42 F is io te ra p ie , J u n ie 1983, d e e l 39, n r 2 POST-MENISCECTOMY REHABILITATION E L L I S J A N K S , B.Sc. (P hy sio ) ( W itw a te rs r a n d ) , B.Sc. ( Me d.) (H o n s .) , S po r t s Sciencc (U.C .T.)* SUM M ARY Rem oval o f the sem i-lunar c a rtila g e /s (m enisci) o f the k n ee is a c o m m o n su r g ic a l p ro c e d u re. S u r g e o n s r e c o g n iz e the im portance o f an exercise p ro g ra m m e supervised by a physiotherapist, in order to obtain the best p ost-operative rehabilitation. However, the b est m e th o d o f post-operative rehabilitation has been a controversial issue. C ontrolled studies to determ ine the relative e ffectiveness o f d ifferent treatm ent regim es are reviewed. S u b sta n tia l research is being carried out to determ ine the physiological e ffe c ts o f surgical procedures, subsequent im m obilization a nd d iffe re n t fo r m s o f exercise oil the leg. These are discussed a nd considered in fo rm u la tin g the ideal p o st-m e n isc ec to m y rehabilitation program m e. The e ffe c ts a nd im portance o f iso k in e tic exercise is em phasized. INTRO DUC TIO N The aim o f a re h ab ili ta ti on p r o g r a m m e is to re tu rn the pa tie n t to full functi on al capa cit y in as short a time as possible. Cl early, functi on al d e m a n d s differ from pa tie nt to pati en t a n d this must be con sid ere d w h e n a r eh abi lit ati on p r o g r a m m e is fo r m u la t ed . T h e physiological c ha ng e s which o c c u r a f t e r m e n i s c e c t o m y a n d t h e s u b s e q u e n t imm ob ili z at io n o f the injure d leg a re reviewed. The physiological effects o f the va rio us types of exercise are cons id ere d a n d these are ap pl ie d in the f o r m u la t io n o f a post- m en isc ect om v r e h ab ili ta ti o n p r o g r a m m e . PRE-OPERATIVE M ANAGEM ENT F o r pa tie nt s with c hr on ic injuries, a pre-o pe ra tiv e p r o g r a m m e o f exercises sh o u l d be p e rfo rm e d. Logic suggests that this sh o u l d s tr e n g th e n the leg p r i o r to surgery ( M c A u s tl a n d , 1943; L uck et a !, 1948; W y n - P a rr y et al„ 1958), a n d sh o u l d in tr o d u c e the pati en t to the type o f exercise he will be requ ired to p e r fo r m imme dia tel y a fte r the o p e r a t io n ( Me eki so n, 1944; Yocu m et al. 1978). It sh o u l d be n o t e d , however, that no c o ntr ol led studi es have been pe r fo r m e d to de te rm in e w h e th er o r not pre-surgical c o n d it i o n in g is o f a n y value. POST-O PERA TIVE CARE Immediately (first hours) after surgery Exercise re h ab ili ta ti on sh o u l d star t soon a fte r the o p e r a t io n , possibly even in the a n aes th eti c recovery room. Logically, this sh o u l d help to minimise muscle a tr o p h y an d we akn es s which results fro m partial o r total po st- ope rat ive imm ob ili z at io n o f the leg ( M c A u s t l a n d . 1943; Luck et a!., 1948; M ee kison. 1944; W y n n - P a r r y eta!., 1958). This has not yet been proven. T o u r n iq u e t - i n d u c e d ischaemic d a m a g e to nerves a n d muscle may pr event effective vo l u n ta r y m o ve m e n t i mm ed iat ely a f te r sur gery ( W e i n g a r d e n et al.. 1979). This p a r t of the exercise p r o g r a m m e m ay there fo re be o f limited value a n d is a possible area for fu r t h e r investigation. *Priv ate P ra cti tio ne r, C a p e To wn . Received 10 J a n u a r y 1983. O P S O M M IN G V erwydering van die sem i-lunere kra a k b ee n (m enisci) van die k n ie is ’n algem ene chirurgiese prosedure. Chirurge erken die belong van oefenprogram onder loesig van 'n fisio te ra p e u t vir die beste post-operatiew e rehabilitasie. Dog. die beste metocle van post-operatiew e rehabilitasie bly betwisbaar. G ekontroleerde studies om die relatiew e e ffc k tiw ite it van verskillende behandelingsprogram m e le b e p a a i word bgskryf. H eelw at navorsing w ord tan sg ed o en om d iefisio lo g ie se e ffe k te van chirurgie, im m obilisasie en verskillende vorm s van o e fe n in g o p die been le b epaai Dil w ord b e sp ree k en oorw eegin die fo rm u le rin g van die ideale p o sl-m e n ise kto m ie rehabilitasie program . Die e ffe k te en belong van isok in e tie se oefening word beklem toon. Subsequent days after surgery. Th er e have been tw o trad it io na l m e t h o d s o f early m a n a g e m e n t o f pati en ts w h o have h a d meniscectomies. In the first t r e a tm e n t regime (I) a co m pr e ss io n b a n d a g e o f the R ob e rt Jo n e s type is ap p lie d f r o m mid -t hi gh to below the knee soon af ter the op e r a t io n , a n d the p a tie n t is con fined to bed for a b o u t ten days, a fte r which his sti tches are removed. T h e pati en t exercises by first pe r fo r m i n g static c on tra ct io n s o f the q u a d r ic ep s femoris muscles a n d later, str aig ht leg raises are a dd e d . Knee flexion is a t t e m p t e d when it is p e r fo r m e d within the limits o f pain ex perienced by the pa tient. T