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Meniscal tears dnbid lecture 2011


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Meniscal tears dnbid lecture 2011

  1. 1. Meniscal Tears Dr. D. N. Bid
  2. 2. The Knee Joint <ul><li>The knee joint has two menisci, a lateral and medial </li></ul><ul><li>They are fibrous cartilage </li></ul><ul><li>They rest on top of the tibia in shallow indentations </li></ul>
  3. 3. Functions of the menisci <ul><li>Aid in lubrication and nutrition of the joint </li></ul><ul><li>Act as shock absorbers </li></ul><ul><li>Evenly distribute weight throughout the knee </li></ul><ul><li>Allows for smoother motions between the femur and tibia </li></ul>
  4. 4. Clinical Background <ul><li>By increasing the effective contact area between the femur and the tibia, the menisci lower the load-per-unit area borne by the articular surfaces. </li></ul><ul><li>Total meniscectomy results in a 50% reduction in contact area. </li></ul><ul><li>The menisci transmit central compressive loads out toward the periphery, further decreasing the contact pressures on the articular cartilage. </li></ul><ul><li>Half of the compressive load in the knee passes through the menisci with the knee in full extension and 85% of the load passes through the knee with the knee in 90 degrees of flexion. </li></ul><ul><li>Meniscectomy has been shown to reduce the shock absorption capacity of the knee by 20%. </li></ul>
  5. 5. <ul><li>The inner 2/3 of the menisci are avascular (without blood supply) </li></ul><ul><li>The remaining outer 1/3 is vascular (with blood supply) </li></ul>
  6. 6. Mechanisms of injury <ul><li>An acute twisting injury from impact during a sport </li></ul><ul><ul><li>Usually the foot stays fixed on the ground and the rest of body rotates </li></ul></ul><ul><li>Getting up from a squatting or crouching position </li></ul><ul><li>Loading the knee from a fixed position </li></ul>
  7. 7. Injuring the meniscus <ul><li>There are several types of tears </li></ul><ul><ul><li>Vertical </li></ul></ul><ul><ul><li>Radial </li></ul></ul><ul><ul><li>Horizontal </li></ul></ul><ul><ul><li>Degenerate </li></ul></ul><ul><ul><li>Complex </li></ul></ul><ul><ul><li>Horn </li></ul></ul><ul><li>A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of the knee </li></ul><ul><li>The lateral meniscus is not attached as firmly to the tibia as the medial meniscus, making it less likely to become injured </li></ul>
  8. 9. Axial Limb Alignment <ul><li>Varus malalignment tends to overload the medial compartment of the knee, with increased stress placed on the meniscus, and valgus malalignment has the same effect on the lateral compartment and lateral meniscus. </li></ul><ul><li>These increased stresses may interfere or disrupt meniscal healing after repair. Patients with limb malalignment tend to have more degenerative meniscal tears, which have been suggested to have an inherently poorer healing capacity. The use of an &quot;unloader&quot; brace has been recommended to help protect the healing meniscus, although no scientific data exist to support this approach. </li></ul>
  9. 10. Meniscal injury statistics <ul><li>Meniscal injuries occur in 15% of ACL injuries </li></ul><ul><li>80% of patients with a history of ACL tears will likely tear their meniscus with incidences of instability of the knee </li></ul><ul><li>70.7% of meniscal injuries are to the medial meniscus </li></ul><ul><li>Almost all meniscal injuries- ages 20 and under are sports related 11 out of 12 cases </li></ul><ul><li>Ages 20-29, 64.5% were sports related </li></ul><ul><li>Ages 30-39, 30.6% were sports related </li></ul><ul><li>Ages 40-49 and 50-59 only 19.6% and 14.3% were sports related </li></ul>
  10. 11. What to look for? <ul><li>Not all meniscal tears are symptomatic </li></ul><ul><li>If there are symptoms you could look for: </li></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Pain along the joint line (tenderness) </li></ul></ul><ul><ul><li>Pain when squatting, kneeling or pivoting </li></ul></ul><ul><ul><li>Locking of the knee </li></ul></ul><ul><ul><li>Loss of full knee extension </li></ul></ul>
