King Khalid University Hospital Rehabilitation Department Ortho Group Rehabilitation Protocol: MENISCAL REPAIR: 1. General Guidelines: Time lines in this rehabilitation protocol are approximate. If the physiotherapist feels the patient is not ready for progression (due to pain, swelling, inadequate ROM or strength), the time line should be extended to suit the patient. Assume 8-12 weeks for adequate healing of Meniscal repair. Time lines in this rehabilitation protocol are approximate. If the physiotherapist feels the patient is not ready for progression (due to pain, swelling, inadequate ROM or strength), the time line should be extended to suit the patient. Patients should be encouraged to exercise independently 3-5 times / week in addition to formal physiotherapy. If there is ANY uncertainty concerning the patient, please contact the surgeon. Functional Milestones: Common functional activities the patient is expected to perform during each rehabilitation phase. Advancement Criteria: Objective criteria used to judge whether or not a patient is ready for progression to the next phase of rehabilitation (see Rehabilitation Progression below). 2. General Precautions: Knee flexion 90 o on all weight bearing exercises (squats) x 4 weeks. Medial Meniscus: Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% Body weight) up to 4 weeks post op. Full weight bearing at 4 weeks as directed by surgeon. Lateral Meniscus: Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% Body weight) up to 6 weeks post op. Full weight bearing at 4-6 weeks as directed by surgeon. Crutches: brace and crutches for 4-6 weeks as directed by the surgeon Avoid weight bearing with twisting exercises (i.e. BAPS board) for a minimum of 6-8 weeks post op. 3. Rehabilitation Progression: The following is a guideline for progression through the rehabilitation process. Progression is based on achieving advancement criteria for the next phase of rehabilitation and should take into account the patient s status and the surgeon s advisement If the patient does NOT meet the advancement criteria, extend the time in the current phase of rehabilitation. If the patient achieves the advancement criteria early, the physiotherapist may choose to advance the patient only AFTER 6 weeks post-op. If there is ANY uncertainty concerning the patient, please contact the surgeon. 4. Surgeon Advisement:
PHASE I Immediate Post-Op - 3 Weeks Post-Op Protect the Meniscal repair. Decrease post-op pain and inflammation (can utilize Cryo-cuff for 8-12 hours/day x 2 weeks). Minimize the effects of immobilization (can utilize C.P.M. for 8-12 hours/day x 2 weeks). Educate patient on rehabilitation progression. 2. Brace / Crutches / Weight Bearing: Brace: Elastic dressing worn at all times to keep compression on the knee. Brace worn at all times, except when under the supervision of the physiotherapist and when bathing. Weight Bearing / Crutches: Crutches 4 to 6 weeks, Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% WB) (medial 4 weeks / lateral 4-6 weeks). Ice after exercise program x 15 min. Week 0 2: Knee flexion 90 o and Non-weight Bearing for all exercises PROM exercise as tolerated (i.e. prone extension hang, heel slides, wall slides). Quad sets and hamstring sets (may consider muscle stimulation if poor quads). Isometric quad exercises, multi-angle 60 o / 0 o Straight leg raise (with brace until no quad lag) in all planes. Hamstring / Gastroc & Soleus stretches. Patellar mobilization as required. Week 2 3: Knee flexion 90 o and 50% WB for all exercises Continue exercises above Begin Active Assisted ROM exercises to 90 o if needed. Normal walking pattern without crutches ( 50% WB on operative leg for Meniscal Repair). 5. Advancement Criteria for Phase II: Full extension Approximately 90 o of flexion No signs of active inflammation Good Quad Set and Straight leg raise without quad lag. Meniscal Repair Rehab Protocol 1/16/2014 2
PHASE II 3 Weeks Post-Op - 6 Weeks Post-Op Protect Meniscal repair. Control swelling. Maintain full extension ROM. Progress with flexion ROM. Return to work: light duties (avoid prolonged standing). 