What is the recommended rehabilitation protocol after meniscal repair?

Rehabilitation After Meniscal Repair

When concomitant meniscal repair is performed, the early rehabilitation phase must be adapted according to the surgeon's specific instructions, as the standard accelerated ACL rehabilitation protocol should be modified to protect the healing meniscus. 1

Key Principle: Surgeon-Directed Modifications

The rehabilitation protocol after meniscal repair depends critically on tear characteristics and surgical technique, requiring direct communication with the operating surgeon 1. Unlike isolated ACL reconstruction where accelerated rehabilitation is mainstream, meniscal repairs demand individualized restrictions based on:

• Tear location: Peripheral tears (vascular zone) versus central one-third tears (avascular zone) 2
• Tear pattern: Simple peripheral tears versus complex multiplanar tears 2
• Tear stability: Stable versus unstable tears 3
• Repair technique: Suture configuration and number of sutures used 4

Weight-Bearing Restrictions

The evidence regarding weight-bearing is contradictory, but the most recent high-quality data suggests caution with immediate full weight-bearing. A 2023 multicenter French Arthroscopy Society study found immediate weight-bearing was associated with a 3.6-fold increased failure rate (OR=3.6, p=0.0016) compared to delayed weight-bearing 3. This directly contradicts older studies from the 1990s that supported accelerated protocols 5, 6.

Recommended Approach:

• Defer full weight-bearing for 4 weeks for large tears or tears involving circumferential fibers 3
• Weight-bearing as tolerated may be considered for small, stable peripheral tears only 5
• Avoid excessive joint compressive forces during the initial healing phase 2

Range of Motion

Immediate knee mobilization should be initiated, but with flexion restrictions that are progressively advanced. 1, 2

Progressive Flexion Protocol:

• Weeks 0-4: Restrict to 90-45° 1
• Week 5: Progress to 90-30° 1
• Week 6: Progress to 90-20° 1
• Week 7: Progress to 90-10° 1
• Week 8: Full ROM 1

The 2023 French study found that flexion limitations (used in 97% of cases) were not associated with increased failure rates, supporting their safety 3.

Bracing

Postoperative knee bracing should NOT be routinely used. The 2023 French study demonstrated that brace use was associated with a 2.83-fold increased failure rate (OR=2.83, p<0.001) and lower quality of life scores 3. Multiple ACL guidelines also recommend against routine postoperative bracing 1.

Exercise Progression

Quadriceps strengthening exercises should be initiated on postoperative day one, but with modifications to protect the meniscus. 2

Early Phase (0-6 weeks):

• Isometric quadriceps exercises (non-weight-bearing and weight-bearing) 1
• Closed kinetic chain exercises should be prioritized over open kinetic chain 1
• Avoid excessive compressive forces that could disrupt healing 2

Intermediate Phase (6-12 weeks):

• Open kinetic chain exercises (90-45°) may begin at 4 weeks, but add no extra weight for first 12 weeks to prevent graft elongation 1
• Neuromuscular training should be combined with strength training 1

Tear-Specific Modifications

Patients with peripheral meniscus tears are progressed more rapidly than those with central one-third tears or meniscal transplants. 2

• Peripheral tears: May follow more accelerated protocols with earlier return to activity 2, 4
• Complex/central tears: Require more conservative progression with extended restrictions 2
• Unstable tears: Warrant additional caution with weight-bearing and loading 3

Common Pitfalls

The major pitfall is applying standard ACL rehabilitation protocols without meniscal-specific modifications. 1 The 2023 Aspetar guideline explicitly states that when concomitant injuries like meniscal repairs are present, the early rehabilitation phase must be adapted 1.

Another critical error is assuming all meniscal repairs require identical restrictions. The wide variation in rehabilitation protocols reported in the literature (from highly restrictive to fully accelerated) reflects the lack of consensus, but recent evidence favors a more cautious approach than 1990s-era accelerated protocols 3, 4.

Return to Sport Criteria

Return to sport should be based on objective criteria, not time alone. 1 Minimum criteria include:

• No pain or swelling 1
• Full knee ROM 1
• Limb symmetry index >90% for strength and hop tests 1
• For pivoting/contact sports, LSI of 100% is recommended 1
• Completion of sports-specific training program 1

The rehabilitation timeline is typically 9-12 months when combined with ACL reconstruction 1, though isolated meniscal repairs may progress faster depending on tear characteristics 2.