Accelerated rehabilitation after meniscus surgery
Gobbi A, Ramces F, Zanazzo M*
Orthopaedics Arthroscopy Surgery International, Milano and *Azimut Riabilitazione, Biella, Italy
In the world of rehabilitation, the term accelerated is particularly in vogue in these last years; but
how is related with our daily practice? Before selecting a particular surgical technique, the surgeon
considers the patient's age, health, lifestyle, and willingness to undergo major surgery and the
location and type of meniscal tear. Pre-operative planning also includes anticipating what can be
encountered intra-operatively which can include meniscal lesions located medially or laterally,
determining the possible mechanism of tear (traumatic lesion from degenerative) and treatment
options available (meniscectomy versus isolated meniscal repair). Patients should be educated about
the pros and cons of the surgery and the extent of their subsequent rehabilitation program. Older or
more sedentary patients are generally more effectively treated with a conventional partial
meniscectomy. Patients should also be informed about the treatment outcome based on which
meniscus was injured and the type of tear that occurred. Chatain et al. (1) reported that patients who
underwent partial lateral meniscectomy did less well than those who underwent partial medial
meniscectomy. Northmore-Ball & Dandy (2) reported a slightly greater frequency of excellent
clinical results after partial medial meniscectomy than after partial lateral meniscectomy.
Is physiotherapy following meniscectomy really required?
Whether or not physiotherapy is required may also depend on the presence or absence of
preoperative strength deficits, and on whether the dominant or non-dominant leg are injured. St
Pierre (3) says, physiotherapy intervention, may not be justified for these patients, except in
professional athletes where a faster return to preoperative status may be desired.
Even if some studies says there is no big improvement in terms of number of days to return to work,
kinematic analysis of knee function during level walking and stair use and vertical and horizontal
hopsafter a partial meniscectomy, we believe that a supervised rehabilitation is always desirable
after a surgical procedure.
In degenerative problems of the meniscus we should never accelerate but, matching with patient
reaction, help him in the progression of weight bearing and neuromuscular work. Normally these
patients use crutches from 5-10 days in cases where cartilage is good, to 30-40 days when a surgery
procedure on cartilage is needed. Supervised exercises are proposed for 2 to 3 months.
Patients who undergo surgery for a traumatic lesion, do not always undergo formal rehabilitation.
However, surgeons prefer that a post-surgical rehabilitation be supervised. Athletes usually desire
minimum recovery time for obvious reasons. More often, physiotherapy also involves advising
patients to slow down, not accelerate. The goal, in any case, is to give the fastest recovery possible.
Many studies give 2-4 weeks as the time needed to go back to normal activity and 4-6 to full sport
practice. An important transition period is when patients pass from therapists to trainers: here,
emphasis is placed on continuity of load and intensity of rehab work.
The biggest discussion in the scientific community is about meniscal repair. Degenerative meniscal
tears display poor repair potential due to the insufficient tissue integrity of both the lesion site and
the adjacent meniscal tissue. Some authors have recommended partial meniscectomy as the surgical
treatment of choice for patients older than 30 years. Very good results when ACL reconstruction is
associated, more attention is needed when is isolated.
Differences in protocols are fundamentally about weight bearing and flexion in the post-op.
Traditionally, a brief period (4 to 6 weeks) of decreased mobility after meniscal repair is
recommended; however, the authors of more recent reports recommend early ROM have no
deleterious effects on meniscal repairs and have suggested that this approach improves articular
cartilage health. Findings in numerous studies support limited weight bearing during the initial 4 to
6 weeks after meniscal repair. In theory, weight bearing alone should not disrupt healing meniscal
tissue, because the hoop stresses are primarily absorbed at the periphery of the meniscus. More
recent reports have recommended earlier weight bearing to promote the restoration of a functional
meniscus. Patients are instructed not to force flexion after 90° for the first 3-4 weeks but with the
absence of pain during flexion, gentle cycling on a stationary bike can be started. Full weight
bearing depends on the grade and location of the tear, and the type of repair utilized: normally this
is allowed at around the 4th week. Running and dynamic exercise are proposed after 2 months and
return to high demand sport activity is permitted after 3 months.
Full Weight-Bearing Flexion Running Sports
Partial meniscectomy 3-5 days free 15 days 3-6 weeks
Meniscal repair 2-4 weeks <90° for 3 weeks 2 months 3-4months
Clarifications have to be made to specify what is really accelerated rehabilitation and what is not.
We have to match associated lesion, pre-injury condition, subjective expectations and goals of
patients regarding their sporting activity. Because we plan for what is best for our patients, we have
to balance what can be achieved at a reasonable timeframe post-operatively to minimize the risks of
possible complications.
References
1. Chatain F et al. A comparative study of medial versus lateral arthroscopic partial meniscectomy
on stable knees: 10-year minimum follow-up. Artrhroscopy. 2003; 19: 842-9
2. Northmore-Ball MD & Dandy DJ. Long term results of arthroscopic partial meniscectomy Clin
Orthop 1982; 67: 34
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3. St-Pierre D. Rehabilitation following arthroscopic meniscectomy. Sports Med 1995; 20:338-47