Pt assessment and managemet of meniscal injury
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Pt assessment and managemet of meniscal injury Pt assessment and managemet of meniscal injury Presentation Transcript

  • PT ASSESSMENT AND MANAGEMENT OF MENISCAL INJURY. By: Seema T. Kotwani, MPT ii On: 2nd July, 2013.
  • CONTENTS • Functions of meniscus • Biomechanics of meniscus • Blood supply • Tears • Healing • Assessment • Rehabilitation 6/29/2013 2
  • FUNCTIONS OF MENISCUS • Improves articular congruency • Increases stability of the knee • Distributes load during movement • Reduces friction between femur and tibia • Shock absorption • Nutrition of articular cartilage • Helps in locking mechanism 6/29/2013 3 Levangie P, Cynthia N. Joint Structure and Function : Fourth edi. 2005.
  • 6/29/2013 4 Levangie P, Cynthia N. Joint Structure and Function : Fourth edi. 2005.
  • BIOMECHANICS OF MENISCUS • The contact force of the menisci on the femur helps guide the femur anteriorly during flexion while the reaction force of the femur on the menisci deforms the menisci posteriorly on the tibial plateau. 6/29/2013 Levangie P, Cynthia N. Joint Structure and Function : Fourth edi. 2005. 5
  • • The posterior deformation of the menisci is assisted by muscular mechanisms. 6/29/2013 Levangie P, Cynthia N. Joint Structure and Function : Fourth edi. 2005. 6
  • BLOOD SUPPLY OF MENISCUS • Medial, lateral, and middle geniculate arteries. • Only 10% to 30% of peripheral medial meniscus border and 10% to 25% of lateral meniscus border receive direct blood supply • Remaining portion receives nourishment from synovial fluid via diffusion 6/29/2013 Brindle T, Nyland J, Johnson DL. The Meniscus : Review of Basic Principles With application to Surgery and Rehabilitation. 2001;36(2):160–9. 7
  • TEARS OF MENISCI Smillie’s Classification 1. Horizontal tears 2. Longitudinal tears:  Bucket handle tears  Posterior horn tear  Anterior horn tear 3. Cystic degeneration 4. Congenital abnormalities 5. Degenerative lesions 6/29/2013 8 Ebnezar J. Essentials of Orthopaedics for Physiotherapists. First edi. 2003
  • 6/29/2013 Brotzman S.B, Wilk K.E., Clinical Orthopaedic Rehabilitation. Second edi. 9
  • 6/29/2013 10 Acute Traumatic Twisting on semiflexed knee with foot on ground Longitudinal and Posterior horn tear Degenerative Tear from minor event Complex and Horizontal tear
  • MENISCAL HEALING Depends on: 1. Location of the tear, 2. Pattern of tear, 3. Type of tear. 6/29/2013 Brindle T, Nyland J, Johnson DL. The Meniscus : Review of Basic Principles With application to Surgery and Rehabilitation. 2001;36(2):160–9. 11
  • ASSESSMENT History – • Combination of twisting on a semi-flexed knee with the foot fixed on the ground. • In elderly - tear from minor event • Locking of the knee joint • Episodes of giving away • Onset – insidious 6/29/2013 Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques. 5th Edi. 12
  • Chief complaints • Severe pain, • Swelling, • Locking of the knee in partial flexion, • Catching, • Clicking, • Episodes of giving away, • Inability to weight bear. Inspection • Swelling • Stands with knee semiflexed • Quadriceps atrophy (chronic) PALPATION • Joint line tenderness • Warmth • Effusion – tap test 6/29/2013 13
  • EXAMINATION • Terminal extension of the knee blocked • End feel – springy if knee is locked. • Pain on forced flexion. • Capsular pattern – gross limitation of flexion, slight limitation of extension. • Limb girth measurement – reduced limb girth in thigh. • Balance testing • Proprioception 6/29/2013 14
  • • Special Tests: 1. McMurray’s test 2. Apley’s test 3. Thessaly test 4. Steinmann sign 6/29/2013 Magee D. Orthopaedic Physical Assessment. Fifth Edition. 15
  • MANAGEMENT 1. Non-operative: • Partial thickness longitudinal tears, • Small (<5mm) full thickness peripheral tears, • Minor inner rim or degenerative tears. 2. Operative: Meniscal repair, Meniscectomy and Meniscal Transplantation. 6/29/2013 Frontera W, Silver J, Rizzo T. Essentials of Physical Medicine and Rehabilitation. Musculoskeletal Disorders, Pain, and Rehabilitation. Second Edition. 16
  • Meniscal repair: 1. lesion in vascular outer third 2. tear extending in central, relatively avascular third of meniscus of a young (<40-50 yrs) or physically active older (>50 yrs) individual.  Partial Meniscectomy: 1. Symptomatic displaced tear in older inactive individual. 2. Tear in central avascular third 6/29/2013 Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques. 5th Edi. 17
