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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.

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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

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trauma, (ii) due to bending, as a result of progression of a degenerative

process, or (iii) as a spontaneous injury caused by fatigue.

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

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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 properly it can lead to a displaced

longitudinal tear, known as a displaced

Bucket Handle tear. This is a complete tear that goes all the way

through and is located near the inner rim of medial meniscus; it is often

associated with a radial tear. This tear accounts for 10% of all meniscus

tears, and causes the knee to lock in flexion. It is seen most often in

young athletes, and happens in conjunction with 50% of ACL injuries.

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 A Horizontal meniscus tear (cleavage tear) starts as a horizontal

split deep in the meniscus. This tear divides the meniscus into a top and

bottom section (like a sliced bun). It is often not visible, and moves from

the posterior horn or mid section to the inside of the meniscus. This tear

is rare and often starts after a minor injury from rotation in the knee or

degeneration. It occurs frequently in the lateral meniscus; however it is

noted in both menisci. A displaced.

Horizontal Flap tear can develop if the tear is overlooked or left

alone. This type of tear is horizontal on the surface of the meniscus and

creates a flap that flicks when the knee moves. It is a result of a strong

force that tears the meniscus from the inner rim; it can easily become a

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complex tear. If this tear extends from the apex of the meniscus to the

outer rim, one may develop a meniscal cyst (a mass that develops from a

collection of synovial fluid along the outside rim of the meniscus).

A Radial split meniscus tear (free-edge transverse tear) starts as

a sharp split along the inner edge of the meniscus and eventually runs

part way or all the way through the meniscus, dividing it into a front and

back section (across the middle body instead of down the length). This

tear generally occurs between the posterior horn and middle section and

is seen frequently in the lateral meniscus. A small tear is difficult to

notice, but when it grows and becomes a complete tear it will open up

and look like a part is missing. This is called a Parrot's Beak tear

(displaced radial tear with a curved inner portion). It generally occurs in

the thicker portion of the lateral meniscus. As it gets larger, it will catch

or lock more frequently, and prevent the meniscus from protecting the

cartilage during weight bearing. This tear is a result of a traumatic event

or forceful and repetitive stress activities; it is often associated with other

injuries. Young athletes tend to suffer from combination tears called

radial/parrot beak tears (the meniscus splits in 2 directions).

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 ANATOMY

Although the knee joint may look like a simple joint, it is one of the

most complex. Moreover, the knee is more likely to be injured than is any

other joint in the body. We tend to ignore our knees until something

happens to them that causes pain. As the saying goes, however, "an

ounce of prevention is worth a pound of cure."

The knee is essentially made up of four bones. The femur, which is

the large bone in thigh, attaches by ligaments and a capsule to tibia.

Just below and next to the tibia is the fibula, which runs parallel to the

tibia. The patella, or what we call the knee cap, rides on the knee joint

as the knee bends.

When the knee moves, it does not just bend and straighten, or, as

it is medically termed, flex and extend. There is also a slight rotational

component in this motion. This component was recognized only within

the last 50 years, which may be part of the reason people have so many

unknown injuries. The knee muscles which go across the knee joint are

the quadriceps and the hamstrings. The quadriceps muscles are on the

front of the knee, and the hamstrings are on the back of the knee. The

ligaments are equally important in the knee joint because they hold the

joint together.

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34
 The knee joint also has a structure made of cartilage, which is

called the meniscus or meniscal cartilage. The meniscus is a C-shaped

piece of tissue which fits into the joint between the tibia and the femur. It

helps to protect the joint and allows the bones to slide freely on each

other. There is also a bursa around the knee joint. A bursa is a little fluid

sac that helps the muscles and tendons slide freely as the knee moves.

To function well, a person needs to have strong and flexible

muscles. In addition, the meniscal cartilage, articular cartilage and

ligaments must be smooth and strong. Problems occur when any of these

parts of the knee joint are damaged or irritated.

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 The medial meniscus is semicircular and attached to the medial

collateral ligament (medial collateral ligament) of the knee joint. It only

moves 2-5 mm within the joint and is hence more prone to tears than the

lateral meniscus which is more circular in shape and moves 9-11mm.

The lateral meniscus is often injured at the same time as the

Anterior Cruciate Ligament (ACL), whereas the medial meniscus is itself

more prone to tears in the chronically 'ACL deficient' knee Bucket Handle

Meniscus Tear.

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Blood supply

The blood supply to the menisci is limited to their peripheries. The

medial and lateral geniculate arteries anastomose into a parameniscal

capillary plexus supplying the synovial and capsular tissues of the knee

joint. The vascular penetration through this capsular attachment is

limited to 10-25% of the peripheral widths of the medial and lateral

meniscal rims. In 1990, Renstrom and Johnson reported a 20% decrease

in the vascular supply by age 40 years, which may be attributed to weight

bearing over time.

The presence of a vascular supply to the menisci is an essential

component in the potential for repair. The blood supply must be able to

support the inflammatory response normally seen in wound healing.

Arnoczky, in 1982, proposed a classification system that categorizes

lesions in relation to the meniscal vascular supply.

An injury resulting in lesions within the blood-rich periphery is

called a red-red tear. Both sides of the tear are in tissue with a

functional blood supply, a situation that promotes healing.

A tear encompassing the peripheral rim and central portion is

called a red-white tear. In this situation, one end of the lesion is in

tissue with good blood supply, while the opposite end is in the

avascular section.

A white-white tear is a lesion located exclusively in the avascular

central portion; the prognosis for healing in such a tear is

unfavorable.

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 BIOMECHANICS

The menisci provide several integral elements to knee function.

These include load transmission, shock absorption, joint lubrication, and

joint nutrition, distribution of load, amount of contact force and stability.

The menisci act as a structural transition zone between the femoral

condyles and tibial plateau. As such, they increase the congruence

between the condyles and the plateau. The menisci appear to transmit

approximately 50% of the compressive load through a range of motion of

0 to 90 degrees. The contact area is increased, protecting articular

cartilage from high concentrations of stress. The circumferential collagen

fiber orientation within the meniscus is uniquely suited to this capacity.

As load is applied, the menisci will tend to extrude from between the

articular surfaces of the femur and tibia. In order to resist this tendency,

circumferential tension is developed along the collagen fibers of the

meniscus as hoop stresses. The circumferential continuity of the

peripheral rim of the meniscus is integral to meniscal function.

The menisci follow the motion of the femoral condyle during knee

flexion and extension. During extension, the femoral condyles exert a

compressive force displacing the menisci antero posteriorly. As the knee

moves into flexion, the condlyes roll back ward onto the tibial plateau.

The menisci deform medial laterally, maintaining joint congruity and

maximal contact area. As the knee flexes, the femur externally rotates on

the tibia, and the medial meniscus is pulled forward.

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39
 AETIOLOGY

All the knee injuries are more common in women than men, men

experience more meniscus injuries and tears (ratio 2.5:1 (Male : Female))

this is belief to be due to mens participation in more aggressive sports

and manual activities. The peak incidence of meniscal injuries for males

is between 31 40 years whereas for females peak incidence is in

between 11 - 20 years.

