2014 Rehabilitation of Meniscal Injury and Surgery

Special Focus Section
459
Rehabilitation of Meniscal Injury and Surgery

John T. Cavanaugh, PT, MEd, ATC, SCS1
Surgery, New York, New York

J Knee Surg 2014;27:459478.
Abstract
Keywords
meniscus
rehabilitation
surgery
Meniscal cartilage plays an essential role in the function and biomechanics of the knee
joint. The meniscus functions in load bearing, load transmission, shock absorption, joint
stability, joint lubrication, and joint congruity. Individuals today are increasingly more
active in later decades of life. Although the incidence of meniscal pathology is difcult to
estimate, this increased exposure to athletic activity increases the risk of injury to these
structures. Hede and coworkers reported the mean annual incidence of meniscus tears
as 9.0 in males and 4.2 in females per 10,000 inhabitants. Tears were found to be more
common in the third, fourth, and fth decades of life. It has become clearer in recent
decades that meniscal excision leads to articular cartilage degeneration. Degenerative
changes have been found to be directly proportional to the amount of meniscus
removed. Therefore, it has been generally recognized that the amount of meniscal
tissue removed should be minimized, repaired, or replaced. Whether a meniscal lesion is
treated conservatively or surgically, the rehabilitation program will play an important
role in the functional outcome. This article will discuss these programs and the various
treatment strategies employed.
Meniscal cartilage plays an essential role in the function and

biomechanics of the knee joint. The meniscus functions in
load bearing, load transmission, shock absorption, joint stability, joint lubrication, and joint congruity.13 Individuals
today are increasingly more active in later decades of life.
Although the incidence of meniscal pathology is difcult to
estimate, this increased exposure to athletic activity increases
the risk of injury to these structures. Hede and coworkers4
reported the mean annual incidence of meniscus tears as 9.0
in males and 4.2 in females per 10,000 inhabitants.
Tears were found to be more common in the third, fourth,
and fth decades of life. It has become clearer in recent
decades that meniscal excision leads to articular cartilage
degeneration.57 Degenerative changes have been found to be
directly proportional to the amount of meniscus removed.8
Therefore, it has been generally recognized that the amount
of meniscal tissue removed should be minimized, repaired, or
replaced.911 Whether a meniscal lesion is treated conservatively or surgically, the rehabilitation program will play an
important role in the functional outcome. This article will
received
May 5, 2014
accepted after revision
September 1, 2014
published online
November 12, 2014
Address for correspondence John T. Cavanaugh, PT, MEd, ATC, SCS,

Sports Rehabilitation and Performance Center, Hospital for Special
Surgery, 535 East 70th Street, New York, NY 10021
(e-mail: cavanaughj@hss.edu).
discuss these programs and the various treatment strategies

employed.
Mechanism of Injury/Presentation
Meniscal lesions can occur from either mechanical or biochemical (degenerative) causes.12 Noncontact forces are the
most frequent mechanism of injury to the menisci.2 Typically,
these stresses result from a sudden acceleration or deceleration in conjunction with a change of direction (rotation force)
that traps the menisci between the tibia and femur, resulting
in a tear. In jumping sports such as basketball and volleyball,
the additional element of a vertical force with angular momentum (varus or valgus) on landing can contribute to a
meniscal injury. Contact injuries involving valgus or varus
forces can contribute to meniscal pathology. Ligament injuries to the anterior cruciate ligament (ACL) or medial collateral
ligament, or both in which increased tibial displacement
occurs, can displace the menisci from its peripheral attachments and result in a tear. In chronic ACL insufciency, the
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1 Sports Rehabilitation and Performance Center, Hospital for Special
Cavanaugh
incidence of meniscal pathology can approach 98%.13 The

medial meniscus injury rate has been found to be higher than
that for the lateral side (86.9 vs. 28.9%) in this population.14
Degenerative lesions are not uncommon in older individuals. As we age, the menisci become stiffer and are less
compliant.15 Mesiha et al16 observed that meniscal tissue
from patients older than 40 years has a lesser cellularity and a
decreased healing response than tissue from younger patients. The most common types of meniscal tears are vertical,
longitudinal, oblique, degenerative, radial, and horizontal.17
Meniscal tears present with varied clinical symptoms such
as pain, effusion, locking, and persistent focal joint line
tenderness. Displaced tears, such as bucket handle tears,
can produce locking and giving way episodes. Nondisplaced
tears can alter meniscus mobility and produce abnormal
traction stresses on the capsule and synovium, which result
in pain and swelling.18
Management (Overview)
Meniscal tears may be treated conservatively based on location within the meniscus, type of lesion, and associated
symptoms. The natural history of longitudinal tears less
than 1 cm is either spontaneous healing or resolution of
symptoms. Stable tears with less than 3- to 5-mm displacement, peripheral tears less than 1 cm that displace less than
3 mm, degenerative tears in arthritic knees, and partial tears
may not require surgical intervention.19,20 Surgical options
include partial meniscectomy, meniscal repair, or meniscus
transplantation. Meniscal tear pattern, geometry, site, vascularity, size, stability, tissue viability or quality, and associated
pathology are all taken into account when determining
whether to resect or repair a meniscal lesion.21
Consideration must also be given to the underlying articular cartilage. Seedhom and Gardreanes22 demonstrated that
removal of 16 to 34% of the meniscus resulted in a 350%
increase in contact forces. Therefore, attempts to preserve the
injured meniscus are made whenever possible.
Improvements in surgical techniques along with advanced
instrumentation and repair methods have enabled orthopedic surgeons to repair menisci that were once thought of
being unrepairable. Meniscal allograft transplantation has
emerged as a treatment option for selected meniscus-decient patients to decrease the articular contact stress, provide
pain relief, and restore normal knee kinematics. The health,
activity level, and aspirations of the patient are taken into
consideration during the decision-making process. Comorbidities, such as heart disease, obesity, axial alignment, and
degenerative joint disease, are considered in the decision
process to excise, repair, replace, or even avoid surgery.
Rehabilitation Principles
Individualize Program: Consider Preinjury Status
The most important principle guiding a rehabilitation program following meniscal injury or surgery is individualization.23 The preinjury status of the patient needs to be taken
under serious consideration, as different patients present
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with diverse physical condition at the time of their initial

evaluation. The patient may be an elite athlete, a recreational
athlete, or a nonathlete in weak physical condition. Media
reports of professional athletes returning quickly to their
sport after arthroscopic meniscal surgery often frustrate
nonathletes or recreational athletes, who may take longer
to achieve their postsurgical goals. The professional athletes
condition and lower extremity strength enable them to
progress through the rehabilitative process at a faster rate
(Table 1).
Apply a Working Knowledge of the Basic Sciences to

