REHABILITATION

PRE-POST (MENISCUS)
SURGICAL INTERVENTION
Damayanti Tinduh
Sport Injury Rehabilitation Division
Department of Physical Medicine and Rehabilitation
Dr. Soetomo General Academic Hospital
Faculty of Medicine Universitas Airlangga
Surabaya - Indonesia
Topics
• Meniscus
• Meniscal Injury
• Conservative vs Operative : What to be considered?
• Basic Principles of Rehabilitation Management
• Summary
Meniscus
The meniscus plays a key role in protecting the knee joint and preserving the articular cartilage
through :
- load distribution,
- shock absorption,
- lubrication
Loss of meniscal tissue via injury or meniscectomy can lead to altered joint kinematics that
increases local tibiofemoral contact forces, resulting in early degenerative changes.
Long-term repair outcomes after meniscus repair depend on :
- injury pattern,
- patient characteristics,
- intraoperative repair technique,
- diligent adherence to postoperative rehabilitation protocols ⇒ specific adaptations to
rehabilitation protocols, because different tear morphologies have unique biomechanical
considerations across repair sites ⇒ a tailored range of motion (ROM) and weight-bearing
protocol
 Meniscus

The menisci are a pair of Important function :

fibrocartilaginous semilunar-wedge 1. Load transmission
shaped discs that play a vital role in the 2. Shock absorption
normal functioning of the human knee. 3. Joint lubrication and nutrition
Lateral meniscus more mobile 4. Proprioception
5. Secondary restraints to anterior translation of the tibia , knee hyperextension
& protect joint margin
6. Facilitate joint gliding
 Meniscus
• Menisci are attached to • Fibrochondrocytes
– The tibia by : – Concentrated in the deeper portion of the menisci
• The coronary ligaments – Synthesize & maintain ECM
• Direct insertion of the anterior and posterior • Fibroblasts
horns into the bone 🡺 is adapted to transmit
sheer & tensile loads from the menisci to – Located in the meniscal surface
tibia – Produce matrix protein (collagen (>>Type I) &
– The joint capsule proteoglycan)
• Medial meniscus attaches to the deep layer • Facilitate load transmission across the knee joint
of the medial collateral ligament 🡺fiber-reinforced solid material 🡺 resistance to
• Lateral meniscus attaches loosely to the forces of tension, compression & shearing
lateral capsule • Resistance to “hoop stresses” during WB
• Posterior horn of the lateral meniscus is
attached to the medial femoral condyle
via the meniscal femoral ligaments
• The capsule attachments of the medial
meniscus are more secure than those of
the lateral meniscus
Hoop mechanism of the meniscus
• Due to its unique wedge-shape, the menisci have a key
role in redistributing compressive loads into tensile
forces around its circumference, thus reducing contact
stresses in the joint and preserving the articulating
surface; this is referred to as the 'hoop stress
mechanism'.

Cong T, Reddy RP, Hall AJ, Ernazarov A, and Gladstone J, 2024. Current Practices for Rehabilitation After Meniscus Repair. A Survey of Members of the American Orthopaedic Society for Sports
Medicine. The Orthopaedic Journal of Sports Medicine, 12(2), 23259671231226134 DOI: 10.1177/23259671231226134
 Meniscus Injury
• The rate of medial meniscal tears increases over time, whereas
lateral meniscal tears do not
• Meniscus Injury Risk Factors :
– Cutting and pivoting sports are risk factors for acute meniscus tears
– Increased age and delayed ACL reconstruction are risk factors for
future medial and lateral meniscus tears
– Female sex, older age, higher body mass index, lower physical
activity, and delayed ACL reconstruction are risk factors for medial
meniscus tears
 Risk Factor of Injury Injury Mechanism

Internal Risk Factors :

prf
• Age ----- x E x C = I
• Sex tms
• Body composition (body weight,
fat mass, BMD, anthropometric)
• Health (history of injury, joint
instability, general health) Exposed Susceptible Injury
• Physical fitness (muscle
strength/power, maximal O2
uptake, range of movement)
• Anatomy (alignment, gap Exposure of External Risk Factors : Inciting event:
between body parts) • Human factors (teammate, opponent, judges) • Playing situation
• Agility level (specific sport • Protective aids (helm, foot protection) • Player/opponent
technic, posture stability) • Sport equipment behavior
• Environment (weather, temperature, ground, • Biomechanics
maintenance) characteristic

