[Physio Explained] Rehab after meniscus surgery: practical guidelines for clinicians with Airelle Giordano

In this episode with Airelle Giordano, we discuss two recent papers which cover the meniscus knee rehabilitation consensus. We explore:

• Patient eligibility for a Menisectomy
• Rehabilitation post Menisectomy
• Precautions and contraindications post menisectomy
• Return to sport post meniscal repair

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Airelle Giordano serves as the Director of Clinical Services, Residency, and Fellowship Training at the University of Delaware Physical Therapy Clinic. She is a Board-Certified Clinical Specialist in both Sports and Orthopedic Physical Therapy and holds the position of Associate Professor in the University of Delaware Doctor of Physical Therapy Program. Currently, she is the President of the American Academy of Sports Physical Therapy (AASPT). Her clinical expertise centers on complex knee injuries, gait retraining, and post-concussion rehabilitation.

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Our host is @James_Armstrong_Physio from Physio Network

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Transcript

SPEAKER_01 0:05

When you move into a meniscus repair right after surgery, we as physical therapists need to understand, and I'm and and I put this out to the surgeons as well to please help us understand what you fixed in there. What was the quality, right? Are you confident in your repair? And there's ways of putting that up prescriptions and letting communicating that to us, right? But I do need to understand: was it a vertical tear? Was it a horizontal or oblique tear? Did you have to add more sutures in order to stabilize it? So knowing that information helps us understand maybe how fast we can move.

SPEAKER_00 0:39

Today on the Physio Explain podcast, we're joined by Ariel Gordano to explore the latest evidence and international consensus on meniscal surgery and rehabilitation. Ariel has been closely involved in two landmark papers, the EU-US Meniscus Rehabilitation 2024 Consensus Part 1, which covers rehabilitation management after menistectomy repair and reconstruction, and part two, which focuses on prevention, non-operative treatment and return to sport. In this episode, we unpack these two papers and what they mean for day-to-day practice, how we should be rehabbing meniscal tears, the key distinctions between menestectomy and repairs, and the patient and tear characteristics that might guide us towards surgery versus conservative care. We also dive into return to sport criteria and highlight the biggest takeaways that can help clinicians refine their approach to this complex but common injury. So if you want to translate cutting-edge consensus into practical strategies for better outcomes, this episode is for you. I'm James Armstrong and this is Physio Explained. Ariel, thank you so much for coming onto the Physio Explained podcast. Really great to have you on to talk about two really interesting papers that you were involved with. So thank you so much for giving up your time today.

SPEAKER_01 2:01

Thank you very much for having me, James.

SPEAKER_00 2:03

We'll kick off for those listeners that may have not seen these two papers of part one and two looking at this miniscule rehabilitation consensus. Talk us through, Ariel, about what the papers were aiming to achieve and why there's a part one and part two. I think that's probably quite an interesting point, isn't it?

SPEAKER_01 2:21

Great question. So these are two larger pieces of work. This is the first time that ESCA, AOSSM, and AASPT have gotten together. So as a physical therapist, this is the first time that the American physical therapy group has been brought into the fold on a consensus document that's worldwide. So that was really exciting for us. I'm the current president of the American Academy of Sports Physical Therapy. So this was a great opportunity for us to be a part of this. And coming into this, we really wanted to get together. There's been a lot of consensus statements out there about different things when it comes to meniscus and many other surgeries too, depending on the country, the demographic, right? There's a lot of differences, cultural variations, and so on that occur. And we wanted to come together across the world and understand how we all treat meniscus injury. And bringing the American side into the fold did bring up some other circumstances that I was pretty passionate about, such as direct access, because we can see people in the United States without a prescription. And so when a patient, client, or athlete, when they don't see a physician first, what happens? And how do we handle that on the physical therapy side? So things like that brought up great conversation. The reason for two papers is because there was so much content. And there were other consensus documents from ESCA in the past in regard to the surgical side of meniscus injury, but we took that one step forward in looking at rehab after surgery, but also rehab without surgery.

SPEAKER_00 3:57

And it is a really interesting read. And I particularly like the way it's separated into the two parts. I actually think it makes it a lot more manageable for the reader and almost tells a story as you work through the two papers. So I think it's it's really nice to see that. So sort of working through the papers then, Ariel. So we we looked at the first paper, which looks at rehabilitation management after meniscus surgery. What does that paper tell us in more detail about how maybe we should be rehabilitating these patients and this patient group?

SPEAKER_01 4:28

Yeah. In a very short period of time, I'll I'll tell you what we came up with. We had a huge steering group. We had 14 countries on this document. We had lots of physicians, lots of physios and physical therapists that were involved. So a lot of opinions, a lot of data, and a lot of conversation. So that was really exciting. This part one dealt with minasectomy. So we split things into more an acute tear or a degenerative tear. And so when you're looking at the acute slash traumatic, that's how you'll see it termed in these documents. So traumatic meaning, right, it happened just now, it's not degenerative over time. We looked at who is eligible for a minisectomy and who isn't. Along with that menisectomy, then you move into if what we're trying to do in all the medical professionals is to keep the meniscus as much as possible. And so hopefully we don't have to resect the meniscus. We can repair the meniscus and who is qualified for that and who isn't. That again, that is really on the surgical side, which wasn't defined in this paper. But what was defined is what type of rehab is done that's different from a menisectomy where you take out part of the meniscus to a repair where you're suturing the meniscus and how that meniscus is left or how the repair has taken. What did the surgeon see in there? What are the circumstances around that repair? Is the is the patient younger? Are they older? Are they athletic? Are they not? What's the environment look like? Is there joint damage, right? All of those factors then leads to how we should look at rehab after the repair or the menisectomy.

