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Meniscal Injuries
55
Meniscal Injuries Michael D’Amato, MD | S. Brent Brotzman, MD | Theresa M. Kidd, BA
CLINICAL BACKGROUND
Meniscal Healing
The importance of the menisci in preserving the health and function of the knee has been well established. Most of the functions performed by the menisci relate to protecting the underlying articular cartilage (Fig. 55.1, A and B). • 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. Total meniscectomy results in a 50% reduction in contact area. • The menisci transmit central compressive loads out toward the periphery, further decreasing the contact pressures on the articular cartilage. • 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. • Meniscectomy has been shown to reduce the shock absorption capacity of the knee by 20%. • Partial meniscectomy has reduced morbidity compared to total meniscectomy. Shelbourne and Dickens (2007) found 88% of patients who underwent partial medial meniscectomy had joint space narrowing of 2 mm or less at a mean follow-up of 12 years. Of patients, 88% to 95% subjectively reported good to excellent results. • Repeat surgery after partial meniscectomy is uncommon; Chatain et al. (2003) reported only 2.2% of patients required a second surgery in the same compartment as the previous partial medial meniscectomy. • Although degenerative changes are known to follow total medial meniscectomy, degenerative change after partial medial meniscectomy is infrequently reported (Shelbourne and Dickens 2007).
King, in 1936, first noted that communication with the peripheral blood supply was critical for meniscal healing. Arnoczky and Warren, in 1982, described the microvasculature of the menisci. In children, the peripheral blood vessels permeate the full thickness of the meniscus. With age, the penetration of the blood vessels decreases. In adults, the blood supply is limited to only the outer 6 mm or about a third of the width of the meniscus (Fig. 55.2). It is in this vascular region that the healing potential of a meniscal tear is greatest. This potential drops off dramatically as the tear progresses away from the periphery. Meniscal healing is also influenced by the pattern of the tear (Fig. 55.3). Longitudinal tears have a more favorable healing potential compared with radial tears. Simple tear patterns are more likely to heal than complex tears. Traumatic tears have higher healing rates than degenerative tears, and acute tears heal better than chronic tears. Fig. 55.4 demonstrates a bucket handle meniscal tear that often results in locking of the knee (inability to fully straighten) when the bucket handle displaces toward the midline.
MENISCAL MOVEMENT The lateral meniscus has been shown to be more mobile than the medial meniscus. In each meniscus, the anterior horn has greater mobility than the posterior horn. The reduced mobility of the posterior medial meniscus may result in greater stresses in this area, leading to increased vulnerability to injury. This would explain the higher rate of meniscal tears that occur in the posterior medial meniscus. Weight bearing has been shown to effect few changes in the movement of the menisci, although it has been suggested that meniscal loading may lead to distraction of radial tears. ROM of the knee, especially increasing rotation and flexion of the knee past 60 degrees, results in significant changes in the anteroposterior position of the menisci. Clinically, second-look arthroscopy has shown that extension of the knee maintains a posterior horn meniscal tear in a reduced position, and knee flexion results in displacement of the tear. 372
REHABILITATION CONSIDERATIONS Weight Bearing and Motion Although weight bearing has little effect on displacement patterns of the meniscus and may be beneficial in approximating longitudinal tears, it may place a displacing force across radial tears. Several studies have confirmed the benefits of early motion by demonstrating meniscal atrophy and decreased collagen content in menisci after immobilization. ROM of the knee before 60 degrees of flexion has little effect on meniscal displacement, but flexion angles greater than 60 degrees translate the menisci posteriorly. This increased translation may place detrimental stresses across a healing meniscus. As knee flexion increases, compressive loads across the meniscus also increase. The combination of weight bearing and increasing knee flexion must be carefully balanced in the development of a rehabilitation protocol.
