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INTRODUCTION
The knee joint has a structure made of cartilage, which is called
the meniscus or meniscal cartilage. The menisci are the shock-absorbers
of the knee - wedged horizontally in between the femur and the tibia.
They fill in the in congruency between the rounded ends of the femur
bone and the flattened ends of the tibia bone upon which the femur sits.
Menisci are squeezed between the rounded ends of the femur (the
femoral condyles or rounded ends of the thigh bone) and the flat upper
surface of the tibia (the tibial plateau or upper surface of the shinbone) so they are difficult to see, and hard to explore.
A torn meniscus is a disruption of the fibrocartilage pads located
between the femoral condyles and the tibial plateaus. The medial and
lateral meniscus provides shock absorption and plays a role in joint
lubrication.
Meniscal injuries are the most common surgically treated knee
injury. Reported rates of meniscal injury are approximately 70 per one
lakh (according to US Statistical Data). Men are affected more than
women. Meniscal injuries can occur in all age groups. In older patients
tears are predominantly degenerated and are commonly caused by
activities of daily living, squatting or activities involving deep flexion. In
younger patients up to 1/3rd of meniscal tears are sports related and are
primarily caused by twisting or cutting movements, hyperflexion or
trauma. In all sports with the exception of wrestling, tears of the medial
meniscus occur more often than tears of the lateral meniscus.
Meniscal injuries often occur in knee pathology, although with
different etiologies. Such injuries may occur (i) as part of a rotational
trauma, (ii) due to bending, as a result of progression of a degenerative
process, or (iii) as a spontaneous injury caused by fatigue.
1
The different etiologies converge into the same symptomatology,
with similar clinical manifestations and treatments, although different
therapeutic results are expected. When associated with the instability of
the knee or with arthrosis at an advanced stage, meniscal injury is
analyzed as a function of the major pathology.
The physiotherapy management of meniscal injuries involves
shifting the focus
of case towards
increasing activity tolerance,
prevention of recurrence apart from treating the pain alone.
2
DEFINITION
Injuries to the crescent-shaped cartilage pads between the two
joints formed by the femur (the thigh bone) and the tibia (the shin bone).
The meniscus acts as a smooth surface for the joint to move on.
The two menisci are easily injured by the force of rotating the knee
while bearing weight. A partial or total tear of a meniscus may occur
when a person quickly twists or rotates the upper leg while the foot stays
still (for example, when dribbling a basketball around an opponent or
turning to hit a tennis ball). If the tear is tiny, the meniscus stays
connected to the front and back of the knee; if the tear is large, the
meniscus may be left hanging by a thread of cartilage. The seriousness of
a tear depends on its location and extent.
Types
The pattern of meniscus tear is important because it will determine
the type of treatment receive (some tears will heal on their own, some can
be treated surgically and some can't be fixed). Tears come in many
shapes and sizes however there are 3 basic shapes for all meniscal tears:
longitudinal, horizontal and radial. If these tears are not treated, they
may become more damaged and develop a displaced tear (moving flap of
meniscus). Complex tears are a combination of these basic shapes and
include more than one pattern.
A Longitudinal meniscus tear (circumferential tear) extends
along the length of meniscus and does not go all the way through. This
tear divides meniscus into an inner and outer section; however the tear
generally never touches the rim of the meniscus. It tends to be more
medial than lateral, and results from repeated movements. It generally
starts as a partial tear in the posterior horn, which can sometimes heal
on its own. However if it doesn't heal properly it can lead to a displaced
longitudinal tear, known as a displaced
3
Bucket Handle tear. This is a complete tear that goes all the way
through and is located near the inner rim of medial meniscus; it is often
associated with a radial tear. This tear accounts for 10% of all meniscus
tears, and causes the knee to lock in flexion. It is seen most often in
young athletes, and happens in conjunction with 50% of ACL injuries.
A Horizontal meniscus tear (cleavage tear) starts as a horizontal
split deep in the meniscus. This tear divides the meniscus into a top and
bottom section (like a sliced bun). It is often not visible, and moves from
the posterior horn or mid section to the inside of the meniscus. This tear
is rare and often starts after a minor injury from rotation in the knee or
4
degeneration. It occurs frequently in the lateral meniscus; however it is
noted in both menisci. A displaced.
Horizontal Flap tear can develop if the tear is overlooked or left
alone. This type of tear is horizontal on the surface of the meniscus and
creates a flap that flicks when the knee moves. It is a result of a strong
force that tears the meniscus from the inner rim; it can easily become a
complex tear. If this tear extends from the apex of the meniscus to the
outer rim, one may develop a meniscal cyst (a mass that develops from a
collection of synovial fluid along the outside rim of the meniscus).
A Radial split meniscus tear (free-edge transverse tear) starts as
a sharp split along the inner edge of the meniscus and eventually runs
part way or all the way through the meniscus, dividing it into a front and
back section (across the middle body instead of down the length). This
tear generally occurs between the posterior horn and middle section and
is seen frequently in the lateral meniscus. A small tear is difficult to
notice, but when it grows and becomes a complete tear it will open up
5
and look like a part is missing. This is called a Parrot's Beak tear
(displaced radial tear with a curved inner portion). It generally occurs in
the thicker portion of the lateral meniscus. As it gets larger, it will catch
or lock more frequently, and prevent the meniscus from protecting the
cartilage during weight bearing. This tear is a result of a traumatic event
or forceful and repetitive stress activities; it is often associated with other
injuries. Young athletes tend to suffer from combination tears called
radial/parrot beak tears (the meniscus splits in 2 directions).
6
ANATOMY
Although the knee joint may look like a simple joint, it is one of the
most complex. Moreover, the knee is more likely to be injured than is any
other joint in the body. We tend to ignore our knees until something
happens to them that causes pain. As the saying goes, however, "an
ounce of prevention is worth a pound of cure."
The knee is essentially made up of four bones. The femur, which is
the large bone in thigh, attaches by ligaments and a capsule to tibia.
Just below and next to the tibia is the fibula, which runs parallel to the
tibia. The patella, or what we call the knee cap, rides on the knee joint as
the knee bends.
When the knee moves, it does not just bend and straighten, or, as
it is medically termed, flex and extend. There is also a slight rotational
component in this motion. This component was recognized only within
the last 50 years, which may be part of the reason people have so many
unknown injuries. The knee muscles which go across the knee joint are
the quadriceps and the hamstrings. The quadriceps muscles are on the
front of the knee, and the hamstrings are on the back of the knee. The
ligaments are equally important in the knee joint because they hold the
joint together.
7
The knee joint also has a structure made of cartilage, which is
called the meniscus or meniscal cartilage. The meniscus is a C-shaped
piece of tissue which fits into the joint between the tibia and the femur. It
helps to protect the joint and allows the bones to slide freely on each
other. There is also a bursa around the knee joint. A bursa is a little fluid
sac that helps the muscles and tendons slide freely as the knee moves.
To function well, a person needs to have strong and flexible
muscles. In addition, the meniscal cartilage, articular cartilage and
ligaments must be smooth and strong. Problems occur when any of these
parts of the knee joint are damaged or irritated.
The medial meniscus is semicircular and attached to the medial
collateral ligament (medial collateral ligament) of the knee joint. It only
moves 2-5 mm within the joint and is hence more prone to tears than the
lateral meniscus which is more circular in shape and moves 9-11mm.
8
The lateral meniscus is often injured at the same time as the
Anterior Cruciate Ligament (ACL), whereas the medial meniscus is itself
more prone to tears in the chronically 'ACL deficient' knee Bucket Handle
Meniscus Tear.
Blood supply
The blood supply to the menisci is limited to their peripheries. The
medial and lateral geniculate arteries anastomose into a parameniscal
capillary plexus supplying the synovial and capsular tissues of the knee
joint. The vascular penetration through this capsular attachment is
limited to 10-25% of the peripheral widths of the medial and lateral
meniscal rims. In 1990, Renstrom and Johnson reported a 20% decrease
in the vascular supply by age 40 years, which may be attributed to
weight bearing over time.
The presence of a vascular supply to the menisci is an essential
component in the potential for repair. The blood supply must be able to
support the inflammatory response normally seen in wound healing.
Arnoczky, in 1982, proposed a classification system that categorizes
lesions in relation to the meniscal vascular supply.
9

