INTRODUCTION The knee joint has a structure made of cartilage, which is called the meniscus or meniscal cartilage. The menisci are the shock-absorbers of the knee - wedged horizontally in between the femur and the tibia. They fill in the in congruency between the rounded ends of the femur bone and the flattened ends of the tibia bone upon which the femur sits. Menisci are squeezed between the rounded ends of the femur (the femoral condyles or rounded ends of the thigh bone) and the flat upper surface of the tibia (the tibial plateau or upper surface of the shinbone) - so they are difficult to see, and hard to explore. A torn meniscus is a disruption of the fibrocartilage pads located between the femoral condyles and the tibial plateaus. The medial and lateral meniscus provides shock absorption and plays a role in joint lubrication. Meniscal injuries are the most common surgically treated knee injury. Reported rates of meniscal injury are approximately 70 per one lakh (according to US Statistical Data). Men are affected more than women. Meniscal injuries can occur in all age groups. In older patients tears are predominantly degenerated and are commonly caused by activities of daily living, squatting or activities involving deep flexion. In younger patients up to 1/3 rd of 1
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INTRODUCTION
The knee joint has a structure made of cartilage, which is called
the meniscus or meniscal cartilage. The menisci are the shock-
absorbers of the knee - wedged horizontally in between the femur and
the tibia. They fill in the in congruency between the rounded ends of
the femur bone and the flattened ends of the tibia bone upon which the
femur sits.
Menisci are squeezed between the rounded ends of the femur
(the femoral condyles or rounded ends of the thigh bone) and the flat
upper surface of the tibia (the tibial plateau or upper surface of the
shinbone) - so they are difficult to see, and hard to explore.
A torn meniscus is a disruption of the fibrocartilage pads located
between the femoral condyles and the tibial plateaus. The medial and
lateral meniscus provides shock absorption and plays a role in joint
lubrication.
Meniscal injuries are the most common surgically treated knee
injury. Reported rates of meniscal injury are approximately 70 per one
lakh (according to US Statistical Data). Men are affected more than
women. Meniscal injuries can occur in all age groups. In older patients
tears are predominantly degenerated and are commonly caused by
activities of daily living, squatting or activities involving deep flexion. In
younger patients up to 1/3rd of meniscal tears are sports related and
are primarily caused by twisting or cutting movements, hyperflexion or
trauma. In all sports with the exception of wrestling, tears of the medial
meniscus occur more often than tears of the lateral meniscus.
Meniscal injuries often occur in knee pathology, although with
different etiologies. Such injuries may occur (i) as part of a rotational
trauma, (ii) due to bending, as a result of progression of a degenerative
process, or (iii) as a spontaneous injury caused by fatigue.
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The different etiologies converge into the same symptomatology,
with similar clinical manifestations and treatments, although different
therapeutic results are expected. When associated with the instability
of the knee or with arthrosis at an advanced stage, meniscal injury is
analyzed as a function of the major pathology.
The physiotherapy management of meniscal injuries involves
shifting the focus of case towards increasing activity tolerance,
prevention of recurrence apart from treating the pain alone.
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DEFINITION
Injuries to the crescent-shaped cartilage pads between the two
joints formed by the femur (the thigh bone) and the tibia (the shin
bone). The meniscus acts as a smooth surface for the joint to move on.
The two menisci are easily injured by the force of rotating the
knee while bearing weight. A partial or total tear of a meniscus may
occur when a person quickly twists or rotates the upper leg while the
foot stays still (for example, when dribbling a basketball around an
opponent or turning to hit a tennis ball). If the tear is tiny, the meniscus
stays connected to the front and back of the knee; if the tear is large,
the meniscus may be left hanging by a thread of cartilage. The
seriousness of a tear depends on its location and extent.
