Rehabilitation and Return to Play Following

Meniscal Repair
Owen M. Lennon, PT, DPT, OCS,* and Trifon Totlis, MD, PhD†

The outcome of meniscal repair has been good to excellent with regard to functional restoration
and return to play (RTP). Athletes represent the most demanding subgroup of patients as they
have high expectations to return to their preinjury level of activity and in doing so they place
maximum stress on any meniscal repair. Physical therapy rehabilitation protocols and RTP
decision-making remains controversial in the setting of meniscal repair. Protective protocols
had been the mainstay of treatment for many years, however, newer research has shown no
harm and quicker RTP for longitudinal and bucket-handle tears located close to the outer
vascular zone of the periphery of the meniscus using accelerated rehabilitation. Protective
protocols and slower RTP remain the most prudent choice in complex, horizontal and radial
tears or those extending into the middle to central third of the more avascular zone of the
meniscus. The authors have therefore, with evidence from current publications, developed
2 separate protocols to treat both peripheral and complex tears. One accelerated and one
protective protocol is established. During the preoperative planning, it would be helpful for the
surgeon, patient, and family to know what can be expected with regard to the surgical success
of meniscal repair and the likelihood of RTP in this active population. A literature review on the
outcome of meniscal repair related to RTP was performed and revealed that the majority of
patients succeed to RTP at the same or similar to their preinjury level, between 4 and 6 months
following meniscal repair. Factors that may affect the outcome and RTP along with
rehabilitative considerations following meniscal repair are discussed.
Oper Tech Sports Med 25:194-207 C 2017 Elsevier Inc. All rights reserved.

KEYWORDS meniscus repair, sports-specific patient reported outcomes, return to play,

rehabilitation protocol, prognostic factors, meniscus preservation

Introduction The medial meniscus covers 64% of the medial tibial plateau
and the lateral meniscus covers 84% of the lateral tibial plateau.

T he knee is one of the most commonly injured joints with

participation in contact sports such as football and rugby
as well as sports requiring quick changes of direction such as
basketball, soccer, and volleyball. The functional importance of
the meniscal tissue has been well described in the literature1
with many studies describing its shock absorption, stabiliza-
tion, proprioceptive, and lubrication or nutrition functions.2
*Professional Orthopedic and Sports Physical Therapy, Uniondale, NY.
†Thessaloniki Minimal Invasive Surgery (TheMIS) Orthopaedic Center,
St. Luke's Hospital, Thessaloniki, Greece.
Address reprint requests to Owen M. Lennon PT, DPT, OCS, 333 Earle
Ovington Blvd, Suite 225, Uniondale 11553, NY. E-mail: olennon@
professionalpt.com
Address reprint requests to Trifon Totlis MD, PhD, TheMIS Orthopaedic
Center, Adrianoupoleos 6, 55133 Kalamaria, Greece. E-mail: totlis@
med.auth.gr
Several biomechanic studies have described the excursion of
the menisci with knee motion. It is generally accepted that the
medial meniscus has approximately 5 mm of movement and
the lateral meniscus 11 mm in the anterior to posterior direction
with knee flexion 0°-120°, respectively.3,4 Less of this motion
occurs at the posterior horns making them more susceptible to
shear forces in ligamentous deficient knees. The peripheral
10%-30% of the medial meniscus border and 10%-25% of the
lateral meniscus are relatively well vascularized, which has
important implications for meniscal healing.5 This meniscal
excursion, accompanied by low vascularity in the inner third of
the meniscus has led to varying approaches in surgical
technique and postoperative rehabilitation over the years.
It is widely accepted that meniscectomy induces degener-
ative changes in the knee.6-10 Especially in high-level athletes,

