Sports Medicine Research: In the Lab & In the Field: Less Restrictive Rehabilitation may be Safe after Isolated Meniscus Repairs (Sports Med Res)


Friday, December 20, 2013

Less Restrictive Rehabilitation may be Safe after Isolated Meniscus Repairs

Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens

Lind M, Neilsen T, Fauno P, Lund B, and Christansen SE. Am J Sports Med. 2013; (41) 12, 2753-2758.

Take Home Message: Following an isolated meniscal repair, it may be safe to permit patients to have early weight-bearing and less range of motion restrictions compared with more traditional restricted rehabilitation programs.

The rehabilitation that follows a meniscal repair is important because it can influence the structural integrity of the meniscus, which is particularly relevant because a healthy meniscus is crucial for the long-term health of a knee. Unfortunately, we still need to identify an optimal post-meniscal repair rehabilitation protocol that could expedite return to play while protecting the meniscus and promoting the long-term health of a knee. Therefore, Lind and colleagues completed a randomized controlled trial to investigate the outcome of an isolated meniscal repair followed by either a free or restricted rehabilitation program. The authors recruited a total of 60 young adults (19 female, 41 male, 18 to 50 years old), screened them for inclusion/exclusion criteria, and randomly assigned them to either a free or restricted rehabilitation group (32 free, 28 restricted). All of the participants presented with a repairable meniscal lesion and were excluded if they: (1) had a concomitant injury, (2) had previous meniscal or ligaments repair, or (3) expected an inability to follow the proposed rehabilitation protocol. The free rehabilitation group had limited knee flexion (0-90 degrees), did not wear a brace, and was permitted to be weight-bearing during the first two weeks. After the first two weeks, the free rehabilitation group had no restrictions. Conversely, participants in the restricted group were non-weight-bearing and limited to 30 degree of flexion during the first two weeks. At 3-4 weeks post-surgery the restricted participants were limited to 60 degree flexion and touch weight-bearing. Then during the next two weeks the restricted rehabilitation participants were limited to 60 degree of flexion but had no weight-bearing limitations. Patients in the free and restricted rehabilitation groups could return to running at 8 and 12 weeks; respectively. The participants attended follow-up evaluations at 3 months, 1 year, and 2 years post-surgery. Patient-reported outcomes included Knee Osteoarthritis Outcome Score (KOOS), Tegner function score, and joint line pain. The authors also assessed two objective outcomes: 1) failure of the meniscal repair (evaluated by arthroscopy) and 2) range of motion. Overall, there was no significant difference between the failure rates between the 2 groups at 1 or 2 year post-surgery. Further, there was no difference between the 2 groups at either time point for the KOOS or Tegner activity score.

Overall, this study suggests that less restrictive rehabilitation following an isolated meniscal repair does not have a detrimental effect on tissue healing, and does not impact patient-reported outcomes compared with more restrictive rehabilitation. These results may be of interest to clinicians as expedited weight-bearing, returning to full range of motion, and running may not be detrimental to the repaired meniscus. This in turn may then be beneficial to the patient because it will help him/her maintain muscle strength and endurance. While these results are encouraging they are only a step towards identifying a gold standard rehabilitation program following meniscal repair. The current study did not report the inclusion of any therapeutic exercises which could have an effect on further maintaining muscle tone. Furthermore, to increase applicability to clinicians, future research should look to include patients with concomitant injuries as this is a frequent occurrence. Ultimately, the data presented in the present study indicates that earlier weight-bearing and larger ranges of motion following an isolated meniscal repair may be safe for our patients.

Questions for Discussion: What restrictions do you place on your patients after an isolated meniscal repair? What therapeutic exercises or modalities do you use to treat patients after a meniscal repair?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

Related Posts:
Evaluating Meniscal Lesions: The Accuracy of Clinical Exams & MRI

Lind M, Nielsen T, Faunø P, Lund B, & Christiansen SE (2013). Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens. The American Journal of Sports Medicine, 41 (12), 2753-8 PMID: 24114748


SandraK said...

Rehabilitation for a meniscal repair is usually longer than a menisectomy, due to the tissue healing that takes place during the repair. It has been thought that the meniscus must be well protected, with limited ROM and weight bearing to avoid damaging or re-injuring the healing cartilage; this is also to prevent long term articular damage on the knee.
I think it it patient and sport dependent whether the rehabilitation is aggressive or conservative, since there is not much research on the long term effects. If the patient was not as active, or performed exercises that did not require knee flexion past 90 degrees, it would seem unreasonable to allow them to flex past this so early on in their rehabilitation program. For athletes that would like to return to play soon, a speedy rehabilitation program may be appropriate, however we do not know the long term effects this can have on the meniscus. It would be interesting to continue following the subjects and making it a longer study to begin to determine these outcomes, since there is not much research on it thus far. I would take highly into consideration the type of rehabilitation done by the patient on their activity level and activities of daily living.

Kyle said...

SandraK, excellent thoughts! Thank you for the comment. I agree with a few of your points. Firstly, the type of rehabilitation chosen is very dependent on the patient and their individual needs/RTP desires. What seems to be a common thread in the literature is if the patient is willing to modify their activity level. Patients who can modify their activity are much better candidates for conservative treatment which may take more time. Patients who wish to (or need to) return to preinjury levels of activity are better candidates for aggressive rehab. I would be cautious thought that more aggressive rehab may have more of a detrimental effect on the long-term health of the joint. This brings me to your second point. I agree 100% that we has clinicians need to be asking what happens to many of these patients further into the future. This will undoubtedly give us the insight into how our rehabilitation decision impact our athletes for the rest of their lives. Another point of caution though would be that with surgical and rehabilitative methods changing everyday, we as clinicians need to be careful to balance the 2 as best of possible. This includes detailed reporting of rehabilitation protocols and using the most up-to-date rehabilitation programs available to clinicians. Again, thanks for the excellent comment. I think we all would benefit from these suggestions.

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