Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Lateral Meniscus Repair in a Professional

Ice Hockey Goaltender: A Case Report With

CASE REPORT
a 5-Year Follow-up
Mario Bizzini, PT, MS 1
Mark Gorelick, MSc 2
Thomas Drobny, MD 3

Study Design: Case report of a professional ice hockey goaltender who underwent an arthroscopi- focused their attention on develop-
cally assisted lateral meniscus repair. ing meniscal repair techniques to
Background: Rehabilitation of isolated meniscal repairs is not well documented in the literature. preserve damaged meniscal tis-
There is little knowledge about the healing time and the choice of rehabilitation exercises to be
sue.35 Studies have shown that the
applied to a repaired meniscus. The objective of this case report is to describe a criterion-based,
supervised, sport-specific rehabilitation protocol for a high-level athlete with a lateral meniscus
outer 10% to 30% of the menisci
repair from the first postoperative day until return to competitive sport, including a 5-year is vascularized,2 so that tears in
follow-up. this region (and also extending in
Case Description: The criterion-based protocol used with this athlete was based on a sport- the midsubstance) are repairable.
specific neuromuscular rehabilitation approach. Data collected included range of motion, strength, Follow-up studies up to 10 years
neuromuscular control, and magnetic resonance images. after meniscal repair have re-
Outcomes: This high-level athlete was able to return to sport 103 days after surgery and no ported about a 90% success rate
reinjury of the lateral meniscus occurred up to 5 years after surgery. (no reinjury) in knees with intact
Discussion: The sport-specific, criterion-based, supervised rehabilitation program described in this anterior cruciate ligament (ACL)
case report showed a safe return to sport and a good long-term outcome. J Orthop Sports Phys
and about 75% in ACL-deficient
Ther 2006;36:89-100.
knees.12,14,15 Rubman et al38 have
Key Words: knee, meniscal repair, surgery advocated arthroscopic repair of
meniscal tears that extend into the
avascular zone, reporting an 80%

T
he menisci contribute to load transmission, shock absorp-
success rate (2-year follow-up)
tion, stress reduction, joint lubrication, joint nutrition, joint
within a young, athletic popula-
congruency, and joint stability, and are crucial to knee
tion. Some authors have promoted
function.20,31 The innervation of the menisci and the
nonsurgical treatment for certain
sensory function described in recent literature suggests that
lateral meniscus tears with com-
the menisci may have a role in the neuromuscular control of the knee
bined ACL reconstruction.19
joint.3,20,33,51 The menisci are a source of proprioceptive information
There is a lack of evidence on
regarding the position, direction, velocity, and acceleration and decelera-
rehabilitation practices after
tion of the knee joint.20
meniscal injury of the knee. The
A complete or partial loss of the menisci can lead to diminished joint
time frames for healing of the
stability,31 increased risk of joint degeneration,36 and neuromuscular
human meniscus and the strength
deficits.24,25 Due to the importance of the fibrocartilagenous structures
capacity of the meniscal repair at
within the knee joint, orthopaedic surgeons over the last 3 decades have
various stages of the healing pro-
cess are unknown.20 Additionally,
1
Research Associate, Departments of Orthopaedics, Sports Medicine and Rehabilitation, Schulthess the effects of loaded exercise on
..
Clinic, Lengghalde 2, 8008 Z u rich, Switzerland.
2
Senior Research Fellow, Research Department, Sports Medicine and Rehabilitation, Schulthess Clinic, the meniscus have not yet been
..
Lengghalde 2, 8008 Zu rich, Switzerland. investigated.16,28,48 Thomson et
3
Head Knee Surgeon, Department of Orthopaedics, Sports Medicine and Rehabilitation, Schulthess al42 in a recent Cochrane review
..
Clinic, Lengghalde 2, 8008 Z u rich, Switzerland.
Address correspondence to Mario Bizzini, Department of Orthopaedics, Sports Medicine and Rehabilita- found 9 randomized controlled tri-
..
tion, Schulthess Clinic, Lengghalde 2, 8008 Z u rich, Switzerland. E-mail: mario.bizzini@kws.ch als on therapeutic interventions

