption [22]. abnormal traction stresses on the capsule and synovium,
The menisci occupy 60% of the contact area between the which result in pain and swelling [41].
tibial and femoral cartilage surfaces and transmit 50% of the
joint compressive forces in full extension and approximately
85% of the load in 90° of extension [30]. The lateral meniscus Surgical management (meniscal repair overview)
picks up 70% of the load transmitted across the lateral com-
partment while the medial meniscus & articular cartilage share Surgical options include meniscectomy (partial or total),
the load across the medial compartment [31]. meniscal repair or meniscus transplantation. Meniscal tear
48 Curr Rev Musculoskelet Med (2012) 5:46–58

pattern, geometry, site, vascularity, size, stability, tissue via- upon suture placement. They include an inside-out repair,
bility or quality, as well as associated pathology, are all taken outside-in repair, and all-inside repair.
into account when determining whether to resect or repair a The arthroscopic inside-out surgical technique involves
meniscal lesion [42]. The physical health, activity level and the placement of sutures across the meniscus inside the joint
aspirations of the patient may be taken into consideration and the sutures are then tied down outside the joint capsule
during the management decision process. Co-morbidities, [60]. (Figure 1) This technique has been successful with
such as heart disease, obesity, axial alignment, and degenera- tears to the middle one-third and to some degree tears of
tive joint disease are considered in the decision process to the posterior horns [61, 62].
excise, repair, replace or even avoid surgery. The aspirations The arthroscopic outside-in surgical technique was devel-
of patients are also considered. oped by Warren as a method to decrease the risk of injury to
Improved surgical techniques along with advanced instru- the peroneal nerve during arthroscopic repair of the lateral
mentation and repair methods have enabled orthopaedic sur- meniscus. The procedure involves the placement of a suture
geons to repair menisci what were once thought of as with a Mulberry knot to one side of the meniscus tear inside
unrepairable. The first reported meniscal repair was reported the joint and then sutures are tied on the joint capsule [63, 64]
by Annandale in 1885 [43]. Meniscal repair techniques have (Fig. 2). This technique has been advocated in repairing tears
evolved from the placement of sutures across the torn meniscus to the mid-one-third and anterior horn regions [65].
through arthrotomy to using arthroscopy. Published meniscal The arthroscopic all inside surgical technique involves the
repair results have supported favorable success at extended placement of a suture anchors, biodegradable screws, darts
follow up in over 70–90% of patients [44–48]. Clinical studies and/or “arrows” through an arthroscopic portal to stabilize the
have demonstrated that the rates of healing after repairs of the tear [66]. Devices include the T-fix (Acufex Microsurgical
lateral meniscus are better than those after repairs of the medial Inc., Mansfield, MA) and Meniscal Arrow (BIONX, Malvem,
meniscus [49–51]. PA). Because it does not make use of any incisions, the all-
The goal of a meniscus repair is to allow the torn edges of inside technique is favorable in decreasing the risk of iatro-
the meniscus to heal once they have been fixated with sutures. genic neurovascular damage. This technique has favorable
The most important factor in determining repairability is the results for posterior horn tears [66–68].
location of the tear, as tears in the vascular periphery of the
meniscus can produce a healing response. The ideal tear is an
acute, vertical, longitudinal tear in the peripheral one-third of
the meniscus in a young patient who has a stable knee or will
have concomitant reconstruction of the ACL [52]. Radially
oriented tears in the posterior horn of the meniscus may be
repaired because of the abundant blood supply in this region,
Repairs of tears that extend 4–5 mm beyond the peripheral rim
of the meniscus traditionally have been not been advocated
due to questions regarding healing potential and possibility of
retears
In younger patients, meniscal repair can be considered for
tears that extend into the central, avascular zone of the
meniscus. Rubman and colleagues reported that 159 (80%)
of 198 knees in which a tear in the central, avascular zone
had been repaired had no symptoms at the time of follow-up
[48]. Arnocsky et al. have demonstrated that insertion of a
fibrin clot in the avascular zone of a meniscal defect has
promoted healing in the canine model [53].
Flap tears and horizontal cleavage tears generally are not
repairable. Radial tears in the middle portion of the meniscus
have a poor potential for healing [54]. Although both acute
and chronic tears can be successfully repaired, clinical studies
have reported better healing rates after acute repair [55, 56].
Surgical procedures to repair the meniscus vary. In rela-
Fig. 1 Inside-Out Meniscal Repair: The arthroscopic inside-out surgi-
tively stable tears the literature has reported the use of cal technique involves the placement of sutures across the meniscus
rasping and trephination [57–59]. Arthroscopic meniscal inside the joint and the sutures are then tied down outside the joint
repair techniques can be divided into three techniques based capsule. (Courtesy HSS Sports Medicine Service)
Curr Rev Musculoskelet Med (2012) 5:46–58 49

a rehabilitation program following meniscal repair surgery

is individualization [69]. The pre-injury status of the patient
needs to be taken under serious consideration as different
patients present in different physical condition at the time of
their initial evaluation. The patient may be an elite athlete, a
recreational athlete, or a nonathlete in weak physical condition.
The rehabilitation specialist should take into consider-
ation the axial alignment of the patient. Habata et al.
reported an association between atraumatic tears of the
medial meniscus and varus deformity [70]. Medial meniscus
repair patients with a varus deformity and lateral meniscus
repair patients with a valgus deformity may need a more
conservative approach in their rehabilitation as the compres-
sive loads in the respective involved compartment are
higher. Surgeons may elect to delay weight bearing and/or
place these individuals in an unloader brace.

Apply a working knowledge of the basic sciences

to the rehabilitation program

To provide quality care to individuals who have undergone a

meniscal repair, a thorough understanding of menisci function
and biomechanics is needed. Knowing how and when the
menisci are placed under stress during activities of daily living
and specific exercises will assist the rehabilitation specialist in
safely advancing the patient through the rehabilitative course
Fig. 2 Outside-In Meniscal Repair: The arthroscopic outside-in surgical and optimize functional outcome. An appreciation of the
technique involves the placement of a suture to one side of the meniscus inflammatory process and nature of tissue healing is invalu-
tear inside the joint and then sutures are tied on the joint capsule.
able in safely preparing the patient to return to the desired
(Courtesy HSS Sports Medicine Service)
level of activity.
Rehabilitation principles for the meniscal repair patient
Base rehabilitation on current clinical research
(Table 1)
Recent rehabilitation guidelines now have a more scientific
Individualize program : consider Pre-injury status rationale and basis. The rehabilitation specialist should keep
abreast of current advances in surgical procedures, clinical
No two meniscal patients with the same diagnosis present evaluation and treatment techniques to ensure that contempo-
identically. Therefore, the most important principle guiding rary interventions are being provided to produce an optimal
outcome.
Table 1 Rehabilitation principles for the meniscal repair patient
Team approach to rehab: responsibilities & communication
Individualize Program: Consider Pre-Injury Status

Apply a Working Knowledge of the Basic Sciences to the

For a successful outcome after meniscal repair, the orthopae-
Rehabilitation Program dic surgeon, rehabilitation specialist and patient must work
Base Rehabilitation on Current Clinical Research responsibly together as a team. Communication among the
Team Approach to Rehab: Responsibilities & Communication team members is vital. The surgeon has the responsibility of
Adhere to the Rules of Rehabilitation performing the proper surgical procedure to address the
Rule #1: Create a safe environment meniscal lesion, as well as directing the postoperative reha-
Rule #2: Do not hurt the patient bilitation program. Discussing the procedure or providing the
Rule #3: Be aggressive without breaking rules #1 and #2 rehabilitation specialist with a copy of the operative note will
Follow a Functional Progression assist the clinician in understanding any post-operative pre-
Follow evaluation-based guidelines
cautions (weight bearing status, range of motion restrictions,
etc.) and in developing realistic and measurable goals. The
50 Curr Rev Musculoskelet Med (2012) 5:46–58