194 http://dx.doi.org/10.1053/j.otsm.2017.07.007
1060-1872//& 2017 Elsevier Inc. All rights reserved.
Meniscal repair
short-term cartilage degeneration has been reported following
meniscectomy.11,12 Therefore, the treatment strategy for
meniscal tears is currently focused on preserving as much
meniscal tissue as possible13 and meniscal repair and partial
meniscectomies have replaced total meniscectomies.14-22
Meniscal repair techniques have significantly advanced,
since originally described by Annandale,23 from open to
semi-open to all-arthroscopic repairs.24,25 Depending on the
type and location of the tear, the meniscus may be repaired
using standard meniscal repair techniques including outside-
in, inside-out, and all-inside repair. The outcome of arthro-
scopic-assisted or all-inside meniscal repair has been good to
excellent.26
As with nearly all orthopedic procedures, the quality of
postoperative rehabilitation makes remarkable effects on out-
comes and return-to-play (RTP) timing and performance. An
excellent repair followed by inadequate physical therapy is
doomed to delay RTP or subsequently fail. The interdiscipli-
nary and integrated contributions by all members of the sports
medicine team enable the greatest likelihood of RTP at
preinjury levels of performance.
Rehabilitation Following
Meniscal Repair
Rehabilitation programs fall into 1 of 2 categories: protective or
accelerated. Protective protocols suggest non-weightbearing
and no knee flexion greater than 90° for the first 6 weeks and
no deep knee flexion for 4-6 months.27 While accelerated
programs allow for early weight-bearing and range of motion
(ROM) with variable progression of strengthening. A recent
meta-analysis by O'Donnell et al,28 noted early range of motion
and immediate postoperative weight-bearing appear to have
no detrimental effect on the chances for clinical success after
isolated meniscal repair. Additionally, a recent study by
McCulloch et al27 found the forces spanning the site of a
longitudinal medial meniscal tear during simulated gait to be
compressive rather than gapping or distraction in all measured
states. Weight-bearing reduces the meniscus and stabilizes the
tear in repaired bucket-handle lesions as well. On the other
hand, in complete radial tears of the lateral meniscus, axial
loading induces circumferential stress, the so-called “hoop
stress,” which may distract the tear margins.98 Contributing to
the challenge of rehabilitation decision-making are the multi-
tude of variables described in the literature; including tear type,
location, tissue quality, surgical technique, concomitant injury,
and patient as well as therapist adherence to the rehab protocol
progression. Published literature regarding efficacy of meniscal
repair has not discussed specific physical therapy treatments
indicated, aside from classification within accelerated or
protective protocol progression and range of motion restric-
tions. Additionally, mechanism of failure (spontaneous or
traumatic), and participation levels at time of reinjury have
been lacking in outcomes reporting.
Longitudinal and bucket-handle tears located close to the
outer third (vascular zone) of the periphery of the meniscus are
progressed more rapidly in the rehabilitation process than
195
complex, horizontal, and radial tears or those extending into the
middle to central third of the more avascular zone of the
meniscus. It is imperative that a good working relationship be
established by the surgeon and sports physical therapist to
ensure communication of specifics of the surgical intervention
which may individualize each rehabilitation protocol. How-
ever, the guiding principles of the rehabilitation program
should be defined clearly.
The following describes the authors preferred approach
to rehabilitation in the patient who has undergone meniscal
repair. It includes two protocols which differ between periph-
eral and complex tears that have been defined previously.
(Tables 1 and 2). Portions have been adapted from pro-
tocols previously published by Brotzman and Wilk,29
Cavanaugh and Killian,30 and Noyes et al.25 It is imperative to
note, progression from one phase to the next is not timeline-
based. This progression is based on meeting specific goal
focused criteria within each phase (as described below).
Each phase should focus on set goals and only once these
goals are accomplished may the patient be advanced to the
next phase. The timelines provided are purely a guide with
respect to the anticipated healing continuum. These times are
the quickest a patient could likely advance in order to protect
the repair within their own strength, power and agility
capabilities.
Protective Phase (0-6 Weeks)
During weeks 0-6 postoperatively (protection phase), care
should be taken to ensure adequate healing and limit stressors
and shear forces to the healing meniscus. Early in the protective
phase (day 1–week 3) pain control, edema reduction, pro-
prioceptive activities, neuromuscular re-education of the
quadriceps, and early return of full passive knee extension
should be the primary focus. Hyperextension should be
avoided for anterior horn repairs. Multidirectional patellar
mobilizations should be performed to prevent hypomobility.
Core strengthening along with upper body ergometer use for
aerobic conditioning should be added in the patient that is
progressing rapidly and in search of additional or continued
conditioning.
Restoration of range of motion typically varies according to
the surgeon's preference alongside intraoperative findings.
However, 0°-90° at the end of week 1, 0-100° at week 2, 0°-
120° at week 3 and 0°-135° (passively) by week 4 are
commonly seen guidelines in peripheral tears, respecting
patient's pain response and avoiding effusion. In complex
posterior tears, ROM is limited to 0°-70° for 3 weeks,
progressing to 0°-90° at week 4, and to 120° at week 5.
Weight-bearing is another frequently variable component of
postoperative rehabilitation protocols. In simple peripheral
repairs where an accelerated protocol will be used, heel touch
weight-bearing as tolerated with a long leg hinged knee
immobilized locked in extension for 6 weeks is our commonly
preferred approach. Weight-bearing is gradually advanced to
reach full weight-bearing at 6 weeks with normalized gait. In
complex repairs, nonweight-bearing for a 6-week period
remains the most protective of the repair. Factors such as
 196
Table 1 Accelerated Rehabilitation Protocol Following Peripheral Meniscal Repair
Bracing: Long leg hinged knee brace (locked in extension during walking) x 6 weeks
Weight-bearing: Heel touch weight bearing as tolerated with gradual return to full weight bearing and normalized gait at 6 weeks
Range of Motion (passive): * Respect patient’s pain response and avoid effusion*
Week 1: 0-90 degrees Week 3: 0-120 degrees
Week 2: 0-100 degrees Week 4: 0-135 degrees
** NO hamstring strengthening x 6 weeks due to semimembranosus and popliteus insertions on medial and lateral meniscus **

I. Protective Phase (0-6 weeks): II. Restoration Phase (6-12 weeks): III. Return To Activity Phase (12-16 weeks):
Manual Treatment: *Patient should have full PROM with no effusion, a normalized gait, and return *Patient must have good frontal and sagittal plane control,
– Multi-directional patellar mobilization of neuromuscular control of the lower extremity to progress appropriate strength, and perform low-level skipping and
Stretching: hopping with good form and no symptoms to initiate running
– Early return of full passive knee extension ROM with overpressure (avoid hyperextension in anterior horn
repairs) – Continue prn (add piriformis, TFL, and psoas) program.
Stretching:

Stretching: as indicated for gastroc, hamstring, quad (within protected Strengthening: – Continue as indicated
ROM ranges) – Initiate closed kinetic chain squatting (above 90 degrees flexion), lunges,
Neuromuscular Re-education of Quadriceps: step-ups and step-downs Strengthening:
– Quad sets with biofeedback or burst mode alternating current (BMAC or Russian e-stim) – Initiate leg press (above 90 degrees) – Increase intensity and decrease repetitions for focus on
– Multi-angle quad isometrics – Begin hamstring strengthening (isometric -4 isotonic) muscular strength/hypertrophy

– Bosu/rocker board squats – Increase depth of closed chain activities (not to exceed 120
degrees flexion)
Strengthening: – Side-stepping – Isokinetic strengthening (if available)
– Straight-leg raises (4 ways) – Wall sits
– Active knee extension – Dead lifting (bilateral -4 unilateral) Balance/Proprioceptive Training:
– Core strengthening – Continue core strengthening – Advance single leg activities with sport specific activities (ie.
ball toss, contralateral kicks, passing, dribbling, etc)
Balance/Proprioceptive Training: Balance/Proprioceptive/Neuromuscular Training:
– Weight-shifting (both legs) – Advance to single leg activities Conditioning: Concept Ergo Ski Machine, interval cycling, or
stair master can be utilized.
– Advance unstable surfaces
Running: (upon surgeon clearance)
Gait Training – Biodex or BOSU balance
– Initiate interval treadmill jogging program.
Conditioning on Upper Body Ergometer (UBE) if desired
– Include eyes closed drills
Stationary cycle once 110 degrees knee flexion achieved
Advance time and intensity of cycling
Cryotherapy x 20 minutes
Modalities prn for edema and pain control May initiate kick board or free style swimming
Cryotherapy x 20 minutes

