The formal EU-US Meniscus Rehabilitation 2024 Consensus: An ESSKA-AOSSM-AASPT initiative. Part I-Rehabilitation management after meniscus surgery (meniscectomy, repair and reconstruction)

Rehabilitation management after partial meniscectomy

• 1.

  What rehabilitation treatment is best indicated for the management of patients after isolated partial meniscectomy? Is there an evidence‐based treatment protocol?

No evidence‐based treatment protocol exists. A criterion‐based rehabilitation protocol, based on milestones, is recommended. Following partial meniscectomy, immediate full weight‐bearing (FWB) and full range of motion (ROM) are permitted as tolerated per symptoms (Grade C).

Although large effusions are uncommon after partial meniscectomy, they occasionally do occur and can lead to significant quadriceps inhibition that may require the use of an assistive device, particularly in older people and those with high body mass index or other comorbidities (Grade D).

To address quadriceps strength and neuromuscular control deficits, the use of neuromuscular electrical stimulation (NMES), open kinetic chain and closed kinetic chain (CKC) strengthening is recommended as is seen in similar patient populations (i.e., after ACL reconstruction) (Grade C). Mean 8.4 ± 1.45, Median 8 (5–9), Relative agreement.

• 2.

  Is there a difference between rehabilitation proposed after medial or lateral partial meniscectomy?

There are no specific rehabilitation protocols after medial or lateral partial meniscectomy. More adverse events (persisting swelling and pain, risk of early chondrolysis) may occur after lateral partial meniscectomy, which may result in delayed return to higher‐impact activities and sports compared to medial partial meniscectomy (Grade D).

Agreement: Mean 7.8 ± 1.36, Median 8 (5–9), Relative agreement.

• 3.

  Is there any difference between traumatic meniscus tears and DMLs in terms of rehabilitation after partial meniscectomy?

There is no comparative data to support any difference between rehabilitation protocols for partial meniscectomy for degenerative lesions and traumatic tears. Rehabilitation protocols can vary based on patient factors and the status of the knee post‐operatively. Partial meniscectomy for degenerative lesions may require slower rehabilitation progression (Grade D).

Agreement: Mean 8.3 ± 1.51, Median 8 (5–9), Relative agreement.

• 4.

  Should non‐WB or partial weight‐bearing (PWB) be recommended after arthroscopic partial meniscectomy?

After arthroscopic partial meniscectomy FWB is allowed early after surgery (Grade A).

Crutches may be recommended for mobility until gait is normalized (Grade D). Agreement: Mean 8.4 ± 1.00, Median 8 (5–9), Relative agreement.

• 5.

  For how long is rehabilitation recommended after arthroscopic partial meniscectomy? What persisting signs and/or symptoms during rehabilitation require a referral to a surgeon (for example, includes time from injury or surgery, ROM, pain, swelling, and activity limitations)?

There are multiple rehabilitation guidelines for return to walking, work and sport, with timeframes often ranging between 4 and 12 weeks. However, rehabilitation after arthroscopic partial meniscectomy should be criterion‐based and not time‐based. Return to these activities requires meeting progressive milestones throughout rehabilitation (e.g., effusion, ROM, quadriceps strength and neuromuscular control) and not just meeting healing time frames (Grade B).

Patients should be referred to an orthopaedic surgeon in cases of persistent pain, recurrence of stiffness and/or effusion, persistent functional instability, mechanical symptoms, any neurological symptoms, suspicion of infection or distal veinous thrombosis (DVT) (Grade B).

The inability to reach clinical milestones related to knee symptoms indicates a referral to the orthopaedic surgeon (Grade D).

Agreement: Mean 7.8 ± 1.02, Median 8 (5–9), Relative agreement.

Rehabilitation management after meniscus repair

• 1.

  What rehabilitation treatment is best indicated for the management of meniscal repair? Is there an evidence‐based treatment protocol?

Whilst no evidence‐based rehabilitation protocol has been shown to be superior to another, post‐operative rehabilitation should consider the meniscal tear pattern and zone of injury, tissue quality and vascularity, surgical repair technique, repair stability, and any patient‐specific characteristics known to influence the surgical prognosis (Grade D).

For isolated meniscal repair, no evidence exists for the use of specific rehabilitation protocol or adjuvant therapies. For knee surgeries where there is concomitant meniscal repair NMES, in the early post‐operative phase, may help in the recovery of quadriceps activation (Grade D).

