Physiotherapy Exercises for Meniscus Tears: Long-Term Care and Considerations

Knee joint plays a crucial role in static and dynamic stability. The meniscus is a wedge-shaped cartilage in knees that acts as a cushion between tibial plateau and femoral condyles. A meniscus tear occurs when there's a forceful rotation of the knee while it's partially flexed.

Looking at meniscus tears from physiologic aspect as well as biomechanically is important as a physiotherapist. The meniscus is divided into two parts, the inner part having no flood supply i.e. it is vascular. Thus it impacts its healing property.

Biomechanically, the meniscus plays a crucial role in load-bearing and shock absorption during activities like walking, running, and jumping, reducing the impact on the articular cartilage in the knee joint.

This knowledge helps the physiotherapist in selecting the treatment options or referring the patient to other health care providers for surgery like arthroscopic surgery.

 

Types of meniscus tear

Location:

• Medial Meniscus Tear: Involves the medial side of the knee.
• Lateral Meniscus Tear: Affects the outer side of the knee.

 

Appearance:

• Radial Tear: Extends from the inner edge to the outer edge, creating a pattern similar to the spokes of a wheel.
• Bucket-Handle Tear: The meniscus gets torn in a way that a portion of it is displaced into the joint, creating a "bucket-handle" appearance.
• Flap Tear: A partial tear where a flap of the meniscus is separated from the rest of the cartilage.

 

Severity:

• Partial Tear: Only a portion of the meniscus is damaged.
• Complete Tear: The meniscus is torn all the way through, separating it into two pieces.

 

Chronicity:

• Acute Tear: Results from a sudden injury or trauma.
• Degenerative Tear: Related to the natural aging and wear-and-tear of the meniscus over time.

 

Symptoms of Meniscus Tear

 

 

Causes of Meniscus Tear

• trauma or Injury during sports activities like soccer, football, basketball, and tennis
• degenerative changes
• repetitive activates leading to wear and tear like squatting, or lifting heavy weights
• obesity
• poor body mechanics
• previous knee injuries
• osteoarthritis

 

Other Risk Factors Include

• men are generally more prone to meniscus tears than women
• occupation routines that put excessive strain on knee joint
• joint abnormalities
• muscle weakness or imbalances
• rheumatoid arthritis

 

Differential Diagnosis

• Anterior Cruciate Ligament (ACL) Tear
• Medial Collateral Ligament (MCL) Tear
• Patellar Tendonitis
• Quadriceps Tendonitis
• Articular Cartilage Injury
• Pes Anserine Bursitis
• Tibial Plateau Fracture
• Osteoarthritis
• Inflammatory Synovitis
• Referred Pain from hip joint
• Septic Arthritis
• Peripheral Nerve Entrapment
• Iliotibial Band (ITB) Syndrome

 

Examination

1. Subjective Assessment:

History Taking: Obtain a detailed history, including the onset and nature of symptoms, any traumatic incidents, activities that aggravate or alleviate pain, and relevant medical history.

2. Objective Assessment:

1. Observation: Observe the patient's gait and general movement patterns for any signs of limping, favoring one leg, or other abnormalities.
2. Palpation: Palpate around the knee joint to identify areas of tenderness, swelling, or warmth. Specific attention may be given to the joint line where the meniscus is located.
3. Range of Motion (ROM): Assess the patient's ability to move the knee through its full range. Restrictions or pain during specific movements may be indicative of a meniscus tear.
4. Muscle Strength Testing: Evaluate the strength of muscles around the knee, as weakness may be associated with a meniscus tear.

Special Tests:

1. McMurray Test: This involves manipulating the knee joint while palpating the joint line to detect clicks or pops, which may suggest a meniscus tear.
2. Apley's Compression Test: Combines compression and rotation to elicit pain or other symptoms associated with a meniscus tear.
3. Thessaly Test: A weight-bearing test involving rotational movements at the knee joint to assess for joint line discomfort.

3. Diagnostic Imaging:

It includes imaging studies such as an MRI.

4. Referral:

If a meniscus tear is suspected or if the patient's symptoms are not improving with conservative management, the physiotherapist may recommend referral to a medical professional, such as an orthopedic doctor, for further assessment and confirmation of the diagnosis.

5. Treatment and Rehabilitation:

Implement appropriate treatment strategies by the physiotherapist including exercises to improve strength and flexibility, manual therapy, and modalities to manage pain and inflammation.

 

Treatment Options for meniscus Tear

Rehabilitation of meniscus require consideration of certain factors by the physiotherapist like type, size, and location of the lesion and whether or not any surgery was performed (e.g., ligament reconstructions).

1. R.I.C.E Protocol:

Rest, Ice, Compression, Elevation: Initial management may involve rest to allow the knee to heal, ice to reduce inflammation, compression to support the joint, and elevation to minimize swelling.

 

2. Pain Management:

Cryotherapy

Ice packs are used initially to reduce swelling approximately for 10 minutes.

Ultrasound

It is given at a 3MHZ frequency to promote tissue healing for around 10 minutes.

Application of Hydro-collateral pack

It is usually done when swelling to the affected area is reduced and may be contraindicated as early treatment method. It decrease pain and promote relaxation.