h e p a tie n t is allowed to walk, first t ak in g partial weight on the injured leg with the aid o f cru tche s, a nd pro gr es sin g to full weight be a r i n g by a b o u t two to three weeks. In the secon d tr e a tm e n t regime (II), a n a n kl e to groin p la st e r cast is applied to the leg o v e r a c o m p r e ss io n ba n d ag e. T h e cast is eit he r ap plied imm e d ia te ly a fte r the o p e r a t io n o r sh or tl y th ereafter. The patient is all owed ou t o f bed a n d walking with the aid o f cr u tc he s within da y s o f the op er ati on . He m ay b e a r full weight on the o p e r a t e d leg as soon as pain permits. A n u m b e r o f co n tr o l l ed studi es have been pe r fo r m e d to deter mine the relative effectiveness o f the two different tr e a tm e n t regimes (Nelson, 1968; R o s b o r o u g h . 1979; G o u g h , 1975; L e o n a r d , 1975). O t h e r s have r e p or te d results ob t ai n e d when using o ne or o t h e r o f the regimes (Smillie, 1963; D u t c h ie a n d M c L o e d , 1943; W y n n - P a r r y et al., 1958; T e r h u r n e et al., 1943; L an tz ou n is , 1931). T he results o f these are su m m a r i z e d in T abl e I. The results in this table suggest t h a t pa tie nt s tr ea te d with regime II a p p e a r to have fewer days o f f wo rk a n d fewer p o st ­ o pe rat ive c o m p l i c a ti o n s t h a n d o p ati en ts tr ea te d with regime I, a l t h o u g h in so m e studies the differences are not m ark ed . The results o f these studies are based purely on subjective ob se rv at io ns . T h e degree o f f u nc tio n that the pati en t has before r e tu r n in g to work m ay vary greatly between individuals. Th eir m o ti v a ti o n to re tu r n to w ork may likewise be d i f f e r e n t . P a i n p e r c e p t i o n a n d p o s t - o p e r a t i v e c o m p li ca tio n s may also be viewed as being largely subjective. Th er e fo re , the results are no t co mpletely valid p a r a m e t e r s on which to base a scientific c o m p a r i s o n o f the respective t r e a tm e n t regimes. A m or e effective m e t h o d o f ev alu ati n g the re tu rn o f muscle str en gth a f te r surgery w o ul d be to R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p h y s io th e ra p y , J u n e 1983, vo l 39, n o 2 43 T able 1. No. o f Regime da ys off A u t h o r T ype of pati en t followed work I II Smillie (1963) Service & heavy X — 90 Du tc h ie & M c L o ed (1943) A rm y X — 82 W y n n - P a r r v el al. (1958) Air Force X — 62 T er hu ne e1 al. (1943) All o c c up a ti on s — X 50 L a n t z o u n i s (1931) All o c c up a ti on s c o m b i n a ­ 38 tion Ne lso n (1968) All o c c up a ti on s X 43.5 X 42 G o u g h (1975) All o c c up a ti on s X 52 X 45 L e o n a r d (1975) All o c c up a ti on s X 53.5 X 51 R o s b o r o u g h (1970) N o t stated X II was X less than I — value no t given Post-operative com pl ica tio ns 23,4% 23% 15,2% 10% mea sur e the st re ng th o f the leg muscles du r i n g isokinetic c on tr a c t i o n t h r o u g h o u t the full ra ng e o f knee m o v e m e n t at different c o n tr a c t i o n velocities. T he m o r e vigo rou s a p p r o a c h o f p u t ti n g the o p e r at ed leg in a plaster cast (regime II) seems to yield slightly be tte r t r e a tm e n t results t h a n the m o r e co nse rvative tr ea tm e nt (Regime I). A dd it io n a l ad vantages o f placing the op e r at ed leg in a plas ter cast im m e d ia te ly a f te r surgery are: • Prote cti on o f the o p e r a t io n site fro m d a m a g e due to m ov em e nt o f the k n e e/ le g. • W h en co n sid eri n g the limited availability o f space a n d staff in hospit als a n d the high costs o f ke e p i n g a patient in hospit al, it m ak e s go od sense to d isc ha rg e the pati en t in the quick es t possible time ( G o u g h , 1975). This is best achieved by placing the op e r at ed leg in a long leg plaster cast a n d gettin g the pa tie n t up a n d walking as s o o n as possible. Possible di sadvantages are: • J o i n t a n d muscle chang es. A lt h o u g h there are definite c ha nge s in a j o i n t a n d its s u r r o u n d i n g s tr uc tu re s whe n the j o i n t is i mm ob ili zed , all soft tissue c ha nge s in r a bb it limbs are reversible if the limb is not imm ob ili zed for m o re th an thirty day s ( M c D o n o u g h , 1981). Similarly, in spite o f the long leg plas ter b e in gc ar e f ul ly appli ed , there will still be a certain a m o u n t o f m o v e m e n t o f the leg within the plaster cast ( K r a c k o w a n d Vetter, 1981). T her ef or e, to put a leg i nto a long leg plas ter cast (ankle to groin) for 10 to 14 day s shou ld no t cause a n y lasting o r irreversible chang es to the knee j o in t o r leg muscles ( E rik ss on. 1981). S U B S E Q U E N T P O S T - O P E R A T I V E T R EA TM EN T Until recently, exercise r e h ab ili ta ti on p r o g r a m m e s f o r this stage o f t re a tm e n t hav e e m p h a si z e d st re ngt h trai nin g f or the injured leg to