Physiotherapy GUIDELINES FOLLOWING ARTHROSCOPIC MENISCECTOMY
Rehabilitation following arthroscopic meniscectomy can be divided into four phases: protection, moderate protection, early functional and late functional.
The word guideline is used instead of the protocol as it allows for individualization.
A. PROTECTION PHASE: The immediate postoperative phase is characterized by soft tissue bleeding and effusion, pain and quadriceps inhibition. Prior to discharge from the hospital, the patient’s involved extremity is placed in a jobs cryo temp in an elevated position for 20 minutes. By utilizing the intermittent compression device, RICE (rest, ice, compression, and elevation) is quickly applied.
The patient is then instructed in a series of home therapeutic exercises, which include quadriceps setting, straight leg raises (SLR) in multiple planes and an active- assisted range of motion exercise. The patient is fitted with crutches and instructed in ambulation training weight bearing as tolerated on all surfaces. The patient is encouraged to follow the RICE principle and to curtail any excessive walking throughout this first phase, which usually lasts 5 to 7 days postoperatively.
Non-steroidal anti-inflammatory drugs are prescribed, as they have been shown to decrease pain and effusion throughout the postoperative period following arthroscopic meniscectomy.
B. MODERATE PROTECTION PHASE: The moderate protection phase is characterized by decreased pain, mild effusion, a range of motion greater than or equal to 90 degrees, and weakness. At the beginning of this phase, approximately 1-week postoperatively, the patient begins rehabilitation. History, measurements, and tests consistent with an initial evaluation are taken. The patient is allowed to discontinue using crutches upon demonstrating a normal gait pattern.
The patient is reminded that‘every step is therapy’ as normal gait will help facilitate a normal range of motion. Using cuff weights, multiple planes SLR are continued in a progressive resisted exercise manner. The leg lift in the supine position should be performed with the involved knee in a slightly flexed position to improve the effectiveness of the exercise on the vastus muscle group.
Proximal (hip) musculature and hamstring isotonic exercises are added to the program, utilizing various progressive resisted machines. In keeping with the concept of total leg strength, calf raises off a step is begun.
Submaximal multiple angle quadriceps isometrics are performed to improve static muscular strength without causing further joint irritation. Strength gains are angle specific, and physiological overflow is about 20 degrees in either direction. This exercise is useful in strengthening the vastus medial oblique, as it has been found to have maximal output in the 60-70 degree range of motion. Electrical stimulation or biofeedback is used in conjunction with the isometric exercise for the patient with advanced quadriceps inhibition. The stationary cycle is initiated to improve range of motion and build muscle strength and endurance.
Ergometric cycling has been shown to be an excellent mode of rehabilitation since tibiofemoral compressive forces during induced during cycling approach only 1.2 times body weight. this is significantly lower than activities of daily living such as walking( two to four times body weight)or stair climbing( three to seven times body weight).
Seat height should be kept high because patella femoral joint compressive force increase with decreased at height. When the range of motion is limited to less than 100 degrees, a short crank ergometer is employed, decreasing the arc of motion necessary to cycle. This gives the patient a psychological boost because it allows for aerobic exercise. Flexibility exercises (in the form of hamstring and calf stretching) are started, preferably after cycling since increased tissue temperature promotes a more effective stretch. Cold application is continued for its analgesic and anti-inflammatory effects.
Transcutaneous electrical nerve stimulation (TENS) is used for patients with increased pain. The patient’s home program is expanded to include cuff weight PRE, stationary bike, and stretching. The patient is also provided with a theraband for standing hip extension, abduction, adduction and seated knee flexion.
C. EARLY FUNCTIONAL PHASE: The early functional phase is characterized by an absence of pain, minimal or no effusion, range of motion greater than or equal to 120 degrees and weakness. Isotonic knee extension exercise inside a limited arc is begun with low resistance. Initially, a 90 to 30-degree arc is employed since patellofemoral forces are displaced over a wider surface area in this range. The therapist should palpate for crepitus and note any discomfort throughout the range of motion. The arc of motion should then be modified accordingly. As we function with our feet on the ground, so should we rehabilitate. In this phase, several closed chain exercises are implemented, keeping in mind the functional progression. Contralateral theraband exercises provide isometric contraction and Proprioceptive input throughout the involved extremity.
The uninvolved extremity attached to the theraband at the ankle performs hip extension and flexion and hip abduction and adduction with the involved extremity in a weight-bearing state with the knee slightly flexed. The resultant forces to the involved knee occur in a sagittal and coronal plane, respectively. The patient is instructed in a proper squatting technique inside a pain-free and crepitus-free arc. The range of motion is limited to no greater than 90 degrees of knee flexion.
The use of sports cord assist the patient in maintaining proper form, making sure the knees stay behind the feet, decreasing patella femoral forces. A similar technique is reinforced as the leg press machine is utilized bilaterally progressing to unilateral exercise. Lateral step ups are added to the program with gradual height increments, starting with a phone book and progressing to a normal step.BAPS (biomechanical ankle platform system) is started to facilitate proprioception training to the involved knee joint.
From the ground up, changes are seen throughout the closed kinetic chain. For example, as the foot pronates, the tibia internally rotates, causing a valgus force at the knee. Hence, the knee joint acclimates itself to forces in multiple planes, much like those experienced in sports activity.
Proprioception is further challenged by increasing the BAPS level and providing the patient with dumbbells, adding the element of intrinsic loading to the exercise. Isokinetic exercise is initiated using short arc, submaximal effort, and intermediate speeds (150 to 210 degrees/sec) and progressing to full arc, submaximal effort, and fast speeds.
D. LATE FUNCTIONAL PHASE: The late functional phase is characterized by a full range of motion, no effusion, and improved muscle strength and flexibility. Advanced closed chain exercises are added in this stage. The profiteer continues Proprioceptive and balance training. Stair master and versa climber are utilized to build muscular strength and endurance as well as aerobic conditioning.
Quadriceps and hip musculature stretching are added as the increased emphasis placed on flexibility in this stage. Isokinetic exercises include the progression to velocity spectrum training(60 to 400 degrees/sec), depending on the needs of the individual patient. Running is initiated when quadriceps strength approaches 80 per cent.
At first, an underwater treadmill system is used since the buoyancy of the water decreases the amount of force is significantly less during retro running versus forward running. Retro running has also been found to increase quadriceps strength at slow Isokinetic speeds. When running forward the patient is encouraged to maintain a controlled sprint rather than a jog. By staying on the ball of the foot, vertical or compressive loading is decreased. Before allowing the patient to return to sports activity, the therapist needs to do more than achieve normal range of motion and muscle strength.
The components of the patient’s sport or activity should be incorporated into the rehabilitation program as well. For example, basketball players need to jump and land. Therefore jumping activities should be included in their program.
More importantly, they should be taught how to land to protect their knees. Golfers rely on a great deal of tibial rotation throughout the swing, their program, therefore, should include an assessment of their swing and a modification made if necessary. Agility drills in the form of figure eights, carioca, and cutting manoeuvres are included here as they replicate components of most team and racquet sports. Prior to discharge from rehabilitation and the full return to sports activity, a series of tests must be satisfactory: Full range of motion Flexibility acceptable for the needs of the activity.
Total work within 10 per cent of the non-involved extremity as muscle strength is measured isokinetically. Muscular endurance within 10 per cent of the non-involved extremity as measured by the number of leg press repetitions using one-half the patient’s body weight.
Functional power as measured by standing broad jump. Proprioception power as measured on the BAPS board. Apprehension (lack of) with sport specific activities.