Journal of Orthopaedic & Sports Physical Therapy 89

after meniscectomy. It was concluded that there was lated to high-level athletes returning to sport after
no significant difference among supervised or knee surgery following a neuromuscular program is
nonsupervised rehabilitation programs. limited. Tyler and McHugh43 and recently Roi et al37
In patients with an isolated meniscal repair it has showed the importance of a sport-specific neuro-
been advised to maintain partial weight bearing for 4 muscular program in 2 elite athletes who successfully
to 6 weeks while using a brace locked in full returned to sports after knee surgery ACL reconstruc-
extension.23,29 Immediate range of motion (ROM) of tion. Currently, to our knowledge, there is no litera-
the knee through exercise or the use of continuous ture on the outcomes of a sport-specific
passive motion (CPM) is recommended, generally neuromuscular program after meniscal repair.
with 0 to 90 of flexion for the first 4 weeks.23,29 The purpose of this case report is to describe the
Although, there is no scientific support for either outcomes of an accelerated criterion-based rehabilita-
ROM (active/passive) or CPM exercise, both are tion intervention prescribed for an isolated lateral
utilized clinically as components of postoperative meniscal repair with a 5-year follow-up.
knee rehabilitation. In the first 6 weeks, the
femorotibial load and shear forces should be mini-
mized to protect the repair; end range of motion in CASE DESCRIPTION
flexion, resisted hamstring exercises, and weight bear-
ing with more than 30 to 40 of flexion should be The patient, a 30-year-old (at time of injury)
avoided.23 Some authors advocate the protection of goaltender in a top Swiss professional ice hockey
the repair during the first 4 postoperative months, league and a member of the national team, injured
with a return to sport after 4 to 6 months.23,29 While his right knee on September 16, 1998. The injury
some believe that integrating weight bearing, ham- occurred during a training session from a sudden
string activation, and knee flexion end range ROM combined valgus/flexion/external rotation move-
early into a rehabilitation program may cause exces- ment of the right knee joint in full weight-bearing,
sive loading on the posterior horn of the menis- while falling backwards. He immediately felt pain and
cus,23,48 a number of authors have shown no negative locking in his knee and was unable to walk. A few
effects of early implementation of including these hours later he was examined by an orthopaedic knee
components in the rehabilitation approach.5,40
specialist. He walked with crutches, without weight
In individuals with combined meniscal repair and
bearing, had a moderate knee effusion/swelling, a
ACL reconstruction, good results in 90% of the cases
knee extension deficit of 20, a negative Lachman
are reported with an aggressive program (no limita-
test, negative valgus/varus tests, and no posterior sag
tions for range of motion, early full weight bearing,
and early return to sports).12,14,15 Accelerated proto- (therefore no cruciates or collateral ligaments le-
cols for isolated meniscal repair have been described sions). He experienced localized pain along the
with positive results.5,40 Shelbourne et al40 showed lateral knee joint line, a locking symptom, and a
that patients with repairs of unstable/peripheral lon- positive McMurray test (at 90 of flexion) with pain
gitudinal meniscal tears who underwent an acceler- along the posterolateral corner of the knee joint. A
ated rehabilitation protocol had a high successful review of all signs and symptoms suggested a bucket-
outcome rate (follow-up time, 3.5 years), with return handle lesion of the lateral meniscus. To confirm this
to sport approximately 10 weeks postoperatively. The diagnosis and to assess the integrity of other knee
criteria for return to sport were full ROM, quadriceps structures, the patient had an MRI that showed a
strength of 75% (compared to the uninvolved leg), large bucket-handle tear (very close to the peripheral
and completion of a functional running program. border) of the lateral meniscus, with an anterior-
However, the details of the rehabilitation program, medial displacement of the damaged structure (Fig-
comprehensive functional outcomes (eg, hamstring ure 1). The patient, who had never suffered a major
strength), the type of sport activity, and the level of injury in his 12-year career, agreed to have surgery of
this activity (recreational/professional) were not his injured knee so that he could play the second
specified. This information may be extremely impor- part of the season and participate in the World
tant to appreciate the impact of accelerated programs Championship Tournament with the national team.
on knee function. Among specialists there is concern The patient had surgery the following day (Septem-
that by accelerating the rehabilitation, the long-term ber 17, 1998), in which a lateral meniscal repair was
outcome may be negatively affected.45 performed. An arthroscopically assisted inside-out
Gray20 stated that rehabilitation following injury technique was used11: the large longitudinal tear (11
or surgery of the menisci should incorporate a mm) was repaired with 6 nonabsorbable sutures
proprioceptive retraining program. Restoring func- (posterior horn and corpus). A small lesion of the
tion and regaining a sport-specific neuromuscular hiatus popliteus did not require a surgical repair. A
control of the injured knee joint is crucial for a small posterolateral incision for suture retrieval and
successful return to competition. The literature re- knot tying was necessary.4

90 J Orthop Sports Phys Ther Volume 36 Number 2 February 2006

 return to sport (phases 3 and 4) was not defined in
time frames, but was allowed only if important
criteria (ROM, strength, sport-specific neuromuscular
control) were met (Table 1). Physiotherapy protocol
was based on the rehabilitation guidelines shown in
the Appendix.

