What is the recommended rehabilitation protocol for a relatively healthy patient with no significant past medical history undergoing medial meniscus repair?

Medial Meniscus Repair Rehabilitation Protocol

Immediate Post-Operative Phase (0-6 Weeks)

For a healthy patient undergoing isolated medial meniscus repair, implement immediate structured rehabilitation with protected weight-bearing for 5 weeks, progressive range of motion restrictions, and early quadriceps activation without added resistance for the first 12 weeks. 1, 2

Weight-Bearing Protocol

• Begin partial weight-bearing immediately post-operatively 2
• Progress to full weight-bearing only after achieving specific functional criteria at approximately 5 weeks 1
• Avoid postoperative knee bracing, as it increases failure rates 2.83-fold and reduces quality of life scores 2

Range of Motion Progression

• Achieve full knee extension (0°) immediately 1
• Follow strict flexion restrictions to protect healing tissue 1, 2:
  • Weeks 0-4: Restrict flexion to 90-45° 1, 2
  • Week 5: Progress to 90-30° 1, 2
  • Week 6: Progress to 90-20° 1, 2
  • Week 7: Progress to 90-10° 1, 2
  • Week 8: Full ROM achieved 1, 2

Early Exercise Protocol

• Initiate quadriceps activation exercises on postoperative day one 1, 2
• Critical caveat: Add no extra weight for the first 12 weeks to prevent graft elongation 1, 2
• Prioritize closed kinetic chain exercises over open kinetic chain 2
• Open kinetic chain exercises (90-45°) may begin at 4 weeks but without added resistance 2
• Maintain no effusion or trace effusion only throughout this phase 1

Intermediate Phase (6 Weeks - 3 Months)

Progression Criteria (Not Time-Based)

Before advancing to this phase, patients must demonstrate 1:

• Limb symmetry index (LSI) >80% for quadriceps strength 1
• LSI >80% eccentric impulse during countermovement jump 1
• Pain-free aqua jogging and Alter-G running 1
• Pain-free repeated single-leg hopping 1

Exercise Advancement

• Initiate closed kinetic chain exercises with progressive resistance 1
• Combine neuromuscular (motor control) training with strength training—these cannot replace each other and must be performed together 1, 2
• Neuromuscular training optimizes self-reported outcomes and reduces secondary injury risk 1

Advanced Phase (3-9 Months)

Neuromuscular Focus

• Continue combining strength training with motor control exercises throughout this phase, as altered neuromuscular function after meniscal repair increases subsequent injury risk 1
• Address psychological factors including self-efficacy, locus of control, and fear of reinjury using objective instruments 1
• Progress to sport-specific training only after meeting objective criteria 1

Return to Sport Criteria (9-12 Months Minimum)

Patients must achieve ALL of the following objective criteria before return to sport—time alone is insufficient 1, 2:

Clinical Criteria

• No pain or swelling 1, 2
• Full knee ROM with stable knee examination 1
• Normalized subjective knee function (IKDC, ACL-RSI, Tampa Scale) 1

Strength and Performance Criteria

• For pivoting sports: Isokinetic quadriceps and hamstring peak torque showing 100% symmetry at 60°/s 1
• For non-pivoting sports: LSI >90% for strength and hop tests 2
• Countermovement jump and drop jump >90% symmetry 1
• Reactive strength index >1.3 for double leg and >0.5 for single leg (field sports) 1
• Running mechanics with >90% symmetry of vertical ground reaction forces 1

Critical Pitfalls to Avoid

• Never progress based on time alone rather than functional criteria—this leads to suboptimal outcomes 1
• Never neglect neuromuscular training in favor of strength training alone—this increases reinjury risk 1, 2
• Never clear patients for return to pivoting sports before achieving 100% strength symmetry—90% is insufficient for these activities 1
• Never use postoperative knee bracing routinely—it nearly triples failure rates 2

Special Considerations

Concomitant ACL Reconstruction

If ACL reconstruction was performed concurrently, extend the total rehabilitation period to 9-12 months minimum before return to high-intensity sport 1, 2. Success rates for meniscal repair are significantly higher (92%) when performed with ACL reconstruction compared to ACL-deficient knees (67%) 3.

Tear Location and Characteristics

The rehabilitation protocol must be adapted based on tear location (red-red zone versus red-white zone), tear size, and surgical technique—direct communication with the operating surgeon is essential 2, 4.