Physical Therapy in Sport 45 (2020) 76e85

Contents lists available at ScienceDirect

Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Review Article

Postoperative rehabilitation and outcomes following arthroscopic

isolated meniscus repairs: A systematic review
Gulcan Harput a, *, Hande Guney-Deniz a, John Nyland b, Yavuz Kocabey c
a
Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey
b
Spalding University, Kosair Charities College of Health and Natural Sciences, Athletic Training Program, Louisville, KY, USA
c
Kocaeli Acıbadem Hospital, Department of Orthopaedic and Traumatology, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The purpose of this study was to review the current literature on rehabilitation protocols
Received 1 October 2019 following arthroscopic meniscus repair.
Received in revised form Methods: A systematic literature review was performed of Medline, Scopus, and Web of Science data-
16 June 2020
bases to identify relevant articles from January 1990 to April 2019. Search terms were (meniscus OR
Accepted 18 June 2020
meniscal repair) AND (repaired OR repair) AND (rehabilitation OR physiotherapy OR physical therapy).
Each study was independently scored for methodological research quality level using the Modified
Keywords:
Coleman Methodology Score (MCMS). The following variables were extracted from each study: publi-
Meniscus
Rehabilitation
cation year, study type, evidence level, subject demographics, injury mechanism, meniscus tear type,
Meniscal repair surgical procedure, rehabilitation program [immobilization, weight bearing, ROM progression, thera-
Failure rate peutic exercises, length of follow-up, patient-reported outcome measurements, return to sport timing/
criteria and failure rate/criteria.
Results: Eighteen studies met the inclusion criteria. The overall MCMS was moderate 59.5 ± 11.7
(range ¼ 42e90). The average MCMS score for postoperative rehabilitation was 4.7 ± 1.18. Only 1 (5.6%)
study was a prospective randomized controlled trial and 14 studies (78%) had retrospective designs.
Fourteen (78%) studies suggested that return to sports should occur between 3 and 6 months post-
surgery. Early range of motion and immediate weight-bearing had no influence over patient-reported
outcomes or failure rates for vertical meniscus tear repairs.
Conclusion: Low MCMS scores, primarily retrospective study designs and poorly described postoperative
rehabilitation protocols made it difficult to design an evidence-based therapeutic rehabilitation program
for patients following arthroscopic repair of an isolated meniscus tear. An arthroscopic isolated meniscal
tear repair rehabilitation protocol is being attempted to present based on a synopsis of existing evidence.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction meniscectomy (Stein, Mehling, Welsch, von Eisenhart-Rothe, & Jager,

2010). Several different meniscal repair methods have been reported
Meniscus injuries are frequently treated with repair or partial in the literature. Accordingly, prescriptive post-surgical rehabilitation
meniscectomy. Recently, preservation of meniscal tissue through programs implement varying periods of knee joint immobilization or
innovative repair methods rather than partial resection has become restricted range of motion (ROM), weight bearing reduction, thera-
the preferred surgical intervention because meniscal tissue loss pre- peutic exercise progressions, length of follow-up, patient-reported
disposes the knee joint to early degenerative changes (Hutchinson, outcome measurements, return to sport timing/criteria, and failure
Moran, Potter, Warren, & Rodeo, 2014; Xu & Zhao, 2015). Patient rate/criteria (Lind, Nielsen, Fauno, Lund, & Christiansen, 2013).
function has also been found to be better following meniscus repair Rehabilitation protocols post-meniscal repair should be
procedures, with reduced osteoarthritis risk compared to partial adjusted based on the tear type, repair location and surgical
method (Barber, 1994; Lind et al., 2013; Noyes & Barber-Westin,
2000; Stein et al., 2010). Unfortunately, no consensus currently
exists regarding standardized rehabilitation protocols for different
* Corresponding author. meniscus tear repair types. While it has been speculated that
E-mail address: gulcan.aktas@hacettepe.edu.tr (G. Harput).

https://doi.org/10.1016/j.ptsp.2020.06.011
1466-853X/© 2020 Elsevier Ltd. All rights reserved.
 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85 77

immediate weight bearing can stabilize the repair site following sexes, clinical trials of any kind, and all levels of evidence. Exclusion
bucket-handle meniscal tear repair (longitudinal tears) (Richards criteria were as follows: Non-English studies, articles that were
et al., 2005, 2008), similar weight bearing loads have also been open meniscus repair, not related to meniscus repair, studies
considered potentially injurious to the repair site (Richards et al., focusing on results after meniscus root repair or meniscus trans-
2005, 2008). Additionally, knee flexion ROM translates both plantation, studies with concomitant procedures (e.g., ligament
menisci posteriorly (especially the lateral meniscus) which may reconstruction, osteotomy, cartilage repair), in vitro or animal
over-stress posterior horn meniscal repair sites if loads are applied studies, radiologic, biomechanical or diagnostic studies, technical
too soon post-surgery (Becker et al., 2005; Hill et al., 2000). notes and letters to editors.
In general, rehabilitation protocol restrictions following menis-
cal repair are associated with non-, or partial weight bearing and
restricted ROM for six weeks following surgery (Barber, 1994; 2.3. Methodological quality assessment
Noyes & Barber-Westin, 2000). In contrast to this, more accelerated
protocols often include immediate weight bearing as tolerated and Quality assessment of the included articles was independently
unrestricted 0 e90 knee flexion (Kocabey, Nyland, Isbell, & performed by two reviewers (GH and HGD). When the reviewers
Caborn, 2004; Lind et al., 2013). In more restricted rehabilitation did not reach consensus, a third reviewer (JN) made the final de-
protocols return to sports is not generally allowed until a minimum cision. All articles were independently scored for methodological
of six months post-surgery, while in accelerated protocols patients research quality level using the Modified Coleman Methodology
are often released back to unrestricted sports participation at Score (MCMS) (Jakobsen et al., 2005). This score assesses the
approximately 3e4 months post-surgery (Kocabey et al., 2004; methodology of clinical studies by using 10 specific quantitative
Lind et al., 2013). and qualitative criteria: study size, mean follow-up, number of
Existing literature suggests that restricted and accelerated surgical procedures, type of study, diagnostic certainty, and
rehabilitation protocols in specific patient groups have similar description of surgical procedure, postoperative rehabilitation,
failure rates (Barber, 1994; Lind et al., 2013; Perkins, Gronbeck, Yue, outcome measures, outcome assessment, and selection process.
& Tompkins, 2018). However, these studies generally did not report The final score ranges from 0 to 100, with a score of 100 indicating
detailed rehabilitation protocols and displayed considerable sur- the highest reported study methodological quality. If the score
gical technique, evaluation method and patient demographic is > 85, the study is considered excellent, a score between 70 and 84
variability (Ahn et al., 2015; Eggli, Wegmuller, Kosina, Huckell, & is considered to be good, a score from 50 to 69 is considered to be of
Jakob, 1995; Gao, Wei, & Messner, 1998; Jakobsen, Engebretsen, & moderate methodological quality, and <50 is poor (Coleman, Khan,
Slauterbeck, 2005). The purpose of this systematic literature re- Maffulli, Cook, & Wark, 2000).
view was to evaluate current meniscal repair literature regarding
prescriptive post-surgical rehabilitation programs such as knee
2.4. Data extraction
joint immobilization or restricted ROM, weight bearing reduction,
therapeutic exercise progressions, length of follow-up, patient-re-
Two authors reviewed and extracted data from studies that ful-
ported outcome measurements, return to sport timing/criteria, and
filled all inclusion criteria (GH and HGD). The following variables
failure rate/criteria. Based upon a synopsis of existing evidence we
were extracted from each study: publication year, study type, evi-
present an evidence-based protocol for arthroscopic isolated
dence level, subject demographics, injury mechanism, meniscus
meniscal tear repair rehabilitation.
tear type, type of surgical procedure, rehabilitation program vari-
ables including immobilization, weight bearing, ROM progression,
2. Materials and methods
therapeutic exercises, length of follow-up, patient-reported
outcome measurements (International Knee Documentation Com-
2.1. Search strategy
mittee (IKDC), Knee Injury and Osteoarthritis Outcome Score
(KOOS), Lysholm score and Tegner score, return to sport timing/
Based on the PICO framework (P ¼ patient following isolated
criteria, failure rate and criteria.
meniscus tear, I ¼ arthroscopic meniscal tear repair, C ¼ arthroscopic
partial meniscectomy or similar control, O ¼ patient reported
functional knee outcome), a systematic literature review was per- 2.5. Statistical analysis
formed searching Medline, Scopus, and Web of Science databases to
identify relevant articles from January 1990 to April 2019 using Descriptive statistical analysis was performed using SPSS
keywords (meniscus OR meniscal repair) AND (repaired OR repair) version 26.0 software (IBM-SPSS Inc., Armonk, NY).
AND (rehabilitation OR physiotherapy OR physical therapy). Ran-
domized controlled trials (RCTs), prospective and retrospective
cohort studies, and case series were included provided that 3. Results
arthroscopic meniscus repair was performed.
3.1. Identification of eligible studies and quality assessment
2.2. Study selection
A total of 18 studies met the study inclusion criteria. The flow
This systematic review was performed in accordance with the diagram according to PRISMA guidelines summarizes the selection
PRISMA (Preferred Reporting Items for Systematic Reviews and protocol (Moher, Liberati, Tetzlaff, Altman, & Group, 2009) (Fig. 1).
Meta-Analyses) guidelines (Fig. 1). After initial identification, the Of the 18 studies included, only one study represented level I evi-
full-text article was screened using the inclusion and exclusion dence, four studies were level 3 evidence and 13 studies were level
criteria as listed in Table 1. 4 evidence (www.kssta.org) The mean MCMS score was 59.5 ± 11.7
The inclusion criteria were as follows: English language studies (range ¼ 42e90) (Table 2). The methodological quality of included
reporting rehabilitation procedures after isolated arthroscopic studies were generally moderate. Comprehensive descriptive sta-
meniscus repair with all inside, inside-out or outside-in, published tistics for each of the 10 MCMS criteria for studies reporting isolated
online or in print in a peer-reviewed journal, any patient age, both meniscus repair patient outcomes is shown in Table 2.
78 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85

Fig. 1. Flowchart of search strategy in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Table 1
Inclusion and exclusion criteria.

Inclusion criteria Exclusion criteria

English language Contaminant or staged ACL reconstruction

Isolated meniscal repair including all inside, inside-out, outside in. Cartilage repair
Human subjects Diagnosed ACL deficiency or other instabilities
Documenting rehabilitation procedures Biomechanical studies
Review articles, technical notes, letters to the editor

3.2. Patient demographic characteristics Most studies treated patients with vertical longitudinal meniscal
tear repairs (Alvarez-Diaz et al., 2016; Eggli et al., 1995; Gallacher
Patient age was 25.6 ± 6.6; range ¼ 13e63 years). All but two of et al., 2010; Horibe et al., 1996; Kimura et al., 2004; Kocabey
18 studies (Kocabey et al., 2004; Tsai, McAllister, Chow, Young, & et al., 2004; Majewski et al., 2006; Stein et al., 2010; Tsai et al.,
Hame, 2004) reported gender distribution, with 26.3% of the pa- 2004), three studies treated patients with radial meniscal tear re-
tients being women. Six studies reported how many meniscus in- pairs (Choi et al., 2010; Lind et al., 2013; Lucas et al., 2015), six
juries were related to sports participation (Ahn et al., 2015; Alvarez- studies treated patients with bucket handle meniscal tears (Ahn
Diaz et al., 2016; Choi, Kim, Son, & Victoroff, 2010; Hagmeijer et al., et al., 2015; Gallacher et al., 2010; Hagmeijer et al., 2019; Lucas
2019; Kimura, Shirakura, Higuchi, Kobayashi, & Takagishi, 2004; et al., 2015; Perkins et al., 2018; Samuelsen et al., 2018), and only
Lind et al., 2013). Only two study restricted subject participation to three studies treated patients with complex meniscal tear repairs
only having experienced a sports-related meniscus injury (Alvarez- (Gallacher et al., 2010; Hagmeijer et al., 2019; Lucas et al., 2015).
Diaz et al., 2016; Hagmeijer et al., 2019). Twelve studies reported Surgical repair techniques also varied between study groups.
preoperative patient activity levels using the Tegner activity rating These studies included a total of 665 relevant patients; 143 patients
(4.9 ± 1.8; range ¼ 0e10) (Ahn et al., 2015; Alvarez-Diaz et al., 2016; underwent an inside-out meniscal tear repair (Eggli et al., 1995;
Choi et al., 2010; Gallacher, Gilbert, Kanes, Roberts, & Rees, 2010; Hagmeijer et al., 2019; Horibe et al., 1996; Kimura et al., 2004;
Hagmeijer et al., 2019; Kimura et al., 2004; Lind et al., 2013; Lucas, Samuelsen et al., 2018; Stein et al., 2010), 342 patients underwent
Accadbled, Violas, Sales de Gauzy, & Knorr, 2015; Majewski, Stoll, an all-inside meniscal repair (Alvarez-Diaz et al., 2016; Choi et al.,
Widmer, Muller, & Friederich, 2006; Stein et al., 2010; Tiftikci & 2010; Gallacher et al., 2010; Hagmeijer et al., 2019; Kocabey et al.,
Serbest, 2016; Tsai et al., 2004). Two studies reported a Tegner 2004; Lind et al., 2013; Lucas et al., 2015; Samuelsen et al., 2018;
score >5 (Kimura et al., 2004; Stein et al., 2010). Solheim, Hegna, & Inderhaug, 2016; Tiftikci & Serbest, 2016; Tsai
et al., 2004), and 106 patients underwent outside-in meniscal
3.3. Tear types and surgical techniques repair (Lucas et al., 2015; Majewski et al., 2006). The surgical
technique used for 74 patients could not be differentiated because
Meniscal tear pattern descriptions were included in all studies. two studies combined two different repair techniques (Ahn et al.,
Table 2
Descriptive data for each of the 10 methods criteria of modified coleman score for studies reporting the outcomes of isolated meniscus repairs.
PART A PART B MCS

Study Size Follow Surgical Study Diagnostic Surgical Rehabilitation Out Tim Reliable Sensitive Recruited Indepen Written Subjects Unbiased Recruit Eligible
up Procedures Type Certainity Procedure Description come ing Measures Measures Subjects dent. Assessment Completion Selection ment Subjects
Description Investi Rate Account
gator

Eggli et al. (Eggli 7 5 10 0 5 5 0 2 2 3 3 5 0 3 3 5 3 0 61

et al., 1995)
Horibe et al. 4 0 10 0 5 5 5 2 2 3 3 5 0 0 0 5 3 0 53
(Horibe et al.,
1996)
Kimura et al. 0 0 0 0 5 3 5 2 2 3 3 5 0 3 3 5 3 0 42
(Kimura et al.,
2004)
Tsai et al. (Tiftikci 4 5 0 0 5 3 5 2 2 3 3 5 0 3 3 5 3 0 51
& Serbest,
2016)
Kocabey et al. 7 0 0 0 5 3 5 2 2 3 3 5 0 0 0 5 5 0 50
(Kocabey et al.,
2004)

G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85

Majewksi et al. 10 5 10 0 5 5 5 2 2 3 3 5 0 3 3 5 3 0 69
(Majewski
et al., 2006)
Stein et al. 7 5 0 0 5 3 5 2 2 3 3 5 4 3 3 5 5 0 60
(Solheim et al.,
2016)
Choi et al. (Choi 10 5 7 0 5 0 5 2 2 3 3 5 0 3 3 5 3 0 61
et al., 2010)
Gallacher et al. 0 5 10 0 5 5 5 2 2 3 3 5 4 3 3 5 3 0 63
(Gallacher
et al., 2010)
Lind et al. (Lind 7 2 10 15 5 5 5 2 2 3 3 5 0 3 3 5 5 5 90
et al., 2013)
Alvarez-Dıaz et al. 0 2 0 0 5 5 5 2 2 3 3 5 0 3 3 5 5 0 48
(Alvarez-Diaz
et al., 2016)
Ahn et al. (Ahn 0 2 7 0 5 5 5 2 2 3 3 5 0 3 3 5 5 0 55
et al., 2015)
Lucas et al. (Lucas 0 5 10 0 5 5 5 2 2 3 3 5 0 3 0 5 3 0 56
et al., 2015)
Tiftikci & Serbest 4 5 10 0 5 5 5 2 2 3 3 5 0 3 3 5 3 0 68
(Stein et al.,
2010)
Solheim et al. 10 5 10 0 5 5 5 2 2 3 3 5 0 0 0 5 5 0 70
(Sherman et al.,
2020)
Perkins et al. 10 5 0 0 0 0 5 2 2 0 0 5 0 0 0 5 3 0 42
(Perkins et al.,
2018)
Samuelsen et al. 4 5 0 0 5 5 5 2 2 3 3 5 0 3 3 5 3 5 62
(Samuelsen
et al., 2018)
Hagmeijer et al. 7 5 10 0 5 5 5 2 2 3 3 5 0 3 3 5 3 0 70
(Hagmeijer
et al., 2019)
Mean ± SD (min- 5.1 ± 3.8 3.7 ± 2.0 5.8 ± 4.8 (0 0.8 ± 3.5 4.7 ± 1.2 (0 4.0 ± 1.7 (0 4.7 ± 1.2 (0e5) 2.4 ± 0.4 (0e3) 2.5 ± 1.0 (0e5) 3.1 ± 0.9 (0e5) 59.5 ± 11.7 (42e90)
max) (0e10) (0e5) e10) (0e15) e5) e5)

79
80 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85

2015; Perkins et al., 2018). Perkins et al. (Perkins et al., 2018) used a reported Knee Injury and Osteoarthritis Outcome (KOOS) scores.
combination of all-inside and inside-out meniscal repair tech- (Lind et al., 2013).
niques, while Ahn et al. (Ahn et al., 2015) used a combination of all- From pre-surgery to post-surgery, five studies reported Tegner
inside and outside-in meniscal repair techniques. score improvements from 4.6 ± 2.1 to 6.9 ± 1.0 at 5.8 years post-
surgery (Ahn et al., 2015; Choi et al., 2010; Hagmeijer et al., 2019;
3.4. Rehabilitation Lucas et al., 2015; Tiftikci & Serbest, 2016), four studies reported
Lysholm score improvements from 62.5 ± 7.7 to 86.3 ± 8.4 at 4.3
Post-operative rehabilitation after meniscus repair was mainly years post-surgery (Choi et al., 2010; Gallacher et al., 2010; Lucas
described in terms of immobilization duration, weight bearing et al., 2015; Tiftikci & Serbest, 2016), two studies reported IKDC
status, knee flexion ROM progression, and return to sports timing score improvements from 56.9 ± 11.9 to 90.3 ± 0.1 at 9.7 years post-
(Table 3). None of the studies documented the post-surgical reha- surgery (Hagmeijer et al., 2019; Tiftikci & Serbest, 2016) and one
bilitation protocol in detail (MCMS ¼ 4.7 ± 1.2). study reported KOOS score improvements from 69.4 to 78.4 at two
Four studies suggested post-surgical immobilization for years post-surgery (Lind et al., 2013).
approximately 2e6 weeks (Ahn et al., 2015; Eggli et al., 1995;
Kimura et al., 2004; Lucas et al., 2015). Weight bearing timing
varied among the studies that contributed to this review, however, 3.6. Failure rate
most studies followed a restricted weight bearing protocol for 6
weeks. Kocabey et al. (Kocabey et al., 2004) described full weight Studies that contributed to this systematic review reported
bearing at four weeks post-surgery for longitudinal meniscal tear meniscal repair failure rates based on MRI (Choi et al., 2010; Eggli
repairs and at 6 weeks for radial meniscal tear repairs. Two studies et al., 1995; Kimura et al., 2004; Lind et al., 2013; Lucas et al.,
compared repaired meniscus healing status between groups that 2015; Samuelsen et al., 2018; Tiftikci & Serbest, 2016), weight-
were allowed immediate weight bearing versus restricted weight bearing radiographs (Majewski et al., 2006; Stein et al., 2010),
bearing until 4e6 weeks post-surgery (Lind et al., 2013; Perkins second-look arthroscopy (Choi et al., 2010; Horibe et al., 1996;
et al., 2018). Based on patient reported outcome surveys (Perkins Kocabey et al., 2004; Lind et al., 2013; Samuelsen et al., 2018;
et al., 2018) and failure rates (Lind et al., 2013; Perkins et al., Solheim et al., 2016), clinical examination (Tsai et al., 2004) or re-
2018) they reported no group differences at 2 years (Lind et al., operation on the same meniscus requiring excision or re-fixation
2013) and 5 years (Perkins et al., 2018) post-surgery. (Gallacher et al., 2010; Hagmeijer et al., 2019; Perkins et al., 2018;
Knee flexion ROM timing and progression also differed between Samuelsen et al., 2018). Mean failure rate was 31.2 ± 16.4%
studies. In 14 studies the rehabilitation goal was to achieve 90 (range ¼ 4e64.5%) (Table 3). The extensive inter-study meniscal
knee flexion by 4e6 weeks post-surgery. Four studies did not repair failure rate variation may be due to different post-surgical
mention the knee flexion progression timeline (Eggli et al., 1995; follow-up timing, meniscal tear type, surgical technique, rehabili-
Horibe et al., 1996; Kimura et al., 2004; Tsai et al., 2004). In four tation progression and patient age.
studies, squatting was not permitted until three months post- Eggli et al. (Eggli et al., 1995) compared the failure rates of
surgery (Solheim et al., 2016; Tiftikci & Serbest, 2016; Tsai et al., patients > or < 30 years of age. They reported that meniscal repair
2004), however, the squat depth angle was not mentioned. failure rates was greater for the older patient group (33% vs. 12%).
Regarding return to sports timing, each of the 16 studies that Studies by Lind et al. (Lin et al., 2013) and Perkins et al. (Morgan,
contributed to this systematic review relied more on time post- Wojtys, Casscells, & Casscells, 1991) identified comparable menis-
surgery to determine release to unrestricted sports participation, cal repair failure rates between restricted and non-restricted
than use of a specific function-based return to sports participation rehabilitation protocols at 2 years (36% vs. 25%) (Lind et al., 2013)
decision-making criteria. Kimura et al. (Kimura et al., 2004), and 5 years post-surgery (37.1% vs. 39.3%) (Perkins et al., 2018).
Kocabey et al. (Kocabey et al., 2004) and Gallacher et al. (Gallacher Samuelsen et al. (Samuelsen et al., 2018) reported similar failure
et al., 2010) suggested return to sports timing at three months post- rates (20%) between all-inside and inside-out meniscal repair
longitudinal repair surgery. Samuelsen et al. (Hagmeijer et al., 2019) techniques.
allowed return to sports participation at 6e9 months following all- Two studies reported that meniscal repair failure rates increased
inside or inside-out meniscal repair. Only Alvarez-Diaz et al. the greater the time post-surgery (Lind et al., 2013; Solheim et al.,
(Alvarez-Diaz et al., 2016) reported return to sports decision- 2016). For vertical meniscus tear repair using an all-inside tech-
making based upon some fundamental criteria such as absence of nique, Lind et al. (Lind et al., 2013) reported a failure rate of 16% at
knee inflammation, full knee flexion ROM and adequate muscle one year post-surgery that increased to 32% by two years post-
strength. Most studies allowed return to sports at 4e6 months surgery. Also, for vertical meniscus tear repair using an all-inside
post-surgery. technique Sholheim et al. (Solheim et al., 2016) reported an 11%
failure rate at six months post-surgery, 23% at one year post-
3.5. Patient reported outcome measures surgery and 28% at two years post-surgery. In evaluating the
meniscal repair failure rates of isolated “white on white” avascular
Thirteen studies used patient reported outcomes for reporting meniscal bucket-handle tear repairs with all-inside technique,
knee function, four studies did not include any knee functional Gallacher et al. (Samuelsen et al., 2018) reported failure rates of 32%
outcomes. Ten studies reported Lysholm scores (Ahn et al., 2015; at four years post-surgery suggesting that many avascular meniscal
Choi et al., 2010; Gallacher et al., 2010; Kimura et al., 2004; Lucas tears could be successfully repaired. There is also evidence sug-
et al., 2015; Majewski et al., 2006; Solheim et al., 2016; Stein gesting that early return to sport may lead to higher failure rates
et al., 2010; Tiftikci & Serbest, 2016; Tsai et al., 2004), ten studies among pediatric patients (Hagmeijer et al., 2019; Lucas et al., 2015;
reported Tegner scores (Ahn et al., 2015; Alvarez-Diaz et al., 2016; Lyman et al., 2013). Hagmeijer et al. (Hagmeijer et al., 2019) found
Choi et al., 2010; Gallacher et al., 2010; Kimura et al., 2004; Lind that early isolated meniscal tear repair failures were caused by
et al., 2013; Majewski et al., 2006; Stein et al., 2010; Tiftikci & acute re-injury trauma within one year post-surgery. Thus, they
Serbest, 2016; Tsai et al., 2004), three reported subjective Interna- assumed that early return to sport may be a risk factor for failure
tional Knee Documentation Committee (IKDC) scores (Ahn et al., since there may not be adequate time for repaired meniscus
2015; Hagmeijer et al., 2019; Tiftikci & Serbest, 2016) and two healing.
Table 3
Patient demographics, rehabilitation protocols and failure rates of the included studies.

Authors Patient Age Gender Meniscal Surgical Immobilization Weight- ROM Exercises Return to sport Failure Rate Failure Rate
(years), (Mean, Lesion Method bearing Assessment
SD or range)

Eggli et al. (Eggli 29 (13-58) F:8, M: 44 vertical or Inside-out 6 weeks NA NA NA 4 months MRI <30 years:
et al., 1995) vertical/ 12%; >30
oblique years: 33%
Horibe et al. 22 (9-48) F:9, M: 26 vertical or Inside-out NA FWB at 5e6 NA NA 4e6 months Second-look 44%
(Horibe et al., oblique weeks arthroscopy
1996)
Kimura et al. 17.9 ± 3.7 F:3, M: 5 longitudinal Inside-out 4 weeks NA NA NA 3 months MRI 50%
(Kimura et al., or bucket-
2004) handle
Tsai et al. (15e44) N longitudinal All-inside NA NA >90 flexion Squats at 3 months NA Only clinical 22%
(Tiftikci & exercise at 3 months exam
Serbest, 2016)
Kocabey et al. 26.7 (13-50) N/A longitudinal, All-inside NA Longitudinal Longitudinal tear NA Longitudinal tear Second-look 4%
(Kocabey radial tear repair, repair: 0 e90 , first repair: 3 months; arthroscopy
et al., 2004) FWB: 3 weeks; 3 weeks; Radial tear repair: 4
Radial tear Radial tear repair, 0 e5 months

G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85

repair, FWB: 6 e90 , at 3e6 weeks
e8 weeks
Majewksi et al. 29.8 (15-60) F:34, M:54 longitudinal Outside-in NA 50% FWB: 6 0 e60 , first 6 NA 4 months WB X-ray 24%
(Majewski or vertical weeks weeks
et al., 2006)
Stein et al. 31.26 (20-63) F:5, M:10 vertical Inside-out NA FWB with full 0 e60 first 4 ROM and isometric exercises in CKC 4 months WB X-ray 7.1%
(Solheim extension: 4 weeks; 0 e90 first positions
et al., 2016) weeks 6 weeks
Choi et al. (Choi 29.9 (16-52) F:3, M:11 radial tear All-inside NA PWB: 6 weeks 0 e90 first 6 weeks ROM and CKC exercises; 6 months MRI, 64.3%
et al., 2010) FWB: 10 weeks Running: 12 weeks Second-look
arthroscopy
Gallacher et al. 26 (13-54) F:14, bucket- All-inside NA PWB: 3 weeks 0 e90 first 6 weeks OKC quadriceps exercises avoided for 12 weeks Repeat surgery 32%
(Gallacher M:73 handle, the first 3 weeks with excision or
et al., 2010) vertical, refixation
complex
Lind et al. (Lind Free rehab: 29 Free rehab vertical All-inside NA Free rehab Free rehab group Free Rehab group allowed to run at 8 Free rehab group MRI, Second- Free rehab: at
et al., 2013) (18e47) F:9, M:23 group 0 e90 first 2 weeks; Restricted rehab group 4 months; look 1 year 7%
Restricted FWB: 3e4 weeks; allowed to run at 12 weeks Restricted rehab arthroscopy at 2 year 28%;
rehab: Restricted weeks; Restricted rehab group Restricted
26 (18-50) rehab Restricted group 6 months rehab: at 1
F: 10, M: rehab group 0e2 weeks 0 e30 year 25%
18 FWB: 5e6 3e4 weeks 0 e60 at 2 year 36%
weeks 5e6 weeks 0 e90
Alvarez-Dıaz 28 (18e37) M: 14 longitudinal All-inside NA PWB: First 4 0 e90 : 4 weeks Squats at 4 months No inflammation, NA NA
et al. (Alvarez- tears weeks ROM deficit,
Diaz et al., adequate muscle
2016) strength
Ahn et al. (Ahn 20 (14-54) F: 6, M: 7 lateral bucket All-inside 2 weeks PWB: First 1 0 e90 : 6 weeks NA NA NA NA
et al., 2015) handle or week
outside-in
Lucas et al. 14 (9-18) F:8, M:9 longitudinal: Outside- 4 weeks NA Passive ROM: 0 CKC exercises for quadriceps 6 months MRI 50%
(Lucas et al., 7 in:18 all- e100
2015) complex: 3 inside:1
horizontal: 3
radial: 2
bucket
handle: 4
Tiftikci & Serbest F: 40.5 ± 9.7 F:11, M:16 horizontal All-inside NA NWB: First 2 Passive ROM: First 2 Isometric quadriceps exercise, full 6 months MRI 3.7%
(Stein et al., M: 38.5 ± 11.1 weeks; FWB: 4 weeks; Full ROM: knee ROM exercise
2010) weeks After 2 weeks

81
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 82 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85

4. Discussion

Abbreviations: F ¼ Female; M ¼ Male; NA ¼ not available; FWB ¼ full weight-bearing; PWB ¼ partial weight-bearing; NWB ¼ non weight-bearing, rehab ¼ rehabilitation; CKC ¼ closed kinetic chain; OKC ¼ open kinetic chain,
28% at 2 years

group: 39.3%

with excision or failure 36.1%

Repeat surgery NWB group:

20%; Inside-
months and
Failure Rate

with excision or 37.1%; WB

All-inside:
Repeat surgery Total 48%;
The most important finding of the current review was that the
23% at 12

Repeat surgery Midterm

out: 20%
with excision or 11% at 6
months,
highly variable postoperative rehabilitation protocols that were
reported did not influence failure rates, patient reported outcomes
or return to sports rate following arthroscopic isolated meniscal
tear repair. However, due to only moderate research study meth-
Failure Rate
Assessment

MRI, repeat
refixation

refixation

refixation
odological quality, it is difficult to suggest a rehabilitation protocol

surgery
based on study evidence. Overall, 14 (78%) of the studies were
retrospective and none provided well-described post-operative
rehabilitation details. Although 12 (66%) studies had a follow-
up > 24 months post-surgery, only two 2 (11%) studies reported use
Return to sport

of an investigator independent of the surgeon. From the studies

Stretching, single leg raise and passive 4e6 months

6e9 months

4e6 months
that contributed to this review, it appeared that time post-surgery
was the more critical factor in return to sports participation
decision-making than achievement of specific functional task
NA

criteria following arthroscopic meniscal tear repair.

ROM progressing through active CKC

Because of the lack of level I randomized prospective controlled

trials, strong recommendations for the ideal postoperative rehabili-
tation program remains difficult to ascertain. The rehabilitation pro-
tocols for 16 studies (89%) included weight bearing, knee flexion ROM
exercises at 3 months

and timing of return to sports participation (Table 3). Weight bearing

status was the most consistently reported post-isolated meniscus
repair rehabilitation factor. Seven (58%) studies, using restricted
rehabilitation protocols and recommended full weight-bearing at
Exercises

4e6 weeks after surgery regardless of the tear type. Only two (11%)
studies, reporting non-restricted rehabilitation protocols, with im-
NA

NA

NA

mediate weight-bearing following vertical meniscus tear repair.

Restricted or delayed weight-bearing are often used to protect the
PWB: First 3e4 0 e90 : First 3e4
0 e90 : 6 weeks

meniscus tear repair site, however, some evidence suggests that early
0 e90 : First 6

0 e90 : First 4

weight bearing may be beneficial for effective longitudinal meniscus

tear repair healing (Richards et al., 2005, 2008). In radial tears,
weeks

weeks

weeks

restrictive rehabilitation protocols were suggested since early

ROM

weight-bearing might displace tear edges and compromise healing

weeks; FWB: 6

NWB group: 4

(Gao et al., 1998; Kocabey et al., 2004). Thus, type of meniscus tear
after surgery;
Immediately
PWB: First 4

PWB: First 4
WB group:

should be a contributing factor when designing the post-operative

e6 weeks
Immobilization Weight-
bearing

rehabilitation protocol (Kocabey et al., 2004).

weeks

weeks

weeks

Despite the known adverse effects of immobilization on

meniscal tear healing (Bray et al., 2001; Dowdy, Miniaci, Arnoczky,
Fowler, & Boughner, 1995; Eriksson & Haggmark, 1979), 22% of the
studies that contributed to this review suggested knee joint
immobilization for variable time periods post-isolated meniscal
All-inside NA

All-inside NA

All-inside: NA

All-inside: NA

tear repair (Ahn et al., 2015; Eggli et al., 1995; Kimura et al., 2004;
Lucas et al., 2015). Most studies suggested use of restricted knee
20 inside-

13 inside-
longitudinal or inside-

flexion ROM to 60 or 90 over the initial 6 weeks post-surgery.

Surgical
Method

out: 20

out: 20

Deep knee flexion was commonly contraindicated during this

out

time period since higher flexion angles place excessive stresses at

handle tears

the posterior lateral meniscus tear repair site (Busenkell & Lee,
longitudinal

complex: 5
handle: 17
simple: 11
or bucket
Meniscal

1992; Morgan et al., 1991). Lin et al. (Lin et al., 2013), however,
vertical,

bucket-
vertical

bucked
handle
Lesion

tears

reported that non-weight bearing open kinetic chain knee ROM

tear

may not be harmful to the meniscus repair site (Lin et al., 2013).
Inside out:
12, M: 23;

F: 6, M:14

F: 5, M:15
F:3, M: 29

WB ¼ weight-bearing, ROM ¼ range of motion.

WB group

All inside:

Lind et al. (Lind et al., 2013) reported that early unrestricted knee
F: 20, M:

F: 56, M:
group F:
Gender

flexion at 3e4 weeks’ post-surgery had no adverse effects on ver-

NWB

tical meniscus tear repair status compared with restricting knee

66

66

flexion to 90 until six weeks post-surgery. The findings from this
(years), (Mean,

Hagmeijer et al. 16.1 (9.9-18.7)

prospective randomized controlled trial suggest that early knee

SD or range)

NWB group:
(Perkins et al., 23.6 ± 11.6;
Patient Age

33 (14e57)

25.8 ± 10.5
WB group:

23.7 ± 6.7;
Inside out:

flexion ROM may enhance vertical meniscus tear repair healing.

Samuelsen et al. All inside:

22.5 ± 7.6

Another weakness of the reviewed studies was a lack of detailed

rehabilitation protocols or therapeutic exercise program descriptions,
Table 3 (continued )

and no information regarding patient rehabilitation program adher-

et al., 2020)

et al., 2018)

et al., 2019)
(Samuelsen

ence or compliance. The MCMS result for postoperative rehabilitation

(Hagmeijer
Solheim et al.

Perkins et al.
(Sherman

was 4.7 ± 1.2 with no study providing adequate details given scoring
2018)
Authors

options of “well described” ¼ 10 points, “not adequately

described” ¼ 5 points, “protocol not reported” ¼ 0. Thus, it is difficult
to describe an evidence-based rehabilitation protocol and therapeutic
 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85 83

Table 4
Postoperative rehabilitation protocol based on meniscus tear type.

Post- Vertical, longitudinal tears Radial and complex tears Key Subjective and Functional Milestones
Surgical
Timing

First 2 Immediate partial weight-bearing, quadriceps No weight-bearing, quadriceps setting exercises with Achieve quadriceps neuromuscular control and
weeks setting exercises with NMES NMES decrease pain and edema
3- 4 Full weight-bearing and 0e90 knee flexion Partial weight-bearing, 0e90 knee flexion ROM, OKC Controlled weight- bearing with good quadriceps
weeks ROM, OKC non-resistive quadriceps and hip non-resistive quadriceps and hip exercises control, increase hip and quadriceps strength
exercises
5-6 Full knee flexion ROM, Full weight-bearing, 0e90 knee flexion ROM, OKC Normalized gait, improve hamstring-quadriceps co-
weeks OKC resistive quadriceps exercises, non- resistive quadriceps exercises, non-resistive hamstring contraction at the knee, increase hamstring strength
resistive hamstring exercises exercises
12 weeks Progressive strengthening exercises, squatting Full knee flexion ROM, squatting to 60 knee flexion Restore normal activities of daily living, begin
to 90 , running running when 60% quadriceps strength symmetry is
achieved
Return to 3e4 months 6 months No knee pain, full knee ROM and at least 90%
sports quadriceps strength symmetry for return to sports

Abbreviations: NMES ¼ neuromuscular electric stimulation, ROM ¼ range of motion, OKC ¼ open kinetic chain.

exercise progression based upon the existing literature. In many between patient groups that followed accelerated and restricted
studies it was also not clear whether or not patients were prescribed rehabilitation approaches, it may be that current patient reported
more independent home-based exercise programs or physical ther- outcome measurements may not possess the sensitivity needed to
apist guided programs. Perkins et al. (Perkins et al., 2018) indicated accurately evaluate differing rehabilitation protocol and therapeu-
that the rehabilitation of all of their patients who underwent tic exercise progression efficacy. Although, safe return to sports
meniscus repair was guided by a physical therapist, however, no in- participation was a major focus of most of these studies, no study
formation was provided regarding program compliance or adherence. adhered to any validated safe return to sports participation
In contrast, Solheim et al. (Solheim et al., 2016) reported a very general decision-making criteria. Most (78%) studies suggested that return
rehabilitation program with all patients being referred to a physical to sports should be between 3 and 6 months post-surgery. There
therapist for stretching exercises, straight leg raises and passive ROM was also limited information about return to sport rate after iso-
exercises before progressing to closed kinetic chain exercises lated meniscus tear repair (Ahn et al., 2015; Choi et al., 2010;
including stationary bicycling and weight training. Conceivably, a Kimura et al., 2004; Majewski et al., 2006; Stein et al., 2010) and no
rehabilitation protocol and therapeutic exercise progression that can reports of how many patients perceived that they had returned at
be adjusted based on isolated meniscal tear type and location might their previous performance level. Kimura et al. (Kimura et al., 2004)
improve patient self-reported functional outcomes, improve return to reported that 100% of patients and Stein et al. (Stein et al., 2010)
sport participation rates and decrease failure rates. Based upon a reported that 96.2% of patients returned to pre-injury activities
synthesis of the information obtained from the 18 studies that post-surgery. Compared to pre-surgery scores, improved post-
contributed to this review, recent guidelines for meniscal lesions surgery Tegner scores following arthroscopic isolated meniscus
(Logerstedt et al., 2018; Sherman, DiPaolo, Ray, Sachs, & Oladeji, 2020) tear repair suggest improved sports activity levels, however, the
and biomechanical studies (Becker et al., 2005, 2006; Hill et al., 2000; follow-up timing heterogeneity of the studies that contributed to
Lin et al., 2013), we attempted to design a conceptual post- this review make it difficult to truly ascertain the likelihood for
arthroscopic isolated meniscal tear repair rehabilitation protocol successful sports return.
with consideration for lesion type (Table 4). Meniscal tear repair has been shown to have varying failure
The studies that contributed to this systematic literature review rates based on patient age (Eggli et al., 1995; Hagmeijer et al., 2019),
primarily relied on patient reported outcomes and failure rates to time post-surgery (Lind et al., 2013; Solheim et al., 2016) and early
validate isolated arthroscopic meniscal tear repair efficacy. Tegner return to sport (Hagmeijer et al., 2019; Lucas et al., 2015). Eggli et al.
and Lysholm scores were the most widely used patient reported (Eggli et al., 1995) observed 21% more failures in patients who were
outcome measurements for describing functional improvements. >30 years of age compared to younger patients. However, they did
When compared to pre-operative scores, patient reported out- not comment on age as a major factor in meniscal tear repair
comes improved following arthroscopic isolated meniscal tear decision-making since they observed good results for two patients
repair (Ahn et al., 2015; Choi et al., 2010; Hagmeijer et al., 2019; that were >50 years of age (tissue quality and patient lifestyle/
Lind et al., 2013; Lucas et al., 2015; Tiftikci & Serbest, 2016). Since health behaviors may be more important than chronological age).
Lind et al. (Lind et al., 2013) and Perkins et al. (Perkins et al., 2018) In contrast, meniscal tear repair failure rates might be higher in
reported no difference in self-reported knee function scores younger patients since they often return to sports earlier than
84 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85

expected (Hagmeijer et al., 2019; Lucas et al., 2015). Lucas et al. Arthroscopic repair of bucket-handle tears of the lateral meniscus. Knee Surgery,
Sports Traumatology, Arthroscopy, 23, 205e210.
(Lucas et al., 2015) reported normal MRI findings in only 50% of
Alvarez-Diaz, P., Alentorn-Geli, E., Llobet, F., Granados, N., Steinbacher, G., &
pediatric patients at 29 months post-surgery. Therefore, use of an Cugat, R. (2016). Return to play after all-inside meniscal repair in competitive
evidence based return to sport criteria might be more important in football players: A minimum 5-year follow-up. Knee Surgery, Sports Trauma-
pediatric populations following isolated meniscus tear repair. tology, Arthroscopy, 24, 1997e2001.
Barber, F. A. (1994). Accelerated rehabilitation for meniscus repairs. Arthroscopy, 10,
Hagmeijer et al. (Hagmeijer et al., 2019) reported a 30% failure rate 206e210.
in patients <18 years of age at approximately 6 years post-surgery Becker, R., Brettschneider, O., Grobel, K. H., von Versen, R., & Starke, C. (2006).
with no additional failures at 17.6 years post-surgery. Similarly for Distraction forces on repaired bucket-handle lesions in the medial meniscus.
The American Journal of Sports Medicine, 34, 1941e1947.
patient reported outcome measurements, failure rate was not Becker, R., Wirz, D., Wolf, C., Gopfert, B., Nebelung, W., & Friederich, N. (2005).
affected by different rehabilitation protocols (Lind et al., 2013; Measurement of meniscofemoral contact pressure after repair of bucket-handle
Perkins et al., 2018), which suggests either that more refined tears with biodegradable implants. Archives of Orthopaedic and Trauma Surgery,
125, 254e260.
measurement sensitivity is needed, that accelerated post-surgical Bray, R. C., Smith, J. A., Eng, M. K., Leonard, C. A., Sutherland, C. A., & Salo, P. T. (2001).
meniscal repair protocols are safe, or both. Vascular response of the meniscus to injury: Effects of immobilization. Journal
There are limitations associated with this systematic review. of Orthopaedic Research, 19, 384e390.
Busenkell, G. L., & Lee, C. S. (1992). Arthroscopic meniscal repair: A posterior can-
First, as with all systematic reviews, review quality is based on the nulated technique. Arthroscopy, 8, 247e253.
quality of the individual contributing studies that were analyzed. Of Choi, N. H., Kim, T. H., Son, K. M., & Victoroff, B. N. (2010). Meniscal repair for radial
the 18 studies that met the inclusion criteria, 14 were Level IV ev- tears of the midbody of the lateral meniscus. The American Journal of Sports
Medicine, 38, 2472e2476.
idence, and the methodological quality was generally moderate.
Coleman, B. D., Khan, K. M., Maffulli, N., Cook, J. L., & Wark, J. D. (2000). Studies of
Furthermore, the relatively small sample size for each individual surgical outcome after patellar tendinopathy: Clinical significance of method-
study also restricts the conclusions that can be drawn. Another ological deficiencies and guidelines for future studies. Victorian institute of
study limitation is the significant heterogeneity that exists between sport tendon study group. Scandinavian Journal of Medicine & Science in Sports,
10, 2e11.
included studies regarding the type of meniscal tear, surgical Dowdy, P. A., Miniaci, A., Arnoczky, S. P., Fowler, P. J., & Boughner, D. R. (1995). The
techniques, and post-surgical rehabilitation. The descriptions of the effect of cast immobilization on meniscal healing. An experimental study in the
rehabilitation protocols in the studies that contributed to this re- dog. The American Journal of Sports Medicine, 23, 721e728.
Eggli, S., Wegmuller, H., Kosina, J., Huckell, C., & Jakob, R. P. (1995). Long-term re-
view only offer a brief synopsis of the standard patient post- sults of arthroscopic meniscal repair. An analysis of isolated tears. The American
operative course. From this information it is difficult to synthesize Journal of Sports Medicine, 23, 715e720.
these findings into strong specific rehabilitation program recom- Eriksson, E., & Haggmark, T. (1979). Comparison of isometric muscle training and
electrical stimulation supplementing isometric muscle training in the recovery
mendations. Last, only English language studies contributed to this after major knee ligament surgery. A preliminary report. The American Journal of
systematic review. However, the 18 papers that were evaluated Sports Medicine, 7, 169e171.
represented the clinical research groups from twelve different Gallacher, P. D., Gilbert, R. E., Kanes, G., Roberts, S. N., & Rees, D. (2010). White on
white meniscal tears to fix or not to fix? The Knee, 17, 270e273.
countries. Gao, J., Wei, X., & Messner, K. (1998). Healing of the anterior attachment of the
rabbit meniscus to bone. Clinical Orthopaedics and Related Research, 246e258.
5. Conclusion Hagmeijer, M. H., Kennedy, N. I., Tagliero, A. J., Levy, B. A., Stuart, M. J., Saris, D. B. F.,
et al. (2019). Long-term results after repair of isolated meniscal tears among
patients aged 18 Years and younger: An 18-year follow-up study. The American
Low MCMS scores, primarily retrospective study designs and Journal of Sports Medicine, 47, 799e806.
poorly described postoperative rehabilitation protocols make it Hill, P. F., Vedi, V., Williams, A., Iwaki, H., Pinskerova, V., & Freeman, M. A. (2000).
Tibiofemoral movement 2: The loaded and unloaded living knee studied by
difficult to design a therapeutic rehabilitation program for patients
MRI. Journal of Bone & Joint Surgery, 82, 1196e1198.
who have undergoing arthroscopic repair of an isolated meniscus Horibe, S., Shino, K., Maeda, A., Nakamura, N., Matsumoto, N., & Ochi, T. (1996).
tear. Accelerated post-operative rehabilitation protocols following Results of isolated meniscal repair evaluated by second-look arthroscopy.
Arthroscopy, 12, 150e155.
arthroscopic isolated vertical meniscus tear repair does not appear
Hutchinson, I. D., Moran, C. J., Potter, H. G., Warren, R. F., & Rodeo, S. A. (2014).
to generate higher failure rates and decreased knee function Restoration of the meniscus: Form and function. The American Journal of Sports
compared with more restricted rehabilitation protocols. Further Medicine, 42, 987e998.
prospective studies are needed to better delineate rehabilitation Jakobsen, R. B., Engebretsen, L., & Slauterbeck, J. R. (2005). An analysis of the quality
of cartilage repair studies. Journal of Bone & Joint Surgery American, 87,
protocol and therapeutic exercise progression efficacy for different 2232e2239.
meniscus tear types and patient populations. Lastly, since isolated Kimura, M., Shirakura, K., Higuchi, H., Kobayashi, Y., & Takagishi, K. (2004). Eight- to
meniscus repair and rehabilitation is primarily performed in 14-year followup of arthroscopic meniscal repair. Clinical Orthopaedics and
Related Research, 175e180.
physically active individuals, more precise decision-making mea- Kocabey, Y., Nyland, J., Isbell, W. M., & Caborn, D. N. (2004). Patient outcomes
surement criteria are needed to better determine safe return to following T-Fix meniscal repair and a modifiable, progressive rehabilitation
activity or sports timing. program, a retrospective study. Archives of Orthopaedic and Trauma Surgery, 124,
592e596.
Lind, M., Nielsen, T., Fauno, P., Lund, B., & Christiansen, S. E. (2013). Free rehabili-
Funding statement tation is safe after isolated meniscus repair: A prospective randomized trial
comparing free with restricted rehabilitation regimens. The American Journal of
Sports Medicine, 41, 2753e2758.
No funding Lin, D. L., Ruh, S. S., Jones, H. L., Karim, A., Noble, P. C., & McCulloch, P. C. (2013). Does
high knee flexion cause separation of meniscal repairs? The American Journal of
Ethical statement Sports Medicine, 41, 2143e2150.
Logerstedt, D. S., Scalzitti, D. A., Bennell, K. L., Hinman, R. S., Silvers-Granelli, H.,
Ebert, J., et al. (2018). Knee pain and mobility impairments: Meniscal and
None declared articular cartilage lesions revision 2018. Journal of Orthopaedic & Sports Physical
Therapy, 48, A1eA50.
Lucas, G., Accadbled, F., Violas, P., Sales de Gauzy, J., & Knorr, J. (2015). Isolated
Declaration of competing interest meniscal injuries in paediatric patients: Outcomes after arthroscopic repair.
Orthopaedic and Trauma Surgery Research, 101, 173e177.
None. Lyman, S., Hidaka, C., Valdez, A. S., Hetsroni, I., Pan, T. J., Do, H., et al. (2013). Risk
factors for meniscectomy after meniscal repair. The American Journal of Sports
Medicine, 41, 2772e2778.
References Majewski, M., Stoll, R., Widmer, H., Muller, W., & Friederich, N. F. (2006). Midterm
and long-term results after arthroscopic suture repair of isolated, longitudinal,
Ahn, J. H., Kim, K. I., Wang, J. H., Kyung, B. S., Seo, M. C., & Lee, S. H. (2015). vertical meniscal tears in stable knees. The American Journal of Sports Medicine,
 G. Harput et al. / Physical Therapy in Sport 45 (2020) 76e85 85

34, 1072e1076. handle meniscal tears: A propensity-matched analysis. Orthopaedics Journal of

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2009). Preferred Sports and Medicine, 6, 2325967118779045.
reporting items for systematic reviews and meta-analyses: The PRISMA state- Sherman, S. L., DiPaolo, Z. J., Ray, T. E., Sachs, B. M., & Oladeji, L. O. (2020). Meniscus
ment. BMJ, 339, b2535. injuries: A review of rehabilitation and return to play. Clinics in Sports Medicine,
Morgan, C. D., Wojtys, E. M., Casscells, C. D., & Casscells, S. W. (1991). Arthroscopic 39, 165e183.
meniscal repair evaluated by second-look arthroscopy. The American Journal of Solheim, E., Hegna, J., & Inderhaug, E. (2016). Long-term outcome after all-inside
Sports Medicine, 19, 632e637. discussion 637-638. meniscal repair using the RapidLoc system. Knee Surgery, Sports Traumatology,
Noyes, F. R., & Barber-Westin, S. D. (2000). Arthroscopic repair of meniscus tears Arthroscopy, 24, 1495e1500.
extending into the avascular zone with or without anterior cruciate ligament Stein, T., Mehling, A. P., Welsch, F., von Eisenhart-Rothe, R., & Jager, A. (2010). Long-
reconstruction in patients 40 years of age and older. Arthroscopy, 16, 822e829. term outcome after arthroscopic meniscal repair versus arthroscopic partial
Perkins, B., Gronbeck, K. R., Yue, R. A., & Tompkins, M. A. (2018). Similar failure rate meniscectomy for traumatic meniscal tears. The American Journal of Sports
in immediate post-operative weight bearing versus protected weight bearing Medicine, 38, 1542e1548.
following meniscal repair on peripheral, vertical meniscal tears. Knee Surgery, Tiftikci, U., & Serbest, S. (2016). Repair of isolated horizontal meniscal tears with all-
Sports Traumatology, Arthroscopy, 26, 2245e2250. inside suture materials using the overlock method: Outcome study with a
Richards, D. P., Barber, F. A., & Herbert, M. A. (2005). Compressive loads in longi- minimum 2-year follow-up. Journal of Orthopaedic Surgery and Research, 11, 131.
tudinal lateral meniscus tears: A biomechanical study in porcine knees. Tsai, A. M., McAllister, D. R., Chow, S., Young, C. R., & Hame, S. L. (2004). Results of
Arthroscopy, 21, 1452e1456. meniscal repair using a bioabsorbable screw. Arthroscopy, 20, 586e590.
Richards, D. P., Barber, F. A., & Herbert, M. A. (2008). Meniscal tear biomechanics: Xu, C., & Zhao, J. (2015). A meta-analysis comparing meniscal repair with menis-
Loads across meniscal tears in human cadaveric knees. Orthopedics, 31, cectomy in the treatment of meniscal tears: The more meniscus, the better
347e350. outcome? Knee Surgery, Sports Traumatology, Arthroscopy, 23, 164e170.
Samuelsen, B. T., Johnson, N. R., Hevesi, M., Levy, B. A., Dahm, D. L., Stuart, M. J., et al. https://www.kssta.org/authors-homepage/level-of-evidence/.
(2018). Comparative outcomes of all-inside versus inside-out repair of bucket-