The two most common causes of meniscus injuries are acute

trauma to the knee and degeneration of the knee joint.

Occupations such as mining or carpet laying (squat position), or

participation in contact sports or repetitive stress activities (such as

running and skiing) or prone to meniscus injuries.

Acute or traumatic meniscus damage:

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 It can result from forceful rotating of a straight or bent knee while

foot is firmly planted and bearing weight, or from hyperflexion or hyper

extension of knee. These injuries are experienced most frequently in

activities such as Rugby, football, baseball, soccer, basketball when one

twist or pivot on the knee, or slow down too quickly. The result will

generally be a partial complete medical meniscus tear. This type of tear

generally affects athletes or those under 40 years of age.

A medial meniscus tear will frequently occur along with other

injuries such as MCL or ACL tear. The combined injuries are seen most

often in contact sports, when an athlete gets hit on the outside of a bend

knee.

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 A lateral meniscus tear will result more often from a knee i.e.., bent

excessively and experiences full weight bearing, while the thigh bone is

turning outward: seen in sports such as skiing. It can also be injured in

collisions that involve deep knee bends.

Degeneration of the knee joint

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 It involves weakening of tissues with age, which results from small

repetitive movements such as squatting or pivoting positions,. Or a minor

meniscus injury that never healed properly. In the younger people

meniscus is very flexible and pliable (like a new rubber tire) as they get

older it becomes less flexible and more brittle, it also develops cracks in it

(like those seen in an aged car tire).

Articular cartilage and meniscus detoriate as age advances, which

can eventually lead to a degenerative tear without any major trauma.

There will be a 20 percent decrease in blood supply to menisci by age 40

due to weight bearing over time; this inhibits bodys ability to heal itself.

This wear and tear over the years may lead to an osteoarthritis condition.

Approximately 60 percent of people over 65 years of age experience some

form of degenerative meniscus tear.

A Discoid meniscus occurs when are born with a more flat, disc

shaped meniscus rather than a crescent shaped, wedge meniscus. It is

generally found in the lateral meniscus and in kids less than 11 years of

age. The symptoms associated with a discoid meniscus can range from

very mild to continuous clicking, snapping, buckling and locking of the

knee joint, decreased range of motion, joint pain and tenderness, and

atrophied quadriceps (muscles wasting away). The meniscus will often

change to a C-shape with maturity and Kids/teens will grow out of their

symptoms; however failure of normal development can be experienced.

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 PATHOPHYSIOLOGY

There are two different mechanisms for tearing a meniscus.

Meniscal tears are common and can be traumatic or degenerative.

Traumatic tears occur classically during twisting forces on the knee in

young active people, are often vertical longitudinal tears and can be

associated with ligamentous injuries. Degenerative tears occur as part of

progressive wear in the whole joint, most frequently in the over 40's.

These tears are usually horizontal cleavage tears or flaps and have

minimal healing capacity. Tears can be described as being complete or

incomplete, stable or unstable and of various patterns.

Traumatic tears result from a sudden load being applied to the

meniscal tissue which is severe enough to cause the meniscal cartilage

to fail and let go. These usually occur from a twisting injury or a blow to

the side of the knee that causes the meniscus to be levered against and

compressed. A football clipping injury or a fall backwards onto the heel

with rotation of the lower leg are common examples of this injury

pattern. In a person under 30 years of age this typically requires a fairly

violent injury although any age group can sustain a traumatic tear.

Degenerative meniscal tears are best thought of as a failure of

the meniscus over time. There is a natural drying-out of the inner

center of the meniscus that can begin in the late 20's and progresses

with age. The meniscus becomes less elastic and compliant and as a

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result may fail with only minimal trauma (such as just getting down into

a squat). Sometimes there are no memorable injuries or violent events

which can be blamed as the cause of the tear. The association of these

tears with aging makes degenerative tears in a teenager almost unheard

of.

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 CLINICAL FEATURES

The list of signs and symptoms mentioned in various sources for

Meniscus injury includes the 6 symptoms listed below:

Knee pain

Pain straightening knee

Knee swelling

Knee locking

Knee clicking

Knee weakness

Generally, when people injure a meniscus, they feel some pain,

particularly when the knee is straightened. If the pain is mild, the person

may continue moving. Severe pain may occur if a fragment of the

meniscus catches between the femur and the tibia.

Swelling may occur soon after injury if blood vessels are disrupted,

or swelling may occur several hours later if the joint fills with fluid

produced by the joint lining (synovium) as a result of inflammation. If the

synovium is injured, it may become inflamed and produce fluid to protect

itself. This makes the knee swell.

Sometimes, an injury that occurred in the past but was not treated

becomes painful months or years later, particularly if the knee is injured

a second time. After any injury, the knee may click, lock, or feel weak.

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Although symptoms of meniscal injury may disappear on their own, they

frequently persist or return and require treatment.

INVESTIGATIONS

Radiological Examination

Most Common Meniscus Injury Diagnostic Tests

A medical professional will sometimes recommend diagnostic

testing to obtain more detailed information, and assess the amount

and/or type of damage done to the knee and meniscus. There are a

variety of different tests available to help them analyze the situation;

however these will be dependent on injury.

X rays

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 X-rays will provide an image of the overall structure of the knee. It

is helpful in identifying abnormal bone shapes, fractures, arthritis, and

degeneration (wear and tear) on the joint. It can identify a discoid

meniscus, or loose bones and bone abnormalities that may mimic a torn

meniscus.

MRI

MRI is the most powerful, accurate, and noninvasive method for

diagnosing meniscal tears. It is more accurate than physical examination

and has influenced clinical practice and patient care by eliminating

unnecessary diagnostic arthroscopies or by identifying alternative

diagnosis that may mimic meniscal tears.

When combined with clinical data, such as the patient's age,

athletic requirements, and physical findings (e.g, possible associated

ligamentous injuries), a treatment plan may be developed by assessing

the need for and timing of surgery and by determining the type of surgery

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(meniscal debridement, rasping, repair, partial or total resection, or

meniscal transplantation). MRI may be used to identify other injuries,

such as ligament tears, especially ACL tears, the presence of which may

also influence the decision whether to perform surgery.

With MRI, physicians may obtain images in several planes,

providing multiple perspectives on meniscal and ligamentous injuries.

Other advantages include the following:

with MRI, the patient is not exposed to ionizing radiation;

MRI does not normally involve the intravenous

administration of contrast material, the use of which is

associated with a small but definite number of adverse

effects;

MRI does not require joint manipulation;

MRI is painless and can be performed in less than 35

minutes; and

MRI does not require the intra-articular injection of iodinated

radiographic contrast material, which is needed for

arthrography. MRI results lead to alterations in therapy in

about one third of cases

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Plain radiography

Plain radiography is extremely limited in the assessment of

meniscal tears. Radiographs may be obtained to rule out unsuspected

lesions, such as osteochondritis desiccans and loose bodies.

In the presence of a DM, radiographs may show widening of the

medial or lateral joint compartments; hypoplasia of the lateral femoral

condyle related to the increased size of the LM; a high fibular head;

cupping of the lateral tibial plateau; or a squared-off lateral femoral

condyle.

