REHABILITATION AFTER MENISCAL INJURY Dr. Ali Abd El-Monsif Thabet

Anatomical considerations The medial meniscus is C shaped and thicker posteriorly. It occupies 50% of the articular contact area of the medial compartment. The lateral meniscus is O shaped and of equal thickness throughout. It covers 70% of the lateral tibial plateau.

 The peripheral portion obtains its nutrition through blood vessels but the central portion must rely on the diffusion of synovial fluid. The process of fluid diffusion to support nutrition requires intermittent loading of the meniscus by either weight-bearing or muscular contractions

Functions  1- Joint lubrication  2- Increase joint congruency  3- Act as a shock absorber  4- Distribute weight-bearing forces

Injury mechanism  Mechanical elements in meniscal injury include force moments of knee joint flexion, compression, and rotation

Injury mechanism  A valgus force sufficient to cause disruption of the MCL also might produce an ACL tear as well as a meniscus tear “unhappy triad”

Pathomechanics Medial meniscus (90%) (Less mobile than lateral meniscus ) Lateral meniscus (10%)

Diagnosis  Injury followed by pain in area of medial or lateral joint lines  Most patients describe pain especially when the knee is straightened.  Effusion develops gradually over 48 to 72 hours, although a tear at the periphery might produce a more acute hemarthrosis.

 1. Apley's Compression test: a combination of tibiofemoral compression and rotation forces that are used to check for the presence of a meniscal tear

Fig. 2. The McMurray test for meniscal tears. flexed, internally and externally the knee.rotate the tibia on the femur.

With the leg externally rotated and in valgus, slowly extend the knee. If click is palpable or audible, With the leg externally rotated, place a valgus stress on the knee. the test is considered positive for a torn medial meniscus, usually in the posterior position.

 Bragard sign This test may be used if anterior joint-line point tenderness is present.  Bounce home test The patient is supine with his heel cupped in the examiner's hand.

 Payr sign With the patient sitting cross-legged, the examiner exerts downward pressure along the medial aspect of the knee. Medial knee pain indicates a posterior horn lesion of the medial meniscus

 First Steinmann sign With the patient supine and the knee and hip flexed at 90°, the examiner forcefully and quickly rotates the tibia internally and externally. Pain in the lateral compartment with forced internal rotation indicates a lateral meniscus lesion. Medial compartment pain during forced external rotation indicates a lesion of the medial meniscus.

 Second Steinmann sign This test is indicated when point tenderness is located along the anterior joint line. When the examiner moves the knee from extension into flexion, the meniscus is displaced posteriorly, along with its lesions. The point of tenderness also shifts posteriorly toward the collateral ligament.

Operative management  The overall treatment goal is to preserve as much meniscal tissue as possible.  Meniscal tears in the outer third or vascular zone will heal and therefore a meniscal repair is recommended.  Meniscal tears that extend beyond the outer third or vascular zone will not heal and therefore a partial meniscectomy is recommended.  A complete meniscectomy may be performed especially with significant degenerative tears to the meniscus.

POSTOPERATIVE REHABILITATION  Goals 1- Control of pain and edema 2- Obtaining and maintaining full ROM 3- Regaining proper quadriceps strength. 4- Immediate weight bearing as tolerated 5- Return to activity

Criteria for Return  The athlete may return to activity when (1) Swelling does not occur with activity. (2) Full ROM has been regained, (3) There is equal bilateral strength in knee flexion and extension, (4) The athlete can successfully complete functional performance tests.

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