Physiotherapy and rehabilitation after arthroscopic menisectomy - Henry Atkinson

Physiotherapy and Rehabilitation following arthroscopic menisectomy
Henry Dushan Edward Atkinson,  Jennifer Michelle Laver,  Elizabeth Sharp

Mr Henry D.E.Atkinson, MBChB, BSc Med Sci, MRCS, FRCS Tr & Orth
Consultant Trauma and Orthopaedic Surgeon
North Middlesex University Hospital, Sterling Way, London N18 1QX
North London Sports Orthopaedics

Miss Jennifer Michelle Laver, B App Sc (Physio)(Hons)
Senior Lower Limb Sports Physiotherapist
SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia

Mrs Elizabeth Sharp MSc (Man Ther) MCSP Grad Dip Phys
Clinical Director ESPH
ESPH ES Physical Health, 116 Lordship Lane, London, SE22 8HD
ESPH, 22 Harley Street, London W1G 9PL


Patients following a well-planned unsupervised home-exercise programme perform as well as those participating in supervised outpatient physiotherapy programmes, with a tendency to have better isokinetic results, an earlier return to work (RTW), and RTS(54,55). Thus there is no need to be routinely reviewed by a physiotherapist after hospital discharge following an uncomplicated meniscectomy. The possible exceptions are elderly patients, the poorly motivated, patients with co-existing pathologies such as ACL injury or degenerative changes, and elite athletes(54,56).

Patients should aim to return to function as quickly as possible, with RTS influenced by quadriceps strength, ROM and any residual effusion(57). Patients typically start walking without support from 1-3 days(58), 91% RTW by 2 weeks, most resume athletic training from 2-4 weeks, and RTS from 3-6 weeks(59).

Several authors have described different phases which can be used to guide the rehabilitation(58,59).

During the immediate post-operative phase (1-5 days):
characterized by bleeding, swelling, pain and quadriceps inhibition, ROM and isometric quadriceps (SLR and inner range quadriceps (IRQ)) may be started(55,57,58,60-62). Other exercises include prone quadriceps stretches, ankle pumps, ankle ROM(60), passive knee extension with a ?phone book? in the seated position with the knee unsupported, knee flexion on a bed or in a chair55 and balance/proprioception exercises(63).

Patients are encouraged to FWB without a brace with as normal a gait as possible(57,59). Prescribed analgesia should be taken as required or just prior to exercising(61) in addition to rest, ice, elevation(55,62) and compression(54,59). Cryotherapy leads to significant improvement in knee pain and swelling(55,62), analgesic consumption, compliance, and weight bearing(60), and may be beneficial for up to 14 days post-operatively(58,59).

During the early healing/progressive phase (days 5-14)
an effusion is still present, there is ongoing quadriceps weakness and reduced ROM, but less pain. Strengthening may commence with isometric exercises (SLR) and progress to isotonic exercises (free weights, gym, theratube) once sufficient strength has returned(58,59). Though pain has usually resolved by the late healing/functional exercise phase (2-3 weeks), there is some residual quadriceps weakness and reduced end-range flexion. Patients increase their isokinetic and resistance activities, and are started with the minitramp, wobbleboard, swimming, running in the pool and bike work. Pilates may also be used to maintain ROM and increase strength(58,59).

There may be some persisting weakness during the conditioning phase (3-5 weeks), and patients continue with CKC, OKC and isokinetic training. Running (initially straight line, followed by cutting and lateral movements), jumping, balance and sports-specific agility drills are also included. Isokinetic testing can be useful in determining any residual strength imbalance prior to RTS(46,47).

In summary:
Week 1
-    Encourage normal unsupported gait
-    General advice for control of swelling (ice, elevation, compression)
-    Activation of VMO with isometric exercises
-    Passive and active  knee exercises
-    ROM 0-120?

Week 2
-    Full ROM
-    Soft tissue mobilization and reduction of scar tissue
-    Isokinetic, resistance and Pilates based exercises to maintain ROM and strengthen quadriceps, hamstring and gluteal muscles
-    Stretching programme for quadriceps, hamstring, ITB, calf, hip rotators

Week 3-4
-    CKC exercises (Wall squats, lunges, steps)
-    Isokinetic CKC and OKC quadriceps and hamstring rehabilitation
-    CKC and OKC resisted exercises in the gym using treadmill, bike and leg press
-    Balance, strength and stability exercises on the gym ball

Week 5
-    One might consider performing isokinetic open chain quadriceps and hamstring tests on the KIN-COM, and initiate strength and stability training to overcome any residual deficits.



Acknowledgements
John R Camens
B App Sc Physio Grad Dip Physio (Orthopaedics), SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia.

Glenn Withers
B.Physio. MCSP Cert. Pilates Instructor MIAPI,
Pilates Art Physiotherapy / London Sports Medicine
50-52 Kilburn High Road, London, NW6 4HJ, UK

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Keywords
Rehabilitation, Physiotherapy, Pilates, Knee surgery, Anterior cruciate ligament reconstruction, Menisectomy, Meniscal repair.


Abstract
Soft-tissue knee surgery is performed for a multitude of conditions and encompasses a large number of procedures. The postoperative management of these conditions is constantly evolving as a result of advances in technology and a better understanding of human physiology, however there remains no consensus on the ideal timeframe over which loading can be progressed. Rehabilitation protocols provide basic guidelines through which effective outcomes can be achieved. However, the rate and extent of recovery will depend on many patient and external factors, and it is questionable whether full recovery or a return to normality is ever complete.
The complex neuromuscular motor patterning, strength and control which are affected by the injury and the surgery is very difficult to gauge, and difficult to recreate. Isokinetic testing affords a validated, reliable and reproducible method of evaluating muscle strength, endurance and antagonist/agonist balance. It may be utilised at the earliest safe opportunity to establish the efficacy of any functional rehabilitation programme and can allow adjustments to be made to optimise outcomes. Future studies into the use of pilates programmes and their effects on earlier muscle pattern retraining may also allow for safer and earlier returns to sporting activity.   
This review establishes an evidence-based approach to the postoperative rehabilitation of the knee following anterior cruciate ligament reconstruction, arthroscopic menisectomy, and meniscal repair surgery.


Volume 24 , Issue 2 , Pages 129-138 (April 2010)
http://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327%2810%2900031-X/abstract
www.sportsortho.co.uk


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