Loose Body Removal or Debridement
Principles:
A partial medial or lateral meniscectomy or loose body removal is performed in order to decrease pain in the knee associated with constant irritation within the knee joint. After surgery the knee may continue to be sore for some time. Patients may also continue to have pain in the anterior of the knee especially during kneeling for 4-6 months following arthroscopic surgery. Rehabilitation after meniscectomy may progress aggressively because there is no anatomic structure that requires protection. Progression to the next phase is based on clinical criteria and meeting the established goals for each phase.
Phase I – Acute Phase:
Goals:
- Diminish pain, decrease swelling
- Restore knee range of motion (goal 0-115, minimum of 0 degrees extension to 90 degrees of flexion to progress to phase II)
- Reestablish quadriceps muscle activity/re-education (goal of no quad lag during straight leg raise.)
- Patients may require education regarding weight bearing as tolerated, use of crutches, icing, elevation and the rehabilitation process
Weight bearing:
- Weight bearing as tolerated. Patients may use two crutches initially and quickly progress to one crutch and then off of crutches as swelling, pain, and quadriceps function dictates.
Modalities:
- Cryotherapy 20 min on and 20 min off as tolerated for the first few days, then as needed throughout the day, this may be accomplished with ice packs or a Thermotec device.
- Electrical stimulation to quadriceps for functional retraining as appropriate
- Manual therapy as needed for fluid mobilization.
Therapeutic Exercise:
- Quadriceps sets
- Straight leg raises
- Hip adduction, abduction and extension
- Calf sets (ankle pumps)
- Gluteal sets
- Heel slides
- Squats to 60 degrees
- Active-assisted ROM stretching, emphasizing full knee extension (flexion to tolerance
- Hamstring and gastroc/ soleus and quadriceps stretches
- Bicycle for ROM when patient has sufficient knee ROM. May begin partial revolutions to recover motion if the patient does not have sufficient knee flexion
Phase II: Internal Phase :
Goals:
- Restore and improve muscular strength and endurance
- Reestablish full pain free ROM
- Gradual return to functional activities
- Restore normal gait without an assistive device
- Improve balance and proprioception
Weight bearing status:
Patients may progress to full weight bearing as tolerated without antalgia. Patients may require one crutch or cane to normalize gait before ambulating without assistive device.
Therapeutic exercise:
- Continue all exercises as needed from phase one
- Toe raises- calf raises
- Hamstring curls
- Continue bike for motion and endurance
- Cardio equipment- stairmaster, elliptical trainer, treadmill and bike as tolerated.
- Lunges- lateral and front
- Leg press
- Lateral step ups, step downs, and front step ups
- Knee extension 90-40 degrees
- Closed kinetic chain exercise terminal knee extension
- Four way hip exercise in standing
- Proprioceptive and balance training
- Stretching exercises- as above, may need to add ITB and/or hip flexor stretches
Phase III – Advanced activity phase:
Goals:
- Enhance muscular strength and endurance
- Maintain full ROM
- Return to sport/functional activities/work tasks
Therapeutic Exercise:
- Continue to emphasize closed-kinetic chain exercises
- May begin plyometrics/ vertical jumping
- Begin running program and agility drills (walk-jog) progression
- Sport specific drills
Criteria for discharge from skilled therapy:
- Non-antalgic gait, pain free /full ROM
- LE strength at least 4+/5
- Independent with home program
- Normal age appropriate balance and proprioception
- Resolved palpable edema