2. Brace / Crutches: Brace worn while sleeping up to week 3 or until patient has full extension May discontinue brace for ambulation when patient has no quad lag. Continue protected partial weightbearing ( 50% Body weight) for 4-6 weeks (medial 4 weeks / lateral 4-6 weeks as directed by surgeon), then progressive protected weight bearing as tolerated. Crutches: Discontinue crutches at 4-6 weeks when full weight bearing, as guided by surgeon. Ice after exercise program x 15 min. Week 3 4: Knee flexion 90 o and 50% BW for all exercises Begin low resistance stationary cycling (begin with high seat and progressively lower to promote ROM). Begin hip flexor / abductor Theraband exercises. Begin Aquatic Exercises: water walking, hip exercises, swim with upper body (incisions must be fully healed) Week 4 6: Progress Knee Flexion > 90 o to Full ROM, Full Weight Bearing: medial 4 weeks / lateral 4-6 weeks as directed by surgeon. Continue low to moderate resistance stationary cycling (increase RPM and/or resistance to increase quad strengthening once adequate ROM achieved). Double leg squat or leg press (do not bend knee past 45 o ). Step-Ups / Step-Downs (start with 4 block and progress to 6-8 block). Proprioceptive exercises: Protected single leg stand on surgical leg. Aquatic Exercises: may begin flutter kicks at side of pool (no whip kick). Theraband / Ankle Weights for resisted quadriceps and hamstring home exercise program. Normal gait without crutches. Progressive increase in ROM and quad strength. StairMaster at 6 weeks Light occupational duties (i.e.: deskwork). Driving automatic or standard vehicle with involved leg at 6 weeks. 5. Advancement Criteria for Phase III: Full active ROM: Full Extension to 90 o Flexion. Strength: Grade 4 / 5 isometric hamstring and quadriceps strength (no extensor quad lag). Normal gait on level surfaces. Meniscal Repair Rehab Protocol 1/16/2014 3
PHASE III 6 Weeks Post-Op - 12 Weeks Post-Op Full ROM. Increase leg strength, endurance and proprioception. Avoid overstressing meniscal repair during remodeling period. Increase functional activities. Begin cross-training to maintain general fitness. Return to work: modified duties (avoid heavy lifting, squatting and kneeling). 2. Brace / Crutches: Already discontinued. Week 6 9: Continue Passive / Active Assisted / Active ROM exercises as needed to achieve full ROM. Begin StairMaster and Wall Squats at 45 o. Begin Stationary Cycling interval training (no standing out of saddle). Proprioceptive exercises: Double leg wobble board. Progress to Single leg wobble board, BAPS board. Aquatic Exercises: progress to water running and flutter board (no whip kick). Begin power walking at 8 weeks. Week 9-12: Progress Wall Squats to 60 o - 90 o (x 2 minutes). Begin Lunges to 90 o with surgical leg in front (20 reps.) at 10 weeks. Advance closed chain strengthening exercises. Begin isokinetic hamstring and quadriceps strengthening. Proprioceptive exercises: Progress to slide board / fitter board Aquatic Exercises: progress swimming (no whip kick). Begin outdoor cycling at 10 weeks (level terrain, low gear, no toe clips). Begin straight line running (10 weeks) (begin walk / run intervals and progress to running at therapist discretion no evidence of patellofemoral irritation). StairMaster at 6 weeks. Power walking at 8 weeks. Outdoor road cycling at 10 weeks (No toe clips). Straight line running at 10 weeks (Begin with run/walk program). Light or modified occupational duties to accommodate functional limitations. 5. Advancement Criteria for Phase IV: Full pain free ROM. Strength: Grade 4 to 5 / 5 (75% of normal on leg press and hamstring curl). Normal gait on stairs. Meniscal Repair Rehab Protocol 1/16/2014 4
PHASE IV 3 Months Post-Op - 6 Months Post-Op Increase and maintain strength, endurance, and proprioception. Sport specific functional exercises. Progressive return to sport after adequate performance on strength and functional tests. Return to work: for activity intensive occupations. Patient education regarding possible restrictions / limitations. 2. Therapeutic Exercises: Months 3 4: Begin weight training / Nautilus equipment strengthening exercises program. Begin sport specific strengthening exercises. Proprioceptive exercises: mini-tramp or skipping (begin bilateral and progress to single leg). Begin plyometric program as appropriate for patient functional goals. Begin agility training. Begin functional progressions: Directional running: forward, backward, and sideways. ½ to ¾ to full speed running. Running up and down stairs. Cutting, cross-over, carioca and agility drills. Swimming whip kick. Months 4-5: Months 5 6: Maintenance program for strength and endurance. Begin sport specific drills as appropriate. Gradual return to Light Sport Activity (ie: golf, skating, cross-country skiing) if: No inflammation or effusion. Full ROM. >75% quadriceps and hamstring strength. Single leg hop test for distance >75% of normal side. Progress to Pivoting and Contact Sports (ie: racket sports, court sports, and field sports, hockey, downhill skiing) if: No inflammation or effusion Full ROM Single leg hop test for distance >90% of normal side >90% quadriceps and hamstring strength on instrumented strength testing (i.e. Lido, Biodex, Cybex) 3. Functional Milestone: Return to Light Sports Activity at 4 5 months 90 100% leg strength with operative to non-operative side comparison. Return to Pivoting and Contact Sports at 5 6 months. Return to work: full duties. Meniscal Repair Rehab Protocol 1/16/2014 5