Knee Surg Sports Traumatol Arthrosc (2009) 17:607616
DOI 10.1007/s00167-009-0723-2
KNEE
Effect of early active range of motion rehabilitation
on outcome measures after partial meniscectomy
Brent M. Kelln Christopher D. Ingersoll
Susan Saliba Mark D. Miller Jay Hertel
Received: 4 August 2008 / Accepted: 16 January 2009 / Published online: 12 March 2009
Springer-Verlag 2009
Abstract Range of motion (ROM) exercises are accepted
as being an essential part of post-operative knee rehabili-
tation but there is little research to support this treatment.
Our purpose was to determine whether a specific early,
active ROM intervention using a bicycle ergometer
equipped with an adjustable pedal arm offered measurable
benefit to post-operative partial meniscectomy patients.
Thirty-one subjects were randomly assigned to experi-
mental or control groups. The experimental group rode a
stationary bicycle equipped with the pedal arm device six
times over 2 weeks post-operatively under the supervision
of a physical therapist while the control group did not.
Subjective measures of gait were significantly different
The views expressed in this article are those of the authors and do not
reflect the official policy of the Department of the Navy, the
Department of Defense, nor the United States Government.
This topic is presented at the ACSM Conference on 27 May 2009.
B. M. Kelln
Clinical Support Services, Naval Health Clinic Hawaii,
Pearl Harbor, HI, USA
C. D. Ingersoll
Department of Sports Medicine, University of Virginia,
Charlottesville, VA, USA
S. Saliba
J. Hertel
Department of Kinesiology, University of Virginia,
Charlottesville, VA, USA
M. D. Miller
Department of Orthopaedic Surgery, University of Virginia,
Charlottesville, VA, USA
B. M. Kelln (&)
1211 Catalina Drive, Honolulu, HI 96818, USA
e-mail: brent.kelln@med.navy.mil
with a positive experimental group response to the super-
vised exercise with improved gait performance at weeks 1,
2 and 4 after surgery (P B 0.05). Early, protected active
ROM exercise on a bicycle ergometer equipped with an
adjustable pedal arm demonstrated promising results in
patients after partial meniscectomy.
Keywords Arthroscopy
Cycle ergometer
Gait

Knee
Quadriceps control
Introduction
Controversy exists over what are the best practice guide-
lines for rehabilitation following uncomplicated knee
partial meniscectomy procedures. Some research supports
the need for supervised physical therapy to achieve optimal
outcomes [14, 15, 25], while others insist that independent
home exercise programs are just as efficacious as super-
vised care [6, 10]. Despite this controversy, there is little
evidenced-based research examining this issue. A pro-
spective study by Roos et al. [23] offers insight to problems
associated with post-operative partial meniscectomy
recovery along with limitations associated with commonly
used clinical outcome measures that fail to address quality
of life concerns.
A noticeable difficulty with clinical trials that have
looked at rehabilitation following partial meniscectomy is
with the rehabilitation programs themselves. Most involve
multifaceted approaches that include disparate interven-
tions ranging from thermal modalities such as cryotherapy
and ultrasound and aggressive strengthening exercises to
independent home programs [7, 10, 15]. The inability to
extract meaningful data from multifaceted clinical inter-
ventions is likely a root cause to the continuing controversy.
123
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In order to see the influence of a given intervention on a
specific patient population, the intervention has to be pro-
vided to the experimental group and not to the control
group. Studies that have used the same interventions
for each group but compare them under supervised and
unsupervised conditions have been criticized for simply
comparing subject compliance rather than offering any
insight as to the most effective interventions [25].
The most common surgical lesion in the knee is a torn
meniscus [5, 6]. Most meniscal injuries that result in pain,
swelling, clicking and locking of the knee joint require
surgical intervention with the goal of preserving as much of
the meniscal tissue as possible [1, 5]. The type of surgery
employed is largely dependent on the type of tear and its
location [5, 22]. Our study focused on patients who have
undergone partial meniscectomy and who were weight-
bearing as tolerated post-operatively. Lesions requiring
meniscal repair were beyond the scope of this study due to
concerns over weight-bearing status and early rehabilita-
tion range of motion (ROM) limitations.
Research has shown that ROM exercises following
orthopedic surgical interventions are key to an effective
recovery [11, 17]. Prolonged immobilization has lost favor
secondary to the well-documented deleterious effects
associated with it [11, 13, 17]. Consequences of not rees-
tablishing a patients knee ROM in an expeditious manner
include the following: strengthening exercises can only be
implemented through a limited range, functional motor
patterns essential to normal gait cannot be restored, without
repetitive muscular contractions and associated limb
movement lymphatic drainage and venous return cannot
effectively promote swelling reduction. What remains
unclear is what kind of ROM exercise to use, when it
should be used, and in what quantity it should be applied to
offer the greatest rehabilitation benefit. A strong consid-
eration for any early intervention needs to be protection of
healing or vulnerable tissues [11]. Continuous passive
motion (CPM) machines became popular in the 1980s [13,
18, 19], but have repeatedly failed to demonstrate favorable
outcome measures in evidence-based research studies [2,
9]. Some advocate aquatic therapy, believing that a mod-
ified weight-bearing environment is best suited to effective
rehabilitation [1]. However, a significant limitation to
aquatic therapy is post-surgical wound healing. Treatment
under water cannot begin until wounds have properly
closed in order to prevent increased risk of infection. An
alternative modified weight-bearing strategy commonly
employed in physical therapy is the use of bicycle erg-
ometry [4]. However, a primary limitation to traditional
bicycle ergometers in early phases of recovery is the
inability of patients to perform complete pedal revolutions
secondary to pain, swelling, joint stiffness and/or
apprehension.
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Knee Surg Sports Traumatol Arthrosc (2009) 17:607616
The dilemma of how to employ bicycle ergometry for
patients with compromised knee ROM can be resolved
using an adjustable pedal arm system [12]. By shortening
the radius of the pedal arm in conjunction with the
appropriate seat height adjustment, patients can achieve
comfortable, full pedal revolutions regardless of their knee
ROM limitations. Bicycle ergometry offers a unique, pro-
tective and controlled environment to engage recovering
tissues with levels of activity that are not overly chal-
lenging. Ericson [4] demonstrated that cycling with a
workload of 120 W produced lower moments of force
about lower extremity joint axes than were generally
observed during normal walking. By implementing an
adjustable pedal arm and reducing pedal resistance, even
greater mechanical advantage and less joint and tissue
stress can be expected.
The purpose of this study was to determine whether an
early, active ROM intervention using a bicycle ergometer
equipped with an adjustable pedal arm system in post-
operative partial meniscectomy patients offers any mea-
surable benefit in limb girth, knee ROM, quadriceps
control, gait and self-reported function.
Methods
Design
A randomized, controlled clinical trial was conducted at a
large university medical center. The independent variables
for the study were group assignment (experimental or
control) and time (pre-operative, and day 1, week 1, week
2, month 1 and month 3 post-operative). Dependent vari-
ables included: knee flexion and extension ROM, lower
extremity girth, quality of quadriceps contraction, sub-
jective gait analysis and patient self-reported function
using the subjective International Knee Documentation
Committee (IKDC) outcomes evaluation.
Subjects
Subjects were included in the study if they were 18
65 years of age, met the criteria necessary to undergo a
partial meniscectomy surgery as dictated by an orthopedic
surgeon, were cleared for weight-bearing as tolerated post-
operatively, were not pregnant and had no known history or
current diagnosis of cancer. Surgical intervention took
place in a same day surgery setting by one of five different
board certified sports medicine, orthopedic surgeons. None
of the subjects had any immediate post-operative compli-
cations requiring additional or overnight care. Thirty-one
subjects (11 males, 20 females, age, 47.1 12.4 years;
height, 170.6 12.7 cm; mass, 90.2 23.8 kg) volunteered
Knee Surg Sports Traumatol Arthrosc (2009) 17:607616
to participate in the study. Random assignment placed five
males and ten females in the control group while the
remaining six males and 10 females were assigned to the
experimental group. Among the experimental group sub-
jects there were 3 lateral meniscectomies, 10 medial
meniscectomies and 3 procedures that included both lateral
and medial involvement. Meanwhile, the control group had
one lateral meniscectomy and 14 medial meniscectomies.
All subjects provided written informed consent prior to the
participation in the study. The study was approved by the
Universitys institutional review board (#HSR 12462).
One experimental group subject withdrew from the
study just prior to the designated 2 week follow-up
appointment for personal reasons. Consequently, data col-
lected from the withdrawn subject were not analyzed. Two
subjects (one from the control group and one from the
experimental group) did not return for their respective 3-
month follow-up appointments. One moved out of the area
and the other did not return for reasons unknown. Using the
measures obtained during their 1-month follow-up for their
missing 3-month measures, we were able to include them
using intention-to-treat analysis. In a similar manner, we
applied intention-to-treat analysis for one other control
subject who missed the week 2 follow-up secondary to
complications with deep venous thrombosis (DVT). This
subject was cleared to return for all remaining sessions.
Instrumentation
Instrumentation for the project included the use of a sta-
tionary bicycle ergometer (Life Cycle 9100, Schiller Park,
IL) equipped with an adjustable pedal arm system (Range
Maker, Rainbow Rehabilitation, Grayling, MI). Knee ROM
measures were obtained using a standard, large, plastic
goniometer. Girth measurements were taken using a stan-
dard tape measure. Subjective patient self-reports of pain
and activity of daily living functional ability scores were
obtained using IKDC documents.
Procedures
Potential subjects identified by their orthopedic surgeon as
needing a partial meniscectomy procedure were consecu-
tively notified of the opportunity to participate in this study
by their attending physician or a research team member.
Two-hundred-forty-eight potential subjects were contacted
resulting in 31 volunteers. The vast majority who did not
choose to volunteer did so because they lived greater than
1 h away from the regional medical center and it was
unreasonable for them to return for supervised exercise three
times per week. Participating subjects met with a researcher
within 1 week of their upcoming surgery at which time they
had initial, baseline clinical measures taken.
609
Outcome measures
Baseline measures included knee girth circumference (mid-
patellar, 10 cm above mid-patella and 10 cm below mid-
patella), knee ROM, gait evaluation, quality of quadriceps
contraction and the completion of three IKDC forms
(demographic, subjective and current health). The three
girth measurements were taken with the subject supine and
with the lower extremity of interest resting in full extension
and slightly elevated by a 15 cm diameter bolster that was
placed under the distal leg just above the ankle. Pen marks
were placed at the mid-patella, 10 cm proximal to the mid-
patella mark and 10 cm distal to the mid-patella mark.
Circumferential girth measurements were taken at the three
markings and recorded.
Knee extension goniometric measurements were taken
in the same supine position with the lower extremity rest-
ing over the bolster in full passive extension. For the knee
flexion measure, the subjects remained supine, but had
their hip on the extremity of interest flexed to 90. From
that position, the subjects actively flexed their knees as far
as possible and the corresponding goniometric measure-
ments were taken.
Gait evaluation and quality of quadriceps contraction
were assessed by a physical therapist via observation and
palpation as necessary. Gait was evaluated in terms of three
subjective observations during level walking: normal
ambulation pattern, presence or absence of pain and pres-
ence or absence of limp. Pain during ambulation was a
subjective report by the subject in response to questioning
by the therapist while gait alterations such as a limp were
simply observations. Observed normal ambulation patterns
were possible in the presence of subjective reports of pain,
but not in the presence of a limp. Quality of quadriceps
contraction was evaluated by subject performance during a
quadriceps setting exercise and was graded as poor, fair or
good and by the subjects ability to perform an independent
straight leg raise with or without an extensor lag. Sub-
jective IKDC forms were completed by the subjects during
the pre-operative visit and at the beginning of each of the
five post-operative follow-up visits.
Interventions
Subjects were randomly allocated to the experimental or
control groups using sealed envelope allocation. Those in
the experimental group initiated their three times per week,
rehabilitation sessions on post-operative day 1 after having
clinical measures taken in a similar manner to the initial
pre-operative appointment. The rehabilitation sessions
consisted of riding a stationary bike equipped with the
adjustable pedal arm system. Seat height, pedal resistance
and pedal arm length were adjusted by the supervising
123
610
physical therapist to allow full pedal revolution in a com-
fortable and uncompensated manner. Subjects were
instructed to ride for two 10-min sessions under supervision
with a 5-min rest period between sessions. All experimental
subjects were able to complete both 10-min exercise ses-
sions on each of their six exercise days during the first
2 weeks following surgery. As subject knee ROM and
comfort level improved, pedal arm length was also
increased. Pedal arm length increases typically occurred on
the subjects subsequent visit; however, there were several
occasions when adjustments were made from one 10-min
session to the next during the same exercise day. Antic-
ipating that most subjects would be able to progress to ride a
standard bicycle ergometer by 2 weeks post-operative, we
choose to have the supervised intervention end at that point.
Control subjects reported to the clinic to have measures
taken on post-operative day one as well, but they did not
perform any supervised exercise. Subjects in both groups
were encouraged to engage in standard home program
management activities as instructed by their orthopedic
surgeon. Subjects were not discouraged from seeking out-
side rehabilitation assistance; however, most found the
guidance provided within the framework of the study to
meet their respective needs. Only one subject, who had
initiated outside physical therapy intervention prior to
surgery, elected to continue that relationship post-opera-
tively while at the same time participating in the program.
No differences in the recovery rate of that individual in
comparison with other group members were evident. In
addition to post-operative day 1, all subjects returned to the
clinic to have follow-up measures taken post-operative
weeks 1 and 2 along with months 1 and 3. If measurement
days coincided with an exercise day for the experimental
group, measurements were always taken prior to any
exercise activity.
Statistical analysis
An a priori power analysis aiming to identify a moderate
effect size (Cohens d = 0.5) for knee flexion ROM
between groups [24], with an alpha level of P \ 0.05, and a
power value of 1 - b = 0.80, revealed an estimated
sample size of 13 subjects per group. We thus over-sam-
pled slightly with a goal of enrolling 15 subjects per group.
For each continuous dependent variable, a 2 9 6 mixed
model ANOVA was performed with group as the between
variable at two levels (experimental, control) and time as
the within (repeated measures) variable at six levels (initial
pre-op, post-op day 1, week 1, week 2, month 1 and month
3). In the case of significant interactions or main effects,
Tukeys post hoc tests were performed to identify specific
differences. Between group effect sizes (Cohens d) were
also calculated at each time interval. The strength of effect
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Knee Surg Sports Traumatol Arthrosc (2009) 17:607616
sizes was interpreted using the guidelines described by
Cohen [3] with values less than 0.4 interpreted as weak,
from 0.41 to 0.7 as moderate, and from greater than 0.7 as
strong. For five of the six categorical dependent measures, a
2 9 2 chi-square analysis was performed for at each of the
six time intervals. For the quadriceps set measure a 2 9 3
chi-square analysis was performed. The significance level
was set a priori at P \ 0.05 for all analyses. SPSS 10.1
(SPSS Inc., Chicago, IL) was used to perform all analyses.
Results
IKDC scores
The IKDC group main effect (P = 0.122) and time 9
group interaction (P = 0.157, 1 - b = 0.553) did not
reach significant levels. However, there is a noteworthy
separation of group means that takes place from post-
operative week 1 through month 1 (Table 1). The spread in
values is supported by strong between group effect sizes at
post-operative week 2 and month 1 (ES = 0.73 and 0.97
respectively) which were substantially higher than those
seen at other time intervals (Table 2). For the IKDC scores,
there was a significant time main effect (P = 0.001). Post
hoc testing revealed pre-operative values to be significantly
less (P B 0.05) for all post-operative measures except for
post-operative day 1.
Range of motion
Neither knee flexion nor knee extension measures had sig-
nificant group main effects (P = 0.096 and P = 0.447,
respectively) or significant time 9 group interactions
(P = 0.765, 1 - b = 0.187 and P = 0.086, 1 - b = 0.650,
respectively). Figures 1 and 2 illustrate a predictable pattern
of ROM loss post-operative day 1 followed by progressive
ROM recovery for both control and experimental groups
over time. Interestingly, there was a strong between group
effect size of 0.71 identified at the 1-month follow-up for
knee flexion in favor of the intervention group (See Table 2).
Both knee flexion and knee extension ROM showed
significant time main effects (P = 0.001). (See Table 1;
Figs. 1, 2) Post hoc evaluation revealed that pre-operative
flexion values were significantly (P B 0.05) less than those
found at post-operative day 1, week 1 and month 3.
Meanwhile, post hoc testing for extension only showed
pre-operative values to be significantly (P B 0.001) less
than post-operative day 1. Because one control subject had
an exceptionally large knee extension deficit secondary to
prolonged aggressive guarding and compensatory gait
strategies after initial injury, that subjects data was
excluded from knee extension analysis.
Knee Surg Sports Traumatol Arthrosc (2009) 17:607616 611

Table 1 Group by time (2 9 6) ANOVA results

Dependent variable Group main Time main Time 9 group Time 9 group interaction
effect (P value) effect (P value) interaction (P value) observed power (1 - b)

Girth 10 cm below mid-patella 0.084 0.630 0.371 0.378

Girth at mid-patella 0.124 0.005* 0.778 0.182
Girth 10 cm up from mid-patella 0.100 0.012* 0.902 0.128
Knee flexion 0.096 0.001* 0.765 0.187
Knee Extension 0.447 0.001* 0.086 0.650
IKDC score 0.122 0.001* 0.157 0.553
* Significance at P B 0.05

Table 2 Effect size (Cohens d) and corresponding confidence interval values for group differences on the six evaluation days
Dependent Variables Pre-operative Post-op day 1 Post-op week 1 Post-op week 2 Post-op month 1 Post-op month 3

Girth 10 cm below 0.59 (-1.64, 2.77) 0.59 (-1.53, 2.72) 0.86 (-1.01, 3.04) 0.67 (-1.50, 2.85) 0.65 (-1.42, 2.73) 0.61 (-1.51, 2.74)
mid-patella
Girth at mid-patella 0.58 (-2.16, 3.61) 0.60 (-2.29, 3.23) 0.49 (-2.54, 3.49) 0.57 (-1.97, 3.34) 0.62 (-2.17, 3.30) 0.62 (-2.17, 3.50)
Girth 10 cm up from 0.57 (-3.84, 4.41) 0.57 (-3.83, 4.27) 0.58 (-4.08, 4.52) 0.55 (-3.61, 4.44) 0.59 (-3.92, 4.33) 0.60 (-3.81, 4.60)
mid-patella
Knee flexion 0.65 (-9.56, 5.07) 0.48 (-9.13, 5.24) 0.18 (-10.25, 9.03) 0.50 (-6.83, 5.72) 0.71 (-7.34, 3.34) 0.59 (-6.41, 4.47)
Knee extension 0.44 (-1.72, 2.07) 0.49 (-2.33, 2.07) 0.31 (-3.34, 1.72) 0.10 (-1.63, 1.10) -0.12 (-1.60, 0.78) -0.07 (-1.67, 0.92)
IKDC score 0.33 (-6.56, 7.97) 0.05 (-6.93, 6.12) 0.35 (-6.37, 7.80) 0.73 (-9.08, 8.58) 0.97 (-8.00, 7.69) 0.47 (-8.92, 9.45)

A positive effect size favors the intervention group

Girth
140

No significant group main effects or time 9 group inter-

120
actions were found among the girth dependent variables
indicating that the two treatment groups did not respond
100
substantially different over time (Table 1). Analysis of girth
Knee Flexion (degrees)

circumference measures showed that there was a significant

80
time main effect for both the mid-patellar circumference
(P = 0.005) and of that 10 cm proximal to mid-patella
60
(P = 0.012). Please refer to Table 1 and Fig. 3. Post hoc
evaluation revealed pre-operative values to be significantly
(P B 0.05) less than those found at post-operative day 1, 40

week 1 and month 1 for the mid-patellar circumference

measure. For the measure 10 cm proximal to mid-patella, 20 Control
pre-operative values were significantly (P B 0.05) less than Experimental
those found at post-operative day 1 and month 1. There was 0
Pre-Op Day 1 Week 1 Week 2 Month 1 Month 3
not a significant time main effect for the girth measurement
10 cm distal to mid-patella (P = 0.630) (Table 1); how- Fig. 1 Comparing group mean (SEM) knee flexion ROM mea-
ever, at post-operative week 1, there was a noticeably surements at each of the six evaluation days. There was not a
higher than average effect size of 0.86 (Table 2). significant group by time interaction (P [ 0.05)

Gait
Chi-square analysis revealed significant differences
between groups for antalgic gait at post-operative week 2
(P = 0.046), limp values at post-operative weeks 1 and 2
as well as month 1 (P = 0.008, P = 0.003 and P = 0.025,
respectively), and normal gait values at post-operative
weeks 1 and 2 along with month 1 (P = 0.020, P = 0.003
and P = 0.025, respectively). In all instances, the inter-
vention group responded better than the control group. In
addition, statistically significant pre-operative values for
limp and normal gait were noted. Please refer to Figs. 4, 5
and 6 as well as Table 3.

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612 Knee Surg Sports Traumatol Arthrosc (2009) 17:607616

4 15
Knee Extension - filter one subject - (degrees)

Control Control
3 Experimental

Number of Patients with Antalgic Gait

Experimental
2 12

0 9
*
-1
6
-2

-3
3
-4

-5
0
-6 Pre-op Day 1 Week 1 Week 2 Month 1 Month 3
Pre-Op Day 1 Week 1 Week 2 Month 1 Month 3
Fig. 4 Comparing number of subjects per group with antalgic gait at
Fig. 2 Comparing group mean (SEM) knee extension ROM each of the six evaluation days (*group difference, P \ 0.05)
measurements at each of the six evaluation days. One control
subjects knee extension data were not used in this analysis due an
15
uncharacteristically large extension deficit in comparison to the rest of
Control
the sample population. There was not a significant group by time * * Experimental
interaction (P [ 0.05)
12
*
Number of Patients with a Limp

50
*
45 9

40
6
Girth at Mid-Patella (cm)

35

30
3
25

20 0
Pre-op Day 1 Week 1 Week 2 Month 1 Month 3
15
Fig. 5 Comparing number of subjects per group with a limp at each
10 of the six evaluation days (*group difference, P \ 0.05)

5
Control None of the quadriceps setting or independent straight leg
Experimental raise results reached statistical significance.
0
Pre-Op Day 1 Week 1 Week 2 Month 1 Month 3

Fig. 3 Comparing group mean (SEM) mid-patellar girth measure-

Discussion
ments at each of the six evaluation days. There was not a significant
group by time interaction (P [ 0.05) The implementation of an early AROM exercise program
utilizing a stationary bicycle with an adjustable-length
Quadriceps control pedal arm resulted in significant improvements in sub-
jective gait measures at the intermediate follow-ups in
There was a statistically significant difference in extensor patients recovering from partial meniscectomy. There were
lag occurrence between group at post-operative day 1 not statistically significant improvements in measures of
(P = 0.032) as well as a value approaching significance at limb girth, knee ROM, self-reported function or quadriceps
post-operative week 1 (P = 0.058) at which point there control due to the experimental intervention; however,
were only three intervention group subjects with a residual effect size analysis for the self-reported function measures
post-operative extensor lag and eight in the control group. revealed some promising trends favoring the intervention.

123
Knee Surg Sports Traumatol Arthrosc (2009) 17:607616 613

15 decline in both knee flexion and extension, both groups

Control showed a steady and progressive return toward normalcy.
Number of Patients with Normal Gait

Experimental
12
* control group at that point in time, but caution must be used
9 *
6
3 significance for this measure; however, the representative
0 month 1, the experimental group gained a mean of
Pre-op Day 1 Week 1
Fig. 6 Comparing number of subjects per group with a normal gait
pattern at each of the 6 evaluation days (*group difference, P \ 0.05)
Early active ROM with a stationary bicycle ergometer,
equipped with an adjustable pedal arm device, did not
appear to cause our experimental group to respond any
differently than our control group with regard to the girth
measurements taken at any of the three respective sites. An
aberration that can be seen in the effect size table (Table 2)
at the 10 cm distal to mid-patella measure at the week 1
follow-up (ES = 0.86) can possibly be explained by the
fact that two of the control subjects experienced substantial
leg swelling complications following surgery around that
time. One was diagnosed with a DVT and the other was
required to wear a compression stocking after DVT had
been ruled out. In this case, it is likely that the large effect
size was influenced more by gross leg swelling of the two
patients rather than by a positive treatment effect. Espe-
cially so, since as their swelling reduced, so did the
corresponding effect size values.
The knee flexion and extension ROM findings followed
a consistent and predictable pattern for both groups as well
(Figs. 1, 2). After the expected initial post-operative
* * The effect size of 0.71 for knee flexion at the 1-month
follow-up could be indicative of a treatment effect given
the trend toward experimental group improvement over the
when interpreting this because of the wide CI around this
point estimate (see Table 2). The observed power for the
knee flexion dependent variable group 9 time interaction
is (1 - b = 0.187). This finding would indicate that our
population sample size was too small to generate statistical
effect size, at a time when treatment effect is most likely,
warrants further research. From post-operative week 1 to
Week 2 Month 1 Month 3
15.0 14.9 of flexion while the control group gained
9.3 17.5. By month 3, the control group had gained an
additional 5.1 7.5 while the experimental group only
picked up an additional 2.6 5.4; however, many of the
experimental group subjects were already near end-range
flexion by month 1, so as a group they had less to gain than
the control group prior to the final month three measure.
The subjective IKDC results did not demonstrate sta-
tistical significance in this study; however, analysis of their
effect size values appears to offer noteworthy information.
Taking notice of the separation in experimental versus
control group IKDC scores (Fig. 7) and identifying the
corresponding effect size values (Table 2) at post-operative
week 2 (ES = 0.73) and month 1 (ES = 0.97), a treatment
effect seems evident. As with the flexion ROM findings,
caution in interpretation of the ES findings must be taken
because of the considerable width of the CIs for these
scores. Given the trend demonstrated by IKDC effect size
values, it may be reasonable to expect significant outcomes
if a larger sample size were incorporated into the study.
Typical management of patients following partial men-
iscectomy surgery includes providing patients with handout
material accompanied by instruction in independent home
care [7, 16, 25]. After 2 weeks, the patient returns to their

Table 3 P values for the Pearson chi-square analyses assessing group differences for the six subjective dependent variables on the six evaluation
days
Dependent variables Pre-operative Post-op day 1 Post-op week 1 Post-op week 2 Post-op month 1 Post-op month 3

Antalgic gait 0.464 0.068 0.456 0.046* 0.361 0.283

Limp 0.008
0.309 0.008* 0.003* 0.025* 1.000
Normal gait 0.008
0.309 0.020* 0.003* 0.025* 1.000
Quad set 0.219 0.307 0.424 0.624 0.595 0.143
Independent SLR 0.309 0.361 0.283 1.000 1.000 1.000


Extensor lag 0.543 0.032 0.058 0.361 1.000 0.143
* Significance at P B 0.05 evident of positive intervention effect


Significance at P B 0.05 prior to onset of intervention; thus, not a result of intervention effect

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614 Knee Surg Sports Traumatol Arthrosc (2009) 17:607616

100 statistically significant value at post-operative day 1

90
(P = 0.032); however, it like the pre-operative gait mea-
sures, offers no significant clinical meaning given that
80 neither group had received any rehabilitation intervention
70
at that time. Conversely, the extensor lag post-operative
week 1 value (P = 0.058) is not quite statistically signifi-
60 cant, but it does offer some possible clinical insight as to
IKDC Scores

50 control versus experimental group treatment effect. At

40
30
20
Control
10
Experimental
0
Pre-Op Day 1 Week 1 Week 2 Month 1 Month 3
Fig. 7 Comparing group mean (SEM) IKDC scores at each of the
six evaluation days. There was not a significant group by time
interaction (P [ 0.05)
orthopedic surgeon for suture removal and may or may not
receive referral for supervised rehabilitation services. In the
case of our study, all subjects, regardless of group
assignment, were allowed to ask questions of the physical
therapist at each follow-up visit. The only intervention
difference between the two groups was that the experi-
mental group subjects were instructed to ride the stationary
bike equipped with the Range Maker for 20 min three
times per week for the first 2 weeks following surgery and
the control group subjects were not.
The subjective outcome measures involved with gait
showed several statistically significant results coinciding
with times indicative of a positive treatment effect for the
experimental group over the control group. There were also
two pre-operative measures (one for limp and the other for
normal gait) that showed statistical significance (Table 3).
Clearly, neither of the pre-operative measures were due to
an intervention effect. There was only one statistically
significant result for the quadriceps control outcome mea-
sures that was associated with extensor lag. It showed a
week 1, eight control subjects presented with an extensor
lag while there were only three in the experimental group.
This study did have a few limitations which must be
acknowledged. Despite random allocation, there were
baseline differences between groups for the girth and knee
flexion ROM measures. These differences can be attributed
directly to mean limb size. On an average, the control
group subjects had larger limbs. Larger limbs result in
larger girth measurements and greater chance for soft tissue
approximation to be a limiting factor for maximal knee
flexion. However, that being said, a quick comparison of
pre-operative and post-operative day 1 measures between
the two groups (Table 4) demonstrates very similar gains
and losses with the respective outcome measures. Another
potential limitation of this study that must be noted is the
fact that the physical therapist performing the pre and post-
operative research evaluations was not blinded to group
assignment.
The intermediate differences seen between the two
groups in this study (i.e. at weeks 1 through month 1) are
consistent with a treatment effect from the intervention. If
differences between the two groups were expected to occur
due to the exercise intervention, the most obvious differ-
ences would be expected to be found around the times that
the intervention was being implemented. That is what
happened in this study. After the intervention was removed
from the experimental group, differences in outcome
measures became less evident. By post-operative month 3,
there were no statistically significant differences between
the control and experimental groups. This raises the con-
troversial question that has been argued in previous work
[7, 10, 15, 25]. If long-term outcome measures between

Table 4 Comparison of mean outcome measures of control and experimental groups from collected pre-operative and post-operative day 1 data
Variable Control Control Control change Experimental Experimental Experimental change
pre-op post-op from pre-op to pre-op post-op day 1 from pre-op to
day 1 post-op day 1 post-op day 1

Girth: 10 cm below mid-patella 40.1 cm 39.9 cm Lost -0.2 cm 37.5 cm 37.4 cm Lost -0.1 cm
Girth: mid-patella 44.2 cm 45.1 cm Gained 0.9 cm 41.1 cm 41.7 cm Gained 0.6 cm
Girth: 10 cm above mid-patella 52.3 cm 52.9 cm Gained 0.6 cm 47.4 cm 47.9 cm Gained 0.5 cm
Knee flexion 120.2 85.7 Lost 34.5 131.7 93.9 Lost 37.8
Knee extension -2.5 0.3 Lost 2.8 -4.2 -2.2 Lost 2
Subjective IKDC score 40.6 29.2 Decreased 11.4 points 44.7 29.9 Decreased 14.8 points

123
Knee Surg Sports Traumatol Arthrosc (2009) 17:607616
treatment and control groups are not statistically different,
why bother with supervised care? The answer generated by
the results of this study is clear. There is evidence to
suggest, that an intervention as simple as early active ROM
exercise for 20 min three times per week can help nor-
malize gait, improve knee flexion and improve a patients
subjective self assessment regarding their rehabilitation
progress sooner in the recovery process. To withhold care
that offers even short-term advantage seems counterintui-
tive. In addition, it may be reasonable to assume that a
longer period of supervised rehab would have generated
greater long-term differences between the two groups.
Demographic analysis of the subjects in our control
and experimental groups revealed that they were fairly
homogenous. Collectively, their mean age was 47.1
12.4 years. It is recognized that along with advanced age
comes greater likelihood for subjects to have other com-
plications such as: DVT, arthritis, obesity and sedentary
lifestyle [8, 21]. Effective screening practices employed by
both the orthopedic physicians and members of the
research team helped to minimize enrollment of subjects at
risk for post-operative complications. Given that results
from this study can only be generalized to subjects with
similar demographic characteristics, it is important for
younger subject populations to be represented in future
intervention studies like this one.
Either the evaluation techniques used in this study,
which are commonplace in clinical practice, were not
sensitive enough to distinguish subtle differences in
quadriceps recovery or quadriceps impairment was not
much of a problem for most of our subjects following
partial meniscectomy. Regardless, it does raise an inter-
esting point. Perhaps, there should be greater concern over
deficits that common clinical evaluation practices are not
designed to identify. Most readily available clinical eval-
uation tools and techniques are able to effectively measure
gross anatomical deficits, differences and abnormalities,
but they cannot detect certain more subtle, yet important
problems such as arthrogenic muscle inhibition [20] and
bone density compromise [26]. Future intervention studies
may want to consider incorporating such measures in their
project designs.
As can be seen in Table 1, the largest observed power
value found for any of the dependent variables used in this
study was (1 - b = 0.65). Given that observed power is
directly correlated to population sample size, this would
indicate that the number of subjects enrolled in this study
was too small. Although our a priori power analysis based
on previously reported values [24] suggested that 13 sub-
jects per group would be adequate, our sample size of 15
per group appears to have been somewhat insufficient. This
does not mean that the findings of this study offer no value
or insight. The positive trends noted in both effect size
615
values and in subjective measure results are indicative of
an experimental group treatment effect that warrants fur-
ther research.
Ultimately, the goal of this line of research is intended to
offer evidence-based support for the most effective reha-
bilitation practices. Future work should investigate
additional early rehabilitation interventions such as a
specific strength training intervention and eventually
combination interventions such as a treatment program that
includes both specific ROM and strength components. In
all cases, it will be important to explore intervention timing
and intensity along with their impact on measurable
outcomes.
Conclusion
Early, protected active ROM on a bicycle ergometer
equipped with an adjustable pedal arm system demon-
strates promising results in the treatment of patients
recovering from partial meniscectomy. Although not all
outcome measures were statistically significant, the posi-
tive treatment effects that coincided with the experimental
group exercise intervention during the first 2 weeks fol-
lowing surgery warrant further study.
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