Combined time and criterion‐based protocols can be recommended. Management of effusion should be addressed in the protocol (Grade D).

Rehabilitation should be progressed according to both time‐ and criterion‐based milestones. A minimum of 4 months of rehabilitation may be recommended for repaired vertical tears of the meniscus, whereas complex, complete radial/root and horizontal tears may require a longer duration of rehabilitation (i.e., 6–9 months) (Grade D).

Agreement: Mean 8.3 ± 1.59, Median 8 (5–9), Relative agreement.

• 2.

  How does the location of meniscus tear/repair (i.e., stable, unstable, root tear, complex tear and white zone tear) influence the progression of rehabilitation after repair (i.e., ROM, WB and loading activities)?

For vertical longitudinal tears, FWB may be recommended, with a limitation of ROM for 6 weeks. For ramp lesions, the rehabilitation protocol is driven by associated procedures (e.g., ACL reconstruction) (Grade C).

Limitation of WB and ROM for 4–6 weeks is recommended for complex, horizontal, radial and root repairs (Grade C).

Following repair‐specific early post‐operative restrictions in ROM and WB, rehabilitation after meniscus repair should follow criterion‐ and time‐based components. Return to activities requires meeting progressive milestones throughout rehabilitation (e.g., effusion, ROM, quadriceps strength, neuromuscular control) and meeting healing time frames. This is different from arthroscopic partial meniscectomy, which is criteria‐based (Grade D).

Agreement: Mean 7.2 ± 1.96, Median 8 (5–9), Relative agreement.

• 3.

  Are there specific exercises that should be avoided following all meniscus repair (e.g., deep loaded flexion—deep squats)? If so, then for how long?

Deep squatting, jumping (deep loaded flexion) and rotational knee movements activities should be avoided for a minimum of 4 months. For vertical longitudinal tears, mini squats up to 30° can be recommended from Weeks 4 to 8, up to 45° from Weeks 8 to 12 and up to 60–90° from Weeks 13 to 16 (Grade D).

Agreement: Mean 7.6 ± 1.34, Median 8 (5–9), Relative agreement.

• 4.

  Does a medial and lateral repaired meniscus tear require different protocols?

Medial and lateral meniscal repairs may be rehabilitated similarly, with the tear type (radial, root and vertical) influencing rehabilitation rather than laterality (Grade C).

Agreement: Mean 7.8 ± 1.70, Median 8 (5–9), Relative agreement.

• 5.

  For how long rehabilitation is recommended after meniscus repair?

Rehabilitation after meniscus repair should be both criterion‐ and time‐based according to the healing process. A minimum of 4 months of rehabilitation may be advised for repaired vertical meniscus tears. Complex, radial, root and horizontal tears may require longer rehabilitation, up to 6–9 months (Grade D).

Agreement: Mean 8.5 ± 1.20, Median 8 (5‐9), Relative agreement.

• 6.

  What are the criteria‐based recommendations after meniscus repair?

Rehabilitation following meniscal repair should be divided into protective, restorative, and preparation to return to activity and sports phases, with additional criterion‐based goals recommended. Criteria for progression to the restorative phase of rehabilitation include full or nearly full passive ROM, no effusion, and neuromuscular control of the quadriceps. Initiation to return to the activity phase of rehabilitation begins once the patient demonstrates full active ROM, strength (larger or equal to 80% of the contralateral leg would be ideal), and adequate single‐leg dynamic knee control. Progression of quadriceps strength is recommended to be tested at each phase of rehabilitation via the use of isokinetic or appropriately stabilized handheld dynamometry (Grade D).

Agreement: Mean 7.9 ± 1.44, Median 8 (5–9), Relative agreement.

• 7.

  Does concomitant ACL reconstruction have an impact on rehabilitation after medial or lateral meniscus repair when compared to meniscus repair on a stable knee?

Rehabilitation protocols for repaired menisci with concomitant ACL reconstruction are similar to protocols for isolated meniscal repairs; however, RTS may be delayed on account of the ACL reconstruction. Meniscus repairs requiring limitation of WB and/or ROM would affect ACL rehabilitation protocols. Most stable vertical meniscal tear repairs do not affect ACL rehabilitation protocols (Grade C).

Agreement: Mean 8.1 ± 1.39, Median 9 (6–9), Relative agreement.

• 8.