An injury resulting in lesions within the blood-rich periphery is
called a red-red tear. Both sides of the tear are in tissue with a
functional blood supply, a situation that promotes healing.

A tear encompassing the peripheral rim and central portion is
called a red-white tear. In this situation, one end of the lesion is in
tissue with good blood supply, while the opposite end is in the
avascular section.

A white-white tear is a lesion located exclusively in the avascular
central portion; the prognosis for healing in such a tear is
unfavorable.
10
BIOMECHANICS
The menisci provide several integral elements to knee function.
These include load transmission, shock absorption, joint lubrication, and
joint nutrition, distribution of load, amount of contact force and stability.
The menisci act as a structural transition zone between the femoral
condyles and tibial plateau. As such, they increase the congruence
between the condyles and the plateau. The menisci appear to transmit
approximately 50% of the compressive load through a range of motion of
0 to 90 degrees. The contact area is increased, protecting articular
cartilage from high concentrations of stress. The circumferential collagen
fiber orientation within the meniscus is uniquely suited to this capacity.
As load is applied, the menisci will tend to extrude from between the
articular surfaces of the femur and tibia. In order to resist this tendency,
circumferential tension is developed along the collagen fibers of the
meniscus as hoop stresses. The circumferential continuity of the
peripheral rim of the meniscus is integral to meniscal function.
The menisci follow the motion of the femoral condyle during knee
flexion and extension. During extension, the femoral condyles exert a
compressive force displacing the menisci antero posteriorly. As the knee
moves into flexion, the condlyes roll back ward onto the tibial plateau.
The menisci deform medial laterally, maintaining joint congruity and
maximal contact area. As the knee flexes, the femur externally rotates on
the tibia, and the medial meniscus is pulled forward.
11
12
AETIOLOGY
All the knee injuries are more common in women than men, men
experience more meniscus injuries and tears (ratio 2.5:1 (Male : Female))
this is belief to be due to men’s participation in more aggressive sports
and manual activities. The peak incidence of meniscal injuries for males
is between 31 – 40 years whereas for females peak incidence is in
between 11 - 20 years.
The two most common causes of meniscus injuries are acute
trauma to the knee and degeneration of the knee joint.
Occupations such as mining or carpet laying (squat position), or
participation in contact sports or repetitive stress activities (such as
running and skiing) or prone to meniscus injuries.
Acute or traumatic meniscus damage:
It can result from forceful rotating of a straight or bent knee while
foot is firmly planted and bearing weight, or from hyperflexion or hyper
extension of knee. These injuries are experienced most frequently in
activities such as Rugby, football, baseball, soccer, basketball when one
13
twist or pivot on the knee, or slow down too quickly. The result will
generally be a partial complete medical meniscus tear. This type of tear
generally affects athletes or those under 40 years of age.
A medial meniscus tear will frequently occur along with other
injuries such as MCL or ACL tear. The combined injuries are seen most
often in contact sports, when an athlete gets hit on the outside of a bend
knee.
A lateral meniscus tear will result more often from a knee i.e.., bent
excessively and experiences full weight bearing, while the thigh bone is
turning outward: seen in sports such as skiing. It can also be injured in
collisions that involve deep knee bends.
Degeneration of the knee joint
It involves weakening of tissues with age, which results from small
repetitive movements such as squatting or pivoting positions,. Or a minor
meniscus injury that never healed properly. In the younger people
meniscus is very flexible and pliable (like a new rubber tire) as they get
14
older it becomes less flexible and more brittle, it also develops cracks in it
(like those seen in an aged car tire).
Articular cartilage and meniscus detoriate as age advances, which
can eventually lead to a degenerative tear without any major trauma.
There will be a 20 percent decrease in blood supply to menisci by age 40
due to weight bearing over time; this inhibits body’s ability to heal itself.
This wear and tear over the years may lead to an osteoarthritis condition.
Approximately 60 percent of people over 65 years of age experience some
form of degenerative meniscus tear.
A Discoid meniscus occurs when are born with a more flat, disc
shaped meniscus rather than a crescent shaped, wedge meniscus. It is
generally found in the lateral meniscus and in kids less than 11 years of
age. The symptoms associated with a discoid meniscus can range from
very mild to continuous clicking, snapping, buckling and locking of the
knee joint, decreased range of motion, joint pain and tenderness, and
atrophied quadriceps (muscles wasting away). The meniscus will often
change to a C-shape with maturity and Kids/teens will grow out of their
symptoms; however failure of normal development can be experienced.
15
PATHOPHYSIOLOGY
There are two different mechanisms for tearing a meniscus.
Meniscal tears are common and can be traumatic or degenerative.
Traumatic tears occur classically during twisting forces on the knee in
young active people, are often vertical longitudinal tears and can be
associated with ligamentous injuries. Degenerative tears occur as part of
progressive wear in the whole joint, most frequently in the over 40's.
These tears are usually horizontal cleavage tears or flaps and have
minimal healing capacity. Tears can be described as being complete or
incomplete, stable or unstable and of various patterns.
Traumatic tears result from a sudden load being applied to the
meniscal tissue which is severe enough to cause the meniscal cartilage
to fail and let go. These usually occur from a twisting injury or a blow to
the side of the knee that causes the meniscus to be levered against and
compressed. A football clipping injury or a fall backwards onto the heel
with rotation of the lower leg are common examples of this injury
pattern. In a person under 30 years of age this typically requires a fairly
violent injury although any age group can sustain a traumatic tear.
Degenerative meniscal tears are best thought of as a failure of
the meniscus over time. There is a natural drying-out of the inner
center of the meniscus that can begin in the late 20's and progresses
with age. The meniscus becomes less elastic and compliant and as a
result may fail with only minimal trauma (such as just getting down
into a squat). Sometimes there are no memorable injuries or violent
events which can be blamed as the cause of the tear. The association of
these tears with aging makes degenerative tears in a teenager almost
unheard of.
16
CLINICAL FEATURES
The list of signs and symptoms mentioned in various sources for
Meniscus injury includes the 6 symptoms listed below:

Knee pain

Pain straightening knee

Knee swelling

Knee locking

Knee clicking

Knee weakness
Generally, when people injure a meniscus, they feel some pain,
particularly when the knee is straightened. If the pain is mild, the person
may continue moving. Severe pain may occur if a fragment of the
meniscus catches between the femur and the tibia.
Swelling may occur soon after injury if blood vessels are disrupted,
or swelling may occur several hours later if the joint fills with fluid
produced by the joint lining (synovium) as a result of inflammation. If the
synovium is injured, it may become inflamed and produce fluid to protect
itself. This makes the knee swell.
Sometimes, an injury that occurred in the past but was not treated
becomes painful months or years later, particularly if the knee is injured
a second time. After any injury, the knee may click, lock, or feel weak.
Although symptoms of meniscal injury may disappear on their own, they
frequently persist or return and require treatment.
17
INVESTIGATIONS
Radiological Examination
Most Common Meniscus Injury Diagnostic Tests
A medical professional will sometimes recommend diagnostic
testing to obtain more detailed information, and assess the amount
and/or type of damage done to the knee and meniscus. There are a
variety of different tests available to help them analyze the situation;
however these will be dependent on injury.
X – rays
X-rays will provide an image of the overall structure of the knee. It
is helpful in identifying abnormal bone shapes, fractures, arthritis, and
degeneration (wear and tear) on the joint. It can identify a discoid
meniscus, or loose bones and bone abnormalities that may mimic a torn
meniscus.
MRI
MRI is the most powerful, accurate, and noninvasive method for
diagnosing meniscal tears. It is more accurate than physical examination
and has influenced clinical practice and patient care by eliminating
18
unnecessary diagnostic arthroscopies or by identifying alternative
diagnosis that may mimic meniscal tears.
When combined with clinical data, such as the patient's age,
athletic requirements, and physical findings (e.g, possible associated
ligamentous injuries), a treatment plan may be developed by assessing
the need for and timing of surgery and by determining the type of surgery
(meniscal debridement, rasping, repair, partial or total resection, or
meniscal transplantation). MRI may be used to identify other injuries,
such as ligament tears, especially ACL tears, the presence of which may
also influence the decision whether to perform surgery.
With MRI, physicians may obtain images in several planes,
providing multiple perspectives on meniscal and ligamentous injuries.
Other advantages include the following:
 with MRI, the patient is not exposed to ionizing radiation;
 MRI
does
not
normally
involve
the
intravenous
administration of contrast material, the use of which is
associated with a small but definite number of adverse
effects;
 MRI does not require joint manipulation;
 MRI is painless and can be performed in less than 35
minutes; and
 MRI does not require the intra-articular injection of iodinated
radiographic
contrast
material,
which
is
needed
for
arthrography. MRI results lead to alterations in therapy in
about one third of cases
19
Plain radiography
Plain radiography is extremely limited in the assessment of
meniscal tears. Radiographs may be obtained to rule out unsuspected
lesions, such as osteochondritis desiccans and loose bodies.
In the presence of a DM, radiographs may show widening of the
medial or lateral joint compartments; hypoplasia of the lateral femoral
condyle related to the increased size of the LM; a high fibular head;
cupping of the lateral tibial plateau; or a squared-off lateral femoral
condyle.
20
CT Scan
CT or CAT scans (computerized tomography) will be used to provide
a more thorough, 3-dimensional assessment of the bones and soft tissues
in and around the knee joint.
Further diagnostic tests such as an ultrasound, electromyogram,
or arthroscopic surgery can be used to determine the degree and location
of the injury if required.
Physical Examination
A complete examination, including that of the lower spine, ipsilateral
hip and thigh, patellofemoral joint, and tibiofemoral joint, is essential
when evaluating knee pain. Associated findings such as a perimeniscal
cyst or ligamentous laxity suggest a higher likelihood of a meniscus
injury. Important findings when examining a patient with a possible
meniscus injury include the following:

Joint line tenderness

Joint line tenderness is an accurate clinical sign.10 This
finding indicates injury in 77-86% of patients with meniscus
tears. Despite the high predictive value, operative findings
occasionally differ from the preoperative assessment.
21

Assess joint lines for palpable pain the location of the
tenderness is not a sure sign for the type of lesion.

Effusion

Effusion occurs in approximately 50% of the patients
presenting with a meniscus tear.

The presence of an effusion is suggestive of a peripheral tear
in the vascular or red zone (especially when acute), an
associated intra-articular injury, or synovitis.

To assess effusion perform the fluid shift test and evaluate
for the presence of the fluctuation sign. The amount of
effusion doesn’t indicate the presence or absence of a
meniscal lesion.

Range of motion

The patient may have difficulty extending the knee fully if a
meniscal tear blocks the motion.

Full flexion, as in squatting, may be painful or impossible
because of a tear.

Assess
the
gait
pattern
looking
for
deviations
or
compensatory movements.

Restricted motion caused by pain or swelling is also
common.

Girth measurement

Girth measurement allow for a general assessment of
effusion and atrophy.

Swelling within the knee joint is measured grossly by a girth
measurement taken at the joint line.

Measurements taken at five Centimetre and 20 centimetre
proximal to the base of the patella and 15 centimetre distal
to the apex of the patella can provide and indirect indication
of atrophy in the VMO segment, Quadriceps femoris muscle
and calf muscles respectively.
22
SPECIAL TESTS
Tests: Perform stability tests for anterior, posterior, and varus-valgus
motion to rule out additional involvement of soft tissue. Several special
tests may be used to assess meniscal involvement. A positive result of
any test does not by itself establish the presence of a meniscal lesion,
but, along with the other objective findings, such a test result can help
differentiate a meniscal tear from other possible knee injuries.

McMurray test

This test indicates tears of the middle or posterior horn
of the meniscus.

With the patient supine and the hip and knee fully
flexed, apply a valgus force and externally rotate the
tibia while extending the knee. An audible or palpable
pop or snap indicates a medial meniscal tear.

Lesions of the lateral meniscus are tested by applying
a varus force and internally rotating the tibia during
knee extension. The snap is produced as the torn
fragment
rides
over
the
femoral
condyle
during
extension.

