The meniscus tear rehab: state of the art of rehabilitation protocols related to surgical procedures

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The meniscus tear: state of the art of rehabilitation protocols related to surgical procedures

Meniscal injuries represent one of the most frequent lesions in sport practicing and in particular in soccer players and skiers. Pain, functional limitation and swelling are typical symptoms associated with meniscal tears.

Epidemiological studies showed that all meniscal lesions, in different sports athletes, involves 24% of medial meniscus, while 8% of lateral meniscus and about 20–30% of meniscal lesions are associated with other ligament injuries.

Meniscal tears can be treated conservatively or surgically. Surgery leads in many cases to complete resolution of symptoms and allows the return to sport activity. However many studies show that this treatment can induce more frequently the development of degenerative conditions if not correctly associated to a specific rehabilitation protocol.

The aim of this article is to compare different timing in specific rehabilitation programs related to the most actual surgical options.

Keywords: knee lesions in sportler, meniscal tear, meniscal surgery and rehabilitation

Anatomical background

Knee joint is composed of incongruent articular surfaces, therefore it relies on other structures to provide both static and dynamic stability: anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, the menisci, the capsule and the muscles crossing the joint. The menisci are two wedge shaped (in cross-section), semilunar fibrocartilage structures and are attached to the tibia, to the femur and to the patella. Medial meniscus appears ‘C’ shaped while the lateral meniscus appears more ‘O’ shaped1.

Fibrochondrocytes are situated in menisci’s inner portion and produce extracellular matrix. Fibroblasts are situated in menisci’s outer portion and synthesize collagen and proteoglycans. This microstructure determines the physical-chemical properties of the meniscus: strength and stretch-, compression- and load- resistance2.

The menisci are supplied by popliteal artery: a plexus of capillaries penetrates 10–30% of medial meniscus and 10–25% of the lateral meniscus widths. Meniscus can be divided into 3 zones: the “red zone”, located in the peripheral third of the meniscal body and densely vascularized, the “red-white zone”, located in the central third of the meniscal body, and “white zone”, located in the inner third of the meniscus and with no vascularization

Meniscus improves load distribution on knee joint and prevents the onset of early joint damages4. Medial and lateral menisci transmit respectively 50% and 70% of supporting load2,5. Meniscus transmits between 30 and 70% of the applied load through the knee, 50% of the joint compressive force (axial forces) in full extension and approximately 85% of the weight at 90° of flexion1.

The knee has two degrees of freedom: flexion-extension and rotation. The movement of flexion-extension is allowed by the simultaneous rotation and translation of the tibia on femur, together with the translation of the patella on the femur. Menisci shift forward during the extension movement, while they are moving back during flexion movement. During rotation the menisci move in opposite directions1.

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Epidemiology of knee lesions

As reported by Majewski, injuries to the menisci are the second most common injury to the knee, with an incidence of 12% to 14% and a prevalence of 61 cases per 100,000 persons6. In his epidemiological study conducted on 17,397 patients in Germany and Switzerland, soccer, followed by skiing, are the sport with an increased risk of meniscal injuries. Among the injuries affecting the knee, he shows that most involve anterior cruciate ligament (ACL) (20.34%), medial meniscus (10.76%) and lateral meniscus (3.66%). He also observes that 85% of patients with meniscal and ACL injuries require arthroscopic treatment7.

For Nielsen, the rate of anterior cruciate ligament injuries and meniscus tears was, respectively, 0.3 and 0.7 (injuries per 1,000 inhabitants per year). Only 27% of the injuries were associated with sports activities, but they were found twice as often among athletes than people injured in nonathletic accidents. Ruptures of the collateral ligament and anterior cruciate ligament were four and seven times more common among athletes, respectively, while athletes sustained fewer meniscus tears than people involved in nonathletic activities8.

Lohmander reported that the highest incidence of ACL tears is seen in adolescents playing sports that involve pivoting, such as football, soccer, basketball, and team handball. Based on an in-hospital clinical diagnosis of ACL rupture, the annual incidence was reported to be 30 per 100 000 in Denmark, but the annual incidence was 81 per 100 000 for the ages between 10 and 64 years in the general population in Sweden. For Lohmander the incidence of symptomatic isolated meniscus tears is difficult to ascertain. The previously quoted in-hospital study reported the annual population incidence to be 70 per 100 000 in Denmark. The majority of patients with an acute ACL injury are younger than 30 years, the age distribution of those diagnosed with an isolated symptomatic meniscus lesion is different, being very broad and with a group mean age around 35 years9.