the Rehabilitation Program
An understanding of the anatomy, function, and biomechanics of the knee joint, as well as the pathophysiology of knee
joint injuries, is needed to provide a quality rehabilitative
experience to individuals who have sustained a meniscal
injury. Knowing how and when these structures are placed
under stress during activities of daily living and specic
exercises will assist the rehabilitation specialist in safely
advancing the patient through the rehabilitative course and
optimize functional outcome.
The menisci consist of approximately 75% of type I collagen.24 Collagen types II, III, IV, and V are also present. Most of
the collagen bers are oriented circumferentially to resist
tensile forces and contain hoop stresses which are generated
while weight bearing.25 Radially oriented ties hold circumferential bers together and provide resistance to shear.26
Each meniscus is divided anatomically into horizontal thirds:
the posterior horn, the mid-body, and the anterior horn.
When looking at blood supply the menisci are divided into
vertical thirds. The most peripheral 20 to 30% of the medial
meniscus and the peripheral 10 to 25% of the lateral meniscus
receive a rich blood supply from the medial and lateral
genicular arteries.27
Vascularization decreases approaching the inner portion
of the meniscus and becomes dependent on diffusion.28
Meniscal tears that extend to the inner avascular area have
a more difcult time with healing. Free nerve endings (nociceptors) and three different mechanoreceptors (Rufni
corpuscles, Pacinian corpuscles, and Golgi tendon organs)
can be found in the horns and in the outer two-thirds of the
body of the menisci, thus supporting the role of menisci in
knee joint proprioception.2832 Karahan et al32 demonstrated
that partial meniscectomy patients had a signicant loss of
Table 1 Rehabilitation principles for the meniscal patient

1. Individualize program: consider preinjury status
2. Apply a working knowledge of the basic sciences to the
rehabilitation program
3. Team approach to rehab: responsibilities and
communication
4. Adhere to the rules of rehabilitation
5. Follow a functional progression
6. Follow evaluation/criteria-based guidelines
460
knee joint position sense at knee exion angles of 60 and 75

degrees at a mean 2-year follow-up.
The menisci stabilize the knee joint and contribute to load
bearing and shock absorption.30 The menisci occupy 60% of
the contact area between the tibial and femoral cartilage
surfaces and transmit 50% of the joint compressive forces in
full extension and approximately 85% of the load in 90
degrees of extension.33 The lateral meniscus picks up 70%
of the load transmitted across the lateral compartment while
the medial meniscus and articular cartilage share the load
across the medial compartment.34 The medial meniscus has
been shown to be a signicant restraint to anterior tibial
displacement. The lateral meniscus is more mobile than the
medial meniscus and may rotate as much as 15 to 20
degrees.35
The function of the meniscus is reected in its anatomy
because its cells and extracellular matrix are arranged in such
a way that compressive forces, shear stresses, circumferentially directed forces, and tensile hoop stresses can be endured and redirected optimally.25,34,36 An appreciation of the
inammatory process and nature of tissue healing is also
invaluable in safely preparing the patient to return to the
desired level of activity.
Team Approach to Rehab: Responsibilities and

Communication
For a successful outcome after meniscal injury and/or surgery,
the physician, rehabilitation specialist, and patient must work
responsibly together as a team.
Communication among the team members is vital. The
physician has the responsibility of ascertaining the proper
diagnosis based on patient history, clinical examination, and
diagnostic information from evaluative procedures (radiographs, magnetic resonance imaging [MRI], surgical observation, etc.). Should the physician be an orthopedic surgeon, he/
she will be responsible for performing the proper surgical
procedure to address the meniscal lesion, as well as directing
the postoperative rehabilitation program. Discussing the
procedure or providing the rehabilitation specialist with a
copy of the operative note will assist the clinician in appreciating any postoperative precautions (weight-bearing status,
range of motion [ROM] restrictions, etc.) and in developing
realistic and measurable goals for the patient. The surgical
technique, including the number of incisions and location of
the meniscectomy or meniscal repair, has a direct effect on
the progression of the patients rehabilitation program. The
more soft tissue dissection there is, especially capsular incisions, the more hemarthrosis and muscle inhibition will
occur postoperatively.37 The physician should also share any
associated pathology ndings, for example, osteoarthritis,
with the rehabilitation specialist.
Patients with degenerative joint disease take longer for
rehabilitate and require a slower therapeutic progression in
their exercise program following arthroscopic partial meniscectomy. Gillquist and Oretorp38 found that the recovery time
was approximately twice as long in patients with degenerative changes as in patients who had normal articular surfaces.
Patients with chondromalacia patellae may not be candidates
Cavanaugh
for certain isotonic or isokinetic knee extension exercises.

Patients with an ACL-decient knee will require increased
proprioceptive and neuromuscular training in their therapeutic exercise program.
The rehabilitation specialist has the responsibility of being
up to date with the most contemporary evidence-based
approaches in rehabilitating this population. He/she also
needs to communicate with the physician regarding the
patients progress and compliance to the therapeutic recommendations of the physician and rehabilitation specialist. The
patient has a responsibility as wellin particular, complying
to the prescribed home therapeutic exercises and recommended activity modications as set by their physician and
rehabilitation specialist.
Adhere to the Rules of Rehabilitation

The rules of rehabilitation as described by Gray39 can be easily
applied to patients who have sustained a meniscal injury or
who have undergone a surgical procedure to address a
meniscal lesion.
Rule No. 1: Create a Safe Environment

The rehabilitation specialist should use his or her knowledge
of the basic sciences to ensure that a prescribed exercise or
activity does not compromise the healing response of a
specic structure. For example, (a) maintain weight-bearing
precautions after a complex meniscal repair procedure; (b)
limit the ROM following a meniscal transplant; and (c)
maintain crutches for ambulation, weight bearing as tolerated, following arthroscopic partial meniscectomy until the
patient establishes a normal, nonantalgic gait pattern.
Rule No. 2: Do Not Hurt the Patient

Prescribe exercises and activities that are pain free. Gains in
ROM, strength, and exibility can best be achieved in this
manner. Modications can be made by adapting pain-free
arcs of motion on strengthening equipment and functional
activities. It is also important to counsel patients not to
perform activities of daily living which are painful to their
involved knee. Hence, a subset of this rule can be Not to have
the patient hurt the patient.
Rule No. 3: Be Aggressive without Breaking Rules No. 1

and No. 2
The rehabilitation specialist can be aggressive as long as a safe
environment is maintained during the prescribed therapeutic
exercises and the patient does not complain of knee pain
during the exercise or activity. Following these rules can
result in a safe, expeditious, and optimal outcome.
Follow a Functional Progression

