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Background:
Case Report

Rehabilitation and Return to Play of an Ice Hockey Athlete after Lateral Meniscus Repair: A Case Report

by
Hyung Gyu Jeon
1,
Jong Hyeon Lee
2,
Tae Kyu Kang
1,3,
Dong Wook Lee
1,
Kyoung Uk Oh
1,
Sae Yong Lee
1,3,4 and
Byong Hun Kim
5,*
1
Department of Physical Education, Yonsei University, Seoul 03722, Republic of Korea
2
Department of Sport Industry Studies, Yonsei University, Seoul 03722, Republic of Korea
3
International Olympic Committee Research Centre KOREA, Yonsei University, Seoul 03722, Republic of Korea
4
Institute of Convergence Science, Yonsei University, Seoul 03722, Republic of Korea
5
Department of Sports Medicine, Dongguk University Wise Campus, Gyeongu-si 38066, Republic of Korea
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(10), 4084; https://doi.org/10.3390/app14104084
Submission received: 10 March 2024 / Revised: 1 May 2024 / Accepted: 2 May 2024 / Published: 11 May 2024
(This article belongs to the Special Issue Sports Medicine, Exercise, and Health: Latest Advances and Prospects)
Browse Figures
Versions Notes

Abstract

:
This report presents the case of an ice hockey player diagnosed with a tear in the anterior horn of the lateral meniscus at 19 years of age. In addition, we suggest a rehabilitation exercise program that enabled an early return to play for an ice hockey athlete in a university sports league. The patient underwent arthroscopic meniscal repair and was discharged one day after surgery. A three-stage rehabilitation program was developed, as follows: Phase I, the protective phase (reduce inflammation symptoms and restore range of motion to enable weight-bearing); Phase II, the restorative phase (improve the strength of the quadriceps muscle and recover cardiovascular endurance); Phase III, the return to full functional activity (familiarize the patient with sport-specific skills and recover a symmetric functional level on both sides). After completing the 10-week rehabilitation program, the patient returned to play and took part in games 71 and 84 days after surgery. The patient had no meniscus reinjury in the 10 years after surgery while playing in university and professional ice hockey leagues. The functional performance-focused rehabilitation program presented in this case report resulted in an early return to sport and good long-term outcomes.