surgical technique, including the number of incisions and activities. It is also important to counsel patients not to hurt
location and nature of the meniscal repair, has a direct effect themselves. Hence a subset of this rule can be, “Not to have
on the progression of the patient’s rehabilitation program. The the patient hurt the patient” This can be achieved by having
more soft tissue dissection there is, especially capsular inci- patients maintain close awareness of the knee and modify
sions, the more hemarthrosis and muscle inhibition will occur their activity level to meet their present condition.
postoperatively [71].
The surgeon should also share any associated pathology Rule #3. Be aggressive without breaking rules #1 and #2
findings with the rehabilitation specialist. Patients with degen-
erative joint disease may take longer for rehabilitate and The rehabilitation specialist can be aggressive as long as a safe
require a slower therapeutic progression than those patients environment is maintained during the prescribed therapeutic
with pristine articular surfaces. Patients with chondromalacia exercises and the patient does not complain of knee pain
patellae may not be candidate’s for certain isotonic or isoki- during the exercise or activity. The goals of athletic individuals
netic knee extension exercises. Patients with an ACL-deficient are often high with a rapid return to sport activity a top priority.
knee will require increased proprioceptive and neuromuscular Following these rules can result in a safe, expeditious and
training in their therapeutic exercise program. optimal outcome.
The responsibilities of the clinician assigned to the patient
with a meniscal repair include: being current with the most Follow a functional progression
contemporary approaches in rehabilitating this population and
communicating with the surgeon as to the patient’s progress A functional progression was defined by Kegerreis as an
and compliance to the therapeutic recommendations of the ordered sequence of activities enabling the acquisition or
physician and rehabilitation specialist. reacquisition of skills required for the safe, effective perfor-
The patient has an important role as well. The patient mance of athletic endeavors [73]. The patient should master
should adhere to the advice given by the surgeon and rehabil- a simple activity before advancing to a more demanding
itation specialist. This includes compliance to prescribed activity. Criteria therefore need to be established to ensure a
home therapeutic exercises and recommended activity mod- safe progression.
ifications in their daily routine. There are 168 h in a week, but An early goal in rehabilitation after meniscus repair surgery
a patient may be under the supervision of the rehabilitation is to have the patient establish quadriceps control. This can be
clinician only three times per week for 3 h (2%). This leaves demonstrated by having the patient perform a straight leg raise
the patient responsible for his or her own care for 165 h (98% without pain or an extensor lag. The functional progression can
of the time). Patient compliance, therefore, is imperative for a be advanced as ROM and muscle strength display improve-
successful outcome. ment. The next criterion in the progression is to have the
patient reestablish a normal non-antalgic gait pattern. Consider
Adhere to the rules of rehabilitation that “every step is therapy” and to encourage the patient to
ambulate with a heal-toe gait pattern while progressively
The rules of rehabilitation as described by Gray [72] can be weight bearing with crutches. Additional strategies used
easily applied to patients who have sustained a meniscal injury include decreasing stride length, emphasizing quality ambula-
or who have underwent a surgical procedure to address a tion over quantity and utilizing water (e.g. underwater treadmill)
meniscal lesion. for ambulation training so as to gradually apply increased load
through the knee joint.
Rule #1. Create a safe environment Walking in chest-deep water results in a 60–75% reduc-
tion in weight bearing, while walking in waist-deep water
The rehabilitation specialist should use his or her knowledge of results in a 40–50% reduction in weight bearing [74, 75].
the basic sciences to ensure that a prescribed exercise or activ- Normalizing a gait pattern facilitates gains in ROM.
ity does not compromise the healing response of the repaired The patient is then asked to exhibit the ability to ascend
menisci… For example: maintain weight bearing and ROM stairs, followed by the ability to descend stairs. After demon-
precautions after a complex meniscal repair procedure. strating the ability to eccentrically control body weight
descending stairs, the patient may initiate a running program.
Rule #2 Do not hurt the patient As muscle strength, balance, and flexibility demonstrate im-
provement, higher-level activities including agility-promoting,
Prescribe exercises and activities that are pain free. Gains in plyometric, and sport-specific activities are introduced as ther-
ROM, strength, and flexibility can best be achieved in this apeutic interventions
manner. Modifications can be made by adapting pain free Following meniscal repair, a designated protective phase
arcs of motion on strengthening equipment and functional will often hold back the patient from this natural progression.
Curr Rev Musculoskelet Med (2012) 5:46–58 51

