Meniscus Injuries

A Review of Rehabilitation and Return to Play

Seth L. Sherman, MDa,*, Zachary J. DiPaolo, MDb,

Taylor E. Ray, BSb, Barbie M. Sachs, PT, DPT, OCSc,
Lasun O. Oladeji, MD, MSb

KEYWORDS
 Meniscus repair  Rehabilitation  Return to play  Blood flow restriction

KEY POINTS
 The menisci play an important role in preserving overall joint health, thus preservation is
paramount.
 Meniscus tear patterns and their associated repair techniques respond differently to phys-
iologic loading, which has a profound influence on rehabilitation strategy.
 An ideal meniscal rehabilitation protocol should consider the tear pattern, location, size,
quality of the repaired tissue, the type and strength of repair construct, and any concom-
itant procedures.

INTRODUCTION

There has been increased awareness of the essential role of the knee menisci in pro-
tecting the articular cartilage by assisting with shock absorption, load transmission,
lubrication, and stability.1–3 Injury to the menisci results in altered knee kinematics
and increased peak contact stresses, which ultimately accelerates the risk of degen-
erative changes and early osteoarthritis.4–6 Similarly, even partial meniscectomy
significantly alters knee stability and joint loading, also leading to increased risk of

Conflicts of interest: The authors have no conflicts of interest.

Disclosures: S.L. Sherman is a board or committee member of ACL Study Group, American Or-
thopedic Society for Sports Medicine, Arthroscopy Association of North America, International
Cartilage Regeneration & Joint Preservation Society, International Society of Arthroscopy, Knee
Surgery, and Orthopedic Sports Medicine; is a paid consultant for and has received research
support from Arthrex, Inc.; is on the editorial board of Arthroscopy; is a paid consultant for
Ceterix Orthopedics and GLG Consulting; an unpaid consultant for Flexion Therapeutics; and
is a paid consultant for JRF Ortho, Moximed, and Vericel.
a
Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA; b Department of
Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, Columbia, MO 65212, USA;
c
Mizzou Therapy Services, University of Missouri, Columbia, MO, USA
* Corresponding author. Stanford Medicine Outpatient Center, 450 Broadway, Pavillion A, Red-
wood City, CA 94063.
E-mail address: [Link]@[Link]

Clin Sports Med 39 (2020) 165–183

[Link] [Link]
0278-5919/20/ª 2019 Elsevier Inc. All rights reserved.
166 Sherman et al

early articular cartilage degeneration.7,8 This information has led surgeons to a recent
paradigm shift toward meniscus preservation. Between 2005 and 2011, the number of
arthroscopic meniscal repairs in the United States doubled.9 This trend is multifacto-
rial and likely related to the improved understanding of the importance of the meniscus
for overall joint health coupled with major advances in surgical technique and biologic
augmentation of meniscal healing.10–14
As surgeons expand their indications for meniscal repair, it is critically important that
they continue to analyze and advance their understanding of rehabilitation and return
to play following meniscal surgery. There are numerous studies on meniscal repair
techniques and their associated outcomes in the literature.15–21 However, there is a
paucity of high-quality studies evaluating rehabilitation protocols following meniscus
repair. Furthermore, there is significant variation between existing postoperative reha-
bilitation protocols.22–25 Despite these limitations, this article summarizes the best
available evidence guiding meniscal rehabilitation progression and return-to-play de-
cision making. In addition, it uses the current rehabilitation protocol to help highlight
the scientific rationale behind rehabilitation progression and to provide a framework
for safe return to activity and sport. This work recognizes inherent limitations in the
existing data and discusses areas that are ripe for future collaborative investigation.

