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.

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 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

3
properly it can lead to a displaced longitudinal tear, known as a
displaced

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,

4
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 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

5
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 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

8
the lateral meniscus which is more circular in shape and moves 9-
11mm.
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.

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Arnoczky, in 1982, proposed a classification system that categorizes
lesions in relation to the meniscal vascular supply.
 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

13
one 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

14
they get 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.

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17
 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.

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 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 unnecessary diagnostic arthroscopies or by identifying
alternative diagnosis that may mimic meniscal tears.

19
 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

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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.

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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.

22
  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.

23
 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.

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 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

25
 tenderness along 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

26
 compartment pain occurring during external rotation
of the tibia indicates a lateral meniscal lesion.
 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

27
  With the patient supine and the knee and hip flexed
at 90°, the examiner forcefully and quickly rotates
the tibia internally and externally.
 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.

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 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

29
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

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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

Social History
• Socio economic status
• Type of job and nature of job
• Steps / Ramp / Lift

Pain Assessment
• Site of pain
• Side of pain
• Type of pain
• Frequency of pain
• Aggravating factor
• Relieving factor

31
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

32
 • Range of motion is decreased
• It is of less significant as no neural involvement
Postural Examination
• Normal or Varied

Gait Examination

Investigations
• X – Ray
• MRI

Suggested Diagnosis
• Meniscal injury
.
Range of motion
• Decreased

Muscle Power
• Acute – Decreased
• Chronic – Quadriceps weakness

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

33
 • Reflex is of less significance as there is no
nerve involvement

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

Prognosis
• Moderate or Good

Follow up care

34
 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 (self-administered) 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

35
tingling or warm 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

36
cyclooxygenase (COX) activity and prostaglandin synthesis. Other
mechanisms may exist 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, enteric-
coated 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

37
tear. If these treatments fail to provide relief, a surgical procedure may
be recommended.

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.

38
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

39
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 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.

40
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,

41
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

42
  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.

43
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.

44
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.

45
  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

Calf Raises

46
  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)

47
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.

Hip Adduction Exercises

48
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
 While keeping the leg straight, take leg out to the side as far as
comfortable
 Slowly return to the start position.

49
  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 patient's previous activity level). Once mileage on
the track has reached 2-3 miles, agility drills and sport-specific
activities may be performed.

50
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.

Daily
Rehabilitative Routine
Phase Strengthening (Repetitions Functional Activities
Exercises X Daily
Frequency)
1 1.Static Quadriceps 10 X 3 In some cases non-weight
Week 0 2.Static Hamstrings 10 X 3 bearing on the injured leg is

51
 Pre- 5X2
advised. Use crutches if
operatio 3.SLR’s
necessary
n
2 1. Static Quadriceps 10 X 3
Week 0- 2. Static Hamstrings 10 X 3
Carry out weight bearing status
1 using therapeutic 5X3
as advised by surgeon.
After elastic band 5X3
If weight bearing has been
Surgery 3. SLR's 10 X 3
advised, concentrate on gait
4. Double Calf Raises 10 X 3
re-education drills.
5. Hip Abduction
6. Hip Flexion
3 1.Leg raises using 10 X 3
Weeks therapeutic elastic 5X3
1-2 band 5X3
Light Cycling and swimming as
2.Half-way Squats 5X3
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 perhaps
Weeks 2.Full range Lunges 10 X 2
short range sprints may be
2-3 3.Single leg squats 5X3
attempted at this stage.
4.Proprioceptive drills 3 Times
Increase resistance on cycling
5.Change of direction Daily
machine
drills Once Daily
5 1.Full Squats 10 X 3
Weeks 2.Full Lunges 10 X 3 At this stage it may be possible
3-5 (extra weights may to return to sport specific
be added to 3 times daily training. Care should be taken
shoulders to increase Once Daily when returning to contact or
difficulty of these impact sports. Short intervals
exercises) are advised rather than over
3.Proprioceptive drills exertion in the early period of
4.Sprinting drills with 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 advocated, an injection may provide an athlete
with a way to control the irritation within the knee so that performance

52
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.

53
 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.

54
 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.

