INTRODUCTION

The knee joint has a structure made of cartilage, which is called

the meniscus or meniscal cartilage. The menisci are the shock-

absorbers of the knee - wedged horizontally in between the femur and

the tibia. They fill in the in congruency between the rounded ends of

the femur bone and the flattened ends of the tibia bone upon which the

femur sits.

Menisci are squeezed between the rounded ends of the femur

(the femoral condyles or rounded ends of the thigh bone) and the flat

upper surface of the tibia (the tibial plateau or upper surface of the

shinbone) - so they are difficult to see, and hard to explore.

A torn meniscus is a disruption of the fibrocartilage pads located

between the femoral condyles and the tibial plateaus. The medial and

lateral meniscus provides shock absorption and plays a role in joint

lubrication.

Meniscal injuries are the most common surgically treated knee

injury. Reported rates of meniscal injury are approximately 70 per one

lakh (according to US Statistical Data). Men are affected more than

women. Meniscal injuries can occur in all age groups. In older patients

tears are predominantly degenerated and are commonly caused by

activities of daily living, squatting or activities involving deep flexion. In

younger patients up to 1/3rd of meniscal tears are sports related and

are primarily caused by twisting or cutting movements, hyperflexion or

trauma. In all sports with the exception of wrestling, tears of the medial

meniscus occur more often than tears of the lateral meniscus.

Meniscal injuries often occur in knee pathology, although with

different etiologies. Such injuries may occur (i) as part of a rotational

trauma, (ii) due to bending, as a result of progression of a degenerative

process, or (iii) as a spontaneous injury caused by fatigue.

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The different etiologies converge into the same symptomatology,

with similar clinical manifestations and treatments, although different

therapeutic results are expected. When associated with the instability

of the knee or with arthrosis at an advanced stage, meniscal injury is

analyzed as a function of the major pathology.

The physiotherapy management of meniscal injuries involves

shifting the focus of case towards increasing activity tolerance,

prevention of recurrence apart from treating the pain alone.

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DEFINITION

Injuries to the crescent-shaped cartilage pads between the two

joints formed by the femur (the thigh bone) and the tibia (the shin

bone). The meniscus acts as a smooth surface for the joint to move on.

The two menisci are easily injured by the force of rotating the

knee while bearing weight. A partial or total tear of a meniscus may

occur when a person quickly twists or rotates the upper leg while the

foot stays still (for example, when dribbling a basketball around an

opponent or turning to hit a tennis ball). If the tear is tiny, the meniscus

stays connected to the front and back of the knee; if the tear is large,

the meniscus may be left hanging by a thread of cartilage. The

seriousness of a tear depends on its location and extent.

Types

The pattern of meniscus tear is important because it will

determine the type of treatment receive (some tears will heal on their

own, some can be treated surgically and some can't be fixed). Tears

come in many shapes and sizes however there are 3 basic shapes for

all meniscal tears: longitudinal, horizontal and radial. If these tears are

not treated, they may become more damaged and develop a displaced

tear (moving flap of meniscus). Complex tears are a combination of

these basic shapes and include more than one pattern.

A Longitudinal meniscus tear (circumferential tear)

extends along the length of meniscus and does not go all the way

through. This tear divides meniscus into an inner and outer section;

however the tear generally never touches the rim of the meniscus. It

tends to be more medial than lateral, and results from repeated

movements. It generally starts as a partial tear in the posterior horn,

which can sometimes heal on its own. However if it doesn't heal

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properly it can lead to a displaced longitudinal tear, known as a

displaced

Bucket Handle tear. This is a complete tear that goes all the

way through and is located near the inner rim of medial meniscus; it is

often associated with a radial tear. This tear accounts for 10% of all

meniscus tears, and causes the knee to lock in flexion. It is seen most

often in young athletes, and happens in conjunction with 50% of ACL

injuries.

A Horizontal meniscus tear (cleavage tear) starts as a

horizontal split deep in the meniscus. This tear divides the meniscus

into a top and bottom section (like a sliced bun). It is often not visible,

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and moves from the posterior horn or mid section to the inside of the

meniscus. This tear is rare and often starts after a minor injury from

rotation in the knee or degeneration. It occurs frequently in the lateral

meniscus; however it is noted in both menisci. A displaced.

Horizontal Flap tear can develop if the tear is overlooked or

left alone. This type of tear is horizontal on the surface of the meniscus

and creates a flap that flicks when the knee moves. It is a result of a

strong force that tears the meniscus from the inner rim; it can easily

become a complex tear. If this tear extends from the apex of the

meniscus to the outer rim, one may develop a meniscal cyst (a mass

that develops from a collection of synovial fluid along the outside rim of

the meniscus).

A Radial split meniscus tear (free-edge transverse tear)

starts as a sharp split along the inner edge of the meniscus and

eventually runs part way or all the way through the meniscus, dividing

it into a front and back section (across the middle body instead of down

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the length). This tear generally occurs between the posterior horn and

middle section and is seen frequently in the lateral meniscus. A small

tear is difficult to notice, but when it grows and becomes a complete

tear it will open up and look like a part is missing. This is called a

Parrot's Beak tear (displaced radial tear with a curved inner portion).

It generally occurs in the thicker portion of the lateral meniscus. As it

gets larger, it will catch or lock more frequently, and prevent the

meniscus from protecting the cartilage during weight bearing. This tear

is a result of a traumatic event or forceful and repetitive stress

activities; it is often associated with other injuries. Young athletes tend

to suffer from combination tears called radial/parrot beak tears (the

meniscus splits in 2 directions).

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ANATOMY

Although the knee joint may look like a simple joint, it is one of

the most complex. Moreover, the knee is more likely to be injured than

is any other joint in the body. We tend to ignore our knees until

something happens to them that causes pain. As the saying goes,

however, "an ounce of prevention is worth a pound of cure."

The knee is essentially made up of four bones. The femur, which

is the large bone in thigh, attaches by ligaments and a capsule to

tibia. Just below and next to the tibia is the fibula, which runs parallel

to the tibia. The patella, or what we call the knee cap, rides on the

knee joint as the knee bends.

When the knee moves, it does not just bend and straighten, or,

as it is medically termed, flex and extend. There is also a slight

rotational component in this motion. This component was recognized

only within the last 50 years, which may be part of the reason people

have so many unknown injuries. The knee muscles which go across the

knee joint are the quadriceps and the hamstrings. The quadriceps

muscles are on the front of the knee, and the hamstrings are on the

back of the knee. The ligaments are equally important in the knee joint

because they hold the joint together.

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The knee joint also has a structure made of cartilage, which is

called the meniscus or meniscal cartilage. The meniscus is a C-shaped

piece of tissue which fits into the joint between the tibia and the femur.

It helps to protect the joint and allows the bones to slide freely on each

other. There is also a bursa around the knee joint. A bursa is a little

fluid sac that helps the muscles and tendons slide freely as the knee

moves.

To function well, a person needs to have strong and flexible

muscles. In addition, the meniscal cartilage, articular cartilage and

ligaments must be smooth and strong. Problems occur when any of

these parts of the knee joint are damaged or irritated.

The medial meniscus is semicircular and attached to the medial

collateral ligament (medial collateral ligament) of the knee joint. It only

moves 2-5 mm within the joint and is hence more prone to tears than

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the lateral meniscus which is more circular in shape and moves 9-

11mm.

The lateral meniscus is often injured at the same time as the

Anterior Cruciate Ligament (ACL), whereas the medial meniscus is itself

more prone to tears in the chronically 'ACL deficient' knee Bucket

Handle Meniscus Tear.

Blood supply

The blood supply to the menisci is limited to their peripheries.

The medial and lateral geniculate arteries anastomose into a

parameniscal capillary plexus supplying the synovial and capsular

tissues of the knee joint. The vascular penetration through this

capsular attachment is limited to 10-25% of the peripheral widths of

the medial and lateral meniscal rims. In 1990, Renstrom and Johnson

reported a 20% decrease in the vascular supply by age 40 years, which

may be attributed to weight bearing over time.

The presence of a vascular supply to the menisci is an essential

component in the potential for repair. The blood supply must be able to

support the inflammatory response normally seen in wound healing.

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Arnoczky, in 1982, proposed a classification system that categorizes

lesions in relation to the meniscal vascular supply.

An injury resulting in lesions within the blood-rich periphery is

called a red-red tear. Both sides of the tear are in tissue with a

functional blood supply, a situation that promotes healing.

A tear encompassing the peripheral rim and central portion is

called a red-white tear. In this situation, one end of the lesion is

in tissue with good blood supply, while the opposite end is in the

avascular section.

A white-white tear is a lesion located exclusively in the avascular

central portion; the prognosis for healing in such a tear is

unfavorable.

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BIOMECHANICS

The menisci provide several integral elements to knee function.

These include load transmission, shock absorption, joint lubrication,

and joint nutrition, distribution of load, amount of contact force and

stability.

The menisci act as a structural transition zone between the

femoral condyles and tibial plateau. As such, they increase the

congruence between the condyles and the plateau. The menisci appear

to transmit approximately 50% of the compressive load through a

range of motion of 0 to 90 degrees. The contact area is increased,

protecting articular cartilage from high concentrations of stress. The

circumferential collagen fiber orientation within the meniscus is

uniquely suited to this capacity. As load is applied, the menisci will

tend to extrude from between the articular surfaces of the femur and

tibia. In order to resist this tendency, circumferential tension is

developed along the collagen fibers of the meniscus as hoop stresses.

The circumferential continuity of the peripheral rim of the meniscus is

integral to meniscal function.

The menisci follow the motion of the femoral condyle during knee

flexion and extension. During extension, the femoral condyles exert a

compressive force displacing the menisci antero posteriorly. As the

knee moves into flexion, the condlyes roll back ward onto the tibial

plateau. The menisci deform medial laterally, maintaining joint

congruity and maximal contact area. As the knee flexes, the femur

externally rotates on the tibia, and the medial meniscus is pulled

forward.

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AETIOLOGY

All the knee injuries are more common in women than men, men

experience more meniscus injuries and tears (ratio 2.5:1 (Male :

Female)) this is belief to be due to men’s participation in more

aggressive sports and manual activities. The peak incidence of

meniscal injuries for males is between 31 – 40 years whereas for

females peak incidence is in between 11 - 20 years.

The two most common causes of meniscus injuries are acute

trauma to the knee and degeneration of the knee joint.

Occupations such as mining or carpet laying (squat position), or

participation in contact sports or repetitive stress activities (such as

running and skiing) or prone to meniscus injuries.

Acute or traumatic meniscus damage:

It can result from forceful rotating of a straight or bent knee while

foot is firmly planted and bearing weight, or from hyperflexion or hyper

extension of knee. These injuries are experienced most frequently in

activities such as Rugby, football, baseball, soccer, basketball when

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one twist or pivot on the knee, or slow down too quickly. The result will

generally be a partial complete medical meniscus tear. This type of

tear generally affects athletes or those under 40 years of age.

A medial meniscus tear will frequently occur along with other

injuries such as MCL or ACL tear. The combined injuries are seen most

often in contact sports, when an athlete gets hit on the outside of a

bend knee.

A lateral meniscus tear will result more often from a knee i.e..,

bent excessively and experiences full weight bearing, while the thigh

bone is turning outward: seen in sports such as skiing. It can also be

injured in collisions that involve deep knee bends.

Degeneration of the knee joint

It involves weakening of tissues with age, which results from

small repetitive movements such as squatting or pivoting positions,. Or

a minor meniscus injury that never healed properly. In the younger

people meniscus is very flexible and pliable (like a new rubber tire) as

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they get older it becomes less flexible and more brittle, it also develops

cracks in it (like those seen in an aged car tire).

Articular cartilage and meniscus detoriate as age advances,

which can eventually lead to a degenerative tear without any major

trauma. There will be a 20 percent decrease in blood supply to menisci

by age 40 due to weight bearing over time; this inhibits body’s ability

to heal itself. This wear and tear over the years may lead to an

osteoarthritis condition. Approximately 60 percent of people over 65

years of age experience some form of degenerative meniscus tear.

A Discoid meniscus occurs when are born with a more flat, disc

shaped meniscus rather than a crescent shaped, wedge meniscus. It is

generally found in the lateral meniscus and in kids less than 11 years

of age. The symptoms associated with a discoid meniscus can range

from very mild to continuous clicking, snapping, buckling and locking of

the knee joint, decreased range of motion, joint pain and tenderness,

and atrophied quadriceps (muscles wasting away). The meniscus will

often change to a C-shape with maturity and Kids/teens will grow out of

their symptoms; however failure of normal development can be

experienced.

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PATHOPHYSIOLOGY

There are two different mechanisms for tearing a meniscus.

Meniscal tears are common and can be traumatic or

degenerative. Traumatic tears occur classically during twisting forces

on the knee in young active people, are often vertical longitudinal tears

and can be associated with ligamentous injuries. Degenerative tears

occur as part of progressive wear in the whole joint, most frequently in

the over 40's. These tears are usually horizontal cleavage tears or flaps

and have minimal healing capacity. Tears can be described as being

complete or incomplete, stable or unstable and of various patterns.

Traumatic tears result from a sudden load being applied to

the meniscal tissue which is severe enough to cause the meniscal

cartilage to fail and let go. These usually occur from a twisting injury

or a blow to the side of the knee that causes the meniscus to be

levered against and compressed. A football clipping injury or a fall

backwards onto the heel with rotation of the lower leg are common

examples of this injury pattern. In a person under 30 years of age this

typically requires a fairly violent injury although any age group can

sustain a traumatic tear.

Degenerative meniscal tears are best thought of as a failure

of the meniscus over time. There is a natural drying-out of the inner

center of the meniscus that can begin in the late 20's and progresses

with age. The meniscus becomes less elastic and compliant and as a

result may fail with only minimal trauma (such as just getting down

into a squat). Sometimes there are no memorable injuries or violent

events which can be blamed as the cause of the tear. The association

of these tears with aging makes degenerative tears in a teenager

almost unheard of.

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CLINICAL FEATURES

The list of signs and symptoms mentioned in various sources for

Meniscus injury includes the 6 symptoms listed below:

Knee pain

Pain straightening knee

Knee swelling

Knee locking

Knee clicking

Knee weakness

Generally, when people injure a meniscus, they feel some pain,

particularly when the knee is straightened. If the pain is mild, the

person may continue moving. Severe pain may occur if a fragment of

the meniscus catches between the femur and the tibia.

Swelling may occur soon after injury if blood vessels are

disrupted, or swelling may occur several hours later if the joint fills with

fluid produced by the joint lining (synovium) as a result of

inflammation. If the synovium is injured, it may become inflamed and

produce fluid to protect itself. This makes the knee swell.

Sometimes, an injury that occurred in the past but was not

treated becomes painful months or years later, particularly if the knee

is injured a second time. After any injury, the knee may click, lock, or

feel weak. Although symptoms of meniscal injury may disappear on

their own, they frequently persist or return and require treatment.

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INVESTIGATIONS

Radiological Examination

Most Common Meniscus Injury Diagnostic Tests

A medical professional will sometimes recommend diagnostic

testing to obtain more detailed information, and assess the amount

and/or type of damage done to the knee and meniscus. There are a

variety of different tests available to help them analyze the situation;

however these will be dependent on injury.

X – rays

X-rays will provide an image of the overall structure of the knee.

It is helpful in identifying abnormal bone shapes, fractures, arthritis,

and degeneration (wear and tear) on the joint. It can identify a discoid

meniscus, or loose bones and bone abnormalities that may mimic a

torn meniscus.

MRI

MRI is the most powerful, accurate, and noninvasive method for

diagnosing meniscal tears. It is more accurate than physical

examination and has influenced clinical practice and patient care

by eliminating unnecessary diagnostic arthroscopies or by identifying

alternative diagnosis that may mimic meniscal tears.

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When combined with clinical data, such as the patient's age,

athletic requirements, and physical findings (e.g, possible associated

ligamentous injuries), a treatment plan may be developed by assessing

the need for and timing of surgery and by determining the type of

surgery (meniscal debridement, rasping, repair, partial or total

resection, or meniscal transplantation). MRI may be used to identify

other injuries, such as ligament tears, especially ACL tears, the

presence of which may also influence the decision whether to

perform surgery.

With MRI, physicians may obtain images in several planes,

providing multiple perspectives on meniscal and ligamentous injuries.

Other advantages include the following:

with MRI, the patient is not exposed to ionizing radiation;

MRI does not normally involve the intravenous

administration of contrast material, the use of which is

associated with a small but definite number of adverse

effects;

MRI does not require joint manipulation;

MRI is painless and can be performed in less than 35

minutes; and

MRI does not require the intra-articular injection of

iodinated radiographic contrast material, which is needed

for arthrography. MRI results lead to alterations in therapy

in about one third of cases

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Plain radiography

Plain radiography is extremely limited in the assessment of

meniscal tears. Radiographs may be obtained to rule out unsuspected

lesions, such as osteochondritis desiccans and loose bodies.

In the presence of a DM, radiographs may show widening of the

medial or lateral joint compartments; hypoplasia of the lateral femoral

condyle related to the increased size of the LM; a high fibular head;

cupping of the lateral tibial plateau; or a squared-off lateral femoral

condyle.

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CT Scan

CT or CAT scans (computerized tomography) will be used to

provide a more thorough, 3-dimensional assessment of the bones and

soft tissues in and around the knee joint.

Further diagnostic tests such as an ultrasound, electromyogram,

or arthroscopic surgery can be used to determine the degree and

location of the injury if required.

Physical Examination

A complete examination, including that of the lower spine, ipsilateral

hip and thigh, patellofemoral joint, and tibiofemoral joint, is essential

when evaluating knee pain. Associated findings such as a perimeniscal

cyst or ligamentous laxity suggest a higher likelihood of a meniscus

injury. Important findings when examining a patient with a possible

meniscus injury include the following:

Joint line tenderness

Joint line tenderness is an accurate clinical sign.10 This

finding indicates injury in 77-86% of patients with meniscus

tears. Despite the high predictive value, operative findings

occasionally differ from the preoperative assessment.

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Assess joint lines for palpable pain the location of the

tenderness is not a sure sign for the type of lesion.

Effusion

Effusion occurs in approximately 50% of the patients

presenting with a meniscus tear.

The presence of an effusion is suggestive of a peripheral

tear in the vascular or red zone (especially when acute), an

associated intra-articular injury, or synovitis.

To assess effusion perform the fluid shift test and evaluate

for the presence of the fluctuation sign. The amount of

effusion doesn’t indicate the presence or absence of a

meniscal lesion.

Range of motion

The patient may have difficulty extending the knee fully if a

meniscal tear blocks the motion.

Full flexion, as in squatting, may be painful or impossible

because of a tear.

Assess the gait pattern looking for deviations or

compensatory movements.

Restricted motion caused by pain or swelling is also

common.

Girth measurement

Girth measurement allow for a general assessment of

effusion and atrophy.

Swelling within the knee joint is measured grossly by a

girth measurement taken at the joint line.

Measurements taken at five Centimetre and 20 centimetre

proximal to the base of the patella and 15 centimetre distal

to the apex of the patella can provide and indirect

indication of atrophy in the VMO segment, Quadriceps

femoris muscle and calf muscles respectively.

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SPECIAL TESTS

Tests: Perform stability tests for anterior, posterior, and varus-valgus

motion to rule out additional involvement of soft tissue. Several special

tests may be used to assess meniscal involvement. A positive result of

any test does not by itself establish the presence of a meniscal lesion,

but, along with the other objective findings, such a test result can help

differentiate a meniscal tear from other possible knee injuries.

McMurray test

This test indicates tears of the middle or posterior

horn of the meniscus.

With the patient supine and the hip and knee fully

flexed, apply a valgus force and externally rotate the

tibia while extending the knee. An audible or

palpable pop or snap indicates a medial meniscal

tear.

Lesions of the lateral meniscus are tested by

applying a varus force and internally rotating the

tibia during knee extension. The snap is produced as

the torn fragment rides over the femoral condyle

during extension.

A snap in extreme flexion is indicative of a posterior

horn tear; a click at 90° of flexion indicates a lesion in

the middle section of the meniscus.

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Apley test

This test is used to distinguish between meniscal and

ligamentous involvement.

With the patient in a prone position, the knee flexed

at 90°, and the leg stabilized by the examiner's knee,

distract the knee while rotating the tibia internally

and externally. Pain during this maneuver indicates

ligamentous involvement.

Then, compress the knee while internally and

externally rotating the tibia again. Pain during this

maneuver indicates a meniscal tear.

Bragard sign

This test may be used if anterior joint-line point

tenderness is present.

To test for a medial lesion, the examiner extends and

externally rotates the tibia, which displaces a

meniscal lesion forward, if one exists. Palpable

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tenderness along the anterior medial joint line is

reduced with flexion and internal rotation.

Bounce home test

The patient is supine with his or her heel cupped in

the examiner's hand.

The examiner fully flexes the knee and then

passively extends the knee. If the knee does not

reach complete extension or has a rubbery or springy

end feel, the knee movement may be blocked by a

torn meniscus.

Childress test

Instruct the patient to squat with the knee fully

flexed and attempt to "duck walk."

If the motion is blocked, a meniscal lesion is

indicated; however, pain in this position may indicate

a meniscal tear or patellofemoral joint involvement.

Merkel sign

Instruct the patient to stand with his or her knees

extended and to rotate the trunk. This movement

causes compression of the menisci.

Medial compartment pain during internal rotation of

the tibia indicates a medial meniscal lesion. Lateral

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compartment pain occurring during external rotation

of the tibia indicates a lateral meniscal lesion.

Modified Helfer test

While the patient is sitting on the edge of a table with

the knee flexed 90°, instruct him or her to extend the

knee.

If knee mechanics are within normal limits, the tibial

tuberosity can be seen in line with the midline of the

patella in full flexion; during extension, the tibia

rotates and the tibial tubercle moves into line with

the lateral border of the patella.

Failure of the tibia to rotate during extension

indicates a meniscal lesion or cruciate ligament

involvement.

O'Donoghue test

With the patient prone, the examiner flexes the knee

90°. The examiner rotates the tibia internally and

externally twice, then fully extends the knee and

repeats the rotations.

Increased pain during rotation in either or both knee

positions indicates a meniscal tear or joint capsule

irritation.

With a valgus force to a flexed and laterally rotated

knee, the medial meniscus, medial collateral

ligament (MCL), and the ACL all may be injured,

representing the O'Donoghue triad.

Payr sign

With the patient sitting cross-legged, the examiner

exerts downward pressure along the medial aspect of

the knee.

Medial knee pain indicates a posterior horn lesion of

the medial meniscus.

First Steinmann sign

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With the patient supine and the knee and hip flexed

at 90°, the examiner forcefully and quickly rotates

the tibia internally and externally.

Pain in the lateral compartment with forced internal

rotation indicates a lateral meniscus lesion. Medial

compartment pain during forced external rotation

indicates a lesion of the medial meniscus.

Second Steinmann sign

This test is indicated when point tenderness is

located along the anterior joint line.

When the examiner moves the knee from extension

into flexion, the meniscus is displaced posteriorly,

along with its lesions. The point of tenderness also

shifts posteriorly toward the collateral ligament.

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DIFFERENTIAL DIAGNOSIS

Anterior Cruciate Ligament Injury : An ACL tear is a common

injury that occurs in all types of sports. This injury usually occurs

during a sudden cut or deceleration, as it typically is a non

contact injury.

Posterior Cruciate Ligament Injury : Posterior cruciate

ligament (PCL) injuries are usually the result of a direct blow to

the anterior part of the tibia, with a hyperextension moment at

the knee.

Knee osteochondritis dissecans

Lumbosacral radiculopathy

Osteoarthritis : Osteoarthritis (OA, also known as degenerative

arthritis, degenerative joint disease), is a group of diseases and

mechanical abnormalities involving degradation of joints,[1]

including articular cartilage and the subchondral bone next to it.

The patient increasingly experiences pain upon weight

bearing, including walking and standing. As a result of decreased

movement because of the pain, regional muscles may atrophy,

and ligaments may become more lax.

Patellofemoral joint dysfunction

Rheumatoid arthritis

Tendon inflammation (tendinitis)

Tibial tubercle avulsion fracture

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GENERAL PHYSIOTHERAPY ASSESSMENT OF MENISCAL INJURIES

The aims of Assessment

To elicitate what is preventing the patient from moving in the

normal way, in order to plan the treatment.

Making frequent reviews possible, so that the treatment can be

altered if necessary.

Recording the patient’s condition accurately for future

therapeutic of statistical purposes.

Subjective Assessment:

Name :

Age :

Sex :

Occupation :

Address :

Date of Assessment :

Chief Complaints of patients:

Difficulty in Straightening the knee.

Difficulty in running and long walking.

Pain during walking.

Weakness of knee

Swelling of knee

Difficulty in twisting the knee joint.

Difficulty in Squatting

History of present illness

Onset - Gradual

Duration

Progression

Treatment taken

Associated Problems

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Diabetes

Hypertension

Any injury to the joint

Any infection to the joint

Past Medical History

History of joint injury

Diabetes mellitus

Hypertension

Present Medical History

Personal History

Smoker

Exercise habits

Alcoholic

Diet

Sedentary or active life style

Social History

Socio economic status

Type of job and nature of job

Steps / Ramp / Lift

Pain Assessment

Site of pain

Side of pain

Type of pain

Frequency of pain

Aggravating factor

Relieving factor

Objective Assessment

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Vital Sign

B.P.

Temperature

Respiratory rate

Pulse rate

All normal or may be some variation

Observative findings

Built of the patient

Posture of patient

Attitude of limb – Slight flexion of knee

Quadriceps Atrophy

Gait

On Examination

On palpation

Swelling

Warmth

Bony Contour

Pain

Muscle wasting

Effusion

Crepitus

Motor Examination

In Acute - Normal

In Chronic – Tone – Quadriceps – Flaccid.

Sensory Assessment

May be normal

Range of motion is decreased

It is of less significant as no neural involvement

Postural Examination

Normal or Varied

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Gait Examination

Investigations

X – Ray

MRI

Suggested Diagnosis

Meniscal injury

.Range of motion

Decreased

Muscle Power

Acute – Decreased

Chronic – Quadriceps weakness

Medical Research counseling

0- No Contraction

1- Flicker of contraction

2- Full range of motion in elimination of gravity

3- Full range of motion against gravity

4- Full range of motion against gravity with

mild resistance

5- Full range of motion against gravity with

maximum resistance

Reflex Examination

Normal or reduced (Knee jerk ) due to

Quadriceps weakness

Reflex is of less significance as there is no

nerve involvement

Problem List

Pain

Swelling

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Tenderness

Difficulty to Squat

Decreased range of motion

Weakness of muscle

Difficult to climb stair

Treatment Goals

Short term goals

To Reduce pain

To reduce tenderness

To reduce swelling

Long term goals

To increase the joint range of motion

To increase the strength of muscle

Make the patient to walk independently

Prognosis

Moderate or Good

Follow up care

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MANAGEMENT OF MENISCAL INJURY

Non Surgical Management of Meniscal injury

An acute meniscus tear can be treated with ice application, rest,

anti-inflammatory medications, and physical therapy. These simple

measures will help decrease swelling and pain in the joint.

RICE The RICE protocol is effective for most sports-related

injuries. RICE stands for Rest, Ice, Compression, and Elevation.

Rest. Take a break from the activity that caused the injury. The

doctor may recommend that one use crutches to avoid putting

weight on the leg.

Ice. Use cold packs for 20 minutes at a time, several times a day.

Do not apply ice directly to the skin.

Compression. To prevent additional swelling and blood loss,

wear an elastic compression bandage.

Elevation. To reduce swelling, recline when rest, and put the leg

up higher than heart.

Ultrasound therapy is a great therapeutic option to decrease

pain, inflammation and soft tissue (muscle, ligament, tendon,

connective and nerve tissue) damage experienced with a meniscus or

knee injury. This can be received using a portable, home ultrasound

device (self-administered) or by seeing a physiotherapist. The

treatment is safe, easy, painless, and generally requires between 5 10

minutes.

It is based on a form of deep tissue therapy, which is generated

through high frequency sound waves (that we can not hear). These

waves send vibrations deep into body and raise the temperature of soft

tissue. The waves are delivered through a hand held transducer and

medicinal conductive gel that are used together in a slow, circular

motion on skin over the injured area. Patient may experience a slight

35

tingling or warm sensation during the process as a result of the gel;

this enhances the therapeutic effects of ultrasound (Phonophoresis).

Ultrasound therapy increases collagen and tissue elasticity, which

in turn promotes circulation (blood flow) and brings oxygen and

nutrients to injured knee area. This cleans tissue by getting rid of cell

waste products and allows meniscus injury to heal correctly. If not

treated properly injured tissue can heal with a weakened state, which

can lead to scar tissue or calcification.

If used on an ongoing basis, ultrasound will help to improve range

of motion by breaking down any scar tissue that may form in the knee

area. Ultrasound waves penetrate deep into tissues, relax muscles,

decrease chronic inflammation and accelerate recovery rate, so one

can return to daily activities as soon as possible.

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.

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities.

Their mechanism of action is not known, but they may inhibit

36

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.

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.

Diclofenac (Voltaren, Cataflam)

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.

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. Seek lowest dose of

celecoxib for each patient.

Depending on the size and type of the meniscus tear, and the

physical demands of the patient, these may be the only treatments

necessary. A cortisone injection can be a helpful treatment to reduce

inflammation within the joint, but it will not help heal the meniscus

37

tear. If these treatments fail to provide relief, a surgical procedure may

be recommended.

Surgical Management of Meniscal Tear

When Surgery is Necessary

If meniscus tear symptoms are not significant, surgery can often

be delayed or avoided altogether. Many people live normal, active

lifestyles despite having a meniscus tear. It is only when the meniscus

tear becomes symptomatic, and interferes with activities, that surgery

to treat the meniscus tear should be considered.

Surgery has the best results when the primary symptoms of the

meniscus tear are mechanical. This means that the meniscus tear is

causing a catching or locking sensation of the knee.

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 Intraoperatively, a decision has to be

made whether to repair, excise, or leave the tear in the meniscus

alone.

Arthroscopic Meniscectomy for Meniscus Tears:

A meniscectomy is a procedure to remove the torn portion of the

meniscus. This procedure is far more commonly performed than a

meniscus repair. The meniscectomy is done to remove the damaged

portion of meniscus, while leaving as much healthy meniscus as

possible. The meniscectomy usually has a quick recovery, and allows

for rapid resumption of activities.

38

Arthroscopic probing of a posterior horn complex meniscal tear with multiple flaps.

Arthroscopic view of medial meniscus after excision of flap tear.

Meniscus Repair

In some situations, surgeon may offer a meniscus repair as a

possible surgery for damaged or torn cartilage. Years ago, if a patient

had torn cartilage, and surgery was necessary, the entire meniscus

39

was removed. These patients actually did quite well after the surgery.

The problem was that over time, the cartilage on the ends of the bone

was worn away more quickly. This is thought to be due to the loss of

the cushioning effect and the diminished stability of the joint that is

seen after a meniscus is removed.

When arthroscopic surgery became more popular, more surgeons

performed partial menisectomies. A partial meniscectomy is performed

to remove only the torn segment of the meniscus. This works very well

over the short and long term if the meniscus tear is relatively small.

But for some large meniscus tears, a sufficient portion of the meniscus

is removed such that problems can again creep up down the road.

How is the meniscus repair performed?

Techniques of meniscus repair include using arthroscopically

placed tacks or suturing the torn edges. Both procedures function by

reapproximating the torn edges of the meniscus to allow them to heal

in their proper place and not get caught in the knee causing the

symptoms.

Meniscus Transplantation

Meniscus transplantation consists of placing the meniscus from a

donor patient into an individual who has had their meniscus removed.

The ideal patient for a meniscus transplant is someone who had their

meniscus removed, and subsequently begins to develop knee pain.

Meniscus transplant is not performed for an acute meniscus tear,

rather it is performed when removal of the entire meniscus has caused

persistent pain in the knee.

40

Physiotherapy Management

A meniscus tear is a common knee joint injury. The knee will heal

and whether surgery will be needed depends in large part on the type

of tear and how bad the tear is.

