Meniscal Repair Protocol
This is a rehab protocol for the post-operative management of a meniscal repair. It is meant to be used as a general reference for clinicians & patients; though, it SHOULD NOT be used to replace genuine expertise or active clinical decision making. In practice, this protocol should be tailored to your patient & modified based on pain level & rate of progress made.
Of course, the specific exercises listed are not the only appropriate tasks to implement in their respective phases; they simply provide the essence of the recommended intensity during said phase. Similarly, the timeframes will vary based on the specifics of the patient, the operating physician, any potential complications, as well as any additional procedures performed.
These protocols were created to be current, convenient, transparent, & easy to implement.
Timeframes & suggestions are based on the latest available evidence & will be elaborated upon below.
There is a growing body of evidence supporting an Accelerated Meniscal Repair protocol — that is, one with unrestricted weight bearing & less restrictions on the progression of Range of Motion.
There are 2 common treatment approaches in patients undergoing meniscus repair: accelerated rehabilitation and restricted rehabilitation. Integrated into the existed research, the accelerated rehabilitation group encouraged participants to try free weight-bearing and reach full weight-bearing at most 4 weeks postoperatively. Also, it required a shorter period of restriction of joint passive or active ROM, and patients should reach full ROM at most 4 weeks postoperatively. The restricted rehabilitation group limited mobilization time, which normally accompanied the usage of a knee brace, and the weight-bearing period was postponed, averaging 2 to 4 weeks later than the accelerated group to reach full weightbearing. (You et. al; 2023)
In defense of those utilizing Accelerated protocols, the latest research would suggest that there is no significant difference in failure rate in those who are Weight Bearing as Tolerated immediately post-procedure & those who begin as partial or non-Weight Bearing.
Weight bearing as tolerated after meniscal repair for peripheral, vertical tears does not result in a higher failure rate than traditional, non-weight bearing over a five year follow-up period. The clinical relevance is that, based on these data, it may be appropriate to allow weight bearing as tolerated following meniscal repair of peripheral, vertical tears (Perkins et. al; 2018)
Of course, every patient & Meniscal tear is different. Not every patient will be a candidate for an Accelerated protocol. There is no good pain — pain tolerance & patient preference should be the major drivers of any rehab course.
Though, we do see that an Accelerated Protocol provides more benefit than just returning to activity more quickly.
Patients with the isolated meniscus lesion in the accelerated group showed significantly higher mean self-reported function at final follow-up. Patients with the meniscus injury and ACL injury in the accelerated group did not present significantly higher functional scores, while it showed a significant increase in tibial tunnel enlargement. Therefore, the accelerated rehabilitation may be more recommended with higher self-reported functions without higher failure rate or extra adverse events. (You et. al; 2023)
Time to Return to Sport or Activity is a major concern for many patients seeking to undergo a meniscal repair. Of course, the significance of the injury is the major dictator in that regard; a large, involved meniscal tear & repair would require a more extensive rehab than a smaller, less involved tear — suggesting that pre-operative imaging & surgical depth should be the major drivers. Calanna, Duthon, & Menetrey spoke to this idea in their recent work:
However, biomechanical evidence suggests that tailoring an individualized protocol based upon the type of lesion and its stability can be reasonable. When the hoop tensile stress effect is preserved, an accelerated rehabilitation program may be suggested. In contrast, when circumferential hoop fibers are disrupted, a restricted rehabilitation protocol may be recommended. (Calanna, Duthon, & Menetrey; 2022)
Lesion Stability based Return to Sport Timeframe Protocol by Calanna, Duthon, & Menetrey utilizng the Tegner Activity Scale
Calanna’s protocol is extremely reasonable & raises a very important point — the level of activity that our patients will return to should also dictate our approach. For example, according to the researchers, a patient with a stable lesion that is only seeking to return to a fairly low intensity job such as secretarial work, may only need 2 months of post-operative rehab.
Along with Calanna’s work, these protocols were heavily influenced by the work of Koch et. al’s 2020 work, as well as the 2020 review by Wiley et. al.
RTP rates following meniscal repairs in athletes are reassuring with 80% to 95% of athletes returning to play. Furthermore, studies to date have demonstrated that athletes undergoing isolated meniscal repairs can expect to RTP around 4 to 6 months. (Wiley et. al; 2020)
Figures from Koch et. al’s 2020 work Demonstrating the Variability of Recommendations from Notable Meniscal Repair Protocols
Timeframes presented in the protocol that has been created are based on commonalities found between the various listed works.
Lastly, aside from swelling & ROM, the KOOS, WOMET, & Various Hop Tests (along with the Leg Symmetry Index) are the major objective criteria utilized as RTS criteria in this protocol. This is simply because of their universality — all easily accessible & easy to implement tests, requiring no special equipment or setting.
KOOS score criteria were based on Roos’s work highlighting various scores at different points in the rehab process of ACL injuries:
WOMET score criteria were based on suggestions made by Sgroi et. al in their 2018 work.
In the present study, the relative score of the WOMET was 15.3% and 15.5% higher than the KOOS and the WOMAC, respectively. The differences between the WOMET and the other 2 questionnaires were significant, but no significant difference was found between the WOMAC and the KOOS. In addition, a significantly higher number of patients achieved a WOMET result in the upper quartile than in the WOMAC and KOOS. The results of the current study therefore suggest that the WOMET has a better ability to detect meniscal tears than the WOMAC or the KOOS. (Sgroi et. al; 2018)
The specific hop tests implemented were utilized due to their ability to test power, coordination, & confidence in the affected limb during both frontal & sagittal plane movements. They were also chosen for their accessibility
The take-home message is that you should utilize these protocols wisely. There is no one size fits all rehab protocol. Use your best judgement & continue to refer to the available literature!
Works Cited & Further Reading
You, M., Wang, L., Huang, R., Zhang, K., Mao, Y., Chen, G., & Li, J. (2022). Does Accelerated Rehabilitation Provide Better Outcomes Than Restricted Rehabilitation in Postarthroscopic Repair of Meniscal Injury?. Journal of sport rehabilitation, 32(3), 335–345. https://doi.org/10.1123/jsr.2022-0069
Perkins, B., Gronbeck, K. R., Yue, R. A., & Tompkins, M. A. (2018). Similar failure rate in immediate post-operative weight bearing versus protected weight bearing following meniscal repair on peripheral, vertical meniscal tears. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 26(8), 2245–2250. https://doi.org/10.1007/s00167-017-4665-9
Calanna, F., Duthon, V., & Menetrey, J. (2022). Rehabilitation and return to sports after isolated meniscal repairs: a new evidence-based protocol. Journal of experimental orthopaedics, 9(1), 80. https://doi.org/10.1186/s40634-022-00521-8
Koch, M., Memmel, C., Zeman, F., Pfeifer, C. G., Zellner, J., Angele, P., Weber-Spickschen, S., Alt, V., & Krutsch, W. (2020). Early Functional Rehabilitation after Meniscus Surgery: Are Currently Used Orthopedic Rehabilitation Standards Up to Date?. Rehabilitation research and practice, 2020, 3989535. https://doi.org/10.1155/2020/3989535
Wiley, T. J., Lemme, N. J., Marcaccio, S., Bokshan, S., Fadale, P. D., Edgar, C., & Owens, B. D. (2020). Return to Play Following Meniscal Repair. Clinics in sports medicine, 39(1), 185–196. https://doi.org/10.1016/j.csm.2019.08.002
Roos, E. M., Roos, H. P., Lohmander, L. S., Ekdahl, C., & Beynnon, B. D. (1998). Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self-administered outcome measure. The Journal of orthopaedic and sports physical therapy, 28(2), 88–96. https://doi.org/10.2519/jospt.1998.28.2.88
Sgroi, M., Kocak, S., Reichel, H., & Kappe, T. (2018). Comparison of 3 Knee-Specific Quality-of-Life Instruments for Patients With Meniscal Tears. Orthopaedic journal of sports medicine, 6(1), 2325967117750082. https://doi.org/10.1177/2325967117750082