The clinician and patient need to respect the restrictions so Gait evaluation (when applicable) can be useful in assessing the
designated to optimize outcome. patient’s biomechanical profile.
The clinical evaluation would not be complete without
defining goals and a treatment plan to meet these goals. The
Follow evaluation-based guidelines information gathered should be reviewed with the patient.
Realistic goals should be discussed and established by the
Today’s rehabilitation programs following meniscal repair patient, surgeon, and rehabilitation specialist. The patient
surgery should follow a plan that is not as structured as the should be brought to understand the magnitude of their
protocols of yesteryear. Each patient will progress at a surgery and the timetable for recovery. Goals should be
different pace. Protocols can accelerate a program too quickly specific to the individual needs of the patient. Goals should
for the patient whose progress is delayed and can hold back be functional and measurable as well. The patient should be
the patient who is progressing very well. Though certain made aware of his or her role in the rehabilitative process.
precautions are established, the rehabilitation specialist should Patient compliance with activity modifications and home
refrain from following a “cookbook” approach to treatment. therapeutic exercises is vital for complete rehabilitation
Instead, the clinician should combine basic scientific knowl- and a successful outcome [69].
edge and physical examination skills to guide the patient A treatment plan can only be developed when the clinical
through the rehabilitative course. Clinical guidelines devel- findings from a comprehensive examination are considered.
oped by treating clinicians and the referring surgeons should The rehabilitation specialist should develop a prioritized prob-
incorporate flexible time frames in the progression to allow for lem list. Specific rehabilitation strategies can then be used to
individualization, for example: “week 4–6 -discontinue address each problem. Examples include utilizing cryotherapy
crutches when non-antalgic gait is demonstrated” versus to control or decrease pain and joint effusion, and ROM
“week 6—discontinue crutches for ambulation.” Continual exercises to address a loss of knee flexion or extension.
reassessment of the patient is vital to ensure a consistent and Throughout the rehabilitative course a criteria-based functional
safe progression of the program. Too rapid a progression in progression of therapeutic exercises should be followed.
therapy or normal functional activities of daily living is dem-
onstrated by increased effusion and pain. This is most likely Treatment strategies after arthroscopic meniscal repair
related to muscular fatigue, which leaves the articular surfaces
unprotected against compressive forces. Therapeutic exercise The post-operative management of a meniscal repair takes
programs, therefore, often must be modified based on changes on a more conservative approach as compared to partial
in subjective and objective findings [76]. meniscectomy to allow for successful healing of the repair.
A comprehensive evaluation sets the baseline from which Rehabilitation guidelines differ among surgeons and remain
progress is measured. A comprehensive history reveals the controversial [77–84]. Discrepancies exist in the amount of
mechanism of injury, how the injury was initially managed, weight bearing and knee flexion allowed in the early post-
medical diagnosis including workup (radiographs, MRI operative time frame as well as the time frame for return to
scans, etc.), surgery date, and postsurgical management. sports activity. Barber reported no differences in healing
Observations document patient’s weight bearing status, gait rates between patients who followed a more conservative
deviations, joint effusion, muscle atrophy, and joint alignment. and protective program and patients who participated in a
Attention to the patient’s subjective complaints is of the utmost more accelerated program (weight bearing, ROM exercises,
importance throughout the rehabilitative process. Reports of and early return to sports activity) [77]. Kocabey [81]
pain (location and description), lack of mobility, and weakness reported excellent results utilizing rehabilitation guidelines
have a direct effect on the progression of a rehabilitation that were individualized depending on type/size of meniscal
program. The physical examination should document available repair. For Anterior Posterior (AP) longitudinal tears ≤3 cm
active (AROM) and passive range of motion (PROM). Girth weight bearing was unrestricted without a brace and ROM
measurements should be taken above, at, and below each knee progressively allowed to 125° of flexion at 3–6 weeks. For
joint for comparison to assess muscle atrophy AP longitudinal tears >3 cm weight bearing was unrestricted
Manual muscle testing may reveal a proximal or distal with a locked brace and 0–125° ROM limit lifted weeks 6–8.
weakness or muscle imbalance. Quadriceps testing is often Return to sport for AP tears allowed at 3 months. Complex
not appropriate in the immediate postoperative setting. Neuro- and Radial meniscus tear protocols restricted weight bearing
vascular integrity should be evaluated. Assessment of patellar and ROM with brace initially, but were FWB with AROM 0–
orientation and tracking where appropriate can provide valuable 125° by 6–8 weeks. Patient’s returned to sport by 4–5 months
information when quadriceps strengthening exercises are post-operatively. Bryant et al. allowed for FWB with crutches
implemented at a later date. Flexibility assessment is important, and brace locked in extension for 3 weeks post surgery
as tight muscles about one joint can alter forces at another joint. but then after allowed for WBAT and unlimited ROM with
52 Curr Rev Musculoskelet Med (2012) 5:46–58