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CT Scan

CT or CAT scans (computerized tomography) will be used to provide

a more thorough, 3-dimensional assessment of the bones and soft

tissues in and around the knee joint.

Further diagnostic tests such as an ultrasound, electromyogram,

or arthroscopic surgery can be used to determine the degree and location

of the injury if required.

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Physical Examination

A complete examination, including that of the lower spine, ipsilateral

hip and thigh, patellofemoral joint, and tibiofemoral joint, is essential

when evaluating knee pain. Associated findings such as a perimeniscal

cyst or ligamentous laxity suggest a higher likelihood of a meniscus

injury. Important findings when examining a patient with a possible

meniscus injury include the following:

Joint line tenderness

Joint line tenderness is an accurate clinical sign. 10 This

finding indicates injury in 77-86% of patients with meniscus

tears. Despite the high predictive value, operative findings

occasionally differ from the preoperative assessment.

Assess joint lines for palpable pain the location of the

tenderness is not a sure sign for the type of lesion.

Effusion

Effusion occurs in approximately 50% of the patients

presenting with a meniscus tear.

The presence of an effusion is suggestive of a peripheral tear

in the vascular or red zone (especially when acute), an

associated intra-articular injury, or synovitis.

To assess effusion perform the fluid shift test and evaluate

for the presence of the fluctuation sign. The amount of

effusion doesnt indicate the presence or absence of a

meniscal lesion.

Range of motion

The patient may have difficulty extending the knee fully if a

meniscal tear blocks the motion.

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 Full flexion, as in squatting, may be painful or impossible

because of a tear.

Assess the gait pattern looking for deviations or

compensatory movements.

Restricted motion caused by pain or swelling is also common.

Girth measurement

Girth measurement allow for a general assessment of

effusion and atrophy.

Swelling within the knee joint is measured grossly by a girth

measurement taken at the joint line.

Measurements taken at five Centimetre and 20 centimetre

proximal to the base of the patella and 15 centimetre distal

to the apex of the patella can provide and indirect indication

of atrophy in the VMO segment, Quadriceps femoris muscle

and calf muscles respectively.

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 SPECIAL TESTS

Tests: Perform stability tests for anterior, posterior, and varus-valgus

motion to rule out additional involvement of soft tissue. Several special

tests may be used to assess meniscal involvement. A positive result of any

test does not by itself establish the presence of a meniscal lesion, but,

along with the other objective findings, such a test result can help

differentiate a meniscal tear from other possible knee injuries.

McMurray test

This test indicates tears of the middle or posterior horn

of the meniscus.

With the patient supine and the hip and knee fully

flexed, apply a valgus force and externally rotate the

tibia while extending the knee. An audible or palpable

pop or snap indicates a medial meniscal tear.

Lesions of the lateral meniscus are tested by applying a

varus force and internally rotating the tibia during

knee extension. The snap is produced as the torn

fragment rides over the femoral condyle during

extension.

A snap in extreme flexion is indicative of a posterior

horn tear; a click at 90 of flexion indicates a lesion in

the middle section of the meniscus.

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 Apley test

This test is used to distinguish between meniscal and

ligamentous involvement.

With the patient in a prone position, the knee flexed at

90, and the leg stabilized by the examiner's knee,

distract the knee while rotating the tibia internally and

externally. Pain during this maneuver indicates

ligamentous involvement.

Then, compress the knee while internally and

externally rotating the tibia again. Pain during this

maneuver indicates a meniscal tear.

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 Bragard sign

This test may be used if anterior joint-line point

tenderness is present.

To test for a medial lesion, the examiner extends and

externally rotates the tibia, which displaces a meniscal

lesion forward, if one exists. Palpable tenderness along

the anterior medial joint line is reduced with flexion

and internal rotation.

Bounce home test

The patient is supine with his or her heel cupped in

the examiner's hand.

The examiner fully flexes the knee and then passively

extends the knee. If the knee does not reach complete

extension or has a rubbery or springy end feel, the

knee movement may be blocked by a torn meniscus.

Childress test

Instruct the patient to squat with the knee fully flexed

and attempt to "duck walk."

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 If the motion is blocked, a meniscal lesion is indicated;

however, pain in this position may indicate a meniscal

tear or patellofemoral joint involvement.

Merkel sign

Instruct the patient to stand with his or her knees

extended and to rotate the trunk. This movement

causes compression of the menisci.

Medial compartment pain during internal rotation of

the tibia indicates a medial meniscal lesion. Lateral

compartment pain occurring during external rotation

of the tibia indicates a lateral meniscal lesion.

Modified Helfer test

While the patient is sitting on the edge of a table with

the knee flexed 90, instruct him or her to extend the

knee.

If knee mechanics are within normal limits, the tibial

tuberosity can be seen in line with the midline of the

patella in full flexion; during extension, the tibia

rotates and the tibial tubercle moves into line with the

lateral border of the patella.

Failure of the tibia to rotate during extension indicates

a meniscal lesion or cruciate ligament involvement.

O'Donoghue test

With the patient prone, the examiner flexes the knee

90. The examiner rotates the tibia internally and

externally twice, then fully extends the knee and

repeats the rotations.

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 Increased pain during rotation in either or both knee

positions indicates a meniscal tear or joint capsule

irritation.

With a valgus force to a flexed and laterally rotated

knee, the medial meniscus, medial collateral ligament

(MCL), and the ACL all may be injured, representing

the O'Donoghue triad.

Payr sign

With the patient sitting cross-legged, the examiner

exerts downward pressure along the medial aspect of

the knee.

Medial knee pain indicates a posterior horn lesion of

the medial meniscus.

First Steinmann sign

With the patient supine and the knee and hip flexed at

90, the examiner forcefully and quickly rotates the

tibia internally and externally.

Pain in the lateral compartment with forced internal

rotation indicates a lateral meniscus lesion. Medial

compartment pain during forced external rotation

indicates a lesion of the medial meniscus.

Second Steinmann sign

This test is indicated when point tenderness is located

along the anterior joint line.

When the examiner moves the knee from extension

into flexion, the meniscus is displaced posteriorly,

along with its lesions. The point of tenderness also

shifts posteriorly toward the collateral ligament.

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59
 DIFFERENTIAL DIAGNOSIS

Anterior Cruciate Ligament Injury: An ACL tear is a common

injury that occurs in all types of sports. This injury usually occurs

during a sudden cut or deceleration, as it typically is a non contact

injury.

Posterior Cruciate Ligament Injury: Posterior cruciate ligament

(PCL) injuries are usually the result of a direct blow to the anterior

part of the tibia, with a hyperextension moment at the knee.

Knee osteochondritis dissecans

Lumbosacral radiculopathy

Osteoarthritis: Osteoarthritis (OA, also known as degenerative

arthritis, degenerative joint disease), is a group of diseases and

mechanical abnormalities involving degradation of joints,[1]

including articular cartilage and the subchondral bone next to it.

The patient increasingly experiences pain upon weight bearing,

including walking and standing. As a result of decreased movement

because of the pain, regional muscles may atrophy, and ligaments

may become more lax.