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Types of meniscal tear

Sharp twist performed by unbalanced load (torsional loading) or a high compressive force between femoral and tibial articular heads (axial loading) cause often meniscus damage. The typical movement is a sudden transition from knee’s hyperflexionto full extension, with meniscus stuck between the femur and tibia.

As reported in numerous studies, lateral meniscus has a greater articular surface and is therefore more interested in absorption and load transmission. It is also more mobile and is less susceptible to fracture than medial meniscus10. Jackson and Dandy’s classification is the most commonly used for meniscal lesions11 (Tab. 1). Lesions may be incomplete, usually superficial and asymptomatic, complete, stable or unstable.

Table 1

Type of meniscal tears12.

Meniscal tears are called stable when they involve less than 50% of total thickness. Longitudinal lesions smaller than 1 cm or radial tears localized in 1/3 of the internal meniscus are belonging to this group as well. Usually they do not require specific treatment13.

As described by Arnoczy and Warren, lateral region is well vascularized and therefore heals better after fracture. Longitudinal tears have greater healing potential than radial tears, as well as simple than complex lacerations and traumatic ruptures than degenerative tears14.

Forriol reported in his study as the mechanism of meniscal repair follow two patterns: the extrinsic pathway in the vascular area, where there is a net of capillaries which supplied undifferentiated mesenchymal cells with nutrients to induce healing, and the intrinsic pathway, based on the self-repair capacity of the meniscal fibrocartilage and the synovial fluid. He described each healing’s mechanical factors: immobilization and unloading are not relevant factors for meniscal healing in the vascular area, despite other authors found better results with meniscal immobilization. However a good fixation seems to be more important than joint immobilization3.

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Conservative treatment

Ice, application moist heat, compression, bandages and anti-inflammatory drugs are the conservative treatment, indicated for asymptomatic tears, for stable vertical longitudinal tears and horizontal cleavage (degenerative), while is not indicated for radial lesions. Rehabilitation treatment provides knee mobilization, muscle strengthening and no load restrictions. Resumption of sporting activities should be gradual and guided by symptoms13.

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Surgical treatment

Surgery is usually indicated in <50 years old- or in good health- and physically active-patients4. Knee osteoarthritis (OA) is the most frequent complication after surgery15.

Partial-total meniscectomy

After total meniscectomy the tibiofemoral contact area decreased by approximately 50%, knee stress absorption capacity is reduced by 20% and therefore leading to an overall increase in contact forces by 2 e 3 times. Partial (16–34%) meniscectomy has been shown to lead to a >350% increase in contact forces on the articular cartilage16,17. Partial meniscectomy varies knee biomechanics: the peak local contact pressure is increased by 65%, while after total meniscectomy peak contact pressure is 235% of normal. A medial meniscectomy decreases contact area by 50% to 70% and contact stress increases by 100%, while lateral meniscectomy decreases contact area by 40% to 50% but contact stress increases by 200% to 300% secondary to the convex surface of the related lateral tibial plateau18. As reported by Metcalf, however, this surgery also bears heavily on degenerative joint disorders19. Partial meniscectomy is indicated for flap tears, radial tears in the inner or a vascular area, and horizontal cleavage tears20.

Positive prognostic factors are: age < 40 years, one simple lesion (bucket handle, flap, radial), short time elapsed between trauma and surgery, minimal chondromalacia21. Risk factors for developing knee OA are: patients older than 40 years, abnormal bones alignment and lateral in respect to medial meniscectomy18.

Surgical suture

High risk of OA degeneration after meniscectomy allowed the development of a less “invasive” surgical technique: surgical suture.

Meniscal sutures are indicated in longitudinal lesions, preferably acute, associated with ACL injury, between 5 mm and 3.4 cm length, in the red-red or red-white zone. Suture in white-white zone has little chance of healing22.

Collagen meniscus implantation (CMI)

CMI (ReGen Biologics, Inc., Hackensack, NJ, USA) is made from purified type I collagen isolated from bovine Achilles tendons, which are minced, washed, purified, filtered, freeze-dried, molded, and cross linked by glutaraldehyde, producing a flexible C-shaped disk23. The CMI provides a 3-dimensional scaffold that is suitable for colonization by precursor cells and vessels and leads to the formation of fully functional tissue. Histologic studies showed that the lacunae of the implant are filled with connective tissue that contains newly formed vessels and fibroblast-like cells24,25. Rodkey has recently highlighted that CMI may be used to replace irreparable or lost meniscal tissue in patients with a chronic meniscal injury. The implant was not found to have any benefits for patients with an acute injury26.

Meniscal allograft transplantation

Meniscal transplantation is indicated especially in patients who underwent subtotal or total meniscectomy and with compartmental pain or early OA evolution, while is contraindicated in advanced OA or knee excessive varus-valgus5,27. This treatment carries considerably difficulties: graft processing, donor cells preservation in the transplanted tissue, sterilization, graft’s immunogenicity28,29.

Recent developments

Recently, new strategies have developed to improve meniscal lesions treatment: non-vascularized meniscus lesions can be treated with free synovium or synovial pedicle flap too. It has been experimentally observed that fibrin clot alone16 or together with endothelial cell growth factor or autogenous precultivated stem cells30 and even implantation of porous polymers15 leads to a better healing in the vascular region of meniscus. However, the strength of the generated scar tissue is weak and reaches only 40% of normality 4 months after implantation30.

Synovial cells treated with hyaluronic acid and Hylan® increased the expression of TGF-b1 and VEGF, however the Hylan® decreased the connective tissue growth factor (CTGF) and the VEGF comparated with the hyaluronic acid3.

One animal study showed that is possible to transplant the meniscus, partially or totally, by a porous composite Polycaprolactone and Hyaff® tissue, a class of polymers hyaluronan derivative obtained by a coupling reaction (Fidia Advanced Biopolymers, Abano Terme, Italy, Europe) with a pore size Between 200 and 3003 m31.

Zhang shows that the injection of bone marrow stromal cells goats with the hIGF-1 Gene Transfection of calcium alginate gel mixed with a meniscal lesion in the region localized White-white, facilitates the healing process to 16 weeks apart32.

Rehabilitation protocol

Type of lesion, type of surgery, timing of biological healing and the patient’s symptoms determine the various types of rehabilitation protocol available for a full recovery.

Rehabilitation after partial meniscectomy

After partial meniscectomy rehabilitation protocol can be aggressive, because in the knee joint anatomical structure should not be protected during the healing phase. Early objectives after surgery are: control of pain and swelling, maximum knee range of motion (ROM) and a full load walking. There is no load limitation, compatibly with the tolerance of the patient20.

The rehabilitative treatment consists of ice-ultrasound therapy, friction massage, joint mobilization, calf raises, steps-ups, extensor exercise, bicycle ergometry33. Moffet et al. reported in a study of 31 subjects the importance of extensor muscles knee reinforcement34. Isokinetic testing data have shown significant strength deficits of the knee extensor muscles: Mattheus and St Pierre assessed muscle strength with isokinetic test before and after surgery. They found that muscle strength returns equal to preoperative state only 4–6 weeks after surgery and it is still reduced compared to non-injured limb up to 12 weeks35. Therefore, in a sportsman, rehabilitation plays a key role in restoring as soon as possible quadriceps’ normal strength in both legs before returning to competitions.

Goodwin et al. showed as patients who receive overseen rehabilitation treatment get the same results in terms of quality of life (SF-36) and knee function than those who do not receive this treatment (going up and down stairs, joint ROM) up to 6 weeks after surgery. In contrast, in a randomized, controlled study, Moffet showed that patients who received supervised rehabilitation had more rapid recovery of the quadriceps femoris muscle than patients in an unsupervised control group34.

Prolonged immobilization has lost favor secondary to the well-documented deleterious effects associated with it. If Continuous Passive Motion (CPM) have repeatedly failed to demonstrate favorable outcome measures in evidence-based research studies, treatment under water cannot begin until wounds have properly closed in order to prevent increased risk of infection36. Kelln instead showed haw the bicycle ergometer’s usefulness in the postoperative phase: exercise on a bicycle ergometer equipped with an adjustable pedal arm demonstrated promising results in patients after partial meniscectomy

Intensive muscle strengthening, proprioceptive and balance exercises are carried out by the third week. The resumption of sport training is allowed when quadriceps’ muscle strength is at least 80% in the operated limb compared to the contralateral limb, while the patient may return to competitions when the quadriceps muscle strength in the operated limb is at least 90% than healthy limb. Generally, patients return to work after 1 or 2 weeks, to sporting activities after 3 to 6 weeks and to competitions after 5 or 8 weeks.

Rehabilitation after meniscal repair

After meniscal sutures, there are two different rehabilitation approaches with regard to load granting, ROM recovery and sporting activities resumption timing.

Some authors in their studies allow a partial incremental loading for 4 weeks after surgery. Furthermore, knee joint is immobilizedin flexed position for 6 weeks after surgery and patient return to sports competitions is only after 5 or 6 months.

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