the exclusion o f all else. It is no w a p p a r e n t that equal, if not m o re a tt e n ti o n m us t be given to • the speed at which the exercises are p e r fo r m e d , a n d • the e n d u r a n c e trai n in g o f the muscles. (Ca m p be ll and Glenn, 1979). T hus, a l t h o u g h knee f un c tio n m ay a p p e a r to be “ n o r m a l ” in th at a ft e r a str e n g th - t r a i n i n g p r o g r a m m e the p a tie n t is able to lift the sa m e weight with o p e r a t e d a n d n on - o p e ra t e d legs, the o p e r a t e d leg m ay in fact not yet be “ n o r m a l ” in o t h e r respects. It may. f or exam pl e, be we ak at hi gh er o r lower c o nt r a ct io n velocities a nd it m ay have reduced e n d u r an c e capacity. Eith er o r both o f these deficiencies are likely to increase the c han ces o f re-injury. The principles o f t r e a tm e n t are: • A pr e -op er ati ve s t r e ng th e ni ng p r o g r a m m e o f exercises sh o ul d be given. • Exercise o f the injured leg is st a r te d a s soon a fte r the o pe ra tio n as possible. • The leg is placed in a plas ter cast until the stitches are re m ov e d . The pati en t can be ar full weight on the op e ra te d leg when pain permits. • Knee flexion exercises are c o m m e n c e d as so o n as the plaster cast is removed. • Exercise t r ai n in g mu st e m p h a si z e the d ev elo p m en t o f both muscle st re n gt h an d e n d ur an c e. T H E N A T U R E O F T H E D E C R E A S E D M U S C L E S T R E N G T H AFTER L IM B I M M O B I L I Z A T I O N Th ere is g o o d evidence th a t muscle st re n g th is decreased a f te r sur gery ( E rik ss on, 1981; Yo cu m el al., 1978). Ther e are three possible r e aso ns f o r this: Muscle fibre atroph y Muscle fibre a tr o p h y b e com es a p p a r e n t shortl y a fte r the o n s e t o f lim b i m m o b i l i z a t i o n , h a v i n g be en f o u n d i mm ed iat ely (Ca mp be ll a n d G l e n n , 1979) o r within the first week (E rik ss on , 1981) after surgery. Change in fibre composition o f the muscle E riksson (1981) show ed t h a t there was a cons id era ble decrease in Type 1 (slow twi tch) leg muscle fibres af ter i m m ob ili zat io n. Foll owi ng a few m o n t h s o f intensive exercise r eh abi lit ati on the original p r o p o r t i o n o f muscle fibre types was achieved. It was also sh o w n that im m o bi liz at io n o f the leg in a pos ition in which the muscle was u n d e r tension, caused less Type 1 muscle fibre a tr o p h y t han o c cu r r e d wh en the muscle was immo bi liz ed in the relaxed position. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 44 F is io te ra p ie , J u n ie 1983, d e e l 39, n r 2 Neurological factors Neurological factors plav an i m p o r t a n t role in the increase in muscle str en gth a l t e r exercise re hab ili tat io n a n d may be m ore i m p o r t a n t th an h y p e r tr o p h y o f the muscle. T he evidence i'or this has been supp li ed by G r i m b y (1982) who reported that when subjects are tr ain ed at low isokinetic (sec following section) c o n tr a c t i o n velocities (60°/s e c ) , increases in their peak t o r q u e p r o d u c ti o n can be achieved without either changes in limb cross-sectional girth or muscle fibre area . But. a fte r b e in g train ed at fast c o n tr a c t i o n velocities (300°/se c) , the increased to r q u e s p r o d u c ed were associated with en lar ge m e n t o f T yp e II fibres. This suggests that increased pe ak t o r q u e values achieved a fte r trai ni ng at high c o n tr a c t i o n velocities are due to h y p e rt r o p h y o f Type II muscle fibres, while at lower con tractile velocities, neurological a d a p t a t i o n s may be ope rative (Coyle el al.. 198 I ). These a d a p t a t i o n s could include: the type o f m o t o r unit being recruited, the n u m b e r o f m o t o r units being recruited a n d the frequency o f m o t o r unit act iv ati on ( S h e r m a n el al., 1982). A m o r e efficient s u m m a t i o n o f m o t o r units woul d also cause the muscle to p r o d u c e increased t or qu e (Coyle el al.. 19 8 1). A n y o r all these a d a p t a t i o n s c o ul d explain the “ cr oss-over effect" in which the st re n gt h o f the c on tr a - la t e r a l, n o n - o p e r a t e d leg is increased a fte r isokinetic t rai ni ng (see later). T hi s for m of st re ngt h increase also occu rs in the ab se nce o f an increase in muscle size. When a muscle c o n tr a c t s t h r o u g h its full range, it pr od u c es different to rq ue s at different muscle lengths o f jo in t angles. T he t o r q u e pr o d u c ed by a muscle in vivo is d e te r m in e d bv two factors: • the a m o u n t of o ve r la p o f the actin a n d m yosin filaments (i.e. the sa r co m e re length) in a c c o r d an c e with the classic len gt h-tension cu rve of muscle c o n tr a c t i o n ( Fo x a nd Ma th ew s. 198 I; G ow it z k e a n d Milner. 