  11. 12. How can the Physiotherapist help? <ul><li>If there is a possible meniscal tear 80-90% of the time an athlete will remember the mechanism of the injury and may report a “pop” or a “snap” </li></ul><ul><li>You could ask the athlete if there is pain when weight bearing, or bending of the knee </li></ul><ul><li>You could also ask the athlete if they are having any locking in their knee or trouble extending the knee all the way </li></ul>
  12. 13. When there is a meniscal injury <ul><li>As a Physio in the event of a meniscal injury you should </li></ul><ul><ul><li>Ice the area in pain </li></ul></ul><ul><ul><li>Limit movement of the knee joint (rest) </li></ul></ul><ul><ul><li>Keep weight bearing limited to a tolerable level of pain for the injured knee </li></ul></ul><ul><ul><li>Sometimes a splint can be applied for comfort </li></ul></ul>
  13. 14. Rehabilitation options <ul><li>There are two common ways that a meniscal tear can be repaired surgically : Open/Arthroscopic </li></ul><ul><li>There is also a non surgical option because the menisci are partially vascular they have the ability to heal themselves </li></ul>
  14. 15. Why choose surgery? <ul><li>Surgery is usually advised for a few different reasons </li></ul><ul><ul><li>The location of the tear, if the tear is in a avascular zone it will most likely not heal itself </li></ul></ul><ul><ul><li>If the tear is longer than 5-8mm </li></ul></ul><ul><ul><li>If the pain limits activities of daily living </li></ul></ul><ul><ul><li>Or if the individual is not happy with their level of function </li></ul></ul>
  15. 16. Rehabilitation after Meniscal Repair <ul><li>Current studies support the use of unmodified accelerated ACL rehabilitation protocols after combined ACL reconstruction and meniscal repair. </li></ul><ul><li>In tears with decreased healing potential (such as white-white tears, radial tears, or complex pattern tears), limiting weightbearing and limiting flexion to 60 degrees for the first 4 weeks have been suggested to better protect the repair and increase the healing potential of these difficult tears. </li></ul><ul><li>Rehabilitation after isolated meniscal repair remains controversial. The healing environment clearly is inferior to that with concomitant ACL reconstruction, but good results have been obtained with accelerated rehabilitation protocols after isolated meniscal repairs. </li></ul>
  16. 17. Surgical techniques <ul><li>The more common technique is arthroscopic partial menisectomy, which consists of removing the torn fragment of the meniscus </li></ul><ul><ul><li>This reduces irritation, but can effect the weight distribution in the knee </li></ul></ul><ul><li>The other option is an arthroscopic repair, which requires suturing the meniscus back together </li></ul><ul><ul><li>This option attempts to conserve the meniscus in hopes of preventing the early onset of arthritis </li></ul></ul>
  17. 18. Rehabilitation after Meniscectomy <ul><li>Because there is no anatomic structure that must be protected during a healing phase, rehabilitation may progress aggressively. </li></ul><ul><li>The goals are early control of pain and swelling, immediate weight-bearing, obtaining and maintaining a full ROM, and regaining quadriceps strength. </li></ul>
  18. 19. Road to recovery <ul><li>Whether you choose the surgical or conservative approach, the rehabilitation is similar </li></ul><ul><li>The rehabilitation time frames can vary depending on the individual and the severity of the tear </li></ul><ul><li>The protocols may vary depending on the surgical approach and physician. A common protocol may include the following </li></ul>
