Meniscus InjuryKhairul Nizam Abdul Rahman4262143008

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 tearLongitudinal 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 tissueRadial 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 testMcMurrays 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 ProtocolAfter 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 ProtocolAfter 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.