Axial Limb Alignment 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. 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 “unloader” brace
55 Meniscal Injuries
373
Transverse intermeniscal ligament
Anterior cruciate ligament
F
Medial collateral ligament Medial meniscus
PCP
Lateral meniscus
Ligament of Wrisberg
T
Posterior cruciate ligament
A
Fig. 55.2 Scan of 5-mm thick frontal section of the medial compartment of the knee (Spalteholz 3×). Branching radial vessels from the peromeniscal capillary plexus (PCP) can be seen penetrating the peripheral border of the medial meniscus in very young patients. The PCP recedes to the very periphery with age. F, femur; T, tibia. (Reprinted with permission from Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med 1982;10(2):90–95.) Arthroscopic meniscal incision lines (
Superficial cells
Deep cells
Superficial zone
Radial tie fibers
Deep zone
Random collagen fibers Circumferential collagen fibers
Vertical tear
Horizontal tear (splits meniscus parallel to tibial plateau)
Oblique tear
)
Radial tear
Complex (degenerative) tear
B Fig. 55.1 A, Anatomy of the menisci viewed from above. Note the differences in position and shape of the medial and lateral menisci. (Adapted with permission from Pagnani MJ, Warren RF, Arnoczky SP, Wickiewics TL. Anatomy of the knee. In Nicholas JA, Hershman EB, eds. The Lower Extremity and Spine in Sports Medicine, ed 2. St. Louis, Mosby, 1995, pp. 581–614.) B, Collagen ultrastructure and cell types in the meniscus. The illustration demonstrates the collagen fiber orientation in the surface and deep zones. The radial tie fibers are also shown. Superficial meniscal cells tend to be fibroblastic, whereas the deep cells have a rounded morphology. (Reprinted with permission from Kawamura S, Lotito K, Rodeo SA. Biomechanics and healing response of the meniscus. In Drez D, DeLee JC, eds. Operative Techniques in Sports Medicine. Philadelphia, WB Saunders, 2003, pp. 68–76.)
has been recommended to help protect the healing meniscus, although no scientific data exist to support this approach.
Rehabilitation After Partial Meniscectomy Because there is no anatomic structure that must be protected during a healing phase, rehabilitation may progress aggressively (Rehabilitation Protocol 55.1). The goals are early control of
Fig. 55.3 Various meniscus tears.
pain and swelling, immediate weight bearing, obtaining and maintaining a full ROM, and regaining quadriceps strength.
Rehabilitation After Meniscal Repair Current studies support the use of unmodified accelerated ACL rehabilitation protocols after combined ACL reconstruction and meniscal repair (Rehabilitation Protocol 55.2). In tears with decreased healing potential (such as white–white tears, radial tears, or complex pattern tears), limiting weight bearing 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. However, we are unaware of any published studies that support these measures. Rehabilitation after isolated meniscal repair remains controversial. The healing environment clearly is inferior to that with concomitant ACL reconstruction, but good results have been
374
SECTION 5 Knee Injuries
A
B
Fig. 55.4 A, Arthroscopic partial meniscectomy of a bucket handle tear of the meniscus. Tear displaced into the notch. This often results in a locked knee, which manifests as the inability to extend (straighten) the knee the last 5 to 15 degrees. B, Arthroscopic partial resection of meniscus torn in the avascular zone with no potential for healing. (Reprinted with permission from Miller M. Surgical Atlas of Sports Medicine. Philadelphia, Saunders, 2003. Fig. 2-8.)
REHABILITATION PROTOCOL 55.1 After Arthroscopic Partial Medial or Lateral Meniscectomy Phase 1: Acute Phase Goals • Diminish inflammation and swelling. • Restore range of motion (ROM). • Re-establish quadriceps muscle activity. Days 1–3 • Cryotherapy • Quadriceps sets • Straight leg raise (SLR) • Electrical muscle stimulation to quadriceps • Hip adduction and abduction • Knee extension • 30-degree mini-squats • Active-assisted ROM stretching, emphasizing full knee extension (flexion to tolerance) • Weight bearing as tolerated (two crutches) • Light compression wrap Days 4–7 • Cryotherapy • Electrical muscle stimulation to quadriceps • Quadriceps sets • Knee extension 90 to 40 degrees • SLR • Hip adduction and abduction • 30-degree mini-squats • Balance/proprioceptive drills • Active-assisted and passive ROM exercises • ROM 0 to 115 degrees (minimal) • Stretching (hamstrings, gastrosoleus, quadriceps) • Weight bearing as tolerated (one crutch) • Continued use of compression wrap or brace • High-voltage galvanic stimulation/cryotherapy
Days 7–10 • Continue all exercises. • Leg press (light weight) • Toe raises • Hamstring curls • Bicycle (when ROM is 0 to 100 degrees with no swelling and able to make a full revolution) Phase 2 Goals • Restore and improve muscular strength and endurance. • Re-establish full nonpainful ROM. • Gradual return to functional activities Days 10–17 • Bicycle for motion and endurance • Lateral lunges • Front lunges • Half squats • Leg press • Lateral step-ups • Knee extension 90 to 40 degrees • Hamstring curls • Hip abduction and adduction • Hip flexion and extension • Toe raises • Proprioceptive and balance training • Stretching exercises • Active-assisted and passive ROM knee flexion (if necessary) • Elliptical trainer Day 17–Week 4 • Continue all exercises. • Pool program (deep-water running and leg exercises) • Compression brace may be used during activities.