A model of injury causation (Meeuwisse, 1994; Bahr & Krosshaug, 2005) Lunch Symposium JPMR 22 July 2017
 Meniscus Injury
Traumatic Atraumatic/degenerative
• Younger • Older
• Acute painful+swollen • Chronic/acute on
• Longitudinal or radial tears chronic/acute painful
• Horizontal cleavages, flap or
complex tears, or meniscal
maceration or destruction
 Meniscus Injury
2nd most common injury to the knee 🡺 almost one quarter of all knee injuries
• Prevalence 12-14%
• Incidence 61 cases/100 000 persons
• High incidence of meniscal tears occur with ACL injury (22-86%) &
prolonged delayed reconstruction
• High prevalence of meniscus tears are present in individuals undergoing
primary & revision ACL reconstruction
• In high school athletes : incidence in girls > boys
• Older individuals have higher rate of meniscus tears compared to younger
individual
• Lateral meniscus tears >> in younger athletes, and medial meniscus tears
>> in older people
Logerstedt DS, Scalzitti D, Bennell KL, et al. Knee pain and mobility impairments: meniscal and articular cartilage lesions revision 2018: clinical practice guidelines linked to the
International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther.
2018;48:A1–A50
 Meniscus Injury
• Individuals who sustain a meniscal tear report a similar history as an
individual with an ACL tear, such as feeling a “pop” while suddenly
changing direction with or without contact (twisting)
• Symptoms :
– Knee pain
– Delayed onset of effusion
– Catching
– Clicking
– Locking
• Signs :
– Painful ROM
– Joint line tenderness
– Positive provocative maneuvers (McMurray’s, Appley’s)
– Meniscal Pathology Composite Score > 3 positive findings
 Meniscus Injury
• Patients with knee pain (ICF b28016 Pain in joint) + mobility
disorders (ICF b7100 Mobility of a single joint) were classified
into the ICD category / diagnosis of MENISCUS TEAR
• Imaging Studies Meniscus Injury
• The Ottawa knee rule has a sensitivity of 0.99 and specificity of 0.49 🡺 A
knee radiograph series is required in patients with any of the following criteria:
• Aged 55 years or older
• Isolated tenderness of patella (no bone tenderness of knee other than patella)
• Tenderness of head of the fibula
• Inability to flex knee to 90°
• Inability to bear weight both immediately and in the emergency department for 4 steps
regardless of limping
• Clinical examination by well-trained clinicians appears to be as accurate as MRI
in regard to the diagnosis of meniscal lesions. A lower threshold of suspicion
of a meniscal tear is warranted in middle-aged and elderly patients. MRI may
be reserved for more complicated or confusing cases and may assist an
orthopaedic surgeon in preoperative planning and prognosis. Imaging may be
used to monitor the status of meniscus repair or articular cartilage repair or
restoration procedures.
 Hoop Stress integrity &
Meniscus Injury Rehabilitation
• Tailored rehabilitation of meniscal tears based on
the integrity of hoop stress and generally
permitted earlier weight-bearing for tears with
retained hoop stress while allowing 0 to 90 ROM
immediately after surgery, irrespective of tear
type.
• Most practitioners braced and utilized in situ
adjuncts for biological healing, while a minority
added extrinsic biologics.
• Rehabilitation recommendations could be provided
for each tear type, which is important, as there
remains a paucity of level 1 evidence studies to
inform rehabilitation guidelines for meniscus repair.

