Rehab Considerations: Meniscus

Transcription

1 Rehab Considerations: Meniscus Steve Cox, PT, DPT Department of Orthopaedics School of Medicine University of Texas Health Science Center at San Antonio 1

2 -Anatomy/ Function/ Injuries -Treatment Options - -Meniscectomy -Meniscal Repair: -Restricted vs Accelerated -ACL and the Meniscus -Evidence Medial meniscus -Crescent shaped -Fused to MCL (1) -Less mobile -Stressed by tibial ER/ femoral IR -Outer 1/3 has better blood supply (1) Lateral meniscus -Circular shaped -More mobile -Stressed by tibial IR/ femoral ER -Avascular inner 2/3 and posterolateral portion (1) Anatomy Photo: 2

3 Function (1, 8, 2, 5, 9, 13, 12) -Shock absorber/ load transmission throughout tibiofemoral joint % of the axial load transmitted through each compartment is dissipated by menisci -Increases congruency of joint -Joint stability -Aids in joint nutrition/ lubrication -Proprioception Photo: Injuries -Types of tears: longitudinal, bucket handle, degenerative, radial -Incidence of 61 cases/100,000 persons (10, 12) -Twisting injury in A CKC position (12) -Greater incidence of MMT than LMT (8) -Seen with MCL and ACL injuries -Most common are radial tears in posteromedial compartment (avascular zone) (12) -Meniscal tear patterns behave differently when subjected to physiological loads (3,6,7) -Avascular regions have poor repair and remodeling capabilities (1) Photo: 3

4 Treatment Options: vs. Meniscectomy vs. Meniscal Repair Photo: See Appendix Conservative Treatment: includes but not limited to: GOALS: -Control inflammation/ swelling/ pain -Adequate quad and hip abduction strength -Protect healing tissues- avoid stressing movements -Full extension ROM TREATMENTS: -Muscle strengthening, knee stretching, patellar mobilization, modalities, neuro reeducation act -Gait training -Return to sport/ activity 4

5 Meniscal Repair + -Allows for joint preservation (12) - -Greater technical demands of surgeon (2) -Longer surgical time (2) -Historically, a more restricted rehabilitation to follow (2) Meniscectomy + -Indicated for radial tears in vascular area (11) -Rehab is simpler and faster; no protection (12) - -Increased point loading within knee joint (12, 2) -Alters joint mechanics (2) -Leads to earlier onset OA (5) Post-Op Meniscectomy: includes but not limited to: -Possible use of hinged knee brace -Control pain, swelling, and inflammation -Full extension ROM -Independent quad set -Gait training: possible need for AD -WB progression, ROM progression, and LE strengthening progression per tolerance as there is no repair to protect (11, 12) 5

6 Meniscal tears and the ACL ACL and meniscectomy - Exposes the ACL to increased strain (14) ACL and meniscus repair - Protective of meniscus repair relative to WB and ROM per surgeon Post-Op Meniscal Repair: includes but not limited to: Continuation of meniscectomy except: -Restricted vs Accelerated: -WB and ROM restrictions vs. Immediate ROM and WBAT -Protected WB(NWB/ TTWB) and controlled ROM up to 90º (8) + of Accelerated protocol -Compliance may be improved in an accelerated program (2) -Early WB and ROM may avoid decline in function associated with disuse seen in restricted protocols (5) 6

7 Research shows: (10) Accelerated vs Restricted Meniscal Repair: -Neither knee position nor load was found to consistently result in loads large enough to cause failure (3) -Mobilization promotes blood flow versus immobilization (4) -105 studies reviewing outcomes revealed both restricted and accelerated rehab protocols showed similar good to excellent results (2) -No detrimental difference between clinical success rates (5) -O Donnell et al reviewed 15 articles (512 repairs) and found the respective rehab protocol and even the type of surgical treatment were dependent upon (5): - Type of tear - Size of tear - Acute versus chronic tear - Fixation technique - Patient demographics 7

8 Appendix- protocols References: 1. Gray JC: Neural and vascular anatomy of the menisci of the human knee. J Orthop Sports Phys Ther 29:23 30, VanderHave KL, MD et al: Weightbearing versus nonweightbearing after meniscus repair. Sportshealth vol 7 no , Becker R et al: Distraction forces on repaired bucket-handle lesions in the medial meniscus. Am J Sports Med 34: , Bray RC et al: Vascular response of the meniscus to injury: effects of immobilization. J Orthop Res 19: , O Donnell K, MD et al: Rehabilation protocols after isolated meniscal repair. Am J Sports Med vol 45, no , Jones RS et al: Direct measurement of hoop strains in the intact and torn human medial meniscus. Clin Biomech vol 11, no ,

9 References: 7. Staerke C et al: Tensile forces on siutures in the human lateral knee meniscus. Knee Surg Sports Traumatol Arthrosc vol 17 no , Logan M, MD et al: Meniscal repair in the elite athlete. Am Jour Spoets Med vol 37, no , Antinolfi P et al: Relationship between clinical, MRI, and arthroscopic findings: A guide to correct diagnosis of meniscus tears. Joints 5: , Antonio F et al: The meniscus tear. State of the art rehabilitation protocols related to surgical procedures. Muscles, Ligaments and Tendons Journal vol 2 no , Brindle T et al: Review of basic principles with application to surgery and rehabilitation. J Athl Train vol 36 no , 2001 References: 12. Patil SS et al: Meniscal preservation is important for the knee joint. Indian J Orthop vol 51 no , Heckman TP et al: Meniscal repair and transplantation: Indications, techniques, rehabilitation, and clinical outcomes. J Ortho Sports Phys Ther vol 36 no , Sprang JT et al: The effect of medial meniscectomy and meniscal allograft transplantation on knee and anterior cruciate ligamanet biomechanics. Arthroscopy vol 26 no ,