Physiotherapy and rehabilitation after arthroscopic menisectomy - Henry Atkinson

Physiotherapy and Rehabilitation following arthroscopic menisectomy
Henry Dushan Edward Atkinson,  Jennifer Michelle Laver,  Elizabeth Sharp

Mr Henry D.E.Atkinson, MBChB, BSc Med Sci, MRCS, FRCS Tr & Orth
Consultant Trauma and Orthopaedic Surgeon
North Middlesex University Hospital, Sterling Way, London N18 1QX
North London Sports Orthopaedics

Miss Jennifer Michelle Laver, B App Sc (Physio)(Hons)
Senior Lower Limb Sports Physiotherapist
SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia

Mrs Elizabeth Sharp MSc (Man Ther) MCSP Grad Dip Phys
Clinical Director ESPH
ESPH ES Physical Health, 116 Lordship Lane, London, SE22 8HD
ESPH, 22 Harley Street, London W1G 9PL


Patients following a well-planned unsupervised home-exercise programme perform as well as those participating in supervised outpatient physiotherapy programmes, with a tendency to have better isokinetic results, an earlier return to work (RTW), and RTS(54,55). Thus there is no need to be routinely reviewed by a physiotherapist after hospital discharge following an uncomplicated meniscectomy. The possible exceptions are elderly patients, the poorly motivated, patients with co-existing pathologies such as ACL injury or degenerative changes, and elite athletes(54,56).

Patients should aim to return to function as quickly as possible, with RTS influenced by quadriceps strength, ROM and any residual effusion(57). Patients typically start walking without support from 1-3 days(58), 91% RTW by 2 weeks, most resume athletic training from 2-4 weeks, and RTS from 3-6 weeks(59).

Several authors have described different phases which can be used to guide the rehabilitation(58,59).

During the immediate post-operative phase (1-5 days):
characterized by bleeding, swelling, pain and quadriceps inhibition, ROM and isometric quadriceps (SLR and inner range quadriceps (IRQ)) may be started(55,57,58,60-62). Other exercises include prone quadriceps stretches, ankle pumps, ankle ROM(60), passive knee extension with a ?phone book? in the seated position with the knee unsupported, knee flexion on a bed or in a chair55 and balance/proprioception exercises(63).

Patients are encouraged to FWB without a brace with as normal a gait as possible(57,59). Prescribed analgesia should be taken as required or just prior to exercising(61) in addition to rest, ice, elevation(55,62) and compression(54,59). Cryotherapy leads to significant improvement in knee pain and swelling(55,62), analgesic consumption, compliance, and weight bearing(60), and may be beneficial for up to 14 days post-operatively(58,59).

During the early healing/progressive phase (days 5-14)
an effusion is still present, there is ongoing quadriceps weakness and reduced ROM, but less pain. Strengthening may commence with isometric exercises (SLR) and progress to isotonic exercises (free weights, gym, theratube) once sufficient strength has returned(58,59). Though pain has usually resolved by the late healing/functional exercise phase (2-3 weeks), there is some residual quadriceps weakness and reduced end-range flexion. Patients increase their isokinetic and resistance activities, and are started with the minitramp, wobbleboard, swimming, running in the pool and bike work. Pilates may also be used to maintain ROM and increase strength(58,59).

There may be some persisting weakness during the conditioning phase (3-5 weeks), and patients continue with CKC, OKC and isokinetic training. Running (initially straight line, followed by cutting and lateral movements), jumping, balance and sports-specific agility drills are also included. Isokinetic testing can be useful in determining any residual strength imbalance prior to RTS(46,47).

In summary:
Week 1
-    Encourage normal unsupported gait
-    General advice for control of swelling (ice, elevation, compression)
-    Activation of VMO with isometric exercises
-    Passive and active  knee exercises
-    ROM 0-120?

Week 2
-    Full ROM
-    Soft tissue mobilization and reduction of scar tissue
-    Isokinetic, resistance and Pilates based exercises to maintain ROM and strengthen quadriceps, hamstring and gluteal muscles
-    Stretching programme for quadriceps, hamstring, ITB, calf, hip rotators

Week 3-4
-    CKC exercises (Wall squats, lunges, steps)
-    Isokinetic CKC and OKC quadriceps and hamstring rehabilitation
-    CKC and OKC resisted exercises in the gym using treadmill, bike and leg press
-    Balance, strength and stability exercises on the gym ball

Week 5
-    One might consider performing isokinetic open chain quadriceps and hamstring tests on the KIN-COM, and initiate strength and stability training to overcome any residual deficits.



