sm knee arthroscopy

7/25/2019 SM Knee Arthroscopy

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Rehabilitation Guidelines

for Knee Arthroscopy

Arthroscopy is a common surgicalprocedure in which a joint is viewedusing a small camera. This techniqueallows the surgeon to have a clear viewof the inside of the knee, which helpsdiagnose and treat knee problems.Recent advances in technology have ledto high definition monitors and highresolution cameras. These and other

improvements have made arthroscopya very effective tool for treating kneeproblems. According to the AmericanOrthopaedic Society for Sports Medicine,more than 4 million knee arthroscopiesare performed worldwide each year.5Knee arthroscopy can be used to treatmensical and articular cartilage tears,fat pad impingement and chronic plicairritation.

There are two types of cartilage in theknee, articular cartilage and meniscuscartilage. Articular cartilage is madeup of collagen, proteoglycans andwater, which line the end of the bonesthat meet to form a joint. The primaryfunction of the articular cartilage isto provide a smooth gliding surfacefor joint motion. Rubbing articularcartilage on articular cartilage isapproximately 5 times more smooth

(i.e. less friction), than rubbing ice onice.3A wide range of injuries can occurto the articular cartilage during sportsinjuries, trauma and degenerativeprocesses. Smaller, partial thicknesstears of the articular cartilage can

cause pain, swelling, or catching inthe knee. These types of tears can betreated with arthroscopy by removing

the torn or frayed articular cartilagewith a shaver. The goal of this is toremove the damaged articular cartilagewhile preserving the remaining intactarticular cartilage.

The meniscus cartilage in the kneeincludes a medial (inside part of theknee) meniscus and a lateral (outsidepart of the knee) meniscus (Figures 1and 2). Together they are referred to asmenisci. The menisci are wedge shaped

and are thinner toward the center of theknee and thicker toward the peripheryof the knee joint (Figures 1 and 3). Thisshape is very important to its functionsince the primary function of the

Lateral

meniscus

Medial

meniscus

Figure 1 Lateral and medial meniscus of the

left knee (shown here from above the knee,

without the femur)

Image property of Primal Pictures, Ltd., primalpictures.com. Use of this

image without authorization from Primal Pictures, Ltd. is prohibited.

Tibia Medial

meniscus

Femur

Figure 2 Medial (inside) view of the knee

Image property of Primal Pictures, Ltd., primalpictures.com. Use of this

image without authorization from Primal Pictures, Ltd. is prohibited.

Tibia Medial

meniscus

Fat

Pad

Femur

Figure 3 Normal MRI (saggital view) of the

knee, lateral side (outside)
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Rehabilitation Guidelines for Knee Arthroscopy

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menisci is to improve load transmission.A relatively round femur sitting ona relatively flat tibia forms the knee

joint. Without the menisci the area ofcontact force between these two boneswould be relatively small, increasing thecontact stress by 235-335% (Figure 4).

The menisci also provide some shockabsorption, lubrication and joint stability.

There are two categories of meniscal

tears, acute traumatic tears anddegenerative tears. Degenerative tearsoccur most commonly in middle-agedpeople as a result of repetitive stresses

to the menisci over time, which severelyweaken the tissue and cause a non-acute, degenerative tear. This processof tissue degeneration makes it veryunlikely that a surgical repair will healor that the surrounding meniscus willbe strong enough to hold the suturesuse to repair it. One report showedthat less than 10% of meniscal tearsoccurring in patients more than fortyyears of age were repairable. Symptomsof a degenerative meniscus may tearinclude swelling, pain along thejoint line, catching, and locking. If adegenerative tear is symptomatic it isusually surgically removed. This is calleda partial menisectomy, which is termedpartial because the surgeons only removethe segment of meniscus containing thetear as opposed to removing the entiremeniscus.

Acute traumatic tears occur mostfrequently in the athletic population asa result of a twisting injury to the kneewhen the foot is planted. Symptoms of

Figure 4Schematic representation of the meniscal effect on contact pressure in the

knee. Contact area is increased by 50% with addition of menisci. This reduces contact pressures.Copyright 2008 UW Sports Medicine Center

withmeniscuswithoutmeniscus

Figure 5 MRI (saggital view) of a lateral

meniscus tear (yellow arrows)

Figure 6Perimeniscular capillary plexus (thick arrow) providing blood supply to the

outer third of the meniscus.

Copyright 2008 UW Sports Medicine Center

Femur

Tibia

Meniscus
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an acute meniscus tear include swelling,pain along the joint line, catching,locking and a specific injury. Oftentimes these tears can be diagnosed by

the history of the problem and a goodphysical examination. Sometimes anMRI will be used to assist in making thediagnosis. The arrow in Figure 3 showsa normal meniscus on an MRI, but thearrows in Figure 5 show a torn meniscus.

If an athlete suffers a meniscal tear thethree options for treatment include:non-operative rehabilitation; surgery totrim out the area of torn meniscus; orsurgery to repair (stitch together) thetorn meniscus. The treatment chosenwill depend on the location of the tear;the size of the tear; the sport to whichthe athlete is returning; ligamentousstability of the knee; and any associatedinjury.2The location of the tear isimportant because the outer portion of

the meniscus has a good blood supplywhereas the inner portion has a verypoor blood supply. Blood vessels (theperimeniscular capillary plexus) enter

the peripheral one third of the meniscus,1

this blood supply is necessary for a tearor surgical repair to heal (Figure 6).Without an adequate blood supply,usually the area of torn meniscus has tobe removed.