Rehabilitation Program

A rehabilitation program helps to regain as much strength and

flexibility in knee as possible. Rehabilitation program probably will

include physical therapy and home exercises.

The goals of rehabilitation are to restore range of motion,

strength, and endurance of the knee. A rehabilitation program usually

includes treatment with a physical therapist at a therapy center and

home treatment in home or at a gym or health club. Physical therapist

will design a program that guides through exercises to reach these

goals on a schedule that takes into account health status, age, and

activity expectations.

Recovery from a meniscus tear depends on many factors. If the

tear is minor and symptoms go away, doctor may recommend a set of

exercises to increase flexibility and strength.

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 Ultrasound. As needed, the patient should

perform flexibility exercises for the lower extremity musculature,

41

including the hamstrings, quadriceps femoris, hip flexors, hip

adductors, and calf muscles.

Static Quadriceps Contractions

This exercise is used to prevent quadriceps muscle degeneration

and weakening in the acute stages of injury and/or directly after injury.

In this stage weight bearing or more difficult exercises may be either

not advised or too difficult. This exercise may be started as soon as

pain will allow and can be done on a daily basis.

Contract the quadriceps muscles at the front of the thigh, keep

toes pointed to the ceiling.

Hold for 10 seconds.

Relax and rest for 3 seconds.

Repeat 10 to 20 times.

← This can be performed either flat on the floor, or with a foam

roller or rolled up towel under the knee.

Static Hamstring Hold

This exercise is used to maintain the strength of the hamstring

muscles when other exercises may be too difficult. Again it may be

started as soon as pain will allow and can be done on a daily basis.

Lie on the stomach

Bend the knee to raise the foot up to about 45 degrees

42

Hold for count of 10 and lower slowly .

Repeat 10 to 20 times.

← This can be progressed by increasing the length of hold, as well

as using some external force such as a partner to increase the

resistance or ankle weights.

Static Hamstring Contractions

This exercise is more difficult than the one above and also helps

in increasing the range of movement in the knee joint.

This involves contracting the hamstring muscles without

movement - by pushing against a static object.

One can do this by attempting to either bend the knee or extend

the hip, or both.

The easiest way of doing this is getting a partner to resist the

movement.

One can also push against a wall, chair or the floor.

Hold for 10 seconds.

Relax and rest for 3 seconds.

Repeat 10 to 20 times.

43

Straight Leg Raises (SLR)

This exercise is more difficult than the static quadriceps exercise

as it involves lifting the entire weight of the leg against gravity. It

mainly targets the knee extensors (the quadriceps) but also functions

in strengthening the hip flexors (Rectus Femoris and Iliopsoas

muscles).

Position the patient sitting on the floor with both legs straight out

in front of the therapist.

Keeping the knee completely straight, lift the entire leg off the

floor

Hold for 10 seconds.

Relax and rest for 3 seconds.

Repeat 10 to 20 times.

44

Knee Extension

This exercise specifically targets the quadriceps muscle group. It

may be used relatively early in the rehab process but care should be

taken not to overload the injured leg. Always seek professional advice

before beginning weight training

Always start each session with a light warm-up set of repetitions

before increasing the weight or resistance.

Keeping your bottom firmly on the bench, straighten and lower

the injured leg in one smooth movement.

An alternative exercise involves using a resistance band to

provide the resistance.

Tie one end of the band to a table leg or other stable structure

Leg Curl

Again, this exercise strengthens the hamstring muscles. You can

perform this with either ankle weights, a resistance band or a weight

machine.

If using ankle weights or a resistance band, lay on your front.

Attach the band around your ankle and also around something

sturdy, close to the floor behind you.

45

Always start resistance band exercises with the band just under

tension, if it is slightly slack, shorten the length you are using by

tying it shorter.

Bend the knee, bringing the heel towards your buttocks, as far as

you comfortably can.

Slowly reverse this movement and return to the starting position

under control.

Aim for 3 sets of 10 repetitions initially with light weights/low

resistance and gradually increasing.

Hip Raises (Bridging)

Lie on your back with your knees bent and feet flat on the floor.

Lift your hips up off the floor as far as they will go, hold for 3

seconds and lower.

Repeat 10 to 20 times.

To progress this exercise, increase the length of time that the

hips are held up, initially to 5 and then to 10 secs

Calf Raises

46

Raise up and down on the toes on the edge of a step in a smooth

movement > Play video

Aim for 3 sets of 20 repetitions.

This exercise can be progressed to single leg calf raises as fitness

and tolerance increases

Squatting

This is arguably the best exercise to increase quadriceps muscle

strength. Nevertheless, extreme care should be taken with this

exercise as it involves large loading of the quadriceps muscles and the

knee joint itself

Squat down half way to horizontal and return to standing.

Try to sink down through the knees, keeping the back straight

and not allowing your knees to move forwards past your toes

Return to the start position and repeat .

Aim for 3 sets of 10 repetitions during rehabilitation.

Progress this exercise by adding weight or moving to single leg

squats.

Later in the rehabilitation process, squats can be progressed to

horizontal (90 degrees flexion at knee and hip)

47

Hip Flexor Exercises

Start with the band tied around your ankle and also something

close to the floor.

Make sure you have something to hold on to.

Raise the knee up towards the chest, against resistance

Slowly return to the start position and repeat.

Aim for 3 sets of 10 repetitions.

← If one do not have rehabilitation band or suitable weights then

this exercise can be done without resistance. However in this

situation more reps should be added to the rehab program.

Hip Adduction Exercises

48

The hip adductors are better known as the groin muscles.

Attach a resistance band around your ankle and then fasten it to

a secure object, to the side of you.

Start with the leg out to the side, away from the body, with the

knee straight.

Pull the leg across your body as far as comfortable, before slowly

returning back to the start position

Hip Abduction Exercises

The hip abductors are vital components in gait as they allow the

hips to support the weight of the body. Thus strengthening exercises

for this muscle group is vital to any lower limb rehabilitation program.

These can be performed in lying in the acute stage and progressed into

standing with a resistance band.

Tie the band around your ankle and around a sturdy object to the

side of you.

Start with the leg to be worked on the opposite side to the

attachment point

While keeping the leg straight, take leg out to the side as far as

comfortable

Slowly return to the start position.

49

This exercise can be progressed using elastic bands to increase

resistance.

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.

If the quadriceps femoris muscle is strong enough (i.e, 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.

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Proprioceptive Exercises

Proprioception can be considered as the body's ability to sense

where it is in space. In the event of an injury this mechanism becomes

disrupted and proper training is needed to re-educate the muscles to

fire at the right time to allow further injury prevention. The most

common way to achieve this is to first stand and then walk on an

uneven surface. As balance continues to improve proprioceptive

exercises can progressed as follows:

Two footed stand on wobble board -aim to maintain balance for

as long as possible

Progress to one legged (injured side) wobble board exercises

Practice hopping on the injured leg on an uneven surface

Gradually increase difficulty by throwing a ball against a wall and

catching it while standing on the wobble-board. Aim to challenge

yourself by throwing the ball outside your comfortable center of

gravity.

Proprioceptive exercises should be continued even after a return

to full fitness to prevent future injury.

Below is an example of a muscle strengthening program

following a meniscal tear or surgery. As with all rehabilitation

programs, the type of exercises, their frequency and intensity is

dependant on the patient's own functional ability and will vary from

person to person. Hence the below table offers only sample

information and figures and should only be carried out as pain allows.

PhaseRehabilitativeStrengthening

Exercises

Daily Routine

(Repetitions X Daily

Frequency)

Functional Activities

1Week 0

1.Static Quadriceps2.Static Hamstrings

10 X 310 X 3

In some cases non-weight bearing on the injured leg is

51

Pre-operatio

n3.SLR’s

5 X 2advised. Use crutches if necessary

2Week 0-

1After

Surgery

1. Static Quadriceps2. Static Hamstrings using therapeutic elastic band3. SLR's4. Double Calf Raises5. Hip Abduction6. Hip Flexion

10 X 310 X 35 X 35 X 3

10 X 310 X 3

Carry out weight bearing status as advised by surgeon.If weight bearing has been advised, concentrate on gait re-education drills.

3Weeks

1-2

1.Leg raises using therapeutic   elastic band2.Half-way Squats3.Small range lunges4.Single calf raises5.Proprioceptive drills

10 X 35 X 35 X 35 X 3

Twice Daily

Light Cycling and swimming as pain allows

4Weeks

2-3

1.Full Squats2.Full range Lunges3.Single leg squats4.Proprioceptive drills5.Change of direction drills

10 X 210 X 25 X 3

3 Times Daily

Once Daily

Some light jogging and perhaps short range sprints may be attempted at this stage.Increase resistance on cycling machine

5Weeks

3-5

1.Full Squats2.Full Lunges(extra weights may be added to shoulders to increase difficulty of these exercises)3.Proprioceptive drills4.Sprinting drills with change of direction

10 X 310 X 3

 3 times dailyOnce Daily

At this stage it may be possible to return to sport specific training. Care should be taken when returning to contact or impact sports. Short intervals are advised rather than over exertion in the early period of return.

Non Surgical rehabilitation

The program for non operative 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 non operative 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

52

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 contra lateral 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.

53

PROGNOSIS

Prognosis

A torn meniscus is certainly not life threatening and once treated,

the knee will usually function normally for many years.

A meniscal tear that catches, locks the knee, or produces

swelling on a frequent or chronic basis should be removed or repaired

before it damages the articular (gliding) cartilage in the knee. A

meniscal tear that produces discomfort but does not produce any of

the symptoms mentioned above may be less likely to damage the rest

of the knee. One may choose to "live" with this type of meniscal tear

instead of treating it operatively.

Following a partial menisectomy most patients are able to

resume to normal non-sporting activities comfortably in a few days.

Generally light sports such as biking and swimming are well tolerated

in 1-2 weeks. Heavy sports such as running, basketball and tennis

usually take longer.

The long-term prognosis depends on how much meniscus was

lost from the tear. Naturally occurring (aging) arthritis is accelerated

depending on the amount of meniscus lost. There are new techniques

designed to repair those menisci that are repairable and replace that

portion of the meniscus which is lost. Entire menisci can be replaced

using cadaver transplants.

54

PREVENTION

Although it is important to be able to treat meniscus injury,

prevention should be your first priority. Some of the things you can do

to help prevent a meniscus injury

1. Warm Up properly A good warm up is essential in getting the

body ready for any activity. A well-structured warm up will

prepare your heart, lungs, muscles, joints and your mind for

strenuous activity.

2. Avoid activities that cause pain This is self-explanatory, but

try to be aware of activities that cause pain or discomfort, and

either avoid them or modify them.

3. Rest and Recovery Rest is very important in helping the soft

tissues of the body recover from strenuous activity. Be sure to

allow adequate recovery time between workouts or training

sessions.

4. Balancing Exercises Any activity that challenges your ability to

balance, and keep your balance, will help what is called,

proprioception: - your body's ability to know where its limbs are

at any given time.

5. Stretch and Strengthen To prevent meniscus injury, it is

important that the muscles around the knee be in top condition.

Be sure to work on the strength and flexibility of all the muscle

groups in the leg.

6. Footwear Be aware of the importance of good footwear. A good

pair of shoes will help to keep your knees stable, provide

adequate cushioning, and support your knees and lower leg

during the running or walking motion.

7. Strapping Strapping, or taping can provide an added level of

support and stability to weak or injured knees.

55

 CASE ASSESSMENT – 1

Name : P. Sujatha

Age : 40 years

Gender : Female

Occupation : House wife

Address : Rapur

Chief complaints : Pain around right knee joint

Pain increases during night

Difficulty in walking and stair

climbing

Presence of Swelling around right

knee joint

History

Present History : Pain around right knee joint and

increases during night

Past History : She had a fall from height

and got

direct injury to knee

Medical History : She has taken analgesics for pain

relief

Surgical History : No Surgical history

Personal History : No history of Hypertension and

Diabetes Mellitus

Pain Assessment

Site : Around knee joint

Side : Right Side

Duration : One Month

Character of pain : Not Radiating

Aggravating Factors : During movement and walking

Relieving Factors : At Rest

56

VAS Scale:

On Observation

Built : Moderate

Attitude of Limb : Slightly flexed

Skin Colour changes : No Changes Seen

External Appliances : No usage

On Palpation

Tenderness : Grade II

Muscle Spasm : Present

Warmth : Present

Swelling : Present

On Examination

Range of motion of knee joint.