A functional progression was dened by Kegerreis40 as an
ordered sequence of activities enabling the acquisition or
reacquisition of skills required for the safe and effective
performance of athletic endeavors. The patient should master
a simple activity before advancing to a more demanding
activity. Criteria therefore need to be established to ensure
a safe progression.
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An early goal in rehabilitation after meniscus injury or

surgery is to have the patient establish quadriceps control.
This can be demonstrated by having the patient perform a
straight leg raise without pain or an extensor lag. Once
established, the functional progression can be advanced as
long as knee ROM and lower extremity muscle strength
display improvement. The next criterion in the progression
is to have the patient reestablish a normal nonantalgic gait
pattern. Consider that every step is therapy and encourage
the patient to ambulate with a heel-toe gait pattern while
progressively weight bearing with crutches. Additional strategies used include decreasing stride length, emphasizing
quality ambulation over quantity, and utilizing water (e.g.,
underwater treadmill) for ambulation training so as to gradually apply increased load through the knee joint. Walking in
chest-deep water results in a 60 to 75% reduction in weight
bearing, while walking in waist-deep water results in a 40 to
50% reduction in weight bearing.41,42 Normalizing a gait
pattern facilitates gains in ROM.
The patient is then asked to exhibit the ability to ascend
stairs, followed by the ability to descend stairs. After demonstrating the ability to eccentrically control body weight
descending stairs, the patient may initiate a running program
if not contraindicated. As lower extremity and core muscle
strength, balance, and exibility demonstrate improvement,
higher-level activities including agility-promoting, plyometric, and sport-specic activities are introduced as therapeutic
interventions.
Follow Evaluation-Based Guidelines

Modern rehabilitation programs following meniscal injury
and/or surgery should follow a plan that is not as structured
as the protocols of yesteryear. Each patient will progress at
a different pace. Protocols can accelerate a program too
quickly for the patient whose progress is delayed and can
hold back the patient who is progressing very well. The
rehabilitation specialist should refrain from following a
cookbook approach to treatment. Instead, he/she should
combine basic scientic knowledge and physical examination skills to guide the patient through the rehabilitative
course. Clinical guidelines can and should be developed by
treating clinicians and the referring physicians. These
guidelines should incorporate exible time frames in the
progression to allow for individualization, for example:
weeks 3 to 5discontinue crutches when nonantalgic
gait is demonstratedversus week 4discontinue
crutches for ambulation. Continual reassessment of the
patient is vital to ensure a consistent and safe progression
of the program. Too rapid a progression in therapy or
normal functional activities of daily living is demonstrated
by increased effusion and pain. This is most likely related to
muscular fatigue, which leaves the articular surfaces unprotected against compressive forces. Therapeutic exercise
programs, therefore, often must be modied based on
changes in subjective and objective ndings.
A comprehensive evaluation establishes the baseline from
which progress is measured. A comprehensive history reveals
the mechanism of injury, how the injury was initially manThe Journal of Knee Surgery
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aged, medical diagnosis including workup (radiographs, MRI

scans, etc.), surgery date, and postsurgical management.
Observations document patients weight-bearing status,
gait deviations, joint effusion, muscle atrophy, and joint
alignment. Attention to the patients subjective complaints
is of the utmost importance throughout the rehabilitative
process. Reports of pain (location and description), lack of
mobility, and weakness have a direct effect on the progression
of a rehabilitation program. The physical examination should
document available active range of motion (AROM) and
passive range of motion (PROM). Girth measurements should
be taken above, at, and below each knee joint for comparison
to assess muscle atrophy. Palpation of joint line tenderness is
a valuable component of the evaluation of a meniscal patient.
Eren43 demonstrated that joint line tenderness as a test for
lateral meniscal tears was 96% accurate, 89% sensitive, and
97% specic. Manual muscle testing may reveal a proximal or
distal weakness or muscle imbalance. Quadriceps testing is
often not appropriate in the immediate postinjury or postoperative setting. Neurovascular integrity should be evaluated. Assessment of patellar orientation and tracking where
appropriate can provide valuable information when quadriceps strengthening exercises are implemented at a later date.
Flexibility assessment is important, as tight muscles about
one joint can alter forces at another joint. Gait evaluation
(when applicable) can be useful in assessing the patients
biomechanical prole.
The clinical evaluation would not be complete without
dening goals and a treatment plan to meet these goals. The
information gathered should be reviewed with the patient.
Realistic goals should be discussed and established by the
patient, physician, and rehabilitation specialist. The patient
should be made to understand the magnitude of their injury
or surgery and the timetable for recovery. Goals should be
specic to the individual needs of the patient. Goals should be
functional and measurable as well. The patient should be
made aware of his or her role in the rehabilitative process. A
treatment plan can only be developed when the clinical
ndings from a comprehensive examination are considered.
The rehabilitation specialist should develop a prioritized
problem list. Specic rehabilitation strategies can then be
used to address each problem. Examples include utilizing
cryotherapy to control or decrease pain and joint effusion,
ROM exercises to address a loss of knee exion or extension,
and gait training to normalize an asymmetrical or antalgic
gait pattern. Throughout the rehabilitative course, a criteriabased functional progression of therapeutic exercises should
be followed.
Conservative Management
When a meniscal lesion is treated conservatively, the referring physician should communicate with the rehabilitation
specialist and share their prognosis for the patient. As discussed earlier, concomitant pathology (degenerative joint
disease, chondromalacia, ligament deciency, chondral injury, etc) should also be identied. Following a comprehensive
examination, the patient should be treated symptomatically,
462
addressing pain, swelling, motion loss, weakness and inhibition, and loss of function.
Following an acute meniscal tear, pain and an ensuing
knee effusion can be expected. Inhibition of the quadriceps
muscle shortly follows. Mechanoreceptors in the joint capsule
respond to changes in tension and in turn inhibit motor
nerves supplying the quadriceps muscles.44
Therefore, controlling posttraumatic effusion leads to
decreased quadriceps inhibition and results in a faster return
of muscle function. Early posttraumatic treatment strategies
include cryotherapy, quadriceps setting, straight leg raises in
multiple planes, progressive weight bearing as tolerated gait
training with crutches, active-assisted range of motion
(AAROM) exercises (Fig. 1), and exibility exercises. The
patient is advised to perform these exercises as part of a
comprehensive home program and to modify ones activity
level until symptoms subside and ROM and muscle strength
demonstrate improvement. Weight bearing crutch ambulation is encouraged until the patient demonstrates a normal
nonantalgic gait pattern. Therapeutic exercises are advanced
to include closed kinetic chain (CKC) exercises, such as leg
press, mini squats, step-ups, step-downs, retro treadmill
ambulation, and balance/proprioception activities. Palmitier
and colleagues45 in a biomechanical model of the lower
extremity demonstrated reduced tibiofemoral shear force
when a compressive force is applied to the knee joint. Co-
Fig. 1 Active-assisted range of motion exercise. The patient supports

