Meniscus Injury

Khairul Nizam Abdul Rahman

4262143008
Introduction
• The semilunar cartilages are commonly called menisci and
form an important shock-absorbing mechanism, which helps
in the gliding movement of the tibia on the femur. Injuries to
the meniscus are common in young adults and are often
sustained by the football players.
Mechanism of injury
• A meniscus tear is usually caused by twisting or turning
quickly. These tears can occur when you lift something heavy
or play sports. As you get older, your meniscus gets worn. This
can make it tear more easily.
• An abduction external rotation violence, on a flexed weight-
bearing knee, causes a tear in the medial meniscus. in
football, it occurs when the player standing on one leg, which
is slightly flexed at the knee, turns to tackle the ball with the
other leg.
• The lateral meniscus is damaged by the opposite violence,
that is, internal rotation and abduction violence of the tibia or
a semiflexed weight-bearing knee.
Clinical Features
• At the first time of the injury, the patient gets an acute pain in
the knee. The knee gets locked in flexion. The knee get gets
swollen soon after, due to effusion. This may subside in about
a week.
• Subsequently, he gets recurrent attacks of ‘locking’ of the
knee with effusion. He feels insecure in the knee while
walking and the knee ‘gives way’. In the typical case, the
patient gives a history of recurrent episodes of locking, pain
and swelling associated with ‘clicking at the knee.
Signs and Symptoms
• Knee pain
• Swelling of the knee within 48hours
• Stiffness of the knee
• Tenderness when pressing on the meniscus (knee joint line)
• Pain with squatting
• Popping or clicking within the knee
• Limited motion of the knee joint
Types of meniscus tear
Longitudinal tear
• Vertical tear in the meniscus with a longitudinal direction; usually
located in the periphery of the meniscus. The longer the tear, the
more unstable it is, and the end result is the dislocated central part
of the meniscus (bucket-handle tear)
Horizontal tear
• Horizontal cleavage in the meniscal tissue
Radial tear
• Vertical tear starting in the free (central) margin of the meniscal
tissue.
Flap tear
• Oblique vertical cleavage causing a flap tear (parrot beak); a flap
tear can also be caused by a horizontal tear.
Tear in degenerative meniscus
• A tear or multiple tears in a degeneratively changed meniscal tissue
Types of meniscus tear
Special test
McMurrays Test
• This test is done with knee flexed as far as possible and the foot and tibia
either externally rotated or internally rotated.
• While the tibia is held in the appropriate position, the knee is brought from
the position of acute flexion into extension.
• The positive finding is a painful pop along the appropriate joint line that is
palpable or audible to the examiner.
• In some knees, significant pain may be elicited over the appropriate joint
line without a true popping.
Special Test
Apley's Test
• This test is done with the patient prone and the knee flexed to 90 degrees.
• The examiner pushes downward on the sole of the patient’s foot toward the
examination table to compress the menisci between the tibia and femur.
• Then, with the tibia in external rotation or internal rotation, the knee is
moved through full ROM while compression is maintained.
• A positive response is pain over the joint line being tested.
Investigation
• Plain x-rays are usually normal, but MRI is a reliable method of
confirming the clinical diagnosis, and may even reveal tears
that are missed by arthroscopy. Arthroscopy has the
advantage that, if a lesion is identified, it can be treated at the
same time.
Management
Medical
• Paracetamol
• Anti-inflammatory medicalYou can also take medication such
as ibuprofen, aspirin, or any other non-steroidal anti-
inflammatory (NSAID) medication to reduce pain and swelling
around your knee.

Surgery
• Partial Meniscectomy surgery - Usually just removal of few
meniscus if there few meniscus injury only
• Meniscectomy surgery - If the meniscus is beyond repair or
partial removal, then this kind of surgery be done in order to
prevent other complication such as OA
Physiotherapy

• Ice pack
• Cryotherapy
• ROM exercises
• Strengthening exercises
• Weight-bearing exercises
Rehabilitation Protocol
After Arthroscopic Partial Medial or Lateral Meniscectomy

PHASE 1: ACUTE PHASE

• Goals
• Diminish inflammation and swelling
• Restore ROM
• Re-establish quadriceps muscle activity

• Days 1-3
• Cryotherapy
• Electrical stimulation of quadriceps
• Quadriceps sets
• SLR
• Hip adduction and abduction
• Knee extension
• ½ squats
• Active-assisted ROM stretching, with emphasis on full knee extension
• Weight-bearing as tolerated (two crutches)
• Light compression wrap
• Days 4-7
• Cryotherapy
• Electrical stimulation of quadriceps
• Quadriceps sets
• SLR
• Hip adduction and abduction
• Knee extension (90-40 degrees)
• ½ squats
• Balance/proprioceptive drills
• Active-assisted and passive ROM exercise
• ROM (0-115 degrees, minimal)
• Stretching (hamstrings, quadriceps, gastrosoleus)
• Weight-bearing as tolerated (one crutch)
• Continued use of compression wrap or brace
• High-voltage galvanic stimulation/cryotherapy

• Days 7-10
• Continue all exercise
• Leg press (low weight)
• Toe raises
• Hamstring curls
• Bicycle (when ROM is 0-102 degrees with no swelling)
PHASE 2: INTERNAL PHASE
• Goals
• Restore and improve muscular strength and endurance
• Re-establish full nonpainful ROM
• Gradual return to functional activities