comparable results [82]. O’Shea and Shellbourne also surgeons defer their patients from returning to pivoting sports
reported high rates of meniscal healing with rehabilitation until 4 or more months post-operatively.
programs that allowed for unrestricted ROM, weight bearing
beginning post-op day 3 meniscal repairs [83]. Noyes and Meniscal repair guidelines post—operative phase
Barber-Westin reported very good results in 76% of patients, I (week 0–6)
87% of which were asymptomatic at 33 months [84]. Weight
bearing was limited for initial 4–6 weeks depending on type of The rehabilitation guidelines following meniscal repair at
repair, and ROM progressively advanced to 135° of flexion our institution are divided into three phases and are outlined
over 6 week period. in Table 2. The first phase is designed to protect the repair
Programs should be individualized to the type of surgical and allow for maximal healing. Rehabilitation is initiated
procedure performed, the type of meniscal tear repaired and immediately post-operatively. The patient is placed in a
the basic science information that is currently available. double-upright knee brace that is locked in full extension.
Therefore, information from the surgeon regarding the classi- This brace is used exclusively for ambulation and sleeping
fication of the tear, the anatomic site of the repair (vascular vs. for the first 4–6 post-operative weeks. A progressive program
nonvascular) and location within the meniscus (anterior or of weight bearing as tolerated is initiated for bucket-handle
posterior) should directly affects the postoperative regimen. and vertical, longitudinal tears. Weight bearing will be limited
During weight bearing, compressive forces are loaded to toe-touch for radial or more complex repairs for 4–6 weeks
across the menisci. These tensile forces create hoop stresses as compressive loading may cause distraction of these repairs.
which expand the menisci in extension [85]. Morgan et al. Weight bearing with the knee in progressive flexion is avoided
demonstrated that extension appears to reduce the meniscus till 4–6 weeks as the meniscus is subjected to greater stress in
to the capsule, whereas flexion causes tears in the posterior this position [89].
horn to displace from the capsule [49]. Becker et al. have The patient is instructed in ROM exercises to attain full
reported that weight bearing flexion from full extension to extension and the recommended degree of flexion AAROM
90° increases the pressure on the posterior horn by, roughly, exercises are performed with flexion restricted to 90° during
a factor of 4 [86]. The compressive loads applied while the initial (4–6 week) protection phase. Repairs to the posterior
weight bearing in full extension following a vertical, horn are limited to 70° for the first 4 weeks, and then pro-
longitudinal repair or bucket-handle repair can reduce the gressed as tolerated. Active or resisted knee flexion is avoided
meniscus and stabilize the tear [65, 85]. In complete during this phase due to the attachment of the semimembra-
transactions of circumferential fiber bundles of the meniscus, nosus muscle on the medial meniscus and the popliteus muscle
such as radial tears that comprise the whole cross-section or on the lateral meniscus [94].
posterior root tears, weight bearing should be delayed because At 4–6 weeks post-operatively, the hinged brace is opened
the hoop stresses would distracts the tear margins and com- to 60° to allow for ROM during gait. Gait training using a pool
promise healing [87]. or underwater treadmill is utilized to unload the involved
The menisci translate dorsally with knee flexion. This extremity. Crutches are discharged when a non-antalgic gait
motion depends not only on the flexion angle but also on the is demonstrated. It is imperative that the prescribed weight
weight bearing condition [88]. Walker and Erkman demon- bearing status and ROM allowance be enforced during in the
strated that progressive knee flexion subjects the menisci to early phase of rehabilitation. These precautions need to be
greater stress [89]. Thompson et al. demonstrated that the reinforced continually to the patient to provide the optimal
meniscus translates posteriorly with flexion; however, menis- environment for meniscal healing.
cal movement was at a minimum at less than 60° of flexion Quadriceps re-education is addressed post-op day one with
[90]. Thus, consideration is given to limiting flexion to 60° the patient instructed to perform quadriceps setting exercises
during the early period of healing. with a rolled towel under their surgical knee. Electrical stim-
Tibial rotation causes large excursions of the meniscus ulation and/or biofeedback can be used should the patient
within the first 30° of flexion [91]. Terminal flexion is demonstrate quadriceps inhibition (Fig. 3).
accompanied by a large dorsal translation of the condyles Straight leg raising in multiple planes are encouraged for
and causes increased compressive stress of the meniscus the development of proximal strength. Weights (progressive
[86, 92]. Therefore, deep squats and tibial rotation are resistive exercise) are added to these exercises when tolerated
avoided in the early phases of rehabilitation following menis- along with exercise machines to further advance proximal
cal repair. strengthening.
There is evidence in a canine model that the maximum Research suggests that a certain level of deafferentation
tensile strength of meniscus repairs reaches 80% by 12 weeks, occurs after lower extremity joint injury [95]. As the central
which suggests that the suture/scar combination provides nervous system receives decreased sensory information,
enough stability for clinical function [93]. However, many there is decreased ability to adequately stabilize the lower
Curr Rev Musculoskelet Med (2012) 5:46–58 53