his involved lower extremity with the noninvolved lower extremity as
the patient attempts to ex the involved knee. Upon reaching the
degree of stretch, the noninvolved extremity assists the involved knee
in returning to the fully extended position.
Cavanaugh
contraction of agonist and antagonist muscles during functional CKC movements provide joint stabilization by decreasing shear forces acting on the knee. CKC exercises also reduce
patellofemoral joint reaction force. Hungerford and Barry46
demonstrated greater patellofemoral contact stress per unit
area during open kinetic chain (OKC) knee extension than
during squatting under body weight between full extension
and 53 degrees of exion. Squatting between 53 and 90
degrees of exion produced greater patellofemoral contact
stress per unit area than that produced during OKC knee
extension in the same range. Retrograde treadmill ambulation on progressive percentage inclines is used to facilitate
quadriceps strengthening.47 As full ROM is improved and
quadriceps control is demonstrated, OKC knee isotonic extension exercises are implemented inside a pain-free/crepitus-free arc of motion. Bilateral knee extensions are initiated
before unilateral knee extension.
Research suggests that a certain level of deafferentation
occurs after lower extremity joint injury.48 As the central
nervous system receives decreased sensory information,
there is decreased ability to adequately stabilize the lower
extremity.48,49 Efforts to regain proprioception loss begin
with balance activities utilizing bilateral support, advancing
to unilateral support.50 A foam-like cushion or a computerized platform device such as the Biodex BioSway System
(Biodex Medical Systems, Shirley, NY) can be used (Fig. 2).
A criteria-based functional progression is followed
throughout the rehabilitation course. Upon demonstration
of full ROM and a controlled 8 step-down (Fig. 3) (without
Fig. 2 Biodex BioSway System (Biodex Medical Systems, Shirley, NY).
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Fig. 3 Step-down exercise. The patient descends an 8 step leading

with his noninvolved lower extremity. The patient is cued to perform
his decent in a slow, controlled manner. The rehabilitation specialist
monitors complaints of knee pain and observes asymmetry.
pain and good lower extremity control without deviations), a

running program is initiated. Backward running is preceded
by forward running, as retrograde running has been shown to
generate lower patellofemoral joint compression forces than
forward running.51 Advanced sport-specic activities such as
deceleration training and plyometrics are added as appropriate to meet the specicity of the individual athletes sports
requirements. Before plyometric exercises are incorporated
into a treatment regime, ROM and exibility should be
restored. Static and dynamic balance should be proved to
be within acceptable ranges. The patient should also demonstrate a lack of apprehension in performing sport-specic
movements. Plyometric training should follow a functional
progression, with the components of speed, intensity, load,
volume, and frequency monitored and advanced accordingly.
Activities should begin with simple drills and advance to
more complex exercises (e.g., double leg in-place jumping vs.
box drills). Dynamic stretching exercises should be included
to develop sport-specic exibility and to enhance performance. This form of stretching incorporates the actual range
of movement about a joint, with the patient overcoming
resistance to movement while performing an activity at the
normal speed.52 To ensure that an athlete is prepared to
return to sport, the rehabilitation specialist should be able to
objectively demonstrate that the athlete has met the criteria
(ROM, exibility, strength, power, endurance) to meet the
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demands of that particular sport. These criteria must be met

to decrease the possibility of reinjury.
Testing provides evidence of progress in a rehabilitation
program and is a vital tool of criteria-based rehabilitation
guidelines. Lower extremity strength and power assessment
is accomplished via isokinetic and functional testing. Testing
can provide a bilateral comparison (involved vs. noninvolved
extremities), represented as limb symmetry (100%) or as a
percentage decit. Isokinetic testing of the knee involves
assessment of the quadriceps and hamstring muscles during
a testing regime in which speed is constant and resistance is
variable and accommodating. Isokinetic testing has been
shown to be both reliable and valid.53,54 Testing velocities
should be determined for the individual patient. Slowervelocity testing (30, 60, and 90 degrees) is avoided in many
meniscal patients, as joint compressive, shear, and tibial
displacement forces are greater at these speeds than at
intermediate (120, 150, and 180 degrees) and fast (240,
300 degrees per second) test velocities.55,56 Faster-velocity
testing can also replicate knee velocity during functional
activity. Wyatt and Edwards57 have reported the angular
velocity of the tibiofemoral joint during walking to be 233
degrees. Data interpretation can include, among other
parameters, peak torque, peak torque to body weight ratio,
total work, average power, quadriceps to hamstring ratio,
force decay rate, and torque curve analysis. Many clinicians
strive for more than 85% limb symmetry in the affected limb
compared with those in the contralateral limb as acceptable
level for a return to sports activities.58 Functional testing
allows a more functional approach to strength assessment by
using a CKC environment during measurement. Functional
testing links specic components of function with the actual
task and provides direct evidence to prove functional status.
Observation during testing can assist the rehabilitation specialist in ascertaining the athletes apprehension or lack
thereof in performing a functional task (e.g., landing from a
jump). Limb symmetry tests include hop tests, vertical jumps,
and leg-press tests. Daniel et al59 introduced the one legged
hop test for distance in 1982 (Fig. 4). Barber et al60 described four hop tests to assess lower extremity functional
limitations: single-legged hop for distance, timed hop, triple
hop for distance, and crossover triple hop for distance. The
single-legged hop for time and the crossover hop have been
reported to be the most sensitive and best indicators of
function.60,61 Normal limb symmetry was identied as
limb values within 85% of one another for both men and
women regardless of limb dominance or sports activity level.
Decits demonstrated in these tests as well as observed
difculty in stabilization on landing, apprehension, or complaints of pain indicate the need for continued therapeutic
interventions in the areas of strength, power, and balance
development. Information obtained, whether subjective or
objective, can be presented to the referring physician for
consideration. The patient/athlete is then advised regarding
the level of sports participation, with or without modications, to which he or she can return. On discharge from a
formal rehabilitation program, the rehabilitation specialist
should provide the patient with a comprehensive home or
464
Cavanaugh
Fig. 5 Game Ready Cold Therapy Compression System (CoolSystems,

Inc., Concord, CA).
Fig. 4 Single-leg hop test. The patient attempts to jump forward as far
as he can rst with the noninvolved and then the involved lower
extremity. Three attempts are recorded and averaged. Limb symmetry
is then calculated.
gym therapeutic exercise program to maintain and advance

the present level of function.
Rehabilitation Strategies after Arthroscopic

Partial Meniscectomy
Surgery of the meniscus is a common orthopedic procedure,
constituting 10 to 20% of surgeries performed in some
practices.62 With the advancement of arthroscopic surgery
in the last three decades, total meniscectomy is less commonly performed. McGinity et al63 have reported diminished
morbidity when partial meniscectomy is performed over
total meniscectomy. Early proper management after surgery
is vital in ensuring a fast and safe recovery. Postoperative
effusion and pain are controlled by encouraging the patient to
use axillary crutches in the immediate postoperative period.
A progressive weight-bearing gait is advised. The rehabilitation specialist needs to encourage the patient to monitor load
and volume of activity in the days following surgery. This
advice is particularly important when dealing with patients
with degenerative joint disease and/or a high body mass
index (BMI). Increased BMI makes surgery more challenging
and subjects the knee to increased contact forces.64,65
As the patient develops a more normal, nonantalgic gait,
use of crutches is discontinued. Cold and compression is
applied postsurgically using a commercial cryotherapy de-
vice, for example, Game Ready Cold Therapy Compression