1. Introduction

The meniscus plays various roles including buffering, load bearing, joint stabilization, congruity, and lubrication [1,2,3,4]. The medial meniscus (MM) has more structures than the lateral meniscus (LM), including the coronary and deep medial collateral ligaments. Therefore, the MM is regarded to have limited mobility [1,5], which could result in a higher risk of injury. Indeed, the MM was shown to be three times more likely to be injured than the LM in past studies [6,7,8,9]. However, there is a higher frequency of LM tears in younger populations (<30 years) and in wrestlers and players of the National Basketball Association and the National Football League, all of which involve pivoting, cutting, and running movements [10,11,12,13,14]. Furthermore, the dynamic nature of ice hockey exposes the LM to potential microtrauma [11]. Nevertheless, epidemiological evidence regarding the precise mechanisms of injury and associated risk factors pertaining to meniscal damage remains scarce [15].
Training and assessment in rehabilitation are essential to restore the range of motion (ROM) and muscle strength of a damaged area to its pre-injury levels [5,6]. A previous case of an ice hockey goaltender who returned to sport 103 days after LM repair has been reported [16]. Bizzini et al. [16] reported an injury mechanism that appeared in an abrupt combination of valgus/flexion/external rotation, and the pain, locking phenomenon, and dysfunction that occurred in the lateral knee joint when the knee was flexed to 90°. At the 13th week of rehabilitation, the isokinetic muscle strength of the affected side recovered by more than 90% of that of the uninjured side, and no injury was observed in the five-year follow-up. However, case studies addressing meniscal injuries in ice hockey field players who engage in dynamic movements such as acceleration, deceleration, and turning are lacking. The wing position also frequently changes direction or decelerates near the goal post, which increases the internal loads in the knee and tests the player’s meniscus function after rehabilitation, making related examinations necessary.
LM tears are rare, and surgery and rehabilitation methods differ depending on the type and direction of the tear [17,18,19,20]. Considering these characteristics, there should be a relevant number of cases of LM tears reporting the systematic procedures taken from rehabilitation to return to daily life. A conservative program that limits load to the injured area could be used for radial LM tears [21,22]; however, Kocabey et al. [23] introduced a guideline with differentiated weight-bearing and knee ROM restrictions and degrees according to meniscal tear characteristics. Moreover, the usefulness of accelerated rehabilitation was suggested, as there were no differences in recovery rates [24]. In a study targeting patients who underwent matrix-induced autologous chondrocyte implantation (also known as MACI) into the medial and lateral sides of the femoral condyle, the accelerated rehabilitation group that performed full weight bearing in the 8th week of rehabilitation training scored 11.77 points higher on the pain subscale, and 7.68 points higher on the symptoms subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS), measured at the 12th week, than the traditional group that performed full weight-bearing in the 11th week [25]. Moreover, among the same type of patients, a study compared a case where full weight bearing was applied in the sixth week of rehabilitation (accelerated group) and a group in which full weight bearing was applied in the eighth week (conservative group); the KOOS and Short Form Health Survey scores at 6 and 12 months after surgery were higher in the accelerated group. In the conservative group, the full ROM of the knee joint was achieved at 12 weeks of rehabilitation, but in the accelerated group, the full ROM of the knee joint was restored at 4 weeks [26].
This evidence indicates the necessity for reliable evidence on the effects of the early application of full weight bearing on subjective function, ROM, and muscle strength in the relatively uncommon fields of ice hockey and LM tears. In addition, the effectiveness of programs freeing weight-bearing restrictions in the early stages of rehabilitation has been observed in several other studies, regardless of the type of meniscus tear [22]. Additionally, it has been reported that 81% of athletes with all types of meniscus injuries successfully returned to sport when limited to full weight bearing for 6 weeks [27]. In the same vein, allowing full weight bearing too early can also have a detrimental effect on healing of the repaired meniscus [27]. As such, the homogeneity of each study is low, and there is no consistent guideline for programs and standards for recovery after isolated meniscus repair [28]. Therefore, more research is needed to improve knowledge of the ROM of the knee joint related to weight bearing and protection of the repaired meniscus.
In addition, it is difficult to find a standardized rehabilitation procedure for injury mechanisms, surgery, and outcomes after a long-term follow-up of overuse-related LM injuries in young athletes. Scholars have also yet to more thoroughly consider matters related to injury recurrence after surgery in this context. Long-term observational studies have demonstrated that 19% of meniscus repairs fail [29]. The surgical method applied for such repairs, the all-inside technique, has shown a higher probability of the player returning to the game after recovery to the pre-injury level than the inside-out technique; at the same time, the injury recurrence rate is higher [30]. In addition, osteoarthritis can occur secondarily to meniscus damage [31], making evaluation through re-measurement of functional aspects a necessity in follow-up studies to identify the negative effects of injuries and surgeries. The overall post-surgery failure rate is 21% and that of MM is 20%, while that of LM, which is the case introduced in this report, is reported to be 44% [32]. Additionally, 10% of patients with isolated meniscus tears were unable to return to sport after repair [33]. This suggests that even if the condition is normal at the time of return, the injury may recur if participation in the sport continues. Therefore, even after completing rehabilitation, it is necessary to conduct long-term follow-ups even after completing rehabilitation to monitor the resumption of sports activities. Accordingly, the current report introduces a case focusing on the rehabilitation protocol for an ice hockey wing position athlete who successfully returned to the game within a relatively short period (71 days) after injury. It also describes the functional aspects of the rehabilitation over time by measuring subjective patient-oriented outcomes, muscle strength, and functional performance after 10 years.