1980). • T he c h an ge in m cchanical a d v a n t a g e experienced by a muscle as the jo in t (a nd there fo re limb) moves t h r o u g h its range o f m o ve m e nt . In vivo, the muscles p ro d u c e their peak to rq u es at the jo in t angle th at p r od u c es the optimal mcchanical ad va nt ag e . D u r i n g knee ex tension, maximal to rq ue is p r o d u c e d at 56° knee flexion a n d this is tr ue for all a n g u l a r velocities o f knee m o ve m e nt . T h u s it is r e ason ab le to concl ud e th at weight lifting as the sole m e t h o d o f exercise r eh abi lit ati on is not a cce pt ab le, as the muscles will be w o r k in g m axi m all y d ur i n g only th ose pa rts of its range of m ov em e nt , a t which the joint has low mec han ic al ad v an t ag e . T o ove rco m e this limitation, isokinetic exercise is suggested. THE CO NC EPT O F ISOK INETIC TRAINING What is isokinetic exercise? D u r i n g isokinetic exercise, m o v em e n t is p e r fo r m e d at a c o n st a n t a n g u l a r velocity. Th is type o f exercise allows the re si st a n c e a g a i n s t wh ic h th e m u sc le c o n t r a c t s to a c c o m m o d a t e to the m u sc u la r force t h a t is developed t h r o u g h o u t the entire ran ge o f jo in t mo tio n . It is therefore possible for the pa tie nt to m ain tai n m a x i m u m force ol muscle c o n tr a ct io n t h r o u g h o u t the full range o f j o i n t / m u s c l e m o tio n ( G r i m b y , 1982; S h e r m a n el al., 1982). T hus , m a x i m u m st re ng th trai ni ng tak e s place t h r o u g h the entire range o f j o i n t / m u s c l e mo tio n . The importance o f contraction speed in muscle rehabilitation T he peak tension that a muscle is abl e to de vel op changes with the speed o f muscle c o n tr a c t i o n , there being a fall in the peak t o r q u e p r o d u c ed a s the speed o f the c o nt r a c t i o n increases. (C oyle el al.. 1979: Fo.x a n d M a th ew s. 1981; Westers, 1982; S h e r m a n el al.. 1982). T h u s there is a 4 0 % fall in the t o r q u e p r o d u c e d as the a n g u l a r velocity is increased from 30 to 180 pe r se co nd ( G ri m b y . 1982). T h e fall in the m ax i m u m t o r q ue has a sim ilar p att ern in men a n d w o m e n of all ages. How eve r, it has been sh ow n th a t muscles with a high pe rcentage o f Type II (fast twitch) fibres sh o w less red uctio n in the m a x i m u m t o r q u e develo ped at increasing c on tr a c t i o n velocities, t h a n d o muscles with a lower pe rcentage o f Type II fibres ( M c A r d l e el al., 1981: Fo x a nd M at he w s. 1981; G r i m b y . 1982). This indicates the i m p o r t a n c e o f Type II fibres in the de v e l o p m e n t o f force at high er c o n tr a c t i o n speeds. W he n exercise is p e r fo r m e d at low c o n tr a ct io n velocities (30% o f m ax i m u m v o lu nt a ry c o nt r a c t i o n (M. V.C.)). glvcogcn dep iction is fo un d mainl y in Type I (slow twitch) muscle fibres, while at 50% M. V. C. . the dep let ion is mainly in Type II fibres ( G r i m b y . 1982). Th us it may be tied need that trai nin g a muscle at different a n g u l a r velocities du ri n g a r eh abi lit ati on p r o g r a m m e will affect different muscle fibre types, so that the training velocity mu st be specific to the velocity achieved d u r i n g the p a r ti c u l a r activity o r sp o r t in w'hich the subject parti cip ate s. Most fu nctional activities e mp lo y muscle c o n tr a c t i o n speeds in excess o f 240 degrees per secon d (°/ se c.) (Smi th an d Melton. 1981). F o r exam pl e, d u r i n g the last 12° o f the swing phase o f the gait cycle, the q ua d r ic ep s muscles c o n tr a c t and extend the knee at 233°/sec. ( W v at t a nd E d w a rd s , 1981). T h u s , high c o n tr a c t i o n velocities sh o ul d be used in the re hab ili tat io n p r o g r a m m e before the person a tt e m p t s functional activities. A se co nd reason for th e use o f last c o n tr a c t i o n speeds d u r i n g re h ab ili ta ti on is th a t at high c o n tr a c t i o n speeds the co m p re ss io n force at the jo in t is less th a n at lower c o n tr a c t i o n speeds. This is due to the lower force th a t the muscles c an pr o d u c e at the high c o n tr a c t i o n velocities ( G r i m b y . 1982). A ft er meni sc ect omy , it would be o f benefit to limit the co m pr e ss io n forces acting on the knee jo in t as these m a y d a m a g e the a rt i c u l a r cartilage. T h u s , high c o n tr a c t i o n velocities sh o ul d be used in the early stages o f the re hab ili tat io n p r o g r a m m e (see isokinetic p r o g r a m m e progression). The effects of training at different contractile velocities Costill el al. (1979) r e p or te d that muscles t rai ned at an a n g u la r velocity o f 180°/sec.. p r o d u c e d in creased peak to r q u e s when c o n tr a c t i n g at l80 °/s ec. o r at slower speeds, bu t not at hi g h er a n g u l a r velocities. Sim ilar findings have been m ad e by Covle el al., (1981) who used c o n tr a c t i o n velocities o f 60 a n d 3 0 0 ° / sec. T he g r o u p t rai ned at 60°/sec. sho w ed im p r o v e m en t s in peak t o r q u e at 60°/scc. a n d at 0 °/ se c. (isometric c o nt r a ct i on s) , while the g r o u p t r ai ne d at 300°/ se c. i m p r o ve d muscle peak to rq u es at 0°. 