Rehabilitation After Meniscal Allograft Reconstruction

Doctor: Robert F. LaPrade, M.D., Associate Professor Sports Medicine Institute, University of Minnesota

General Guidelines:

The following guidelines serve as a general rule for the rehabilitation program after a meniscal allograft reconstruction procedure of the knee. It is essential that motion be achieved as soon as possible after meniscal allograft reconstruction so that knee stiffness and adhesions do not develop. It is also important to recognize that depending upon other concurrent reconstructions in the knee (such as autogenous cartilage implantation, fresh osteoarticular allograft reconstruction, or ligamentous reconstruction) that there may be individual variations in the rehabilitation process which would be determined by the surgeon at the time of surgery.

Postop Day (POD) 1 - Postop Week 2:

1. Nonweight bearing of the operative extremity is followed with the use of 2 crutches utilized for ambulation.

2. The following exercises are allowed in the immobilizer only: Quadriceps sets (firing the quadriceps muscle hard, as would be done when firing it initially to perform a straight leg raise) are performed for 30 repetitions up to 10 times daily. Straight leg raises should be performed in sets of 10 to 30, depending upon strength, up to 4 times daily.

3. The knee should be taken out of the knee immobilizer 4 times a day to work on gentle range of motion of the knee. Other concurrent procedures may utilize a CPM machine to achieve this purpose.

Postop Week 3 - Week 6:

1. Partial protected weight bearing up to 45 lbs and the use of 2 crutches is initiated.

2. Range of motion of the knee should be at least 90° by week 4 with progression to at least 120° of knee flexion by week 6. If the CPM machine is not used, the knee should be taken out of the immobilizer for 6 to 10 times daily to work on achieving this range of motion. Range of motion should only be performed within the limits of minimal discomfort.

3. Straight leg raises should be performed only in the immobilizer. Three to 5 lbs of ankle weights may be added at this point in time.

Postop Week 7 - Week 12:

1. A gradual increase in weight bearing with the use of 2 crutches is initiated with progress to full body weight allowed if there is no pain or limping. The patient should progress from full weight bearing with the use of 2 crutches to full weight bearing with the use of 1 crutch (under the contralateral arm). The crutches may be discontinued once they can walk without a limp.

2. Immobilizer use: The immobilizer may be discontinued once the patient can perform a straight leg raise without a sag. If there is any loss of extension when performing the straight leg raise, the immobilizer should continue to be used until this extension sag is eliminated.

3. Straight leg raises: Straight leg raises with 3 to 5 lbs of ankle weights should be continued to be performed. A Theraband rubber tubing may also be used for performing standing straight leg resistance in all 4 primary directions.

4. Closed chain kinetic exercises: Closed chain kinetic exercises may be initiated at this time. Gentle leg presses (with maximal knee flexion to 70° of up to 1/4 body weight is allowed. Standing wall slides may also be initiated to work on quadriceps strengthening.

5. Exercise bike: The exercise bike is allowed in this phase if the arc of motion of the knee is 100° or greater. The purpose of the exercise bike at this time is to initially achieve range of motion so no resistance should be performed at this point. Once the patient can tolerate 20 minutes per session without any significant discomfort, progressive resistance of the exercise bike may be performed.

6. Walking program: The goal at this phase is to walk up to 3 miles on uneven ground without a limp. The patient should start out with walking up to ½ mile initially and then progressing 1/4 mile over time based on how their knee feels. It is recommended that during the first week of this walking program that the sessions be performed every other day rather than daily. This will allow a good assessment of whether the knee has any discomfort with this portion of the rehabilitation program. If there is no discomfort, the sessions may be increased to daily.

Postop Week 11 - Week 16:

1. Exercise bike: The exercise bike is a significant portion of the rehabilitation program. At this point in time the patient should be using one for 20 to 30 minutes a day with increasing resistance as tolerated. o Advancement of the closed chain rehabilitation program is pursued at this point in time. Leg presses and squats (with no more than 70° of knee flexion) of up to ½ of body weight is allowed. These can be performed every other day with 10 to 12 repetitions per set.

2. Jogging program: This program needs to be individualized according to the patient and also according to the amount of chondromalacia and other concurrent injuries found at the time of surgery. For isolated meniscal reconstructions, the patient needs to be able to walk fast on uneven ground without pain prior to initiating a jogging program. When the patient can walk 3 miles on uneven ground without problems, a jogging program may be initiated. The patient should start with a 100 yard jog, followed by 500 yards of walking. This should be repeated 5 times and then the knee should be allowed to rest 1 day to assess its symptoms. An increase of 100 to 200 yards per session is gradually allowed over time. If there is no discomfort once ½ mile of jogging is achieved, the patient is allowed to jog on a daily basis. Due to the fact that most knees that need a meniscal allograft have some mild underlying chondromalacia, it is generally recommended that distances greater than 3 miles be avoided as maximal cardiovascular reserve is achieved at 3 miles and there is no significant benefit achieved at up to 10 miles per session.

3. Swimming: The freestyle crawl with use of the straight leg kick is allowed. The breast stroke should be avoided until at least 6 months after surgery and it is important to make sure that the knee is pain free.

Postop Week 17 On:

1. The goal at this point is for a return to sports and activities as tolerated based on other concurrent surgical reconstructions and the findings at the time of surgery.

2. Full range of motion of the knee must be achieved.

3. Proprioceptive function must be near normal. A program of advanced proprioception and balance must be coordinated with the physical therapist to work on lateral and diagonal movement and dynamic balancing.

4. Once full range of motion of the knee has been achieved, there is no associated pain, swelling, or instability, and the athlete is making good progression on the exercise regimen, a functional and eccentric/concentric strength assessment (with the use of Biodex or LIDO machines) should be performed. It is important to have at least 80 to 85% of leg strength compared to the contralateral knee prior to returning back to desired activities.