2. Case Report

2.1. Case Presentation and Differential Diagnosis

The patient initially complained of ongoing knee discomfort at 17 years old and was diagnosed with tenosynovitis of the anterior part of the knee at 19 years old; however, there were no major abnormalities, and the patient continued to exercise. After competing in games until the age of 20, the patient began experiencing pain and visited the hospital. The patient was diagnosed with tears and wearing of the anterior horn of the LM of the right knee (Figure 1) by the medical staff after a magnetic resonance imaging revealed tears and granulation in the injured area, which were caused by repetitive overuse. An anterior cruciate ligament (ACL) cyst was also diagnosed, and there was no additional damage to the ACL, posterior cruciate ligament (PCL), medial or lateral collateral ligament, and MM, nor joint effusion. The doctor recommended surgery, to which the patient agreed. The patient was admitted to the hospital and completed the questionnaires, as shown in Table 1.

2.2. Surgical Procedure

Before surgery, the right knee could not be flexed over 90°. The arthroscopic meniscal repair was performed with the patient supine and under spinal anesthesia. A pneumatic tourniquet was set at 320 mmHg along the upper thigh. Skin preparation and draping were performed in a sterile orthopedic manner. After creating the parapatellar, anterolateral, and far-anteromedial working portals, an intra-articular procedure was performed. Arthroscopic findings revealed an intact suprapatellar pouch, medial gutter, ACL, PCL, and MM. A long vertical tear in the anterior horn of the LM was observed, and an arthroscopic meniscal repair with polydioxanone sutures was performed using the all-inside technique with three suture materials. During ACL debridement, the cyst was biopsied and debrided from the mid-substance of the ACL to the lateral side across the tibial attachment. The wound was sutured layer by layer, a drain was inserted, and an aseptic dressing was applied (Figure 2 and Figure 3). After the application of a cylinder splint, the patient was transferred to the recovery room. After surgery, the blood loss was 50 mL, and tissue-to-pathology, drain, and sponge count corrections were also included. The patient was discharged on the following day.

2.3. Outcome Measurement

The International Knee Documentation Committee (IKDC), KOOS, Kujala Knee score, and Lysholm Knee scores were used to measure subjective knee function and general activity level. A visual analog scale (VAS) was used to measure pain levels. Measurements were conducted 16 days preoperatively and after a 10-year follow-up. The active ROM (AROM) and passive ROM (PROM) of knee flexion in both legs and thigh circumference on both sides were measured at the mid-patella and 5, 10, and 15 cm above the patella to examine muscular atrophy. These measurements were taken at 4, 25, and 38 days after surgery, and after a 10-year follow-up, the ratio of the unaffected side to the injured side was examined, and the values of both sides were compared. After the 10-year follow-up, the isokinetic strength of both knee extensors and flexors were measured at the angular velocity of 180°/s, 240°/s, and 300°/s, respectively, by CON-TREX® (MJ, PHYSIOMED, Schnaittach, Germany); these measurements served to examine the symmetry of the quadriceps and hamstring muscle strength on both sides. Furthermore, single hop forward, lateral, and medial hop tests using both legs were conducted to monitor the patient’s overall knee function during sports activities and detect asymmetries in the distance records after follow-up.

2.4. Rehabilitation Exercise Protocol

The entire rehabilitation exercise program used in this case is summarized in Table 2 (e.g., set, repetition, and duration of each exercise, and phase of the goal).