A snap in extreme flexion is indicative of a posterior
horn tear; a click at 90° of flexion indicates a lesion in
the middle section of the meniscus.
23

Apley test

This test is used to distinguish between meniscal and
ligamentous involvement.

With the patient in a prone position, the knee flexed at
90°, and the leg stabilized by the examiner's knee,
distract the knee while rotating the tibia internally and
externally.
Pain
during
this
maneuver
indicates
ligamentous involvement.

Then,
compress
the
knee
while
internally
and
externally rotating the tibia again. Pain during this
maneuver indicates a meniscal tear.

Bragard sign

This test may be used if anterior joint-line point
tenderness is present.

To test for a medial lesion, the examiner extends and
externally rotates the tibia, which displaces a meniscal
lesion forward, if one exists. Palpable tenderness along
24
the anterior medial joint line is reduced with flexion
and internal rotation.

Bounce home test

The patient is supine with his or her heel cupped in
the examiner's hand.

The examiner fully flexes the knee and then passively
extends the knee. If the knee does not reach complete
extension or has a rubbery or springy end feel, the
knee movement may be blocked by a torn meniscus.

Childress test

Instruct the patient to squat with the knee fully flexed
and attempt to "duck walk."

If the motion is blocked, a meniscal lesion is indicated;
however, pain in this position may indicate a meniscal
tear or patellofemoral joint involvement.

Merkel sign

Instruct the patient to stand with his or her knees
extended and to rotate the trunk. This movement
causes compression of the menisci.

Medial compartment pain during internal rotation of
the tibia indicates a medial meniscal lesion. Lateral
compartment pain occurring during external rotation
of the tibia indicates a lateral meniscal lesion.
25
 Modified Helfer test
 While the patient is sitting on the edge of a table with
the knee flexed 90°, instruct him or her to extend the
knee.
 If knee mechanics are within normal limits, the tibial
tuberosity can be seen in line with the midline of the
patella in full flexion; during extension, the tibia
rotates and the tibial tubercle moves into line with the
lateral border of the patella.
 Failure of the tibia to rotate during extension indicates
a meniscal lesion or cruciate ligament involvement.

O'Donoghue test

With the patient prone, the examiner flexes the knee
90°. The examiner rotates the tibia internally and
externally twice, then fully extends the knee and
repeats the rotations.

Increased pain during rotation in either or both knee
positions indicates a meniscal tear or joint capsule
irritation.

With a valgus force to a flexed and laterally rotated
knee, the medial meniscus, medial collateral ligament
(MCL), and the ACL all may be injured, representing
the O'Donoghue triad.

Payr sign

With the patient sitting cross-legged, the examiner
exerts downward pressure along the medial aspect of
the knee.

Medial knee pain indicates a posterior horn lesion of
the medial meniscus.

First Steinmann sign

With the patient supine and the knee and hip flexed at
90°, the examiner forcefully and quickly rotates the
tibia internally and externally.
26

Pain in the lateral compartment with forced internal
rotation indicates a lateral meniscus lesion. Medial
compartment pain during forced external rotation
indicates a lesion of the medial meniscus.

Second Steinmann sign

This test is indicated when point tenderness is located
along the anterior joint line.

When the examiner moves the knee from extension
into flexion, the meniscus is displaced posteriorly,
along with its lesions. The point of tenderness also
shifts posteriorly toward the collateral ligament.
27
DIFFERENTIAL DIAGNOSIS
 Anterior Cruciate Ligament Injury: An ACL tear is a common
injury that occurs in all types of sports. This injury usually occurs
during a sudden cut or deceleration, as it typically is a non contact
injury.
 Posterior Cruciate Ligament Injury: Posterior cruciate ligament
(PCL) injuries are usually the result of a direct blow to the anterior
part of the tibia, with a hyperextension moment at the knee.
 Knee osteochondritis dissecans
 Lumbosacral radiculopathy
 Osteoarthritis: Osteoarthritis (OA, also known as degenerative
arthritis, degenerative joint disease), is a group of diseases and
mechanical
abnormalities
involving
degradation
of
joints,[1]
including articular cartilage and the subchondral bone next to it.
The patient increasingly experiences pain upon weight bearing,
including walking and standing. As a result of decreased movement
because of the pain, regional muscles may atrophy, and ligaments
may become more lax.
 Patellofemoral joint dysfunction
 Rheumatoid arthritis
 Tendon inflammation (tendinitis)
 Tibial tubercle avulsion fracture
28
GENERAL PHYSIOTHERAPY ASSESSMENT OF MENISCAL
INJURIES
The aims of Assessment
 To elicitate what is preventing the patient from moving in the
normal way, in order to plan the treatment.
 Making frequent reviews possible, so that the treatment can be
altered if necessary.
 Recording the patient’s condition accurately for future therapeutic
of statistical purposes.
Subjective Assessment:
Name
:
Age
:
Sex
:
Occupation
:
Address
:
Date of Assessment
:
Chief Complaints of patients:

Difficulty in Straightening the knee.

Difficulty in running and long walking.

Pain during walking.

Weakness of knee

Swelling of knee

Difficulty in twisting the knee joint.

Difficulty in Squatting
History of present illness

Onset - Gradual

Duration

Progression

Treatment taken
29
Associated Problems

Diabetes

Hypertension

Any injury to the joint

Any infection to the joint
Past Medical History

History of joint injury

Diabetes mellitus

Hypertension
Present Medical History
Personal History

Smoker

Exercise habits

Alcoholic

Diet

Sedentary or active life style

Socio economic status

Type of job and nature of job

Steps / Ramp / Lift
Social History
Pain Assessment

Site of pain

Side of pain

Type of pain

Frequency of pain

Aggravating factor

Relieving factor
30
Objective Assessment
Vital Sign

B.P.

Temperature

Respiratory rate

Pulse rate

All normal or may be some variation
Observative findings

Built of the patient

Posture of patient

Attitude of limb – Slight flexion of knee

Quadriceps Atrophy

Gait
On Examination
On palpation

Swelling

Warmth

Bony Contour

Pain

Muscle wasting

Effusion

Crepitus
Motor Examination

In Acute - Normal

In Chronic – Tone – Quadriceps – Flaccid.
Sensory Assessment

May be normal

Range of motion is decreased

It is of less significant as no neural involvement
31
Postural Examination

Normal or Varied
Gait Examination
Investigations

X – Ray

MRI
Suggested Diagnosis

Meniscal injury
.
Range of motion

Decreased

Acute – Decreased

Chronic – Quadriceps weakness
Muscle Power
Medical Research counseling

0- No Contraction

1- Flicker of contraction

2- Full range of motion in elimination of gravity

3- Full range of motion against gravity

4- Full range of motion against gravity with mild
resistance

5- Full range of motion against gravity with
maximum resistance
Reflex Examination

Normal or reduced (Knee jerk ) due to
Quadriceps weakness

Reflex is of less significance as there is no nerve
involvement
32
Problem List

Pain

Swelling

Tenderness

Difficulty to Squat

Decreased range of motion

Weakness of muscle

Difficult to climb stair
Treatment Goals
Short term goals

To Reduce pain

To reduce tenderness

To reduce swelling
Long term goals

To increase the joint range of motion

To increase the strength of muscle

Make the patient to walk independently

Moderate or Good
Prognosis
Follow up care
33
MANAGEMENT OF MENISCAL INJURY
Non Surgical Management of Meniscal injury
An acute meniscus tear can be treated with ice application, rest,
anti-inflammatory medications, and physical therapy. These simple
measures will help decrease swelling and pain in the joint.
RICE The RICE protocol is effective for most sports-related injuries.
RICE stands for Rest, Ice, Compression, and Elevation.

Rest. Take a break from the activity that caused the injury. The
doctor may recommend that one use crutches to avoid putting
weight on the leg.

Ice. Use cold packs for 20 minutes at a time, several times a day.
Do not apply ice directly to the skin.

Compression. To prevent additional swelling and blood loss, wear
an elastic compression bandage.

Elevation. To reduce swelling, recline when rest, and put the leg
up higher than heart.
Ultrasound therapy is a great therapeutic option to decrease pain,
inflammation and soft tissue (muscle, ligament, tendon, connective and
nerve tissue) damage experienced with a meniscus or knee injury. This
can be received using a portable, home ultrasound device (selfadministered) or by seeing a physiotherapist. The treatment is safe, easy,
painless, and generally requires between 5 10 minutes.
It is based on a form of deep tissue therapy, which is generated
through high frequency sound waves (that we can not hear). These waves
send vibrations deep into body and raise the temperature of soft tissue.
The waves are delivered through a hand held transducer and medicinal
conductive gel that are used together in a slow, circular motion on skin
over the injured area. Patient may experience a slight tingling or warm
34
sensation during the process as a result of the gel; this enhances the
therapeutic effects of ultrasound (Phonophoresis).
Ultrasound therapy increases collagen and tissue elasticity, which
in turn promotes circulation (blood flow) and brings oxygen and nutrients
to injured knee area. This cleans tissue by getting rid of cell waste
products and allows meniscus injury to heal correctly. If not treated
properly injured tissue can heal with a weakened state, which can lead to
scar tissue or calcification.
If used on an ongoing basis, ultrasound will help to improve range
of motion by breaking down any scar tissue that may form in the knee
area. Ultrasound waves penetrate deep into tissues, relax muscles,
decrease chronic inflammation and accelerate recovery rate, so one can
return to daily activities as soon as possible.
The goals of pharmacotherapy are to reduce morbidity and prevent
complications.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure
patient comfort and have sedating properties, which are beneficial for
patients who have sustained injuries.
Acetaminophen (Tylenol, Feverall, Tempra, Aspirin-Free Anacin)
DOC for pain in patients with documented hypersensitivity to
aspirin or NSAIDs, with upper GI disease, or who are taking oral
anticoagulants.
Nonsteroidal anti-inflammatory drugs
Have analgesic, anti-inflammatory, and antipyretic activities. Their
mechanism of action is not known, but they may inhibit cyclooxygenase
(COX) activity and prostaglandin synthesis. Other mechanisms may exist
35
as well, such as inhibition of leukotriene synthesis, lysosomal enzyme
release, lipoxygenase activity, neutrophil aggregation, and various cell
membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory
reactions and pain by decreasing prostaglandin synthesis.
Naproxen (Naprelan, Anaprox, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions
and pain by decreasing activity of COX, which results in a decrease of
prostaglandin synthesis.
Diclofenac (Voltaren, Cataflam)
Rapidly absorbed; metabolism occurs in liver by demethylation,
deacetylation, and glucuronide conjugation. Delayed-release, entericcoated form is diclofenac sodium, and immediate release form is
diclofenac potassium. Has relatively low risk for bleeding GI ulcers.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible
isoenzyme, induced during pain and by inflammatory stimuli. Inhibition
of COX-1 may contribute to NSAID GI toxicity. Seek lowest dose of
celecoxib for each patient.
Depending on the size and type of the meniscus tear, and the
physical demands of the patient, these may be the only treatments
necessary. A cortisone injection can be a helpful treatment to reduce
inflammation within the joint, but it will not help heal the meniscus tear.
If these treatments fail to provide relief, a surgical procedure may be
recommended.
36
Surgical Management of Meniscal Tear
When Surgery is Necessary
If meniscus tear symptoms are not significant, surgery can often be
delayed or avoided altogether. Many people live normal, active lifestyles
despite having a meniscus tear. It is only when the meniscus tear
becomes symptomatic, and interferes with activities, that surgery to treat
the meniscus tear should be considered.
Surgery has the best results when the primary symptoms of the
meniscus tear are mechanical. This means that the meniscus tear is
causing a catching or locking sensation of the knee.
Operative management
Once a decision has been made to proceed with operative
management, further decisions regarding the surgical treatment of the
meniscus tear need to be made Intraoperatively, a decision has to be
made whether to repair, excise, or leave the tear in the meniscus alone.
Arthroscopic Meniscectomy for Meniscus Tears:
A meniscectomy is a procedure to remove the torn portion of the
meniscus. This procedure is far more commonly performed than a
meniscus repair. The meniscectomy is done to remove the damaged
portion of meniscus, while leaving as much healthy meniscus as
possible. The meniscectomy usually has a quick recovery, and allows for
rapid resumption of activities.
37
Arthroscopic probing of a posterior horn complex meniscal tear with
multiple flaps.
Arthroscopic view of medial meniscus after excision of flap tear.
Meniscus Repair
In some situations, surgeon may offer a meniscus repair as a
possible surgery for damaged or torn cartilage. Years ago, if a patient had
torn cartilage, and surgery was necessary, the entire meniscus was
removed. These patients actually did quite well after the surgery. The
problem was that over time, the cartilage on the ends of the bone was
worn away more quickly. This is thought to be due to the loss of the
38
cushioning effect and the diminished stability of the joint that is seen
after a meniscus is removed.
When arthroscopic surgery became more popular, more surgeons
performed partial menisectomies. A partial meniscectomy is performed to
remove only the torn segment of the meniscus. This works very well over
the short and long term if the meniscus tear is relatively small. But for
some large meniscus tears, a sufficient portion of the meniscus is
removed such that problems can again creep up down the road.
How is the meniscus repair performed?
Techniques of meniscus repair include using arthroscopically
placed tacks or suturing the torn edges. Both procedures function by
reapproximating the torn edges of the meniscus to allow them to heal in
their proper place and not get caught in the knee causing the symptoms.
Meniscus Transplantation
Meniscus transplantation consists of placing the meniscus from a
donor patient into an individual who has had their meniscus removed.
The ideal patient for a meniscus transplant is someone who had their
meniscus removed, and subsequently begins to develop knee pain.
Meniscus transplant is not performed for an acute meniscus tear, rather
it is performed when removal of the entire meniscus has caused
persistent pain in the knee.
39
Physiotherapy Management
A meniscus tear is a common knee joint injury. The knee will heal
and whether surgery will be needed depends in large part on the type of
tear and how bad the tear is.
Rehabilitation Program
A rehabilitation program helps to regain as much strength and
flexibility in knee as possible. Rehabilitation program probably will
include physical therapy and home exercises.
The goals of rehabilitation are to restore range of motion, strength,
and endurance of the knee. A rehabilitation program usually includes
treatment with a physical therapist at a therapy center and home
treatment in home or at a gym or health club. Physical therapist will
design a program that guides through exercises to reach these goals on a
schedule that takes into account health status, age, and activity
expectations.
Recovery from a meniscus tear depends on many factors. If the tear
is minor and symptoms go away, doctor may recommend a set of
exercises to increase flexibility and strength.
Rehabilitation following meniscectomy
Initial phase
When the patient first reports to outpatient physical therapy 4-7
days after surgery, he or she usually is able to bear full weight or as
much weight as tolerated on the involved leg. Modalities are used as
needed to decrease pain or swelling, including heat/ice contrasts, ice
alone, transcutaneous electrical nerve stimulation (TENS), electric
galvanic stimulation, and Ultrasound. As needed, the patient should
perform flexibility exercises for the lower extremity musculature,
40
including the hamstrings, quadriceps femoris, hip flexors, hip adductors,
and calf muscles.
Static Quadriceps Contractions
This exercise is used to prevent quadriceps muscle degeneration
and weakening in the acute stages of injury and/or directly after injury.
In this stage weight bearing or more difficult exercises may be either not
advised or too difficult. This exercise may be started as soon as pain will
allow and can be done on a daily basis.

Contract the quadriceps muscles at the front of the thigh, keep
toes pointed to the ceiling.

Hold for 10 seconds.

Relax and rest for 3 seconds.

Repeat 10 to 20 times.
This can be performed either flat on the floor, or with a foam roller
or rolled up towel under the knee.
Static Hamstring Hold
This exercise is used to maintain the strength of the hamstring
muscles when other exercises may be too difficult. Again it may be
started as soon as pain will allow and can be done on a daily basis.

Lie on the stomach

Bend the knee to raise the foot up to about 45 degrees
41

Hold for count of 10 and lower slowly .

Repeat 10 to 20 times.
This can be progressed by increasing the length of hold, as well as
using some external force such as a partner to increase the resistance
or ankle weights.
Static Hamstring Contractions
This exercise is more difficult than the one above and also helps in
increasing the range of movement in the knee joint.

This
involves
contracting
the
hamstring
muscles
without
movement - by pushing against a static object.

One can do this by attempting to either bend the knee or extend
the hip, or both.

The easiest way of doing this is getting a partner to resist the
movement.

One can also push against a wall, chair or the floor.

Hold for 10 seconds.

Relax and rest for 3 seconds.

Repeat 10 to 20 times.
42
Straight Leg Raises (SLR)
This exercise is more difficult than the static quadriceps exercise as
it involves lifting the entire weight of the leg against gravity. It mainly
targets the knee extensors (the quadriceps) but also functions in
strengthening the hip flexors (Rectus Femoris and Iliopsoas muscles).

Position the patient sitting on the floor with both legs straight out
in front of the therapist.

Keeping the knee completely straight, lift the entire leg off the floor

Hold for 10 seconds.

Relax and rest for 3 seconds.

Repeat 10 to 20 times.
43
Knee Extension
This exercise specifically targets the quadriceps muscle group. It
may be used relatively early in the rehab process but care should be
taken not to overload the injured leg. Always seek professional advice
before beginning weight training

Always start each session with a light warm-up set of repetitions
before increasing the weight or resistance.

Keeping your bottom firmly on the bench, straighten and lower the
injured leg in one smooth movement.

An alternative exercise involves using a resistance band to provide
the resistance.

Tie one end of the band to a table leg or other stable structure
Leg Curl
Again, this exercise strengthens the hamstring muscles. You can
perform this with either ankle weights, a resistance band or a weight
machine.

If using ankle weights or a resistance band, lay on your front.

Attach the band around your ankle and also around something
sturdy, close to the floor behind you.
44

Always start resistance band exercises with the band just under
tension, if it is slightly slack, shorten the length you are using by
tying it shorter.

Bend the knee, bringing the heel towards your buttocks, as far as
you comfortably can.

Slowly reverse this movement and return to the starting position
under control.

Aim for 3 sets of 10 repetitions initially with light weights/low
resistance and gradually increasing.
Hip Raises (Bridging)

Lie on your back with your knees bent and feet flat on the floor.

Lift your hips up off the floor as far as they will go, hold for 3
seconds and lower.

Repeat 10 to 20 times.

To progress this exercise, increase the length of time that the hips
are held up, initially to 5 and then to 10 secs
45
Calf Raises

Raise up and down on the toes on the edge of a step in a smooth
movement > Play video

Aim for 3 sets of 20 repetitions.

This exercise can be progressed to single leg calf raises as fitness
and tolerance increases
Squatting
This is arguably the best exercise to increase quadriceps muscle
strength. Nevertheless, extreme care should be taken with this exercise
as it involves large loading of the quadriceps muscles and the knee joint
itself

Squat down half way to horizontal and return to standing.

Try to sink down through the knees, keeping the back straight and
not allowing your knees to move forwards past your toes

Return to the start position and repeat .

Aim for 3 sets of 10 repetitions during rehabilitation.

Progress this exercise by adding weight or moving to single leg
squats.

Later in the rehabilitation process, squats can be progressed to
horizontal (90 degrees flexion at knee and hip)
46
Hip Flexor Exercises

Start with the band tied around your ankle and also something
close to the floor.

Make sure you have something to hold on to.

Raise the knee up towards the chest, against resistance

Slowly return to the start position and repeat.

Aim for 3 sets of 10 repetitions.
If one do not have rehabilitation band or suitable weights then this
exercise can be done without resistance. However in this situation
more reps should be added to the rehab program.
47
Hip Adduction Exercises
The hip adductors are better known as the groin muscles.

Attach a resistance band around your ankle and then fasten it to a
secure object, to the side of you.

Start with the leg out to the side, away from the body, with the
knee straight.

Pull the leg across your body as far as comfortable, before slowly
returning back to the start position
Hip Abduction Exercises
The hip abductors are vital components in gait as they allow the hips
to support the weight of the body. Thus strengthening exercises for this
muscle group is vital to any lower limb rehabilitation program. These can
be performed in lying in the acute stage and progressed into standing
with a resistance band.

Tie the band around your ankle and around a sturdy object to the
side of you.

Start with the leg to be worked on the opposite side to the
attachment point
48

While keeping the leg straight, take leg out to the side as far as
comfortable

Slowly return to the start position.

This exercise can be progressed using elastic bands to increase
resistance.
Intermediate phase
The patient should have full ROM to begin this phase. Modalities
are continued as indicated by symptoms. Flexibility and strengthening
exercises are continued, increasing resistance as tolerated.
If the quadriceps femoris muscle is strong enough (i.e, if the patient
can lift 10 lb during short-arc quadriceps femoris muscle exercise), the
running program may be initiated. The first stage of the running program
is jogging in place on a trampoline. Unless pain or swelling occurs, the
patient gradually progresses to jogging for 10-15 minutes.
Advanced phase
During the advanced phase, the patient continues to progress in
strength-training exercises while beginning to return to sports activities.
Track running may begin when the patient is able to run on the treadmill
for 10-15 minutes at a pace of 7-8 minutes per mile (depending upon the
49
patient's previous activity level). Once mileage on the track has reached
2-3 miles, agility drills and sport-specific activities may be performed.
Proprioceptive Exercises
Proprioception can be considered as the body's ability to sense where
it is in space. In the event of an injury this mechanism becomes
disrupted and proper training is needed to re-educate the muscles to fire
at the right time to allow further injury prevention. The most common
way to achieve this is to first stand and then walk on an uneven surface.
As balance continues to improve proprioceptive exercises can progressed
as follows:

Two footed stand on wobble board -aim to maintain balance for as
long as possible