Evidence-based Considerations for Meniscus Repair Rehabilitation

Biomechanical studies have shown that the various meniscus tear patterns and their
associated repair techniques respond differently when subjected to physiologic
loading. For example, weight bearing across the knee helps reduce and compress
vertical longitudinal and bucket-handle tears, which may improve healing rates
following repair.2 In contrast, weight bearing causes displacement and distraction of
radial, root, and complex tears, which likely decreases the chances of successful heal-
ing.26,27 As a result, accelerated rehabilitation protocols with early weight bearing and
range of motion (ROM) have shown positive results in patients with vertical and more
stable tear patterns.23,28 Lind and colleagues23 randomized 60 patients undergoing
repair of unstable peripheral vertical meniscus lesions to either an accelerated or con-
servative postoperative rehabilitation plan. The accelerated plan consisted of 2 weeks
of 0 to 90 ROM without a brace and touch-down weight bearing followed by unre-
stricted weight bearing and ROM. This group returned to running at 8 weeks and con-
tact sports at 4 months. Compared with the restricted group, there were no
differences in functional or subjective outcomes at 1 or 2 years. However, there is
limited evidence to support these advanced protocols for more complex and unstable
tear patterns.22 Kocabey and colleagues29 achieved positive results using a tear-
specific rehabilitation protocol. Fifty-five patients undergoing a T-fix meniscal repair
were stratified according to tear size. Patients with anteroposterior longitudinal menis-
cal tears less than 3 cm in length were full weight bearing following surgery but ROM
was restricted to 0 to 90 for 3 weeks and 0 to 125 from 3 to 6 weeks. Patients with
tears greater than 3 cm were immobilized in a knee brace for 3 weeks but allowed
weight bearing. Patients were restricted to passive motion from 0 to 90 with a contin-
uous passive motion (CPM) device. Between weeks 3 and 6, patients were allowed to
progress to active knee flexion between 0 and 90 . In addition, patients progressed to
0 to 125 for weeks 6 to 8, after which all restrictions were terminated. Patients with
complex and radial tears were further limited with respect to initial postoperative
weight bearing and ROM (ie, non–weight bearing and no flexion >90 for 6 weeks). Ul-
timately, patients with longitudinal tears were allowed to return to sport at 3 months,
whereas patients with complex and radial tears were allowed to return to sport be-
tween 4 and 5 months. The investigators reported that 96% of patients with isolated
 Meniscus Injuries 167

meniscus repair and 100% with combined anterior cruciate ligament (ACL) recon-
struction and meniscus repair showed excellent outcomes. Given these findings, it fol-
lows that an ideal protocol must consider the tear pattern, location, and size; quality of
the repaired tissue; the type and strength of repair construct; and any concomitant
procedures (eg, ligament repair/construction, realignment osteotomy, cartilage resto-
ration) that may have been performed.
The early postoperative period is crucial to protect the meniscal repair such that
compression is maintained across the repair site. If the compressive forces across
the repair site are lost, the odds of successful meniscal healing decrease signifi-
cantly.2,30 Two main factors are at play with regard to compression at the repair
site: (1) the strength and security of the fixation at the time of surgery, and (2) the
weight bearing status postoperatively. The quality of the repair construct is under
the control of the surgeon and every attempt should be made at anatomic reduction
and fixation of the torn meniscus in order to optimize its healing potential and to
restore normal knee biomechanics.31 There has been an evolution of fixation strate-
gies to assist surgeons in achieving this goal. A myriad of all-inside, inside-out,
outside-in, and novel suture passers and fixation devices are available for most tear
patterns, including meniscal root and ramp lesions. Having a broad arsenal for menis-
cal repair can assist surgeons in achieving the goal of anatomic reduction and strong
time-zero meniscus fixation. In addition, the weight-bearing status is determined both
by surgeon preference and patient compliance. Early weight bearing can be helpful to
provide compression and reduction in more stable tear patterns, and these patients
should be allowed to weight bear as tolerated (WBAT) immediately following sur-
gery.32 In contrast, weight bearing can create distractive forces for unstable tear pat-
terns, specifically radial, complex, and posterior root tears, and thus these patients
should be made non–weight bearing for a period of several weeks (Fig. 1).2,33,34
It is also important to consider the axial alignment of the patient before advancing
weight-bearing status. Previous work has shown that patients with varus deformity
are at higher risk of developing atraumatic medial meniscus tears.35 Therefore,

Fig. 1. (A) A 17-year-old boy with a complex lateral meniscus flap tear treated with an
all-inside repair. This patient was limited to foot-flat 0% weight bearing for 6 weeks. (B)
A 14-year-old female dancer who sustained a noncontact injury and presented with a
bucket-handle medial meniscus tear that was treated with a hybrid all-inside and inside-
out repair. This patient was allowed to WBAT immediately after surgery. (C) A lateral
meniscus transosseous posterior root repair in a patient who was limited to foot-flat 0%
weight bearing for 6 weeks. (D) A horizontal cleavage tear treated with all-inside circumfer-
ential stitch. This patient was allowed to WBAT immediately after surgery.
168 Sherman et al

patients with varus malalignment undergoing rehabilitation following a medial

meniscus repair may benefit from a more conservation approach to progressive
weight bearing. The same principles should be applied to those with valgus alignment
undergoing a lateral meniscus repair because of the increased compressive loads in
the lateral compartment.2 These select patients may also benefit from a medial or
lateral unloader brace when initiating weight bearing postoperatively to reduce loads
across the meniscus repair within the compartment at risk.36,37
In addition to the postoperative weight-bearing status, knee ROM also needs to be
carefully considered. It has been shown that immobilization following meniscal repair
is detrimental to meniscal healing.38–41 Protected early ROM is important for healing
and to reduce the risk of postsurgical arthrofibrosis. However, it is imperative to avoid
deep flexion given that cadaveric studies have shown greater femorotibial contact
pressures in higher degrees of knee flexion as opposed to full extension or low de-
grees of knee flexion.42–44 The progression toward high knee flexion angles during
weight bearing leads to higher peak contact pressures, which may be detrimental to
meniscal healing, particularly following radial and root repairs.27 However, these re-
strictions may not be required following fixation of more stable tear patterns (ie, verti-
cal longitudinal tears).44–46 Extrapolating data from the knee cartilage restoration and
repair literature, it seems that early gravity-assisted ROM (even past 90 ) and/or use of
CPM are likely safe and beneficial in the early postsurgical period.47,48 Progression to
loaded deep-flexion activities should be avoided until meniscus healing is well under-
way (ie, 3 months) because of the increased loads and translation experienced by the
menisci in higher degrees of knee flexion.49–51