Other structures in the knee that cancause pain and limit function wheninjured or chronically inflamed arethe fat pad (Figure 3) and the plica.These problems can arise from a varietyof causes, but if they do not improvewith non-surgical measures it may benecessary to use knee arthroscopy toremove the tissue. Secondary problemsmay also arise from injury, such as scartissue or cysts, which need to be removed.

After knee arthroscopy, rehabilitationwith a physical therapist or athletictrainer is usually required to optimizethe outcome. Rehabilitation will focus

on restoring range of motion, developingstrength and movement control, andguiding the athletes return to sport. Therehabilitation guidelines are presentedin a criterion based progression. Specifictime frames, restrictions and precautionsare given to protect healing tissuesand the surgical repair/reconstruction.General time frames are also given forreference to the average, but individualpatients will progress at different rates

depending on their age, associatedinjuries, pre-injury health status,rehabilitation compliance and injuryseverity. The size and location of themeniscal tear also may affect the rate ofpost-operative progression.


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PHASE I (surgery to 2-3 weeks after surgery)

Appointments Rehabilitation appointments begin 3-5 days after surgery

Rehabilitation Goals Protect the post-surgical knee

Restore normal knee range of motion

Normalize gait

Eliminate swelling (i.e. effusion)

Restore leg control

Precautions Use axillary crutches for normal gait

Avoid impact exercises for the first 4-6 weeks if the articular cartilage was debrided

Range of Motion (ROM)

Exercises

(Please do not exceed the

ROM specified for each

exercise and time period)

Knee extension on a bolster

Prone hangs

Supine wall slides

Heel slides

Suggested Therapeutic

Exercise

Quadriceps sets

Isometric wall press

4 way leg lifts in standing for balance and hip strength

Gait drills

Cardiovascular Exercise Upper body circuit training or Upper Body Ergometer (UBE)

Progression Criteria Normal gait

No effusion Full knee range of motion


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PHASE II (begin after meeting Phase I criteria)

Appointments Rehabilitation appointments begin once every 1 to 2 weeks

Rehabilitation Goals Good control with single leg stand

Good control and no pain with functional movements, including step up/down,squat, partial lunge

Precautions Post-activity soreness should resolve within 24 hours

Avoid post-activity swelling


Exercise

Non-impact balance and proprioceptive drills

Stationary bike

Hip and core strengthening

Stretching for patient specific muscle imbalances

Quadriceps strengthening

Cardiovascular Exercise Non-impact endurance training; stationary bike; Nordic track; swimming; deep waterrun; and cross trainer

Progression Criteria Normal gait on all surfaces

Ability to carry out functional movements without unloading the affected leg or pain,while demonstrating good control

Single leg balance greater than 15 seconds


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PHASE III (begin after meeting Phase II criteria)

Appointments Rehabilitation appointments are once every 1 to 2 weeks

Rehabilitation Goals Good control and no pain with sport and work specific movements, includingimpact

Precautions Post-activity soreness should resolve within 24 hours

Avoid post-activity swelling


Exercise

Impact control exercises beginning 2 feet to 2 feet, progressing from 1 foot to otherand then 1 foot to same foot

Movement control exercises beginning with low velocity, single plane activities andprogressing to higher velocity, multi-plane activities

Sport/work specific balance and proprioceptive drills

Hip and core strengthening

Stretching for patient specific muscle imbalances

Cardiovascular Exercise Replicate sport or work specific energy demands

Return To Sport/Work Criteria Dynamic neuromuscular control with multi-plane activities, without pain or swelling

These rehabilitation guidelines were developed collaboratively by Marc Sherry, PT, DPT, LAT, CSCS([email protected]) and the UW Health Sports Medicine physician group.

This material may not be reproduced without permission. Utilization of this material in the development of newdocuments or presentations should be appropriately referenced.Updated 1/2011

REFERENCES

At UW Health, patients may have advanced diagnostic and /or treatment options, or may receive educational materials that vary from this information. Please be aware that this information is not intended to replacethe care or advice given by your physician or health care provider. It is neither intended nor implied to be a substitute for professional advice. Call your health provider immediately if you think you may have a medical

emergency. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any question you may have regarding a medical condition.

Copyright 2011 UW Health Sports Medicine Center

SM-26954-10

1. Arnoczky SP and Warren RF.

Microvasculature of the human meniscus.

Am J Sport Med, 1982

2. Fowler PJ and Pompan D. Rehabilitation

after mensical repair.Tech in Ortho, 8(2):

137-139, 1993.

3. Ulrich GS and Aronczyk SP. The basic

science of meniscus repair. Tech in Ortho,

8(2): 56-62, 1993.

4. Zacharias J. Mensical Injuries: Anatomy,

Diagnosis and Treatment. UW Sports

Medicine conference.September 8, 1999.

5. American Academy of Orthopedic

Surgeons: orthoinfo.aaos.org

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