CASE REPORT
Phase 1: Criteria to Begin Full Weight Bearing
The patient remained at the clinic for 4 days
following the meniscal repair, with rehabilitation
treatment focused on passive ROM and swelling and
pain control (Appendix). The use of a CPM device
and an electrical muscle stimulation unit (Compex-2,
MediCompex SA, Ecublens, Switzerland) for
quadriceps strengthening was initiated immediately
and given for home utilization at discharge.9 Starting
7 days after the surgery, the patient came to the
clinic for a 1-hour rehabilitation session daily (exclud-
ing weekends). Initially, the patient was instructed to
FIGURE 1. Bucket-handle tear with anteromedial displacement of walk on crutches with a knee brace locked in
the lateral meniscus (T1 weighted MRI images, September 16, extension.
1998). Partial weight bearing was advocated for the first 4
weeks, with a progression of load (20%, 50%, 70% of
REHABILITATION PROGRAM body weight [Appendix]). Gentle ROM exercise
within pain tolerance were progressed from 10 to
The rehabilitation program was divided in 4 phases 70 (knee extension-flexion) to 0 to 130 within 4
(Table 1). Rather than adhering to a strict treatment weeks (Figure 2). Active ROM exercises for extension
regimen, the rehabilitation progression was based on were performed from week 2, whereas active ROM
the joint condition and the neuromuscular control of exercises for flexion were initiated (gently) by week 4.
the operated knee, which were reassessed daily. After Passive ROM exercises for flexion were not forced at
phase 1, the athlete underwent an intensive func- the end of the available ROM. Emphasis was put on
tional progression (phase 2), focused on the soft tissue treatment, swelling control, and safe mobi-
neuromuscular control of the injured knee. The lization (CPM, stationary bike). Neuromuscular and

TABLE 1. Criterion-based rehabilitation program. The table outlines the criteria needed to obtain the specified function goal and when
this particular patient satisfied all the requirements for each phase. Balance and strength index are expressed as a percentage of the
involved leg normalized to the uninvolved leg. Detailed physiotherapy interventions are described in the Appendix.
Phase 1 Phase 2 Phase 3 Phase 4
Weight-Bearing Without Begin Individual Ice Begin Team Ice Play in Official
Crutches Training Training Competition
Criteria to ROM: flexion, 120; ROM: flexion, 140; ROM: symmetrical (in- ROM: symmetrical (in-
complete extension, 0 extension, 0 cluding heel-sitting po- cluding heel-sitting posi-
each Minimal swelling/pain No swelling, no pain sition) tion)
phase Balance index 80% Balance index 95% No swelling, no pain No swelling, no pain
Isometric quadriceps Isokinetic quadriceps Isokinetic quadriceps Isokinetic quadriceps
strength index 75% strength index 80% strength index 85% strength index 90%
Initiated stabilization Completed agility/ Completed agility, coor- Completed full team
training progression coordination training dination on ice training training program
Normal gait patterns progression program Successfully regained all
Successfully exercised goaltender moves (as
all basic goaltender controlled by PT and
moves (as controlled by goaltender coach)
PT and goaltender
coach)
Reached by Week 5 Week 7 Week 9 Week 13

Abbreviations: PT, physiotherapist; ROM, range of motion.

J Orthop Sports Phys Ther Volume 36 Number 2 February 2006 91

 balance training, from bilateral stance to unilateral
stance on the involved limb, were performed first on
stable surfaces (eg, floor) then on unstable surfaces
(eg, rebounder for weight shifts, wobble board for
balancing) (Figure 3). Such exercises were also pro-
gressed with the athlete wearing his own skates
(Figure 4). During this phase, weight-bearing was
restricted to the first 20 of knee flexion. In the
bilateral stance, stabilization exercises were per-
formed with 40 of knee flexion starting at week 4.
Gait training was performed in the pool and isomet-
ric and isokinetic quadriceps strengthening was initi-
ated by week 2. Isometric exercises for the hamstring
were initiated in week 4 (Appendix). Pain (at worst)
FIGURE 2. Knee passive range of motion (ROM) during rehabilita-
tion. The 2 dotted lines represent the uninvolved (UNINV) knee decreased from 6 to 2 on a 10-point visual analogue
joint ROM. The data for the involved (INV) knee depict the scale (VAS), and swelling decreased to complete
progressive increase in ROM throughout a 9-week period. elimination by the middle of week 4. At the end of

