What is the best course of treatment for a patient with a history of knee surgery who has undergone meniscal repair surgery using an inside-out technique on the anterior horn area?

Post-Operative Management of Anterior Horn Meniscal Repair Using Inside-Out Technique

For anterior horn meniscal repairs performed with the inside-out technique, implement immediate structured rehabilitation with protected weight-bearing for 5 weeks, followed by progressive functional restoration over 9-12 months, as meniscal repair demonstrates superior long-term outcomes compared to meniscectomy. 1, 2

Immediate Post-Operative Phase (0-6 Weeks)

Weight-Bearing Protocol

• Maintain non-weight-bearing status for 5 weeks post-operatively 3
• This extended protection period is critical for anterior horn repairs to allow adequate tissue healing before mechanical loading 3
• Progress to full weight-bearing only after achieving specific criteria (see below) 4

Early Rehabilitation Goals

• Achieve full knee extension range of motion immediately 4
• Progress knee flexion gradually: restrict to 90-45° during weeks 0-4, then advance to 90-30° by week 5,90-20° by week 6,90-10° by week 7, and full ROM by week 8 4
• Maintain no effusion or trace effusion only 4
• Begin quadriceps activation exercises immediately, but avoid adding extra weight for the first 12 weeks to prevent graft elongation 4

Technical Considerations for Inside-Out Repairs

The inside-out technique you've used for the anterior horn is particularly well-suited for this location, as it allows predictable avoidance of neurovascular injury without requiring large posterior incisions 5. Inside-out repairs demonstrate equivalent clinical success rates (88% at 3 years) compared to other techniques when combined with appropriate rehabilitation 3.

Intermediate Phase (6 Weeks - 3 Months)

Progression Criteria

Before advancing, patients must demonstrate:

• Limb symmetry index (LSI) >80% for quadriceps strength 4
• LSI >80% eccentric impulse during countermovement jump 4
• Pain-free aqua jogging and Alter-G running 4
• Pain-free repeated single-leg hopping 4

Strength Training Protocol

• Initiate closed kinetic chain exercises with progressive resistance 4
• Add neuromuscular (motor control) training to strength training—these cannot replace each other and must be combined 4
• Neuromuscular training optimizes self-reported outcomes and reduces risk of secondary injury 4

Advanced Phase (3-9 Months)

Functional Restoration

• Combine strength training with motor control exercises throughout this phase, as altered neuromuscular function after meniscal repair increases risk of subsequent injury 4
• Address psychological factors including self-efficacy, locus of control, and fear of reinjury using objective instruments 4
• Progress to sport-specific training only after meeting objective criteria 4

Return to Sport Criteria (9-12 Months Minimum)

Do not clear patients for full return to sport until ALL of the following are achieved:

Objective Measures Required

• No pain or swelling 4
• Full knee ROM with stable knee examination 4
• Normalized subjective knee function (IKDC, ACL-RSI, Tampa Scale) 4
• Isokinetic quadriceps and hamstring peak torque showing 100% symmetry at 60°/s for pivoting sports 4
• Countermovement jump and drop jump >90% symmetry 4
• Reactive strength index >1.3 for double leg and >0.5 for single leg (field sports) 4
• Running mechanics with >90% symmetry of vertical ground reaction forces 4

Goal-Based vs. Time-Based Progression

Use functional goal-based criteria rather than rigid time-based protocols 4. Patients advance to the next phase only when specific objective goals are achieved and confirmed with testing 4. This "traffic-light method" ensures patient-tailored rehabilitation and accounts for individual differences in neuromotor learning 4.

Critical Pitfalls to Avoid

Common Errors

• Premature weight-bearing before 5 weeks risks repair failure, particularly for anterior horn tears 3
• Progressing based on time alone rather than functional criteria leads to suboptimal outcomes 4
• Neglecting neuromuscular training in favor of strength training alone increases reinjury risk 4
• Clearing patients for return to sport before achieving 100% strength symmetry for pivoting sports 4

Monitoring for Failure

Clinical success is defined as absence of swelling, joint line tenderness, locking, negative McMurray test, and no need for subsequent meniscectomy 6. The overall clinical success rate for inside-out anterior horn repairs is 88-92% when proper rehabilitation protocols are followed 3, 6.

Concomitant ACL Considerations

If ACL reconstruction was performed concurrently (which improves meniscal repair success rates), extend the total rehabilitation period to 9-12 months minimum before return to high-intensity sport 4. The presence of ACL reconstruction significantly improves meniscal repair healing rates compared to isolated meniscal repair 5, 3.