IV. Sports Preparation Phase (16-20/24 weeks): V. Return To Play (based on surgeon preference):
*Patient should be able to single leg half squat, free weight squat of 1.5 – 2.5x body mass (BM) Cutting: Return to play testing at 20-24 weeks
and squat 60% of BM in 5 seconds in order to progress to plyometric training (Davies et al 2015) 45 degree turns progressing to 90 degree cutting at week 16-20 – Star Excursion balance test (SEBT)
Dynamic Activity:
– Agility t-test
– Initiate Mach Drills (A-Skip, B-Skip) Sports Specific Skills:
– Hop Testing
– Lateral shuffle, carioca – Consider specific demands of sport and incorporate activities simulative of
Single leg hop distance
sport.
Triple hop for distance
– Sports Cord drills Consider/mimic fatigue associated with game play.
Crossover hop for distance
– Broad jump
6m hop for time
– Vertical jump

O.M. Lennon, T. Totlis

– Vertical Jump Testing
Plyometric Training:
– Computerized testing
– Begin with bilateral activities. DorsaVi, Dart Fish video analysis, and/or jump map
testing
– Advance plyometrics once single leg broad jump 490% uninvolved leg.
– Focus on short ground contact time to train tissue elasticity
Table 2 Protective Rehabilitation Protocol Following Complex Meniscal Repair

Meniscal repair
Weight-bearing: Non-weight bearing x 6 weeks Bracing: Long leg hinged knee brace (locked in extension) x 6 weeks
Range of Motion (passive): * Respect patient’s pain response and avoid effusion*
Week 0-3: 0-70 degrees Week 5-8: 0-120 degrees
Week 4: 0-90 degrees Week 9: 0-135 degrees
** NO hamstring strengthening x 6 weeks due to semimembranosus and popliteus insertions on medial and lateral meniscus **

I. Protective Phase (0-6 weeks): II. Restoration Phase (6-12 weeks): III. Return To Activity Phase (12-16 weeks):
Manual Treatment: *Patient should exhibit 120 degrees passive knee flexion *Patient should have full active knee range of motion, appropriate strength, and
– Multi-directional patellar mobilization with no effusion and return of neuromuscular control adequate dynamic knee control in single leg activities to progress
of the quadriceps to progress Stretching:
– Early return of full passive knee extension ROM with overpressure (avoid
hyperextension in anterior horn repairs) Stretching: – Continue as indicated
– Continue as indicated (add piriformis, TFL, and psoas)
Stretching: as indicated for gastroc, hamstring, quad (within protected ROM ranges) Strengthening:
Neuromuscular Re-education of Quadriceps: Strengthening: – Increase intensity and decrease repetitions for focus on muscular strength/
– Quad sets with biofeedback or burst mode alternating current (BMAC or Russian – Initiate closed kinetic chain squatting (above 90 degrees flexion), lunges, hypertrophy
e-stim) step-ups and step-downs – Increase depth of closed chain activities (not to exceed 90 degrees flexion until
– Multi-angle quad isometrics – Initiate leg press (above 90 degrees) after 14 weeks)
– Begin hamstring strengthening (isometric -4 isotonic) – Isokinetic strengthening (if available)
Strengthening: – Side-stepping
– Straight-leg raises (4 ways) – Wall sits (begin at 70 degrees) Balance/Proprioceptive Training:

– Active knee extension – Dead lifting (bilateral -4 unilateral) – BOSU or Biodex Balance

– Core strengthening – Continue core strengthening – Introduce eyes closed drills

– Bosu/rocker board squats (within protected range)
Crutch training: NWB x 6 weeks Balance/Proprioceptive/Neuromuscular Training: – Advance to single leg activities with sport specific activities after 14 weeks (ie.
ball toss, contralateral kicks, passing, dribbling, etc)
Conditioning on Upper Body Ergometer (UBE) if desired
– Begin with weight-shifting (both legs)
Cryotherapy x 20 minutes
Modalities prn for edema and pain control – Advance to single leg activities
Conditioning:
– Progress cautiously to unstable surfaces
– Advance time and intensity of stationary cycling.
– Concept Ergo Ski Machine or stair master may be used
Gait Training: Slowly advance gait training with emphasis on heel-toe patterning
Initiate stationary cycling
– Freestyle swimming or kick board are permitted but breast stroke should be
avoided
Cryotherapy x 20 minutes
Continue modalities prn for edema and pain control

IV. Sports Preparation Phase (16-24 weeks): Return To Play (based on surgeon preference):
*Patient must have good frontal and sagittal plane control, appropriate strength, and *Patient should be able to single leg half squat, free weight squat of 1.5 – 2.5x Return to play testing at 24 weeks
perform low-level skipping and hopping with good form and no symptoms to initiate body – Star Excursion balance test (SEBT)
running program mass (BM) and squat 60% of BM in 5 seconds in order to progress to
Strengthening: plyometric training (Davies et al 2015)
– Agility t-test

– Increase depth of closed chain activities to 120 degrees Plyometric Training: – Hop Testing
Single leg hop distance
– Advance single leg closed chain strengthening – Begin with bilateral activities Triple hop for distance
– Advance plyometrics once single leg broad jump 490% uninvolved leg Crossover hop for distance
Running: (upon surgeon clearance) – Gradually progress to short ground contact time to train tissue elasticity 6m hop for time
– Initiate interval treadmill jogging program @ 16-24 weeks dependent on tear
characteristics, healing, and patient progress Cutting: – Vertical Jump Testing

– 45 degree turns (20-22 weeks) progressing to 90 degree cutting at week – Computerized testing
Dynamic Activity: (22-24 weeks) DorsaVi, Dart Fish video analysis, and/or jump map testing
– Initiate Mach Drills (A-Skip, B-Skip)
– Lateral shuffle, carioca (20 -22 weeks) Sports Specific Skills:

– Sports Cord drills – Consider specific demands of sport and incorporate activities simulative of
sport. Consider/mimic fatigue associated with game play
– Broad jump

197
– Vertical jump
198 O.M. Lennon, T. Totlis

body mass index (BMI), tear location, tissue quality, patient

compliance, and concurrent injury, all play a role in the
decision-making process for gradual return to full weight-
bearing.
It is important to note that the semimembranosus has an
attachment at the posterior horn of the medial meniscus and
the popliteus on the lateral meniscus; and, as such, care should
be taken with hamstring exercise for 6-weeks postoperatively.
The upper body ergometer can be used to maintain
conditioning in the nonweight-bearing or range of motion
restricted patient. Stationary cycling should not be added until
the patient can easily achieve 110° flexion and should not be
utilized to gain ROM due to the shear forces exerted on the
repair. Figure 2 Trap bar deadlift. (Color version of the figure available
online.)

Restoration Phase (6-12 Weeks)

To progress to the next stage in the rehabilitative process, the
patient should have full PROM with no effusion, a normalized
gait, and return of neuromuscular control of the lower
extremity. Quadriceps control as well as frontal and sagittal
plane stability about the knee should be good and the patient
must have the appropriate confidence to progress with a closed
chain program.
ROM in complex tears may remain at 0°-120° for the first
2 weeks of this phase (weeks 7 and 8 postoperatively) due to an
effort to further protect the repair in situations of friable tissue
or other intraoperative concerns. In the complex tear, the
patient will require gait retraining at the onset of this phase and
balance - proprioceptive training will be initiated beginning
with weight-shifting.
Closed kinetic chain squatting along with forward and
lateral step-ups or step downs (Fig. 1), dead-lifting (Fig. 2), and
single leg strengthening activities can be advanced (within
protected ranges). Additional focus should be placed on single
leg balance - proprioceptive activities during this period.
Swimming can be used as a conditioning tool if available;
however, kick-boards, freestyle, or backstroke should be the
only strokes used as breast-stroke involves a significant varus
and valgus moment at the knee and could potentially
contribute to shear forces across the repair.
Return to Activity Phase and Sport Preparation
Phase (12-24 Weeks)
The primary initial goal during the return to activity phase is to
advance strength to preinjury levels. Return to activity further
advances neuromuscular training and subsequently proceeds
to advance from low-level hopping exercises to a controlled
interval jogging program. Conditioning activities are advanced
for full restoration of cardiovascular conditioning. The goal of
the sport preparation phase is to assure adequate explosive
strength, elastic or reactive strength, and speed with excellent
knee mechanics. Activities that mimic the fatigue and loads
associated with sports participation but in a controlled
environment that continue to protect the repair are used as
described later.
Assuming the patient has progressed in an uncomplicated
fashion, strengthening activities can continue to be advanced in
this stage (increased intensity with decreased repetitions).
Closed chain activities can be progressed in ranges below

