1. Update on Rehab Protocols Knee Meniscus Tears and Cartilage Defects: How to protect the repair Andrew Opett, DPT Physical Therapist STAR Physical Therapy

2. Meniscus Repair  Phase I (Protection, ROM, muscle activation; 0-2 weeks) Typically 0-2 weeks in brace NWB*; ROM 0-90° in NWB FWB by 1-2 weeks brace locked in EXT Exercises: heel slides*, QS/HS, patellar mobs, gastroc/soleus stretches, SLR (in locked brace if extensor lag) Other considerations: » patient education, gluteal muscle activation (SLRs all planes, terminal ext, understanding of preinjury status 5 »*If meniscal root repair, no isolated hamstring contraction (PROM flexion only) and NWB up to 6 wks »“Respect the restrictions”

3. Meniscus Repair  Phase II (WB tolerance; 4-6 weeks) Full WB brace unlocked 0-90°, Full ROM NWB (2-4 weeks) FWB without brace (4-6 weeks) avoiding flex > 90° in WB Exercises: calf raises, closed chain quads Other considerations: »LE alignment as WB stresses are increased »“do no harm” - exercises performed in pain free ranges and intensities »Aquatic therapy (up to 75% reduction in WB in chest deep H20) »Non antalgic gait pattern? »Early DL proprioceptive activities »Consider translational, rotational, compressive stresses to meniscus with ADL

4. Meniscus Repair  Phase III (Endurance; 6-12 weeks) Full unrestricted ROM with WB Progression of closed chain ex, initiate hs exercises, lunge/leg press 0-90°, proprioception, balance/core ex, stationary bike Other considerations »“functional progression” concentric  eccentric »Double leg closed chain exercises  single leg with proper form, technique »Reassessment of muscle strength, length, patellar alignment/mobility »Consider the effects of fatigue on muscle performance and technique

5. Meniscus Repair  Phase IV (Strength, Progress to sport specifics; 12-20 weeks) Progress all phase III exercises Swimming permitted 12 weeks If symmetrical ROM, good quad control, no antalgia: progress to sport specific drills/running/jumping 16 weeks Other considerations »Introduction of plyometrics with gradual increased intensity »Isokinetic testing »Functional testing (single leg hop, cross over hop) looking for limb symmetry »Sport/activity specific drills and activities. »Many protocols delay running initiation to at least 4 months post op »Consider the mechanics of running and effects of fatigue during this phase.

6. Partial Meniscectomy  Fewer restrictions  Early treatment considerations include controlling edema and pain, increasing ROM, WBAT to full WB, early balance and proprioception by day 10-12  10 days to 2 weeks include progression of closed chain eccentrics and proprioception  Begin running and sport specific activities weeks 4-7 as tolerated

7. Rehabilitation after Cartilage Repair How to protect the repair while maximizing the rate of progress

8. Rehabilitation after Cartilage Repair Considerations – Procedure: restorative (allograft) vs reparative technique (microfx, ACT) – Patellofemoral vs. femoral condyles vs. tibial plateau – Avoid overload of graft; adherence to WB restriction crucial – Patient Education – Pre-injury status, age, BMI, psychological factors – Individualized criterion based rehab recommended with mindfulness of biology of repair technique – Concomitant procedures? – Pain/swelling are primary indicators poor tolerance to interventions – Communication between MD and PT

9. Rehabilitation after Cartilage Repair Phase/Stage I – Biologic Phase: graft integration and stimulation – Rehabilitation Phase: Protection and joint activation Phase/Stage II – Biologic Phase: Matrix production and organization – Rehabilitation Phase: Progressive joint loading and functional restoration Phase/Stage III – Biological Phase: Repair cartilage maturation and adaptation – Rehabilitation Phase: Activity restoration – **often MD approval necessary for progression to each phase Mithoefer et al 2012.

10. Rehabilitation after Cartilage Repair Phase I: 0-6 wks Patient education crucial: avoid overload of graft Reduce pain and effusion Monitor WB restrictions – Femoral defects: up to 6 wks TDWB w crutches – Patellar/trochlear defects: early WB brace locked in ext Early ROM and motor control interventions – Goal >90° flexion by 3 weeks, 110° by 6 wks – Patellar mobilization – QS, SLR (braced) – Aquatic therapy?

11. Rehabilitation after Cartilage Repair Phase II: 7-12 wks WB 50% for weeks 7 and 8, full WB by week 9 Continue previous interventions Discontinue brace if good SLR control Full AROM by 12 weeks Open chain quads, hs, hip abd, hip ext Closed chain TKE 0-40° at 9-10 weeks as tolerated Aquatic therapy Modification of activity levels in this phase based on patient symptoms

12. Rehabilitation after Cartilage Repair Phase III: 13+ wks No brace, full WB as tolerated, Full ROM, minimal pain or effusion, 20% deficit with isokinetics, 10% deficit with single leg hop test (with MD approval) Open chain resistance exercises <20lbs through 6 months Closed chain ex and proprioceptive activities Cycling on level surface/TM walking No pivoting sports/activities until MD clearance No squats or leg press allowed without clearance

13. Thank you!