Meniscus Repair

The menisci are two fibrocartilaginious discs shaped like cresents. They deepen the articular surfaces of the condyles of the tibia and partially divide the joint cavity into upper and lower compartments. Flexion and Extension of the knee takes place in the upper compartment where is rotation takes place in the lower compartment. The medial meniscus is nearly semicircular being wider behind then in front. The posterior fibres of the anterior end are continuous with the transverse ligament. Its peripheral margin is adherent to the deep part of the tibial collateral ligament.

The lateral meniscus is nearly circular. The tendon of the popliteus and capsule separate this meniscus from the fibular collateral ligament. The mobility of the posterior end of this meniscus is controlled by popliteus. The menisci are attached to several structures so the motion of the menisci is limited to a greater extent.

The functions:

1) They help to make the articular surface more congruent. Because of the flexibility that can adapt their contour to the curvature of the femoral condyles, as it glides over the Tibia.

2) They serve as shock absorbers and they help in lubricating the joint cavity.

3) Because of their nerve supply they also have sensory function they give rise to proprioceptive impulses.

The mechanism of injury:

The medial meniscus is injured more frequently than the lateral meniscus. The meniscal injuries may occur during femur on tibia rotation during weight bearing when the foot is formally fixed on the ground. It may occur during pivoting, getting out of a car or in many sport or work related activity. At times the medial meniscus tear is accompanied by ACL tears. Simple squatting or high force trauma such as in gym activities may also cause meniscus tear.

Injury may cause:

Medial meniscus tear can cause acute locking of the knee or symptoms with intermittent catching /locking.

There is joint swelling and some degree of quadriceps atrophy with pain along the joint line during forced hyper extension for maximum flexion.

The knee does not fully extend during locking and there is springy end feel with passive extension.

Due to swelling usually end range flexion or extension motion limitation.

The McMurray test or Apley's compression test maybe positive.

The patient is unable to bear weight on the involved sides with unexpected locking or giving away during ambulation occurs.

It usually requires surgical management with pre and post operative physiotherapy for rehabilitation.

Post operative management

1) Immobilization

Immobilization by bracing is mandatory after surgery for about 4-6 weeks in the early phase of rehabilitation. The duration depends it depends on the type of procedure, quality of fixation and patient assessment post surgery. It is of two types:

a) Rehabilitative bracing: It uses a hinged orthosis with a locking mechanism that can restrict the allowable Range of motion. It is worn only for first 6 weeks following surgery.

b) Functional Bracing: Functional Brace is worn when returning to high demand activities such as sports or any avoid reinjury related to work demands.

The patient can be weaned from the brace at about 6 weeks once full extension is achieved. Full, active extension and 90-100 degrees of flexion is expected by 4 to 6 weeks post surgery.

During Day 1 to Week 4

Goals:

Protect the healing tissues.

Prevent reflex inhibition of muscles

Decrease joint effusion while working on the Range of motion of knee joint.

Home Exercise program.

Intervention:

1) The patient is instructed to apply hot fomentation before exercises on the surrounding muscles of the knee i.e. thigh, hamstring muscles behind the thigh and calf muscles. No Hot fomentation on the knee.

2) Icing is mandatory around the knee joints after exercises and at least every two hours to reduce pain and swelling in the knee.

3) Maintain compulsory bracing, rest, ice compression and mobility through exercise.

4) Gait Training: Teaching the patient to walk with the walker or crutches.

5) Muscle setting exercises: Static Quads, Static hams, static glutes.

6) Active or Passive Movements: ATMs, SLR, Abduction and side lying exercises.

7) Stretching exercises for the calf and Hamstring.

Week 5- Week 10

Goals:

Full, painfree ranges

Strength: 4/5

Dynamic control of knee

Normal walking and activities of daily living.

Intervention:

1) Advanced Strengthening exercises and flexibility exercises.

2) Stabilization exercises

3) Balancing Exercises

4) Proprioceptive training

Week 11- Week 24

Goals:

No joint instabilty

Full Knee ROM and strength.

Symmetrical Gait.

Unrestricted ADL

Reduce risk of reinjury

Intervention:

1) Initiate running, jumping.

2) Advanced closed chain exercises

3) Initiate plyometric drills e.g. bouncing, jumping ropes

4) Simulated Work or sport specific training.

5) Transition to full speed jogging, running.

Reference:

1) B.D Chaurasia Anatomy

2) Maggee

3) Therapeautic Exercise: By Carolyn Kisner.

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