1. Meniscus Tears: Non-operative management
Dr Wajeeha Mehmood

2. Mechanism of injury
The medial meniscus is injured more frequently than the lateral meniscus.
Insult may occur when the foot is fixed on the ground and the femur is rotated internally, as when pivoting, getting out of a car, or receiving a clipping injury.
An ACL injury often accompanies a medial meniscus tear.
Lateral rotation of the femur on a fixed tibia may tear the lateral meniscus.
Simple squatting or trauma may also cause a tear.

3. IMPAIREMENTS AND FUNCTIONAL LIMITATIONS
A meniscus tear can cause acute locking of the knee or chronic symptoms with intermittent catching/locking.
Pain during forced hyperextension or maximum flexion occurs along the joint line (due to stress to the coronary ligament) along with joint swelling and some degree of quadriceps atrophy.
When there is joint catching/locking, the knee does not fully extend, and there is a springy end feel when passive extension is attempted.
If the joint is swollen, there is usually slight limitation of flexion or extension.
The McMurray test or Apley’s compression/distraction test may be positive.
When the meniscus tear is acute, the patient may be unable to bear weight on the involved side. Unexpected locking or giving way during ambulation often occurs, causing safety PROBLEMS

4. MANAGEMENT
Often the patient can actively move the leg to “unlock” the knee, or the unlocking happens spontaneously.
Passive manipulative reduction of the medial meniscus may unlock the knee
After acute symptoms have subsided, exercises should be performed in open- and closed-chain positions to improve strength and endurance in isolated muscle groups and to prepare the patient for functional activities

5. Patient position and procedure: Supine. Passively flex
the involved knee and hip, and simultaneously rotate
the tibia internally and externally. When the knee
is fully flexed, externally rotate the tibia and apply
a valgus stress at the knee. Hold the tibia in this position,
and extend the knee. The meniscus may click
into place.
■ Once reduced, the knee may react as an acute joint
lesion. If this occurs, treat as described earlier in the
chapter in the section on nonoperative management of
joint hypomobility.
■ After acute symptoms have subsided, exercises should be performed in open- and closed-chain positions to improve strength and endurance in isolated muscle groups and to prepare the patient for functional activities.

6. Meniscus Tears: surgical and post op management

7. When a significant tear or rupture of the medial or lateral meniscus occurs or if nonoperative management of a partial tear has been unsuccessful, surgical intervention often is necessary.
Current-day surgical procedures are designed to retain as much of the meniscus as possible as a means of preserving the load transmission and shock-absorbing functions of the menisci and to reduce stress on the tibiofemoral articular surfaces

8. Primary surgical options
partial meniscectomy
meniscal repair
Selection of procedure depends upon:
The location and nature of the tear
patient’s age and level of activity.
Tears of the outer area of a meniscus, which has a rich vascular supply, heal well, whereas tears extending into the central portion, where the vascular supply is considerably less, have marginal healing properties

9. Indications for surgery
A lesion in the vascular outer third of the medial or lateral meniscus
A tear extending into the central, relatively avascular third of the meniscus of a young (younger than age 40 to 50) or physically active older (older than age 50) individual

10. Complecations
Intraoperative damage to the neurovascular bundle at the posterior aspect of the knee
Saphenous nerve with medial meniscus repair and peroneal nerve with lateral meniscus
Flexion contracture
Extensor lag

11. Post operative management

12. Immobilization and protective bracing
The knee is held in full extension, first in the postoperative immobilizer and then in a long-leg brace when the bulky compression dressing is removed a few days after surgery.
To protect the repaired meniscus during the first few postoperative weeks, the range-limiting brace is worn continuously (day and night) and is locked in full extension.
Soon after surgery, it is unlocked periodically during the day to initiate early ROM exercises and for bathing.

13. Immobilization and protective bracing
0 to <90 degrees knee flexion in first 2 weeks
Increase ROM by 10 degrees each week
The brace is unlocked throughout the day as early as 2 weeks if the patient has achieved full knee extension.
After a central zone repair, the patient typically wears the brace for about 6 weeks or until adequate quadriceps control has been re-established.
After a meniscal transplant, the brace may be worn a few weeks longer.

14. Weight bearing considerations
Following a peripheral zone repair, partial weight bearing (ranging from 25% to 50%) during ambulation with crutches and with the brace locked in full extension is allowed during the immediate postoperative period (first 2 weeks)
The percent of body weight permitted during weight bearing is progressed more cautiously after a central zone repair or meniscus transplantation. If quadriceps control is sufficient, full weight bearing may be permitted by 4 weeks after a peripheral repair and by 6 to 8 weeks after a central repair or transplantation.

16. Maximum protection phase 1-4 weeks
Gait training with crtucthes started 1st day post op
Cold, compression , elevation , ankle pumps
Patient education on home exercise and weight bearing considerations
Knee ROM
Patellar mobility
Activation of knee muscles
Neuromuscular control/responses proprioception, and balance
Flexibility and strength of hip and ankle
Cardiopulmonary function

17. Moderate protection phase 4-6 weeks
Gait: The knee brace is discontinued at about 6 to 8 weeks if there is adequate control of the knee and no extensor lag. Use of a cane or single crutch is advisable to provide some degree of protection during ambulation.
ROM progression
Muscle performance
Neuromuscular control/responses proprioception, and balance
Flexibility of the hip and ankle
Cardiopulmonary fitness
Functional activities.

18. Minimum protection phase 12-16 weeks
During advanced resistance training, focus on movement patterns that simulate functional activities.
Begin and gradually progress drills, such as plyometric training and agility drills, to improve power, coordination, and rapid response times.
Continue to stress the importance of proper trunk and lower extremity alignment.
Increase the duration or intensity of the aerobic conditioning program.
Transition from a walking program to a jogging/running program, if desired, at about 4 to 6 months.