SPEAKER_00 6:04

And in terms of some of the things, it often gets talked about in terms of meniscule surgery or rehabilitation post-operatively and also ACLs. We talk about these precautions and things we shouldn't be doing. And it is sometimes debated. What's this consensus coming out with in terms of some of the things that we still should be avoiding for certain times?

SPEAKER_01 6:26

I think that's a really important question. Even here in the United States, I do think it's different with some of the surgeons that were on this call with tons and tons of experience that work in academia, that publish, right? That are they're really involved in the research side of things. At times they do things differently, meaning some surgeons have the ability to communicate better with their physical therapists, right? Some own their physical therapy practice, some don't. Some are in rural areas, so they don't have much communication. It all depends on many factors. I know some of the experiences I have that we will get a prescription from the physician and it'll say, meniscus repair. Well, then I'm looking at the knee and I'm determining am I seeing an incision on the medial side, the lateral side? The patient usually doesn't know. Sometimes they do, sometimes they don't. How much was repaired? Was it horizontal? Was it vertical? Was it complex? Are there other factors such as an ACL reconstruction or something like that, which does possibly change the environment for healing when you're talking about a meniscus repair? So there's more, there's more blood and healing factors that are in there after an ACL reconstruction. So sometimes the environment's a little better for meniscus repair than if you're repairing the meniscus alone. And that's where you'll also see some of our literature here. An ACL tear and a meniscus tear often come together, right? They occur simultaneously. And so we're seeing a lot of those surgeries together. So trying to split the evidence and only looking at ACL or only looking at meniscus was hard. You know, our prevention and some of our return to sport things are really based on the ACL literature as well, because ACL includes meniscus. So things we should be avoiding. So in a minisectomy, you're looking, you're most everyone's weight bearing is tolerated afterwards. You want to decrease joint irritation. But when the meniscus is taken out and there's nothing repaired, you're a little more free as a physical therapist to get them moving, start weight bearing. What I think is really important is you need to understand what the joint looks like. So if you're talking about a menisectomy in a 55-year-old, my guess is their joint isn't going to look the same as a meniscus a menisectomy in a 22-year-old. And so you may be able to move a little faster in the 22-year-old. But then on the flip side, you're thinking about how do I educate them? Because now without that meniscus and that cushioning for our joints as we age, you're going to be increasing, you're going to be advancing that degenerative process probably a little faster than if I were taking that meniscus out for the first time at the age of 55. When you move into a meniscus repair right after surgery, we as physical therapists need to understand. And I'm, and I put this out to the surgeons as well to please help us understand what you fixed in there. What was the quality, right? Are you are you confident in your repair? And there's ways of putting that on prescriptions and letting communicating that to us, right? But I do need to understand was it a vertical tear? Was it a horizontal or oblique tear? Did you have to add more sutures in order to stabilize it? So knowing that information helps us understand maybe how fast we can move. And also when you're when they're doing the repairs at this time, there are certain things that the certain materials that they're using that also can injure the meniscus while they're trying to repair it, right? They're they're putting things through the meniscus. That's a very thin and soft structure. And so just understanding how that works is really important. If you only understand that that the medial, the lateral side has been repaired, that's not really helpful as a rehab individual. So in the beginning after repair, most likely, in the consensus agreed, is that we would be restricting weight bearing for a period of time. Most likely four to six weeks. The more complicated the repair gets, right? Posterior horizontal root repair, and you're adding more complicating factors and sutures, the longer the weight bearing takes to return. And the longer you're limited in weight bearing and flexion, right? So first you need to weight bear and extension and fully weight bear, then you weight bear into more knee flexion, watching your shear forces. So those are the things as rehab professionals, we need to be cautious on cautious in. And then if you understand where the repair is, then you think about the activities you're giving to them. And in the rehab process, you need to work through those activities from, you know, adding more weight bearing to then adding more weight bearing with motion because you're going to be straining those healing structures. That's probably more of the precautions, weight bearing precautions and some range of motion precautions in the beginning, especially if you have a repair.

SPEAKER_00 11:00

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarize the latest and most clinically relevant research for instant application in your clinic. So you can save time and effort keeping up to date. Click the link in the show notes to try Physio Network's research reviews for free today. So essentially, it's really quite useful to, if you don't get enough information, is to ask for more information from the surgeon. If you don't necessarily have that direct contact with them all the time, is still seek that information out and gain more information rather than just treating it as a meniscal repair.

SPEAKER_01 11:39

Correct. I would I would try to get the op report. We know sometimes it is really hard to communicate with surgeons. It's not their fault. They're very busy, they have lots going on. And so if we can get better communication via the prescription, or let's try to get their op report and that will hopefully give you some up some information.

