Return to Activity After Knee Arthroscopy

James H. Lubowitz, M.D., Myna Ayala, S.T., and David Appleby, M.P.H.

Purpose: Although knee arthroscopy is described as minimally invasive, return to activity has been poorly quantitated. Our purpose is to test the hypothesis that most patients return to unrestricted activity within 4 weeks after knee arthroscopy. Methods: After prospective power analysis, 72 consecutive patients who underwent arthroscopic knee partial medial meniscectomy, partial lateral meniscectomy, chondroplasty, loose body removal, or synovectomy (or some combination thereof) by a single surgeon were included. Patients with Workers Compensation claims were excluded. Postoperative instructions were standardized. Patients completed a diary preoperatively and at 1, 2, 3, 4, 8, 12, 16, 20, and 24 weeks postoperatively indicating their highest International Knee Documentation Committee (subjective) level of activity, as well as whether activity was restricted for knee-related reasons. Results: Preoperatively, 88% of patients described knee-related activity restriction. By 2 weeks postoperatively, only 74% described knee-related activity restriction, a signicant difference (P .039); this improved to 38% at 4 weeks and was only 4% at 20 weeks. In addition, 82% returned to light activity such as walking, housework, or yard work after 1 week, with 94% after 2 weeks and 100% after 4 weeks. Conclusions: Our results support the hypothesis: Most patients had no knee-related activity restriction 4 weeks after arthroscopy. Level of Evidence: Level IV, therapeutic case series. Key Words: Knee arthroscopyRehabilitationSportsRecoveryActivity.

atients preparing to have knee arthroscopy want to know: How soon after surgery can I return to activity? How soon can I walk? Unfortunately, return to activity after knee arthroscopy has not been well quantitated. Knee arthroscopy is considered a minimally invasive, low-morbidity surgery with a rapid recovery,1 but few studies address the rate of return to activity. Review of the published literature reveals 2 studies quantitating knee arthros-

From the Taos Orthopaedic Institute Research Foundation (J.H.L., M.A.), Taos, New Mexico, U.S.A., and Smith & Nephew (D.A.), Andover, Massachusetts, U.S.A. The authors have a nancial relationship (grant funding, consultant, or employee) with Smith & Nephew, Andover, Massachusetts, related to the topic of this manuscript. Address correspondence and reprints requests to James H. Lubowitz, M.D., 1219-A Gusdorf Rd, Taos, NM 87571, U.S.A. E-mail: jlubowitz@kitcarson.net 2008 by the Arthroscopy Association of North America 0749-8063/08/2401-6372$34.00/0 doi:10.1016/j.arthro.2007.07.026
Note: To access the supplementary tables accompanying this report, visit the January issue of Arthroscopy at www. arthroscopyjournal.org.

copy recovery time in athletes. Lysholm and Gilquist2 reported that 68% of athletes resumed full athletic training within 2 weeks of arthroscopic meniscectomy, and Stetson and Templin3 reported that recreational athletes having 2-portal or 3-portal arthroscopy return to work or normal activity at a mean of 9 days or 19 days after knee arthroscopy. However, neither of these studies evaluated a diverse population including athletes and nonathletes, and neither of these studies evaluated whether study subjects had knee-related activity limitation despite return to full athletic training or return to work or normal activity. The purpose of this investigation is to quantitate return to unrestricted activity (no knee-related activity limitation) after knee arthroscopy in a diverse population of knee arthroscopy patients. We hypothesize that most patients return to unrestricted activity within 4 weeks after knee arthroscopy. METHODS After sample size analysis and institutional review board approval, consecutive patients undergoing routine knee arthroscopy by a single surgeon were in-

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Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 1 (January), 2008: pp 58-61