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REHABILITATION PROTOCOL 55.1 After Arthroscopic Partial Medial or Lateral Meniscectomy—cont’d Phase 3: Advanced Activity Phase: Weeks 4–7* Criteria for Progression to Phase 3 • Full, nonpainful ROM • No pain or tenderness • Satisfactory isokinetic test • Satisfactory clinical examination (minimal effusion)
Goals • Enhance muscular strength and endurance. • Maintain full ROM. • Return to sport/functional activities. Exercises • Continue to emphasize closed kinetic chain exercises. • May begin plyometrics • Begin running program and agility drills.
*Patients can begin phase 3 when criteria are met, which may be earlier than week 4.
REHABILITATION PROTOCOL 55.2 Accelerated Rehabilitation After Meniscal Repair Bernard R. Bach, MD, Michael D’Amato, MD Phase 1: Weeks 0–2 Goals • Full motion • No effusion • Full weight bearing Weight Bearing • As tolerated Treatment • ROM as tolerated (0–90 degrees) • Cryotherapy • Electrical stimulation as needed • Isometric quadriceps sets • Straight leg raise (SLR) Phase 2: Weeks 2–4 Criteria for Progression to Phase 2 • Full motion • No effusion • Full weight bearing
obtained with accelerated rehabilitation protocols after isolated meniscal repairs. REFERENCES A complete reference list is available at https://expertconsult. inkling.com/. FURTHER READING Anderson AF, Anderson CN. Correlation of Meniscal and Articular Cartilage Injuries in Children and Adolescents With Timing of Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014;43.2:275–281. Web.
Goals • Improved quadriceps strength • Normal gait Therapeutic Exercises • Closed kinetic chain resistance exercises 0 to 90 degrees • Bike and swim as tolerated • Early-phase functional training Phase 3: Weeks 4–8 Criteria for Progression to Phase 3 • Normal gait • Sufficient strength and proprioception for advanced functional training Goals • Strength and functional testing at least 85% of contralateral side • Discharge from physical therapy to full activity Therapeutic Exercises • Strength work as needed • Sport-specific functional progression • Advanced-phase functional training
Bhatia S, Laprade CM, Ellman MB, et al. Meniscal Root Tears: Significance, Diagnosis, and Treatment. Am J Sports Med. 2014;42.12:3016–3030. Web. Herrlin, Sylvia V, Peter O, et al. Is Arthroscopic Surgery Beneficial in Treating Non-traumatic, Degenerative Medial Meniscal Tears? A Five Year Follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;21.2:358–364. Web. Noyes, Frank R, Barber-Westin Sue D. Treatment of Meniscus Tears During Anterior Cruciate Ligament Reconstruction. Arthrosc J Arthroscopic Relat Surg. 2012;28.1:123–130. Web. Katz JN, Brophy RH, Chaisson CE et al. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. N Engl J Med. 2013;369(7):683. Web.
REFERENCES Shelbourne KD, Dickens JF. Joint space narrowing after partial medial meniscectomy in the anterior cruciate ligament-intact knee. J Am Acad Orthop Surg. 2007;15(9):519-24. Chatain F, Adeleine P, Chambat P, et al. A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up. Arthroscopy 2003;19:842–9.
King D. The healing of semilunar cartilages. J Bone Joint Surg. 1936;18:333–342. Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med. 1982;10:90–95. 7081532.