Cong T, Reddy RP, Hall AJ, Ernazarov A, and Gladstone J, 2024. Current Practices for Rehabilitation
After Meniscus Repair. A Survey of Members of the American Orthopaedic Society for Sports
Medicine. The Orthopaedic Journal of Sports Medicine, 12(2), 23259671231226134 DOI:
10.1177/23259671231226134
Conservative vs Surgery :What to be considered?
• The clinical course for most patients after meniscus injury managed
with or without surgery is satisfactory, though these patients will
report lower knee function compared to the general population
• Patients who have nonoperative management for meniscus tear
have similar to better outcomes in terms of strength & perceived
knee function in the short term and intermediate term compared
to those who had Arthroscopic Partial Meniscectomy (APM)
• Impairments in proprioception and muscle strength and poor
patient-reported outcomes are :
– present early after meniscal injury and in the short-term time period (<6
months) post APM 🡺 may resolve within 2y after APM
– perceived knee function and quality of life are < healthy controls as much
as 4y post APM
 Conservative vs Surgery :
What to be considered?
• Demographics, meniscus tear location, physical impairments, and
functional levels as determined by performance-based tests and
patient-reported outcomes can influence return-to-sport rates
after APM
• Young patients who have meniscus repair have similar to better
perceived knee function, less activity loss, and higher rates of
return to activity compared to those who have APM
– elite and competitive athletes or athletes younger than 30 years are likely
to return to sport less than 2 months after APM
– athletes older than 30 years are likely to return by 3 months after APM
 Surgery Procedure
• Partial meniscectomy is the primary surgical procedure used
to treat meniscus tears
• US : 10-20% of all orthopaedic surgeries consist of surgery to
meniscus 🡺 850 000 patients/year
– Individuals older than 45 years old >> meniscectomy
– Individuals younger than 35 years old >> meniscus repair
– The incidence rate of meniscus procedures (partial meniscectomies
and meniscus repairs) has substantially increased over the past
decade
 Healing Process after Meniscus Surgery
Barber-Westin & Noyes, 2014 evaluate 767 meniscus repairs in the R/W zone from 23 studies
• Concurrent ACL reconstruction was performed in 955 patients (78%)
• Of the repairs, 637 (83%) clinically healed (ie, no additional surgery, no obvious clinical
meniscus symptoms)
• The inside-out technique was used in 470 repairs, of which 382 (81%) clinically healed (range,
43% to 100%)
• All-inside suture systems were used in 297 repairs, of which 255 (86%) clinically healed (range,
20% to 100%)
• Age, chronicity of injury, involved tibiofemoral compartment, gender, and ACL reconstruction
did not adversely affect the results
• There were insufficient data to assess healing rates according to the type of meniscus tear
except for single longitudinal tears
• Long-term assessment of the chondroprotective effect of the repairs was performed in only 2
studies with >10 yr of follow-up

