STUDENT PAPER

Knee rehabilitation after meniscus surgery

ATANASIU LAURENTIU OVIDIU 25.01.2018

COMPREHENSIVE COURSE 2015-2016 LOCATION: Pilates in Tuscany, Via Frascati 44, Prato, Italy

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ABSTRACT

The knee complex is one of the most often injured joints in the human body. The myriad of

ligamentous attachments, along with numerous muscles crossing the joint, provide insight into

the joint’s complexity. This anatomic complexity is necessary to allow for the elaborate interplay

between the joint’s mobility and stability roles. The knee joint works in conjunction with the hip

joint and ankle to support the body’s weight during static erect posture.

Knee traumas are frequent in adult active population specially those involved in high risk sports

like ski, martial arts, soccer and others. This kind of traumatic injury hugely impedes the daily

living activities.

Meniscus injury is very common in knee traumatology. The meniscus can be injured in many

ways and on different locations (flap tear, bucket handle tear, vertical tear, horizontal tear,

complex tear), thus causing a variety of histories and different clinical findings.

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TABLE OF CONTENTS

Anatomical description……………………………………………………………….…page 3

Case study………………………………………………………………….…………....page 5

Conditioning Program………………………………………………………….………..page 6

Conclusion…………………………………………………………………...…………..page 10

Bibliography……………………………………………………………………….…….page 11

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ANATOMICAL DESCRIPTION

The fact that the knee must fulfill major stability as

well as major mobility roles is reflected in its structure

and function. The knee complex is composed of two

distinct articulations located within a single joint

capsule: the tibiofemoral joint and the patellofemoral

joint.

Tibiofemoral congruence is improved by the medial

and lateral menisci, forming concavities into which

the femoral condyles sit.

In addition to enhancing joint congruence, these accessory joint structures play an important role

in distributing weight-bearing forces, in reducing friction between the tibia and the femur, and in

serving as shock absorbers.

Although compressive forces in the knee may reach one to two times body weight during gait

and stair climbing and three to four times body weight during running, the menisci assume 50%

to 70% of this imposed load (pg. 414-458 “Joint Structure and Function”).

The meniscus consists of semilunar shaped fibrocartilage tissue. There are two menisci, a lateral

one which is somewhat more circular than the C-shaped medial meniscus.

A normal lateral meniscus forms five-sixths of a circle. It has an average width of about 12 mm

and a height of 4–5 mm, although the normal anatomy varies considerably with regard to

dimension and shape. In adults, the C-shaped medial meniscus covers 50% of the medial tibial

plateau and is connected firmly to the joint capsule by coronary, meniscotibial, and deep medial

Figure 1: knee joint anatomy

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collateral ligaments; whereas the lateral meniscus covers 70% of the lateral tibial plateau and has

firm anterior and posterior attachments, while its lateral joint capsule attachment is loose because

there is no attachment at the popliteal hiatus and lateral collateral ligament. Therefore, the

normal lateral meniscus has more mobility than the medial meniscus, allowing an increased

excursion of the lateral femoral condyle (pg. 288-295 “Sports Injuries Prevention, Diagnosis,

Treatment, and Rehabilitation”).

The meniscus also serves to help

distribute the forces between the two

bones over a greater area (rather than

point to point), helps supply nutrition

to the cartilage that lines the bones

(articular cartilage), and helps stabilize

the knee.

The meniscus is a rubbery tissue that loses its elasticity with age. Nonetheless, each individual

meniscus can be torn. Meniscus tears are very common, occurring in up to one third of all sports

injuries. The inner or medial meniscus is injured most often.

Figure 2: meniscus tear

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CASE STUDY

Using my expertise as a certified physical therapist, with a bachelors and master’s degree in this

field and combining it with the knowledge and expertise in the pilates method I am able to work

frequently with clients with musculoskeletal pathologies or injuries that are suitable to be treated

in a pilates studio environment, especially after surgery and/or in the later stages of their

rehabilitation program.

The perfect example is Mihaela S, a client of

the gym facility where I regularly teach

private sessions and group classes. She used

to come for pilates and yoga group sessions

frequently for few years.

In the winter of 2016 a ski injury to her left

knee is what brought a lot of pain and

discomfort to her and after investigations she

was recommended for surgery.

Her diagnosis was posterior meniscal

longitudinal tear of the lateral meniscus, incomplete tear of the lateral patelofemural ligament

(lateral retinacul) and lesion of the posterior-medial face of the patella due to abnormal taking.

For the surgery, the doctors used laparoscopic technology for minimum damage to the

surrounding tissues and a faster recovery time.

After surgery Mihaela S. had no immobilization devices and she did 20 sessions of physical

therapy at the hospital.

Figure 3: ligaments of the knee

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After her physical therapy sessions she contacted me for some pilates private lessons in which

she wanted to continue her knee rehabilitation program but also to get the rest of her body back

in shape.

In our first session I did an evaluation of her knee and noted that she had pain and swelling,

muscle atrophy on her left thigh especially on her VMO (vastus medialis oblique), the knee joint

could not move past 120 degrees of flexion and she had restriction for movements like squats,

lunges and quatrupedia position.

My approach for Mihaela`s rehabilitation plan was according to the following stages:

1. Decrease pain and swelling

2. Improve knee range of motion and flexibility

3. Increase strength and recruitment of quadriceps and other lower extremity

muscles

4. Correct movement patterns

CONDITIONING PROGRAM USING BASI BLOCK SYSTEM

Warm up:

In this category my goal was to get my client ready for the session both physically but also

mentally, so while getting her muscles and joints ready I also tried to get her attention to what we

were going to do and away from her usual thoughts. I used 6-8 repetitions for each exercise.

• Chest lift on the mat

• Chest lift with rotation on the mat

• Supine spine twist

• Pelvic curl (mat)

• Roll Up on the mat

• Roll Up with Roll Up Bar on the

Cadillac

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• Rolling (Roll-Like-A-Ball)

Foot work:

This category was very important in the overall rehabilitation program as it builds the much

needed tonus in the muscles around the knee joint. Below, you have an example of the reformer

foot work series however the Cadillac was also used very often for this category. I used 10

repetitions for each exercise.

• Parallel toes foot work series

(reformer)

• Parallel hells foot work series

(reformer)

• V position toes foot work series

(reformer)

• Open V toes foot work series

(reformer)

• Open V hells foot work series

(reformer)

• Prehensile foot work Series

(reformer)

• Calf Raise foot work Series

(reformer)

• Prances foot work Series (reformer)

Hip work:

I put this category right after the hip work as I wanted to benefit from the lower body focus that

Mihaela had gotten with the previous exercises, also from a physiological point of view I

considered to be beneficial to build the stimulus to the lower limbs muscles by having these two

categories one after the other. Also, trying to build tonus and volume to the lower limbs

muscles, for this category I used 10 repetitions for each exercise.

• Frog (basic leg springs)

• Circles (down, up) (basic leg

springs)

• Walking (basic leg springs)

• Bicycle (basic leg springs)

• Bicycle (single leg supine)

• Frog (single leg supine)

• Circles (down, up) (single leg

supine)

• Hip extension (single leg supine)

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• Changes (single leg side series) • Scissors (single leg side series)

Abdominal work:

• Mini roll-ups

• Mini roll up oblique

• Double legs (abdominal legs in

straps)

• Roll up bottom loaded

• Teaser 1 (Cadillac)

Spinal articulation:

• Bottom lift with extensions • Jack Knife (Wunda Chair)

Stretches:

• Standing lunge hamstring stretch

group

• Bottom lift with extensions

Full body integration 1:

• Scooter

Arm work:

• Circles (up, down) (arms standing

series)

• Chest expansion (arms standing

series)

• Butterfly arms (standing series)

Full body integration 2:

• Up stretch 1 (up stretch series)

• Up stretch 2 (up stretch series)

• Up stretch 3 (up stretch series

• Long stretch (up stretch series)

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Leg work:

• Leg press standing

• Terminal

knee extension

Fig 4 (a) and (b)

• Sitting knee flexion Fig 6 (a) and (b)

• Sitting knee flexion, single leg Fig 7

These last three exercises were presented in the “Injuries

and Pathologies” workshop and were very beneficial for my

client’s needs.

I used ten repetitions for each of the leg work exercises.

Figure 4 (a)

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Figure 4 (b)

Figure 6 (a)

Figure 6: sitting knee flexion (a)

Figure 7: sitting knee flexion, single leg

Figure 6 (b)

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Lateral flexion/rotation:

• Side reach (push through series)

• Saw (push through series)

Back extension:

• Prone 1 (push through series)

• Prone 2 (push through series)

• Hanging back (hanging series)

CONCLUSION

Pilates was a perfect match for Mihaela S. as she needed method of training that would bring

quality and control into every movement. She needed a system of training that would provide

balance between rehabilitating her knee including the quadriceps, hamstrings, glutes and all the

other important muscles along the lower limb but in the same time build up the rest of the body

and state of the mind. Going through the process of rehabilitation, pilates is a method able to

provide exercises and techniques for stability, improve muscle recruitment and activation,

improve the power exerted by each muscle, and also improve muscle mass to counter the atrophy

noticed after surgery.

In the approach to rehabilitation the injured knee the pilates method in general and the BASI way

in particular was a valuable help. Using all the knowledge from the comprehensive course and

also from the “Injuries and pathologies” workshop, I was able to bring captivating, safe and very

efficient exercises and principles that made each session a definite step forward on Mihaela`s

way to rehabilitation and general wellbeing.

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BIBLIOGRAPHY

1. Prof. Mahmut Nedim Doral M.D, Editor, “Sports Injuries Prevention, Diagnosis,

Treatment, and Rehabilitation”, Springer 2012 ,

Copyright © Springer-Verlag Berlin Heidelberg 2012.

2. Angela D. SMITH, MD, Christer G. ROLF, MD “Musculoskeletal Injuries: Diagnosis,

Treatment, and Rehabilitation”, Lippincott Williams & Wilkins Asia Ltd 2001,

Copyright © 2001 International Federation of Sports Medicine.

3. Cynthia C. Norkin, PT, EdD, Pamela K. Levangie, PT, DSc “Joint Structure and

Function: A Comprehensive Analysis”, F. A. Davis Company, 2005,

Copyright © 2005 by F. A. Davis Company.

4. Figure 1: knee joint anatomy;

http://wuxifhff.com/knee-meniscus-anatomy/meniscal-tears-knee-meniscus-anatomy-

with-preeminent-of-knee-meniscus-anatomy/

5. Figure 2: meniscus tear

http://realsurgery-meniscustear.com/about-meniscus-surgery-background/

6. Figure 4: ligaments of the knee

American Academy of Family Physicians,http://www.aafp.org/afp/2007/0115/p194.html

7. Figure 4-8 pictures taken by the author of this paper during the knee rehabilitation

program of Mihaela S, presented with her consent.