FIGURE 3. Unstable-surfaces devices and progression. All devices were used first bilaterally and then unilaterally during rehabilitation.
Progression (moving from most stable to least stable) from one device to another was done after the patient showed sufficient ability to
stabilize the knee joint. Perturbation techniques were performed as described by Fitzgerald et al.18 (Modified with permission from Bizzini.8)

92 J Orthop Sports Phys Ther Volume 36 Number 2 February 2006

 and balance training was continued. Sport-specific
neuromuscular training was intensified (eg, skating
sequences on a slide-board, stabilization training on
skates, simulated goaltender moves). A strengthening
program (including isokinetics) and endurance train-
ing were initiated to improve the patients general

CASE REPORT
conditioning. Strengthening exercises for the ham-
string were progressed from isometric (week 4), to
isotonic (week 5), and to isokinetics (week 7). Active
ROM exercises for both extension and flexion, with-
out restrictions, were performed from week 5. More
agressive passive ROM exercises to improve end
range knee flexion ROM were performed from week
6 (criteria: no pain). The athlete was instructed to
execute a kneeling exercise (criteria: no swelling/
pain) where he gently sat back on his heels, utilizing
a firm wedged pillow between the buttocks and heels.
Regaining end range of flexion in this weight-bearing
position was imperative for the patients profession as
a goaltender. At the end of week 6, seated isokinetic
strength testing (Biodex, speeds 180/s and 300/s)
utilizing the protocol suggested by Wilk et al47
revealed a quadriceps deficit of 13% and 18%, while
the hamstrings were 6% and 9% stronger then those
of the injured knee (Table 2). At this point he had a
nearly symmetrical single-leg balance score, with a 4%
deficit in the involved leg (same test protocol as
stated above). By week 7 the patient met the criteria
FIGURE 4. Neuromuscular training in the mini-squat position. for returning to sport and was, for the first time since
Physiotherapist applies perturbations to the trunk while the patient the injury, skating for approximately 20 minutes.
was wearing skates (about 4 weeks post surgery).
week 4, seated isometric strength testing (60 knee Phase 3: Criteria to Begin Team Ice Training
flexion) on the Biodex Multi Joint System 2 (Biodex
Medical Systems, Shirley, NY) revealed a quadriceps After 8 weeks, passive ROM was 145 of flexion to
strength deficit of 25% and a hamstring deficit of 2 of hyperextension (Figure 2), but there was still an
35% in the involved knee. Analysis of single-leg approximately 10 difference between knees in the
balance (knee position in 20 of flexion) was per- sitting-on-heels exercise. By week 8, the complete
formed on a Biodex Stability System (test: 20 seconds, training program was now divided within a weekly
level 5) by comparing the combined stability index period: strength training (isokinetic and weight ma-
score of the uninvolved with the involved leg.34 After chines) on Monday, Wednesday, and Friday, and
4 weeks, the patient had a deficit in single-leg balance sport-specific neuromuscular training followed by en-
of 19%. By week 5, the patient had reached the durance training on Tuesday and Thursday. The
criteria to walk without crutches and was allowed to athlete skated alone on the ice 3 times per week,
progress to the next phase (Table 1). performing typical ice hockey drills. At the end of
week 8, an isokinetic test (as described above) re-
Phase 2: Criteria to Begin With Individual Ice
Training TABLE 2. Isokinetic strength during rehabilitation. Bilateral com-
parison of peak torque during isokinetic testing of the involved
The extension brace was exchanged for a neoprene knee. Isokinetic strength index expressed as a percentage of the
sleeve to allow for more ROM of the knee and to involved leg normalized to the uninvolved leg.
enhance proprioceptive stimuli during gait.24 The Knee Extension Index Knee Flexion Index
patient met the criteria to fully weight bear by week 5 (%) (%)
and was told to avoid stairs until week 6. During this
180/s 300/s 180/s 300/s
phase, weight-bearing exercises were performed with
increasingly more knee flexion (40-90), according 7 wk 82 87 109 106
to the quality of neuromuscular control of the knee. 9 wk 87 90 115 122
13 wk 93 95 117 124
Positions with more than 90 of knee flexion were
included at the end of this phase. Neuromuscular

J Orthop Sports Phys Ther Volume 36 Number 2 February 2006 93

vealed a quadriceps deficit of 10% and 13%, and the
hamstrings were stronger than the injured knee by
15% and 20% (Table 2). By week 9, passive ROM,
including in the heel-sitting position, was symmetrical
(145 of flexion, 5 of hypertension) (Figure 2). The
knee joint was still symptom free with no pain or
swelling. The agility and neuromuscular program was
continued on the ice with increased intensity. The
basic goaltender moves, with the patient wearing his
equipment, were progressively modified under guid-
ance of the physiotherapist and the goaltender coach.
By week 9 the athlete met the criteria to begin
team ice training and trained for the first time with
the team (45 minutes). Extreme movements, as the
butterfly (Figure 5), were performed in a controlled
manner and explosive movements, as the kick save
(Figure 6), were avoided.13

FIGURE 7. Healed lateral meniscus repair, showing no desinsertion

signs at 10 weeks post surgery (T1 weighted arthro-MRI image,
December 1, 1998).

Phase 4: Criteria to Play in Official Competition

Starting on week 10, the athlete practiced with the
team 4 times per week (about 1 hour per session),
trying to increase the intensity level each time.
Explosive movements were performed separately in a
FIGURE 5. The butterfly move. The goaltender drops to both knees, controlled manner. An MRI with intra-articular con-
resting his weight primarily on the medial aspect of the knees, while trast dye1 on week 10 showed a well-healed meniscus,
spreading the pads in a V shape to cover the low corner of the net. with some scar formations near the peripheral border
In this figure, the goaltender is showing the half butterfly, where the
knee joint is stressed in a flexion, valgus, and external position.
(same location of the knots on the external capsule)
(Figure 7). In week 11, the athlete trained daily (a
70-minute session) during the week with the team
and progressively regained his goaltending skills. The
extreme movements (eg, butterfly) were performed
fully in the training sessions; however, explosive
movements (eg, kick save) were not. The rehabilita-
tion program was continued until week 12, as was the
daily ice training with the team (90-minute session)
during the week. The explosive movements were
progressively included in the program. At the end of
week 12 an isokinetic test (as described above)
revealed a quadriceps deficit of 7% and 9%, while
the hamstrings were 17% and 24% stronger than the
injured knee (Table 2). The physiotherapy visits at
the clinic were terminated, with the athlete training
only at the stadium facility. During week 13, the
athlete trained twice a day (about 2 hours daily) with
FIGURE 6. The kick save. The goaltender drops down to 1 knee, the team, progressively regaining all of his preinjury
while spreading maximally the other leg to the side. This movement
is characterized by a forceful hip abduction with a sudden rapid skills and reaction speed. The knee joint status,
knee extension, supporting two thirds of the body weight on his strength, endurance, sport-specific neuromuscular
extended leg. control, and the integration in team training were

94 J Orthop Sports Phys Ther Volume 36 Number 2 February 2006

 nament with the Swiss national team. Two years post
surgery, the patient suffered a bone bruise in the
superior region of the lateral femoral condyle of the
right knee joint after being hit by a puck in an
unprotected knee area. For diagnostic purposes, an
arthro-MRI was performed, which revealed that the

CASE REPORT
ligamentous structures were intact and the repaired
lateral meniscus showed no sign of reinjury (Figure
8). The physical examination showed a pain- and
symptom-free knee, with symmetrical ROM and
isokinetic strength values. Five years post surgery the
athlete suffered a minor sprain to the medial (tibial)
collateral ligament of the same knee; however, this
did not disrupt the healthy state of the lateral
meniscus structure, as depicted by an MRI (Figure 9).
After recovery from this minor injury, the athlete was
still playing regularly with his team and his knee was
100% functional and asymptomatic.