2.4.1. Phase I: Protective Phase (4–24 Days after Surgery)

The patient underwent rehabilitation for 10 weeks, five times a week or more. Because of the limited peripheral blood supply [17,34], it was difficult for the patient to recover from the meniscal tear without exercise [35,36]. As the patient needed to return to sport quickly, we increased the number of training sessions by dividing the exercise program into morning and afternoon sessions during the early rehabilitation stage. The following four objectives were established: 1. effusion, inflammation, and swelling should be reduced to maximize protection; 2. full ROM must be recovered (Table 3 shows that the ROM of the affected side was significantly lower than that of the uninjured side); 3. the quadricep muscle activity, which is involved in knee flexion/extension, should be restored to the normal range; 4. move on to Phase II and perform full weight bearing for functional exercises.
In the morning session, ROM recovery was first attempted by performing limited movement exercises around the surgical site, which were followed by strength and proprioception exercises, including sit-ups, D1 and D2 patterns, and use of an arm ergometer (Table 2). After completing the exercises in the morning and afternoon sessions, icing was performed at the surgical site for 20 min. Furthermore, considering that the patient was an athlete, closed-kinetic chain and open-kinetic chain exercises were administered concurrently, and slight pain occurred during the knee flexion motion. Ibuprofen was administered twice, once in the morning and once in the afternoon. Outside of exercise time, compression and elevation of the surgical area were performed, and a brace and crutch were used during walking.

2.4.2. Phase II: Restorative (25–37 Days after Surgery)

After Phase I, normal gait and weight-bearing exercises were performed. Strengthening exercises were performed by comparing the differences between the two sides to maintain balance. Considering that strength, power, and endurance should be gradually increased at this stage, we aimed to improve the knee joint ROM. Through functional exercises, exercises that were more advanced than those in Phase I were performed, and the goal was to maintain and develop body conditioning. A swimming pool and a sports center were used for Phase II training. Aqua running was performed in a 2 m pool with an initial 5 min warm-up and 25 min of interval training. The patient started from a deep position and was permitted to go back and forth for 15 m in 2 min sets. All aquatic exercises were conducted five times/set, and the patient was instructed to start immediately after taking a 15 s break for each set. After 30 min of these exercises, the final 10 min was spent cooling down through slow walking with the water level at the mid torso.
On the ground, weight training was increased to improve muscle strength. Several functional exercises were added to increase the intensity of quadriceps muscle training compared to Phase I. The training load was increased to improve muscle strength, and several functional exercises were added (e.g., core stabilization and multifidus exercises). As cardiorespiratory endurance was performed in the pool before ground training, the frequency of the arm ergometer was gradually reduced on the ground. Because the crutch caused spasms in the patient’s uninjured leg, the frequency of use was reduced, and normal gait was attempted as much as possible.

2.4.3. Phase III: Return to Full Functional Activity (38–71 Days after Surgery)

Phase III focused on returning the patient to full functional activity. We attempted to maintain the functions of the injured part similarly to those of the uninjured side and focused on sufficient tissue healing and reconditioning. The aim was to ensure the patient’s return to sport while maintaining ROM, flexibility, proprioception, strength, power, and endurance under optimal conditions. Ultimately, we attempted to familiarize the player with the normal skill patterns in ice hockey and restore confidence through functional training activities after rehabilitation. This phase aims to optimally restore all body components, autonomous participation, and promote full activity resumption in the athlete.
The rehabilitation training was conducted primarily on the ground (Table 2), and the goal was to enable full ROM without discomfort and for normal gait to occur naturally without a brace or crutches. Fortunately, the patient maintained an average PROM of 150° and did not experience any discomfort, even when the weight was lifted to a certain level during the squat. Quadriceps strength increased by 90% in the uninjured leg. Eventually, after all the three phases, the patient was able to exercise independently.