System (CoolSystems, Inc., Concord, CA) (Fig. 5) to control
pain and inammation. Nonsteroidal anti-inammatory
drugs are recommended by some surgeons. Rasmussen et
al66 reported on 120 patients, randomized to either naproxen
twice a day or placebo for 10 days after arthroscopy. At
20 days after surgery, patients in the naproxen group had
less effusion and pain and more ROM and walking activity.
Quadriceps setting and straight leg raises in multiple
planes are encouraged immediately after surgery to regain
motor control and inhibit atrophy. AROM and AAROM exercises are started to improve motion. Initiation of postoperative outpatient rehabilitation is recommended as soon as
possible. A comprehensive evaluation is performed, postoperative exercises reviewed, and activity modications identied. Gait is assessed and an appropriate assistive device
(crutches or cane) is recommended. When ROM reaches
approximately 85 degrees, a short crank ergometer can be
used to develop strength, ROM, and cardiovascular conditioning. Schwartz et al67 have demonstrated that these therapeutic effects of stationary cycling can be attained early in the
postoperative course by changing the ergometer crank from a
standard 170 mm to smaller crank lengths (14080 mm). As
knee exion ROM approaches 110 degrees, the patient is
progressed to a standard ergometer. The rehabilitation program is then advanced in a similar fashion following the
criteria-based functional progression as described earlier in
this article. The guidelines for postpartial meniscectomy are
found in Table 2.
Rehabilitation Strategies after Arthroscopic

Meniscal Repair
The rst reported meniscal repair was presented by Annandale in 1885.68 Surgical techniques to repair the meniscus
have evolved from the placement of sutures across the torn
meniscus through arthrotomy to using arthroscopy. Published meniscal repair results have supported favorable success at extended follow-up in over 70 to 90% of patients.6973
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Table 2 Partial meniscectomy rehabilitation guidelines

Postoperative phase 1 (wk 03)
Goals
Control postoperative pain/swelling
Range of motion 0 ! 130 degrees
Prevent quadriceps inhibition
Restore normal gait
Normalize proximal musculature muscle strength
Independence in home therapeutic exercise program
Precautions
Progressive weight bearing with crutches
Activity modications
Treatment strategies
Activeassistive range of motion exercises (pain-free ROM)
Towel extensions
Patella mobilization
Progressive weight bearing as tolerated with crutches
D/C crutches when gait is nonantalgic
Computerized force plate (Biodex) for weight bearing progression/patient education

Underwater treadmill system (gait training) if incision benign
Quadriceps reeducation (Quad Sets with EMS or EMG)
Multiple angle quadriceps isometrics (bilaterallysubmaximal)
Short crank ergometry ! standard ergometry
SLRs (all planes)
Hip progressive-resisted exercises
Leg press (80 ! 0 degrees arc) bilaterally
Initiate forward step-down program
Mini-squats
Proprioception/Balance training: bilateral support
Proprioception board/Balance systems
Lower extremity exibility exercises

Upper extremity cardiovascular exercises as tolerated
Cryotherapy
Home therapeutic exercise program: evaluation based
Emphasize patient compliance to home therapeutic exercise program and weight bearing progression
Criteria for advancement
Normalized gait pattern
ROM 0 ! 130 degrees
Proximal muscle strength 5/5
SLR (supine) without extension lag
Goals
ROM 0 degrees ! WNL
Normal patella mobility
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Table 2 (Continued)
Ascend and descend 8 stairs with good control without pain
Precautions
Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment is demonstrated
Avoid pain with therapeutic exercise and functional activities
AAROM exercises
Patella mobilizations
Leg press (90 ! 0 degrees arc) bilateral ! eccentric
Progress squat program
Retrograde treadmill ambulation/running
Proprioception/balance training: bilateral ! unilateral support
Proprioception board/contralateral Theraband exercises/balance systems
Progress forward step-up program

Initiate forward step-down program
Stairmaster
Elliptical trainer
SLRs (progressive resistance)
Lower extremity exibility exercises
OKC knee extension: Bilaterally (pain/crepitus-free arc)
ROM 0 degrees ! WNL
Demonstrate ability to ascend and descend 8 step
Normal patella mobility
Postoperative phase 3 (wk 6-?)
Goals
Demonstrate ability to descend 8 stairs with good leg control without pain
85% limb symmetry on Isokinetic testing
Return to normal ADL
Improve lower extremity exibility
Precautions
Avoid running till adequate strength development and MD clearance
Progress squat program
Leg press (90 ! 0 degrees emphasizing eccentrics)
OKC knee extensions 90 ! 0 degrees (pain/crepitus-free arc)
Advanced proprioception training (perturbations)
Agility exercises (sport cord)
Elliptical trainer
Forward treadmill running
Hamstring curls/proximal strengthening
Lower extremity stretching
(Continued)
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Table 2 (Continued)
Isokinetic test
Functional hop test
Ability to descend 8 stairs with good leg control without pain
85% limb symmetry on Isokinetic testing
Source: Hospital for Special Surgery Sports Rehabilitation and Performance Center.
The postoperative management of a meniscal repair takes on

a more conservative approach as compared with partial
meniscectomy to allow for successful healing of the repair.
Rehabilitation guidelines differ among surgeons and remain controversial.7477 Discrepancies exist in the amount of
weight bearing and knee exion allowed in the early postoperative time frame as well as the time frame for return to
sports activity. Barber74 reported no differences in healing
rates between patients who followed a more conservative
and protective program and patients who participated in a
more accelerated program (weight bearing, ROM exercises,
and early return to sports activity). Programs should be
individualized to the type of surgical procedure performed,
the type of meniscal tear repaired, and the basic science
information that is currently available. Therefore, information
from the surgeon regarding the classication of the tear, the
anatomic site of the repair (vascular vs. nonvascular), and
location within the meniscus (anterior or posterior) should
directly affect the postoperative regimen.
During weight bearing, compressive forces are loaded
across the menisci. These tensile forces create hoop stresses
which expand the menisci in extension.75 Morgan et al 78
demonstrated that extension appears to reduce the meniscus to the capsule, whereas exion causes tears in the
posterior horn to displace from the capsule. Becker et al79
have reported that weight bearing from full extension to
90-degree exion increases the pressure on the posterior
horn by, roughly a factor of four. The compressive loads
applied while weight bearing in full extension following a
vertical, longitudinal repair or bucket-handle repair can
reduce the meniscus and stabilize the tear.7482 In complete
transactions of circumferential ber bundles of the meniscus, such as radial tears that comprise the whole cross
section or posterior root tears, weight bearing should be
delayed because the hoop stresses would distract the tear
margins and compromise healing.83 The surgeon and rehabilitation specialist should take into consideration the axial
alignment of the patient. Habata et al84 reported an association between atraumatic tears of the medial meniscus and
varus deformity. Medial meniscus repair patients with a
varus deformity and lateral meniscus repair patients with a
valgus deformity may need a more conservative approach
in their rehabilitation, as the compressive loads in the
respective involved compartment are higher. Surgeons
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may elect to delay weight bearing and/or place these

individuals in an unloader brace.
The menisci translate dorsally with knee exion. This
motion depends not only on the exion angle but also on
the weight bearing condition.85 Walker and Erkman34 demonstrated that progressive knee exion subjects the menisci
to greater stress. Thompson et al86 demonstrated that the
meniscus translates posteriorly with exion; however, meniscal movement was at a minimum at less than 60 degrees of
exion. Thus, consideration is given to limiting exion to 60
degrees during the early period of healing. Tibial rotation
causes large excursions of the meniscus within the rst 30
degrees of exion.87 Terminal exion is accompanied by a
large dorsal translation of the condyles and causes increased
compressive stress of the meniscus.76,85 Therefore, deep
squats and tibial rotation are avoided in the early phases of
rehabilitation following meniscal repair. There is evidence in
a canine model that the maximum tensile strength of meniscus repairs reaches 80% by 12 weeks, which suggests that the
suture/scar combination provides enough stability for clinical
function.88 However, many surgeons defer their patients
from returning to pivoting sports until 4 or more months
postoperatively.
Meniscal Repair Guidelines Postoperative