55
 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

56
VAS Scale:

On Observation
Built : Moderate
Attitude of Limb : Slightly flexed
Skin Colour changes : No Changes Seen
External Appliances : No usage
On Palpation
Tenderness : Grade II
Muscle Spasm : Present
Warmth : Present
Swelling : Present
On Examination
Range of motion of knee joint.
Passive:
Movemen Right knee Left knee
t
Flexion 0-110 Degrees 0- 130 degrees
Extension 110- 0 130- 0 Degrees
Degrees
Active:
Movemen Right knee Left knee
t
Flexion 0-100 Degrees 0- 130 degrees
Extension 100- 0 130- 0 Degrees
Degrees
Manual muscle testing
Muscles Right knee Left knee
Flexors Grade – 4 Grade – 5
Extensors Grade – 3 Grade – 5
Deep Tendon Reflexes
Jerk Right Left
Knee + ++
Ankle ++ ++
Plantar ++ ++

57
 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
Treatment
Pain : Ultra Sound, TENS, Cryotherapy
Swelling : Crep bandage, Elevation of limb
Joint Movement : Limb mobilization
Muscle strength : Isometrics to hamstrings,
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.

58
 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

59
VAS Scale:

On Observation
Built : Moderate
Attitude of Limb : Slightly flexed
Skin Colour changes : Not Seen
External Appliances : No Usage
On Palpation
Tenderness : Grade II
Muscle Spasm : Positive
Warmth : Positive
Swelling : Positive
On Examination
Range of motion of knee joint.
Passive
Movemen Right knee Left knee
t
Flexion 0-130 Degrees 0-110 Degrees
Extension 130-0 Degree 110-0 Degrees

Active
Movemen Right knee Left knee
t
Flexion 0-130 Degrees 0-100 Degrees
Extension 130-0 Degree 100-0 Degrees
Manual muscle testing
Muscles Right knee Left knee
Flexors Grade – 5 Grade – 3
Extensors Grade – 5 Grade - 3
Deep Tendon Reflexes
Jerk Right Left
Knee ++ +
Ankle ++ ++
Plantar ++ ++

60
 ADL : Activities like walking, stair
climbing, jumping are difficult.
Investigations
Provisional Diagnosis : Post operative Knee pain
Treatment
Pain : Ultra Sound, IFT, Cryotherapy
Swelling : Crep bandage, Elevation of limb
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

61
 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.

62
 BIBLIOGRAPHY

♦ Achleshwar Gandora “Gross Anatomy”, 1st Edition, 2000, Jaypee

Brothers Medical Publications

♦ B.D. Chaaurasia’s “Human Anatomy”, 4th Edition, 2004, Satish

Kumar Jain for CBS Publishers and Distributors.

♦ Caralyn Kisner “Therapuetic Exercises” 4 th

Edition, 2002, Jaypee

Brothers Medical Publications.

♦ Chaudhari “Medical Physiology” 2nd Edition, New Central Book

Agency (Pvt.,) Ltd.,

♦ C. Rex “Clinical Assessment and Examination in Orthopaedics”,

1st Edition, 2002 Jaypee Brothers Medical Publications.

♦ Colour Atlas of Clinical Orthopaedics, 2nd Edition, Jones, Owen.

Mosby Wolfe Publishers.

♦ Cynthia C. Norkins Mela D. Levangie “Joint Structure and

Funciton” 2nd Edition, 2001 Jaypee Brothers Medical Publications.

♦ David J. Magee “Orthopaedic Physical Assessment”.

♦ Jayant Joshi & Prakash Kotwal “Essential of Orthopaedics &

Applied Physiotherapy” 2007 Published by Elsevier Pvt. Ltd.,

♦ John Ebinezer “Text Book of Orthopaedics” 2nd Edition 2000,

Jaypee Brothers Medical Publications.

63
♦ Caren Atikison Fionacaults Anne Marie Hassen Kamp

“Physiotherapy in Orthopaedics” 2nd Edition, 2005 British Library

Cataloging in publication Data.

♦ Maheswari “Essential Orthopaedics” 3 rd

Edition May 2005 Mahata

Publishers.

♦ Natarajan’s “Text book of Orthopaedics & Traumautology” 6th

Edition, 2005, All India Publishers and Distributors.

♦ Patricia A. Downie “Cash Text Book of Orthopaedics &

Rheumatology for Physiotherapy” 1st Edition, Jitten Dar P Vij for

Jaypee Brothers Medical Publications.

♦ Stuart B. Povter “Tidy’s Physiotherapy” 13 th

Edition Published by

Elsevier Pvt., Ltd.,

♦ S.Sundar’s “Text Book of Rehabilitation” 2nd Edition Jaypee

Brothers Medical Publications.

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