  Questions for all repaired meniscus lesions

• –

  Should non‐WB or PWB be recommended after meniscus repair (for lateral or medial meniscus)? If yes, for how long?

• –

  If FWB is allowed, is the usage of crutches recommended after meniscus repair? If so, for how long crutches should be used?

• –

  Is there any restriction in terms of ROM in the post‐operative period?

• –

  Is there any indication for a knee brace after meniscus repair in the post‐operative period (locked brace or soft brace)?

• –

  There are different categories of repaired traumatic meniscus tears, and a specific rehabilitation protocol should be considered for each of them (Grade C).

Agreement: Mean 7.3 ± 1.42, Median 8 (5–9), Relative agreement.

Two summary tables are provided (Tables 1 and 2).

Meniscus reconstruction (transplantation or scaffold)

• 1.

  Is there any difference between different types of meniscus reconstruction (transplantation or scaffold) in terms of rehabilitation management?

Scaffolds and Allografts rehabilitation protocols follow the same rules and restrictions (Grade D).

Agreement: Mean 7.6 ± 1.82, Median 8 (5–9), Relative agreement.

• 2.

  What rehabilitation protocol is best indicated for the management of meniscus reconstruction (transplantation or scaffold)?

Rehabilitation after meniscus reconstruction should be criterion‐ and time‐based. Different stages of rehabilitation are an early protective phase, followed by an intermediate restorative phase, and finally a return to activity phase. Progression through phases will vary significantly for each patient based on associated procedures, level of activity and individual rates of recovery. Rehabilitation protocols could follow those of meniscus root repair (two roots are repaired after MAT), which require up to 9 months (or more) of rehabilitation. The consensus group suggests RTS at 12 months or more (Grade D).

Agreement: Mean 8.4, Median 9 (7–9), Strong agreement.

• 3.

  Is there a difference between rehabilitation proposed after medial or lateral meniscus reconstruction (transplantation or scaffold)?

Similar rehabilitation protocols can be used for medial or lateral meniscus reconstruction (Grade D).

Agreement: Mean 7.9 ± 1.00, Median 8 (6–9), Relative agreement.

• 4.

  What are the WB precautions recommended after meniscus reconstruction (transplantation or scaffold)?

Early WB has been shown to increase the risk of meniscus extrusion after meniscus reconstruction. Therefore, non‐WB is recommended for 6 weeks, progressing to FWB gait after 8 weeks. WB status may also be affected by other concomitant procedures such as osteotomy, cartilage or ligament surgeries. Weight‐bearing through a flexed knee (e.g., stairs, squatting and lunging) should be delayed. Initial WB should occur in relative knee extension, such as with gait and standing (Grade C).

Agreement: Mean 8.1 ± 1.46, Median 9 (7–9), Strong agreement.

• 5.

  Should the ROM be restricted in the post‐operative period after meniscus reconstruction (transplantation or scaffold)? If yes, for how long?

90° of non‐WB flexion should not be exceeded until 6 weeks post‐operatively. Associated surgical procedures may alter further ROM restrictions (Grade D).

Agreement: Mean 8.1 ± 1.21, Median 8 (6–9), Relative agreement.

• 6.

  Is a brace useful after meniscus reconstruction (transplantation or scaffold) in the post‐operative period (postop/unloading or functional for return to activity)?

There is a lack of evidence for bracing after meniscus reconstruction. The consensus group has no recommendation on the use of a knee brace. The use of a knee brace after meniscus reconstruction surgery is dependent on surgeon preference and concomitant procedures (Grade D).

Agreement: Mean 8.3 ± 1.11, Median 9 (6–9), Relative agreement.

After meniscectomy

Knee pain, lack of mobility, effusion, and quadriceps weakness are the most common clinical findings after a partial arthroscopic meniscectomy procedure. Regaining quadriceps strength is of utmost importance [22].

So, a criterion‐based rehabilitation protocol, based on milestones, is recommended. A systematic review that included 18 randomized controlled trials, out of which 6 were pooled in meta‐analysis, was published in 2013 [7] and highlighted already this point.

When comparing outpatient physical therapy with home exercise to home exercise alone, significant improvement was found in favour of the outpatient physical therapy group for the outcome of patient‐reported knee function on the Lysholm questionnaire, and for the knee flexion ROM. Expert opinion advocated that the treatment should include outpatient care and a home exercise programme. The following interventions are advised: early WB, progressive knee mobilization exercises, quadriceps and hamstring strengthening exercises (isometric and dynamic), sensory‐motor training, thermotherapy and an early return to activities. It may use adjuvants such as NMES, electromyography biofeedback and isokinetics [7].