Acknowledgements
John R Camens
B App Sc Physio Grad Dip Physio (Orthopaedics), SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia.

Glenn Withers
B.Physio. MCSP Cert. Pilates Instructor MIAPI,
Pilates Art Physiotherapy / London Sports Medicine
50-52 Kilburn High Road, London, NW6 4HJ, UK

References

1. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Physical Therapy Sport 2004; 5: 125-145.

2. Trees AH, Howe TE, Dixon J, White L. Exercise for treating isolated anterior cruciate ligament injuries in adults. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005316 DOI: 10.1002/14651858.CD005316.pub2.

3. Decarlo MS, Shelbourne KD, McCarroll JR, Rettig AC. Traditional Versus Accelerated Rehabilitation following ACL Reconstruction: A One-Year Follow-Up. J Orthop Sports Phys Ther. 1992;15(6):309-16.

4. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990; 18(3):292-9.

5. Bynum EB, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med. 1995; 23(4):401-6.

6. Feller JA, Webster KE, Taylor NF, Payne R, Pizzari T. Effect of physiotherapy attendance on outcome after anterior cruciate ligament reconstruction: a pilot study. Br J Sports Med. 2004; 38(1):74-7.

7. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo MS. Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program. Am J Sports Med. 1995; 23(5):575-9.

8.  Fu FH, L-Y Woo S, Irrgang JJ. Current Concepts for Rehabilitation following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 1992; 15(6):270-8.

9. Wilk KE, Andrew JR. Current concepts in the treatment of anterior cruciate ligament disruption. J Orthop Sports Phys Ther 1992;15(6):279-293.

10. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. 1997; 25(6):786-95.

11. Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols CE, Fleming BC, Poole AR, Roos H.
Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med. 2005; 33(3):347-59.

12. Feller JA, Cooper R, Webster KE. Current Australian trends in rehabilitation following anterior cruciate ligament reconstruction. Knee. 2002; 9(2):121-6.

13. Grant JA, Mohtadi NG, Maitland ME, Zernicke RF. Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. Am J Sports Med. 2005; 33(9):1288-97.

14. De Carlo MS, Sell KE. The effects of the number and frequency of physical therapy treatments on selected outcomes of treatment in patients with anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 1997; 26(6):332-9.

15. Beard DJ, Dodd CA. Home or supervised rehabilitation following anterior cruciate ligament reconstruction: a randomized controlled trial. J Orthop Sports Phys Ther. 1998; 27(2):134-43.

16. Eckersley EA, Fritz JM, Irrgang JJ. Criterion-Based Rehabilitation Program After Anterior Cruciate Ligament Reconstruction. Operative Techniques in Orthopaedics 1995; 5(3): 266-9.

17. Revenas A, Johansson A, Leppert J. A randomized study of two physiotherapeutic approaches after knee ligament reconstruction. Advances in Physiotherapy 2009; 11(1):30-41.

18. Manal TJ, Snyder-Mackler L. Practice Guidelines for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation Progression. Operative Techniques in Orthopaedics 1996; 6(3):190-196.

19. Shelbourne KD, Klootwyk TE, Decarlo MS. Update on accelerated rehabilitation after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 1992; 15(6):303-8.

20. Kartus J, Stener S, K?hler K, Sernert N, Eriksson BI, Karlsson J. Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace. Knee Surg Sports Traumatol Arthrosc. 1997;5(3):157-61.

21. Shaw T, Williams MT, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother. 2005;51(1):9-17.

22.  Shaw T, McEvoy M, McClelland J. An Australian survey of in-patient protocols for quadriceps exercises following anterior cruciate ligament reconstruction. J Sci Med Sport. 2002; 5(4):291-6.

23. Noyes FR, Mangine RE, Barber S. Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. 1987; 15(2):149-60.

24.  Jensen K, Graf BK. The effects of knee effusion on quadriceps strength and knee intraarticular pressure. Arthroscopy1993; 9(1):52-6.

25. Lessard LA, Scudds RA, Amendola A, Vaz MD. The efficacy of cryotherapy following arthroscopic knee surgery. J Orthop Sports Phys Ther. 1997; 26(1):14-22.