• Days 10-17
• Bicycle for motion and endurance
• Lateral lunges
• Front lunges
• 1/2squats
• Leg press
• Lateral step-ups
• Knee extension (90-40 degrees)
• Hamstring curls
• Hip adduction and abduction
• Hip flexion and extension
• Toe raises
• Proprioceptive and balance training
• Stretching exercises
• Active-assisted and passive ROM knee flexion
• StairMaster or elliptical trainer

• Days 17-week 4
• Continue all exercises
• Pool program
• Compression brace may be used during activities
• PHASE 3: ADVANCED ACTIVITY PHASE – WEEKS 4-7
• Criteria for progression to phase 3
• Full, nonpainful ROM
• No pain or tenderness
• Satisfactory isokinetic test
• Satisfactory clinical examination (minimal effusion)

• Goals
• Enhance muscular strength and endurance
• Maintain full ROM
• Return to sport/functional activities

• Exercises
• Continue to emphasize closed-kinetic chain exercises
• May begin polymeric
• Begin running program and agility drills
Rehabilitation Protocol
After Meniscal Repair

• PHASE 1: MAXIMUM PROTECTION – WEEKS 1-6

• Stage 1: immediate postoperative period – Days 1-Week 3
• Ice, compression, elevation
• Electrical muscle stimulation
• Brace locked at 0 degrees
• ROM (0-90degrees)
• Patellar mobilization
• Scar tissue mobilization
• Passive ROM
• Quadriceps isometrics
• Hamstring isometrics
• Hip abduction and adduction
• Weight-bearing as tolerated with crutches and brace locked at 0 degrees
• Proprioception training

• Stage 2: Weeks 4-6

• PREs- 1-5pounds
• Limited-range knee extension
• PHASE 1: MAXIMUM PROTECTION – WEEKS 1-6
• Toe raises
• Mini-squats
• Cycling (no resistance)
• Surgical tubing exercises (diagonal patterns)
• Flexibility exercises

• PHASE 2: MODERATE PROTECTION – WEEKS 6-10

• Criteria for progression to phase 2
• ROM (0-90 degrees)
• No change in pain or effusion
• Quadriceps control

• Goals
• Increase strength, power, endurance
• Normalize ROM of knee
• Prepare patients for advanced exercises

• Exercise
• Strength – PRE progression
• Flexibility exercises
• Lateral
• Step-ups
• Mini-squats
• Isokinetic exercises
• Endurance program
• Swimming
• Cycling
• Nordic-Trac
• Stair machine
• Pool running

• Coordination program
• Balance board
• High-speed bands
• Pool sprinting
• Backward walking

• Polymetric program
• PHASE 3: ADVANCED PHASE – WEEKS 11-15
• Criteria for progression to phase 3
• Full, nonpainful ROM
• No pain or tenderness
• Satisfactory isokinetic test
• Satisfactory clinical examination

• Goals
• Increase power and endurance
• Emphasize return to skill activites
• Prepare for return to full unrestricted activites

• Exercises
• Continue all exercises
• Increse tubing progra, pluometrics, pool program
• Initiate running program

• Return to activity: criteria

• Full, nonpainful ROM
• Satisfactory clinical examination
• Satisfactory isokinetic test
THANK YOU
Effect of isokinetic training on the function recovery of knee meniscus injuries following arthroscope
• Li X-H, Ren Y-B, Xi G-P
• Zhongguo Linchuang Kangfu [Chinese Journal of Clinical Rehabilitation] 2006 Nov 25;10(44):193-
195
• clinical trial
• 4/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: No; Baseline
comparability: No; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-
up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and
variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has
been confirmed*
• BACKGROUND: Rehabilitation training after sports injury is of so great importance in the
remaining and relieving of exercise ability that the researches in this field need to develop.
OBJECTIVE: To evaluate the influence of isokinetic training on the functional recovery of knee
flexors and extensors and the muscle force around the joint after knee meniscus injuries receiving
arthroscopy. DESIGN: Case-control observation. SETTING: Department of Police Training, Liaoning
Advanced Police Officer School. PARTICIPANTS: A total of 20 patients with acute meniscus injury of
lateral knee joint were selected from the Department of Surgery, Affiliated Hospital of Dalian
Medical University between September 2004 and January 2005. They were randomly divided into
experimental group and control group, including 11 cases respectively. METHODS: All the patients
were treated with arthroscope operation, additionally the control patients received routine
blocking, physiotherapy and massage, etc to recover the function. From the 2nd to 4th days
postoperative, the patients of experimental group began to carry out the functional rehabilitation,
and received isokinetic exercise in both knees flexors and extensors with the Cybex-6000
isokinetic dynamometer 3 weeks later. MAIN OUTCOME MEASURES: Peak torque values, total
work, torque accelerating energy and average power in both knee flexors and extensors at
different angular velocities (60, 120 and 180 degrees/s). RESULTS: A total of 22 patients were
involved in the result analysis. (1) After arthroscope operation and isokinetic training, the range of
joint movement were extended, and the maximum flexion angle changed from (132 +/- 25)
degrees to (158 +/- 21) degrees. There were significant differences before and after training by t
test (p < 0.01). (2) The experimental group had statistical significance compare with control group
in the test index at 60, 120 and 180 degrees/s (p < 0.05). CONCLUSION: The arthroscope
combining with isokinetic training can speed up the rehabilitation after knee meniscus injury,
enhance the muscle force around knee joint and maintain the stability of knee joint and motor
ability.