SPEAKER_00 11:57

Absolutely. And in in terms of the the types of patients and the types of tears that we're more likely to see go through forward to surgery, is there any consensus on on that at all?

SPEAKER_01 12:09

In meniscus back in the day, it was easy. You took a piece of it out, you got them back after a menisectomy in four weeks. Medial side, maybe you got them back in two weeks. Or they maybe they didn't even see you after a rehab. It was easier with the ACL too. Took out the meniscus, you could, you had no precautions pretty early after surgery. Now we realize that's not the great thing to do, right? We have osteoarthritis that sets in regardless of whether you have your ACL reconstructed or not after an ACL tear, you're going to have arthritis. And the meniscus really affects that and its progression and how fast that happens. So we want to save that meniscus as much as possible. I would say that's probably the number one thing out of anything we do with these patients is if we can prevent that surgery, as long as it's it's it's in a stable environment and people can return to function, then we should do that. And so trying to take the least amount out of there as possible or repair it so that we can try to save that environment for as long as possible.

SPEAKER_00 13:06

So then we move on to an interesting area, which is the return to sport criteria. What's it telling us more about this?

SPEAKER_01 13:14

This is something we haven't hit on, but which covers every aspect of rehab that we're doing in these documents is criterion-based milestones versus time-based. And especially return to sport and our rehab guidelines throughout this process are all related to time and criterion. There's only few only time requirements. And that's really in the meniscus repair that you get to that healing time frame. So when you return to sport, you need to reach a timeline, a time related guideline as well as criterion. And if one hits first, that doesn't matter. You have to wait for both of them, right? So if we're at six months and you had a medial meniscus repair and you're only at 70% quad index and you have an effusion, I don't care if you're a year out, maybe you shouldn't be going back to sport, right? Now, that's also opens the door for harder conversations and complexities and those type of things when you're way beyond the time frame and you're not meeting the criterion-based milestones. However, if you hit all the criteria and you haven't hit the time, in these cases, that really does not mean you should be going back to sport. So our sport timeline or our sport criteria, you'll see them parallel the ACL literature. The recommendations here aren't as highly rated as far as like grade A and grade B evidence. And it is more C and D, meaning the expert opinion of the group, because we took a lot of it from ACL. It's grade A evidence in the ACL literature, but again, we can't necessarily pull out just meniscus rehab in those individuals. There's not enough data out there. So we did parallel that to ACL and recommend similar guidelines in return.

SPEAKER_00 15:00

Brilliant, brilliant. It's pretty interesting. I think a lot of people are going to want to take a much deeper dive into both these papers, and I'd highly recommend it. But from your point of view, Ariel, what would you say are some key takeaways that would help the physiotherapists and therapists listening to improve their rehabilitation of meniscal injuries, whether that be pre or post?

SPEAKER_01 15:23

I would say understand load management. So we need to load tissue. And more than ever, I feel like we're we we need to understand a loading progression. And after that meniscus, whether it's taken out and now you're loading the tissue that no longer has that meniscus in between it. And so that tissue is being loaded for the first time, or you're post meniscus repair and you're loading that new heeled tissue or scarred down tissue potentially, you need to be cautious about how to do that, what planes of motion you're doing that in, and of course getting through body weight before adding other torques and motions and weight, right? So understanding mode management, how is the knee responding? This is a great example of swelling, is effusion is often telling you whether the knee is unhappy or not. And yes, people say, Oh, I'm a sweller. Well, the knee's swelling and telling us something, not just because you ate something bad today. So it's telling us if we loaded too much. Or sometimes actually you'll see that swelling hangs around when you're unloaded altogether, because we also need load to heal, but too much load is also detrimental. So we need to get the quad going, load management, effusion management, and then I would say measuring what you do. So are you measuring quad strength? How are you measuring quad strength? It is laid out here that a manual muscle test is not adequate. And even handheld dynamometry is not adequate unless it's tethered down in some way, shape, or form. So that you have a real isometric test and that you're measuring. You should be doing NMES for the quad. But beyond that, know your milestones, know how to measure them so that you can meet them and/or say why you're not meeting them. These people find really good ways after knee injury to cheat. And they'll get around using that quad and they'll use their glute and they'll use their posterior chain. And sometimes it's really hard to look at and to find. And if you're measuring their quad, and obviously their hamstring and their gastroc and all those things, but really largest focus on the quad, you'll see that you'll be improving if those factors that you're measuring are improving.

SPEAKER_00 17:40

Brilliant, brilliant. So we've managed to do it pretty much in time as well. But I think I can't recommend highly enough to have a look at both these papers because they do really set things out very, very straightforward. It's very, it's quite an easy read, I'd say. It's very well structured. But I think we've covered some really key points today, Ariel. So thank you so much for your time. As you mentioned, we could talk about this for absolutely hours, and I know you could probably talk about it for days and days and days. So I really appreciate this the short amount of time that we've given you to do such a great job. So thank you.

SPEAKER_01 18:11

Thank you very much. Thanks for having me.

SPEAKER_00 18:13

All the best