After meniscus repair

Rehabilitation should be adapted to the type of repair lesion, whatever the meniscus treated (lateral or medial) and whatever the status of the ACL (reconstructed or stable), following time‐based (to favour meniscus healing) and criterion‐based protocols.

Regarding root tear repair, there have been no long‐term studies comparing the efficacy of varying rehabilitation protocols for patients recovering from meniscal root repairs, especially regarding the time course for introducing WB, increasing ROM and beginning strength training. Nonetheless, biomechanical models of cyclic loading have underscored the need for more gradual and cautious rehabilitation protocols compared with other types of meniscal lesions [16, 21].

With radial/root repairs of meniscus, a strict emphasis on non‐WB should be implemented for the first 6 weeks, during which time, ROM should also be limited to 90 degrees [17].

One systematic review evaluated the management of ramp lesions. Seven studies have been analyzed, two RCTs and five retrospective case series. At least 2 weeks of non‐WB were indicated in all the studies, and FWB was permitted between 4 and 12 weeks. All authors allowed immediate post‐operative passive joint movements from 0° to 90° to avoid stiffness. At 6 weeks after surgery, a full ROM was permitted. The use of brace was prescribed in 181 (41%) of cases [1]. The literature with higher levels of evidence seems to support WB as tolerated, with no specific indications about crutch weaning [15, 18, 23].

Even individually analyzing all the papers of a systematic review about the comparison of accelerated and conservative rehabilitation protocols, we cannot draw strong conclusions. Some authors do not specify details on crutch use, and when it is specified, there are no clear indications about the duration of use [23]. Nevertheless, the recommendations of the consensus group are summarized in Table 1.

Concerning longitudinal/vertical tears, the literature [15, 18, 23] supports free motion as tolerated as soon as possible after surgery. Deep squats may be restricted initially. No standardized indications were found about the use of a knee brace. In the protocols in which ROM and WB are restricted, the brace is indicated for a 3‐ to 6‐week post‐operative period. In more accelerated protocols, the use of the brace is not routinely mentioned. The authors that mention it describe its use for the first post‐operative days in some cases or for the first weeks only to protect the knee during WB.

After meniscus allograft transplantation

There are no high‐level studies available to guide the direction of rehabilitation in this setting. The literature focuses mainly on indications, techniques, outcomes, complications and RTS, with little being reported on the effect of rehabilitation management or differing strategies.

Nevertheless, experts' opinions and literature reviews make similar proposals. Patients who undergo meniscal allograft transplantation (MAT) are recommended to follow a dual restriction protocol [10], time‐based and criterion‐based. Biology and graft maturation may be of importance, so recovery may be slower than other meniscus procedures (meniscectomy or repairs) [14].

Rehabilitation is based on active and passive exercises depending on the time after surgery, with rehabilitation guidelines and goals being more delayed than accelerated [14]. WB is restricted for 6 weeks, and RTS is delayed to 9 months, if possible, at all, at a competitive level [20]. We acknowledge that there will be significant variability for each patient based on concomitant procedures, desired level of activity, and individual rates of recovery [8].

This consensus has some limitations.

This is not a systematic review and meta‐analysis of the entire literature on meniscus rehabilitation. The overall LOE of the literature covering meniscus rehabilitation is relatively low. The weight of the clinical expertise is higher when compared with scientific evidence on this topic. However, there are many strengths: This is an international worldwide consensus with a rigorous methodology based on five criteria (1—pluralism, 2—iterative process, 3—refereeing, 4—literature search and 5—transparency) which dramatically reduces the selection and confirmation biases which could appear [3].

There is (1) a large pluralism (more than 100 people involved) of the experts, selected according to precise rules. This is (2) an iterative process with totally independent groups working at different steps (steering and rating groups). These people, by their geographic distribution and medical specialties, do represent exactly the community‐target (3 Refereeing). Literature search (4) was performed according to precise rules and by an independent group. All the content of the search (literature summaries and reference list) is available on the website for complete transparency. Finally, this initiative has been done under the umbrella of established scientific societies with the assistance of a ‘neutral’ consensus projects advisor.