Postoperative Rehabilitation Protocol Arthroscopic Medial/Lateral Meniscectomy

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Arthroscopic meniscectomy or repair.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

* If meniscal repair is performed the patient should adhere to NO weightbearing flexion of the knee greater than 90 degrees until a minimum of 6 weeks post-op. 

*Return to play is sport-specific.  Any athlete wishing to resume play must undergo evaluation in the office prior to obtaining clearance.  

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

 

Phase 1- Early Post-Operative Phase (Post-op Day 0-14)

The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity, and maximize the patient’s mobility with a goal of functional independence.  Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential. Use of a knee immobilizer/brace is not mandatory unless directed specifically by our team. 

Goals: 

  1. Full weight bearing ability on the operative extremity.  Wean crutches as soon as possible when sufficient quad activation and minimal compensatory gait, pain sufficiently controlled
  2. Achieve Passive Range of Motion (PROM) equal to or greater than 110 degrees of flexion and maintain passive extension to 5 degrees from zero or less.  Both PROM and AROM may be progressed as tolerated 
  3. Perform independent Straight Leg Raise (SLR) without lag 
  4. Implement use of nonpharmacologic modalities to control pain and swelling such as icing, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. Assess surgical wound for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment and post-treatment AROM/PROM, efficiency/safety/necessity of ambulatory assistive devices
  5. Assess for signs of large intra-articular effusion, DVT (Homan’s sign, calf circumference, Well’s Criteria), Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Isometric quadriceps, hamstring, and gluteal exercises
  2. Patella mobilizations 
  3. Heel slides
  4. Stationary bike no/low resistance 
  5. Straight leg raises (flexion,extension,ADDuction, ABDuction) 
  6. Sidelying Clamshell
  7. Gastroc/soleus stretching
  8. Assess balance, gait pattern, and weight transfer 
  9. Ensure neutral hip motion and address any core/postural deficiencies

Precautions:

  1. WBAT (Weight Bearing As Tolerated), initially with assistive devices and wean use as patient demonstrates sufficient locomotor proficiency
  2. Avoid weights or resistance bands
  3. Avoid rotational torque and/or twisting of the knee while weight bearing
  4. Avoid kneeling or direct pressure on the incision/anterior knee
  5. Avoid placing supports behind the surgical knee to facilitate obtaining full extension

*Patient may progress to Phase II when able to demonstrate sufficient quadriceps activation, independent SLR, Active ROM 5-90 degrees flexion or greater, adequate pain control, ability to transfer independently, and ambulate greater than 250 ft with minimal or no assistive devices.  

Phase II (Post-op Week 2-6)

Goals:

  1. Improve ROM with a goal of 0-135 degrees flexion by end of phase II

*No WB flexion > 90 degrees until 6 weeks post-op if medial AND/OR lateral meniscus repair performed

  1. Minimize compensatory gait  
  2. Continue proprioceptive training and gait training (Encourage early discontinuation of assistive devices and immobilizer/brace)
  3. Decrease swelling/inflammation

Assessment by Therapist:

  1. Assess pain using 1-10 or visual analog scores
  2. Assess use of narcotic and non-narcotic analgesics
  3. Assess pre-treatment and post-treatment PROM/AROM 


Therapeutic Exercises:

Week 2-4

  1. Encourage AROM flexion/extension exercises
  2. Patella mobilizations 
  3. Continue isometric quadriceps, hamstring, gastroc/soleus, and core/gluteal exercises
  4. Supine Heel Slides and seated Long Arc Quad (LAQ)
  5. SLR in all planes (flexion, extension, ADDuction, ABDuction)
  6.  NMES of quads based on necessity (lack of appropriate activation).  May progress NMES from isometric to isotonic and functional activity

Week 4-6

  1. Continue Phase I exercises
  2. Front and Lateral step up/down
  3. Begin toe raises, balance exercises (single leg stands)
  4. Begin lunge progression (50% depth max if meniscal repair performed) 
  5. May incorporate resisted seated rowing exercises as tolerated
  6. Leg press, seated hamstring curl machine, hip abductor and adductor machine, and seated calf machine
    1. Goal is increase reps before resistance 

Precautions:

  1. Monitor for increase in edema/swelling with increased activity levels, consider graduated compression stockings or knee compression sleeve if accepted/indicated
  2. No return to sport before 6 weeks 

*Patient may progress to Phase III after achieving PROM 0-125 degrees or greater, adequate quadriceps activation, and able to ambulate without assistive device or significant gait disturbance

 

Phase III (Post-op Week 6-12)

Goals:

  1. Demonstrate Normal Gait pattern
  2. No extensor lag with SLR 
  3. Establish Home/Gym Exercise Plan in conjunction with therapist recommendations
  4. Return to sport or work by end of phase III

Therapeutic Exercises:

  1. Continue Phase II exercises and progress resistance, strengthening, and repetitions as tolerated
  2. OK progress lunges to full depth and closed chain strengthening as tolerated
  3. Progress balance and proprioceptive exercises as appropriate
  4. Advance Open Chain exercises and plyometrics as tolerated after 9 weeks including cutting and pivoting sport specific drills

Precautions:

  1. No return to sport without clearance from physician 
  2. OK to begin interval running program when quad strength 80% of non-operative extremity and progress ONLY if no pain/swelling after exercise