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

FIGURE 1. Bucket-handle tear with anteromedial displacement of
the lateral meniscus (T1 weighted MRI images, September 16,
1998).
REHABILITATION PROGRAM
The rehabilitation program was divided in 4 phases
(Table 1). Rather than adhering to a strict treatment
regimen, the rehabilitation progression was based on
the joint condition and the neuromuscular control of
the operated knee, which were reassessed daily. After
phase 1, the athlete underwent an intensive func-
tional progression (phase 2), focused on the
neuromuscular control of the injured knee. The
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
walk on crutches with a knee brace locked in
extension.
Partial weight bearing was advocated for the first 4
weeks, with a progression of load (20%, 50%, 70% of
body weight [Appendix]). Gentle ROM exercise
within pain tolerance were progressed from 10 to
70 (knee extension-flexion) to 0 to 130 within 4
weeks (Figure 2). Active ROM exercises for extension
were performed from week 2, whereas active ROM
exercises for flexion were initiated (gently) by week 4.
Passive ROM exercises for flexion were not forced at
the end of the available ROM. Emphasis was put on
soft tissue treatment, swelling control, and safe mobi-
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


FIGURE 2. Knee passive range of motion (ROM) during rehabilita-
tion. The 2 dotted lines represent the uninvolved (UNINV) knee
joint ROM. The data for the involved (INV) knee depict the
progressive increase in ROM throughout a 9-week period.
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)
decreased from 6 to 2 on a 10-point visual analogue
scale (VAS), and swelling decreased to complete
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


FIGURE 4. Neuromuscular training in the mini-squat position.
Physiotherapist applies perturbations to the trunk while the patient
was wearing skates (about 4 weeks post surgery).
week 4, seated isometric strength testing (60 knee
flexion) on the Biodex Multi Joint System 2 (Biodex
Medical Systems, Shirley, NY) revealed a quadriceps
strength deficit of 25% and a hamstring deficit of
35% in the involved knee. Analysis of single-leg
balance (knee position in 20 of flexion) was per-
formed on a Biodex Stability System (test: 20 seconds,
level 5) by comparing the combined stability index
score of the uninvolved with the involved leg.34 After
4 weeks, the patient had a deficit in single-leg balance
of 19%. By week 5, the patient had reached the
criteria to walk without crutches and was allowed to
progress to the next phase (Table 1).
Phase 2: Criteria to Begin With Individual Ice
Training
The extension brace was exchanged for a neoprene
sleeve to allow for more ROM of the knee and to
enhance proprioceptive stimuli during gait.24 The
patient met the criteria to fully weight bear by week 5
and was told to avoid stairs until week 6. During this
phase, weight-bearing exercises were performed with
increasingly more knee flexion (40-90), according
to the quality of neuromuscular control of the knee.
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
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
for returning to sport and was, for the first time since
the injury, skating for approximately 20 minutes.
Phase 3: Criteria to Begin Team Ice Training
After 8 weeks, passive ROM was 145 of flexion to
2 of hyperextension (Figure 2), but there was still an
approximately 10 difference between knees in the
sitting-on-heels exercise. By week 8, the complete
training program was now divided within a weekly
period: strength training (isokinetic and weight ma-
chines) on Monday, Wednesday, and Friday, and
sport-specific neuromuscular training followed by en-
durance training on Tuesday and Thursday. The
athlete skated alone on the ice 3 times per week,
performing typical ice hockey drills. At the end of
week 8, an isokinetic test (as described above) re-
TABLE 2. Isokinetic strength during rehabilitation. Bilateral com-
parison of peak torque during isokinetic testing of the involved
knee. Isokinetic strength index expressed as a percentage of the
involved leg normalized to the uninvolved leg.
Knee Extension Index Knee Flexion Index
(%) (%)
180/s 300/s 180/s 300/s
7 wk 82 87 109 106
9 wk 87 90 115 122
13 wk 93 95 117 124
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 5. The butterfly move. The goaltender drops to both knees,
resting his weight primarily on the medial aspect of the knees, while
spreading the pads in a V shape to cover the low corner of the net.
In this figure, the goaltender is showing the half butterfly, where the
knee joint is stressed in a flexion, valgus, and external position.
FIGURE 6. The kick save. The goaltender drops down to 1 knee,
while spreading maximally the other leg to the side. This movement
is characterized by a forceful hip abduction with a sudden rapid
knee extension, supporting two thirds of the body weight on his
extended leg.
94
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
controlled manner. An MRI with intra-articular con-
trast dye1 on week 10 showed a well-healed meniscus,
with some scar formations near the peripheral border
(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
the team, progressively regaining all of his preinjury
skills and reaction speed. The knee joint status,
strength, endurance, sport-specific neuromuscular
control, and the integration in team training were
J Orthop Sports Phys Ther Volume 36 Number 2 February 2006

FIGURE 8. Intact lateral meniscus repair at about 1.5 years after
surgery (T1 weighted arthro-MRI image, January 17, 2000).
FIGURE 9. Intact lateral meniscus repair at about 4.5 years after
surgery (T1 weighted MRI image, February 17, 2003).
considered to be back to preinjury levels. Therefore,
the athlete, who did not have any complications
during his rehabilitation, met the criteria to return to
play in an official game by week 13 (Table 1).
5-Year Follow-up
One hundred three days (14.5 weeks) after surgery,
the athlete played his first game (completing all 3
periods) with his team. He continued with the team,
playing the second half of the Swiss championship
and participating in the World Championship Tour-
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
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-
sary because of the required knee movements for an
ice hockey goaltender, including a large amount of
weight-bearing knee movements in combined valgus/
flexion/external rotation (Figure 5). This was pos-
sible within 9 weeks, using the described
rehabilitation protocol. Shelbourne et als40 acceler-
ated group achieved full ROM between 1 and 20
weeks (mean, 6 weeks). Considering that our athlete
needed to regain full ROM in various weight-bearing
situations (including the heel-sitting, deep squats, and
butterfly positions), 9 weeks seemed to represent a
realistic expectation to achieve symmetrical ROM.
ROM should not only be evaluated in a supine
position but also in weight-bearing situations that
reflect the needs of the athlete.
95
 Active flexion ROM implies that there is sufficient
hamstring activation; therefore, in this case there was
a concern in delaying the initiation of hamstring-
strengthening exercises. Conservative rehabilitation
recommends that resistive hamstring exercise should
be avoided in the first 6 weeks,23 while such guide-
lines are not specifically reported in accelerated-
rehabilitation literature.5,40 The typical hockey
goaltender position is a combination of bilateral knee
flexion (half-squat) with at least 30 trunk flexion,
which places a high demand on the hamstrings. The
impetus to initiate early hamstring activation and
strengthening was to further promote neuromuscular
control strategies to prepare the athlete for later
sport-specific tasks that would require increased ham-
string activation.
We believe that the neuromuscular control of the
injured knee was a key aspect of this rehabilitation
protocol. Several authors3,20,33,51 have described the
innervation of the meniscus and its importance as a
source of proprioceptive information. On the basis of
this evidence, Gray20 suggested that rehabilitation
exercises after meniscal injury or surgery should
challenge the balance, stability, and coordination
skills of the patient. In addition to improving
strength and endurance, improving sport-specific co-
ordination from the onset of rehabilitation is essen-
tial for the return to sport.7,8,37,43 Neuromuscular,
balance, reactive, and agility training were considered
crucial in this attempt. The different exercises re-
flected important motor learning concepts utilizing
random and variable practice methods).18,32,39 Differ-
ent body positions (from basic to sport specific),
different speeds of movements (static, dynamic, reac-
tive, explosive), different surfaces (floor, unstable
boards, slide boards, ice), and different environments
(clinic, ice stadium) were considered in the rehabili-
tation progression. A sport-specific neuromuscular
training means that the choice of exercises is tailored
to the needs and demands of the patient. Tyler43
reported the successful use of a specific
neuromuscular training program, including simulated
skating strides, with an elite female ice hockey player
after ACL reconstruction. In our case the patient was
a goaltender, therefore the choice of exercises fo-
cused on specific goaltender movement and save
skills. Recently Roi et al37 described a similar specific
rehabilitation for an elite male soccer player after
ACL reconstruction.
Evidence on the efficacy of neuromuscular rehabili-
tation programs on knee joint function is available
for rehabilitation of individuals with an ACL-deficient
knee.6,18,22,49,50 ACL-deficient knees and knees after a
meniscus repair show analogous knee impairments/
limitations and therefore may benefit from similar
rehabilitation approaches.23 Beard et al7 and Zat-
terstrom et al50 showed, in randomized clinical trials,
a positive effect of neuromuscular training for pa-
96
tients with an ACL-deficient knee. Fitzgerald et al18
described effective perturbation training in a ran-
domized trial using a similar group of patients. Ihara
and Nakayama22 and Wojtys et al49 also showed in
ACL-deficient patients significantly improved muscle
reaction times with proprioceptive and agility training
exercises.
In this case report, the athlete and physiotherapist
worked closely together (5 days per week, at least 1
hour each day) in the first 12 weeks. The athletes
knee joint status and the neuromuscular control of
the knee could be constantly monitored, which may
only be possible with a professional athlete.37,43 This
could suggest that a supervised criterion-based reha-
bilitation has the potential for safe return to sport,
with a possible good long-term outcome. Studies are
needed to investigate if professional athletes benefit
significantly from such an intensive supervised reha-
bilitation program. Previous studies on the effect of
supervised versus home-based rehabilitation programs
have shown a trend towards better functional results
for physiotherapist-led programs in the rehabilitation
of patients after meniscectomy in a short-term
follow-up of 6 months.30,44 Barber5 reported a failure
rate of the meniscal repair in 10% of patients
following an accelerated rehabilitation program
(mean follow-up of 20 months). Shelbourne et al40
reported a similar failure rate in patients following an
accelerated program with a mean follow-up time of
3.5 months and a return-to-sport time of 10 weeks. As
Wilk45 stated recently, the ultimate goal of a rehabili-
tation program should be a healthy knee 5 to 10
years after surgery, not only after a few months. Many
studies report a limited follow-up time, which may
not reflect the true long-term outcome.
Return to high-level sport was allowed only when
these criteria were met: full ROM in nonweight-
bearing and weight-bearing situations, 90% isokinetic
quadriceps strength index, achievement of sport-
specific neuromuscular control, and full participation
in team training. Isometric and isokinetic strength
measurements were used as tools to monitor the
progression from one rehabilitation phase to the
next, in addition to performance-based and sports-
specific tasks. The criteria for return to sport may
differ with type of sport and intensity of practice.
Shelbourne et al40 utilized the following criteria with
patients following meniscal repair: full ROM,
quadriceps index of at least 75% in the involved leg,
and completion of a functional running program.
The patient group had a mean quadriceps index of
82% at 2 months and 84% at 4 months post surgery.
Our athlete had a quadriceps index greater than 87%
at 9 weeks and greater than 90% at 13 weeks, with
similar strength increases also displayed in the ham-
strings. A running program was not considered in
this case, due to different environmental conditions
(skating on ice). Some authors29 are concerned
J Orthop Sports Phys Ther Volume 36 Number 2 February 2006
about the potential negative effects of jogging on
meniscal repairs, but Shelbourne et al40 showed no
differences in outcomes after delaying or accelerating
a running program.40 Shelbourne et als40 criteria
may be sufficient for a recreational athlete, but not
for a high-level athlete. Other authors26,46 have advo-
cated the need for the use of criterion-based program
in ACL rehabilitation, which is similar to the philoso-
phy incorporated into this rehabilitation progression.
As stated above, the sport-specific components should
be taken into account in the criteria for return to
sport. This may allow a differentiation between types
of sports, individual needs and demands, and perfor-
mance level of the athlete.
Imaging techniques, such as MRI, are often used to
document intra-articular injuries10; however, MRI has
shown not to be a useful diagnostic tool for docu-
menting reinjury after meniscal repair.17 For this case
report an arthro-MRI utilizing intra-articular contrast
dye (Gadolinium-DOTA, 0.0025mmol/Gd/ml,
Artirem) was used because of its higher sensitivity
than a normal MRI in detecting meniscal tears.1 We
are aware that the findings of the arthro MRI cannot
completely rule out possible meniscal reinjury, but it
was the only way to objectively document the repair.
An arthroscopic evaluation21 could not be taken into
consideration, for obvious reasons.
CONCLUSION
The sport-specific, criterion-based, supervised reha-
bilitation program described in this case report
showed a safe return to sport and a good long-term
outcome. This high-level athlete was able to return to
sport 103 days after surgery and no reinjury of the
lateral meniscus occurred up to 5 years after surgery.
Randomized controlled trials are needed to conclude
if high-level athletes significantly improve their short-
and long-term outcome using a sport-specific,
criterion-based, and highly supervised rehabilitation
program.
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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