RETURN TO ACTIVITY AFTER KNEE ARTHROSCOPY cluded in this prospective case series. Routine knee arthroscopy included the following procedures: partial medial meniscectomy, partial lateral meniscectomy, chondroplasty, loose body removal, or synovectomy. Excluded were patients having meniscus repair, lateral retinacular release, ligament reconstruction, or cartilage restoration procedures; patients unwilling to complete study informed consent or follow-up; and patients with Workers Compensation insurance claims. All patients had 2-portal knee arthroscopy performed under general anesthesia in a hospital-based ambulatory surgery center. Patients completed a diary preoperatively and at 1, 2, 3, 4, 8, 12, 16, 20, and 24 weeks postoperatively indicating their highest level of activity, as well as whether the level of activity was restricted for kneerelated reasons. Patient age and gender were also recorded. Level of activity was dened according to the 2000 International Knee Documentation Committee Subjective Knee Evaluation Form as follows: very strenuous activities like jumping or pivoting as in basketball or soccer, strenuous activities like heavy physical work, skiing or tennis, moderate activities like moderate physical work, running or jogging, light activities like walking, housework or yard work, or unable to perform any of the above activities due to knee pain. A study coordinator contacted each study subject by phone at the time of each follow-up to conrm with the patient that the diary had been completed (or to the patient to do so). Postoperative instructions were standardized and provided to each patient in writing. In addition, they were provided with a Patient Introduction to Knee Surgery Rehabilitation and Return to Activity designed to minimize study bias by encouraging them to determine their own return to activity (Table 1, online only, available at www.arthroscopyjournal.org). Patients were instructed to arrange their rst follow-up evaluation 1.5 weeks postoperatively. Physical therapy was prescribed according to the following algorithm: if a patient showed a tense knee effusion, gross quadriceps muscle inhibition, exion contracture, exion less than 90, or pain deemed out of proportion to the magnitude of the procedure or if a patient requested physical therapy, a written Physical Therapy Prescription was completed in a standardized manner designed to minimize study bias (Table 1, online only, available at www.arthroscopyjournal .org). If patients did not meet these criteria, formal physical therapy was not prescribed. Statistical Methods

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A priori power analysis was performed. A sample size of 70 was calculated to have greater than 90% power to test the hypothesis that most patients would have no knee-related activity limitations at 4 weeks postoperatively. The Fisher exact test was applied to detect a difference in the proportion of patients without knee-related activity limitation from preoperatively to postoperatively. P .05 was considered statistically signicant. RESULTS This study included 72 consecutive patients (36 male and 36 female; mean age, 44 years [range, 12 to 75 years]). No patients were lost to follow-up. No patients had infection, deep venous thrombosis, or other notable postoperative complications. Results are indicated in Fig 1 and Tables 2 and 3 (online only, available at www.arthroscopyjournal.org). Preoperatively, 88% of patients indicated kneerelated activity restriction. By 2 weeks postoperatively, only 74% of patients described knee-related activity restriction, a signicant difference from preoperatively (P .039); this improved to 38% at 4 weeks and 4% at 20 weeks (Fig 1). In addition, 82% of patients returned to (restricted or unrestricted) light activities like walking, housework, or yard work (or higher level of activity) after 1 week, with 94% after 2 weeks and 100% after 4 weeks (Table 2, online only, available at www.arthroscopyjournal.org). DISCUSSION Knee arthroscopy is described as minimally invasive surgery, and patients preparing to have knee arthroscopy are often told that the procedure has a rapid recovery.1 Patients preparing to have knee arthroscopy may be so counseled: our results show that at 4 weeks postoperatively, most patients (62%) returned to activity with no restrictions for knee-related reasons. In addition, 82% of patients returned to walking by 1 week postoperatively, and all patients returned to walking by 4 weeks postoperatively. Our results also show that knee arthroscopy is efcacious. Preoperatively, 88% of patients described knee-related activity restriction. At 20 weeks postoperatively (and at nal follow-up of 24 weeks), only 4% of patients described knee-related activity restriction. We acknowledge as a limitation of our study, however, that a minimum of 24 months follow-up

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J. H. LUBOWITZ ET AL.

FIGURE 1.

Percentage of patients with knee-related restriction of activity over time.

may be required to determine efcacy (as discussed later) and evaluation of efcacy was not our purpose. A paucity of literature specically quantitates the rate of return to activity after knee arthroscopy; rather, a literature review generally revealed articles related to the effectiveness of physical therapy4 or related to return to activity after anterior cruciate ligament reconstruction and rehabilitation.5 However, Lysholm and Gilquist2 did report that 68% of athletes resumed full athletic training within 2 weeks of arthroscopic meniscectomy. This is a faster return to activity than in our investigation and may suggest that athletes recover more quickly than a diverse population of athletes and nonathletes. Hau et al.6 evaluated driving reaction time after right knee arthroscopy. Most patients had signicant improvement in reaction time from preoperatively to 4 weeks postoperatively. Bearing in mind that we report return to unrestricted activity as compared with driving reaction time, our results are similar; future research will include investigation of driving ability after knee arthroscopy. In patients who had knee arthroscopy using either a 2- or 3-portal technique, Stetson and Templin3 compared the times from surgery to return to work or normal activities. There were no Workers Compensation patients in the study, and all patients were recreational athletes. Patients in the 2-portal group returned to work and normal activities at a mean of 9 days after surgery compared with 19 days in the 3-portal group. This is a faster return to activity than in our investigation. (All patients in our study had 2-portal arthroscopy.) Again, this may suggest that

athletes recover more quickly than a diverse population of athletes and nonathletes. In addition, this investigation does not consider whether study subjects had knee-related activity limitation despite return to work and normal activities. Noyes et al.7 evaluated work-related activity limitation as a result of knee disorders. Return to (non work-related) activity was not the purpose of their study. Nevertheless, they did emphasize the importance of determining whether limitations were kneerelated; thus, our study design adapted this method. Goodwin et al.8 evaluated the effectiveness of supervised physical therapy after arthroscopic partial meniscectomy. Although rate of return to activity was not specically quantitated, they did emphasize the importance of accurately reect[ing] real life by avoiding tight control over the activities performed by subjects. They also emphasized that diaries to record . . . activities for subjects . . . would have been useful; thus our study design adapted these methods. Limitations of our study include examples of selection bias: some patients required physical therapy, and some did not. In addition, patients were of diverse age and sex and had diverse pathology. By design, our series represents the real world of arthroscopic knee surgery practice, and we minimize selection bias by using strict inclusion and exclusion criteria and a practical clinical algorithm to determine indications for physical therapy. Future research could use more rigorous inclusion or exclusion criteria and could use physical therapy in all patients (or in no patients). An additional limitation is that different patients may have been encouraged to return (or not return) to activity at different rates (despite

RETURN TO ACTIVITY AFTER KNEE ARTHROSCOPY our attempt to minimize this bias with standardized written instructions). Another limitation is that follow-up was 24 weeks (6 months). Although this follow-up is suitable for quantitation of rate of return to activity, a minimum of 24 months follow-up is required to determine efcacy. Future research will evaluate patient outcome at 24 months follow-up. Our study also has strengths. Transfer bias was minimized: complete follow-up was obtained on all patients. Performance bias was minimized: a single surgeon performed all operations. Reporting bias was minimized: the described levels of activity and the terminology (restricted due to knee-related reasons) have been validated by the International Knee Documentation Committee, which is widely reported. REFERENCES

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CONCLUSIONS Our results support the hypothesis that most patients return to unrestricted activity within 4 weeks after knee arthroscopy.

1. Paulos LE, Rosenberg TD, Beck CL. Postsurgical care for arthroscopic surgery of the knee and shoulder. Orthop Clin North Am 1988;19:715-723. 2. Lysholm J, Gilquist J. Arthroscopic meniscectomy in athletes. Am J Sports Med 1983;11:436-438. 3. Stetson WB, Templin K. Two- versus three-portal technique for routine knee arthroscopy. Am J Sports Med 2002;30:108111. 4. Jokl P, Stull PA, Lynch JK, Vaughan V. Independent home versus supervised rehabilitation following arthroscopic knee surgeryA prospective randomized trial. Arthroscopy 1989;31: 285-290. 5. Schenck RC Jr, Blaschak MJ, Lance ED, Turturro TC, Holmes CF. A prospective outcome study of rehabilitation programs and anterior cruciate ligament reconstruction. Arthroscopy 1997;5: 298-305. 6. Hau R, Csongvay S, Bartlett J. Driving reaction time after right knee arthroscopy. Knee Surg Sports Traumatol Arthrosc 2000; 8:89-92. 7. Noyes FR, Mooar LA, Barber SD. The assessment of workrelated activities and limitations in knee disorders. Am J Sports Med 1991;19:178-188. 8. Goodwin PC, Morrissey MC, Omar RZ, Brown M, Southall K, McAuliffe TB. Effectiveness of supervised physical therapy in the early period after arthroscopic partial meniscectomy. Phys Ther 2003;6:520-535.

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TABLE 1. Standardized Patient Instructions or Prescriptions

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1. Postoperative instructions: Minimize activity the day of surgery. Elevate the knee above the waist, on pillows, while reclining. Walk with crutches for 1-2 days, and then discontinue the use of crutches; bend the knee to tolerance. Exercise the calf by pumping the foot for 5 minutes, 3 times a day, and straight leg raising 10-15 times, 3 times a day. Do not use exercise equipment (except stationary cycle if availablewait 3 days and be gentle). 2. Patient introduction to knee surgery rehabilitation and return to activity: After surgery, your body, including your knee, may not respond as it has in the past. Be cautious and test your body and knee before you resume activity. Each patients recovery is different: if you have questions, check with your doctor. There are no medical rules with regard to when a patient may return to activity after knee surgery. Patients must determine on an individual case-by-case basis when they feel they are able to return to activity in consultation with their physician and/or physical therapist. Rehabilitation after knee arthroscopy: Patients having knee arthroscopy must follow their Postoperative Instructions sheets and may gradually resume activities. At their rst follow-up ofce visit (1.5 weeks), formal physical therapy may be recommended for patients with signicant swelling, weakness, stiffness, or pain. (Formal physical therapy will not be prescribed in all cases.) 3. Physical therapy prescription: Physical therapy evaluate and treat. Diagnosis: knee arthroscopy.

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TABLE 2.
Knee-Related Activity Limitation Postoperatively 1 wk Yes 0 0 5 48 13 66 0 1 1 4 0 6 0 0 7 42 4 53 1 1 6 11 0 19 0 0 3 35 2 40 3 3 11 15 0 32 0 1 2 24 0 27 3 4 18 20 0 45 0 1 2 16 0 19 5 7 20 21 0 53 No Yes No Yes No Yes No Yes No Yes 0 1 3 11 0 15 2 wk 3 wk 4 wk 8 wk 12 wk No 5 8 21 23 0 57

Number of Patients With and Without Knee-Related Activity Restriction by Level of Activity Over Time

Preoperatively

16 wk Yes 0 0 3 5 0 8 No 6 8 25 25 0 64

20 wk Yes 0 0 0 3 0 3 No 6 10 27 26 0 69

24 wk Yes 0 0 0 3 0 3 No 6 10 27 26 0 69

J. H. LUBOWITZ ET AL.

Yes

No

Level of activity Very strenuous Strenuous Moderate Light Unable Total

3 0 11 36 13 63

2 1 2 4 0 9

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TABLE 3. Cohort Demographics and Results

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Preoperative KneeRelated Procedure Postoperative Knee-Related Activity Limitation Age Physical Patient Activity Gender (yr) MM Chondro LM LB Syno Limitation 1 wk 2 wk 3 wk 4 wk 8 wk 12 wk 16 wk 20 wk 24 wk Therapy No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 Male Female Male Female Female Male Female Male Female Female Male Female Male Male Female Male Male Female Male Male Female Male Female Male Male Female Female Male Female Male Male Male Female Male Female Male Male Female Male Female Male Male Female Female Male Male Male Male Female Male Male Female Female Female Female Male Male Male Female Female Female Female Female Female Male 53 17 44 22 56 54 73 63 75 61 61 69 44 54 51 43 55 17 51 55 54 51 40 16 33 12 58 58 39 56 53 52 42 15 62 55 51 38 12 44 17 45 13 26 55 27 54 36 61 47 16 67 21 14 49 49 59 18 53 28 38 43 60 42 35 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X

X X X

X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X

X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X X

X X X

X X

X X X X X X X X X X X X X X

X X X X X X X

X X

X X

X X X X X X X X X X X X X

X X

X X X X X X X X X X X X X X X X

X X

X X X X X X X X X X X X X X

X X X X X X X X X X X X X

X X X X

X X X X X X X X

X X X X X X X X

X X X X X X X X

X X X X X X

X X X X X X X X X X X X X X X X

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J. H. LUBOWITZ ET AL.
TABLE 3. Continued

Preoperative KneeRelated Procedure Postoperative Knee-Related Activity Limitation Age Physical Patient Activity Gender (yr) MM Chondro LM LB Syno Limitation 1 wk 2 wk 3 wk 4 wk 8 wk 12 wk 16 wk 20 wk 24 wk Therapy No. 66 67 68 69 70 71 72 Female Female Female Female Male Female Male 38 52 60 61 44 53 40 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X

Abbreviations: Chondro, chondroplasty; LB, loose body removal; LM, partial lateral meniscectomy; MM, partial medial meniscectomy; Syno, synovectomy.