A B

Figure 1 (A) 8′′ Lateral step down and (B) 8′′ forward step-down. (Color version of the figure available online.)
Meniscal repair
90° but not to exceed 120° in peripheral tears. In complex
tears, closed chain exercises squatting and leg press should
remain above 90° until after 14 weeks. Care should be taken to
avoid patellofemoral pain or patellar tendon overload symp-
toms from compensation with progressive load.
Although isokinetic machines have fallen out of favor in the
noninstitutional setting due to their size and pricing, if they are
available to the clinician they can be used during this stage to
comprehensively evaluate for peak torque, work, power, and
other qualitative data. This allows for continued targeted
strengthening to combat persistent muscular weakness and
asymmetries.
Aerobic conditioning continues to be of benefit during the
return to activity phase. Advanced interval cycling, concept
ergo ski machine, or stair master may all be used based on their
availability. It is important to monitor for compensation, be
mindful of cumulative patellar tendon loads and to avoid
excessive patellofemoral loads associated with fatigue in these
conditioning activities.
Many surgeons clear jogging by 12-16 weeks postoperatively
in peripheral tears and 16-24 weeks for complex tears.
Graduated return to jogging (with surgeon clearance) is
allowed, provided that patients have good frontal and sagittal
plane control, appropriate strength, and perform low-level
skipping and agility activities with good form and no symp-
toms. Return to jogging should be performed in a controlled
setting, beginning with interval jogging and with slow, con-
trolled progression of distance (treadmill or track). This will
vary based on the athlete's sport participation (cross-country
runner vs line-backer) but not to exceed 20%-25% per week
until they have met their preinjury distances.
Resistive lateral exercises (sports-cords) (Fig. 3) can be
added in this phase with careful monitoring to avoid tibial
external rotation bias compensation upon hip abductor or
external rotator fatigue.
Following a successful return to jogging a plyometric
program can carefully be progressed. Care should be taken
because ground reaction forces experienced during such
activities place tremendous amounts of stress on the athlete's
structure. While jumping, ground reaction force can be
4-11 times one's body weight.31 Davies et al31 determined
the criteria needed to initiate a plyometric program as the
ability to perform a single leg half squat (Fig. 4), free weight
A B
Figure 3 (A-C) Sport cord lateral bounding. (Color version of the figure available online.)
199
squat of 1.5-2.5× body mass (BM) and squat 60% of BM
(Fig. 5) 5 times in 5 seconds. The initiation of plyometric's in
the meniscus repaired athlete should be carefully considered
and not based solely on the timeline on a protocol.
Lateral shuffling, carioca, and Figure 8 runs can be
progressed after 16-18 weeks in the peripheral repair and after
20-22 weeks in the complex repair. This can be slowly
progressed to 45° turns and eventually 90° cuts in the later
stages of rehab closely followed by RTP testing at 20 weeks for
peripheral tears and 24 weeks for complex tears.
Return to Play
As has been described extensively in the literature with regard
to RTP following anterior cruciate ligament (ACL) reconstruc-
tion, there is not one singular test but rather a battery of tests
that have been shown to be effective in assisting in RTP
decision-making. Panariello et al,32 described a rehab-modified
hierarchy of athletic development for guidance in RTP
decision-making. Single leg hop, cross-over hop, and timed
6-m hop testing has also been described in the literature with
age, sex, and activity based norms for guidance in RTP as
well.33,34 Plisky et al.35 and Gribble et al.36 describes normative
data for the star excursion balance test. The authors advocate
completion of comprehensive testing, with not only compar-
ison to the nonsurgical limb, but to the aforementioned norms
that have been published in the literature which we believe are
most suggestive of the demands of the game and play a critical
role in RTP decision-making.
In the ideal patient population (tear in vascular zone, ideal
tissue, excellent fixation, and aggressive early weight-bearing
program) permission to RTP is given at 4-5 months. Under-
standably, in complex tears or in situations where other factors
contribute to concern for healing, RTP may take upwards of
6 months or greater. RTP will be further discussed in the
following sections.
RTP Following Meniscal Repair
Meniscal Repair Outcome
Different methods have been used to interpret the results of
meniscal repairs. These have included patient history and
C
200
A B
Figure 4 (A and B) Single leg half squat. (Color version of the figure available online.)
clinical examination, diagnostic tests such as arthrography or
magnetic resonance imaging (MRI), and follow-up arthro-
scopic evaluation. Arthrography or MRI has not been accurate
in evaluating the postoperative meniscal status. These imaging
studies have limited sensitivity in determining tear patterns,
actual tear size, the portion of the tear that did not heal, or
degeneration in a meniscus after repair.37-40 Second-look
arthroscopy is the most objective method to assess healing
after meniscal repair.38,41-43
The rate of complete healing after meniscal repair is only
around 60% in the literature.44,45 However, it has been shown
that patients with incompletely healed menisci may remain
asymptomatic.46 Namely, Ahn et al46 reviewed meniscal
repairs in 140 patients who underwent simultaneous ACL
reconstruction. The authors reported only 84.3% completely
healed meniscal repairs at the second-look arthroscopy,
whereas the clinical success rate was 96.4%. This is because
some patients in the incompletely healed group showed no
Figure 5 Squat 60% of body mass (BM) 5 times in 5 seconds. (Color
version of the figure available online.)
O.M. Lennon, T. Totlis
meniscus-related symptoms.46 The clinical presentation of the
patient with a repaired meniscus trumps MRI or arthroscopic
appearance. Tenuta et al noticed 5 incompletely healed but
asymptomatic meniscal repairs during second-look arthro-
scopy. They introduced the term “satisfactory healed” meniscal
repairs for both the completely healed and the incompletely
healed but asymptomatic menisci.47 The condition of the
incompletely healed meniscus and its potential risk of increas-
ing failure rate with time and long-term protective effect on
cartilage are still unknown. Pujol et al. found no decreasing
outcomes with time, even for partially healed menisci.
They reported that the repaired meniscus, if still present, retain
a biomechanical function protecting articular cartilage from
degenerative changes.48
A meniscal repair is considered clinically successful when
there is no residual or recurrent meniscus–related pain or
mechanical symptoms and no subsequent surgical procedures
on the repaired meniscus.49-51 Α good to excellent clinical
success rate has been reported in most long-term follow-up
studies with a range between 59% and 100%.50,52-63 In a
systematic review and meta-analysis of studies with greater
than 5-years follow-up, the overall clinical success rate was
76.9%.64
Meniscal Repair Outcome Relevant to RTP
When considering RTP as an outcome measure, a postoper-
atively asymptomatic knee is only the beginning. Meniscal
repair is usually protected during the early postoperative
period to optimize healing. Immobilization and disuse have
a cost on knee function and the athlete has to regain muscular
control, proprioception, and confidence of use of his knee.65
Athletes represent the most demanding subgroup of patients
mainly for 2 reasons. First, they have high expectations to
return to their preinjury level of activity; and second, they place
the most load on the menisci and, as a result, place maximum
stress on any meniscal repair.50 Thus, during the preoperative
Meniscal repair 201

planning it is useful for the surgeon, patient, and family to have
realistic expectations with regard to the surgical success of
meniscal repair and the likelihood of RTP in this active
population.51
RTP Success Rate
In the literature there is high evidence to support the concept of
meniscal preservation by repair of torn tissue in the athletic
population.14-22 Overall, it seems the most patients succeed to
RTP following meniscal repair (Table 3). Logan et al50 reported
an 81% RTP rate in elite athletes of numerous sports, whereas
the remaining 19% did not want to risk reinjury and therefore
did not attempt return to their previous sporting level.
Tucciarone et al66 evaluated the results of meniscal repair in
professional football, American football, and basketball players.
They reported a 90% RTP after a minimum 2-year follow-up.
In another study by Mintzer et al, on individuals 17 years of age
or younger involved in varsity athletics at the time of injury,
92.3% of the patients successfully RTP at minimum follow-up
of 2 years. Only 2 patients did not return to their previous level
of sports activity due to reasons unrelated to their meniscal
surgery.51 Alvarez-Diaz et al26 reported that 89.6% of football
players succeeded to RTP after recovering from meniscal
repair.
Postoperative Sports-Specific Patient Reported
Outcomes
Other authors evaluated RTP following meniscal repair based
upon improvement of sports-specific patient reported out-
comes, such as the Tegner activity level. It seems that apart
from a high RTP rate, meniscal repair followed by a certain
rehabilitation program is consistently associated with a sig-
nificant improvement of Tegner activity level (Table 3). A high
postoperative Tegner score of 8 following meniscal repair on
patients younger than 18 years has been reported by Krych
et al73 after a 40.8-months mean follow-up period. Ahn et al74
reported the median Tegner activity level to be significantly
improved from 3 preoperatively to 7 after an average
59-months period from the meniscal repair. In the study of
Barber et al,76 the Tegner score was improved from 3.4
preoperatively to 7.2 after a mean of 30.7 months of follow-
up. In another investigation, the postoperative Tegner activity
score was improved significantly from 3.2 preoperatively to 5.7
after an 18-months mean follow-up period.77 Tiftikci and
Serbest72 reported as well a significant Tegner score improve-
ment from 3.7 preoperatively to 6.4, with a mean follow-up
period of 29 months.
Time From Surgery to RTP
Time from surgery to RTP may play a significant role in
decision-making when facing an athlete with meniscus tear.
A central question of an athlete who suffers a meniscal tear to
the physician is often related to this issue. Athletes who
demand early RTP may favor partial meniscectomy over
repair. In the literature, the average time for a patient who
underwent meniscal repair to fully participate in sports
activities range between 4 and 6 months. The authors
encountered only 3 studies reporting the exact time that
patients needed to RTP following isolated meniscal repair.
Alvarez et al26 reported a mean of 4.3 months for patients with
meniscal repair to RTP, whereas both of the other studies
mentioned that the mean time for RTP for the meniscal
tear group of their studies was 5.6 months.50,68 Other
investigators did not refer to when patients managed to
RTP. They only mentioned when patients were allowed to
return to sports activities according to the rehabilitation

Table 3 Review of the Literature on Return-to-Play (RTP) Rate and Activity Level Following Meniscal Repair
Study RTP (%) Preinjury Tegner Preoperative Tegner Postoperative Tegner
50
Logan et al 81
Tucciarone et al66 90
Mintzer et al51 92.3
Alvarez-Diaz et al26 89.6
Griffin et al67 80
Vanderhave et al68 88.9 8.0
Tsai et al69 8.0
Krych et al70 8.0
Lucas et al71 3.9 7.1
Tiftikci and Serbest72 3.7 6.4
Krych et al73 1.9 6.2
Ahn et al74 3.0 7.0
Barber and Coons52 2.8 6.1
Chiang et al75 3.5 6.2
Barber et al76 3.4 7.2
Kotsovolos et al77 6.42 3.21 5.7
Hetsroni et al78 8.0 4.0 7.0
Kraus et al79 7.6 7.0
Albrecht-Olsen and Bak80 6.0 5.0
Gallacher et al81 6.0 6.0
Schmitt et al82 7.6 7.3
Stein et al83 6.3 5.9
202 O.M. Lennon, T. Totlis

program guidelines that is between 4 and 6 months.72,84-88 Factors that May Affect the
(Table 4).
Outcome and RTP Following
Meniscal Repair
Activity Level Following Meniscal Repair
Another important variable is whether the patient will be able The factors that may affect meniscal repair success and RTP
to return to the preinjury level of activity or at a decreased level following meniscal repair are mainly related to the patient
following meniscal repair. Meniscal repair is associated with characteristics, the time of injury, the nature of the meniscus
return to a high level of activity, which may be the same or at tear or concomitant injuries, the activity level of the patient, the
least approximate to the preinjury level. Alvarez et al26 reported operative techniques and the postoperative rehabilitation.
that 89.6 % of the football players who underwent meniscal Taking into consideration the prognostic factors during
repair returned to the same level of competition after the decision-making may be helpful to the proper patient selection
postoperative rehabilitation program. In another study, all for meniscal repair and application of the appropriate treat-
5 patients who were followed up for an average of 31 months ment options for each individual. This will maximize success of
succeeded to return to the former levels of activity.84 the repair and percentage of postoperative RTP (Table 5).
Kamimura et al86 noted that 60% (6 of 10) of the total number
of patients achieved their preinjury score, when the other 40% Patient Characteristics
recovered postoperatively to just 1 level below their preinjury
Gender and BMI of the patient have not been found to be
Tegner activity level. Most studies are in accordance with those
significant factors for success in meniscal repair.49,86
rates, showing that almost all patients return to the preinjury
level of sports and the average postoperative Tegner score is
Age
either equal or less than 1 point decreased from the preinjury
It has been found that meniscal tissue contains more cells and
score77-83 (Table 3). Τhe initial high rate of RTP following
has a better healing capability in younger individuals.93,94 As a
meniscal repair or the level of sports activities may over time
result, someone might expect a better outcome of meniscal
decrease in the long-term follow-up. However, this decrease in
repair in young patients, but the literature is not clear on this
RTP rates or level of activity is rather related to the patients'
point. Tenuta et al47 evaluated healing with respect to age and
personal life instead of the repaired meniscus itself (Alvarez
although overall there was no significant difference, in the
et al26, personal unpublished data).
concomitant ACL reconstruction group there was a significant
difference favoring younger ages. Tengrootenhuysen et al49
reported a significantly higher success rate in younger patients
Table 4 Time From Isolated Meniscal Repair to Return to Play as well. In a study that included only patients 17 years of age or
and Time From Isolated Meniscal Repair to Permission to younger the success rate was 100%.51 Eggli et al13 found
Participate in Full Sports According to Rehabilitation retears to be more frequent in older patients. On the other
Guidelines hand, some series have found no effect of age on healing rate
Study Return to Play Sports Permitted and outcome following meniscal repair.50,54,95,96 A recent
(mo) (mo) study with a 10-years follow-up compared meniscal repairs in
Alvarez et al26 4.3 patients younger than 40 years with patients 40 and older.
Logan et al50 5.6 They found no difference in success rate and general outcome
Vanderhave 5.56 4 between the 2 age groups. However, there was a significantly
et al68 higher Tegner activity scale in the young age, which may be
Çetinkaya et al85 6 explained by the fact that Tegner score and age have a
Kamimura et al86 6 significant correlation.97 This finding confirms Starke et al.
Tiftikci et al72 6 who mentioned that higher demands in sports and occupation
Biedert87 4
in the young population might compromise the outcome
Haklar et al84 4-5
Noyes et al88 6
despite a better intrinsic healing potential. At any rate, in
Noyes et al25 5-7 younger patients, meniscal preservation should be the pre-
Gallacher et al81 3 ferred option to reduce the risk of subsequent arthritis. Age
Majewski et al57 4 increases the likelihood of encountering a tear that is not
Krych et al70 4-6 suitable for repair and also additional factors, such as osteo-
Lind et al89 4-6 arthritic changes and alignment, should be taken into
Kotsovolos et al77 5 consideration.98
Bugonovic et al90 6
Chiang et al75 6
Choi et al91 6 Time of Injury
Hetsroni et al78 6 Time from injury to surgery appears to play a role in the
Lucas et al71 6 healing and general outcome of meniscal repairs. Many studies
Martin-Fuentes 6 have demonstrated that healing rates are improved when the
et al92
meniscal repair is done closer to the time of injury, especially
Meniscal repair 203

Table 5 Factors That Have Been Associated With Positive Outcome and Should be Considered in Decision-Making When Facing an
Athlete With a Meniscus Tear (RTP, Return to Play)
Factors Associated With Positive Strong Notes
Outcome Evidence
Young age – Repair is favored to reduce arthritis
Injury time less than – Prevents secondary tearing and fragments deformation/muscle atrophies
6-8 weeks and loss of proprioception
Longitudinal tear, bucket-handle tear, X Repair of horizontal and complete radial tears may be favored in young
meniscocapsular separation patients but needs conservative rehabilitation and delayed RTP
Small length of the tear – Success rates decline in tears larger than 4 cm
Lateral meniscus tear – Repair is favored because the potential sequelae of meniscectomy are more
serious
Tear in the red-red or X Repair of tears extending to the white-white zone may be favored in young
red-white zone patients due to increased healing capabilities
Concomitant ACL reconstruction – Healing may be enhanced but RTP follows the ACL reconstruction timeline

when it is performed earlier than 6-8 weeks from
injury.41,47,49,99-102 However, there are also plenty of recent
studies,54,63,86,95,103-105 as well as a systematic review by
Nepple et al64 including only long-term studies, which have
reported comparable results for both chronic and acute tears. A
reason for this might be the more careful indications for repair
or advancement of the operative techniques, including bio-
logical healing enhancement techniques. Early repair is
encouraged because chronicity may lead to deformation of
the fragments as well as secondary tears, which may render
either the fragments or the peripheral rim unsuitable for
repair.106 In athletes, repairing a meniscus tear soon after the
injury has not only the potential advantages on healing, but
also avoids the postinjury consequences on the affected limb,
such as muscle atrophies and loss of proprioception which
may delay postoperative RTP.
Meniscus Tear Characteristics
A meniscus tear has certain characteristics that the surgeon
must consider in his or her decision of whether or not to repair
or resect.98 These include tear type, the tear size, tear location
in the lateral or medial meniscus, and location according to
Cooper zones. These could be characterized as the “personality
of the tear” and may have prognostic value on the fate of the
meniscal repair.
Tear Type
The tear types which are universally thought to be the most
amenable to repair include longitudinal vertical tears, bucket-
handle tears, and meniscocapsular separations. Conversely, in
complex tears, such as degenerative tears, radial tears, and tears
with horizontal cleavage planes or multiple flaps, and also in
some oblique, undersurface tears that can extend from the
vascular zone to avascular zone, repair may be problematic and
partial meniscectomy has indications.107 In a study by Rubman
et al108 the reoperation rates for tibiofemoral joint symptoms
were 12% for single longitudinal tears, 27% for complex
multiplanar tears, 27% for radial tears, and 29% for horizontal
tears. Tengrootenhuysen et al49 found that the bucket-handle
tears had the greatest success ratio but overall the difference
among types was not significant.
In a systematic review of studies in which meniscal
horizontal cleavage tears were repaired, results showed that
existing studies of repaired horizontal cleavage tears demon-
strate a comparable success rate to repairs of other types of
meniscal tears.109 Pujol et al48 reported a 79% success rate at a
median follow-up of 40 months after open meniscal repair of
horizontal tears, with the regression curve by age demonstrat-
ing a significant decline in the functional results in patients
aged over 30 years. Twenty patients returned to sporting
activity at the preoperative level, but RTP was delayed at a
mean of 10 months after surgery, while the median KOOS
sports was 78 ± 25.48 In another study meniscal repair of
degenerative horizontal cleavage tears using fibrin clots
resulted into return to the preinjury Tegner activity level in
60% of the patients and to one level below the preinjury level
in 40% of the patients.86 Both of these studies allowed
patients to return to full sports not earlier than 6 months
postoperatively.48,86
Repair of radial tears has also shown improved short-term
clinical outcomes in a recent systematic review including
6 studies, where the vast majority of the tears were located
on the lateral meniscus. Three studies reported a satisfactory
average postoperative Tegner activity scores which ranged
from 5.7-6.7.110 Partial radial tears are usually problematic
because they often affect the central avascular parts, which limit
the chance of healing. In these cases, particularly in small radial
tears, debridement of loose edges is usually sufficient because
the important circumferential fiber bundles are mostly intact
and the function of the meniscus is retained.98
Tear Length
The influence of the tear length on the failure rate is
controversial. Kimura et al111 found no association between
the length of the tear and healing rate. In the study by Tenuta
et al47 tears measuring 3-4 cm demonstrated a higher failure
rate but the difference with smaller tears was not significant.
Other authors have reported a substantially lower healing rate
for tears larger than 4 cm (50%) in comparison to tears smaller
than 2 cm (90%).41
204
Tear Location
As for the location of the tear, it has been reported that tears
extending from the posterior to the middle segments demon-
strate a better healing rate in comparison with the ones isolated
on the posterior segment. Furthermore, although some studies
could not observe any significant difference in the outcome of
repair for the medial and lateral meniscus,47,63 it seems that in
long-term studies there is a trend toward a slightly lower failure
rate in lateral meniscal repairs.64 Apart from this trend, we
would agree with Starke et al98 that since the potential sequelae
of meniscectomy are more serious in the lateral meniscus, then,
in the decision-making process, it matters which of the menisci
is affected.
Tear Vascularity
Most surgeons limit repair to lesions located in the red-red
(Cooper zone 1) and red-white zones (Cooper zone 2). In a
meta-analysis of long-term studies, similar failure rates were
encountered for tears located in Cooper zones 1 and 2 (20.9%
and 20.7%, respectively), but literature data on meniscal tears
in the white-white zone was limited.64 Two separate studies
reported a great decrease in the healing rates if the rim width
exceeded 4 mm from the meniscosynovial junction.41,47
Nevertheless, an extension of the tear into the avascular area
is not a contraindication for repair. Tears extending into the
avascular zone have been repaired with satisfactory
results.86,108 Especially in young athletes, where not only
increased healing capabilities exist but also meniscus preser-
vation is crucial, the chance of healing probably outweighs the
potential risks of the procedure.112
Attempts have been made to encourage bleeding in the
avascular white-white zone of the meniscus. Several authors
have used exogenous fibrin clots to augment repair and
promote healing in tears located in the avascular zone.45,86
Although both of these studies included few cases, this
technique was successful and associated with return to the
previous or close to the previous level of sports.45,86 Another
bleeding stimulation technique which has been shown to
significantly reduce retear rate following repair of tears
extending to the white-white zone is trephination of vascular
channels on the free meniscal edges.113 Other clinical applica-
tions that augment meniscal repair and may promote healing
include microfracture of the intercondylar notch and platelet-
rich plasma.86
Concomitant ACL Reconstruction
There is an ongoing debate on the positive effect of
concomitant ACL reconstruction on the healing of the
repaired meniscus. Many studies have reported superior
healing rates following meniscal repair in conjunction with
ACL reconstruction compared to meniscal repair alone in
knees without ACL injury.47,49,63,66,114-116 The explana-
tion is well-known and it is based on the hemarthrosis
generated during ACL reconstruction, which provides
the joint cavity with serum factors and fibrin clots
that modulate the healing response of meniscal
O.M. Lennon, T. Totlis
fibrochondrocytes. On the other hand, several authors
did not find any positive effect of the ACL reconstruction
on the success rate of the meniscal repair.26,50,108
Patients with isolated meniscal repair, as mentioned earlier,
usually RTP between 4 and 5 months postoperatively. How-
ever, concurrent ACL reconstruction elongates the time from
surgery to RTP. Vanderhave et al68 allowed sports at 6 months
following surgery in the combined meniscal repair and ACL
reconstruction group, whereas the isolated meniscal repair was
cleared to RTP at 4 months. In both groups permission for RTP
was based on clinical progress.68 Most authors allow patients
who underwent meniscal repair along with ACL reconstruc-
tion to participate in sports activities after 6 months post-
operatively if certain clinical goals have been achieved.95,117,118
In the study of Vanderhave et al,68 the isolated meniscal repair
group succeed to RTP almost 3 months earlier (mean ¼ 5.56
months) than the concomitant ACL group (mean ¼ 8.23
months). Further, the postoperative activity level for patients
without ACL was found to be significantly greater (mean
Tegner score 8.00) than that for patients with ligament
reconstruction (mean Tegner score 6.8). The longer time from
surgery to RTP in patients with concurrent ACL reconstruction
and meniscal repair is confirmed by Logan et al, but the
postoperative Tegner score was similar in both groups in the
study of Alvarez et al.26
Repair Technique
Whether the repair technique can affect the healing response
and long-term outcome may concern the surgeon. As for the
suture orientation, in general, vertical sutures are preferred to
horizontal stitches, as they result in stiffer repairs.98 Several
studies have been published in an attempt to establish the
optimum repair technique. A systematic literature review
reported no difference in failure rates between inside-out and
all-inside meniscal repair techniques for isolated meniscal tears.
The postoperative Tegner activity scale was also found to be
equal between both techniques.119 All-inside techniques were
associated with a higher rate of implant-related complications,
whereas the prevalence of nerve symptoms was higher with the
inside-out technique.119 Today, open meniscal repair is rarely
performed. Indications might include a very tight medial
compartment or concomitant pathologies, which need to be
addressed through an incision, such as meniscal cysts. Pujol
et al48 reported high healing and RTP rates following open
meniscal repair of horizontal meniscal tears in young patients
at mean of 4 years. However, it seems that open meniscal repair
needs a more conservative rehabilitation protocol and delays
RTP.48
Postoperative Rehabilitation Program
The most controversial factors in rehabilitation protocols are
immobilization and weight-bearing status. A recent systematic
review on this issue concluded that early ROM and immediate
postoperative weight-bearing has no influence over clinical
outcomes after isolated meniscal repair.28 How the therapist
Meniscal repair
should deal with ROM and weight-bearing as well as with
other details of the rehabilitation program was discussed in the
first section of this article.
Summary
Current evidence suggest that rehabilitation programs should
be individualized and take into consideration the “personality”
of the tear and concurrent procedures, aiming at an accelerated
rehabilitation process and RTP while avoiding deleterious
effect on healing of the repaired meniscus. On this manner,
in the present study, we established 2 different rehabilitation
protocols. An accelerated program for peripheral meniscus
tears and a conservative program for complex tears. In the
long-term, meniscal repair is associated with a high success rate
in returning athletes back to their sports, which ranges between
59% and 100%. Postoperative RTP level is usually the same or
similar to the preinjury level. When isolated repair is
performed RTP is accomplished in approximately 5 months,
whereas when it is combined with an ACL reconstruction
6 months or more are needed. Strong evidence to support
meniscal repair over meniscectomy in decision-making exists
in meniscocapsular separation, longitudinal and bucket-han-
dle tear types, and those tears located in the 2 outer thirds of
the meniscus. Other factors which have been associated with
superior outcome following meniscal repair include young age
of the patient, less than 6-8 weeks between injury and
operation, small length of the tear, location of the tear in lateral
meniscus and concomitant ACL reconstruction.
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