60° an d 300°/ se c. Ho w ev e r, the greatest increase in the pe ak t or qu e o ccu rr ed at the sp e c if i c a n g u l a r v e lo c i ty at which the muscles were t rai ned . Similarly. S he r m an el al. (1982) trained athle tes, w h o ha d u n d e r g o ne menis cec tomie s, at high velocities. How ever, when the st re ngt h o f the o p e r a t e d leg had fully recovered at high c o n tr a c t i o n velocities, th ere were still stren gth deficits o f up to 20% d ur i n g lower speed isokinetic co n tr a c t i o n s. T h u s, the leg mu st be t r e a t e d a t slow a nd fast c o nt r a c t i o n velocities to ensure th at it has regained its full stren gth. THE EFFECTS O F END URA NCE TRAINING Re-injury o f a limb may result from the p r e m a tu r e R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p h y s io th e ra p y , J u n e 1983, vol 39, n o 2 45 fatiguing o f muscles t h a t have h a d insufficient e nd ur an c e trai nin g after surgery. C o still e/ a/. ( I977) c o m p a r e d a g r o u p of patie nts w h o h a d un d e r g o n e m eni scectomies a n d did progressive st re ngt h train ing , with a similar g r o u p who supp le men ted th eir s tr e ng th trai nin g p r o g r a m m e with 20 to 30 m in u t e s’ one-legged cycling daily, with the o p e r a t e d leg. They found th a t su c c in a te d e h y d ro ge n a se ( S . D . H .) activity in the o pe rat ed leg. which had decreased a f te r the leg had been im m obilized in a plas ter cast, had not re tu rn e d to co ntrol levels when only str en gth trai ni ng was pe rfo rm e d. However, the p a tie nt s th at p e r fo r m e d b o t h str ength an d e nd u r an c e tr ain in g, ha d high er S . D . H . activity in the o p e ra t ed leg muscles th an in the no il- op e ra te d legs. In su m m a r y , the studies reviewed ab ov e indicate that exercise trai ni ng o f a limb must involve a co mp le te r eh abilitation p r o g r a m m e which includes: • isokinetic t ra in in g at a full ra nge o f muscle c o nt ra c t i o n velocities. On ly in this way will all muscle fibres (Type I a nd T ype II fibres) be str e ng th e ne d . • e n d u r a n c e training. Unless the muscles have regained their full st re ng th a n d e n d u ra n c e, the pa tie nt is not r eady to res um e his normal spo rt in g o r daily activities d ue to risk o f re-injury. TH E REHABILITATION PROGRAM ME T he following is an e xa m pl e o f a n ideal rehabi lit ati on p r o g r a m m e f or a p a t i e n t w h o h a s u n d e r g o n e a m eniscectomy. It take s into a c c o u n t the asp ect s o f muscle physiology which have been ou tlined . T h e p r o g r a m m e requires the use o f isokinetic exercising a p p a r a t u s . In a dd iti on , the pati en t will req uire a sub sta nt ial a m o u n t o f supervision in o r d e r to carry o u t the entire rehabi lit ati on p r o g r a m m e . T h e p hy si o t h er a p i st will no t always be in a po sit ion to pr ovi de a c o m pl e te p r o g r a m m e d u e to the un av ailability o f so m e a p p a r a t u s a n d / o r supe rv isi on time. Th er e fo re , im pr ov isa tio n mu st be m ad e where necessary. Pre-operative programme A im s • T o stre ngt he n the muscles a r o u n d the knee. • T o familiarize the p a ti e n t with the p os t- op er ativ e exercises. E xercises • S t a tic /is om e tr ic q u a d r ic e p s c o n tra ct io ns . These are best d on e with the foot in do rsi flexion ( G o u g h and Ladlev, 19 7 1). • Stra ight leg raising (S. L.R .) in su pi ne , i.e. hip flexion. • S.L.R. in pr one , i.e. hip extension. • S.L.R. in side-lying, i.e. hip ab d uc ti on . • Resisted knee flexion a nd extension, pe r fo r m e d in pr o n e a nd using the unaffected leg to resist the injure d leg. • Knee flexion a nd ex tension, using isokinetic a p p a r a t u s (only in cases where the injury is chronic). Proviso Exercises m a y c a u s e excessive pa in a n d / o r fu r t h e r da m a g e to the p a t i e n t ’s knee. Post-operative programme S tage I Im me di ate ly p os t- o pe r at iv e until the removal o f the pl as te r cast. In the anaesthetic recovery room A im s • T o m ain tai n muscle stre ngt h. • T o prevent muscle a tr o ph y . • To aid h a e m o d v n a m i c function. E xercises • St a ti c /i s o m e tr i c q u a d r ic ep s c o n tr a ct io ns . • Active ankle a n d foot mov em en ts. • A t t e m p t e d S.L .R. in supine. Proviso It may not be possible to p e rfo rm these exercises du e to neural d a m a g e du ri ng the o p e r a t io n , e.g. to u r n iq u e t- in d u c ed ischaemia. In the ward A im s • T o m a i n t a i n / i n c r e a s e muscle str ength. • T o prevent muscle a tro p hy . Principles • T he exercises are pe rfo rm e d ho urly , initially u n d e r supervision a n d later w