Table 2 Meniscus repair rehabilitation guidelines Table 2 (continued)

Meniscal Repair Guidelines Post – Operative Phase I (Week 0-6) Meniscal Repair Guidelines Post – Operative Phase I (Week 0-6)

Goals: • Avoid running and sport activity

• Emphasis on full passive extension Treatment Strategies:
• Control post-operative pain/swelling • Progressive Weight Bearing/WBAT with crutches/cane (brace
opened 0→60°), if good quadriceps control (good quad set/ability
• Range of Motion →90° flexion
to SLR without lag or pain)
• Regain quadriceps control
• Aquatic therapy – Pool ambulation or Underwater Treadmill
• Independence in home therapeutic exercise program
• D/C crutches/cane when gait is non-antalgic
Precautions:
• Brace changed to MD preference (Unloader brace,
• Avoid active knee flexion Patella sleeve, etc.)
• Avoid ambulation without brace locked @ 0° prior to 4 weeks • Active-assistive range of motion exercises
• Avoid prolonged standing/walking • Patella mobilization
Treatment Strategies: • SLR’s (all planes) with weights
• Towel extensions, prone hangs, etc. • Proximal progressive resisted exercises
• Quadriceps re-education (Quad Sets with EMS or EMG) • Neuromuscular training (Bilateral→Unilateral Support)
• Progressive Weight Bearing PWB→WBAT with brace locked o Balance Apparatus, Foam surface, Perturbations
at 0°with crutches
• Short Crank ergometry °→Standard ergometry (if knee ROM>115°)
o Toe-Touch Weight Bearing for complex or radial tears
• Leg Press (bilateral/eccentric/unilateral progression)
• Patella mobilization
• Squat program (PRE) 0°→60°
• ctive-Assisted flexion/extension 90→0° Exercise
• OKC quadriceps isotonics (pain-free arc of motion)
• SLR’s (all planes)
• Initiate Forward Step Up & Step Down programs
• Hip progressive resisted exercises
• Stairmaster
• Proprioception Board (bilateral weight bearing)
• Retrograde treadmill ambulation
• Aquatic therapy – Pool ambulation or Underwater
• Quadriceps stretching
Treadmill (Week 4-6)
• Eliptical Machine
• Short Crank ergometry (if ROM > 85°)
• Forward Step Down Test (NeuroCom)
• Leg Press (bilateral/60→0° arc) (if ROM > 85°)
• Upper extremity cardiovascular exercises as tolerated
• OKC quadriceps isometrics (submaximal/bilateral @ 60°)
(if ROM > 85°) • Cryotherapy
• Upper extremity cardiovascular exercises as tolerated • Emphasize patient compliance to home therapeutic exercise program
• Hamstring and calf stretching Criteria for Advancement:
• Cryotherapy • ROM to WNL
• Emphasize patient compliance to home therapeutic exercise program • Ability to descend 8”stairs with good leg control without pain
and weight bearing and Range of motion precautions/progression Meniscal Repair Guidelines Post – Operative Phase 3 (Week 14-22)
Criteria for Advancement: Goals:
• Ability to SLR without Quadriceps lag • Demonstrate ability to run pain free
• ROM 0→90° • Maximize strength and flexibility as to meet demands of activities
• Demonstrate ability to unilateral (involved extremity) weight of daily living
bear without pain • Hop Test>85% limb symmetry
Meniscal Repair Guidelines Post – Operative Phase 2 (Week 6-14) • Isokinetic test>85% limb symmetry
Goals: • Lack of apprehension with sport specific movements
• Restore Full ROM • Flexibility to accepted levels of sport performance
• Restore normal gait (non-antalgic) • Independence with gym program for maintenance and progression
• Demonstrate ability to ascend and descend 8”stairs with good of therapeutic exercise program at discharge
leg control without pain Precautions:
• Improve ADL endurance • Avoid pain with therapeutic exercise & functional activities
• Improve lower extremity flexibility • Avoid sport activity till adequate strength development
• Independence in home therapeutic exercise program and MD clearance
Precautions: Treatment Strategies:
• Avoid descending stairs reciprocally until adequate quadriceps • Progress Squat program<90° flexion
control & lower extremity alignment • Lunges
• Avoid pain with therapeutic exercise & functional activities • Retrograde treadmill running
54 Curr Rev Musculoskelet Med (2012) 5:46–58