  • Total Meniscectomy: Extensive damage to major portion of meniscus and it is determined to be unsalvagable. Meniscal Transplant: young/active patient who previously underwent total meniscectomy and now is symptomatic because of early osteoarthritic changes in the tibiofemoral joint. 6/29/2013 Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques. 5th Edi. 18
  • REHABILITATION • Rehabilitation in non-operative and partial meniscectomy cases is the same. PHASE 1: ACUTE PHASE Goals • Diminish inflamation and swelling • Restore range of motion(ROM) • Re-establish quadriceps muscle activity 6/29/2013 Brotzman S.B, Wilk K.E., Clinical Orthopaedic Rehabilitation. Second edi. 19
  • Days 1-3 • Cryotherapy • Quadriceps sets • Straight leg raise • Electrical muscle stimulation to quadriceps • Hip adduction and abduction
  • • Active assisted ROM • Stretching • Weight bearing as tolerated (two crutches) Days 4-7 • Same as previous • Knee extension 90-40 degrees • Balance/proprioceptive drills • Active assisted, passive ROM • Stretching exercises • Continued use of compression wrap or brace • Weight bearing as tolerated (one crutch)
  • Days 7-10 • Continue all exercises • Leg press (light weight) • Toe raises • Hamstring curls • Bicycle (when ROM 0-105˚ with no swelling)
  • Phase 2: Internal Phase Goals • Restore and improve muscular strength and endurance • Reestablish full nonpainful ROM • Gradual return to functional activities Days 10-17 • Bicycle • Lateral lunges • Front lunges
  • • ½ squats • Leg press • Lateral step ups • Knee extension (90-40 degrees) • Hamstring curls • Hip adduction and abduction
  • • Hip flexion and extension • Toe raises • Proprioceptive and balance training • Stretching exercises
  • Day 17-Week 4 • Continue all exercises • Pool program (deep water running and leg exercises) • Compression brace may be used during activities Criteria for progression to Phase 3 • Satisfactory clinical examination (minimal effusion) • Full/nonpainful ROM • No pain or tenderness • Satisfactory isokinetic test
  • Phase 3: Advanced Activity Phase Weeks 4-7 Goals • Enhance muscular strength and endurance • Maintain full ROM • Return to sport/functional activities Intervention • Cycling • Increased resistance on weight training • Full squat • Full leg press(resisted) • Continue to emphasize closed-kinetic chain exercises
  • • May begin plyometrics – jumping, hopping, increasing height, jump and twist • Begin running program – zig-zag, stop/start, figure of eight, uneven surface • Sport specific skills – kicking
  • REHABILITATION FOLLOWING MENISCAL REPAIR • Maximum Protection Phase: day 1 – 4 weeks: Goals: 1. Restore functional ROM 2. Prevent patellar restriction 3. Re-establish control of knee musculature 4. Restore postural stability 5. Improve strength and flexibility of hip & ankle 6/29/2013 Kisner C, Colby L. Therapeutic Exercise. Foundations and techniques. 5th Edi. 29
  • 6. Maintain cardiopulmonary fitness  Intervention: • Cold, compression, elevation. • CPM • A-AROM & AROM • Knee flexion restricted by hinged, controlled motion brace. (first two weeks: 60 to 90 degrees. After 4 weeks, 120 degrees) • Gravity assisted knee bending • Heel slides in supine • Patella mobilisation 6/29/2013 30
  • • Quadriceps setting exercise • SLR • Electrical stimulation of quadriceps • Hamstring setting • Balance activities (brace locked) • When it is permissible to unlock the brace, begin mini squats, wall slides (initially limit flexion to no more than 45 degrees) • Stretching • Upper body ergometer for aerobic conditioning. 6/29/2013 31
  • Moderate protection phase:4-12 weeks.  Goals: 1. Restore full ROM 2. Improve LE strength, flexibility and endurance 3. Improve aerobic fitness  Intervention: • Stretching • Stationary cycling • Pool walking program • Hip and ankle strengthening exercises 6/29/2013 32
  • • Elastic resistance for open and closed chain knee exercises • Balance training • When bilateral WB is permissible, begin partial lunges, step ups and step downs • Walking on unstable surface (9-12 weeks) • Resume light functional activities. 6/29/2013 33
  • Minimum protection phase ( 12-16 weeeks):  Goals: 1. Resume full level of functional activities  Intervention: • Incorporate functional movement patterns during resistance training • Plyometric training • Increase duration and intensity of aerobic conditioning program • Transition from walking to jogging/running. 6/29/2013 34
  • 6/29/2013 35