26. Ohkoshi Y, Ohkoshi M, Nagasaki S, Ono A, Hashimoto T, Yamane S. The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction. Am J Sports Med. 1999; 27(3):357-62.

27. Dervin GF, Taylor DE, Keene GC. Effects of cold and compression dressings on early postoperative outcomes for the arthroscopic anterior cruciate ligament reconstruction patient. J Orthop Sports Phys Ther. 1998; 27(6):403-6.

28. Edwards DJ, Rimmer M, Keene GC. The use of cold therapy in the postoperative management of patients undergoing arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. 1996; 24(2):193-5.

29.  McEvoy M, Shaw T. Australian Survey of Inpatient Management Following Anterior Cruciate Ligament Reconstruction. Hong Kong Physiotherapy Journal 2004; 22:7-13.

30. Risberg MA, Holm I, Steen H, Eriksson J, Ekeland A. The effect of knee bracing after anterior cruciate ligament reconstruction. A prospective, randomized study with two years' follow-up. Am J Sports Med. 1999; 27(1):76-83.

31 Beynnon BD, Good L and Risberg MA (2002): The Effect of Bracing on Proprioception with Knees with Anterior Cruciate Ligament Injury. Journal of Orthopaedic and Sports Physical Therapy 32 (1): 11-15

32 Harilainen A and Sandelin J (2006): Post-operative use of knee brace in bone-tendon-bone patellar tendon anterior cruciate ligament reconstruction: 5-year follow-up results of a randomized prospective study. Scandinavian Journal of Medicine and Science in Sports 16: 14-18

33 Tyler TF, McHugh MP, Gleim GW and Nicholas SJ (1998): The Effect of Immediate Weightbearing After Anterior Cruciate Ligament Reconstruction. Clinical Orthopaedics and Related Research 357:141-148

34 Myer GD, Paterno MV, Ford KR, Quatman CE and Hewett TE (2006): Rehabilitation After Anterior Cruciate Ligament Reconstruction: Criteria Based Progression Through the Return-to-Sport Phase. Journal of Orthopaedic and Sports Physical Therapy 36 (6): 385-402

35 Renstrom P, Arms SW, Stanwyck TS, Johnson RJ and Pope MH (1986): Strain within the anterior cruciate ligament during hamstring and quadriceps activity. American Journal of Sports Medicine 14 (1): 83-87

36 Tovin BJ, Wolf SL, Greenfield BH, Crouse J and Woodfin BA (1994): Comparison of the Effects of Exercise in Water and on Land on the Rehabilitation of Patients With Intra-articular Anterior Cruciate Ligament Reconstructions. Physical Therapy 74 (8): 710-719.

37 Pollock ML, Gaesser GA, Butcher JD, Despres JP, Dishman RK, Franklin BA and Garber CE (1998): ACSM Position Stand: The Recommended Quantity and Quality of Exercise For Developing and Maintaining Cardiorespiratory And Muscular Fitness, And Flexibility In Healthy Adults. Medicine and Sceince in Sports 30 (6): 975-991

38 Fitzgerald GK (1997): Open Versus Closed Kinetic Chain Exercise: Issues in Rehabilitation After Anterior Cruciate Ligament Reconstructive Surgery. Physical Therapy 77 (12): 1747-1754.

39 Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renstrom PA and Pope MH (1995): Anterior Cruciate Ligament Strain Behavior During Rehabilitation Exercises In Vivo. American Journal of Sports Medicine 23 (1): 24-34

40 Mikkelsen C, Werner S and Erikkson E (2000): Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surgery, Sports Traumatology, Arthroscopy 8: 337-342

41 Beynnon BD, Johnson RJ, Fleming BC,, Stankewich CJ, Renstrom PA and Nichols CE (1997): The Strain Behavior of the Anterior Cruciate Ligament During Squatting and Active Flexion-Extension: A Comparison of an Open and a Closed Kinetic Chain Exercise. American Journal of Sports Medicine 25 (6): 823-829

42 Hooper DM, Morrissey MC, Drechsler W, Morrissey D and King J (2001): Open and Closed Kinetic Chain Exercises in The Early Period after Anterior Cruciate Ligament Reconstruction: Improvements in Level Walking, Stair Ascent, and Stair Descent. American Journal of Sports Medicine 29(2): 167-174