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Meniscal Injuries Michael D’Amato, MD | S. Brent Brotzman, MD | Theresa M. Kidd, BA
CLINICAL BACKGROUND
Meniscal Healing
The importance of the menisci in preserving the health and function of the knee has been well established. Most of the functions performed by the menisci relate to protecting the underlying articular cartilage (Fig. 55.1, A and B). • 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. Total meniscectomy results in a 50% reduction in contact area. • The menisci transmit central compressive loads out toward the periphery, further decreasing the contact pressures on the articular cartilage. • 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. • Meniscectomy has been shown to reduce the shock absorption capacity of the knee by 20%. • Partial meniscectomy has reduced morbidity compared to total meniscectomy. Shelbourne and Dickens (2007) found 88% of patients who underwent partial medial meniscectomy had joint space narrowing of 2 mm or less at a mean follow-up of 12 years. Of patients, 88% to 95% subjectively reported good to excellent results. • Repeat surgery after partial meniscectomy is uncommon; Chatain et al. (2003) reported only 2.2% of patients required a second surgery in the same compartment as the previous partial medial meniscectomy. • Although degenerative changes are known to follow total medial meniscectomy, degenerative change after partial medial meniscectomy is infrequently reported (Shelbourne and Dickens 2007).
King, in 1936, first noted that communication with the peripheral blood supply was critical for meniscal healing. Arnoczky and Warren, in 1982, described the microvasculature of the menisci. In children, the peripheral blood vessels permeate the full thickness of the meniscus. With age, the penetration of the blood vessels decreases. In adults, the blood supply is limited to only the outer 6 mm or about a third of the width of the meniscus (Fig. 55.2). It is in this vascular region that the healing potential of a meniscal tear is greatest. This potential drops off dramatically as the tear progresses away from the periphery. Meniscal healing is also influenced by the pattern of the tear (Fig. 55.3). Longitudinal tears have a more favorable healing potential compared with radial tears. Simple tear patterns are more likely to heal than complex tears. Traumatic tears have higher healing rates than degenerative tears, and acute tears heal better than chronic tears. Fig. 55.4 demonstrates a bucket handle meniscal tear that often results in locking of the knee (inability to fully straighten) when the bucket handle displaces toward the midline.
MENISCAL MOVEMENT The lateral meniscus has been shown to be more mobile than the medial meniscus. In each meniscus, the anterior horn has greater mobility than the posterior horn. The reduced mobility of the posterior medial meniscus may result in greater stresses in this area, leading to increased vulnerability to injury. This would explain the higher rate of meniscal tears that occur in the posterior medial meniscus. Weight bearing has been shown to effect few changes in the movement of the menisci, although it has been suggested that meniscal loading may lead to distraction of radial tears. ROM of the knee, especially increasing rotation and flexion of the knee past 60 degrees, results in significant changes in the anteroposterior position of the menisci. Clinically, second-look arthroscopy has shown that extension of the knee maintains a posterior horn meniscal tear in a reduced position, and knee flexion results in displacement of the tear. 372
REHABILITATION CONSIDERATIONS Weight Bearing and Motion Although weight bearing has little effect on displacement patterns of the meniscus and may be beneficial in approximating longitudinal tears, it may place a displacing force across radial tears. Several studies have confirmed the benefits of early motion by demonstrating meniscal atrophy and decreased collagen content in menisci after immobilization. ROM of the knee before 60 degrees of flexion has little effect on meniscal displacement, but flexion angles greater than 60 degrees translate the menisci posteriorly. This increased translation may place detrimental stresses across a healing meniscus. As knee flexion increases, compressive loads across the meniscus also increase. The combination of weight bearing and increasing knee flexion must be carefully balanced in the development of a rehabilitation protocol.