Phase I (Weeks 06)
Rehabilitation guidelines following meniscal repair are divided into three phases and are outlined in Table 3.
The rst phase is designed to protect the repair and allow
for maximal healing. Rehabilitation is initiated immediately
postoperatively. The patient is placed in a double-upright
knee brace that is locked in full extension. This brace is used
exclusively for ambulation and sleeping for the rst 4 to 6
postoperative weeks. A progressive program of weight bearing as tolerated is initiated for bucket-handle and vertical,
longitudinal tears. Weight bearing will be limited to toetouch for radial or more complex repairs for 4 to 6 weeks as
compressive loading may cause distraction of these repairs.
Weight bearing with the knee in progressive exion is
avoided for 4 to 6 weeks, as the meniscus is subjected to
greater stress in this position.
The patient is instructed in ROM exercises to attain full
extension and the recommended degree of exion AAROM
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469
Table 3 Meniscal repair rehabilitation guideline

Meniscal repair guideline postoperative phase 1 (wk 06)
Goals
Emphasis on full passive extension
Range of motion ! 90-degree exion
Regain quadriceps control
Precautions
Avoid active knee exion
Avoid ambulation without brace locked at 0 degrees before 4 wk
Avoid prolonged standing/walking
Towel extensions, prone hangs, etc.
Quadriceps re-education (Quad Sets with EMS or EMG)
Progressive weight bearing PWB ! WBAT with brace locked at 0 degrees with crutches
Toe-touch weight bearing for complex or radial tears
Active-assisted exion/extension 90 ! 0 degrees exercise
SLRs (all planes)
Proprioception board (bilateral weight bearing)
Aquatic therapypool ambulation or underwater treadmill (wk 46)
Short crank ergometry (if ROM > 85 degrees)
Leg press (bilateral/60 ! 0-degree arc) (if ROM > 85 degrees)
OKC quadriceps isometrics (submaximal/bilateral at 60 degrees) (if ROM > 85 degrees)
Hamstring and calf stretching
Cryotherapy
Emphasize patient compliance to home therapeutic exercise program and weight bearing and range of motion precautions/
progression
Ability to SLR without quadriceps lag
ROM 0 ! 90 degrees
Demonstrate ability to unilateral (involved extremity) weight bear without pain
Goals
Restore full ROM
Restore normal gait (nonantalgic)
Demonstrate ability to ascend and descend 8 stairs with good leg control without pain
Improve ADL endurance
Precautions
Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment
(Continued)
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Table 3 (Continued)
Avoid running and sport activity
Progressive weight bearing/WBAT with crutches/cane (brace opened 0 ! 60 degrees), if good quadriceps control
(good quad set/ability to SLR without lag or pain)
Aquatic therapypool ambulation or underwater treadmill
D/C crutches/cane when gait is nonantalgic
Brace changed to MD preference (unloader brace, patella sleeve, etc.)
Active-assistive range of motion exercises
SLRs (all planes) with weights
Proximal progressive-resisted exercises
Neuromuscular training (bilateral ! unilateral support)
Balance apparatus, foam surface, perturbations
Short crank ergometry ! standard ergometry (if knee ROM > 115 degrees)
Leg press (bilateral/eccentric/unilateral progression)
Squat program (PRE) 0 ! 60 degrees
OKC quadriceps isotonics (pain-free arc of motion)
Initiate forward step-up and step-down programs
Stairmaster
Retrograde treadmill ambulation
Quadriceps stretching
Elliptical machine
Cryotherapy
Emphasize patient compliance to home therapeutic exercise program
ROM to WNL
Ability to descend 8 stairs with good leg control without pain
Goals
Demonstrate ability to run pain free
Maximize strength and exibility as to meet demands of activities of daily living
Hop test 85% limb symmetry
Isokinetic test > 85% limb symmetry
Lack of apprehension with sport-specic movements
Flexibility to accepted levels of sport performance
Independence with gym program for maintenance and progression of therapeutic exercise program at discharge
Precautions
Avoid sport activity till adequate strength development and MD clearance
Progress squat program < 90-degree exion
Lunges
Retrograde treadmill running
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471
Table 3 (Continued)
Start forward running (treadmill) program at 4 mo post-op if 8 step-down satisfactory
Continue LE strengthening and exibility programs
Agility program/sport specic (sport cord)
Start plyometric program when sufcient strength base demonstrated
Isotonic knee exion/extension (pain and crepitus-free arc)
Functional testing (hop test)
Isokinetic testing
Symptom-free running and sport-specic agility
Hop test 85% limb symmetry
Lack of apprehension with sport-specic movements
Flexibility to accepted levels of sport performance
Independence with gym program for maintenance and progression of therapeutic
exercises are performed with exion restricted to 90 degrees

during the initial (46 weeks) protection phase. Repairs to the
posterior horn are limited to 70 degrees for the rst 4 weeks,
and then progressed as tolerated. Active or resisted knee
exion is avoided during this phase due to the attachment of
the semimembranosus muscle on the medial meniscus and
the popliteus muscle on the lateral meniscus.89
At 4 to 6 weeks postoperatively, the hinged brace is opened
to 60 degrees to allow for ROM during gait. Gait training using
a pool or underwater treadmill is utilized to unload the
involved extremity. Crutches are discharged when a nonantalgic gait is demonstrated. Quadriceps reeducation is
addressed post-op day 1 with the patient instructed to
perform quadriceps setting exercises with a rolled towel
under their surgical knee. Electrical stimulation and/or biofeedback can be used should the patient demonstrate quadriceps inhibition. Straight leg raising in multiple planes is
encouraged for the development of proximal strength.
Weights (progressive resistive exercise) are added to these
exercises when tolerated along with exercise machines to
further advance proximal strengthening. Proprioceptive and
balance training are started as soon as the patient demonstrates the ability to bear 50% of their weight. A rocker board
is utilized starting in a sagittal plane and is then progressed to
a more challenging coronal plane. A computerized balance
platform can be utilized for patient feedback.
As exion ROM improves to greater than 85 degrees, select
OKC and CKC exercises are introduced to the therapeutic
exercise program. Bilateral leg press and mini-squats are
performed inside a 60- to 0-degree arc of motion. Quadriceps
isometrics are performed submaximally at 60 degrees of
exion. Stationary bicycling is added to the rehabilitation

program by utilizing a short crank (90 mm) ergometer.
Hamstring and calf stretching exercises are added into both
formal and home therapeutic exercise programs. Cryotherapy
and electrical stimulation (TENS) may be utilized for pain
control. Home therapeutic exercise programs are continually
updated.