43 Morrissey MC, Drechsler WI, Morrissey D, Knight PR, Armstrong PW and McAuliffe TB (2002): Effects of Distally Fixated Versus Nondistally Fixated Leg Extensor Resistance Training on Knee Pain in the Early Period After Anterior Cruciate Ligament Reconstruction. Physical Therapy 82 (1): 35-43
 
44 Morrissey MC, Hudson ZL, Drechsler WI, Coutts FJ, Knight PR and King JB (2000): Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy 8: 343-348

45 Perry MC, Morrissey MC, King JB, Morrissey D and Earnshaw P (2005): Effects of closed versus open kinetic chain knee extensor training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy 13: 357-369

46 Hanten WP, Ramberg CL.Effect of stabilization on maximal isokinetic torque of the quadriceps femoris muscle during concentric and eccentric contractions. Phys Ther. 1988 68(2):219-22.

47 Steiner LA, Harris BA, Krebs DE. Reliability of eccentric isokinetic knee flexion and extension measurements. Arch Phys Med Rehabil. 1993:74 (12): 1327-1335


48 Mykelbust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE and Bahr R (2003):
Prevention of Anterior Cruciate Ligament Injuries in Female Team Handball Players: A Prospective Intervention Study Over Three Seasons. Clinical Journal of Sports Medicine 13 (2): 71-78

49 Carrafa A, Cerulli G, Projetti M, Aisa G and Rizzo A (1996) :Prevention of anterior cruciate ligament injuries in soccer: A prospective controlled study of proprioceptive training. Knee Surgery, Sports Traumatology, Arthroscopy 4 (1): 19-21

50 Hopper D (1986): A Survey of Netball Injuries and Conditions Related to These Injuries. The Australian Journal of Physiotherapy 32 (4): 231-239


51 Lui-Ambrose T, Taunton JE, MacIntyre D, McConkey P and Khan KM (2003): The effects of proprioceptive or strength training on the neuromuscular function of the ACL reconstructed knee: a randomized clinical trial. The Scandinavian Journal of Medicine and Science in Sports 13: 115-123

52 Rudolph KS, Axe MJ and Snyder-Mackler L (2000): Dynamic stability after ACL Injury: who can hop? Knee Surgery, Sports Traumatology, Arthroscopy 8: 262-269

53 Wilk KE, Clancy WG, Andrews JR, Fox GM. Assessment of medial capsular injuries. In Ellenbecker TS: Knee Ligament rehabilitation, Philadelphia, 2000, Churchill Livingstone

54 Jokl P, Stull PA, Lynch K and Vaughan V (1989): Independent Home versus Supervised Rehabilitation Following Arthroscopic Knee Surgery ? A Prospective Randomized Trial. Arthroscopy: The Journal of Arthroscopy and Related Surgery 5 (4): 298-305

55 Goodwin PC, Morrissey MC, Omar RZ, Brown M, Southall K and MacAuliffe TB (2003): Effectiveness of Supervised Physical Therapy in the Early Period After Arthroscopic Partial Meniscectomy. Physical Therapy 83 (6): 520-535

56 Goodyear-Smith F and Arroll B (2001): Rehabilitation after arthroscopic meniscectomy: a critical review of the clinical trials. International Orthopaedics 24: 350-353

57 Paulos LE, Wnorowski DC and Beck CL (1991): Rehabilitation Following Knee Surgery: Recommendations. Sports Medicine 11 (4): 257-275

58 Zairns B, Boyle J and Harris BA (1985): Knee Rehabilitation Following Arthroscopic Meniscectomy. Clinical Orthopaedics and Related Research 198: 36-42

59 Wheatley WB, Krome J and Martin DF (1996): Rehabilitation Programmes Following Arthroscopic Meniscectomies in Athletes. Sports Medicine 21 (6): 447-456

60 Lessard LA, Scudds RA, Amendola A and Vaz MD (1997): The Efficacy of Cryotherapy Following Arthroscopic Knee Surgery. Journal of Orthopaedic and Sports Physical Therapy 26 (1): 14-22.