DISCUSSION
FIGURE 8. Intact lateral meniscus repair at about 1.5 years after
surgery (T1 weighted arthro-MRI image, January 17, 2000). The optimal rehabilitation program after isolated
meniscus repair is still controversial, with a large
variety of proposed rehabilitation protocols.5,20,27,40
In this particular case, with the athletes expectations
and the teams pressure to have him return as soon
as possible, the medical team (surgeon and physio-
therapist) was in a dilemma. A conservative rehabilita-
tion approach would have probably compromised the
season; on the other hand, the medical team did not
feel comfortable using a very aggressive approach
with this top athlete. A solution was chosen that was a
compromise between the 2 extremes: an early conser-
vative approach followed by a very intensive sport-
specific neuromuscular rehabilitation, based on the
knees response to treatment. The primary concern
was not only the healing of the repaired meniscus,
but also the regaining of full knee function. During
flexion and rotation, the lateral meniscus has a
greater displacement than the medial meniscus.41 It
was imperative that the repaired lateral meniscus
should reacquire its original mobility to permit full
knee ROM. Complete, unrestricted healing was neces-
FIGURE 9. Intact lateral meniscus repair at about 4.5 years after sary because of the required knee movements for an
surgery (T1 weighted MRI image, February 17, 2003). ice hockey goaltender, including a large amount of
weight-bearing knee movements in combined valgus/
considered to be back to preinjury levels. Therefore, flexion/external rotation (Figure 5). This was pos-
the athlete, who did not have any complications sible within 9 weeks, using the described
during his rehabilitation, met the criteria to return to rehabilitation protocol. Shelbourne et als40 acceler-
play in an official game by week 13 (Table 1). ated group achieved full ROM between 1 and 20
weeks (mean, 6 weeks). Considering that our athlete
5-Year Follow-up needed to regain full ROM in various weight-bearing
situations (including the heel-sitting, deep squats, and
One hundred three days (14.5 weeks) after surgery, butterfly positions), 9 weeks seemed to represent a
the athlete played his first game (completing all 3 realistic expectation to achieve symmetrical ROM.
periods) with his team. He continued with the team, ROM should not only be evaluated in a supine
playing the second half of the Swiss championship position but also in weight-bearing situations that
and participating in the World Championship Tour- reflect the needs of the athlete.

J Orthop Sports Phys Ther Volume 36 Number 2 February 2006 95

 Active flexion ROM implies that there is sufficient tients with an ACL-deficient knee. Fitzgerald et al18
hamstring activation; therefore, in this case there was described effective perturbation training in a ran-
a concern in delaying the initiation of hamstring- domized trial using a similar group of patients. Ihara
strengthening exercises. Conservative rehabilitation and Nakayama22 and Wojtys et al49 also showed in
recommends that resistive hamstring exercise should ACL-deficient patients significantly improved muscle
be avoided in the first 6 weeks,23 while such guide- reaction times with proprioceptive and agility training
lines are not specifically reported in accelerated- exercises.
rehabilitation literature.5,40 The typical hockey In this case report, the athlete and physiotherapist
goaltender position is a combination of bilateral knee worked closely together (5 days per week, at least 1
flexion (half-squat) with at least 30 trunk flexion, hour each day) in the first 12 weeks. The athletes
which places a high demand on the hamstrings. The knee joint status and the neuromuscular control of
impetus to initiate early hamstring activation and the knee could be constantly monitored, which may
strengthening was to further promote neuromuscular only be possible with a professional athlete.37,43 This
control strategies to prepare the athlete for later could suggest that a supervised criterion-based reha-
sport-specific tasks that would require increased ham- bilitation has the potential for safe return to sport,
string activation. with a possible good long-term outcome. Studies are
We believe that the neuromuscular control of the needed to investigate if professional athletes benefit
injured knee was a key aspect of this rehabilitation significantly from such an intensive supervised reha-
protocol. Several authors3,20,33,51 have described the bilitation program. Previous studies on the effect of
innervation of the meniscus and its importance as a supervised versus home-based rehabilitation programs
source of proprioceptive information. On the basis of have shown a trend towards better functional results
this evidence, Gray20 suggested that rehabilitation for physiotherapist-led programs in the rehabilitation
exercises after meniscal injury or surgery should of patients after meniscectomy in a short-term
challenge the balance, stability, and coordination follow-up of 6 months.30,44 Barber5 reported a failure
skills of the patient. In addition to improving rate of the meniscal repair in 10% of patients
strength and endurance, improving sport-specific co- following an accelerated rehabilitation program
ordination from the onset of rehabilitation is essen- (mean follow-up of 20 months). Shelbourne et al40
tial for the return to sport.7,8,37,43 Neuromuscular, reported a similar failure rate in patients following an
balance, reactive, and agility training were considered accelerated program with a mean follow-up time of
crucial in this attempt. The different exercises re- 3.5 months and a return-to-sport time of 10 weeks. As
flected important motor learning concepts utilizing Wilk45 stated recently, the ultimate goal of a rehabili-
random and variable practice methods).18,32,39 Differ- tation program should be a healthy knee 5 to 10
ent body positions (from basic to sport specific), years after surgery, not only after a few months. Many
different speeds of movements (static, dynamic, reac- studies report a limited follow-up time, which may
tive, explosive), different surfaces (floor, unstable not reflect the true long-term outcome.
boards, slide boards, ice), and different environments Return to high-level sport was allowed only when
(clinic, ice stadium) were considered in the rehabili- these criteria were met: full ROM in nonweight-
tation progression. A sport-specific neuromuscular bearing and weight-bearing situations, 90% isokinetic
training means that the choice of exercises is tailored quadriceps strength index, achievement of sport-
to the needs and demands of the patient. Tyler43 specific neuromuscular control, and full participation
reported the successful use of a specific in team training. Isometric and isokinetic strength
neuromuscular training program, including simulated measurements were used as tools to monitor the
skating strides, with an elite female ice hockey player progression from one rehabilitation phase to the
after ACL reconstruction. In our case the patient was next, in addition to performance-based and sports-
a goaltender, therefore the choice of exercises fo- specific tasks. The criteria for return to sport may
cused on specific goaltender movement and save differ with type of sport and intensity of practice.
skills. Recently Roi et al37 described a similar specific Shelbourne et al40 utilized the following criteria with
rehabilitation for an elite male soccer player after patients following meniscal repair: full ROM,
ACL reconstruction. quadriceps index of at least 75% in the involved leg,
Evidence on the efficacy of neuromuscular rehabili- and completion of a functional running program.
tation programs on knee joint function is available The patient group had a mean quadriceps index of
for rehabilitation of individuals with an ACL-deficient 82% at 2 months and 84% at 4 months post surgery.
knee.6,18,22,49,50 ACL-deficient knees and knees after a Our athlete had a quadriceps index greater than 87%
meniscus repair show analogous knee impairments/ at 9 weeks and greater than 90% at 13 weeks, with
limitations and therefore may benefit from similar similar strength increases also displayed in the ham-
rehabilitation approaches.23 Beard et al7 and Zat- strings. A running program was not considered in
terstrom et al50 showed, in randomized clinical trials, this case, due to different environmental conditions
a positive effect of neuromuscular training for pa- (skating on ice). Some authors29 are concerned

96 J Orthop Sports Phys Ther Volume 36 Number 2 February 2006

about the potential negative effects of jogging on ment deficiency. A prospective randomised trial of two
meniscal repairs, but Shelbourne et al40 showed no physiotherapy regimes. J Bone Joint Surg Br.
differences in outcomes after delaying or accelerating 1994;76:654-659.
7. Biedert RM, Meyer S. Propriozeptives Training bei
a running program.40 Shelbourne et als40 criteria Spitzensportlern. Sportorthop Sporttraumatol. 1996;
may be sufficient for a recreational athlete, but not 12:102-105.
for a high-level athlete. Other authors26,46 have advo- 8. Bizzini M. Sensomotorische Rehabilitation nach

CASE REPORT
cated the need for the use of criterion-based program Beinverletzungen. Mit Fallbeispielen in allen
in ACL rehabilitation, which is similar to the philoso- Heilungsstadien. Stuttgart, Germany: Thieme; 2000.
phy incorporated into this rehabilitation progression. 9. Brocherie F, Babault N, Cometti G, Maffiuletti N,
As stated above, the sport-specific components should Chatard JC. Electrostimulation training effects on the
physical performance of ice hockey players. Med Sci
be taken into account in the criteria for return to Sports Exerc. 2005;37:455-460.
sport. This may allow a differentiation between types 10. Bronstein R, Kirk P, Hurley J. The usefulness of MRI in
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Artirem) was used because of its higher sensitivity In-line Hockey. Champaign, IL: Human Kinetics; 1998.
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are aware that the findings of the arthro MRI cannot
15. DeHaven KE, Lohrer WA, Lovelock JE. Long-term results
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An arthroscopic evaluation21 could not be taken into 16. Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk
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closed kinetic chain and open kinetic chain exercises.
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18. Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy
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21. Horibe S, Shino K, Maeda A, Nakamura N, Matsumoto
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N, Ochi T. Results of isolated meniscal repair evaluated
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22. Ihara H, Nakayama A. Dynamic joint control training
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Appendix
Details of the Rehabilitation Program (Sport-Specific Components for Ice Hockey)

CASE REPORT
Week 1
Continuous passive motion (CPM): passive range of motion (ROM) 10-70 (knee extension/flexion), 3
60 min/d
No active ROM exercises
Partial weight bearing with crutches (20% of body weight)
Knee brace locked in extension (for 4 wk); wear brace day and night; remove brace for exercising and CPM
Modalities to decrease swelling and pain: ice 6 10 min/d, transcutaneous electrical nerve stimulation
(TENS) 2 20 min/d
Patella mobilizations, low grade, 5 min/d
Soft tissue massage (posterolateral, suprapatellar), 15 min/d
Isometric quadriceps contractions (in 20 flexion), 10 30 s/d
Electrical muscle stimulation (EMS) for quadriceps (in 20 flexion): 30 contractions per d (4-s duration [85
Hz], 20-s rest time per day)
Upper body ergometer aerobic program, 10 min/d
Upper extremity and trunk strengthening program, 30 min/d

Week 2
Continue with the above program
Partial weight bearing with crutches (20% of body weight)
Passive ROM goal: 0-90
Active ROM exercises for extension (in available range)
No active ROM for flexion
Seated isotonic quadriceps contractions, 60-0 of flexion (against manual resistance, Theraband), 6 20
reps per d
EMS for quadriceps (60 of flexion), 30 contractions per day (4-s duration [85 Hz], 20-s rest time)
Pool exercises (gait, balance, coordination), 20 min/d

Week 3
Continue with the above program
Partial weight bearing with crutches (50% of body weight)
ROM goal: 0-120, discontinue CPM when goal reached
Flexibility exercises for quadriceps (Thomas position), 6 30 s/d
Bilateral proprioceptive exercises (knee flexion, 10-20), on different unstable surfaces, and also on skates,
6 1 min/d
Bilateral balance exercises (Biodex Stability System), 6 30 s/d
Isokinetics (speeds 30/s and 60/s) in limited ROM (40-90 of flexion) for quadriceps, 3 20 reps per d
Stationary bike for gentle ROM exercise (low resistance), 3 15 min/d

Week 4
Continue with the above program
Partial weight bearing with crutches (70% of body weight)
ROM goal: 0-130
Begin active gentle ROM exercises for flexion
Bilateral mini-squats (0-40), also on skates, 6 20 reps per d
Unilateral proprioceptive and balance training (knee flexion, 10-20), 6 20 s/d
Isometric hamstring exercises (in 0, 20, 40, 60, 80 of flexion), 6 30 reps per d
Simulated leg press on the closed-chain attachment (Biodex Systems), range 0-60, speed 90/s, 3 30 reps
per d
Deep-water running program (with wet vest), 20 min/d

J Orthop Sports Phys Ther Volume 36 Number 2 February 2006 99

Week 5
Continue with the above program
Full weight bearing for level gait (avoid stairs), stop the use of crutches
ROM goal: ensure 0-130 with active and passive exercises
Discontinue knee brace, use of knee neoprene sleeve
Flexibility exercises: add stretching for hamstrings, gastrocnemius/soleus, iliotibial band, hip flexors,
adductors, 3 30 s for each muscle group
Unilateral proprioceptive and balance training on skates (knee flexion, 10-20), 6 30 s/d
Isokinetics quadriceps (speeds, 30/s, 60/s, 90/s, 120/s, 150/s, 180/s; range, 110-0), 6 10 reps
(each speed) per d
Hamstring exercises (0-90 flexion) with Theraband, 5 20 reps per d
Stationary bike (increase resistance), 3 20 min/d

Week 6
Continue with the above program
Exercise passive flexion end of ROM (unloaded flexion), 6 10 min/d
Bilateral semi-squats (0-60), 6 20 reps per d
Bilateral reactive/quickness training, 10 30 s/d
Agility training (lateral movements with Sport Cord), 3 15 min/d
Training on Reebok Slide (skating specific), 4 10 min/d

Week 7
Continue with the above program
Sit back on heels exercise (loaded flexion), 12 1 min/d
Stairs allowed
Unilateral mini-squats (0-40), 6 20 reps per d
Isokinetics quadriceps AND hamstring (speeds 180/s, 210/s, 240/s, 270/s, 300/s; range, 110-0), 6
10 reps (each speed) per d
Strengthening program on weight machines (leg press, leg curls), 1 30 min/d
Endurance program on bike, 1 45 min/d
Begin free ice skating

Week 8
Continue with the above program
Passive ROM goal: symmetrical
Progress unilateral mini-squats to semi-squats
Lunges program (front, lateral, diagonal), 3 25 each
Stairmaster, 1 30 min/d
Rollerblading program, 2 30 min/d
Ice skating exercises, 1 45 min/d

Week 9
Continue with the above program
Intensify strengthening (2 45 min/d) and endurance program (1 60 min/d)
Specific ice skating with equipment (in this case: movement saves, goaltender)

Week 10
Continue with the above program
Sit back on heels goal: symmetrical
Plyometrics program (bilateral vertical and horizontal jumping), 1 20 min/d
Controlled progression with ice training (under physiotherapist and coach supervision)
Week 11 to 14
Continue with the above program
If no problems, discontinue rehabilitation by end of week 12
Intensify sport-specific ice training until complete integration in the team training

100 J Orthop Sports Phys Ther Volume 36 Number 2 February 2006