Passive:

Movement

Right knee Left knee

Flexion 0-110 Degrees 0- 130 degrees

Extension 110- 0 Degrees

130- 0 Degrees

Active:

Movement

Right knee Left knee

Flexion 0-100 Degrees 0- 130 degrees

Extension 100- 0 Degrees

130- 0 Degrees

Manual muscle testing

Muscles Right knee Left kneeFlexors Grade – 4 Grade – 5Extensors Grade – 3 Grade – 5

Deep Tendon Reflexes

Jerk Right Left

Knee + ++

Ankle ++ ++

Plantar ++ ++

57

ADL : Activities like walking and stair

climbing is difficult

Special Test : Apley’s grinding test –

Positive

Mcmurray test- Positive

Lachman’s Test – Negative

Anterior Drawer Test - Negative

Investigations

X- Ray : Bony abnormalities are seen

MRI : Meniscal tear

Provisional Diagnosis : Meniscal Injury

Treatment

Pain : Ultra Sound, TENS, Cryotherapy

Swelling : Crep bandage, Elevation of limb

Joint Movement : Limb mobilization

Muscle strength : Isometrics to hamstrings,

Isometrics to Quadriceps

Straight Leg Raises

Leg Extension exercises

Home Programme

Static and dynamic quadriceps exercises are taught

Stair climbing is advised to avoid.

Prognosis

Pain get decreased

Range of motion get increased

ADL activities like walking and stair climbing are improved.

58

CASE ASSESSMENT - 2

Name : K. Arjun

Age : 35 Years

Gender : Male

Occupation : Sports Master

Address : Podalakur

Chief complaints : Pain around left knee during

walking

Weakness is felt

Difficulty in Walking

Difficulty in stair climbing

Decreased movement

History

Present History : Pain around left knee during

walking

Weakness is felt

Decreased movement

Past History : He had a slip during foot ball

play

and under gone surgery before two

months

Medical History : Analgesics for pain relief

Surgical History : He had surgery before two months

Personal History : No History of hypertension and

Diabetes Mellitus

Pain Assessment

Site : Around Knee

Side : Left side

Duration : Two months

Character of pain : Not Radiating

Aggravating Factors : During movement and at work

Relieving Factors : At Rest

59

VAS Scale:

On Observation

Built : Moderate

Attitude of Limb : Slightly flexed

Skin Colour changes : Not Seen

External Appliances : No Usage

On Palpation

Tenderness : Grade II

Muscle Spasm : Positive

Warmth : Positive

Swelling : Positive

On Examination

Range of motion of knee joint.

Passive

Movement

Right knee Left knee

Flexion 0-130 Degrees 0-110 Degrees

Extension 130-0 Degree 110-0 Degrees

Active

Movement

Right knee Left knee

Flexion 0-130 Degrees 0-100 Degrees

Extension 130-0 Degree 100-0 Degrees

Manual muscle testing

Muscles Right knee Left kneeFlexors Grade – 5 Grade – 3Extensors Grade – 5 Grade - 3

Deep Tendon Reflexes

Jerk Right Left

Knee ++ +

Ankle ++ ++

Plantar ++ ++

60

ADL : Activities like walking, stair

climbing, jumping are difficult.

Investigations

Provisional Diagnosis : Post operative Knee pain

Treatment

Pain : Ultra Sound, IFT, Cryotherapy

Swelling : Crep bandage, Elevation of limb

Week 0-1 after surgery : Static Quadriceps

Static hamstrings

Straight leg raises

Calf raises

Hip abduction

Hip Flexion

Week 1-2 after surgery : Half way squats

Lunges

Single Calf raises

Proprioceptive exercises

Week 2-3 after surgery : Full squats

Full lunges

Proprioceptive exercises

Single leg squat

Week 3-5 after surgery : Full squats

Full lunges

Proprioceptive exercises

Home Programme

Static and dynamic quadriceps exercises are taught

Stair climbing is advised to avoid.

Prognosis

Pain get decreased

Range of motion get increased

ADL activities like walking, stair climbing and jumping are

improved

61

CONCLUSION

Meniscal tears are common and can be part of degenerative

change within the knee joint or secondary to trauma. They can cause

symptoms that affect the function of the joint and require surgical

intervention.

The majority of symptomatic tears require arthroscopic partial

meniscectomy but in a few select cases the tear may be amenable to

repair done as an open or arthroscopic procedure.

Effective rehabilitation should be there for spontaneous recovery.

Rehabilitation interventions seek to promote recovery and

independence in daily activity, to promote better health and prevent

secondary complication.

The utilization of effective treatment intervention focus on real

life environments can cause successful attainment of functional

outcomes.

By the proper rehabilitation programme treated for five weeks of

the present case with meniscal injuries have been shown to improve

functional outcome and allowed the patient to regain independence in

daily life.

It is concluded that, with proper rehabilitation program, we can

regain patient functional activity to maximum level and prevent

secondary complication.

62

BIBLIOGRAPHY

Achleshwar Gandora “Gross Anatomy”, 1st Edition, 2000, Jaypee

Brothers Medical Publications

B.D. Chaaurasia’s “Human Anatomy”, 4th Edition, 2004, Satish

Kumar Jain for CBS Publishers and Distributors.

Caralyn Kisner “Therapuetic Exercises” 4th Edition, 2002, Jaypee

Brothers Medical Publications.

Chaudhari “Medical Physiology” 2nd Edition, New Central Book

Agency (Pvt.,) Ltd.,

C. Rex “Clinical Assessment and Examination in Orthopaedics”,

1st Edition, 2002 Jaypee Brothers Medical Publications.

Colour Atlas of Clinical Orthopaedics, 2nd Edition, Jones, Owen.

Mosby Wolfe Publishers.

Cynthia C. Norkins Mela D. Levangie “Joint Structure and

Funciton” 2nd Edition, 2001 Jaypee Brothers Medical Publications.

David J. Magee “Orthopaedic Physical Assessment”.

Jayant Joshi & Prakash Kotwal “Essential of Orthopaedics &

Applied Physiotherapy” 2007 Published by Elsevier Pvt. Ltd.,

John Ebinezer “Text Book of Orthopaedics” 2nd Edition 2000,

Jaypee Brothers Medical Publications.

Caren Atikison Fionacaults Anne Marie Hassen Kamp

“Physiotherapy in Orthopaedics” 2nd Edition, 2005 British Library

Cataloging in publication Data.

63

Maheswari “Essential Orthopaedics” 3rd Edition May 2005 Mahata

Publishers.

Natarajan’s “Text book of Orthopaedics & Traumautology” 6th

Edition, 2005, All India Publishers and Distributors.

Patricia A. Downie “Cash Text Book of Orthopaedics &

Rheumatology for Physiotherapy” 1st Edition, Jitten Dar P Vij for

Jaypee Brothers Medical Publications.

Stuart B. Povter “Tidy’s Physiotherapy” 13th Edition Published by

Elsevier Pvt., Ltd.,

S.Sundar’s “Text Book of Rehabilitation” 2nd Edition Jaypee

Brothers Medical Publications.

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