2.4.4. Return to Full Functional Activity and Follow-Up after Rehabilitation

Table 1 shows the patients’ subjective function, pain, and activity levels before the LM repair. Furthermore, Table 3 shows that four days after the LM repair, knee flexion AROM and PROM on the injured side were significantly lower than those on the uninjured side. However, they gradually recovered to a level similar to that of the healthy side 25 and 38 days after surgery. Additionally, the thigh circumference gradually recovered.
Despite the doctor’s prediction that recovery would take more than four months, the patient returned to play 71 days post-surgery and played three full-time periods in the intercollegiate championship 84 days after surgery. One year after surgery, magnetic resonance imaging was repeated to confirm the repair status. Although a signal change was observed in the anterior horn of the LM, no remarkable findings were observed in the ACL, PCL, medial collateral ligament, lateral collateral ligament, or MM. All subjective functions, knee pain, and physical activity levels, including the IKDC, KOOS, Kujala score, Lysholm Knee score, Marx activity scale, and Tegner activity scale, had improved to normal at the 10-year follow-up (Table 4). The subjective pain level (VAS) decreased from four before surgery to one, revealing that the patient had no perceived functional disabilities when performing activities as an athlete after a 10-year follow-up, as shown in Table 4. Remeasurement of these values at the 10-year follow-up showed that both sides were symmetrical (Table 5). The AROM of the injured leg was lower than that of the unaffected leg. However, considering the value of the subjective function measurements (i.e., IKDC, KOOS, Kujala score, Lysholm Knee score, Tegner activity scale, VAS, and isokinetic strength of the knee flexors and extensors) and two functional performance tests, the symmetry of the two sides did not seem to interfere with normal athletic activity (Table 5). No recurrence or subsequent meniscus injuries occurred during the 10-year follow-up period. Subsequently, he has played in university and professional leagues in the Republic of Korea and is currently playing in the East Coast Hockey League.

