Meniscus Injuries Part 3 - Manual Therapy & Exercise
Updated: May 5
MANUAL THERAPY AND EXERCISE - NON SURGICAL CONSERVATIVE CARE
Two of the primary goals of nonsurgical, conservative meniscus treatment is to reduce pain, and improve function. If these goals are met effectively, then in many cases, surgery may be avoided.
This does not mean that nonsurgical options can completely heal a meniscus injury.
As we had mentioned menisci have a very poor blood supply and often do not heal.
In my experience, most medical practitioners (including surgeons), FIRST recommend non-operative types of treatment before considering surgery (except in cases of knee locking). These conservative forms of nonoperative treatment would include rest, manual therapy, activity modification, exercise and time. In many cases of meniscus tears, non-operative measures of treatment are more than adequate to reduce pain and increase function.
OBJECTIVES OF MANUAL THERAPY AND EXERCISE
The objectives of manual therapy and exercise are to:
Restore range-of-motion and flexibility.
Decrease pain and inflammation.
Prevent flexion and extension contractures. A flexion contracture is the most common type of contracture seen with a meniscus injury. If an individual is not able to properly straighten their knee, then they will have difficulty in increasing knee strength or developing stability in the knee. (1)
Improve neuromuscular coordination.
Increase weight-bearing capacity in a progressive manner. Progressive weight-bearing with increased joint stress are essential components of effective meniscal repair.
THE MSR APPROACH
Motion Specific Release - MSR is a multidisciplinary, hands-on treatment system developed by Dr. Brian Abelson DC. Dr. Abelson has a developed a treatment protocol, specifically designed to address meniscus. MSR is not technique but a treatment system that draws on multiple forms of manual therapy to achieve the best results for the patient.
Some of the most common forms of the treatments we integrate into our protocols are derived from: Pin and Stretch Modalities, Fascial Research, Joint mobilization, Acupuncture, Thai Massage, and Sports Medicine.
There is good evidence for using a combination of manual therapy and exercise for the treatment of meniscus injuries (1,14).
Releasing the Medial Meniscus - Motion Specific Release™ (MSR): This is just one of ways we release Meniscus Entrapment's (primarily using Pin and Stretch). This procedure must be combined with other manual therapy techniques for best results. (this video is being released for the the general public on December 21/2020).
MSR - 5 Point Knee Joint Mobilization: Improving joint mobility is critical if you are going to effectively address the body's full kinetic chain. In fact, we greatly reduce the effectiveness of any myofascial treatment if we don’t also address restrictions in joint mobility.
Caution: MSR protocols should only be performed by certified MSR practitioners, and are not for practice by the general public. The videos we provide are strictly used for demonstration purposes only!
ADDRESSING LOCAL AND GLOBAL TENSEGRITY
Certain meniscus injuries will only involve local structures while other cases involve a much larger kinetic chain. In MSR (Motion Specific Release) we use the terms Local Tensegrity and Global Tensegrity to denote issues that are limited to a localized area, or issues involving the larger kinetic chain. The concept of tensegrity originates with Buckminster Fuller and has been greatly expanded by Thomas Myers of Anatomy Trains.
The following section provides examples of possible structures that are involved in both Local and Global Tensegrities of the Knee. Exactly which structures are to be addressed, and which protocols are used to treat the problem will vary greatly based on the specific needs of that individual case.
For example, in addition to the critical step of taking pressure directly off of the meniscus, we may also need consider the following structures which are commonly involved in a meniscus injury:
Structure: Semimembranosus muscle
Anatomical Significance: Secondary hip extensor.
Meniscus Relationship: The semimembranosus muscle attaches to the posterior horn of the medial meniscus (through fascial connections). Any tension or alteration in the performance of the semimembranosus could potentially affect the function of the medial meniscus. (12)
Structure: Popliteus Muscle
Anatomical Significance: The popliteus muscle medially rotates the tibia on the femur if the femur is fixed (when you sit down) or laterally rotates femur on the tibia if the tibia is fixed (when you stand up).
Meniscus Relationship: The popliteus muscle attaches directly to the posterior horn of the lateral meniscus (by an aponeurosis). Thus, any tension or restrictions in the popliteus muscle could affect the function of the lateral meniscus. (13)
Structure: Anterior Cruciate Ligament (ACL)
Structure: Medial Collateral Ligament (MCL)
Anatomical Significance: The MCL is a primary static stabilizer of the knee.
Meniscus Relationship: The medial meniscus is more commonly injured because it is firmly attached to the medial collateral ligament and joint capsule.
The Terrible Triad (O’Donoghues Unhappy Triad): Meniscus tears are sometimes accompanied by an ACL (anterior cruciate ligament) and a MCL (medial cruciate ligament) tears. (11). This is referred to as “The Terrible Triad - Unhappy Triad”. Initially researchers thought it was just the medial meniscus that this occurred with. With the advent of arthroscopic findings, we have found that “The Terrible Triad” is even more prevalent with lateral meniscal injuries. This make bio-mechanical sense (especially with lateral trauma) since the lateral tibiofemoral compartment is compressed with a lateral impact injury.
EXERCISE AND MENISCUS INJURIES
There was an interesting study that was done in the British Medical Journal about the effectiveness of rehabilitative exercises and meniscus injuries.
This study showed that exercise therapy is as effective as surgery for middle aged patients suffering from a meniscal tear. (9)
The following exercise recommendations are general in nature for individuals who do NOT need surgery, or individuals that have been cleared by their surgeon to perform these exercises.
Initial Phase of Exercise
The objectives during the Initial Phase are to decrease swelling [RICE], prevent further injury [bracing may be necessary], increase ROM, prevent muscle atrophy and maintain overall strength. During this initial phase (which can last for several weeks depending on the degree of injury, four weeks if post-operative) further injury must be prevented. During this stage appropriate exercises would include:
Isometric exercises for the Quadriceps (especially the VMO). Electrical muscle stimulation can also be used to help increase contraction of the VMO.
Range of motion exercises [passive and active if appropriate]. Start with Wall Slides. After the patient has achieved 110-115 degrees of knee flexion Heel Slides can be used.
Stationary cycling - single leg cycling using only the uninjured leg
Intermediate Phase of Exercise (Patient can now flex and extend knee)
The objective of the Intermediate Phase is to return to full weight-bearing on the injured leg and to increase muscular endurance. It is important to combine soft-tissue mobilization with exercise to avoid scar tissue formation. During this stage appropriate exercises would include open chain kinetic exercises such as:
Limited open chain resisted tubing exercises of the ankles, knee, and hip.
Stationary cycling with no or only minimal tension.
Stationary cycling can begin when when the patient attains 115-120° of knee flexion.
Make sure the patients ROM is sufficient, otherwise cycling may increased pressure, irritating the knee when the motion is forced.
One leg stands where the patient alternates standing on one leg for approximately 20 to 30 seconds, then shifting body weight back and forth. This can only be done if the patient is able to tolerate weight-bearing.
An upper extremity weight-training program.
Deep-water running program.
Strengthening exercises for the hamstring muscles can begin when the patient can flex the injured knee to at least 80-90°.
Stretches should include the quadriceps, hamstrings, hip rotators, iliotibial band, and calf muscles.
Note: with Open Kinetic Chain exercises, the segment furthest away from the body (known as the distal aspect (usually the hand or foot)) is free and not fixed to an object. In a Closed Kinetic Chain exercise, the hand or foot is fixed, or stationary.
Scandinavian Research: In the case of degenerative meniscal injuries, the research coming out of Denmark and Norway recommends:
First try the, non-surgical treatment route.
Patients should attend manual therapy at least once per week and do a series of prescribed exercises for at least two or three months. A very effective program originating in Denmark is GLA:D Knee program.
If, after this period of time, the patient still has pain and dysfunction - then surgery may be the best choice depending on recommendations from the medical community. (14)
Six Great Exercises for Knee Osteoarthritis
This video demonstrates some of the exercises that we prescribe to our patients who suffer from osteoarthritis and knee pain.
These mobility exercises can be performed three or four times per day. Remember, the exact combination of exercises that are prescribes will vary from case to case.
Click here to watch a video of these exercises.
SURGICAL SOLUTIONS FOR MENISCUS INJURIES
Sometimes, after trying conventional care (non-operative care), you may find that meniscus surgery is the required option . When surgery is required, there are usually two options - Debridement and Meniscal Repair.
Debridement Surgery - Option 1
In cases where there is a small meniscus tear, the surgeon can trim out a small section of the torn meniscus (a debridement procedure).
Note: Removing a small already damaged area of meniscus does not negatively affect the shock absorption capacity of the knee since the torn piece of meniscus is already unable to effectively cushion the knee joint.
This surgery is a far cry from the early days of meniscus surgery. Nowadays, when surgery is performed, most surgeons will remove only a small section of the meniscus. Research has show that removal of the entire meniscus will soon result in the development of osteoarthritis (8). In fact, when the entire meniscus is removed there will be 235% increase in the stress at the knee joint (tibiofemoral contact area) (8). I had a classmate in University who had a complete meniscus removal in both knees (many years ago). Just a few years later she was in for a complete knee replacement on both knees.
The debridement surgeries of today are a very different matter. After a short arthroscopic surgery (key hole surgery), most patients are able to walk out of the hospital and only have to use crutches for a few days. After about 4 weeks, 80% of athletes can return to their sports. (8)
This should not be taken as a general guideline since the recovery time can vary greatly between individuals. That being said, most patients are allowed to return to their activities/sport after they have regained full range-of-motion and once the majority of their strength has returned.
Meniscal Repair Surgery - Option 2
In contrast, a case of meniscal repair surgery, is where the damaged area is stitched back together. This type of surgery can have a much longer recovery period as it may take a considerable amount of time to begin weight-bearing.
In many cases the patient will have to wear a brace for four to six weeks to limit motion, especially flexion of the knee. Physical therapy will take an addition six to eight weeks. Often, it will be almost four months before most patients are able to return to their sporting activities.
Clinical Note: In cases where patients have significant osteoarthritis in combination with a meniscus tear, it should be noted that the meniscus tear is a aspect of the osteoarthritic condition. In such cases, arthroscopic surgery of the knee may not eliminate all symptoms. To eliminate all symptoms, a full knee replacement may be the recommended option. This is a discussion to have with your orthopedic surgeon.
In my experience, most medical practitioners, recommend non-operative (conservative) treatment first before considering surgery. These conservative forms of nonoperative treatment must include rest, manual therapy, activity modification, functional exercise programs, and time to heal.
The primary goals of non-surgical meniscus treatment is to reduce pain and improve function. If these goals are met, then surgery is often avoided. This does not mean that nonsurgical options will heal a meniscus injury. Whether or not the meniscus heals will depend on several factors such as, the location of injury, the type of tear, the age of the patient, and other factors.
My recommendation (with the approval of your physician) is to first try conservative non-operative therapy and exercise (unless the injured knee is locking). If non-operative conservative care works, then great! If not, keep your mind open to the option of surgery.
Do whatever it takes to get back to a healthy functional life style, one where you are NOT in constant pain! Take control of your life!
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.
Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!
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