  19. 20. Steps to recovery <ul><li>The patient may be full weight bearing right after the surgery with or without crutches </li></ul><ul><li>Initial symptoms can be reduced using certain modalities and manual techniques </li></ul><ul><li>Stretching/ flexibility exercises focusing on hamstrings, quadriceps, hip flexors, hip adductors and calf muscles </li></ul><ul><li>Strengthening </li></ul><ul><li>Balance training </li></ul><ul><li>Dynamic exercises/plyometrics </li></ul>
  20. 21. Initial physical therapy <ul><li>The first few sessions of physical therapy may consist more of modalities and some manual techniques to address inflammation, pain and ROM such as: </li></ul><ul><ul><li>Heat/ice </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>Electrical stimulation </li></ul></ul><ul><ul><li>Manual stretching </li></ul></ul><ul><ul><li>Scar and patella mobilizations </li></ul></ul><ul><ul><li>Passive range of motion for full knee flexion and extension </li></ul></ul><ul><ul><li>Retrograde massage to decrease swelling </li></ul></ul>
  21. 22. <ul><li>Once pain and swelling are reduced the sessions mainly focus on increasing the strength and flexibility of the lower extremity as tolerated </li></ul><ul><li>The progression will vary depending on the individual </li></ul><ul><li>Some examples of stretching and strengthening exercises are illustrated in the following slides </li></ul>
  22. 23. Stretching <ul><li>Hamstrings </li></ul><ul><li>Quadriceps </li></ul><ul><li>Calf muscles </li></ul>
  23. 24. Stretching continued <ul><li>Hip flexors </li></ul><ul><li>Hip adductors </li></ul>
  24. 25. Strengthening <ul><li>Focusing on strengthening the muscles around the knee is essential in rehabilitation </li></ul><ul><li>Quad sets Straight leg raises (in all planes) </li></ul><ul><li>Heel raises Leg Curl </li></ul><ul><li>Leg extension </li></ul>
  25. 26. Balance <ul><li>Balance can sometimes be compromised after an injury or surgery </li></ul><ul><li>Here are some balance exercises that can help </li></ul>
  26. 27. Dynamic exercises/plyometrics <ul><ul><li>Progression to more dynamic sports specific exercises helps with the transition back into sports </li></ul></ul>
  27. 28. Return to play <ul><li>This can vary widely from athlete to athlete </li></ul><ul><li>When the athlete can participate in sport specific exercises without pain or weakness </li></ul><ul><li>Full ROM is apparent in the injured knee </li></ul><ul><li>Collaborate decision between athlete, physical therapist and physician </li></ul>
  28. 29. Prevention <ul><li>The prevention of meniscal tears is very similar to the rehabilitation </li></ul><ul><li>Research has shown that more flexible and stronger joints are less likely to get injured </li></ul><ul><li>The athlete would continue stretching and strengthening the lower extremities </li></ul>
  29. 30. Bibliography <ul><li>Learmonth, DJA. “Aspects of the knee: meniscal injury and surgery.” Trauma. 2000. Vol. 2 p. 223-230 </li></ul><ul><li>Gilbert, Rob. Ashwood, Neil. “Meniscal repair and replacement: a review of efficacy.” Trauma. 2007. Vol. 9 p. 189-194 </li></ul><ul><li>Lento, Paul. Akuthota, Venu. “Meniscal injuries: A critical review.” Journal of Back and Musculoskeletal Rehabilitation. 2000. Vol. 15 p. 55-62 </li></ul><ul><li>Boyd, Kevin. Myers, Peter. “Meniscus preservation; rationale, repair techniques and results.” The Knee. March 2003. Vol. 10 Iss. 1 p. 1-11 </li></ul><ul><li>Brindle, Timothy. Nyland, John. Johnson, Darren. “The Meniscus: Review of Basic Principles With Application of Surgery and Rehabilitation.” Journal of Athletic Training. Apr-Jun. 2001. Vol. 36 p. 160-169 </li></ul><ul><li>Drosos, G.I. Pozo, J.L. “The causes and mechanisms of meniscal injuries in the sporting and non-sporting environment in an unselected population.” The Knee. April 2004. Vol. 11 Iss. 2 p. 143-149 </li></ul><ul><li>Magee, David. “Orthopedic Physical Assessment 2 nd edition.” Philadelphia: W.B. Saunders Company, 1992 </li></ul>
  30. 31. Meniscus Protocols <ul><li>See pdf. </li></ul><ul><li>1. Meniscus repair Palomar </li></ul><ul><li>2. Meniscus repair protocol </li></ul>