Rehabilitation and RTP process after meniscal repair in sports

Introduction

A meniscus is a fibrocartilaginous anatomical structure divided in two parts and placed in the knee-joint cavity between the femur and the tibia. Its main functions are the knee-joint stabilization and reduce the stress by increasing the contact areas between the femur and the tibia. 

The meniscus injury incidence is high in contact and pivoting sports such as soccer, basket or handball. The loss of meniscal tissue increases the direct contact between the femur and the tibia, which results on premature arthrosis and long-term functional decline. Preservation of meniscal function is among the most important goals for athletes. Therefore, the meniscal repair is an important procedure that aims to preserve tissue and prevent future arthrosis.

Meniscal repair rehabilitation

There is a multitude of factors contributing to meniscal healing which affect to the rehabilitation protocols following meniscal repair.

• Tear location (peripheral vs central) and pattern (longitudinal, radial, complex).
• Meniscal vascular supply is the most important factor influencing the meniscal healing. The vascular supply is very low, although there are differences according to the meniscal area:
  • Peripheral area (red-red zone); 30% vascular supply. 
  • Inner area (red-white and white-white zone); relatively avascular.
• Timing and type of meniscal tear may also impact healing:
  • Acute, traumatic tears: higher healing rates than chronic and atraumatic tears.
  • Longitudinal tears: more amenable to repair due to their vertical orientation.
  • Radial tears: extending to the central relatively avascular ‘white-white’ zone. Are more challenging for healing. 
• Age
• ROM and weight-bearing capacity before the meniscal repair.
• Other factors (tear chronicity, concomitant injuries, alignment, tissue quality, surgical technique) may impact physical therapy protocols and clinical outcomes.

Rehabilitation guidelines specific to the tear’s characteristics:

• Anterior-posterior longitudinal tears <3 cm; weight-bearing as tolerated without a brace. ROM progressed to 125° between 3 and 6 weeks. RTP was allowed after 3 months. 
• A-P longitudinal Tears >3 cm; weight-bearing was allowed in a locked brace. ROM was limited to 0°–125° until 6 or 8 weeks. RTP: 3 months. 
• Complex and radial tears; weight-bearing as tolerated with brace ranging from 0° to 125° for 6 to 8 weeks. RTP between 4 and 5 months.

Traditional vs accelerated rehabilitation approaches

The literature shows two approaches of postoperative rehabilitation protocols: protective vs accelerated. The traditional approach is based on the leg immobilization in extension, non-weight-bearing and limiting knee flexion to 90º for the first 4 to 6 weeks. The accelerated approach is based on the athlete progression and consists on earlier weight-bearing and unrestricted ROM, with individualized timing. However, there is controversy regarding to the adequacy of leg immobilization (quadriceps atrophy and fibrovascular scar formation). Besides, authors have not found any differences in failure rates or functional performance on RTP, and athletes return to play 2-fold faster with accelerated rehabilitation compared to traditional approach (10 weeks vs 20 weeks). Therefore, the accelerated process seems more adequate. 

Accelerated approach: phases of rehabilitation after a meniscal repair.

Protective Phase (weeks 0 to aprox 6)

• It is usually the most time-driven phase of rehabilitation to allow an adequate period of meniscal healing.
• Early Focus (0-3 weeks): pain/edema control, early patellar mobilization, full ROM (without a brace*), and quadriceps neuromuscular training, Core, aerobic training.
• The aerobic fitness should never be the limiting factor in the RTP phase of training.
• Peripheral longitudinal tears may be advanced from toe-touch weight-bearing in extension to full weight-bearing in extension over the first 6 weeks.
  • ROM may progress rapidly from 0-90º by the end of week 1; to 0-135º by week 4. 
• Complex or radial repairs may be held at partial weight-bearing longer.
  • ROM limiting flexion to 70º up to week 3, 90º at week 4, and 120º at week 5. 
• Hamstring strengthening should be avoided.
• Normalized gait pattern free of bracing is the goal at 6 weeks.
• Criteria for progression (to restorative phase): full passive ROM, no effusion, and neuromuscular control of quadriceps.

*Depends of the tear’s type.

Restorative Phase (weeks 6 to 12)

• Focus: closed kinetic chain strengthening, squatting >90º flexion, lunges, and step-ups, initiating hamstring strengthening, proprioceptive and single-leg balance training.
• Criteria for progression: once the patient demonstrates full active ROM and adequate single-leg dynamic knee control.

Return to Activity (weeks 12 to 16)

• Early focus: increasing neuromuscular control and building strength, isokinetic exercises, jumping and landing maneuvers; progress to plyometry, changes of directions (CODs). 
• Late focus: sport-specific high-load and high-speed maneuvers that simulate the on-field requirements of competition in a controlled environment (specifically by athlete and positional demands).
• Dynamic maneuvers challenge the athlete both eccentrically and concentrically in a way that continues to recreate the unpredictable and varied environment.
• Particular attention to landing with too little knee flexion or breakdowns in balance.
• Return to jogging:
  • Peripheral tears: it may be possibly from week 12, when the patient has appropriate strength, good frontal and sagittal plane control, and performs low-level agility exercises without pain.
  • Complex tears: from 16 to 24 weeks.
• Criteria for progression: absence of effusion, full active ROM, 70% operative leg strength versus contralateral, and Lysholm and SANE subjective scores >75 points.
• Observation of subtle signs of breakdown in core kinetics such as decreased knee flexion, poor postural control, or “leading” with the opposite leg must be recognized and addressed during this protected period before the athlete is released to return to full competition.

RTP

• Shared decision between the physician, the athlete, and the rehab trainer.
• A second-look arthroscopy before RTP may be indicated if one is concerned with reinjury or persistent pain, it is not recommended in an asymptomatic athlete because of the potential risks and costs.
•  Criteria for progression: full, symmetric, pain-free ROM at the knee, no obvious strength discrepancies, ability to perform single leg squat, normal running mechanics and sufficient neuromuscular control when performing dynamic sport-specific activities.
• Several factors may influence healing and increase the risk of reinjury following meniscal repair: tear type, rim width/zone of tear, medial versus lateral meniscus tear, and the presence of concomitant injuries.
  • Tears having rim widths >3 mm being significantly more likely to fail.
  • no significant difference exists regarding isolated medial vs lateral meniscus repair.
• Concomitant meniscal injuries in the presence of acute ACL rupture is extremely common: up to 80% ACL ruptures to have associated meniscal tears.
  • The forces about the meniscus to increase up to 200% in the ACL deficient knee, suggesting an increased rate of failure following meniscal repair in an ACL deficient knee.
• % of RTP rate following meniscal repairs: 80 to 95%. 
• RTP timing:
  • Isolated meniscal tear: 5.6 months (3-8 months).
  • ACL + meniscal tear: 11.8 months.

Meniscal repair outcomes

Meniscal repair can provide excellent results for RTP. Multiple repair techniques: inside-out (gold standard), all-inside, and open repair. 

Meniscal repair vs Meniscectomy

• Isolated meniscectomy has been performed in situations whereby there is nonviable meniscal tissue or non-satisfactory healing potential.
• Isolated partial lateral (LM) vs medial meniscectomy (MM)
  • Athletes return to previous level at an average of 5 to 7 weeks.
  • Faster returning for LM, but may presents adverse events; persistent effusions and lateral joint line pain or required subsequent arthroscopic surgery.
• Partial meniscectomy can provide an opportunity for more rapid RTP than meniscal repair, but there is significant risk of future cartilage degeneration.
• Although partial meniscectomy generally produces good to excellent results with low complication rates, several studies have reported persistent knee pain requiring athletes to decrease their activity level.
• Partial meniscectomy is frequently preferred by patients and surgeons to allow earlier RTP. Furthermore, it presents excellent short-term results, necessary in high-level sport.
• Meniscal repair records significantly high functional scores at long-term follow-up, but requires a longer rehabilitation period and is a more technically challenging procedure than partial meniscectomy.

References

• Barcia AM, Kozlowski EJ, Tokish JM. Return to Sport After Meniscal Repair. Clin Sports Med. 2012; 31(1): 155–66.
• Wiley TJ, Lemme NJ, Marcaccio S, Bokshan S, Fadale PD, Edgar C, et al. Return to Play Following Meniscal Repair. Clin Sports Med. 2020; 39(1): 185–96. 
• Spang RC, Nasr MC, Mohamadi A, Deangelis JP, Nazarian A, Ramappa AJ. Rehabilitation following meniscal repair: A systematic review. BMJ Open Sport Exerc Med. 2018; 4(1): 1–12. 
• Kozlowski EJ, Barcia AM, Tokish JM. Meniscus Repair: the role of accelerated rehabilitation in return to sport. Sports Med Arthrosc. 2012; 20(2): 121–6.

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This article has been made based on the references showed, other studies reviewed but not showed and according to the experience and knowledge of the author. In this way, it may include subjective ideas and opinions not contrasted in the research.