PT ASSESSMENT AND MANAGEMENT OF MENISCAL INJURY.

By: Seema T. Kotwani,MPT ii

On: 2nd July, 2013.

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CONTENTS

• Functions of meniscus• Biomechanics of meniscus• Blood supply• Tears• Healing• Assessment• Rehabilitation

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FUNCTIONS OF MENISCUS

• Improves articular congruency• Increases stability of the knee• Distributes load during movement• Reduces friction between femur and tibia• Shock absorption• Nutrition of articular cartilage• Helps in locking mechanism

6/29/2013Levangie P, Cynthia N. Joint Structure and Function :

Fourth edi. 2005.

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Levangie P, Cynthia N. Joint Structure and Function : Fourth edi. 2005.

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BIOMECHANICS OF MENISCUS

• The contact force of the menisci on the femur helps guide the femur anteriorly during flexion while the reaction force of the femur on the menisci deforms the menisci posteriorly on the tibial plateau.

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edi. 2005.

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• The posterior deformation of the menisci is assisted by muscular mechanisms.

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Levangie P, Cynthia N. Joint Structure and Function : Fourth edi. 2005.

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BLOOD SUPPLY OF MENISCUS

• Medial, lateral, and middle geniculate arteries.

• Only 10% to 30% of peripheral medial meniscus border and 10% to 25% of lateral meniscus border receive direct blood supply

• Remaining portion receives nourishment from synovial fluid via diffusion

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Brindle T, Nyland J, Johnson DL. The Meniscus : Review of Basic Principles With application to Surgery and Rehabilitation.

2001;36(2):160–9.

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TEARS OF MENISCISmillie’s Classification

1. Horizontal tears2. Longitudinal tears:

Bucket handle tears Posterior horn tear Anterior horn tear

3. Cystic degeneration4. Congenital abnormalities 5. Degenerative lesions

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Physiotherapists. First edi. 2003

96/29/2013Brotzman S.B, Wilk K.E., Clinical Orthopaedic Rehabilitation.

Second edi.

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Acute Traumatic

Twisting on semiflexed knee

with foot on ground

Longitudinal and Posterior horn

tear

Degenerative

Tear from minor event

Complex and Horizontal tear

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MENISCAL HEALING

Depends on:

1. Location of the tear,

2. Pattern of tear,

3. Type of tear.

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Brindle T, Nyland J, Johnson DL. The Meniscus : Review of Basic Principles With application to Surgery and Rehabilitation. 2001;36(2):160–9.

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ASSESSMENT

History – • Combination of twisting on a semi-flexed knee

with the foot fixed on the ground. • In elderly - tear from minor event• Locking of the knee joint• Episodes of giving away• Onset – insidious

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Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques. 5th Edi.

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Chief complaints

• Severe pain,• Swelling,• Locking of the

knee in partial flexion,

• Catching,• Clicking,• Episodes of

giving away,• Inability to

weight bear.

Inspection

• Swelling• Stands with

knee semiflexed

• Quadriceps atrophy (chronic)

PALPATION

• Joint line tenderness

• Warmth • Effusion – tap

test

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EXAMINATION• Terminal extension of the knee blocked• End feel – springy if knee is locked.• Pain on forced flexion.• Capsular pattern – gross limitation of flexion,

slight limitation of extension. • Limb girth measurement – reduced limb girth

in thigh.• Balance testing• Proprioception

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• Special Tests:

1. McMurray’s test2. Apley’s test3. Thessaly test4. Steinmann sign

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Magee D. Orthopaedic Physical Assessment. Fifth Edition.

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MANAGEMENT1. Non-operative:

• Partial thickness longitudinal tears,• Small (<5mm) full thickness peripheral tears,• Minor inner rim or degenerative tears.

2. Operative: Meniscal repair, Meniscectomy and Meniscal Transplantation.

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Frontera W, Silver J, Rizzo T. Essentials of Physical Medicine and Rehabilitation. Musculoskeletal Disorders, Pain, and

Rehabilitation. Second Edition.

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Meniscal repair:1. lesion in vascular outer third2. tear extending in central, relatively

avascular third of meniscus of a young (<40-50 yrs) or physically active older (>50 yrs) individual.

Partial Meniscectomy:1. Symptomatic displaced tear in older

inactive individual.2. Tear in central avascular third

6/29/2013Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques.

5th Edi.

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Total Meniscectomy:Extensive damage to major portion of meniscus and it is determined to be unsalvagable.

Meniscal Transplant:young/active patient who previously underwent total meniscectomy and now is symptomatic because of early osteoarthritic changes in the tibiofemoral joint.

6/29/2013Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques.

5th Edi.

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REHABILITATION• Rehabilitation in non-operative and partial

meniscectomy cases is the same.

PHASE 1: ACUTE PHASEGoals • Diminish inflamation and swelling• Restore range of motion(ROM)• Re-establish quadriceps muscle activity

6/29/2013Brotzman S.B, Wilk K.E., Clinical Orthopaedic Rehabilitation. Second edi.

Days 1-3• Cryotherapy• Quadriceps sets• Straight leg raise• Electrical muscle stimulation to quadriceps • Hip adduction and abduction

• Active assisted ROM • Stretching• Weight bearing as tolerated (two crutches)

Days 4-7• Same as previous• Knee extension 90-40 degrees• Balance/proprioceptive drills• Active assisted, passive ROM• Stretching exercises• Continued use of compression wrap or

brace• Weight bearing as tolerated (one crutch)

Days 7-10• Continue all exercises • Leg press (light weight)• Toe raises • Hamstring curls • Bicycle (when ROM 0-105˚ with no swelling)

Phase 2: Internal Phase

Goals • Restore and improve muscular strength and

endurance • Reestablish full nonpainful ROM • Gradual return to functional activities Days 10-17• Bicycle• Lateral lunges• Front lunges

• ½ squats• Leg press • Lateral step ups• Knee extension (90-40 degrees)• Hamstring curls • Hip adduction and abduction

• Hip flexion and extension• Toe raises • Proprioceptive and balance

training • Stretching exercises

Day 17-Week 4• Continue all exercises • Pool program (deep water running and leg exercises)• Compression brace may be used during activities

Criteria for progression to Phase 3• Satisfactory clinical examination (minimal effusion) • Full/nonpainful ROM • No pain or tenderness • Satisfactory isokinetic test

Phase 3: Advanced Activity Phase Weeks 4-7

Goals • Enhance muscular strength and endurance • Maintain full ROM • Return to sport/functional activities Intervention• Cycling • Increased resistance on weight training• Full squat• Full leg press(resisted)• Continue to emphasize closed-kinetic chain exercises

• May begin plyometrics – jumping, hopping, increasing height, jump and twist

• Begin running program – zig-zag, stop/start, figure of eight, uneven surface

• Sport specific skills – kicking

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REHABILITATION FOLLOWING MENISCAL REPAIR

• Maximum Protection Phase: day 1 – 4 weeks:Goals:1. Restore functional ROM2. Prevent patellar restriction3. Re-establish control of knee musculature4. Restore postural stability5. Improve strength and flexibility of hip & ankle

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6. Maintain cardiopulmonary fitness Intervention:• Cold, compression, elevation.• CPM• A-AROM & AROM• Knee flexion restricted by hinged, controlled

motion brace. (first two weeks: 60 to 90 degrees. After 4 weeks, 120 degrees)

• Gravity assisted knee bending• Heel slides in supine• Patella mobilisation6/29/2013

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• Quadriceps setting exercise• SLR• Electrical stimulation of quadriceps• Hamstring setting• Balance activities (brace locked)• When it is permissible to unlock the brace,

begin mini squats, wall slides (initially limit flexion to no more than 45 degrees)

• Stretching• Upper body ergometer for aerobic

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Moderate protection phase:4-12 weeks. Goals:1. Restore full ROM2. Improve LE strength, flexibility and endurance3. Improve aerobic fitness Intervention:• Stretching• Stationary cycling• Pool walking program• Hip and ankle strengthening exercises

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• Elastic resistance for open and closed chain knee exercises

• Balance training• When bilateral WB is permissible, begin partial

lunges, step ups and step downs• Walking on unstable surface (9-12 weeks)• Resume light functional activities.

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Minimum protection phase ( 12-16 weeeks): Goals:1. Resume full level of functional activities Intervention:• Incorporate functional movement patterns

during resistance training• Plyometric training• Increase duration and intensity of aerobic

conditioning program• Transition from walking to jogging/running.

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THANK YOU