Blood Flow Restriction Therapy: A Novel Approach to Quadriceps Atrophy

It is well known that knee pain and effusion can lead to quadriceps dysfunction and
atrophy; this is particularly true in the setting of a meniscal tear, both preoperatively
and postoperatively.52–55 Furthermore, there is likely a correlation between the length
of time a patient has a meniscal tear (ie, longer time with painful effusion) and the
amount of quadriceps dysfunction and/or atrophy (ie, longer duration of quadriceps
avoidance). It has been shown that the return of quadriceps function and strength in
the setting of ACL injury and reconstruction is related to improved patient out-
comes.56,57 However, it can be difficult to restore quadriceps muscle strength and
size while protecting a meniscal repair. The American College of Sports Medicine rec-
ommends a resistance training load of 70% to 85% of the 1-repetition maximum
(1RM) to promote muscle hypertrophy.58 It is often challenging or impossible for post-
operative patients to achieve these loads early in the recovery process while protect-
ing the meniscus, particularly in the setting of complex tear patterns and repairs that
require early limitations in weight bearing and ROM. Blood flow restriction therapy
(BFRT) has become a growing part of the preoperative and postoperative rehabilita-
tion regimen to combat this difficult problem.
During a blood flow restriction session, a specialized blood pressure cuff is placed
on the patient’s extremity (Fig. 2). Most commonly, this is the operative extremity, but
it may be used on other extremities as well. The specialized cuff measures the pa-
tient’s blood pressure and sets the cuff pressure at a specific level to prevent venous
outflow from the patient’s limb, which ultimately results in the development of an
anaerobic environment with subsequent release of growth factors. It is the release
of these growth factors that promotes muscle hypertrophy.59–61 The beauty of
BFRT is that it can stimulate an anaerobic environment using loads much less than
the traditional 70% to 85% of 1RM, thus minimizing stresses to the meniscal repair.
Most studies on BFR use loads near 30% of 1RM, with results showing significant
 Meniscus Injuries 169

Fig. 2. A patient undergoing a therapy session while wearing the blood flow restriction
tourniquet.

increases in both muscle hypertrophy and strength.62 Although there are scant data on
the use of BFR following meniscal repair, there are encouraging studies in the ACL
reconstruction literature proving the safety and efficacy of BFRT.59,63 According to a
recent meta-analysis, strength and muscle hypertrophy were significantly greater in
the groups performing exercise with BFR 2 to 3 d/wk compared with those exercising
4 to 5 d/wk.64
In our practice, our physical therapists are certified in BFRT and use it in select pa-
tients with complex repairs requiring prolonged weight-bearing limitations. We also
use this in our athletic population following standard or complex repairs to accelerate
the return of quadriceps function and to help facilitate earlier return to sport. We are
actively collecting prospective data on several populations using BFR for rehabilitation
following ACL reconstruction (randomized controlled trial enrolling), meniscus repair,
and cartilage restoration; and should have data on its efficacy for early quadriceps re-
turn and functional outcomes in the near future.

MENISCAL REPAIR REHABILITATION

This article focuses on isolated meniscal repair in patients with otherwise normal
knees. Our guidelines for rehabilitation following meniscal repair are divided into 4
phases. They can be referenced in Tables 1–4.

Phase I, Postinjury Phase, Protected Motion

Following an isolated meniscal repair, the immediate postoperative period should
focus on minimizing effusion, pain control, as well as the return of quadriceps function
(see Table 1). Cryotherapy and compression are used until effusion is controlled. A
transcutaneous electrical nerve stimulation unit may be indicated to reduce narcotic
170 Sherman et al

Table 1
Meniscus rehabilitation protocol, phase I

Phase I: Immediate Postoperative/Postinjury Phase (Protected Motion)