Patellofemoral joint dysfunction

Rheumatoid arthritis

Tendon inflammation (tendinitis)

Tibial tubercle avulsion fracture

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 GENERAL PHYSIOTHERAPY ASSESSMENT OF MENISCAL
INJURIES

The aims of Assessment

To elicitate what is preventing the patient from moving in the

normal way, in order to plan the treatment.

Making frequent reviews possible, so that the treatment can be

altered if necessary.

Recording the patients condition accurately for future therapeutic

of statistical purposes.

Subjective Assessment:

Name :

Age :

Sex :

Occupation :

Address :

Date of Assessment :

Chief Complaints of patients:

Difficulty in Straightening the knee.

Difficulty in running and long walking.

Pain during walking.

Weakness of knee

Swelling of knee

Difficulty in twisting the knee joint.

Difficulty in Squatting

History of present illness

Onset - Gradual

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 Duration

Progression

Treatment taken

Associated Problems

Diabetes

Hypertension

Any injury to the joint

Any infection to the joint

Past Medical History

History of joint injury

Diabetes mellitus

Hypertension

Present Medical History

Personal History

Smoker

Exercise habits

Alcoholic

Diet

Sedentary or active life style

Social History

Socio economic status

Type of job and nature of job

Steps / Ramp / Lift

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 Pain Assessment

Site of pain

Side of pain

Type of pain

Frequency of pain

Aggravating factor

Relieving factor

Objective Assessment

Vital Sign

B.P.

Temperature

Respiratory rate

Pulse rate

All normal or may be some variation

Observative findings

Built of the patient

Posture of patient

Attitude of limb Slight flexion of knee

Quadriceps Atrophy

Gait

On Examination

On palpation

Swelling

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 Warmth

Bony Contour

Pain

Muscle wasting

Effusion

Crepitus

Motor Examination

In Acute - Normal

In Chronic Tone Quadriceps Flaccid.

Sensory Assessment

May be normal

Range of motion is decreased

It is of less significant as no neural involvement

Postural Examination

Normal or Varied

Gait Examination

Investigations

X Ray

MRI

Suggested Diagnosis

Meniscal injury

.
Range of motion

Decreased

Muscle Power

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 Acute Decreased

Chronic Quadriceps weakness

Medical Research counseling

0- No Contraction

1- Flicker of contraction

2- Full range of motion in elimination of gravity

3- Full range of motion against gravity

4- Full range of motion against gravity with mild

resistance

5- Full range of motion against gravity with

maximum resistance

Reflex Examination

Normal or reduced (Knee jerk ) due to

Quadriceps weakness

Reflex is of less significance as there is no nerve

involvement

Problem List

Pain

Swelling

Tenderness

Difficulty to Squat

Decreased range of motion

Weakness of muscle

Difficult to climb stair

Treatment Goals

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 Short term goals

To Reduce pain

To reduce tenderness

To reduce swelling

Long term goals

To increase the joint range of motion

To increase the strength of muscle

Make the patient to walk independently

Prognosis

Moderate or Good

Follow up care

66
 MANAGEMENT OF MENISCAL INJURY

Non Surgical Management of Meniscal injury

An acute meniscus tear can be treated with ice application, rest,

anti-inflammatory medications, and physical therapy. These simple

measures will help decrease swelling and pain in the joint.

RICE The RICE protocol is effective for most sports-related injuries.

RICE stands for Rest, Ice, Compression, and Elevation.

Rest. Take a break from the activity that caused the injury. The

doctor may recommend that one use crutches to avoid putting

weight on the leg.

Ice. Use cold packs for 20 minutes at a time, several times a day.

Do not apply ice directly to the skin.

Compression. To prevent additional swelling and blood loss, wear

an elastic compression bandage.

Elevation. To reduce swelling, recline when rest, and put the leg

up higher than heart.

Ultrasound therapy is a great therapeutic option to decrease pain,

inflammation and soft tissue (muscle, ligament, tendon, connective and

nerve tissue) damage experienced with a meniscus or knee injury. This

can be received using a portable, home ultrasound device (self-

administered) or by seeing a physiotherapist. The treatment is safe, easy,

painless, and generally requires between 5 10 minutes.

It is based on a form of deep tissue therapy, which is generated

through high frequency sound waves (that we can not hear). These waves

67
send vibrations deep into body and raise the temperature of soft tissue.

The waves are delivered through a hand held transducer and medicinal

conductive gel that are used together in a slow, circular motion on skin

over the injured area. Patient may experience a slight tingling or warm

sensation during the process as a result of the gel; this enhances the

therapeutic effects of ultrasound (Phonophoresis).

Ultrasound therapy increases collagen and tissue elasticity, which

in turn promotes circulation (blood flow) and brings oxygen and nutrients

to injured knee area. This cleans tissue by getting rid of cell waste

products and allows meniscus injury to heal correctly. If not treated

properly injured tissue can heal with a weakened state, which can lead to

scar tissue or calcification.

If used on an ongoing basis, ultrasound will help to improve range

of motion by breaking down any scar tissue that may form in the knee

area. Ultrasound waves penetrate deep into tissues, relax muscles,

decrease chronic inflammation and accelerate recovery rate, so one can

return to daily activities as soon as possible.

The goals of pharmacotherapy are to reduce morbidity and prevent

complications.

Analgesics

Pain control is essential to quality patient care. Analgesics ensure

patient comfort and have sedating properties, which are beneficial for

patients who have sustained injuries.

Acetaminophen (Tylenol, Feverall, Tempra, Aspirin-Free Anacin)

68
 DOC for pain in patients with documented hypersensitivity to

aspirin or NSAIDs, with upper GI disease, or who are taking oral

anticoagulants.

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their

mechanism of action is not known, but they may inhibit cyclooxygenase

(COX) activity and prostaglandin synthesis. Other mechanisms may exist

as well, such as inhibition of leukotriene synthesis, lysosomal enzyme

release, lipoxygenase activity, neutrophil aggregation, and various cell

membrane functions.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory

reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprelan, Anaprox, Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions

and pain by decreasing activity of COX, which results in a decrease of

prostaglandin synthesis.

Diclofenac (Voltaren, Cataflam)

Rapidly absorbed; metabolism occurs in liver by demethylation,

deacetylation, and glucuronide conjugation. Delayed-release, enteric-

coated form is diclofenac sodium, and immediate release form is

diclofenac potassium. Has relatively low risk for bleeding GI ulcers.

69
Celecoxib (Celebrex)

Primarily inhibits COX-2. COX-2 is considered an inducible

isoenzyme, induced during pain and by inflammatory stimuli. Inhibition

of COX-1 may contribute to NSAID GI toxicity. Seek lowest dose of

celecoxib for each patient.

Depending on the size and type of the meniscus tear, and the

physical demands of the patient, these may be the only treatments

necessary. A cortisone injection can be a helpful treatment to reduce

inflammation within the joint, but it will not help heal the meniscus tear.

If these treatments fail to provide relief, a surgical procedure may be

recommended.

Surgical Management of Meniscal Tear

When Surgery is Necessary

If meniscus tear symptoms are not significant, surgery can often be

delayed or avoided altogether. Many people live normal, active lifestyles

despite having a meniscus tear. It is only when the meniscus tear

becomes symptomatic, and interferes with activities, that surgery to treat

the meniscus tear should be considered.