i th ou t supervision. • Each exercise is pe rfo rm e d until the muscles fatigue. • T he pati en t m ay sta rt to walk, with the aid o f c r u t c h e s . a s s oo n as he wishes. T h e p h ys io th era pi st mu st ensure that the pati en t is able to m ai n ta in his b ala n ce before allowing him to walk w it h o ut supervision. The pati en t mav toe- toucli at first a n d progressively ta k e m ore weight on the op e ra te d leg until lie bear s full weight on it. • T h e patie nt s h o ul d exercise the rest o f his b o d y in o r d e r to mai ntai n general fitness. E xercises • Iso m etr ic q u a d r ic e p s c o n tr a ct io ns . If there is evidence o f strain on the o p e r a t io n site, q u a d r ic e p s c o n tr a c t i o n s and S . L .R . ’s can be a t t e m p t e d with the hip held in slight internal r o t a t i o n ( Y oc u m et al., 1979). • A t t e m p t e d S.L .R. in supine. • A t t e m p t e d S.L.R. in prone. • A t t e m p t e d S.L.R. in side-lying. Sta ge II The p eriod a fte r the p la ster cast is re m o v ed A im s • T o st re ng th en the leg muscles fully. • T o train the leg muscle e n du r an c e. • T o achieve full range knee m ov em e n t. Principles • The exercises a r e p e r fo r m e d 3 - 7 times p e r week in a suit abl y e q u ip p e d g ym n as iu m . • T he pa tie n t m ay at first walk with crutches, progres sing to u n a id e d gait when str ength, pain a n d confidence allows. • S.L.R. is pe rfo rm ed with light weights (e.g. 1 kg) placed on the foot. Progre ssion is m ade bv increasing the mass of weights lifted. W hen 10 k g c a n be lifted 10 times w it ho ut a rest, isokinetic trai nin g mav be sta rte d ( S he r m an et al., 1981). • Knee flexion exercises are star ted im m ed iat ely a fte r the cast is remov ed . • If the knee jo in t beco mes painful o r oe de m a to us, treat by a p p r o p r i a t e p h y s i ot he r a p eu ti c techniques. • Isokinetic exercise pr ocedure: (based on the p ro ced ur e de scribed by S h e r m a n et al., 1981). — Begin knee flexion a n d ex tension exercises at 60°/ se c. a n d pro gr es s to 120. 180, 240 and 300°/ se c. — H ig he r a n g u l a r velocity exercises are p e r fo r m e d as s oo n as a t o r q u e can be de ve lo p ed at th a t higher speed (i.e. weak muscles c a n n o t de vel op t or qu e R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 46 F is io te ra p ie , J u n ie 1983, d ee I 39, n r 2 wh en c o n tr a c t i n g at high velocities). T hi s will help to minimise possible j o i n t d a m a g e caus ed by the high jo in t co m pr e ss io n forces asso ci ate d with high tension, low velocity muscle action. — Exercising at a p a r t i c u l a r a n g u l a r v e l o c i t v i s s t o p p e d when the t or qu e ge ner ate d is 50% o f the initial t o r q u e d u r i n g that p a r ti c u l a r set. — T w o sets o f exercise until fatigue are pe r fo rm e d at each trai n in g velocity with a 3 - 5 m inu te rest between sets. • Cycling exercises m a y be st a r te d when the kn e e has a b o ut 20° flexion. At first, the patient will not hav e e n ou g h flexibility to cycle a n d will simp ly move the pedal b a ck w a r d a nd fo r w a rd t h r o u g h a partial revolution. Flexibility will im p r o v e until a sufficient ra nge o f m ot i o n allows cycling. The s t a ti o n a r y bicycle will allow the patient to do low intensity work f o r p ro lo n g ed periods and th erefore impr ov e m u sc u la r e n d u r a n c e fitness o f the leg. E xercises • S.L.R. with w e i gh t/ s on the foot. • Knee flexion exercises. St ar ted with a pillow u n d e r the knee a n d p ro gr es s by lowering the m an u a l ly s u p p o r t e d leg. while the th igh is fully s u p p o r t e d on a c h a i r o r p l i n t h . • One-legged cycling ( 1 5 - 2 0 mins.), progressing to using tw o legs (30 - 40 mins.). • Isokinetic exercises. • F u n c tio n a l exercises. St a rt with w a l k i n g a n d later include walking o n inclines, bala nce b o a rd t rai ni ng, sto p-start jog ging and figure-of-8 r u nn in g. Special att e n ti o n must be given to the activities which the person will later be required to p e r fo r m d u r i n g s p o r t o r functi on al activity. Fu n c tio na l d e m a n d s will differ betw een individuals. R eturn to sport The pati en t sh ou ld u nd e rg o a vig o ro u s fitn e s s test before he may re tu rn to comp etitiv e spor t. The test sho ul d include the type o f exercise a n d physical stresses th at are likely to be placed on the kn e e du r i n g the p a rticu la r s p o r t in w hich the pa tie nt wishes to c o mp et e. If the patie nt has pa in a n d / o r swelling in o r a r o u n d the kne e following the test, he is not r ead y to return to com pe tit iv e sp o r t a n d m us t un de rg o fu r th er r e h ab ili ta ti on befo re being re-tested. C O N C L U SIO N Knee menisc ect omy is one o f the most co m m o n l y pe rfo rm ed op e ra t io n s . There has been a general lack o f aw are ne ss o f the need for r eh