Frequency Rehabilitation appointments begin within 10–14 d of surgery and
continue 2–3 times per week
Rehabilitation  Protect healing of repaired tissues
Goals  Reduce pain and swelling in the knee, foot, and ankle
 Restore full knee extension
 Restore quadriceps and surrounding muscle activation
Precautions  Maximum protection of inflamed joint
 No running, jumping, plyometric activity
 Modified weight bearing with assistive device
Inflammation  TENS
Control  Cryotherapy
 Compression (garment/bandage)
 Elevation with straight knee (extra support under ankle)
ROM Interventions  Patellar mobility (superior/inferior/medial)
 Full passive terminal extension equal to contralateral limb
 Seated or supine low-level long-duration stretch
 Emphasize hamstring/gastrocnemius soft tissue mobility
 Long sitting gastrocnemius stretch
 Flexion progression per guidelines
 Gravity-assisted knee flexion/CPM
 Therapist assisted without overpressure
 Stationary bike (high seat, no or low resistance)
 Assisted heel slides (supine or wall with towel/belt)
Therapeutic  Core stabilization
Exercises  Supine core activation
 Hip strengthening
 Straight leg raises (extension/abduction/adduction)
 Clam shells (within flexion restrictions)
 Quadriceps recruitment progression without patellofemoral pain
 Isometric quadriceps sets
 Prone TKE (only if WBAT)
 Short-arc quadriceps (with physician approval)
 Straight leg raise
 Gait (with weight-bearing approval)
 Weight shifting
 Marching
 Step over/hurdle walking
 Retroversion/side stepping
 Double-limb balance (with weight-bearing approval)
Cardiovascular None at this time
Exercises
Requirements  Full active knee extension (equal to contralateral side)
for Progression  Normal gait without compensation (hip hiking, adequate extension
during midstance)
 No active effusion (negative or trace Brush test)
 Normal patellar mobility (superior, inferior, medial)
 Ability to complete 20 straight leg raises without extensor lag
 Physician clearance to WBAT, brace, and crutches

Abbreviations: TENS, transcutaneous electrical nerve stimulation; TKE, terminal knee extension.
 Meniscus Injuries 171

Table 2
Meniscus rehabilitation protocol, phase II

Phase II: Intermediate Phase (Low Impact)

Frequency Rehabilitation appointments continue 1–3 times per week
Rehabilitation Goals  Restore full knee ROM (within guidelines on face sheet)
 Restore normal weight-bearing kinematics
 Restore normal balance on the operative/injured limb
 Normalize gait pattern without assistive device
 Return to light work/moderately heavy labor (eg, truck
driving)
 Return to recreational sports (swimming, cycling, walking,
linear jogging 2 times per week)
Precautions  Clearance required for running, jumping, plyometric activity
 Full weight bearing (with the exception of weight bearing
past 90 with closed chain exercises)
ROM Interventions  Maintain knee extension
 Progress flexion per restrictions
 Upright/recumbent bike
 Manual interventions
 Aquatic therapy as needed
Therapeutic Exercises  Neutral spine/core stabilization
 Plank progression (side/prone)
 Emphasize posterior kinetic chain (hamstrings, gluteals,
anterior core, gastrocnemius)
 Closed chain exercises
 Double-limb activity (equal weight bearing, knees stay
behind toes, patella in line with second toe, stable trunk,
no pain through motion)
- Leg press
- Squat progression
- RDL/deadlift
- Bridge progression
- Heel raises
- Side stepping (with/without resistance)
- Split squat/lunge
 Single-limb activity (no pelvic drop)
- RDL
- Squat progression
- Bridge progression
- Balance progression
- Heel raises
- Step-ups forward/lateral
- 4-way resisted hip with single-leg stance (flexion/
extension/abduction/adduction)
- Hip hikes
Open Chain Exercises
 Hamstring curls
 Straight leg raises with quadriceps activated
 Short-arc quadriceps (unweighted)
 Long-arc quadriceps (unweighted)
Begin applying dual-task modifiers during exercise (cognitive/
visual/balance)
 Spelling, verbalizing days of the week backward, reciting
alphabet, counting, memory recall, and so forth

(continued on next page)

172 Sherman et al

Table 2
(continued )
Phase II: Intermediate Phase (Low Impact)
Cardiovascular Exercises Swimming (without frog kicking)
Stationary/level-surface biking without resistance
Elliptical without or minimal resistance
Requirements for Progression  Ability to reciprocally ascend/descend 1 flight of stairs
without compensation
 Soreness lasting no longer than 24 h after activity
 Performs squat to 75 without pain and symmetric weight
bearing
 Good understanding and self-correction of exercise
techniques
 Single-leg stance for 30 s without loss of balance
 Return-to-work functional testing (per discretion of
physician)
 Return to linear running testing (per discretion of physician)
 Modified return-to-sport testing at 3 mo
- Isokinetic testing
 70% quadriceps/quadriceps strength
 70% hamstring/hamstring strength
 Lateral step-down: no more than mild dynamic valgus

Abbreviation: RDL, Romanian deadlift.