Surgery has the best results when the primary symptoms of the

meniscus tear are mechanical. This means that the meniscus tear is

causing a catching or locking sensation of the knee.

Operative management

70
 Once a decision has been made to proceed with operative

management, further decisions regarding the surgical treatment of the

meniscus tear need to be made Intraoperatively, a decision has to be

made whether to repair, excise, or leave the tear in the meniscus alone.

Arthroscopic Meniscectomy for Meniscus Tears:

A meniscectomy is a procedure to remove the torn portion of the

meniscus. This procedure is far more commonly performed than a

meniscus repair. The meniscectomy is done to remove the damaged

portion of meniscus, while leaving as much healthy meniscus as

possible. The meniscectomy usually has a quick recovery, and allows for

rapid resumption of activities.

71
 Arthroscopic probing of a posterior horn complex meniscal tear with
multiple flaps.

Arthroscopic view of medial meniscus after excision of flap tear.

Meniscus Repair

In some situations, surgeon may offer a meniscus repair as a

possible surgery for damaged or torn cartilage. Years ago, if a patient had

torn cartilage, and surgery was necessary, the entire meniscus was

removed. These patients actually did quite well after the surgery. The

problem was that over time, the cartilage on the ends of the bone was

worn away more quickly. This is thought to be due to the loss of the

cushioning effect and the diminished stability of the joint that is seen

after a meniscus is removed.

When arthroscopic surgery became more popular, more surgeons

performed partial menisectomies. A partial meniscectomy is performed to

remove only the torn segment of the meniscus. This works very well over

72
the short and long term if the meniscus tear is relatively small. But for

some large meniscus tears, a sufficient portion of the meniscus is

removed such that problems can again creep up down the road.

How is the meniscus repair performed?

Techniques of meniscus repair include using arthroscopically

placed tacks or suturing the torn edges. Both procedures function by

reapproximating the torn edges of the meniscus to allow them to heal in

their proper place and not get caught in the knee causing the symptoms.

Meniscus Transplantation

Meniscus transplantation consists of placing the meniscus from a

donor patient into an individual who has had their meniscus removed.

The ideal patient for a meniscus transplant is someone who had their

meniscus removed, and subsequently begins to develop knee pain.

Meniscus transplant is not performed for an acute meniscus tear, rather

it is performed when removal of the entire meniscus has caused

persistent pain in the knee.

73
Physiotherapy Management

A meniscus tear is a common knee joint injury. The knee will heal

and whether surgery will be needed depends in large part on the type of

tear and how bad the tear is.

Rehabilitation Program

A rehabilitation program helps to regain as much strength and

flexibility in knee as possible. Rehabilitation program probably will

include physical therapy and home exercises.

The goals of rehabilitation are to restore range of motion, strength,

and endurance of the knee. A rehabilitation program usually includes

treatment with a physical therapist at a therapy center and home

treatment in home or at a gym or health club. Physical therapist will

design a program that guides through exercises to reach these goals on a

schedule that takes into account health status, age, and activity

expectations.

Recovery from a meniscus tear depends on many factors. If the tear

is minor and symptoms go away, doctor may recommend a set of

exercises to increase flexibility and strength.

Rehabilitation following meniscectomy

Initial phase

When the patient first reports to outpatient physical therapy 4-7

days after surgery, he or she usually is able to bear full weight or as

much weight as tolerated on the involved leg. Modalities are used as

74
needed to decrease pain or swelling, including heat/ice contrasts, ice

alone, transcutaneous electrical nerve stimulation (TENS), electric

galvanic stimulation, and Ultrasound. As needed, the patient should

perform flexibility exercises for the lower extremity musculature,

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.

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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

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

76
 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.

Straight Leg Raises (SLR)

77
 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.

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

78
 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.

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.

79
 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

80
Calf Raises

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

81
 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)

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.

82
 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

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

83
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.

This exercise can be progressed using elastic bands to increase

resistance.

84
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.

Proprioceptive Exercises

85
 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.

86
 Daily Routine
Rehabilitative
(Repetitions
Phase Strengthening Functional Activities
X Daily
Exercises
Frequency)
1 10 X 3
In some cases non-weight
Week 0 1.Static Quadriceps 10 X 3
bearing on the injured leg is
Pre- 2.Static Hamstrings 5X2
advised. Use crutches if
operatio 3.SLRs
necessary
n
2 1. Static Quadriceps 10 X 3
Week 0-1 2. Static Hamstrings 10 X 3 Carry out weight bearing
After using therapeutic elastic 5X3 status as advised by
Surgery band 5X3 surgeon.
3. SLR's If weight bearing has been
10 X 3
4. Double Calf Raises advised, concentrate on gait
10 X 3
5. Hip Abduction re-education drills.
6. Hip Flexion
3 1.Leg raises using 10 X 3
Weeks 1- therapeutic elastic 5X3
2 band 5X3 Light Cycling and swimming
2.Half-way Squats 5X3 as pain allows
3.Small range lunges
Twice Daily
4.Single calf raises
5.Proprioceptive drills
4 1.Full Squats 10 X 2 Some light jogging and
Weeks 2- 2.Full range Lunges 10 X 2 perhaps short range sprints
3 3.Single leg squats 5X3 may be attempted at this
4.Proprioceptive drills 3 Times Daily stage.
5.Change of direction Increase resistance on
Once Daily
drills cycling machine
5 1.Full Squats 10 X 3
At this stage it may be
Weeks 3- 2.Full Lunges 10 X 3 possible to return to sport
5 (extra weights may be
specific training. Care should
added to shoulders to 3 times daily be taken when returning to
increase difficulty of Once Daily contact or impact sports.
these exercises)
Short intervals are advised
3.Proprioceptive drills
rather than over exertion in
4.Sprinting drills with
the early period of return.
change of direction

Non Surgical rehabilitation

87
 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 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.

88
 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

using cadaver transplants.

89
 PREVENTION

Although it is important to be able to treat meniscus injury,

prevention should be your first priority. Some of the things you can do to

help prevent a meniscus injury

1. Warm Up properly A good warm up is essential in getting the body

ready for any activity. A well-structured warm up will prepare your

heart, lungs, muscles, joints and your mind for strenuous activity.

2. Avoid activities that cause pain This is self-explanatory, but try

to be aware of activities that cause pain or discomfort, and either

avoid them or modify them.

3. Rest and Recovery Rest is very important in helping the soft

tissues of the body recover from strenuous activity. Be sure to allow

adequate recovery time between workouts or training sessions.

4. Balancing Exercises Any activity that challenges your ability to

balance, and keep your balance, will help what is called,

proprioception: - your body's ability to know where its limbs are at

any given time.

5. Stretch and Strengthen To prevent meniscus injury, it is

important that the muscles around the knee be in top condition.

Be sure to work on the strength and flexibility of all the muscle

groups in the leg.

6. Footwear Be aware of the importance of good footwear. A good pair

of shoes will help to keep your knees stable, provide adequate

cushioning, and support your knees and lower leg during the

running or walking motion.

7. Strapping Strapping, or taping can provide an added level of

support and stability to weak or injured knees.

90
91
 CASE ASSESSMENT 1

Name : P. Sujatha

Age : 40 years

Gender : Female

Occupation : House wife

Address : Rapur

Chief complaints : Pain around right knee joint

Pain increases during night

Difficulty in walking and stair

climbing

Presence of Swelling around right

knee joint

History

Present History : Pain around right knee joint and

increases during night

Past History : She had a fall from height and got

direct injury to knee

Medical History : She has taken analgesics for pain

relief

Surgical History : No Surgical history

Personal History : No history of Hypertension and

Diabetes Mellitus

Pain Assessment

Site : Around knee joint

Side : Right Side

Duration : One Month

Character of pain : Not Radiating

Aggravating Factors : During movement and walking

92
Relieving Factors : At Rest

93
VAS Scale:

On Observation

Built : Moderate

Attitude of Limb : Slightly flexed

Skin Colour changes : No Changes Seen

External Appliances : No usage

On Palpation

Tenderness : Grade II

Muscle Spasm : Present

Warmth : Present

Swelling : Present

On Examination

Range of motion of knee joint.

Passive:

Movemen Right knee Left knee

t

Flexion 0-110 Degrees 0- 130 degrees

Extension 110- 0 Degrees 130- 0 Degrees

Active:

Movemen Right knee Left knee

t

Flexion 0-100 Degrees 0- 130 degrees

Extension 100- 0 Degrees 130- 0 Degrees

Manual muscle testing

Muscles Right knee Left knee

94
 Flexors Grade 4 Grade 5

Extensors Grade 3 Grade 5

Deep Tendon Reflexes

Jerk Right Left

Knee + ++

Ankle ++ ++

Plantar ++ ++

ADL : Activities like walking and stair

climbing is difficult

Special Test : Apleys grinding test Positive

Mcmurray test- Positive

Lachmans Test Negative

Anterior Drawer Test - Negative

Investigations

X- Ray : Bony abnormalities are seen

MRI : Meniscal tear

Provisional Diagnosis : Meniscal Injury

Treatment

Pain : Ultra Sound, TENS, Cryotherapy

Swelling : Crep bandage, Elevation of limb

Joint Movement : Limb mobilization

Muscle strength : Isometrics to hamstrings,

Isometrics to Quadriceps

Straight Leg Raises

Leg Extension exercises

Home Programme

95
 Static and dynamic quadriceps exercises are taught

Stair climbing is advised to avoid.

Prognosis

Pain get decreased

Range of motion get increased

ADL activities like walking and stair climbing are improved.

A 16 year old female presented with right medial knee pain that began 1 week prior to presentation after
a fall down the stairs. The patient reported that she missed a stair approximately 1 month prior and
fell down the stairs which at the time caused a small amount of pain in the right knee, but reports that
she ignored this pain assuming that it would disappear in time. She reported that approximately two
weeks prior to her visit to the chiropractic office, she once again missed a stair and fell but did not
have any increased pain immediately. She was unable to report specifically how she landed on her knee.
She reported that the pain began in her right knee one week prior to her visit and could not identify a
specific cause for the pain other than the two prior falls. She reported that she had attended the
emergency room a few days prior and that x-rays were taken of her right knee and found to be
unremarkable. She reported that she was referred to an orthopaedic surgeon but that the appointment
was not for two weeks. She reported that she then went to see a naturopath one day prior who
prescribed topical arnica to control the inflammation and performed acupuncture therapy which the
patient reported did not change the pain. She reported that nothing seemed to ease the pain and that
walking aggravated the pain to such a degree that she missed a few days of school. She rated the pain as
a 10/10 on the Verbal Rating Scale where 0 is no pain and 10 is the worst pain she has ever experienced
and reported that the pain was very sharp in nature. Her past medical history was unremarkable.

She presented for the examination being carried in to the clinic by her boyfriend and when asked to
weight-bear during the examination, required support on both her right and left side. Inspection of the
right knee did not reveal any edema or bruising. Range of motion of the right knee was found to be full
in extension and limited to 90 degrees of flexion with pain reported at the end range of both motions.
There was pain reported on light palpation of the medial joint line of the knee and the medial coronary
ligament of the right knee. Neurological testing of the upper and lower extremities was found to be
unremarkable bilaterally. The following orthopaedic tests were found to be positive for the right knee:
Apleys compression/distraction, and McMurrays test. The anterior and posterior drawer test, as well as
valgus and varus stress testing at zero and thirty degrees were found to be negative. The patient was
diagnosed with a right knee medial meniscus tear with medial coronary ligament involvement and
started on a one month course of therapy consisting of edema control methods, rehabilitation in clinic
twice per week as well as a home exercise program.

During the first visit, the patient was treated with instrument assisted fascial stripping using Gua Sha
tools over the right medial knee and coronary ligament as well as laser therapy. She was instructed with
VMO exercises as described above. After the pain and edema control methods were completed on the
first visit, the patient was able to get off of the table on her own and ambulate unassisted, though with a
slight limp favouring her right knee. She was given instructions to ice four times per day for 10 minutes
each as well as do 1015 repetitions of the VMO exercises three times daily to ensure the maintenance
of quadriceps strength. During the first week of care she was also given simple squatting exercises as
well as wobble board exercises to perform in the clinic as well as at home. After the first week of care,
she presented to the clinic reporting that her pain levels had dropped to 0/10 and reported that she
continued her exercises daily. She was given further advanced squatting exercises including squats with
adduction and one legged squats during her second week of care. At the end of two weeks of her four
week rehabilitation program, the patient and her mother elected to drop out of care, despite the advice of

96
the doctor to the contrary, as she reported that her pain had not returned. On a three month and 6 month
follow up with the patients mother it was reported that the patients pain had not returned.

97
A 16 year old male football player presented with right medial knee pain of two days duration after having been
tackled during practice from the left side at the level of his lower thighs and knees. He reported that the force of
the tackle was directed at his lower legs and that his feet were planted on the ground at the time of the tackle. He
reported that following the tackle he was unable to get off the field due to knee pain. He attended his medical
doctor the day after the injury and was told he had a medial collateral ligament sprain and was advised to seek
physiotherapy, ice, and elevate the leg.

He presented to the chiropractic clinic the following day favouring his right leg due to pain and unable to bend or
straighten his right knee fully. He reported that his mother gave him oral arnica on the evening prior to the
assessment and that he iced several times over the course of the evening, both of which he felt helped his pain
and inflammation. The specific dosage of arnica was not known. He reported that putting pressure over the
outside of his knee and walking tended to increase the pain. He described the pain as being dull with occasional
sharpness associated with certain movements such as walking or pivoting, ascending and descending stairs, as
well as quick movements. He denied referred pain or any parathesias and rated the pain as 3/10 in the office and
7/10 at its worst on a Verbal Rating Scale where 0 is no pain and 10 is the worst pain he had ever experienced.
Past medical history was unremarkable.

