Best exercises for a client rehabing a lateral/medial meniscus injury
Shane,
With any meniscal injury the goal is one thing, unload the meniscus.
Exercises such as quad sets and straight leg raises are static exercises that are performed early in rehab and will really not be effective when meeting a client.
Biomechanically remember with knee flexion, the tibia glides posterior as well as bringing the meniscus back(posterioly), while the collateral ligaments become on slack. With knee extension(leg extension machine for example), the opposite happens. Tibia slides up(anteriorly), meniscus slides forward and collateral ligaments become taught.
Specifically, you need to look at the type of meniscal injury.
Partial menisectomy or full menisectomies, the goal is hamstring strengthening, to provide posterior support as the hamstrings have been shown through evidenced based research, RCTs, CCT’s(randomized controlled trials, and clinical controlled trials) to be weaker. This is further supported via Vldamir Janda’s work and through the NSCA.
With a menisectomy client, hamstring strengthening, standing hip extension or reverse lunges(glute max), diagonal lunges(glute med/min), monster walks(where you tie tubing around the patients hip or above knee joint line) and the client partially lunges in a forward diagonal position, stops and keeps one foot on the floor while raising the opposite slightly off the floor and holds(great stability exercise)!! As well as one foot on 1/2 roll and performing trunk rotation with cable or diagonal wood chop with cable!
With a meniscal repair, we in Physiotherapy, want to stop at 90 degrees of knee flexion, because going past 90 degrees, creates a posterior shear.
Therefore, this type of client needs hamstring strengthening stopping at 90 degree, leg press is excellent co-contraction exercise, reverse diagonal lunges targeting the weaker glute med/minimus and compound exercises such as forward lunges with medicine ball rotation or cable keeping the toes past 90 degrees.
Try this–as this is not only evidenced based, but has really worked for me in my 12 yr career.
Hello Shane!
The goal of an exercise program for someone with meniscal problems, is to emphasize quadriceps and hip strength,
Karin has given you some great exercises I’ m going to add Eccentric Knee Extension done with very low weight. It should be done at the beginning of the program to initiate quad strength.
The Standing terminal Knee Ext Karin refers is done with tubing and it should be as taut as possible without causing the client to lose balance. Great exercise for increasing weight bearing.
Best of luck
As mentioned above, if your client is working with or has been discharged from Physical Therapy, it’s best practice to contact the PT. I’ve found that visiting the PT (especially during the client’s session) is the absolute best strategy. Asking your client to provide the initial request from the PT and perhaps a phone number is a great place to start. In the end, you get face to face time with a potential referral source AND your client will appreciate your efforts.
As for the type of exercises, the bottom line is “pain-free”. If I’m working with a client who is recovering from an injury or surgery, my job is to find pain-free motion that loads the joint and provides a foundation to build from. From there, it all depends on the client goals matched with your professional understanding of how the joint will function best. My “post-rehab” clients all perform closed chain movements (or at least partial weight bearing) as this is the end game. If I can find a pain free way to load the recovering joint, then I start adding different upper extremity motions in all three planes and gradually reduce external supports. Once they are able to take a forward step (small ROM lunge), then you can drive the arms in different directions to help restore the 3D function of the joint.
Example:
For simplicity let’s assume a client is recovering from a R knee MCL repair.
Goal: Load the joint with a closed chain exercise (lunge motion) that reduces the medial forces on the R knee.
I would start with a small R foot lateral step and return as this provides good proprioceptive joint stimulation with minimal load on the medial R knee (unless the client lands with a valgus knee motion…which is unlikely during a small step and return. However, you can help the knee avoid this by sending the R hand laterally overhead in the opposite direction as the step). Once they are able to add pain free ROM to the lunge, then I progressively tweak the lunge toward the anterior (i.e., First set to 3 ‘oclock, second set to 2 o’clock and eventually straight forward to 12 o’clock. If there is any pain, I’ll ask the client to clasp the hands out front at about shoulder ht and send the hands to the R in the Transverse Plane (or laterally overhead to the opposite side as mentioned above).
From there, it’s all about gradual loading of the medial knee and eventually using small hand weights during the reaches.
Just a reminder that the example above is for an MCL injury. With the MCL/LCL combo, you will have to determine which plane of motion to drive the hands (or the lunging foot) to find the pain free zone (i.e., perhaps adding reaches in the sagittal plan (anterior/posterior).
Bottom Line: Find Success and THEN Progress!
Hope this helps!
Jeff Groh
www.AuthenticMotion.com
San Diego, CA
Make sure you get a release and talk to the physical therapist. It is always a good idea to connect to them in case you have a quesiton later. I never knew a physical therapist who did not happily agree to it.
Before I would worry about the leg itself, I would do an assessment including a gait assessment. After a knee surgery, the gait is always off somewhere, and it is a good opportunity to look at the entire person and identify those imbalances that have moved in secondarily to the actual knee injury. This gives you an opportunity to work on those and ‘sprinkle’ the knee specific exercises throughout the workout
I would initially continue with the PT exercises (which are probably quad sets, straight leg raises, hamstring curls, calf raises, shallow knee bends) and gradually add lateral step ups and other closed chain unilateral exercises. There is one I use with many of my ‘knee’ people. It is called ‘Terminal Knee Extension’ and works the end range of this movement. I picked it up years ago at a post rehab course from Dr. Michael Jones and have used it ever since. I actually found a Youtube video for it which saves me a lot of words. http://www.youtube.com/watch?v=ZscBVtoX62U
Particularly when I begin working with a client as a continuation of physical therapy, I often end the session with an ice pack on the client’s knee. The knee is often still swollen anyway, and it really calms the area down very well.