Types
The pattern of meniscus tear is important because it will
determine the type of treatment receive (some tears will heal on their
own, some can be treated surgically and some can't be fixed). Tears
come in many shapes and sizes however there are 3 basic shapes for
all meniscal tears: longitudinal, horizontal and radial. If these tears are
not treated, they may become more damaged and develop a displaced
tear (moving flap of meniscus). Complex tears are a combination of
these basic shapes and include more than one pattern.
A Longitudinal meniscus tear (circumferential tear)
extends along the length of meniscus and does not go all the way
through. This tear divides meniscus into an inner and outer section;
however the tear generally never touches the rim of the meniscus. It
tends to be more medial than lateral, and results from repeated
movements. It generally starts as a partial tear in the posterior horn,
which can sometimes heal on its own. However if it doesn't heal
including the hamstrings, quadriceps femoris, hip flexors, hip
adductors, and calf muscles.
Static Quadriceps Contractions
This exercise is used to prevent quadriceps muscle degeneration
and weakening in the acute stages of injury and/or directly after injury.
In this stage weight bearing or more difficult exercises may be either
not advised or too difficult. This exercise may be started as soon as
pain will allow and can be done on a daily basis.
Contract the quadriceps muscles at the front of the thigh, keep
toes pointed to the ceiling.
Hold for 10 seconds.
Relax and rest for 3 seconds.
Repeat 10 to 20 times.
← This can be performed either flat on the floor, or with a foam
roller or rolled up towel under the knee.
Static Hamstring Hold
This exercise is used to maintain the strength of the hamstring
muscles when other exercises may be too difficult. Again it may be
started as soon as pain will allow and can be done on a daily basis.
Lie on the stomach
Bend the knee to raise the foot up to about 45 degrees
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Hold for count of 10 and lower slowly .
Repeat 10 to 20 times.
← This can be progressed by increasing the length of hold, as well
as using some external force such as a partner to increase the
resistance or ankle weights.
Static Hamstring Contractions
This exercise is more difficult than the one above and also helps
in increasing the range of movement in the knee joint.
This involves contracting the hamstring muscles without
movement - by pushing against a static object.
One can do this by attempting to either bend the knee or extend
the hip, or both.
The easiest way of doing this is getting a partner to resist the
movement.
One can also push against a wall, chair or the floor.
Hold for 10 seconds.
Relax and rest for 3 seconds.
Repeat 10 to 20 times.
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Straight Leg Raises (SLR)
This exercise is more difficult than the static quadriceps exercise
as it involves lifting the entire weight of the leg against gravity. It
mainly targets the knee extensors (the quadriceps) but also functions
in strengthening the hip flexors (Rectus Femoris and Iliopsoas
muscles).
Position the patient sitting on the floor with both legs straight out
in front of the therapist.
Keeping the knee completely straight, lift the entire leg off the
floor
Hold for 10 seconds.
Relax and rest for 3 seconds.
Repeat 10 to 20 times.
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Knee Extension
This exercise specifically targets the quadriceps muscle group. It
may be used relatively early in the rehab process but care should be
taken not to overload the injured leg. Always seek professional advice
before beginning weight training
Always start each session with a light warm-up set of repetitions
before increasing the weight or resistance.
Keeping your bottom firmly on the bench, straighten and lower
the injured leg in one smooth movement.
An alternative exercise involves using a resistance band to
provide the resistance.
Tie one end of the band to a table leg or other stable structure
Leg Curl
Again, this exercise strengthens the hamstring muscles. You can
perform this with either ankle weights, a resistance band or a weight
machine.
If using ankle weights or a resistance band, lay on your front.
Attach the band around your ankle and also around something
sturdy, close to the floor behind you.
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Always start resistance band exercises with the band just under
tension, if it is slightly slack, shorten the length you are using by
tying it shorter.
Bend the knee, bringing the heel towards your buttocks, as far as
you comfortably can.
Slowly reverse this movement and return to the starting position
under control.
Aim for 3 sets of 10 repetitions initially with light weights/low
resistance and gradually increasing.
Hip Raises (Bridging)
Lie on your back with your knees bent and feet flat on the floor.
Lift your hips up off the floor as far as they will go, hold for 3
seconds and lower.
Repeat 10 to 20 times.
To progress this exercise, increase the length of time that the
hips are held up, initially to 5 and then to 10 secs
Calf Raises
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Raise up and down on the toes on the edge of a step in a smooth
movement > Play video
Aim for 3 sets of 20 repetitions.
This exercise can be progressed to single leg calf raises as fitness
and tolerance increases
Squatting
This is arguably the best exercise to increase quadriceps muscle
strength. Nevertheless, extreme care should be taken with this
exercise as it involves large loading of the quadriceps muscles and the
knee joint itself
Squat down half way to horizontal and return to standing.
Try to sink down through the knees, keeping the back straight
and not allowing your knees to move forwards past your toes
Return to the start position and repeat .
Aim for 3 sets of 10 repetitions during rehabilitation.
Progress this exercise by adding weight or moving to single leg
squats.
Later in the rehabilitation process, squats can be progressed to
horizontal (90 degrees flexion at knee and hip)
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Hip Flexor Exercises
Start with the band tied around your ankle and also something
close to the floor.
Make sure you have something to hold on to.
Raise the knee up towards the chest, against resistance
Slowly return to the start position and repeat.
Aim for 3 sets of 10 repetitions.
← If one do not have rehabilitation band or suitable weights then
this exercise can be done without resistance. However in this
situation more reps should be added to the rehab program.
Hip Adduction Exercises
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The hip adductors are better known as the groin muscles.
Attach a resistance band around your ankle and then fasten it to
a secure object, to the side of you.
Start with the leg out to the side, away from the body, with the
knee straight.
Pull the leg across your body as far as comfortable, before slowly
returning back to the start position
Hip Abduction Exercises
The hip abductors are vital components in gait as they allow the
hips to support the weight of the body. Thus strengthening exercises
for this muscle group is vital to any lower limb rehabilitation program.
These can be performed in lying in the acute stage and progressed into
standing with a resistance band.
Tie the band around your ankle and around a sturdy object to the
side of you.
Start with the leg to be worked on the opposite side to the
attachment point
While keeping the leg straight, take leg out to the side as far as
comfortable
Slowly return to the start position.
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This exercise can be progressed using elastic bands to increase
resistance.
Intermediate phase
The patient should have full ROM to begin this phase. Modalities
are continued as indicated by symptoms. Flexibility and strengthening
exercises are continued, increasing resistance as tolerated.
If the quadriceps femoris muscle is strong enough (i.e, if the
patient can lift 10 lb during short-arc quadriceps femoris muscle
exercise), the running program may be initiated. The first stage of the
running program is jogging in place on a trampoline. Unless pain or
swelling occurs, the patient gradually progresses to jogging for 10-15
minutes.
Advanced phase
During the advanced phase, the patient continues to progress in
strength-training exercises while beginning to return to sports
activities. Track running may begin when the patient is able to run on
the treadmill for 10-15 minutes at a pace of 7-8 minutes per mile
(depending upon the patient's previous activity level). Once mileage on
the track has reached 2-3 miles, agility drills and sport-specific
activities may be performed.
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Proprioceptive Exercises
Proprioception can be considered as the body's ability to sense
where it is in space. In the event of an injury this mechanism becomes
disrupted and proper training is needed to re-educate the muscles to
fire at the right time to allow further injury prevention. The most
common way to achieve this is to first stand and then walk on an
uneven surface. As balance continues to improve proprioceptive
exercises can progressed as follows:
Two footed stand on wobble board -aim to maintain balance for
as long as possible
Progress to one legged (injured side) wobble board exercises
Practice hopping on the injured leg on an uneven surface
Gradually increase difficulty by throwing a ball against a wall and
catching it while standing on the wobble-board. Aim to challenge
yourself by throwing the ball outside your comfortable center of
gravity.
Proprioceptive exercises should be continued even after a return
to full fitness to prevent future injury.
Below is an example of a muscle strengthening program
following a meniscal tear or surgery. As with all rehabilitation
programs, the type of exercises, their frequency and intensity is
dependant on the patient's own functional ability and will vary from
person to person. Hence the below table offers only sample
information and figures and should only be carried out as pain allows.
PhaseRehabilitativeStrengthening
Exercises
Daily Routine
(Repetitions X Daily
Frequency)
Functional Activities
1Week 0
1.Static Quadriceps2.Static Hamstrings
10 X 310 X 3
In some cases non-weight bearing on the injured leg is
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Pre-operatio
n3.SLR’s
5 X 2advised. Use crutches if necessary
2Week 0-
1After
Surgery
1. Static Quadriceps2. Static Hamstrings using therapeutic elastic band3. SLR's4. Double Calf Raises5. Hip Abduction6. Hip Flexion
10 X 310 X 35 X 35 X 3
10 X 310 X 3
Carry out weight bearing status as advised by surgeon.If weight bearing has been advised, concentrate on gait re-education drills.
3Weeks
1-2
1.Leg raises using therapeutic elastic band2.Half-way Squats3.Small range lunges4.Single calf raises5.Proprioceptive drills
10 X 35 X 35 X 35 X 3
Twice Daily
Light Cycling and swimming as pain allows
4Weeks
2-3
1.Full Squats2.Full range Lunges3.Single leg squats4.Proprioceptive drills5.Change of direction drills
10 X 210 X 25 X 3
3 Times Daily
Once Daily
Some light jogging and perhaps short range sprints may be attempted at this stage.Increase resistance on cycling machine
5Weeks
3-5
1.Full Squats2.Full Lunges(extra weights may be added to shoulders to increase difficulty of these exercises)3.Proprioceptive drills4.Sprinting drills with change of direction
10 X 310 X 3
3 times dailyOnce Daily
At this stage it may be possible to return to sport specific training. Care should be taken when returning to contact or impact sports. Short intervals are advised rather than over exertion in the early period of return.
Non Surgical rehabilitation
The program for non operative rehabilitation is similar in principle
to the program that follows meniscectomy. Cryotherapy and
nonsteroidal anti-inflammatory drugs (NSAIDs) play a very important
role in the management of non operative meniscal injury. These
medications help control the amount of swelling and provide some pain
relief. Sometimes, aspiration is useful to decrease the effusion, and,
rarely, an athlete may need a judicious 1-time corticosteroid injection.
Although not routinely advocated, an injection may provide an athlete
with a way to control the irritation within the knee so that performance
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may not falter. Maintenance of ROM of the knee is important, as are
muscular strength and endurance.
A reasonable goal before return to athletic activity is strength of
the injured lower extremity within 20-30% of the contra lateral side.
Initially, activity modification is useful, particularly in athletes who are
"weekend warriors." The time frame for return to activity depends on a
number of factors. Returning to competition depends on the demands
and motivation of the athlete, as well as on the severity of the meniscal
tear.
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PROGNOSIS
Prognosis
A torn meniscus is certainly not life threatening and once treated,
the knee will usually function normally for many years.
A meniscal tear that catches, locks the knee, or produces
swelling on a frequent or chronic basis should be removed or repaired
before it damages the articular (gliding) cartilage in the knee. A
meniscal tear that produces discomfort but does not produce any of
the symptoms mentioned above may be less likely to damage the rest
of the knee. One may choose to "live" with this type of meniscal tear
instead of treating it operatively.
Following a partial menisectomy most patients are able to
resume to normal non-sporting activities comfortably in a few days.
Generally light sports such as biking and swimming are well tolerated
in 1-2 weeks. Heavy sports such as running, basketball and tennis
usually take longer.
The long-term prognosis depends on how much meniscus was
lost from the tear. Naturally occurring (aging) arthritis is accelerated
depending on the amount of meniscus lost. There are new techniques
designed to repair those menisci that are repairable and replace that
portion of the meniscus which is lost. Entire menisci can be replaced