Meniscus Repair Rehab Protocol

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The goal of this protocol is to provide a clinical guideline for the post-surgical course of physical therapy for a patient who has had a knee meniscal repair surgery.  This is not intended to substitute clinical decision making regarding the patient’s proper progression based on evaluation findings, individual progress, and if/when post-operative complications arise.  If a clinician requires assistance in the progression of a post-surgical patient the surgeon should be consulted. 

GENERAL GUIDELINES:

• Partial weight-bearing (PWB) status (<50%) or Non-Weightbearing (NWB) per MD orders.
•  Walk with crutches. Heel lift in opposite shoe to normalize gait.
• Surgical knee will be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks post-op.
• Regular assessment of gait to avoid compensatory patterns.
• Regular manual mobilizations to surgical wounds and associated soft tissue to decrease the incidence of fibrosis.
• No high impact or cutting / twisting activities for at least 6 months post-op.
• No resisted lateral movement for 12 weeks.
• During the first 4 weeks: TWICE PER DAY: Without brace, allow GRAVITY ONLY (passive only) to bend knee back as tolerated BUT NO MORE THAN 90 DEGREES for a good knee stretch without increase in pain. Relax knee and stretch for 60 seconds.
• Pass VTFC Knee Functional Performance Test 1 at 3 months
• Pass VTFC Knee Functional Performance Test 2 at 6 months
• Return to work as directed by PT/MD based on work demands

Rehabilitation Progression

PHASE I: Week 0 – 4:

Goals:

• Protect meniscus and minimize effects of immobilization 
• Decrease pain, promote an optimal healing environment, and control inflammation/swelling.
• Re-establish quadriceps control 
• Full passive and active knee extension/hyperextension range of motion.  
  • Avoid hyperextension greater than 10 degrees. 
• Week 1: Passive range of motion 0-70 degrees.  Week 2-4: Passive range of motion 0-90 degrees.
• Gait: Partial-weight bearing (<50%) with brace locked in extension. Crutches used with gait.
• Educate patient on rehabilitation progression.
  • Keep knee straight when sitting or lying down.  Do not place a towel behind knee. 
  • Do not actively bend your knee; support surgical leg with transfers.
  • Do not pivot on your surgical leg.

Brace:

• Surgical knee will be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks post-op.

Weight Bearing Status:

• Non-weightbearing or partial weightbearing status (<50%), unless otherwise ordered by MD. Walk with crutches. Heel lift in opposite shoe to normalize gait.

Exercises:

• Game Ready / Ice and elevation every 2 hours for 15-20 min each session.
• Soft tissue treatments for edema/pain control and to posterior musculature, ITB, add, quad, calf. 
• No direct palpation of surgical portals x 4 weeks.
• Straight leg raise exercises (lying, seated, and standing), quadriceps/adduction/ gluteal sets, ankle pumps.
• NMES supine knee extensions
• Well-leg stationary cycling, upper body ergometer for cardio. Add upper body and core conditioning.
• Daily edge of bed dangle for passive knee flexion (allow knee to hang in pain-free range with light stretch).

PHASE II: Weeks 4-8:

Criteria to advance to Phase II:

• Full extension
• Good quad set, SLR, without extension lag
• Flexion to 90°
• Minimal swelling/inflammation
• Normal gait on level surfaces

Goals:

• Gait- unlock brace; wean off brace and crutches. Emphasize proper gait mechanics.
• Passive range of motion 0-120 degrees.

Brace/Weight Bearing Status:

• Wean off the use of rehab brace.

Exercises:

• Stretching, exercises and manual treatments to improve range of motion (especially flexion). 
• Initiate surgical portal scar mobilization if portals are completely closed.
• Incorporate functional exercises (i.e. partial squats, calf raises, mini-step-ups, proprioception).
• Stationary bike low cadence, low resistance.
• Aquatic Treadmill: Slow walking on treadmill for gait training 

Phase III:  Week 6 to 12:

Criteria to advance to Phase III:

• No patellofemoral pain
• Minimum of 90° of flexion
• Sufficient strength and proprioception to prepare for higher-level closed chain exercises(aquatic treadmill)
• Minimal swelling/inflammation

Exercises:

• Complete VTFC Knee Functional Performance Test 1
• Continue with soft tissue, joint mobilizations, as needed for ROM, decrease pain, muscle guarding.
• Add lateral training exercises (side-step ups, lateral stepping).
• Introduce more progressive closed chain and agility leg exercises.
• Patients should be pursuing a home program with emphasis on sport/activity-specific training.
• Increase the intensity of functional exercises (i.e. cautiously increase depth of closed-chain exercises., Shuttle/leg press). Do not overload closed or open-chain exercises.

Goals:

• Gait- no limp present, good mechanics.
• Week 8: Passive range of motion 0-135 degrees.
• Tolerate 90/90 squat.
• Week 12: Full range of motion.
• Initiate lateral training with no resistance.

Phase IV: Week 12 to 16:

Criteria for advancement to Phase IV:

• Gait- no limp present, good mechanics.
• Full range of motion.

Goals:

• Prepare for VTFC Knee Functional Performance Test 1 at 3 months post-surgery
• Complete and Pass VTFC Knee Functional Performance Test 1
• Return to sports clearance.

Exercises:

• Low-impact activities until 16 weeks.
• Increase the intensity of strength and functional training for gradual return to activities.
• Initiate resisted lateral training.