abi lit ati on with regard to e n d u r a n c e a n d st re ng th trai ni ng at a full range o f a n gu la r velocities o f knee m o ve m e nt . T h er e is a need for rehabi lit ati on cent res which hav e a d e q u a te facilities which includes isokinetic exercising eq u ip m e nt . T h e p h y s i o t h e r a p i s t c o n d u c t i n g the r e h a b i l i t a t i o n p r o g r a m m e mu st have a g oo d kno wle dge o f the spo rt or activities that the pa ti e n t will be re q ui re d to p e rfo rm following his retu rn to norm al activities. This ensur es th at the pa tie nt is t rai ned a n d lat er tested in the specific activities he will later be pe r fo r m i n g . T h is may help to prev ent re-injury to the leg. References C ampbe ll, D. E. a n d Gl en n W. (1979). F o o t p o u n d s o f torqu e o f the no rm al knee an d the re habilitated p ost -m eni sce c­ to m y knee. Phys. Ther., 59, 418-421. C l a r k s o n , P. M., J o h n s o n , J. . D e x t r a t e u r , D. , Leszeznski, W „ Wai, J. a n d M e l ch io n da , A. (1982). T he relationship a m o n g isokinetic e n d u r an c e initial st re ngt h level a n d fibre type. Res. Q. Exerc. Sport, 53, 15-19. Costill, D. L., Fi n k . W. J. and H a b in sk v, A. J. (1977). Muscle r eh abi lit ati on a fte r knee surgery. P hysician Sports M ed.. 5, 71-74. Costill, D. L., Covle. E. F.. Fink. W. J „ Lesmes, G. R. and W itz ma n , F. A. (1979). A d a p t a t i o n s in skeletal muscle fol­ lowing strength training. J.A .P ., 46, 96-99. Coyle, E. F.. Costill. D. L. a nd Lesmes. G. R. (1979). Leg extension p ow er a n d muscle fibre com po sit io n. Med. Sci. Sports. 2, 12-15. Covle. E. F., Feiring, D. C.. Rotkis, T. C., Cote III, R. W., Roby. F. B„ Lee, W. a n d Wil more. J. H. (1981). Specifi­ city o f p ow e r im p r o v e m en t s t h r o u g h slow and fast isoki­ netic t r a i n i n g . J.A .P ., 51, 1437-1442. Dut ch ic. J. J. R. a n d M c L o ed . J. G. (1943). Reh abi lit ati on after meniscectomy. Lancet. I, 197-199. Eriksson, E. (1981). Re hab ilitatio n o f muscle function after sp or t injury. A m aj o r pro bl em in sp o r t s medicine. Int. J. Sp o rts M ed., 2, 1-6. Fo x. E. L. a n d M a th ew s. D. K. (1981). T h e physiological basis o f physical e du c a ti o n an d athletics. Sa un de rs College Publishing. Philad el ph ia. 101-102; 140-141. G ri m b y . G. (1982). Isokinetic training. Int. J. S p o rts M ed., 3, 61-64. G o u g h . J. V. (1975). Post-o pe ra tiv e m a n a g e m e n t of meni sc ect om y patients. Physiother., 61, 109-110. G o u g h , J. V. an d Ladley, G. (1971). A n investigation into the effectiveness o f va rio us forms o f q u a dr ic ep s exercises. Physiother., 57, 356-361. Go w itz k e, B. A. a n d Milner. M. (1980). U n d e r s t a n d i n g the scicntific basis o f h u m a n m ov em e nt . 2nd ed. Williams a n d Wilkins, Baltimore, p. 141. Kr ack ow , K. A. a n d Vetter, W. L. (1981). Knee m o ti o n in a long leg cast. Am. ./. S p o rts M ed., 9, 233-239. Lan tzo un is , L. A. (1931). D e r a n g e m e n t o f the menisci o f the knee jo int. Surg. Gynec. O bstet., 53, 182-188. L eo n a r d . M. A. (1975). A n e v a l u a t i o n o f two post- men is cec ­ to m y regimes. P hysiother., 60, 110-111. L uck, J. V., Smith, H. M. A., Lacy, H. B. a n d Sh a nd s, A. R. (1948). O rt h o p e d ic survey in the a r m y a ir forces d u r i n g Wo rld W a r II. I n t r o d u c t i o n to internal d e r an g e m e n t s of the knee. Arch. Surg., 57, 642-674. M c A u s tl a n d , R. W. (1943). A study o f d e r a n g e m e n t of semi- lu n ar cartilages based on 850 cases. Surg. Gynec. O bster, 77, 141-152." M c D o n o u g h , A. L. (1981). Effects o f i m m o b ili z at io n and j exercise on a rt i c u l a r cartilage. A review o f literature. ./. Ortho. S p o rts Phys. Ther., 13, 2-5. Mc Ard le, W. D. , K a t c h . F. 1. a n d Ka tch, V. L. (198 I). Exer­ cise physiology. Lea a n d Febinger. Philad el ph ia, p. 175. Mc ekison. D. M. (1944). T h e o pe rat ive tr ea tm e n t o f injuries to the s e m ilu n a r cartilages in per son nel o f the British Air Force. Can M ed. Assoc. ./., 51, 517-520. Nelson, M. A. (1968). Early a m b u l a ti o n following meniscec­ tomy. Ann. Phys. M ed., 9, 282-287. R o s b o r o u g h , D. (1970). A c o m p a r i s o n o f tw o m e t h o d s of p o s t - o p e r a t i v e m a n a g e m e n t o f p a t i e n t s fo l lo w in g meniscectomy. J. Bone Jo in t Surg., 52(B), 1, 177. Sh er m an . W. M., Pea rso n, D. R., Plyley, M. J.. Costill, D. L., H a b a n s k y , A. J. a n d Vogelsang, D. A. (1982). Isokinetic re hab ili tat io n af ter surgery. Am. J. S p o rts M ed., 10, 155- 161. Smillie, I. S. (1949). T he qu a d r ic ep s in relation to recovery from injuries to the knee jo int . P hysiother., 35, 51-57. Smith. M. J. a nd Mel ton , P. (1981). Isokinetic versus isotonic varia ble training. A m . J. S p o rts M ed., 9, 275- 279. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p h y s io th e ra p y , J u n e 1983, vol 39, n o 2 47 Tcrh urn e, S. R., E d d le m a n . T, S.. T h o m p s o n . S. B. and Read. B. S. (1943). The care o f the kne e following excision o f the meniscus. ./. Bone Joint Surg.. 15, 663-669. Wcin gard cn . S. I.. Louis, D. L. a n d Wavlonis. G. W. (1979). E l e c t r o m y o g r a p h i c c h a n g e s in p o s t - m c n i s c e c t o m v patients. JA M A . 241, 1248-1250. Westers. B. M. (1982). Fa c to rs influencing str ength testiim and exercise prescription. Physiother., 68, 42-44. Wyatt. M. P. and Ed w a rd s . A. M. (1981). Co n i p a rison of qu a d r ic ep s and h a m s tr i ng to rq u e values d u r in g exercise. J. O nho. S p o rts Phys. Ther., 3, 48-56. W y n n - P a rr v . C. B., Nichols. P. J. R. a n d Lewis, M. R. (1958). Mcnisccctomv. A review o f I 723 cases. Ann. P hys M ed 4, 201-215. Yocum, L. A.. Ba ch m an . D. C., Noble-Bates, H. a n d H oo v e r, R. L. (1978). T h e d e r an g e d knee. R e st or at io n o f function. Am. ./. S ports Med.. 6, 51-53. CORRESPONDENCE M a d a m . May I. t h r o u g h y o u r J o u r n a l express my th a n k s to^Mrs Molly Wilson a n d all involved, for the course on G e ri at ric Re hab ilitatio n held at Disa H o u s e on I I a n d 12 M a r c h 1983. u n d e r the auspices o f the S.A. G e r o n t o lo g i c a l As soc iation . Fo r those o f you u'ho were un a b le t o be pre sen t 1 can a ssu re yo u th at y ou really missed som eth in g. Perhaps spea kers o f the calibre of Pr of es so r Wicht, Professor W ate rm ey cr, D r H e ch t , Profe ss or Meiring w h o c hai red the l u st session, and the p h ys io th er a p is ts a n d oc cu pa tio n a l therapists who gave th eir time a n d kno wl ed ge to make this course so in val ua ble could be p e r su ad e d t o su b m it their p a p er s for pu b lic a tio n in the J o u r n a l at a futu re date. Read ers w ou ld no t be di sa p p o in t e d . Ageing is, a fte r all, a process we c a n n o t escape, any m ore th an we can ignore our inv olvement at the pre sen t m o m e n t , as m em be rs o f a mu ltidisc iplina ry team. As m a i n t a i n e r s a n d restorers of function all p h ys io th er a p is ts a n d o c cu p a ti o n a l therapists sh ou ld be allowed to benefit from the kno wledge a n d experience pr esented at this course. It co uld be an excellent follow-up o f the D e c e m b e r 1982 issue of the S.A..I.P. We are. after all, on e ye ar ol d e r and . we hope , one year wiser. Yours sincerely. B. M. J a h o l k o w s k i (Mrs) D e a r M a d a m 1 was interested t o read the letter in the D e c e m b e r 1982 issue o f yo u r J o u r n a l fro m Mrs M oi ra van O o r d t . 1 am in co mple te a g r ee m e nt u'ith the first po in t she makes c o n c e r n i n g the i m m e n s e w o r k l o a d u n d e r t a k e n by ph y si o th er a p is ts for their pr of es sio nal societies in an h o n o r a r y capacity. Thes e de d ica te d pe opl e rcceive little th a n k s o r recogn iti on for th eir invaluable work. 1 w ou ld take issue with her secon d point. I woul d like evidence “ th at in mo st o t h e r co un tri es p h y si o t h er a p i st s are em pl oy e d full-time by their Societies to pe r fo r m these tas ks” . F o r example, in the Uni ted K i ng dom the C h a r te r e d So c i e t y o f P h y s i o t h e r a p y has o n e f u l l- t i m e pa id p h y si o th er a pi st o n its staff. T h e r e ma ini ng u'o r k l o ad , which is vast, is u n d e r ta k e n by a n u m b e r o f ph y si o th er a p is ts in a vo l u n ta r y capacity. Only their travelling a n d subsistence costs are met. A l t h o u g h 1 a m in f a v o u r o f these h a r d -w o r k in g people receiving rec o m pe n s e in so m e for m for th e i r a r du o us activities, 1 th in k we mu st always b e ar in m in d that the pe op le w h o k n o w mo st a b o u t the practice o f o u r profession are th ose w h o are directly engaged in it every day. Th er e c ou ld be c o ns id era ble d a n g e r in losing the i n p u t fro m these i m p o r t a n t people if t o o m uch responsibility for policy m ak in g a n d decisions rests with full-time paid empl oy ees of the Society. I t hin k Mrs van O o r d t has hi gh lighted an i m p o r t a n t subject b u t it is o n e with facets which merit co n si d er a b le discussion by the m em b e rs o f any pro fessio nal Society. It has to be re m e m b e r e d that th ere are aspects of r u n n i n g such a Society which call f o r talents a n d skills which few p h y si ot he r a p is ts at pre sen t possess. We must a vo id any sense o f p ar o ch ial ism which might imply th a t ph y sio th era p is ts k n o w best a b o u t everything. May I take this o p p o r t u n i t y to se nd my best wishes t o all the m em be rs o f the S o u t h Afri can Society for which 1 have gre at respect a n d feel sincere pe rso nal w a r m th . Yours faithfully LOIS D Y E R M C S P S R P P h ys io th e r ap y Officer H o n o r a r y Life Vi ce-P residcnt S A S P R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )