Role of Strength Training and Therapeutic Activities as a Rehabilitation Protocol After Meniscus Repair for Return to Functional and Recreational Activities: A Case Report
Original Editor -Dr. Jyoti Jani
Top Contributors -Dr. Jyoti Jani
Abstract[edit | edit source]
Background And Purpose: The meniscus is an important part of the knee joint. The crescent-shaped soft tissue structure plays an important role to provide significant stability, shock absorption performance, and lubrication for the joint. Post-op rehab is important to regain and maintain all these qualities. Meniscus injuries are common and are caused by any distortions due to poor muscle strength, balance and movement control, sudden turns, and high-impact sports-related injuries. Therefore, rehabilitation after the repair is important to improve pain, range of motion (ROM), strength and return the patient to prior functional activities. The purpose of this case report is to describe the effectiveness of strength training and therapeutic activities to regain the prior level of function in the patient with post-operative complex meniscus repair.
Case Description: This patient is a 31-year-old male post-op status of meniscus repair in the maximum protection phase is 12-14 weeks, with rehabilitation occurring for up to 6-10 months by using the phase-wise progressive examination.
Outcome: Outcomes measures used in this case were the Lower Extremity Functional Scale (LEFS) and manual muscle testing (MMT) which were improved by 90% from initial examination to discharge. This patient gained maximum benefits from treatment and returned to full functional activity of daily living (ADL) activities in 12 weeks and recreational sports in 6-10 months.
Discussion: A phase-wise rehabilitation is best for the patient with meniscus repair to meet the desired goal of pain relief, Improved strength, and lower extremity functions.
Background and purpose[edit | edit source]
Background and purpose:
Menisci are the major structures of the knee joint consists medial and lateral parts located between femoral condyles and the tibial plateau.1 Meniscus injuries are the most common result of wear and tear of the knee due to lack of stability at the knee joint and can be one of the early signs of osteoarthritic changes of the knee. Studies show the incidence of meniscus tear both simple and complex is at 60 individuals per 100,000, being 80% more common in men than women.2
The meniscus is an avascular structure, so it takes more time to heal conservatively. The meniscus plays an important role in maintaining congruency of joint surfaces, shock absorption, and distributed transmission of forces while doing high-impact activities such as running.2 The majority of complex meniscus tears requires surgery and post-operative physical therapy (PT) rehabilitation to regain proper function and maximum strength to return to activities. 2
This case report presents a case of a 31-year-old male who sustained a sudden sports-related injury followed by a complex meniscus tear with 50% improved muscle guarding as a compensatory mechanism. The purpose of this case report is to highlight the complete progression of 6-10 months of functional rehabilitation which was divided into 3 phases: maximum protection phase moderated protection phase and return to sports via strength training and therapeutic activities.
Client Characteristics and system review[edit | edit source]
The patient was a 30-year-old male cricket player. He was seen at a PT outpatient facility 10 days after post-operative meniscus repair for rehabilitation. The height of the patient is 71 inches; his weight was 175 pounds. This patient injured his knee during cricket in February 2020. He went
for conservative management for 6 weeks, but his pain intensity did not reduce. His orthopedic surgeon ordered an MRI, which showed a medial meniscus tear with posterior horn complex overlapped flapping The patient was sent to surgery and referred to an outpatient facility with partial weight bearing (PWB) status.
At the initial evaluation, the patient’s chief complaints were reduced strength, range of motion (ROM), and increased pain with ambulation. The patient reports that before surgery his pain was intense, sharp, and radiated down the upper shaft of the medial border of the tibia. The patient had a feeling of his knee giving way with walking or any light recreational activity. The patient's general health is excellent as he is an athlete. The patient did not have any other systemic comorbidities except musculoskeletal deficiency related to his injuries such as joint edema, reduced flexibility, and ROM. The patient’s goal is to continue PT to return to sports by improving strength and mobility and to regain his ability to safely participate in cricket next summer.
Examination Findings[edit | edit source]
When the patient was seen at the PT clinic for the first visit, his weight-bearing status was 50% partial weight-bearing with bilateral axillary crutches. Objective examination shows the patient had significant muscle guarding of hamstring and grade zero joint effusion. He rated his pain as 3-4/10 on the VAS scale. The LEFS was used as an outcome measure to determine the difficulty of tasks in the daily activity of living. The total score at the initial evaluation was 29/80. The LEFS has a test-retest reliability of .94 which is excellent; its minimal detachable change (MDC) is 9 with a confidence interval of 90%.3 His knee ROM and MMT are presented in Table 1.
Clinical Hypothesis[edit | edit source]
CLINICAL IMPRESSION #1
Considering the patient's history and preoperative MRI, this patient is a good candidate for rehabilitation with excellent rehab potential. Further examination will include various functional and strength measurement tools such as the LEFS and MMT to determine appropriate criteria to create a plan of care.
CLINICAL IMPRESSION #2:
Based on the detailed examination patient has excellent rehabilitation potential. It is expected that strength training and therapeutic exercises will increase ROM, strength, and his LEFS score. The patient will be progressed from PWB to full weight bearing (FWB) followed by a return to sport with advanced agility training.
Intervention[edit | edit source]
PT intervention consisted of 3 phases to achieve maximum goals of rehabilitation after Meniscus repair.
Phase 1: (post-op 0-4 weeks)
The initial phase of intervention aimed to restore established goals for the early/maximum protection phase, goals were to prevent post-op swelling, pain relief, progression to FWB, regain maximum ROM at the knee as tolerated by the patient, and activation of knee stabilizers.
Education was provided to the patient for crutch use, activity modification for ambulation, turning, sitting to standing transitions. Patellar mobilization grades 1-2 and cryotherapy were used to reduce pain. The plan involved in this phase were, active-assisted and passive ROM of knee movements, along with knee, active-assisted ROM at hip flexion, extension, and abduction were also included. The quadriceps activation via muscle setting of quads (isometric quadriceps contraction), and muscle settings for hamstring, and adductor.
The above-outlined intervention was followed by the patient 2-3 times daily including clinic and home exercises programs. At the end of the first phase, pain progressed to full weight-bearing, nearly full ROM at the knee. Reduced joint inflammation and pain relief by 90%
Phase 2: (4-6 weeks)
Phase 2 is considered a moderate protection phase. As the post-op pain and joint edema subside, the second phase of rehabilitation starts with FWB status. The patient was started with re-established goals of functional rehabilitation which were to achieve full pain-free AROM, improve muscle strength at the knee and hip stabilizers by grade 5/5, and improve balance and proprioception.
In this phase, the patient was started with full AROM at the hip and knee joint, which was comprised of heel slides standing straight leg raises focuses on iliopsoas, gluteus medius, and hip extensor group of muscle. All were performed as 3 sets of 10 repetitions. Closed chain exercises such as mini squats, supported stair training, light resistance exercises were initiated and brought up to maximum resistance exercises by the end of the late subacute phase. Cold therapy was used for this patient in phase 2 as needed when significant soreness was noted after the session. By the end of this phase, the patient was able to tolerate all the resistance exercise with improved strength and endurance.
Phase 3: (6 weeks-return to sports)
This is the minimum protection phase or returns to sports. The patient returns to fully functional status by the end of Phase 2 with muscle strength 5/5 bilaterally, pain 0/10 on the VAS scale, and complete AROM. Phase 3 was comprised of transitioning to recreational activities, resuming cricket, and reinforcing long-term joint protection.
This phase was primarily focused on plyometric and agility training. balance exercises on the Bosu board, neurocognitive training, wobble board exercises for proprioceptive responses, heel dig hamstring curls followed by Nordic hamstring curls with variations as tolerated by patient and lateral walking with squats using gray resistance belt were performed as 3 sets of 30 repetitions, single-leg squats at 1 set of 30 repetitions, as well as re-education for running, jumping, twisting, and turning.
After the completion of phase 3, the patient continued the home exercise program for about 10 months and prepared for a cricket tournament in the summer.
Outcome[edit | edit source]
In the conclusion of the patient rehabilitation, the patient demonstrated a 100% LEFS score, demonstrating that the patient has gained full functional integrity of the knee joint. He reported his pain level post-rehabilitation remained 0/10 on the VAS. All the outlined measures were included in the outcome noted at the time of discharge and will be measured after 10 months of follow-up right before the patient started playing cricket again.
The LEFS was used as a primary outcome measure, that in phase 2 of rehabilitation, the patient improved in 50% of criteria for activities, such as standing on the ground for 1 hour, walking, getting out of the car, heavy activities around the house, going up and down the stairs partial squatting was gained without any difficulty at the end of the second phase of rehabilitation. The remaining activities such as hopping, pivoting, running on even and uneven surfaces were accomplished during the recreational phase. Detailed measurements of ROM, strength, and LEFS are found in table 1.
Discussion[edit | edit source]
The purpose of this case report is to report on return to 100% of function for a post-operative meniscus repair through therapeutic exercises. The interventions resulted in meeting the goals which were established during phases of rehabilitation. The treatment plan in this case report was able to provide maximum joint and meniscus protection for the long term.
Therapeutic exercise and neuromuscular and progressive agility training require an established protocol to meet the functional requirements to return to the specific sports.4 The patient in this case report demonstrated compliance with PT for a successful outcome. Individuals' needs should be accounted for to motivate and educate the patient throughout rehabilitation. Meniscus repair and rehabilitation play a key role in the significant preservation of the joint to prevent future integrity of the joint, as every post of surgery for meniscus repair requires an optimal rehabilitation duration to return to sports or any progressive recreational activities.5 Each surgery and rehabilitation should have a set goal for athletes to provide evidence-based rehabilitation.6 Evidence supports post meniscus rehabilitation more than 60% of athletes can return to play, at their prior level of function.7
In conclusion, the outlined intervention for the patient who is a professional cricket player was achieved in 6-10 months of complete rehabilitation via progressive therapeutic exercises, with the achievable goal of return to cricket tournament without any recurrent injury or impairments which could prevent him to play.
Tables[edit | edit source]
|Measures||Initial evaluation||At 6th week post injury||12th week post injury|
|Right knee AROM|
|Right knee strength|
|Right hip strength|
|Clinical outcome measure|
References[edit | edit source]
1. Makris EA, Hadidi P, Athanasiou KA. The knee meniscus: structure–function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials. 2011 Oct 1;32(30):7411-31.
2. Bhan K. Meniscal Tears: Current Understanding, Diagnosis, and Management. Cureus. 2020 Jun;12(6).
3. Binkley JM, Stratford PW, Lott SA, Riddle DL, North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Physical therapy. 1999 Apr 1;79(4):371-83.
4. Pabian P, Hanney WJ. Functional rehabilitation after medial meniscus repair in a high school football quarterback: a case report. North American journal of sports physical therapy: NAJSPT. 2008 Aug;3(3):161.
5. Spang III RC, Nasr MC, Mohamadi A, DeAngelis JP, Nazarian A, Ramappa AJ. Rehabilitation following meniscal repair: a systematic review. BMJ open sport & exercise medicine. 2018 Apr 1;4(1):e000212.
6. Wiley TJ, Lemme NJ, Marcaccio S, Bokshan S, Fadale PD, Edgar C, Owens BD. Return to play following meniscal repair. Clinics in sports medicine. 2020 Jan 1;39(1):185-96.
7. Fried JW, Manjunath AK, Hurley ET, Jazrawi LM, Strauss EJ, Campbell KA. Return-to-Play and Rehabilitation Protocols Following Isolated Meniscal Repair—A Systematic Review. Arthroscopy, sports medicine, and rehabilitation. 2020 Dec 24.