The examination revealed limitations in right knee flexion which was absent for the last ten degrees of flexion
and found to be full in extension with pain reported at the end range of both motions. The neurological screening
of the upper and lower extremities was found to be unremarkable bilaterally. A focused examination of the right
knee revealed no edema or bruising when compared to the left knee. Varus stress testing at zero and thirty degrees
of flexion was negative bilaterally. Valgus stress testing of the right knee at zero and thirty degrees was reportedly
painful and revealed a slight laxity when compared to the left knee which was considered a weak positive test for
a medial collateral ligament injury. Anterior and posterior drawer testing was found to be negative bilaterally.
Apleys compression and distraction test of the right knee produced pain in both compression and distraction
(compression portion of test: with the patient prone with knee flexed to 90 degrees clinician grasps calcaneus and
applies a downward force while rotating the tibia internally and externally to test for meniscal tear; distraction
portion: with the patient prone with knee flexed to 90 degrees, clinician stabilizes upper leg above knee and
distracts the lower leg grasping the ankle and rotates the tibia internally and externally to assess collateral
ligaments and for meniscal tears).3 McMurrays test (with the patient supine, the clinician places one hand at knee
joint line and other hand grasping distal tibia. With the knee maximally flexed to begin, extend knee with external
rotation of the tibia; pain or snapping indicates a possible medial meniscus tear) 3 was positive when performed on
the right knee. Palpation of the medial coronary ligament of the right knee elicited pain. Based on the orthopaedic
testing and history, the patient was diagnosed with a right knee medial collateral ligament sprain, likely a grade 1,
and possible medial meniscus tear with medial coronary ligament involvement.

A course of therapy consisting of two visits per week for four weeks was initiated and consisted of
Transcutaneous Electrical Nerve Stimulation (TENS) and laser therapy to the right medial knee to control
inflammation with instructions to ice four times per day for ten minutes. An in clinic and home rehabilitation
exercise program was also initiated. The rehabilitation exercises consisted of VMO exercises to strengthen the
quadriceps femoris muscle, wobble board exercises including double and single leg balancing and double leg
squats, squats, squats with adduction using a ball for resistance, resisted side stepping and the subsequent
progression of these exercises. For the VMO exercises the patient was instructed to sit with his knee bent and
approximately 4 inches from the floor and then to slowly straighten his lower leg without moving the thigh
(Figure A i and andii).ii). He was instructed to do ten to fifteen repetitions three times per day. During the first
week, the rehabilitation focused on VMO exercises, wobble board exercises and simple squat exercises with the
other exercises and progressions being added in the second week of treatment. VMO exercises were given with
the intention of ensuring the maintenance of strength of the quadriceps muscle rather than specifically treating the
injured tissue. After two weeks of therapy, the patient reported that he no longer had any pain unless he was
running at full speed doing sprints in practice. By the middle of the third week of care, he no longer had any pain
during practice and was cleared to return to play by the team doctor. He was at this time provided instruction for
advanced wobble board training (one legged squats) at home. He was discharged after the fourth week of care
and reported no return of pain and no difficulty playing football. On a three month and 4 month follow up of the
patient, he did not report any return of pain or disability in his right knee.

98
https://anneccpa.wordpress.com/2013/07/14/ortho-case-study-

25m-with-knee-pain/

http://www2.fiu.edu/~dohertyj/Sample_Manuscript%20Draft.pdf

Lateral Meniscus Tear with Grade 1 Lateral Collateral Ligament

Sprain

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Objective:

Informing of a 21-year-old female, senior, NCAA division three college

basketball player who acquired a lateral meniscus and later collateral
ligament (LCL) sprain on her left knee during pre-season scrimmage .
Mechanism came from an awkward twisting landing from going after a jump
ball.

Background:

In women athletes, most twisting mechanisms of the knee can lead to

an anterior cruciate ligament (ACL) rupture . In this case however, the twisting
mechanism upon landing has caused a grade 1 LCL sprain and lateral
meniscus tear.

Different Diagnosis:

Lateral collateral ligament sprain, meniscus tear, IT band friction

syndrome, and subluxation of patella.

Treatment:

Patient was given crutches for the weekend and a full rehabilitation
program was given to regain full extension of knee before returning to play .

Uniqueness:

While most female basketball player injuries from a mechanism of

twisting knee while landing result in ACL ruptures , the following case study
focuses on a lateral meniscus tear with a grade 1 LCL sprain . This patient also
has had previous surgery of a complete ACL rupture five years ago on the
same knee.

Conclusion:

In conclusion, the following case study presents the diagnoses ,

treatment, and rehabilitation process of a female basketball player with a

100
grade 1 LCL sprain and lateral meniscus tear with previous history of an ACL
rupture.

Key Words:

Lateral Meniscus, Lateral Collateral Ligament, Knee Injury, College

Athlete

Abstract

The knee joint functions to support the body weight and to shorten and
lengthen the lower limb (1). The knee is a hinge joint with many major
structures running through it, such as, the anterior cruciate ligament (ACL),
the lateral collateral ligament (LCL), and the meniscal cartilage; all of which
will be further explained in this report . The National Collegiate Athletic
Association (NCAA) has gathered statistics over a three year periodshowing
that women suffered anterior cruciate ligament injuries more often than men ,
nearly 4 times as often in basketball, 3 times as often in gymnastics, and
nearly 2 and a half times as often in soccer (2) . This is mainly because of the
womans increased Q angle. The Q angle is a measure of the angle between
the quadriceps muscle on the front of the thigh and the patellar tendon at the
knee (2). This angle is greater in women because of their ability to have a
child and leaves them more susceptible to mainly ACL , as well as other knee
injuries. And between the two menisci , the medial menisci has a much higher
incidence of injury that does the lateral meniscus (3) .

In this case report, I would like to present a senior NCAA division 3

basketball player who suffered a Grade 1 LCL sprain and lateral meniscus tear
who has a previous history of a complete rupture and surgical repair of her
ACL in the same knee. With this injury, I will explain the diagnosing process
along with her rehabilitation process and how return to play was determined .

Case Report

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 A 21-year-old, senior, NCAA division 3 womens basketball player was
competing in a pre season scrimmage when she went up for a rebound and
came down, landing awkwardly, twisting her left leg. She limped a few steps
before taking a knee and coming off the court . We performed a quick
evaluation to determine whether or not she could return to play . She
described moderate pain on her left lateral knee but nothing really severe . No
clicking or swelling was present at the time . She showed full range of motion
(ROM) and full functionality through jumping and cutting so we allowed her to
return to play. After the game we iced and told her to come in tomorrow
before practice for another look at the injured knee .

The next day before practice she came in for us to take another look at
it. She complained hours after the game, her knee had some swelling and
had some instances of clicking, and a little pain with going up and down
steps. We had prior knowledge of her previous ACL rupture and surgery on
that same knee about five years before . She described her pain as a 6 and
like a radiating pain. She also stated that ice made it feel slightly better .

During the observation process, we noticed her left knee was slightly
more swollen then her right. No discoloration was present, nor were there any
sighs of obvious deformities. We had her stand up and demonstrate her walk
for us and she displayed an obvious limp . No forefoot varus or valgus was
present when observing her gait. Neither was there any genuvalgum,
genuvarum, or genurecravartum.