Axial Limb Alignment 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. 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 “unloader” brace
55 Meniscal Injuries
373
Transverse intermeniscal ligament
Anterior cruciate ligament
F
Medial collateral ligament Medial meniscus
PCP
Lateral meniscus
Ligament of Wrisberg
T
Posterior cruciate ligament
A
Fig. 55.2 Scan of 5-mm thick frontal section of the medial compartment of the knee (Spalteholz 3×). Branching radial vessels from the peromeniscal capillary plexus (PCP) can be seen penetrating the peripheral border of the medial meniscus in very young patients. The PCP recedes to the very periphery with age. F, femur; T, tibia. (Reprinted with permission from Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med 1982;10(2):90–95.) Arthroscopic meniscal incision lines (
Superficial cells
Deep cells
Superficial zone
Radial tie fibers
Deep zone
Random collagen fibers Circumferential collagen fibers
Vertical tear
Horizontal tear (splits meniscus parallel to tibial plateau)
Oblique tear
)
Radial tear
Complex (degenerative) tear
B Fig. 55.1 A, Anatomy of the menisci viewed from above. Note the differences in position and shape of the medial and lateral menisci. (Adapted with permission from Pagnani MJ, Warren RF, Arnoczky SP, Wickiewics TL. Anatomy of the knee. In Nicholas JA, Hershman EB, eds. The Lower Extremity and Spine in Sports Medicine, ed 2. St. Louis, Mosby, 1995, pp. 581–614.) B, Collagen ultrastructure and cell types in the meniscus. The illustration demonstrates the collagen fiber orientation in the surface and deep zones. The radial tie fibers are also shown. Superficial meniscal cells tend to be fibroblastic, whereas the deep cells have a rounded morphology. (Reprinted with permission from Kawamura S, Lotito K, Rodeo SA. Biomechanics and healing response of the meniscus. In Drez D, DeLee JC, eds. Operative Techniques in Sports Medicine. Philadelphia, WB Saunders, 2003, pp. 68–76.)
has been recommended to help protect the healing meniscus, although no scientific data exist to support this approach.
Rehabilitation After Partial Meniscectomy Because there is no anatomic structure that must be protected during a healing phase, rehabilitation may progress aggressively (Rehabilitation Protocol 55.1). The goals are early control of
Fig. 55.3 Various meniscus tears.
pain and swelling, immediate weight bearing, obtaining and maintaining a full ROM, and regaining quadriceps strength.
Rehabilitation After Meniscal Repair Current studies support the use of unmodified accelerated ACL rehabilitation protocols after combined ACL reconstruction and meniscal repair (Rehabilitation Protocol 55.2). In tears with decreased healing potential (such as white–white tears, radial tears, or complex pattern tears), limiting weight bearing 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. However, we are unaware of any published studies that support these measures. Rehabilitation after isolated meniscal repair remains controversial. The healing environment clearly is inferior to that with concomitant ACL reconstruction, but good results have been
374
SECTION 5 Knee Injuries
A
B
Fig. 55.4 A, Arthroscopic partial meniscectomy of a bucket handle tear of the meniscus. Tear displaced into the notch. This often results in a locked knee, which manifests as the inability to extend (straighten) the knee the last 5 to 15 degrees. B, Arthroscopic partial resection of meniscus torn in the avascular zone with no potential for healing. (Reprinted with permission from Miller M. Surgical Atlas of Sports Medicine. Philadelphia, Saunders, 2003. Fig. 2-8.)
REHABILITATION PROTOCOL 55.1 After Arthroscopic Partial Medial or Lateral Meniscectomy Phase 1: Acute Phase Goals • Diminish inflammation and swelling. • Restore range of motion (ROM). • Re-establish quadriceps muscle activity. Days 1–3 • Cryotherapy • Quadriceps sets • Straight leg raise (SLR) • Electrical muscle stimulation to quadriceps • Hip adduction and abduction • Knee extension • 30-degree mini-squats • Active-assisted ROM stretching, emphasizing full knee extension (flexion to tolerance) • Weight bearing as tolerated (two crutches) • Light compression wrap Days 4–7 • Cryotherapy • Electrical muscle stimulation to quadriceps • Quadriceps sets • Knee extension 90 to 40 degrees • SLR • Hip adduction and abduction • 30-degree mini-squats • Balance/proprioceptive drills • Active-assisted and passive ROM exercises • ROM 0 to 115 degrees (minimal) • Stretching (hamstrings, gastrosoleus, quadriceps) • Weight bearing as tolerated (one crutch) • Continued use of compression wrap or brace • High-voltage galvanic stimulation/cryotherapy
Days 7–10 • Continue all exercises. • Leg press (light weight) • Toe raises • Hamstring curls • Bicycle (when ROM is 0 to 100 degrees with no swelling and able to make a full revolution) Phase 2 Goals • Restore and improve muscular strength and endurance. • Re-establish full nonpainful ROM. • Gradual return to functional activities Days 10–17 • Bicycle for motion and endurance • Lateral lunges • Front lunges • Half squats • Leg press • Lateral step-ups • Knee extension 90 to 40 degrees • Hamstring curls • Hip abduction and adduction • Hip flexion and extension • Toe raises • Proprioceptive and balance training • Stretching exercises • Active-assisted and passive ROM knee flexion (if necessary) • Elliptical trainer Day 17–Week 4 • Continue all exercises. • Pool program (deep-water running and leg exercises) • Compression brace may be used during activities.
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REHABILITATION PROTOCOL 55.1 After Arthroscopic Partial Medial or Lateral Meniscectomy—cont’d Phase 3: Advanced Activity Phase: Weeks 4–7* Criteria for Progression to Phase 3 • Full, nonpainful ROM • No pain or tenderness • Satisfactory isokinetic test • Satisfactory clinical examination (minimal effusion)
Goals • Enhance muscular strength and endurance. • Maintain full ROM. • Return to sport/functional activities. Exercises • Continue to emphasize closed kinetic chain exercises. • May begin plyometrics • Begin running program and agility drills.
*Patients can begin phase 3 when criteria are met, which may be earlier than week 4.
REHABILITATION PROTOCOL 55.2 Accelerated Rehabilitation After Meniscal Repair Bernard R. Bach, MD, Michael D’Amato, MD Phase 1: Weeks 0–2 Goals • Full motion • No effusion • Full weight bearing Weight Bearing • As tolerated Treatment • ROM as tolerated (0–90 degrees) • Cryotherapy • Electrical stimulation as needed • Isometric quadriceps sets • Straight leg raise (SLR) Phase 2: Weeks 2–4 Criteria for Progression to Phase 2 • Full motion • No effusion • Full weight bearing
obtained with accelerated rehabilitation protocols after isolated meniscal repairs. REFERENCES A complete reference list is available at https://expertconsult. inkling.com/. FURTHER READING Anderson AF, Anderson CN. Correlation of Meniscal and Articular Cartilage Injuries in Children and Adolescents With Timing of Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014;43.2:275–281. Web.
Goals • Improved quadriceps strength • Normal gait Therapeutic Exercises • Closed kinetic chain resistance exercises 0 to 90 degrees • Bike and swim as tolerated • Early-phase functional training Phase 3: Weeks 4–8 Criteria for Progression to Phase 3 • Normal gait • Sufficient strength and proprioception for advanced functional training Goals • Strength and functional testing at least 85% of contralateral side • Discharge from physical therapy to full activity Therapeutic Exercises • Strength work as needed • Sport-specific functional progression • Advanced-phase functional training
Bhatia S, Laprade CM, Ellman MB, et al. Meniscal Root Tears: Significance, Diagnosis, and Treatment. Am J Sports Med. 2014;42.12:3016–3030. Web. Herrlin, Sylvia V, Peter O, et al. Is Arthroscopic Surgery Beneficial in Treating Non-traumatic, Degenerative Medial Meniscal Tears? A Five Year Follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;21.2:358–364. Web. Noyes, Frank R, Barber-Westin Sue D. Treatment of Meniscus Tears During Anterior Cruciate Ligament Reconstruction. Arthrosc J Arthroscopic Relat Surg. 2012;28.1:123–130. Web. Katz JN, Brophy RH, Chaisson CE et al. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. N Engl J Med. 2013;369(7):683. Web.
REFERENCES Shelbourne KD, Dickens JF. Joint space narrowing after partial medial meniscectomy in the anterior cruciate ligament-intact knee. J Am Acad Orthop Surg. 2007;15(9):519-24. Chatain F, Adeleine P, Chambat P, et al. A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up. Arthroscopy 2003;19:842–9.
King D. The healing of semilunar cartilages. J Bone Joint Surg. 1936;18:333–342. Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med. 1982;10:90–95. 7081532.
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