requirements and for muscle stimulation. Aspiration of postsurgical hemarthrosis is

indicated at the first postoperative visit if there is swelling that is causing increased
pain, difficulty with ROM, or excessive quadriceps atrophy. All meniscal repair patients
begin rehabilitation with a hinged knee brace locked in extension for sleeping and
ambulation. Crutches should be used until the patients is able to WBAT without
pain or antalgic gait. The brace is removed for hygiene and for ROM exercises. The
purpose of the hinged knee brace is 3-fold. First, it provides rotational control of the
patient’s extremity; this is important because most acute meniscal injuries occur as
the result of combined rotational and flexion forces.65 Second, it allows early pro-
tected weight bearing despite relative quadriceps weakness caused by pain, effusion,
and shutdown. Third, as quadriceps activation returns, the brace can be set to only
permit flexion to a specific degree, further protecting the meniscus repair from
deep-flexion weight bearing.
Stable tear patterns (ie, vertical longitudinal, bucket handle, horizontal) are typically
allowed to WBAT in a hinged knee brace locked in extension for the first 4 weeks.23,25
The brace can be unlocked to allow full flexion with adequate quadriceps control after
that time, and discontinued no sooner than 6 weeks postoperatively. Complex
meniscus repairs, including radial, root, and flap tears, with poor tissue quality are pro-
tected with foot-flat 0% weight bearing for 4 weeks in a hinged knee brace locked in
extension. These patients can typically progress to WBAT in the hinged brace after
4 weeks. The brace can be unlocked to 90 with quadriceps control, typically by
6 weeks postoperatively, and discontinued shortly thereafter.
Patients should begin early ROM shortly after surgery. In general, ROM is either
gravity assisted using the nonoperative limb in the seated position or with a CPM ma-
chine. ROM exercises can be performed without the hinged knee brace in a protected
environment. However, the brace should be reapplied for sleeping, ambulation, and
any other transfers until adequate quadriceps control is attained. In general, there
are no restrictions on non–weight-bearing ROM following meniscus repair. The goal
 Meniscus Injuries 173

Table 3
Meniscus rehabilitation protocol, phase III

Phase III: Minimal Protection Phase (Linear)

Frequency Rehabilitation appointments continue 1–3 times per week
Rehabilitation  Maintain full knee ROM
Goals  Restore normal weight-bearing kinematics
 Restore stability during single-limb activities
 Restore proprioception of the lower limb
 Restore normal running gait
 Return to work/heavy labor (eg, construction)
 Return to competitive cycling, recreational sports (tennis, racquetball,
skiing, jogging 5 times per week)
Precautions  No pivoting, cutting activities
 No plyometrics
Therapeutic  Strength/endurance (continue phase II exercises with progressions to the
Exercises following)
 Quadriceps
- Split squat/lunge
- Lateral step-down
- Single-leg squat

- Squat progression (including beyond 75 as indicated)
 Hamstrings/gluteals
- Single-leg RDL
 Integrated
- Lateral/posterior kinetic chain strengthening
 Multiplanar balance/stability training
 Push/pull
 Controlled rotational
 Uneven/unstable surface progression
 Low-velocity, low-amplitude agility drills
 Forward/backward skipping
 Side shuffle
 Skaters/carioca/crossovers
 Forward/backward jog
 Shallow double-limb jump landings
 Integrated dual-task activities
 Cognitive
 Visual
 Balance
Cardiovascular  Swimming (all strokes, pain free)
Exercises  Stationary biking with resistance
 Elliptical trainer with moderate resistance
 Treadmill/walking (incline/decline)
 Jogging/deep water running (linear only, no cutting/pivoting/hopping)
 Stair stepper
Requirements  <2 out of 10 pain with weight-bearing exercise
for  Cleared to hop/run/jog per physician discretion (not before 3 mo for
Progression reconstruction/repair, or 6 wk for arthroscopy or nonoperative knee injury)
 Good single-leg balance without dynamic valgus
 Normal jogging gait pattern
 Modified return-to-sport testing
 Isokinetic testing
- 75% quadriceps/quadriceps strength
- 75% hamstring/hamstring strength
 Lateral step-down: no more than trace dynamic valgus
174
Table 4
Meniscus rehabilitation protocol, phase IV

Phase IV: Return to Activity Phase (High Impact)

Frequency Rehabilitation appointments continue 1–2 times per week
Rehabilitation  Progression through running/agility interval program
Goals  Normal double-leg and single-leg landing control without side-to-side
differences or compensations
 Return to recreational contact sports
 Return to competitive/elite sports (soccer, football, rugby, wrestling,
gymnastics, hockey, basketball, track and field events, running)
Precautions  No pain allowed during any strength or plyometric activity
 Soreness lasting >24 h requires 1 d of rest, repeat last routine at next
training day
Therapeutic  Strength/endurance (continued from phase III with inclusion of the
Exercises following)
 Deadlift
 Squat
 Dynamic posterior kinetic chain progression
 Hip strengthening (prevention of hip adduction at landing and stance)
 Plyometrics/agility/jumping progression
 Double limb to single limb
 Uniplanar to multiplanar
 Hopping to plyometric progression (emphasize appropriate mechanics
with landing)
 Skipping/side shuffle/skaters/carioca/crossovers/agility ladder
 Power
 Higher amplitude double-leg and single-leg landing drills
 Uniplanar to multiplanar
 Neuromuscular Reeducation
 Unanticipated movement control drills, cutting/pivoting
 Balance and proprioceptive drills
 Core strength and stabilization (prevent frontal plane trunk lean during
landing and single-leg stance)
 Sport-specific training
Cardiovascular  Interval running program
Exercises  Swimming
 Biking
 Elliptical/stair climber
 Row machine
Requirements  0 out of 10 pain with all activity
for Return  ACL-RSI Questionnaire 65%
to Sport  No active effusion (negative brush test)
 Quadriceps girth within 1.5 cm bilaterally
 Return-to-sport testing
 ROM equal or within 2 of contralateral limb
 Isokinetic testing
- 90% quadriceps/quadriceps ratio
- 90% hamstring/hamstring ratio
- 66% hamstring/quadriceps ratio
 Y balance testing
- Anterior reach within 4 cm bilaterally
- Composite score 90% bilaterally
 Lateral step-down (no dynamic valgus)
 Hop testing (90% contralateral limb)
- 5-0-5 test
- Single hop
- Triple hop
- Triple crossover hop
- 6 m hop
 Meniscus Injuries 175

is gravity-assisted ROM at or past 90 by 4 weeks and 120 by 6 weeks. In the case of
tenuous repair or poor tissue quality, ROM may be held for 1 to 2 weeks at minimal
increased risk of postsurgical stiffness. Weight-bearing ROM is not initiated until after
4 weeks for stable patterns and after 6 weeks for complex tears. As discussed earlier,
deep squatting past 90 is limited for 3 months following meniscus repair to reduce
risk of undue stress on the repair site in deeper flexion.23,25,66,67
Early focus is on edema control, patella mobilization, regaining full terminal passive
extension or hyperextension (hamstring stretching), foot/ankle pumps, calf stretching,
and quadriceps isometrics. Progression of quadriceps activation from isometrics to
short-arc quadriceps to straight leg raise should be implemented in the immediate
postoperative period without any detrimental effects on meniscal healing. Early quad-
riceps activation can help minimize effusion, allow an earlier return to weight bearing,
and potentially lead to better overall functional outcomes.68,69 As previously stated,
BFR therapy can be used during the period of protection to maximize quadriceps re-
turn without compromising the integrity of the repair construct. Core stabilization and
hip strengthening exercises are also safely implemented in phase I.

Phase II, Low Impact; and Phase III, Linear

Criteria to progress into phase II (see Table 2) include full active knee extension,
normal gait, no effusion, normal patella mobility, and ability to complete 20 straight
leg raises without extensor lag. Patients should be able to WBAT without an assist de-
vice in this phase. A compression sleeve or unloader brace may be used, as indicated.
As discussed earlier, the timing of progression into this phase is variable and depen-
dent on the type of tear, quality of the repair, and functional progression of the individ-
ual patient. For example, patients should not progress past painful effusion or terminal
extension ROM loss just because they have passed time criteria. Advancing weight
bearing under these conditions creates a vicious feedback cycle that increases the
risk of worsening pain and swelling. This cycle exacerbates the lack of quadriceps
control and the inability to achieve full knee extension. Most stable tear patterns enter
phase II by 6 weeks. Unstable patterns may take 6 to 8 weeks or longer to initiate
phase II rehabilitation. Certain patients achieve knee homeostasis (ie, no effusion,
full ROM) sooner than others and thus are able to pass through each phase more
quickly.
The length of phases II to IV is highly variable and not as time dependent as the
phase I period of protection. In the later phases of rehabilitation, patients progress
at their own pace from one phase to the next based on performance measures.
Emphasizing a time-dependent rehabilitation protocol is counterproductive and
potentially harmful to the repaired meniscus because the patient may not have
adequate ROM, strength, or proprioceptive control to progress to the next phase.
Phase II of the rehabilitation process emphasizes neutral spine, core stabilization,
posterior chain strengthening (hamstring, gluteus, gastrocnemius), and double-limb/
single-limb closed chain activities, and progression toward pain-free open chain exer-
cises (ie, hamstring curls, weighted SLR), swimming, stationary bike, and elliptical.
Criteria for progression into phase III (see Table 3) include ability to reciprocally
ascend/descend 1 flight of stairs without compensation, squat to 75 without pain
or asymmetry, and single-leg stance for 30 seconds without balance loss. Phase III
focuses on strength and endurance training; multiplanar balance/stability training;
low-velocity, low-amplitude agility drills; and integrated dual-task activities. Patients
progress on the treadmill toward jogging, deep water running, and/or use of stair step-
per at this time. Consideration for initiation of linear jogging/running include lateral
step-down test with no more than mild dynamic valgus (no pain) and isokinetic testing
176 Sherman et al

showing greater than 70% side-to-side quadriceps/quadriceps and hamstring/

hamstring strength. Low-demand patients with Tegner activity goal levels of 0 to 3
may not choose to progress toward jogging/running and may return to their sedentary
or medium-demand occupations during this phase, likely by 3 to 4 months after sur-
gery. Patients with Tegner activity goals of 4 to 5 (recreational sports, competitive
cycling, jogging) should complete phase III before returning to their normal activities.
Return to this level of activity may take 4 to 6 months or longer. Athletes and heavier
laborers progress into phase III to IV before clearing for higher-level activities and
sport.

Phase IV, Return to Activity (High Impact)

Progression to phase IV (see Table 4) is reserved for those patients with Tegner activ-
ity goal levels of 6 to 10. Criteria for progression into this phase include pain level less
than 2 for all prior activities, good single-leg balance, normal jogging pattern, lateral
step-down with no pain and at most trace valgus, and isokinetic side-to-side testing
greater than 80%. These criteria are important because athletes who return to play
before achieving functional stability and strength are more likely to encounter a
poor outcome.70 The final phase of the rehabilitation process builds on prior phases
and focuses on functional strength/endurance, plyometrics/agility, power, neuromus-
cular reeducation, and sport-specific training.
Patients undergo return-to-play functional evaluation (Box 1) at the completion of
phase IV. This evaluation includes subjective outcome scores and confidence
measures (ie, ACL–Return to Sport after Injury Scale questionnaire) and a battery of
objective functional tests supervised by an independent athletic trainer or physical
therapist objective testing. The athlete should have a visual analog scale of 0 to 2
with all activities without the presence of an effusion. Furthermore, quadriceps girth
of the repaired extremity should be within 1.5 cm of the noninjured extremity. During
the return-to-sport testing, ROM must be within 2 of the contralateral extremity. Iso-
kinetic testing must also reveal a quadriceps/quadriceps and hamstring/hamstring ra-
tio of at least 90%. The hamstring/quadriceps ratio should be at least 66%. Y balance
testing is performed and the athlete must have an anterior reach within 4 cm bilaterally
and a composite score of at least 90% bilaterally. Lateral step-down and automated
drop vertical jump test should show no evidence of dynamic valgus, asymmetry, or
pain. Triple-hop tests should be greater than 90% of the opposite limb. Ultimately,
the benefit of this approach is that it places an objective score on the patient’s perfor-
mance that can be followed over time to evaluate the appropriate timing for clearance
to return to play.

Box 1
Return-to-sport functional evaluation

Subjective assessment
1. SANE score: if 100% is normal, what percentage of normal is your knee?
a. A score less than 90% indicates evaluation failure
2. Baseline visual analog scale (VAS): please rate your baseline pain on a scale from 0 to 10,
with 0 being no pain and 10 being the worst imaginable pain
a. A score of 2 out of 10 or greater on any of the physical assessments below indicates
evaluation failure
3. ACL–Return to Sport after Injury Scale questionnaire: a psychological and functional
readiness test (a score of <65 indicates evaluation failure)
 Meniscus Injuries 177

Physical assessment
1. Full knee motion compared with other side
a. Loss of knee extension by more than 2 indicates evaluation failure
2. No or trace effusion using modified brush test
3. Less than 1 cm difference in quadriceps girth at 15 cm above joint line
4. Biodex strength testing: Biodex testing is performed for 5 repetitions at 90 /s, 10 repetitions
at 180 , and 15 repetitions at 300 /s
a. Less than 90% average of all 3 testing speeds for quadriceps/quadriceps and hamstring/
hamstring ratios or less than 66% average of all 3 testing speeds for hamstring/
quadriceps ratios indicates evaluation failure
5. Assessment of single-leg step-down on 20-cm (8-inch) step for 3 repetitions
a. Pain reported greater than 2 out of 10 and/or balance loss and more than mild dynamic
knee valgus indicates evaluation failure
6. Y balance test
a. Composite reach of at least 90% of leg length
b. Difference of uninvolved to involved anterior reach length of 4 cm or less
7. Kinect-drop jump test (measure knee/ankle separation ratio for 3 trials)
a. An average of less than 0.65 knee ankle separation at initial contact or pain greater than
2 out of 10 indicates evaluation failure
8. Single-leg hop tests (3 trials each test per leg)
a. Single-leg hop for distance
b. Triple hop for distance
c. Crossover triple hop for distance
d. Meter timed hop test
e. Less than 90% average of all 4 hop tests involved to uninvolved or VAS pain greater than
2 out of 10 indicates evaluation failure