Table 2 (continued)

Meniscal Repair Guidelines Post – Operative Phase I (Week 0-6)

• Start forward running (treadmill) program at 4 months post-op

if 8” step down satisfactory
• Continue LE strengthening & flexibility programs
• Agility program/sport specific (sport cord)
• Start plyometric program when sufficient strength base demonstrated
• Isotonic knee flexion/extension (pain & crepitus free arc)
• Isokinetic training (fast→moderate→slow velocities)
• Functional testing (Hop Test)
• Isokinetic Testing
• Home therapeutic exercise program: Evaluation based
Criteria for Advancement:
• Symptom-free running and sport-specific agility
• Hop Test>85% limb symmetry
• Isokinetic Test>85% limb symmetry
• Lack of apprehension with sport specific movements
• Flexibility to accepted levels of sport performance
• Independence with gym program for maintenance and progression of
therapeutic exercise program at discharge

© Hospital For Special Surgery Sports Rehabilitation & Performance

Center

extremity [95, 96]. Efforts to regain proprioception loss

begin as soon as the patient demonstrates the ability to bear
50% of their weight. A rocker board with bilateral support is
utilized starting in a sagital plane and is then progressed to a
more challenging coronal plane. A computerized balance Fig. 4 Dynamic stabilization training using Biodex Balance System
(Biodex Medical Systems, Shirley, NY).
platform can be utilized for patient feedback (Fig. 4).
As flexion ROM improves to greater than 85°, select OKC
and CKC exercises are introduced to the therapeutic exercise performed submaximally at 60° of flexion. Stationary bicycling
program. Bilateral leg press and mini-squats are performed is added to the rehabilitation program by utilizing a short crank
inside a 60°−0° arc of motion. Quadriceps isometrics are (90 mm) ergometer.
Hamstring and calf stretching exercises are added into both
formal and home therapeutic exercise programs. Cryotherapy
and electrical stimulation (TENS) may be utilized for pain
control. Home therapeutic exercise programs are continually
updated [97].