Interferential therapy

It increases local blood flow, relief pain.

 

3. Range of Motion (ROM) Exercises:

Active and Passive ROM Exercises: Gentle movements to maintain or gradually restore normal knee joint range of motion. It includes:

• Hip Flexion
• Hip Extension
• Hip Abduction
• Hip Adduction
• External Rotation
• Internal Rotation
• Knee Flexion
• Knee Extension
• Ankle Dorsiflexion
• Ankle Plantarflexion

 

4. Strengthening Exercises:

• quadriceps isometrics
• hamstrings isometrics
• straight leg raise
• dynamic quadriceps
• Toe raises
• mini squats
• hamstrings stretching
• calf stretching
• Close chain exercises like bridging

 

5. Balance and Proprioception Training:

Activities that challenge balance and proprioception to improve joint awareness and stability.

 

6. Functional Training:

Sport-Specific Exercises: Tailoring exercises to mimic specific movements required in the patient's sport or daily activities.

Gait Training: Correcting any alterations in gait patterns caused by the meniscus tear.

 

7. Neuromuscular Control Exercises:

Exercises aimed at improving neuromuscular control and joint stability.

8. Post-Operative Strategies:

• first 6 weeks are crucial and require proper healing time
• patient should be informed about the risk of a repeated meniscus tear due to high impact activity
• patient should be checked for deep vein thrombosis (DVT) risk and an inherited clotting disorder
• The onset of pain or clicking in the tibiofemoral joint line is a sign of unsuccessful transplantation and should be evaluated again

9. Gradual Return to Activity:

Progressive Loading: Gradually reintroducing weight-bearing and strengthening exercises to promote tissue healing without causing further damage.

Cardiovascular Exercise: Low-impact aerobic activities to maintain overall fitness during the recovery period.

10. Assistive Devices:

Bracing or Kinesio Taping: Depending on the severity of the tear, a physiotherapist may recommend the use of a knee brace or taping to provide additional support.

Knee Brace for Meniscus Tear

• Functional Knee Brace - preferred during weight bearing activities to prevent excessive rotation
• Hinged Knee Brace - used when either one or both of them is involved i.e. ligament and meniscus
• Neoprene Sleeve - used for mild degree of injury or to provide compression to reduce swelling
• Patellar Stabilizing Brace - it stabilize the patella reducing stress on the meniscus.
• Unloader Brace - used by individuals having  meniscus tear as well as osteoarthritis, it shifts weight away from weight bearing area.

Complications

• can progress towards chronic pain
• contribute to joint instability
• decreased range of motion
• functional impairment:
• increases the process of joint degeneration
• joint effusion
• muscle weakness and atrophy
• secondary ligament injuries such as an anterior cruciate ligament (ACL) tear
• reduced quality of life

 

Frequently Asked Questions

Can a meniscus tear heal on its own?

The ability of a meniscus tear to heal on its own depends on the location and extent of the tear, blood supply to the injured area, and the individual's age and overall health. The outer portion of the meniscus, known as the "red zone," has a better blood supply and may have a higher chance of healing on its own compared to the inner portion, the "white zone," which has a limited blood supply.

 

How much time a meniscus tear take to recover?

It depends upon following factors:

1. adherence to Rehabilitation
2. gradual progression in exercises helps prevent re-injury and promotes long-term joint health.
3. follow-Up done to monitor progress
4. giving the knee sufficient time to heal before returning to full activities

 

What is radial meniscus tear?

A radial meniscus tear involves a tear extending from the inner edge of the meniscus (near the center of the knee) towards the outer edge. The term "radial" refers to the direction of the tear, which is perpendicular to the usual longitudinal fibers of the meniscus.

It is classified further:

• Peripheral Radial Tear:

This type of tear occurs in the outer, more vascularized portion of the meniscus (red-red zone). Peripheral radial tears in this zone have a better chance of healing because of the improved blood supply.

• Central Radial Tear:

This tear occurs in the inner, less vascularized portion of the meniscus (red-white or white-white zone). Central radial tears in the less vascularized zone are less likely to heal on their own.

The symptoms of a radial meniscus tear can include pain, swelling, stiffness, and a locking or catching sensation in the knee. The severity of symptoms can vary depending on the size and location of the tear.

 

What is bucket handle meniscus tear?

This type of tear typically occurs in the inner, more central portion of the meniscus, and it often extends longitudinally along the length of the meniscus.

Below are some key characteristics of a bucket-handle meniscus tear:

• occur in the inner (medial or lateral) part of the meniscus
• twisting and compression forces on the knee
• the meniscus may get caught between the femur and tibia during a forceful rotation of the knee
• catching or locking sensation in the knee

 

How to treat knee meniscus tear with arthritis?

The specific approach may vary depending on the severity of the tear, the extent of arthritis, and individual factors. Here are some general strategies:

• Physical Therapy
• Pain Medications (such as acetaminophen or nonsteroidal anti-inflammatory drugs - NSAIDs)
• Assistive Devices
• Corticosteroid Injections
• Hyaluronic Acid Injections
• Surgical Options
• Arthroscopic Surgery
• Partial Meniscectomy
• Total Knee Replacement