However, there are no well-established guidelines in the meniscal repair literature

guiding return to play.71 Most of the recommendations discussed earlier have
evolved from the literature following ACL reconstruction. Following clearance to re-
turn, athletes should progress from individual and noncontact drills to contact drills,
team practice, and eventually full game play. During this progression, the athletes
should be able to perform sport-specific tasks with adequate strength, speed, and
coordination in the noncompetition environment before being fully released to
sport. It is important to counsel the patients on the potential risk of reinjury and
to emphasize the importance of a maintenance advanced functional training pro-
gram to be performed on a regular basis. These programs allow the athletes to
build on the gains they have made since surgery and, it is hoped, to prevent a
recurrent meniscus tear or ligamentous injury to the same or contralateral
extremity.72
Ultimately, time to return to play is highly variable and based on patient-specific and
sport-specific factors in addition to the type of meniscus repair that was performed. In
general, patients with noncomplex meniscus tears and low-risk sports (ie, running,
cycling, swimming) may be able to return to sport as early as 3 to 4 months, provided
they meet the necessary criteria and pass the return-to-play functional evaluation.
Alternatively, patients with complex meniscal tears who play high-risk sports (ie, soc-
cer, basketball, football) may not be able to return to sport until 6 to 8 months. Again,
the emphasis on return to play is not time dependent; it is predicated on the patient’s
ability to perform sport-specific tasks with solid neuromuscular and proprioceptive
control as well as sufficient speed and strength.
178 Sherman et al

Table 5
Outcomes and return to sport following meniscal repair

Time to RTS
Follow- RTS (Isolated
Study N Technique up (%) Meniscus)
Logan et al,74 2009 42 (45 repairs) Inside out 8.5 y 81 5.6 mo (isolated
repairs)
Stein et al,76 2010 26 Inside out 8.8 y 94.4 Not listed
Vanderhave et al,75 2011 45 (49 knees) Inside out 27 mo 88.9 5.56 mo (isolated
repairs)
Hirtler et al,77 2015 37 All inside 24.7 wk 100 27 wk
Tucciarone et al,78 2012 20 All inside 24 mo 90 Not listed
Alvarez-Diaz et al,73 2016 29 All inside 6y 89.6 4.3 mo

Abbreviation: RTS, return to sport.

OUTCOMES FOLLOWING MENISCAL REPAIR AND RETURN TO PLAY

Outcomes of meniscal repair and return-to-sport data are summarized in Table 5.

Overall, patients typically experience high levels of success following meniscal repair.
Most studies report a mean return to play in the range of 4 to 6 months; however, com-
plex tears may require more time for return.73–75 Eberbach and colleagues72 per-
formed a systemic review of 28 studies and found that mixed-level athletes returned
to their preinjury levels of sport in 90% of cases, whereas professional athletes
returned in 86% of cases. Willinger and colleagues71 recently presented the results
of a study that included young athletes with traumatic meniscus tears treated with
arthroscopic repair. The 30 patients included in this study underwent MRI at the
following time points: preoperatively and 6, 12, and 26 weeks after surgery. By the final
study visit at 6 months, 100% of participants had returned to sport but only 44.8% had
returned to their preinjury level of sport. Note that, despite this high level of return to
activity, only 55.9% of those included in the study showed complete healing on
MRI. Although most patients experience good outcomes and return to sport within
6 months, in most cases the meniscus is still healing during this period. These findings
further reinforce the importance of counseling patients on the potential risk of reinjury
and possibility of future surgical intervention.

SUMMARY

Given the critically important role of the knee menisci, there has been a growing trend
toward meniscal preservation. Along with improvements in meniscal repair techniques
and technology, there have been similar advances in concepts surrounding meniscal
repair rehabilitation and return to play. Rehabilitation and return-to-sport consider-
ations following meniscal repair are multifactorial and must be patient specific. Biome-
chanical and clinical data support the use of accelerated rehabilitation protocols for
vertical longitudinal and horizontal cleavage tear patterns treated with stable fixation.
Caution is needed when considering accelerated rehabilitation for radial, root, and
complex meniscal repairs. BFRT is an innovative way to promote muscle hypertrophy
without increased stress at the repair site. However, there remains a paucity of data
specific to meniscus repair. There are few established guidelines or clear criteria to
guide return to play following meniscal repair. Using best-evidence time-based and
criteria-based progression allows safe and successful return to play in most cases.
 Meniscus Injuries 179

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