Meniscal repair guidelines post—operative

phase 2 (week 6–14)

The second post-operative phase following meniscal repair

is dedicated to restoring normal ROM to the involved knee
and improving muscle strength to the level needed to perform
activities of daily living.
The demonstration of a normal gait pattern is an early goal
of this phase. AAROM exercises are progressed as tolerated
with the goal of attaining full ROM by the end of this phase.
Fig. 3 Quadriceps setting utilizing Kneehab Electrical Stimulation As ROM improves to 110° → 115° cycling is advanced to a
Device (NeuroTech Biomedical Research, Galway, Ireland) standard 170 mm ergometer. Quadriceps stretching is added as
Curr Rev Musculoskelet Med (2012) 5:46–58 55

range of motion increases to greater than 120°. Leg press and balance systems training. As these activities are mastered,
exercise will progress to eccentric and eventually unilateral the rehabilitation specialist can incorporate less stable surfaces
training utilizing greater range of motion (<90°). A squat (foam rollers, rocker boards, etc.) as well as perturbation
program with progressive resistance is initiated utilizing a training to these activities to further enhance neuromuscular
physioball for support and comfort inside a 60°→ 0° arc of development.
motion. A forward step up program is begun on successive Attainment of ROM and muscle strength is crucial to
step heights (4”, 6”, 8”). Stairmaster and elliptical machine allow for a safe advancement through the rehabilitation
are incorporated as symptoms allow. Retrograde treadmill program. Reciprocally descending stairs, for example,
ambulation on progressive percentage inclines is utilized to should be avoided until a sufficient lower extremity strength
facilitate quadriceps strengthening. When full ROM and base is demonstrated. Pain while performing ROM and
improved quadriceps control is demonstrated OKC knee strengthening exercises is the best indicator in knowing
isotonic extension exercises are implemented inside a pain- when to modify treatment choices. Patellofemoral symptoms
free/crepitus-free arc of motion. Bilateral knee extensions should be continually monitored.
are initiated prior to unilateral exercise. The patient’s home therapeutic exercise program is contin-
A forward step down program is initiated on successive ually updated based evaluative findings and functional level.
height increments (4”, 6”, 8”). The functional strength goal at
the end of this phase is for the patient to demonstrate pain-free Meniscal Repair Guidelines Post—Operative
descent from an 8” step with adequate lower extremity control Phase 3 (Week 14–22)
without deviations (Fig. 5). At 14 weeks post-operatively a
Forward Step Down Test [98] is performed to assist in objec- The focus of the final phase of rehabilitation following
tively measuring functional lower extremity muscle strength. meniscal repair is directed at optimizing functional capabili-
The test entails having the patient step down from an 8” step ties and preparing the patient/athlete for a safe return to sport
onto a forceplate as slowly and controlled as possible with activities.
each leg. Lower extremity control is observed for deviations. At 4 months post-operatively, given symmetrical ROM
Mean impact and limb comparison are calculated and com- and demonstrated quadriceps control, a running program on
pared to the established norms of 10% body weight and 85% a treadmill is initiated. Retrograde running is preceded by
symmetry, respectively. forward running. An initial emphasis on speed over shorter
Neuromuscular training is advanced to include unilateral distances vs. slower distance running is recommended.
balance activities, such as contralateral elastic band exercises Lower extremity strengthening and flexibility programs are
continued. Advanced strengthening activities including
isokinetic and plyometric training are introduced. Plyometric
training should follow a functional sequence with the compo-
nents of speed, intensity, load, volume and frequency being
monitored and progressed accordingly. Activities begin with
simple drills and advance to more complex exercises (e.g.
double leg jumping vs. box drills). Agility exercises are intro-
duced with the demands of the individual’s sport taken into
consideration, e.g. deceleration, cutting, sprinting. The reha-
bilitation specialist should be certain to observe any appre-
hension during the agility activity progression.
To quantify strength and power both isokinetic and func-
tional testing are performed. The goals of isokinetic testing
include a less than 15% deficit for quadriceps and hamstring
average peak torque and total work at test velocities of 180°
and 300°/s. Functional testing links specific components of
function and the actual task and provides direct evidence to
prove functional status. Single-leg hop test [99] and cross-
over hop test [100] are performed with the goal of achieving
an 85% limb symmetry score.
The results of these tests along with any other pertinent
clinical findings including the lack of apprehension with sport
Fig. 5 Forward step-down from an 8” step, demonstrating quadriceps specific movements are presented to the referring orthopaedic
control in the post-surgical extremity surgeon for the final determination of sports participation [88].
56 Curr Rev Musculoskelet Med (2012) 5:46–58

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joint with special reference to the role of the menisci, part II.
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The rehabilitation specialist should consider each patient as Joint Surgery Am. 1982;64A(6):883–8.
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