Progress to one legged (injured side) wobble board exercises

Practice hopping on the injured leg on an uneven surface

Gradually increase difficulty by throwing a ball against a wall and
catching it while standing on the wobble-board. Aim to challenge
yourself by throwing the ball outside your comfortable center of
gravity.
Proprioceptive exercises should be continued even after a return to
full fitness to prevent future injury.
Below is an example of a muscle strengthening program following a
meniscal tear or surgery. As with all rehabilitation programs, the type of
exercises, their frequency and intensity is dependant on the patient's own
functional ability and will vary from person to person. Hence the below
table offers only sample information and figures and should only be
carried out as pain allows.
50
Phase
Rehabilitative
Strengthening
Exercises
Daily Routine
(Repetitions
X Daily
Frequency)
Functional Activities
1
10 X 3
In some cases non-weight
1.Static Quadriceps
Week 0
10 X 3
bearing on the injured leg is
2.Static Hamstrings
Pre5X2
advised. Use crutches if
3.SLR’s
operation
necessary
2
1. Static Quadriceps
10 X 3
Week 0-1 2. Static Hamstrings
10 X 3
Carry out weight bearing
After using therapeutic elastic
5X3
status as advised by
Surgery band
5X3
surgeon.
3. SLR's
10 X 3
If weight bearing has been
4. Double Calf Raises
10 X 3
advised, concentrate on gait
5. Hip Abduction
re-education drills.
6. Hip Flexion
3
1.Leg raises using
10 X 3
Weeks 1- therapeutic elastic
5X3
2
band
5X3
Light Cycling and swimming
2.Half-way Squats
5X3
as pain allows
3.Small range lunges
Twice Daily
4.Single calf raises
5.Proprioceptive drills
4
1.Full Squats
10 X 2
Some light jogging and
Weeks 2- 2.Full range Lunges
10 X 2
perhaps short range sprints
3
3.Single leg squats
5X3
may be attempted at this
4.Proprioceptive drills
3 Times Daily stage.
5.Change of direction
Once Daily Increase resistance on
drills
cycling machine
5
1.Full Squats
10 X 3
At this stage it may be
Weeks 3- 2.Full Lunges
10 X 3
possible to return to sport
5
(extra weights may be
specific training. Care should
added to shoulders to
3 times daily
be taken when returning to
increase difficulty of
Once Daily
contact or impact sports.
these exercises)
Short intervals are advised
3.Proprioceptive drills
rather than over exertion in
4.Sprinting drills with
the early period of return.
change of direction
Non Surgical rehabilitation
The program for non operative rehabilitation is similar in principle
to the program that follows meniscectomy. Cryotherapy and nonsteroidal
anti-inflammatory drugs (NSAIDs) play a very important role in the
management of non operative meniscal injury. These medications help
control the amount of swelling and provide some pain relief. Sometimes,
aspiration is useful to decrease the effusion, and, rarely, an athlete may
need a judicious 1-time corticosteroid injection. Although not routinely
51
advocated, an injection may provide an athlete with a way to control the
irritation
within
the
knee
so
that
performance
may
not
falter.
Maintenance of ROM of the knee is important, as are muscular strength
and endurance.
A reasonable goal before return to athletic activity is strength of the
injured lower extremity within 20-30% of the contra lateral side. Initially,
activity modification is useful, particularly in athletes who are "weekend
warriors." The time frame for return to activity depends on a number of
factors. Returning to competition depends on the demands and
motivation of the athlete, as well as on the severity of the meniscal tear.
52
PROGNOSIS
Prognosis
A torn meniscus is certainly not life threatening and once treated,
the knee will usually function normally for many years.
A meniscal tear that catches, locks the knee, or produces swelling
on a frequent or chronic basis should be removed or repaired before it
damages the articular (gliding) cartilage in the knee. A meniscal tear that
produces discomfort but does not produce any of the symptoms
mentioned above may be less likely to damage the rest of the knee. One
may choose to "live" with this type of meniscal tear instead of treating it
operatively.
Following a partial menisectomy most patients are able to resume
to normal non-sporting activities comfortably in a few days. Generally
light sports such as biking and swimming are well tolerated in 1-2 weeks.
Heavy sports such as running, basketball and tennis usually take longer.
The long-term prognosis depends on how much meniscus was lost
from the tear. Naturally occurring (aging) arthritis is accelerated
depending on the amount of meniscus lost. There are new techniques
designed to repair those menisci that are repairable and replace that
portion of the meniscus which is lost. Entire menisci can be replaced
using cadaver transplants.
53
PREVENTION
Although it is important to be able to treat meniscus injury,
prevention should be your first priority. Some of the things you can do to
help prevent a meniscus injury
1. Warm Up properly A good warm up is essential in getting the body
ready for any activity. A well-structured warm up will prepare your
heart, lungs, muscles, joints and your mind for strenuous activity.
2. Avoid activities that cause pain This is self-explanatory, but try
to be aware of activities that cause pain or discomfort, and either
avoid them or modify them.
3. Rest and Recovery Rest is very important in helping the soft
tissues of the body recover from strenuous activity. Be sure to
allow adequate recovery time between workouts or training
sessions.
4. Balancing Exercises Any activity that challenges your ability to
balance, and keep your balance, will help what is called,
proprioception: - your body's ability to know where its limbs are at
any given time.
5. Stretch and Strengthen To prevent meniscus injury, it is
important that the muscles around the knee be in top condition.
Be sure to work on the strength and flexibility of all the muscle
groups in the leg.
6. Footwear Be aware of the importance of good footwear. A good pair
of shoes will help to keep your knees stable, provide adequate
cushioning, and support your knees and lower leg during the
running or walking motion.
7.
Strapping Strapping, or taping can provide an added level of
support and stability to weak or injured knees.
54
CASE ASSESSMENT – 1
Name
:
P. Sujatha
Age
:
40 years
Gender
:
Female
Occupation
:
House wife
Address
:
Rapur
Chief complaints
:
Pain around right knee joint
Pain increases during night
Difficulty in walking and stair
climbing
Presence of Swelling around right
knee joint
History
Present History
:
Pain around right knee joint and
increases during night
Past History
:
She had a fall from height and got
direct injury to knee
Medical History
:
She has taken analgesics for pain
relief
Surgical History
:
No Surgical history
Personal History
:
No history of Hypertension and
Diabetes Mellitus
Pain Assessment
Site
:
Around knee joint
Side
:
Right Side
Duration
:
One Month
Character of pain
:
Not Radiating
Aggravating Factors
:
During movement and walking
Relieving Factors
:
At Rest
55
VAS Scale:
On Observation
Built
:
Moderate
Attitude of Limb
:
Slightly flexed
Skin Colour changes
:
No Changes Seen
External Appliances
:
No usage
Tenderness
:
Grade II
Muscle Spasm
:
Present
Warmth
:
Present
Swelling
:
Present
On Palpation
On Examination
Range of motion of knee joint.
Passive:
Movement Right knee
Left knee
Flexion
0-110 Degrees
0- 130 degrees
Extension
110- 0 Degrees
130- 0 Degrees
Active:
Movement Right knee
Left knee
Flexion
0-100 Degrees
0- 130 degrees
Extension
100- 0 Degrees
130- 0 Degrees
Manual muscle testing
Muscles
Right knee
Flexors
Grade – 4
Extensors
Grade – 3
Deep Tendon Reflexes
Left knee
Grade – 5
Grade – 5
Jerk
Right
Left
Knee
+
++
Ankle
++
++
Plantar
++
++
56
ADL
:
Activities like walking and stair
climbing is difficult
Special Test
:
Apley’s grinding test – Positive
Mcmurray test- Positive
Lachman’s Test – Negative
Anterior Drawer Test - Negative
Investigations
X- Ray
:
Bony abnormalities are seen
MRI
:
Meniscal tear
Provisional Diagnosis
:
Meniscal Injury
Pain
:
Ultra Sound, TENS, Cryotherapy
Swelling
:
Crep bandage, Elevation of limb
Joint Movement
:
Limb mobilization
Muscle strength
:
Isometrics to hamstrings,
Treatment
Isometrics to Quadriceps
Straight Leg Raises
Leg Extension exercises
Home Programme
 Static and dynamic quadriceps exercises are taught
 Stair climbing is advised to avoid.
Prognosis
 Pain get decreased
 Range of motion get increased
 ADL activities like walking and stair climbing are improved.
57
CASE ASSESSMENT - 2
Name
:
K. Arjun
Age
:
35 Years
Gender
:
Male
Occupation
:
Sports Master
Address
:
Podalakur
Chief complaints
:
Pain around left knee during
walking
Weakness is felt
Difficulty in Walking
Difficulty in stair climbing
Decreased movement
History
Present History
:
Pain around left knee during
walking
Weakness is felt
Decreased movement
Past History
:
He had a slip during foot ball play
and under gone surgery before two
months
Medical History
:
Analgesics for pain relief
Surgical History
:
He had surgery before two months
Personal History
:
No History of hypertension and
Diabetes Mellitus
Pain Assessment
Site
:
Around Knee
Side
:
Left side
Duration
:
Two months
Character of pain
:
Not Radiating
Aggravating Factors
:
During movement and at work
Relieving Factors
:
At Rest
58
VAS Scale:
On Observation
Built
:
Moderate
Attitude of Limb
:
Slightly flexed
Skin Colour changes
:
Not Seen
External Appliances
:
No Usage
Tenderness
:
Grade II
Muscle Spasm
:
Positive
Warmth
:
Positive
Swelling
:
Positive
On Palpation
On Examination
Range of motion of knee joint.
Passive
Movement Right knee
Left knee
Flexion
0-130 Degrees
0-110 Degrees
Extension
130-0 Degree
110-0 Degrees
Active
Movement Right knee
Left knee
Flexion
0-130 Degrees
0-100 Degrees
Extension
130-0 Degree
100-0 Degrees
Manual muscle testing
Muscles
Right knee
Flexors
Grade – 5
Extensors
Grade – 5
Deep Tendon Reflexes
Left knee
Grade – 3
Grade - 3
Jerk
Right
Left
Knee
++
+
Ankle
++
++
Plantar
++
++
59
ADL
:
Activities like walking, stair
climbing, jumping are difficult.
Investigations
Provisional Diagnosis
:
Post operative Knee pain
Pain
:
Ultra Sound, IFT, Cryotherapy
Swelling
:
Crep bandage, Elevation of limb
Treatment
Week 0-1 after surgery :
Static Quadriceps
Static hamstrings
Straight leg raises
Calf raises
Hip abduction
Hip Flexion
Week 1-2 after surgery :
Half way squats
Lunges
Single Calf raises
Proprioceptive exercises
Week 2-3 after surgery :
Full squats
Full lunges
Proprioceptive exercises
Single leg squat
Week 3-5 after surgery :
Full squats
Full lunges
Proprioceptive exercises
Home Programme
 Static and dynamic quadriceps exercises are taught
 Stair climbing is advised to avoid.
Prognosis
 Pain get decreased
 Range of motion get increased
 ADL activities like walking, stair climbing and jumping are
improved
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CONCLUSION
Meniscal tears are common and can be part of degenerative change
within the knee joint or secondary to trauma. They can cause symptoms
that affect the function of the joint and require surgical intervention.
The majority of symptomatic tears require arthroscopic partial
meniscectomy but in a few select cases the tear may be amenable to
repair done as an open or arthroscopic procedure.
Effective rehabilitation should be there for spontaneous recovery.
Rehabilitation interventions seek to promote recovery and independence
in daily activity, to promote better health and prevent secondary
complication.
The utilization of effective treatment intervention focus on real life
environments can cause successful attainment of functional outcomes.
By the proper rehabilitation programme treated for five weeks of
the present case with meniscal injuries have been shown to improve
functional outcome and allowed the patient to regain independence in
daily life.
It is concluded that, with proper rehabilitation program, we can
regain patient functional activity to maximum level and prevent
secondary complication.
61
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