Meniscal Injuries

1. Meniscal Injuries • Daniel S. Lamar M.D. • Board Certified Orthopedic Surgeon Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

2. Overview • Meniscal Injuries • Treatment • Rehabilitation Principles • Emerging Concepts • Return to Play Criteria Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

3. Meniscal Anatomy • Medial- C shaped, firmly fixed • Lateral- circular, mobile • Function- absorb, nourish, distribute, stabilize • Blood supply- med and lat inferior geniculates • Age related changes Daniel S. Lamar, MD Consulting Physician to: 3

4. Meniscal Injuries • Mechanism of injury • Symptoms • Signs • Pattern of tear Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

5. Treatment Options • Non-operative • aging athletes • incomplete tears • Operative • menisectomy • repair Daniel S. Lamar, MD Consulting Physician to: 5

6. Repair • Principles • healthy tissue • good vasculature • stable enviroment • Repair techniques • all inside • inside out Daniel S. Lamar, MD Consulting Physician to: 6

7. Surgical Treatment • Most repairs on longitudinal tears • positioning relative to periphery • 2mm 90% heal • 3mm- 75% • 4mm- 50% Daniel S. Lamar, MD Consulting Physician to:

8. Orientation of the sutures/repair critical to rehab strategy Daniel S. Lamar, MD Consulting Physician to: 8

9. Orientation Daniel S. Lamar, MD Consulting Physician to: 9

10. Soft Tissue Biology • Strategies to expedite • Biologics vs mechanical stress • PRP, stem cells, cytokines, periosteal grafts, US, shock wave treatment, laser • environmental and technical challenges • Good vs bad biologic remodeling • increasing cellularity and vascularity not necessarily beneficial Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

11. Rehabilitation Principles • Protect repair • Improve limb function • Apparent conflicting goals but not always at odds- some mechanical stress is necessary to facilitate healing Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

12. Rehab Protocol • Bucket handle or longitudinal tears • Axial load helpful • 0-4 weeks • 50-100%WB with leg braced in full extension • limit flexion to 90 degrees • emphasis on isometrics, quad activation edema control • Radial tears Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

13. Rehab Protocol • 4-8 weeks • increase ROM to full • WBAT without brace • avoid loading knee in flexion • bike vs treadmill Daniel S. Lamar, MD Consulting Physician to: 13

14. Rehab Protocol • 8-12 weeks • road cycle in saddle • light agility with early lateral training • avoid loaded rotational stress • 12-16 weeks • add running • early sport specific challenges • increase loads Daniel S. Lamar, MD Consulting Physician to: 14

15. Radial Tears • Important to understand difference • Strict NWB x 6weeks • Axial load problematic • much slower progression to loaded activity • 4-6 months before any substantial load Daniel S. Lamar, MD Consulting Physician to: 15

16. RTP criteria • Goal is to measure strength, limb control and performance • Minimal to no side to side differences • Quantitative and qualitative • Before and after fatigue challenge • Testing must be safe and reliable Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

17. RTP criteria • Drop down test- 5 reps • Single leg press one rep max • Single leg hop- stick landing • Triple single leg jump • Triple crossover jump • Fatigue proto x 5 min then repeat • 95%of opposite limb with good form Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

18. Blood Flow Restriction Training • Concept is to restrict arterial flow to 20% of normal and completely occlude venous outflow and perform low load resistance exercise at 20-40% of a 1RM. • The goal is to elevate the factors responsible for cell growth and hypertrophy by recreating the hypoxic stimulus the muscle/body would typically see at much higher loads and durations Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

19. Blood Flow Restriction Training • Identified effects appear both locally and systemically • increase muscle swelling • increase intra muscular anabolic and anti catabolic activity • proliferation of myogenic stem cells • increase IGF-1, growth hormone • results seem to show increase hypertrophy Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

20. Blood Flow Restriction Training • Increasing enthusiasm and incorporation in rehab protocols around the NFL • Particularly attractive in injury situations where large volume changes and strength loss ensues quickly following injury and surgery Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

21. Blood Flow Restriction Training • Tennessee Titans protocol • incorporate early in both pre and post-surgical treatment • inflate cuff, set of 30reps then 30sec rest with cuff inflated followed by 15 reps and 30sec rest with a total of 4 sets of 15, 3 x a week. Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to:

22. Thank You Text Daniel S. Lamar, MD Consulting Physician to: Daniel S. Lamar, MD Consulting Physician to: