Rehabilitation Protocol for Arthroscopic Meniscal Repair

Massachusetts General Brigham Sports Medicine

This protocol is intended to guide clinicians through the post-operative course for meniscal repair. This protocol is time

based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the

individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes

contained within this guideline may vary based on surgeon’s preference, additional procedures performed, and/or

complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with

the referring surgeon.

The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic

interventions should be included and modified based on the progress of the patient and under the discretion of the

clinician.

Considerations for the Post-operative Meniscal Repair

Many different factors influence the post-operative meniscal repair rehabilitation outcomes, including type and location

of the meniscal tear and repair. Consider taking a more conservative approach to range of motion, weight bearing, and

rehab progression with more complex tears or all-inside meniscal repairs. Additionally, this protocol does not apply to

meniscus root repairs or meniscus transplants. It is recommended that clinicians collaborate closely with the referring

physician regarding intra-operative findings and satisfaction with the strength of the repair.

Post-operative considerations

If you develop a fever, intense calf pain, excessive drainage from the incision, uncontrolled pain or any other symptoms

you have concerns about you should call your doctor.

PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Protect repair

• Reduce swelling, minimize pain

• Restore patellar mobility

• Restore full extension

• Flexion < 90 degrees

• Minimize arthrogenic muscle inhibition, re-establish quad control, regain full active extension

• Patient education

• Keep your knee straight and elevated when sitting or lying down. Do not rest with a towel

placed under the knee.

• Do not actively bend your knee; support your surgical side when performing transfers (i.e.

sitting to laying down)

• Do not pivot on your surgical side.

Weight Bearing

Walking

• Brace locked, crutches

• Partial weight bearing

• When going up the stairs, make sure you are leading with the non-surgical side, when going down

the stairs, make sure you are leading with the crutches and surgical side.

Massachusetts General Brigham Sports Medicine

Interventions

Swelling Management

• Ice, compression, elevation (check with MD re: cold therapy)

• Retrograde massage

• Ankle pumps

Range of motion/Mobility

• Patellar mobilizations: superior/inferior and medial/lateral

• Seated assisted knee flexion extension and heel slides with towel

o ***Avoid active knee flexion to prevent hamstring strain on the posteromedial joint

• Low intensity, long duration extension stretches: prone hang, heel prop

• Seated hamstring stretch

Strengthening

• Quad sets

• NMES high intensity (2500 Hz, 75 bursts) supine knee extended 10 sec/50 sec, 10 contractions,

2x/week during sessions—use of clinical stimulator during session, consider home units

distributed immediate post op

• Straight leg raise

o **Do not perform straight leg raise if you have a knee extension lag

• Hip abduction: side lying or standing

• Multi-angle isometrics 90 and 60 deg knee extension

Criteria to

Progress

• Knee extension ROM 0 deg

• Knee flexion ROM 90 degrees

• Quad contraction with superior patella glide and full active extension

• Able to perform straight leg raise without lag

PHASE II: INTERMEDIATE POST-OP (3-6 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Continue to protect repair

• Reduce pain, minimize swelling

• Maintain full extension

• Flexion < 90 degrees unless further direction from MD

Weight Bearing

Walking

• Continue partial weight bearing unless directed otherwise by MD

• Consult with referring MD regarding unlocking brace

Additional

Interventions

*Continue with Phase I

interventions

Range of motion/Mobility

• Stationary bicycle: gentle range of motion only (see Phase III for conditioning)

Cardio

• Upper body ergometer

Strengthening

• Calf raises

• Lumbopelvic strengthening: Sidelying hip external rotation clamshell in neutral, plank, bridge

with feet elevated

Balance/proprioception

• Double limb standing balance utilizing uneven surface (wobble board)

• Joint position re-training

Criteria to Progress

• No swelling (Modified Stroke Test)

• Flexion ROM 120 degrees

• Extension ROM equal to contra lateral side

PHASE III: LATE POST-OP (6-9 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Continue to protect repair

• Maintain full extension

Massachusetts General Brigham Sports Medicine

• Normalize gait.

• Flexion within 10 degrees of contra lateral side.

• Safely progress strengthening.

• Promote proper movement patterns.

• Avoid post exercise pain/swelling.

Weight Bearing

• May discontinue use of brace/crutches after 6 weeks per MD and once adequate quad control is

achieved and gait in normalized.

Additional

Interventions

*Continue with Phase

I-II Interventions as

indicated

Range of motion/Mobility

• Supine active hamstring stretch

• Gentle stretching all muscle groups: prone quad stretch, standing quad stretch, kneeling hip

flexor stretch, standing gastroc stretch and soleus stretch

• Rotational tibial mobilizations if limited ROM

Cardio

• Stationary bicycle, flutter kick swimming, pool jogging

Strengthening

• Partial squat exercise 0-60 degrees

• Ball squats, wall slides, mini squats from 0-60 deg

• Hamstring strengthening: prone hamstring curls, standing hamstring curls

• Lumbopelvic strengthening: bridges on physioball, bridge on physioball with roll-in, bridge

on physioball alternating, hip hike

• Gym equipment: leg press machine, standing hip abductor and adductor machine, hip

extension machine, roman chair, seated calf machine

• Progress intensity (strength) and duration (endurance) of exercises

Balance/proprioception

• Single limb balance progress to uneven surface including perturbation training

Criteria to Progress

• No swelling/pain after exercise

• Normal gait

• ROM equal to contra lateral side

• Joint position sense symmetrical (<5 degree margin of error)

PHASE IV: TRANSITIONAL (9-12 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Maintain full ROM.

• Safely progress strengthening.

• Promote proper movement patterns.

• Avoid post exercise pain/swelling.

Additional

Interventions

*Continue with Phase

I-III interventions as

indicated

Cardio

• Elliptical, stair climber

Strengthening

o **The following exercises to focus on proper control with emphasis on good proximal

stability

• Squat to chair

• Lateral lunges

• Single leg progression: partial weight bearing single leg press, slide board

lunges: retro and lateral, step ups and step ups with march, lateral step-ups, step downs, single

leg squats, single leg wall slides

• Knee Exercises for additional exercises and descriptions

• Gym equipment: seated hamstring curl machine and hamstring curl machine

• Romanian deadlift

Criteria to Progress

• No episodes of instability

• 10 repetitions single leg squat proper form through at least 60 deg knee flexion

• KOOS-sports questionnaire >70%

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• Functional Assessment

o Quadriceps index ≥80%; HHD mean preferred (isokinetic testing if available)

o Hamstring, glut med, glut max index ≥80%; HHD mean preferred (isokinetic testing for HS

if available)

PHASE V: EARLY RETURN TO SPORT (3-5 MONTHS AFTER SURGERY)

Rehabilitation

Goals

• Safely progress strengthening.

• Safely initiate sport specific training program.

• Promote proper movement patterns.

• Avoid post exercise pain/swelling.

Additional

Interventions

*Continue with

Phase II-IV

interventions as

indicated

• Interval running program

o Return to Running Program

• Progress to plyometric and agility program (with functional brace if prescribed).

o Agility and Plyometric Program

Criteria to Progress

• Clearance from MD and ALL milestone criteria below have been met

• Completion of jog/run program without pain/swelling

• Functional Assessment

o Quad/HS/glut index ≥90%; HHD mean preferred (isokinetic testing if available)

o Hamstring/Quad ratio ≥ 70% with isokinetic testing if available)

o Hop Testing ≥90% compared to contra lateral side

• KOOS-sports questionnaire >90%

• International Knee Committee Subjective Knee Evaluation >93

• Psych Readiness to Return to Sport (PRRS)

PHASE VI: UNRESTRICTED RETURN TO SPORT (6+ MONTHS AFTER SURGERY)

Rehabilitation

Goals

• Continue strengthening and proprioceptive exercises.

• Symmetrical performance with sport specific drills.

• Safely progress to full sport.

Additional

Interventions

*Continue with Phase

II-V interventions as

indicated

• Multi-plane sport specific plyometrics program

• Multi-plane sport specific agility program

• Include hard cutting and pivoting depending on the individuals’ goals

• Non-contact practice→ Full practice→ Full play

Criteria to

Discharge

• Quad/HS/glut index ≥90%; HHD mean preferred (isokinetic testing if available)

• Hop Testing ≥90% compared to contra lateral side

Revised 4/2021

Contact

Please email MGHSportsPhysicalThe[email protected] with questions specific to this protocol

References:

1. Adams D, Logerstedt D, et al. Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation

Progression. JOSPT 2012 42(7): 601-614.

2. DeFroda SF, Bokshan SL, et al. Variability of online available physical therapy protocols from academic orthopedic surgery programs for arthroscopic

meniscus repair. The Physician and Sports Medicine. 2018. 46 (3): 355-360.

3. Glazer DD. Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of Athletic

Training. 2009;44(2):185-189.

4. Harput, G., Guney-Deniz, H., Nyland, J., & Kocabey, Y. (2020). Postoperative rehabilitation and outcomes following arthroscopic isolated meniscus

repairs: A systematic review. Physical Therapy in Sport, 45(2020), 76–85.

5. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am J

Sports Med. 2001;29:600-613.

Massachusetts General Brigham Sports Medicine

6. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate

Ligament Injuries in Female Athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003-1010.

7. Noyes, FR, Heckmann TP, et al. Meniscus Repair and Transplantation: A Comprehensive Update. JOSPT 2012 42(3): 274-290.

8. VanderHave KL, Perkins C, et al. Weightbearing versus nonweightbearing after meniscus repair. Sports Health. 2015. 7 (5): 399-402.

9. Vedi V, Williams A, et al. Meniscal movement: an in-vivo study using dynamic MRI. JBJS. 1999. 81: 37-41.

10. Wilk KE, Macrina LC, et al. Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries. JOSPT 2012 42(3): 153-171.

Massachusetts General Brigham Sports Medicine

Return to Running Program

This program is designed as a guide for clinicians and patients through a progressive return-to-run program. Patients

should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or

meniscus repair). Specific recommendations should be based on the needs of the individual and should consider clinical

decision making. If you have questions, contact the referring physician.

PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES

Day

Week 1

W5/J1x5

W4/J2x5

Week 2

W3/J3x5

W2/J4x5

Week 3

W2/J4x5

W1/J5x5

Return to

Run

Key: W=walk, J=jog

**Only progress if there is no pain or swelling during or after the run

PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES

Week

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

20 min

25 min

30 min

35 min

40 min

45 min

50 min

55 min

60 min

Recommendations

• Runs should occur on softer surfaces during Phase I

• Non-impact activity on off days

• Goal is to increase mileage and then increase pace; avoid increasing two variables at once

• 10% rule: no more than 10% increase in mileage per week

Massachusetts General Brigham Sports Medicine

Agility and Plyometric Program

This program is designed as a guide for clinicians and patients through a progressive series of agility and plyometric

exercises to promote successful return to sport and reduce injury risk. Patients should demonstrate > 80% on the

Functional Assessment prior to initiating this program. Specific intervention should be based on the needs of the

individual and should consider clinical decision making. If you have questions, contact the referring physician.

PHASE I: ANTERIOR PROGRESSION

Rehabilitation

Goals

• Safely recondition the knee

• Provide a logical sequence of progressive drills for pre-sports conditioning

Agility

• Forward run

• Backward run

• Forward lean in to a run

• Forward run with 3-step deceleration

• Figure 8 run

• Circle run

• Ladder

Plyometrics

• Shuttle press: Double leg alternating leg single leg jumps

• Double leg:

o Jumps on to a box jump off of a box jumps on/off box

o Forward jumps, forward jump to broad jump

o Tuck jumps

o Backward/forward hops over line/cone

• Single leg (these exercises are challenging and should be considered for more

advanced athletes):

o Progressive single leg jump tasks

o Bounding run

o Scissor jumps

o Backward/forward hops over line/cone

Criteria to Progress

• No increase in pain or swelling

• Pain-free during loading activities

• Demonstrates proper movement patterns

PHASE II: LATERAL PROGRESSION

Rehabilitation

Goals

• Safely recondition the knee

• Provide a logical sequence of progressive drills for the Level 1 sport athlete

Agility

*Continue with Phase I

interventions

• Side shuffle

• Carioca

• Crossover steps

• Shuttle run

• Zig-zag run

• Ladder

Plyometrics

*Continue with Phase I

interventions

• Double leg:

o Lateral jumps over line/cone

o Lateral tuck jumps over cone

• Single leg(these exercises are challenging and should be considered for more

advanced athletes):

o Lateral jumps over line/cone

o Lateral jumps with sport cord

Criteria to Progress

• No increase in pain or swelling

• Pain-free during loading activities

• Demonstrates proper movement patterns

Massachusetts General Brigham Sports Medicine

PHASE III: MULTI-PLANAR PROGRESSION

Rehabilitation

Goals

• Challenge the Level 1 sport athlete in preparation for final clearance for return to

sport

Agility

*Continue with Phase

I-II interventions

• Box drill

• Star drill

• Side shuffle with hurdles

Plyometrics

*Continue with Phase

I-II interventions

• Box jumps with quick change of direction

• 90 and 180 degree jumps

Criteria to Progress

• Clearance from MD

• Functional Assessment

o Quad/HS/glut index ≥90% contra lateral side (isokinetic testing if

available)

o Hamstring/Quad ratio ≥70%

o Hop Testing ≥90% contralateral side

• KOOS-sports questionnaire >90%

• International Knee Committee Subjective Knee Evaluation >93

• Psych Readiness to Return to Sport (PRRS)

Massachusetts General Brigham Sports Medicine