61 Mazzocca AD and Bush-Joseph CA (2003): Arthroscopic menisectomy. Operative Techniques in Sports Medicine 11 (2): 77-82

62 Morrissey MC, Milligan P and Goodwin PC (2006): Evaluating Treatment Effectiveness: Benchmarks for Rehabilitation After Partial Meniscectomy Knee Arthroscopy. American Journal of Physical Medicine and Rehabilitation 85 (6): 490-501

63 Dixon J, Trees AH and Howe TE (2005): Exercise for treating isolated meniscal injuries of the knee in adults. Cochrane database of Systematic Reviews 2005, Issue 3. Art. No.: CD005466. DOI: 10.2002/14651858.CD005466

64 Asik M, Sen C and Erginsu M (2002): Arthroscopic meniscal repair using T-fix. Knee Surgery, Sports Traumatology, Arthroscopy 10: 284-288.

65 Boyd KT and Myers PT (2003): Meniscus preservation: rationale, repair techniques and results. Knee 10: 1-11

66 Heckmann TP, Barber-Westin SD and Noyes FR (2006): Meniscal Repair and Transplantation: Indications,Techniques, Rehabilitation, and Clinical Outcomes. Journal of Orthopaedic and Sports Physical Therapy 36 (10): 795-814

67 Kocabey Y, Nyland J, Isbell WM and Caborn DNM (2004): Patient outcomes following T-Fix meniscal repair and a modifiable, progressive rehabilitation program, a retrospective study. Arch Orthop Trauma Surg 124: 592-596

68 Barber FA (1994): Accelerated Rehabilitation for Meniscus Repairs. Arthroscopy: The Journal of Arthroscopic and Related Surgery 10 (2): 206-210

69 Wilk KE, Briem K, Reinold MM, Devine KM, Dugas JR and Andrews JR (2006): Rehabilitation of Articular Lesions in the Athlete?s Knee. Journal of Orthopaedic and Sports Physical Therapy 36 (10): 815-827

70 Morgan CD, Wojtys EM, Casscells CD and Casscells SW (1991): Arthroscopic meniscal repair evaluated by second-look arthroscopy. American Journal of Sports Medicine 19 (6): 632-637

71 Tenuta JJ and Arciero RA (1994): Arthroscopic Evaluation of Meniscal Repairs: Factors That Effect Healing. American Journal of Sports Medicine 22 (6): 797-802

Keywords
Rehabilitation, Physiotherapy, Pilates, Knee surgery, Anterior cruciate ligament reconstruction, Menisectomy, Meniscal repair.


Abstract
Soft-tissue knee surgery is performed for a multitude of conditions and encompasses a large number of procedures. The postoperative management of these conditions is constantly evolving as a result of advances in technology and a better understanding of human physiology, however there remains no consensus on the ideal timeframe over which loading can be progressed. Rehabilitation protocols provide basic guidelines through which effective outcomes can be achieved. However, the rate and extent of recovery will depend on many patient and external factors, and it is questionable whether full recovery or a return to normality is ever complete.
The complex neuromuscular motor patterning, strength and control which are affected by the injury and the surgery is very difficult to gauge, and difficult to recreate. Isokinetic testing affords a validated, reliable and reproducible method of evaluating muscle strength, endurance and antagonist/agonist balance. It may be utilised at the earliest safe opportunity to establish the efficacy of any functional rehabilitation programme and can allow adjustments to be made to optimise outcomes. Future studies into the use of pilates programmes and their effects on earlier muscle pattern retraining may also allow for safer and earlier returns to sporting activity.   
This review establishes an evidence-based approach to the postoperative rehabilitation of the knee following anterior cruciate ligament reconstruction, arthroscopic menisectomy, and meniscal repair surgery.


Volume 24 , Issue 2 , Pages 129-138 (April 2010)
http://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327%2810%2900031-X/abstract
www.sportsortho.co.uk


Please log in to view the content of this page.
If you are having problems logging in, please refer to the login help page.


© 2011 Orthoteers.co.uk Website by Regency Medical Marketing 
Biomet supporting orthoteersOrthoteers is a non-profit educational resource. Click here for more details
Bunion Surgery - The Scarf Osteoto...
Lesser Toe Surgery - Weil Osteotomy
Physiotherapy and rehabilitation af...
Physiotherapy and rehabilitation af...
Physiotherapy and rehabilitation af...
Physiotherapy and rehabilitation af...
Physiotherapy and rehabilitation af...
OWLS Advertise on Orthoteers
Orthoteers Junior Orthoteers Orthopaedic Biomechanics Orthopaedic World Literature Society Educational Resources Image Gallery About Orthoteers Orthoteers Members search
Hide Menu