Phase 2 (Weeks 614)
The second postoperative phase following meniscal repair is
dedicated to restoring normal ROM to the involved knee and
improving muscle strength to the level needed to perform
activities of daily living. The demonstration of a normal gait
pattern is an early goal of this phase. AAROM exercises are
progressed as tolerated with the goal of attaining full ROM by
the end of this phase. As ROM improves to 110 ! 115 degrees,
cycling is advanced to a standard 170 mm ergometer. Quadriceps stretching is added as ROM increases to greater than
120 degrees. Leg press exercise will progress to eccentric and
eventually to unilateral training utilizing greater ROM (< 90
degrees). A squat program with progressive resistance is
initiated utilizing a physioball for support and comfort inside
a 60 ! 0-degree arc of motion. A forward step-up program is
begun on successive step heights (4, 6, and 8). Stairmaster
and elliptical machine are incorporated as symptoms allow.
Retrograde treadmill ambulation on continual progressive
percentage inclines is utilized to facilitate quadriceps
strengthening. A forward step-down program is initiated
on successive height increments (4, 6, and 8). The
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Isokinetic training (fast ! moderate ! slow velocities)
Cavanaugh
functional strength goal at the end of this phase is for the

patient to demonstrate pain-free descent from an 8 step with
adequate lower extremity control without deviations.90
Neuromuscular training is advanced to include unilateral
balance activities, such as contralateral elastic band exercises
and balance systems training. As these activities are mastered, the rehabilitation specialist can incorporate less stable
surfaces (foam rollers, rocker boards, etc.) as well as perturbation training to these activities to further enhance neuromuscular development. The patients home therapeutic
exercise program is continually updated based on evaluative
ndings and functional level.

Phase 3 (Weeks 1422)
The focus of the nal phase of rehabilitation following
meniscal repair is directed at optimizing functional capabilities and preparing the patient/athlete for a safe return to sport
activities.
At 4 months postoperatively, given symmetrical ROM and
demonstrated quadriceps control, a running program on a
treadmill is initiated. Retrograde running is preceded by
forward running. An initial emphasis on speed over shorter
distances versus slower distance running is recommended.
Lower extremity strengthening and exibility programs are
continued. Advanced strengthening activities including isokinetic and plyometric training are introduced. Plyometric
training should follow a functional sequence with the components of speed, intensity, load, volume, and frequency
being monitored and progressed accordingly. Activities begin
with simple drills and advance to more complex exercises (e.
g., double-leg jumping vs. box drills) (Fig. 6). Agility exercises are introduced with the demands of the individuals
sport taken into consideration, for example, deceleration,
cutting, sprinting. The rehabilitation specialist should be
certain to observe any apprehension during the agility activity progression.
To quantify strength and power, both isokinetic and
functional testing are performed. The goals of isokinetic
testing include a less than 15% decit for quadriceps and
hamstring average peak torque and total work at test velocities of 180 and 300 degrees. Functional testing links specic
components of function and the actual task and provides
direct evidence to prove functional status. Single-leg hop
test59 and crossover hop test60 are performed with the goal
of achieving an 85% limb symmetry score. The results of these
tests along with any other pertinent clinical ndings including the lack of apprehension with sport-specic movements
are presented to the referring orthopedic surgeon for the nal
determination of sports participation.
Rehabilitation Strategies following Meniscal

Transplantation
The meniscal transplantation procedure was rst described by
Milachowski in 1984.91 The procedure has evolved into a
primarily arthroscopic technique in which a cadaveric menisThe Journal of Knee Surgery
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Fig. 6 Plyometric exercise: box jumps. The patient jumps consecutively on both lower extremities inside the pattern, rst clockwise,
then counterclockwise.
cus is inserted into a meniscus-decient knee. Ideal candidates

for this procedure include patients whose knees are normally
aligned, stable, and demonstrate little degenerative changes.
Meniscal transplantation may also be indicated during concomitant ACL reconstruction, as the absence of the meniscus
could preclude satisfactory stabilization.21,92,93 Numerous
studies have demonstrated statistically signicant improvements in pain and function using various clinical outcome
measures following meniscal transplantation.26,9398 Rehabilitation programs following meniscal transplantation are dependent on surgical technique, concomitant procedures, and
pathology, as well as surgeons preference.
The principles used for rehabilitation after meniscal repair
are utilized with some variation. The loads placed on the
healing meniscal allograft during rehabilitation activities are
unknown. The failure strength of meniscal horn xation in a
drill tunnel in the tibia is also unknown. As meniscal transplants are thought to be under higher stresses in a joint with
early degenerative changes, a more conservative guideline
(Table 4) is followed rather than a meniscal repair guideline.
Weight bearing following meniscal transplantation is limited to toe-touch ambulation with the involved knee maintained in full extension for the rst 4 weeks. Gradual
progression to full weight bearing occurs by 6 weeks postoperatively. A double upright hinged brace is used during this
designated protection phase. Meniscal transplantation protection during this phase is supported by a rabbit study where
472
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473
Table 4 Meniscal transplantation guideline

Meniscal transplantation guideline postoperative phase 1 (wk 06)
Goals
Emphasis on full passive extension
Range of motion ! 90-degree exion
Regain quadriceps control
Precautions
Avoid active knee exion
Avoid ambulation without brace locked at 0 degrees before 4 wk
Avoid prolonged standing/walking
Towel extensions, prone hangs, etc.
Quadriceps reeducation (Quad Sets with EMS or EMG)
Toe-touch weight bearing with brace locked at 0 degrees with crutches for 4 wk
Progressive weight bearing PWB ! WBAT, wk 46
Continuous passive motion (CPM) machine
Active-assisted exion/extension 90 ! 0 degrees exercise
SLRs (all planes)
Proprioception board (bilateral weight bearing)
Aquatic therapypool ambulation or underwater treadmill (week 46)
Short crank ergometry (if ROM > 85 degrees)
Leg press (bilateral/60 ! 0 degrees arc) (if ROM > 85 degrees) (wk 46)
OKC quadriceps isometrics (submaximal/bilateral at 60 degrees) (if ROM > 85 degrees)
Hamstring and calf stretching
Cryotherapy
Emphasize patient compliance to home therapeutic exercise program and weight bearing and range of motion precautions/
progression
Ability to SLR without quadriceps lag
ROM 0 ! 90 degrees
Demonstrate ability to unilateral (involved extremity) weight bear without pain
Goals
Restore full ROM
Restore normal gait (nonantalgic)
Demonstrate ability to ascend 8stairs with good leg control without pain
Improve ADL endurance
Precautions
Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment
(Continued)
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Cavanaugh
Table 4 (Continued)
Avoid running and sport activity
Progressive weight bearing/WBAT with crutches/cane (brace opened 0 ! 60 degrees), if good quadriceps control (good quad
set/ability to SLR without lag or pain)
Aquatic therapypool ambulation or underwater treadmill
D/C crutches/cane when gait is nonantalgic
Brace changed to MD preference (OTS brace, patella sleeve, etc.)
Active-assistive range of motion exercises
SLRs (all planes) with weights
Proximal progressive-resisted exercises
Neuromuscular training (bilateral ! unilateral support)
Balance apparatus, foam surface, perturbations
Short crank ergometry

Standard ergometry (if knee ROM > 115 degrees)
Leg press (bilateral/eccentric/unilateral progression)
Squat program (PRE) 0 ! 45 degrees
OKC quadriceps isotonics (pain-free arc of motion) (CKC preferred)
Initiate forward step-up program
Stairmaster
Retrograde treadmill ambulation
Quadriceps stretching
Elliptical machine
Cryotherapy
Emphasize patient compliance to home therapeutic exercise program
ROM to WNL
Ability 8 stairs with good leg control without pain
Goals
Maximize strength and exibility as to meet demands of activities of daily living
Demonstrate ability to descend 8 stairs with good leg control without pain
Precautions
Treatment strategies:
Initiate forward stepdown program
Isotonic knee exion/extension (pain and crepitus-free arc)
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474
Cavanaugh
475
Table 4 (Continued)
Isokinetic testing
Goals
Demonstrate ability to run pain free
Maximize strength and exibility as to meet demands of recreational activity
Lack of apprehension with recreation type sport movements
Precautions
Treatment strategies:
Retrograde treadmill running
Start forward running (treadmill) program at 6 mo post-op if 8 step-down satisfactory
Isotonic knee extension (pain and crepitus-free arc)
Isokinetic testing
Symptom-free running (if appropriate)
Flexibility to accepted levels of recreational activity
alterations in stiffness and viscoelasticity were found in the

early postoperative period, with gradual recovery over
time.99
Immediate ROM is encouraged. Early motion has been
shown to minimize the deleterious effects of immobilization,
such as articular cartilage degeneration, excessive adverse
collagen formation, and pain.100,101 The goal during the rst
phase is to achieve full extension and 90 degrees of knee
exion. Flexion is limited to 90 degrees for the rst 6 weeks,
as progressive knee exion subjects the meniscus to greater
stress.34,78,82 Continuous passive motion (CPM) machine,
AAROM exercises, and towel extensions are used as treatment
interventions in the initial phase to achieve these goals. ROM
is progressed as tolerated at 6 weeks with the goal of
achieving full ROM by 14 weeks postoperatively.
Treatment strategies for strengthening and neuromuscular training, though more conservatively applied, are similar
to those employed following meniscal repair. Squatting is
limited to 45 degrees for the rst 3 months, 60 degrees for
5 months, and 90 degrees for 6 months. Running is not
recommended before 6 months. Return to high-load activities
involving cutting, jumping, and pivoting are not currently
recommended after meniscal transplantation.90
Conclusion
An improved understanding in basic science over the last
three decades has contributed tremendously to our knowledge of the meniscis function and reparability. Advances in
arthroscopic techniques have enhanced the surgeons ability
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Ability 8 stairs with good leg control without pain
Cavanaugh
to salvage what were once considered irreparable lesions and

to successfully transplant menisci. Clinical research has laid a
foundation for which the rehabilitation following meniscal
repair and transplantation is based. Further research in the
form of laboratory science and clinical outcomes are needed
to substantiate treatment strategies employed during the
rehabilitation of these patients. The rehabilitation specialist
should consider each patient as an individual and progress
the patient along a criteria-based progression to achieve a
safe and satisfactory outcome.
19 Faryniarz DA, Wickiewicz TL. The adult knee. In: Callaghan J,
20
21
22
23
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Special Focus Section

Rehabilitation of Meniscal Injury and Surgery

Surgery, New York, New York

Meniscal cartilage plays an essential role in the function and

Address for correspondence John T. Cavanaugh, PT, MEd, ATC, SCS,

discuss these programs and the various treatment strategies

Copyright 2014 by Thieme Medical

1 Sports Rehabilitation and Performance Center, Hospital for Special

Rehabilitation of Meniscal Injury and Surgery

incidence of meniscal pathology can approach 98%.13 The

with diverse physical condition at the time of their initial

Apply a Working Knowledge of the Basic Sciences to

Table 1 Rehabilitation principles for the meniscal patient

knee joint position sense at knee exion angles of 60 and 75

Team Approach to Rehab: Responsibilities and

for certain isotonic or isokinetic knee extension exercises.

Adhere to the Rules of Rehabilitation

Rule No. 1: Create a Safe Environment

Rule No. 2: Do Not Hurt the Patient

Rule No. 3: Be Aggressive without Breaking Rules No. 1

Follow a Functional Progression

Rehabilitation of Meniscal Injury and Surgery

Rehabilitation of Meniscal Injury and Surgery

An early goal in rehabilitation after meniscus injury or

Follow Evaluation-Based Guidelines

aged, medical diagnosis including workup (radiographs, MRI

Fig. 1 Active-assisted range of motion exercise. The patient supports

Fig. 2 Biodex BioSway System (Biodex Medical Systems, Shirley, NY).

The Journal of Knee Surgery

Rehabilitation of Meniscal Injury and Surgery

Rehabilitation of Meniscal Injury and Surgery

Fig. 3 Step-down exercise. The patient descends an 8 step leading

pain and good lower extremity control without deviations), a

demands of that particular sport. These criteria must be met

Fig. 5 Game Ready Cold Therapy Compression System (CoolSystems,

gym therapeutic exercise program to maintain and advance

Rehabilitation Strategies after Arthroscopic

vice, for example, Game Ready Cold Therapy Compression

Rehabilitation Strategies after Arthroscopic

Rehabilitation of Meniscal Injury and Surgery

Rehabilitation of Meniscal Injury and Surgery

Table 2 Partial meniscectomy rehabilitation guidelines

D/C crutches when gait is nonantalgic

Computerized force plate (Biodex) for weight bearing progression/patient education

Proprioception board/Balance systems

Lower extremity exibility exercises

The Journal of Knee Surgery

Rehabilitation of Meniscal Injury and Surgery

Proprioception board/contralateral Theraband exercises/balance systems

Progress forward step-up program

The Journal of Knee Surgery

Rehabilitation of Meniscal Injury and Surgery

The postoperative management of a meniscal repair takes on

may elect to delay weight bearing and/or place these

Meniscal Repair Guidelines Postoperative

Rehabilitation of Meniscal Injury and Surgery

Table 3 Meniscal repair rehabilitation guideline

Toe-touch weight bearing for complex or radial tears

Independence in home therapeutic exercise program

Rehabilitation of Meniscal Injury and Surgery

Balance apparatus, foam surface, perturbations

The Journal of Knee Surgery

Rehabilitation of Meniscal Injury and Surgery

exercises are performed with exion restricted to 90 degrees