Moving to ROM, both actively and passive flexion of the knee was full
without pain. When we moved to extension however , she could not extend
fully and had some pain. Resistive also had the same results.

There was no neurological test or manual muscle test done because of

no complaints of numbness or tingling so we went straight to special test .
First test done was a Varus Stress test where she had slight pain when
performed and the same results when performed at 30 degrees . We also had
her grab her lay down supine and had her grab her leg and have her heel
touch her side (Bartilozzi Test) and she had pain in her lateral joint line . Other

102
test such as Varus Stress Test, McMurrays Test, and Apleys
Compression/Distraction test were performed but all had negative results .

From these factors we determined it was a Grade 1 LCL sprain and

lateral meniscus tear. I believe this because the clicking, pain with stairs,
positive bartilozzi test, and unable to gain full extension lead me to believe
its a torn lateral meniscus. And her mechanism, location of pain, and
positive varus stress test points toward a grade 1 LCL sprain . We began
exercises to start with extension and fitted her with crutches to use for the
weekend. She was kept out of practice until she regained full extension and
had no more limping.

Her exercises consisted of warming up ten minutes on the bike , then

she would do straight leg raises with no weight for the first day; three sets of
ten. Next, would be passive extension; four sets of thirty . Finally, standing
knee flex; three sets of ten. We would then ice her knee after. The following
day her swelling had went down so we added a five pound ankle weight to
her straight leg raises and standing knee flex . We also added a new exercise
where she laid flat with her knee on the edge of the table with the five-pound
weight on her ankle. We continued this for three more days until she regained
full extension.

We then gave her a LCL tape job for more stability and had her perform
some functional test to determine whether or not she could return to play . We
had her do a box drill where she would sprint up , shuffle to her right, back
pedal, and then shuffle to her left a few time; She had no complaints . We
then had her do some sprinting. Finally we had her do some jumping lay-ups
on each side of the net and had no complaints . We allowed her to return to
practice with the limitations of no scrimmaging yet and she would continue to
come in for treatment. After practice she felt fine with her limitations and the
following practice was able to return fully with no limitations .

Discussion

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 With injuries like these, its very important to gain full range of motion .
Sports Science Orthopedic Clinic explains, The ultimate goal of ACL
reconstructive surgery is to provide dynamic stability while maintaining full
range of motion. (4) But that can go for any injury that looses ROM . If ROM is
lost in the knee and never regained, it will cause limping due to leg
discrepancy, which can then lead to more and more problems caused my
your kinetic chain thrown of by not having full ROM . With this athlete in
particular, its important to know the history of the injury to make sure her
previous ACL reconstruction wasnt upset and that the LCL and lateral
meniscus heal properly.

Conclusion

In conclusion, Ive shown you a 21-year-old female, senior, NCAA

division three college basketball player who acquired a lateral meniscus and
later collateral ligament (LCL) sprain on her left knee from coming down
awkwardly in a twisting motion. Ive also provided you with the systematic
evaluation process and how we diagnosed, treated, and got her back to
100%. The main thing Ive learned from this case study is how to rehab
properly to regain full range of motion and the proper things the look for
during a functional test for the athlete to return to play.

References:

1.Clarkson, Hazel M. Musculoskeletal Assessment. Philadelphia,

PA: Lippincott Williams and Wilkins; 1989

2. Physical Therapy Corner: Knee Injuries and the Female

Athlete. 2007. Available At:
http://www.nismat.org/ptcor/female_knee

3. Prentice, William E. Principles of Athletic Training. New

York: McGraw Hill; 2011

4. The Sports Science Orthopedic Clinic: Reconstructive

Surgery. 2011. Available At: http://www.ssoc.co.za/acl-
injuries.html

104
 CASE ASSESSMENT - 2
Name : K. Arjun

Age : 35 Years

Gender : Male

Occupation : Sports Master

Address : Podalakur

Chief complaints : Pain around left knee during

walking

Weakness is felt

Difficulty in Walking

Difficulty in stair climbing

Decreased movement

History

Present History : Pain around left knee during

walking

Weakness is felt

Decreased movement

Past History : He had a slip during foot ball play

and under gone surgery before two

months

Medical History : Analgesics for pain relief

Surgical History : He had surgery before two months

Personal History : No History of hypertension and

Diabetes Mellitus

Pain Assessment

Site : Around Knee

Side : Left side

105
Duration : Two months

Character of pain : Not Radiating

Aggravating Factors : During movement and at work

Relieving Factors : At Rest

106
VAS Scale:

On Observation

Built : Moderate

Attitude of Limb : Slightly flexed

Skin Colour changes : Not Seen

External Appliances : No Usage

On Palpation

Tenderness : Grade II

Muscle Spasm : Positive

Warmth : Positive

Swelling : Positive

On Examination

Range of motion of knee joint.

Passive

Movemen Right knee Left knee

t

Flexion 0-130 Degrees 0-110 Degrees

Extension 130-0 Degree 110-0 Degrees

Active

Movemen Right knee Left knee

t

Flexion 0-130 Degrees 0-100 Degrees

Extension 130-0 Degree 100-0 Degrees

Manual muscle testing

107
 Muscles Right knee Left knee

Flexors Grade 5 Grade 3

Extensors Grade 5 Grade - 3

Deep Tendon Reflexes

Jerk Right Left

Knee ++ +

Ankle ++ ++

Plantar ++ ++

ADL : Activities like walking, stair

climbing, jumping are difficult.

Investigations

Provisional Diagnosis : Post operative Knee pain

Treatment

Pain : Ultra Sound, IFT, Cryotherapy

Swelling : Crep bandage, Elevation of limb

Week 0-1 after surgery : Static Quadriceps

Static hamstrings

Straight leg raises

Calf raises

Hip abduction

Hip Flexion

Week 1-2 after surgery : Half way squats

Lunges

Single Calf raises

Proprioceptive exercises

Week 2-3 after surgery : Full squats

Full lunges

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 Proprioceptive exercises

Single leg squat

Week 3-5 after surgery : Full squats

Full lunges

Proprioceptive exercises

Home Programme

Static and dynamic quadriceps exercises are taught

Stair climbing is advised to avoid.

Prognosis

Pain get decreased

Range of motion get increased

ADL activities like walking, stair climbing and jumping are

improved

109
 CONCLUSION
Meniscal tears are common and can be part of degenerative change

within the knee joint or secondary to trauma. They can cause symptoms

that affect the function of the joint and require surgical intervention.

The majority of symptomatic tears require arthroscopic partial

meniscectomy but in a few select cases the tear may be amenable to

repair done as an open or arthroscopic procedure.

Effective rehabilitation should be there for spontaneous recovery.

Rehabilitation interventions seek to promote recovery and independence

in daily activity, to promote better health and prevent secondary

complication.

The utilization of effective treatment intervention focus on real life

environments can cause successful attainment of functional outcomes.

By the proper rehabilitation programme treated for five weeks of

the present case with meniscal injuries have been shown to improve

functional outcome and allowed the patient to regain independence in

daily life.

It is concluded that, with proper rehabilitation program, we can

regain patient functional activity to maximum level and prevent

secondary complication.

110
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