MENISCUS REPAIR Protocol: INTRODUCTION
- This MENISCUS REPAIR reconstruction protocol is criterion based. Patients must demonstrate specific functional criteria at each physical therapy visit before progressing to more advanced interventions.
- Throughout this protocol, time references (in weeks since surgery) represent the EARLIEST that a patient may begin an exercise/activity following MENISCUS REPAIR reconstruction.
PROTOCOL UTILIZATION
Each time reference in the protocol is categorized into four sections:
Functional Criteria
In this section, the therapist will see criteria for how a typically progressing patient should present following surgery. The patient should be able to demonstrate the listed criteria at the start of the physical therapy visit. If able, progress to the therapeutic exercise listed below. If unable, continue to focus on PT intervention strategies from prior sessions that will assist the patient in achieving these functional criteria before the next clinic visit.
Patient Education
In this section, the therapist will see points of education that should be discussed with the patient including: Frequency of home program, use of brace, exercise technique, return to sport.
Therapeutic Exercise
The therapeutic exercise listed in this protocol conveys the appropriate load for the patient given the time elapsed and the functional progress made since surgery. This is not a complete listing of rehabilitation strategies. Only teach patients exercises appropriate for this time frame if they were able to demonstrate functional criteria listed above.
Outcome Measures
The Lower Extremity Functional Scale and MENISCUS REPAIR – Return to Sport Index will be used throughout recovery to gauge patient perceived function and self-efficacy with activity.
First 2 weeks are generally completed by patient independently, just working on swelling and pain control with some early activation of the quads and gentle range of motion.
WEEK 0-2 after MENISCUS REPAIR : Focus on controlling effusion and pain; obtaining full extension; quads activation
Functional Criteria
-Ambulation with drop-lock brace locked in full extension with axillary crutches, TTWB.
-Full extension is emphasized
Patient Education
-Inform patient that they can expect daily rehab from now until return to sport
-Complete home program TWICE per day
-Continuous wear of brace locked in full extension, including sleep.Exception: home exercise program with brace unlocked.
-Continue to ice/elevate for 20 minutes up to three times per day.
Therapeutic Exercise
-Heel slides progression to 90 degrees flexion
-Quad sets
-SLR with brace on
-Ankle pumps
Outcome Measures
-Lower Extremity Functional Scale
Begin physical therapy with 2-3 visits at one week intervals. Then every other week until the patient has passed functional tests. Emphasis is placed on independent completion of instructed home exercise program. Approximately 12-18 clinic visits in PT from surgery to return to activity/sport.
WEEK 2-4 after MENISCUS REPAIR : Focus on maintaining full extension, quad recruitment and no lag with SLR
Functional Criteria (General guideline only)
-Range of motion 0-90 degrees by week 4 (no overpressure).
-Ambulation with drop-lock brace and axillary crutches, continue TTWB.
Patient Education
-Inform patient that they can expect up to one hour of daily rehab from now until return to sport
-Complete home program TWICE per day (two 30 minute sessions)
-Continuous wear of brace in full extension. Brace wear for sleep continues. Exception: home exercise program with brace unlocked
-Continue to ice/elevate for 20 minutes up to three times per day
-Remind the patient that the following time references are the EARLIEST that a specific activity may be started: Running: 14-16+ weeks after surgery. Non-contact activity/sports: 4+ months after surgery. Contact sports: 6+ months after surgery
Therapeutic Exercise
-Heel slides progression (no overpressure)
-Prone hangs
-Quad sets -SLR with brace on – Need to make sure brace is fitting properly due to atrophy
– remove brace once no lag
-Clam shell with no band (minimize TFL contribution)
-Standing or laying hip extension and hip abduction with brace on
-Patellar mobilizations in all directions
Outcome Measures
-Lower Extremity Functional Scale
WEEK 4-6: Focus on ROM to normal limits, normalization of gait, quad strength
Functional Criteria
-Extension symmetrical in prone
-Flexion progress to full- should be 90 or greater by week 4
-Continue use of brace, progressing PWB to FWB as tolerated. May begin unlocking brace per quad and pain control.
Patient Education
-Remind patient that they can expect up to one hour of daily rehab from now until return to sport
-Complete home program ONCE per day
-Continued brace use at gradually increased flexion degrees per quad control for ambulation and CKC activities with progression of WB status as tolerated.
-Continue to ice/elevate for 20 minutes once per day
-Educate patient that even though pain is minimal, graft is weak during this time frame.
-Continue patellar mobilization 5 minutes daily
-Avoid hyperextension with stance phase of gait
-No pivoting on planted foot
-Prevent dynamic knee valgus and hip internal rotation
Therapeutic Exercise
-Prone hang, prone knee flexion
-SLR 4-way
-Mini Wall squats 0-60 degrees
-Heel raises- double legged
-Clam shell with orange/red or green band
-Early hamstring strengthening
-Double leg balance
WEEK 6-8 after MENISCUS REPAIR : Focus on restoring normal mechanics, preserve quad control/engagement, LE/core strength progression
At this point rehab begins to strongly focus on the gluteus medius and maximus by implementing the Powers Program. This is an evidence based progression of exercises designed to maximize the recruitment and strength of the gluteals. Take care to prevent dynamic knee valgus and hip internal rotation- as well as minimize
contribution of the TFL.
The program consists of eight levels with three separate focuses:
Levels 1-3: Gluteal activation/recruitment
Levels 4-5 Gluteal strength
Levels 6-8: Functional applications and sport specific skill acquisition
It is imperative that the therapist provides extensive education to the patient while progressing through the Powers Program. Make sure the patient feels the exercises challenging the glutes. The quads, of course, will continue to function during weight bearing exercises. The following are the necessary cues for appropriate form:
1) Lower extremity alignment
2) Hips down and back
3) Pelvis level
4) Trunk vertical (no lateral lean)
5) Soft landings
Functional Criteria
-Extension symmetrical
-Flexion symmetrical
-GAIT ASSESSMENT: Progressing toward normalized gait pattern FWB
-Completion of adequate SLR and pelvic floor/TA contraction
-FWB and weaning out of brace- may still need for higher risk situations outside the home
Patient Education
-Complete home program once per day
-Brace use when outside of home in an open position as needed
-Continue to ice/elevate for 10-15 minutes once per day
-Discuss importance of gluteal strength in alignment of the lower extremity. Strong glutes = diminished strain through the knee
Therapeutic Exercise
-Non weightbearing activation of gluteus medius/maximus with isometric holds (Powers Level 1)
-Prone hang, prone knee flexion, ITB/gluteal stretch, gastrocnemius/soleus stretches
-Continue quad sets, mini-squats, SLR 4-way. May add weight to distal thigh
-Leg press (10-60 degrees)
-Heel raises (single leg)
-Begin progression of hamstring strengthening
-Progress CKC drills and balance to single limb per control
-Start step up/down progression
Cardio: -Initiate basic cardio with stationary bike (10-15 minutes, start with seat high or recumbent bike at no resistance and build to low resistance)
WEEK 8-12 after MENISCUS REPAIR : Focus on static double leg activation of gluteus medius/maximus, normal stair climbing
Functional Criteria
-Full ROM
-Multi-planar LE and core strength 5/5 with MMT
-Subjective report of completing clam shell with blue band for 60 seconds 5x on right and left for a minimum of
three consecutive days
-Objective observation of clam shell with blue band for 60 seconds bilaterally with appropriate form
-GAIT ASSESSMENT: Normalized gait pattern with no gross biomechanical deviations. No brace use.
-STAIRS ASSESSMENT: Progression of reciprocal pattern on stairs
Patient Education
-Complete home program once per day
-Remind patient of the importance of gluteal strength in alignment of the lower extremity
-With exercises, should feel glutes working more than quads
-Observe for return of effusion/pain with increased activity
-Teach patient to watch technique/form in the mirror
-Knee aligned over second toe
-Hips down and back
Therapeutic Exercise
-Static double leg activation of gluteus medius/maximus (Powers level 2)
-Prone hang, prone knee flexion, ITB/gluteal stretch, gastrocnemius/soleus stretches
-Progression of balance- add challenges and progress double to single as able
-Progression CKC drills with directional challenge (resisted side-stepping)
-Continue standing hamstring curls and calf raises
-Leg press (10-70 degrees)
-Double leg squats starting with no weight and progressing to half of body weight
Cardio:
-Progress biking and add elliptical, walking (20-25 minutes, moderate intensity, steady pace)
Outcome Measure
Lower Extremity Functional Scale
Week 12-16 after MENISCUS REPAIR : Focus on proper self-awareness of LE alignment, static single leg activation of gluteus medius/maximus and dynamic double leg strength, muscular endurance
Functional Criteria
-Full ROM
-Quadriceps function at 70% of unaffected leg with less than 2cm of atrophy
-Able to perform proper double and single leg squats
-GAIT ASSESSMENT: Normalized walking speed and distance
-STAIRS ASSESSMENT: Up/down 12 steps with reciprocal pattern/no rail with no gross biomechanical deviations
Patient Education
-Complete home program every other day
-Normalization of gait and appropriate quadriceps function are necessary in order to begin return to run
program
-Observe for return of effusion/pain with increased activity
-No pivoting activities/sports until 4+ months post-op
Therapeutic Exercise
-Static single leg activation of gluteus medius/maximus (Powers level 3)
-Dynamic double leg strength (Powers level 4)
-Prone hang, prone knee flexion, ITB/glute stretch, gastroc/soleus stretches
-Quad strengthening – no open chain knee extension
-Hamstring strengthening
-Single leg balance progression with challenge
-Progress weight training to single leg (first with eccentric phase only)
-Progression of CKC drills to higher reps and trunk/UE movement
Cardio: Progression of biking, elliptical, walking (25-40 minutes, moderate intensity with 3-5 brief near maximal
intensity bursts with recovery periods)
Return to Run Program
– Running may begin around 14-16 weeks for peripheral repairs, may push back for complex repairs
– Observe jogging in clinic. Use clinical judgment.
-If pain free and biomechanical deviations are small, cue patient and issue Return to Run Program
-If painful and/or biomechanical deviations are moderate+, reassess at next visit.
Return to Weight Lifting
-Patient may begin a slow, graduated return to strength training in the gym
-Max of every other day
-Give the ok for: Leg press, prone or seated ham curls, hip abduction, squats with smith/bar, dead lifts, heel
raises
-Do not start more advanced Olympic lifts at this time
-No seated knee extension
-Two to three sets of 12-15 at appropriate weight
-Gradual increase in weight (max of 10% once per week).
-Fatigue and muscle soreness is ok. No pain in knee.
WEEK 16-18 after MENISCUS REPAIR : Focus on dynamic single leg strength and progression of running
Functional Criteria
-Normal quad girth
-Gluteus medius strength a minimum of 5-/5 bilaterally
-SQUAT ASSESSMENT: Complete 15/15 functional squats with appropriate alignment of lower extremities and hips down/back with no verbal cues
-STEP DOWN ASSESSSMENT: Complete 10/10 step downs from 6” box with appropriate alignment of lowerextremities, hips down/back, pelvis level, trunk vertical. All with no verbal cues and no visual feedback.
Patient Education
-Complete home program every other day
-No pivoting activities/sports until 4+ months post-op and no contact sports until 6+ months post-op
-Remind patient of the importance of gluteal strength in alignment of the lower extremity
-With exercises, should feel glutes working more than quads
-Teach patient to watch technique/form in the mirror
-Knee aligned, Hips down and back, Pelvis level and Trunk vertical (no lateral lean)
Therapeutic Exercise
-Dynamic single leg strength of gluteals (Powers level 5)
-Prone hang, prone knee flexion, ITB/glute stretch, gastroc/soleus stretches
-Single leg balance with challenge and dynamic component
-After integration of proper return to run program may start progression of plyometrics (increase intensity,double to single leg, direction changes, surface challenge)
-Basic 2 legged plyometric drills (emphasize proper landing techniques)
-Ballistic double leg skill re-education (Powers level 6)
-Integrate sports specific activity/footwork/agility
-May begin integration into controlled drills/team practices without contact per MD approval Cardio:
-Continue with biking, running, elliptical, walking at higher intensities
Outcome Measures
Lower Extremity Functional Scale
ACL – Return to Sport Index
WEEK 18-20 after MENISCUS REPAIR : Focus on ballistic double leg skill re-education
Functional Criteria
-Able to run 20 minutes symptom free
-Subjective report of consistent completion of home program every other day
-Normal quad girth.
-Self-awareness of proper LE mechanics and alignment with high level drills.
-DECELERATION ASSESSMENT: Complete 3/3 deceleration-back pedal drills bilaterally with appropriatealignment of lower extremities, hips down/back, pelvis level, trunk vertical, soft landings. All with no verbalcues.
Patient Education
-Complete home program every other day
-No contact sports until 6+ months post-op
-Teach patient to watch technique/form in the mirror
-Knee aligned
-Hips down and back
-Soft landings
Therapeutic Exercise
-Continue with 1 set of hip hike, single leg squat
-Progression of balance drills
-Progression of sports specific activity/footwork/agility
– Once able to run for 20 minutes symptom free may initiate sprint drills (linear, focus on acceleration, progress
intensity per fatigue/symptoms)
– Progress running into sprinting with proper deceleration
-May continue controlled drills/team practices without contact
Cardio:
-Regular cardio workouts 4-6 times per week
WEEK 20-22 after MENISCUS REPAIR : Focus on single leg skill re-education
Functional Criteria
-Normal quad girth.
-Self-awareness of proper LE mechanics and alignment with high level drills.
Patient Education
-Complete home program every other day
-No contact sports until 6+ months post-op
-Teach patient to watch technique/form in the mirror
-Knee aligned
-Hips down and back
-Soft landings
Therapeutic Exercise
-Continue with 1 set of hip hike, single leg squat
-Progression of balance drills
-Progression of sports specific activity/footwork/agility
-Ballistic single leg skill re-education once double leg is mastered (Powers level 7)
-May continue controlled drills/team practices without contact
Cardio:
-Regular cardio workouts 4-6 times per week
- WEEK 22+: Focus on cutting skill re-education
Functional Criteria
-Gluteus medius strength of 5/5 or greater bilaterally
-SINGLE LEG SQUAT ASSESSMENT: Complete 10/10 single leg squats with appropriate alignment of lower extremities, hips down/back, pelvis level, trunk vertical. All with no verbal cues.
Patient Education
-Complete home program every other day
-No contact sports until 6+ months post-op
-Teach patient to watch technique/form in the mirror
-Knee aligned
-Hips down and back
-Pelvis level
-Trunk vertical (no lateral lean)
-Soft landings
Therapeutic Exercise
-Progress agility/footwork drills
-Plyometrics with then without challenge
-Cutting skill acquisition (Powers level 8)
-Sprint/deceleration work
-May continue controlled drills/team practices without contact Cardio:
-Regular cardio workouts 4-6 times per week
Outcome Measures
Lower Extremity Functional Scale (Appendix 2)
ACL – Return to Sport Index (Appendix 3)
Week 24+after MENISCUS REPAIR : Focus on sport specific integration
Functional Criteria
-Gluteus medius strength 5/5 bilaterally
-BROAD JUMP ASSESSMENT: Complete a triple broad jump with appropriate alignment, hips down/back, soft
landings. All with no verbal cues.
Patient Education
-Complete home program every other day
-Continue to focus on technique/form.
-Self-awareness of proper LE mechanics and alignment with sporting activities
Therapeutic Exercise
-Continue sport specific drills
-Progression of sprint drills (increase intensity, direction change, deceleration drills)
Cardio:
-Regular cardio workouts 4-6 times per week
-Progression of sprint drills
-May begin integration into team practices with contact per MD approval if functional testing is passed
Outcome Measures
Lower Extremity Functional Scale
ACL – Return to Sport Index
Functional Testing
-Powers Functional Test
Step down, drop jump, lateral shuffle, deceleration, triple hop, run-cut
-Noyes Functional Test
Single, triple, cross-over, timed hop tests
Do not test until passed Powers Functional Test
*Most patients do not pass on the first attempt of functional tests. If not passing, re-establish home exercise
program to focus on areas of functional deficit. Then retest in 2-3 weeks.
*If passing scores are obtained during functional testing, recheck with surgeon for return to sport clearance.