Barber-Westin SD and Noyes FR, 2014. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 1 (January), 2014: pp 134-146
Time needed to return to activities
Activity Uncomplicated menisectomy Meniscus repair surgery
Bear weight (put weight on knee Right away, as tolerated Right away, but only with a brace
while standing or walking)
Walk without crutches 2-7 days 4-6 weeks
Drive, if the affected leg is to be 1-2 weeks if : 4-6 weeks
used for gas and brake or for • Already regained motion with minimal
clutch pain
• No opioids
Regain full ROM 1-2 weeks Bending is typically restricted to not
more than 90 degrees for first 4-6
weeks to allow the meniscus to heal
Return to heavy work or sports 4-6 weeks, if : 3-6 months
• Already regained motion and strength
• Knee is not swollen or painful
 Rehabilitation Management after
Joint Injury/Repair
• Early controlled movement
– Cyclical compressive stress 🡺 naturally nourished in the joint and compressive stress helps the
cartilage to adapt and increase in thickness
– Shear stress 🡺 should be avoided as much as possible as it disrupts the articular cartilage fibers
resulting in wear
• In the early stages after surgery,
– Continuous Passive Motion (CPM) machine 🡺 controlled passive range of movement
– Gentle exercises for facilitated heel slide
• For the first few weeks :
– Controlled weight bearing with assistive device
– Controlled active range of movement with orthosis
 Postoperative Rehabilitation Management
• Early rehabilitation strategies
– Progressive motion : progressive active and passive knee motion following
knee meniscal surgery
• Early to late rehabilitation strategies
– Progressive weight bearing
– Progressive return to activity
– Supervised rehabilitation
– Therapeutic exercises (supervised progressive ROM exercises, progressive
strength training of the knee and hip muscles and neuromuscular training)
– Neuromuscular electrical stimulation/biofeedback
• Provide neuromuscular stimulation/re-education to increase quadriceps strength,
functional performance and knee function
Logerstedt DS, Scalzitti D, Bennell KL, et al. Knee pain and mobility impairments: meniscal and articular cartilage lesions revision 2018: clinical practice guidelines
linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J
Orthop Sports Phys Ther. 2018;48:A1–A50
A low load over a long duration is applied to the knee to improve Electrical muscle stimulation is applied to
extension. This stretch would be utilized for 10 to 12 minutes, 3 to 4 the quadriceps to enhance muscle
times per day contraction
Weight-bearing exercises performed on a Functional exercises: lateral lunges Progressive loading program may include
‘‘balance trainer’’ device (UniCam Inc, performed onto foam to stimulate running on an elliptical trainer
Ramsey, NJ). Feedback regarding percent proprioception and neuromuscular
body weight on each lower extremity is control while reducing ground reaction
provided forces
Training Load
• Training load is important to consider due to the
competitive mentality of athletes to be the best;
training harder and longer will enable them to
perform better.
• This training mentality often pushes athletes to
extreme physical limits. Overloading does not
only cause overuse injuries; it is thought to
contribute to acute soft tissue injuries as well.
• Gabbett 2016, describes the ‘Training-Injury
Prevention Paradox’ established from current
evidence that non-contact soft tissues injuries
are a result of an incorrect training regimes.
– Consistent loading from training has a reduced risk
of injury of less than 10% (based on extrinsic
factors or intrinsic factors (rateable perceived
value)) if training load was 5% less or 10% more
than the previous week.
– Injury risk increased rapidly to between 21% and
49% if the load increased by 15% or more.
Gabbett T. The training-injury prevention paradox: should athletes be training
smarter and harder? Br J Sports Med 2016;50:273-280. Doi:10.1136/bjsports-2-15-
095788 [published Online First: 12 January 2016]
 Neuromuscular Re-education
One Cognition Another
motor Being active motor
behavior Feed-back/forward behavior
adaptive Repetition adaptive
state state
Similarity
CNS HIGHER CENTERS
• Headquarters at cerebral cortex
• Motor commands can be issued in the
absence of sensory stimulus
Cognitive • Responses to stimuli are modified on the Autonomous
bases of planning, memory & learning
Cognitive motor Motor programmes
Conscious Subconscious
Reflex response
Fragmented Continuous patterns
Energy consuming PNS Energy efficient
Dominance of co- Somatic Somatic Less co-contraction, more
contraction strategy sensory motor reciprocal activation
Ability only to perform the pathways pathways Able to multitask
particular task
Much error Little/no error
Need guidance No guidance
Receptors in
head, neck, body Skeletal muscles
wall, limbs
 • Goal adjustment, sense of loss • Relief, escape from pressure
• Optimistic, pessimistic beliefs • Fear of movement, reinjury
• Pressure, stress perceptions • Burnout, fatigue, recovery
• Impression management • Sadness, depression, grief
• Meaning interpretations • Anxiety, fear, tension
• Challenge appraisals • Emotional inhibition
• Causal attributions • Anger, frustration
• Self-perceptions Cognition Affects • Feeling of guilt
• Pain perceptions • Vigor, boredom
Interpretations Emotions
Appraisals Feelings
Beliefs Moods
Biopsychosocial model of post-
sport injury response and recovery
(Reprinted by Wiese-Bjornstal, 2010)
Results Efforts
Effects Actions
Surgery vs Consequences Activities
• Health status • Malingering
Conservative • Healing effects Outcome Behavior • Risky behavior
• Relapse, reinjury • Substance use Psychology
• Recovery progress • Suicidal behavior
Stem Cell • Sport performance • Social connection
• Functional outcomes • Coping, help seeking Rehabilitatio
• Rehabilitation results • Exercise dependence
Rehabilitation • Return to training or play • Psychological interventions
n
• Career transition, termination • Rehab adherence, compliance

27
 Summary
• Understanding the mechanism of injury
• Understanding about hoop stress mechanism & integrity to
prescribe the rehabilitation program after meniscus injury
• Regimen of Meniscus Rehabilitation should involve the load &
proprioceptive reeducation
• Understanding factors contributing in meniscus injury recovery
Thank you