3. Discussion

The patient developed a long vertical tear of the LM, which was considered to generate a valgus force instead of a force directed toward the anterior region owing to synovial plica stress. This force would have occurred more frequently in situations that required physical contact and movement in ice hockey, such as when breaking through the defense and obtaining a puck for a scoring chance. Ultimately, repetitive stress (e.g., unnatural movements of skating) experienced during training and competitions in adolescence led to microtrauma in the LM. Furthermore, the tear in the LM occurred because muscle strength was underdeveloped during adolescence owing to microtrauma caused by repetitive stress. The meniscal repair was performed because a lateral meniscectomy, particularly in young athletes, can cause rapid chondrolysis [37]. The surrounding neurovascular tissue may also be negatively affected by the inside-out technique, which is considered the gold standard. Therefore, an all-inside technique was applied for surgery even if the suture caused discomfort [17,38]. Vertical, longitudinal tears may also heal faster than other tears [39], and meniscal tears could lead to secondary deteriorations, such as osteoarthritis [31]. Therefore, exercise rehabilitation can be deemed as essential for returning to sports activities through recovery.
Several studies have suggested primary variations in meniscal recovery with respect to weight bearing, ROM, time to return to sport, immediate partial weight bearing, and unrestricted ROM as components of an accelerated rehabilitation protocol [40,41,42,43,44]. According to the existing clinical practice literature related to the biomechanism of an isolated meniscus lesion, when damage has occurred in the circumferential hoop fibers of the meniscus, weight bearing during rehabilitation should generally be restricted for 6 weeks after initiating rehabilitation, and the limit of knee flexion ROM should also set to 90 degrees [21]. However, in the case of a vertical long tear, as in this case, the hoop tensile effect is preserved, so partial weight bearing of about 20 kg at 90 degrees is allowed from the first 4 weeks, and, thereafter, weight bearing is performed to the patient’s pain-free level [45]. Additionally, the restricted protocol is more appropriate in the case of the radial tear mechanism, whereas the axial compressive load may relieve the lesions in cases of excessive mobility of the LM and a long vertical tear; therefore, an accelerated protocol could be suggested in this case [46,47,48,49]. Furthermore, cases of inside-out meniscal repair with an ACL-accompanied injury showed an early return to the game after performing exercises with full weight bearing without limiting ROM [40,50]. In a study of 22 patients who underwent outside-in repair surgery, three patients developed a re-tear owing to immediate weight bearing with no ROM restriction [44]. Regarding an anteroposterior vertical tear, maximum weight bearing is allowed as much as possible while wearing a brace [23]. Moving forward from the previous literature where the rehabilitation periods were 4–6 months [27,51,52,53,54,55], the patient in this case returned to play in 71 days and won top scorer, contradicting the doctor’s expectation that it would take more than 4 months. In this case, the patient showed a strong desire to return to sport, and, accordingly, accelerated rehabilitation was carried out compactly, divided into mornings and afternoons, 5 days a week, and restrictions in rehabilitation were significantly adjusted according to the player’s subjective awareness of pain and discomfort. This suggests that partial freeing hastened the time to return to sport after rehabilitation. A discussion of the rehabilitation program from surgery until return to sport is as follows.
In this report, heel raise, wall slide, weight shift, and squat exercises were performed early on in the rehabilitation, allowing the patient to autonomously limit the ROM level before experiencing pain. Then, weight bearing became possible at Phase II, such that the patient could perform single-leg exercises within 3 weeks after surgery; therefore, this could be suggested as an appropriate case of applying accelerated rehabilitation. Here, compared to the existing literature [45], it was confirmed that full weight bearing occurred about a week earlier. Furthermore, based on previous research showing that loads in a state where the knee is excessively flexed should be avoided for four months after surgery [56], the lunge motion was not deepened in Phase II, but the rest of the rehabilitation exercises were performed aggressively and within the range where the patient did not feel pain. Additionally, because information on proprioception, balance, and coordination is essential during rehabilitation after meniscal injury [57,58,59], Phase I encompassed the performance of proprioceptive exercises that improved compensatory movements to avoid pain, and this allowed for most of the exercises planned in Phases II and III to be performed without difficulty. Therefore, the patient’s subjective feedback on their performance indicated improvement. However, the efficacy of supervised meniscal tear rehabilitation remains controversial. In one study, those who were supervised had higher vertical jump heights and single-hop distances than those who were not [60,61]. In another study, there was no significant difference in patient-oriented outcomes at the early and intermediate follow-ups [62]. Instead of supervising ROM and weight bearing directly, we designed contraindications for training in sports centers based on the patient’s subjective feelings and/or symptoms while indirectly observing the patient in the sports center. In our case, the treatment was considered effective because the patient was willing to return. Thus, in clinical practice, it is necessary to selectively attempt home-based training while considering patient adherence.
In Phase I, knee flexion AROM and PROM recovered significantly. In the conservative protocol, hamstring resistance exercises are restricted for the first six weeks [63]. However, after closed-kinetic chain training, squats, and various other exercises in the current case, both knee flexion AROM and PROM improved (Table 2). Furthermore, the thigh circumference of the affected side recovered, and muscle atrophy was resolved. After confirming that weight bearing was possible, the program proceeded to Phase II, and a water exercise was added to restore the balance and function of the injured leg. This broke the existing rules for the four recovery stages (1. recovery stage, 2. repair stage, 3. strength stage, and 4. functional stage), and the patient recovered quickly without any risk.
The patient was transferred to full functional activity one month after rehabilitation. As shown in Table 2, AROM of the injured leg recovered to the same level as that of the uninjured leg, and the goal of ROM recovery to 125° within 3–6 weeks was achieved [23]. The criterion that the quadriceps index for recovery should be at least 75% higher than that of the unaffected side was also met [50], and a value > 90% was observed. In Phase III, the difficulty of the balance and proprioceptive exercises increased through star excursion and trampoline movements with added weight, and strength was improved by increasing the weight. Early return to sport after an injury is important for team performance, and studies examining the time from isolated meniscal tears to return to play are rare. Regardless of such rarity, meniscal repairs are often performed in young athletes. After surgery, it is generally recommended for the athlete to return to competitive sports involving frequent physical contact only after 4–6 months [27,51,52,53,54,55]. However, in the current case, only 71 days were required to complete all rehabilitation phases. In another study, it was reported that it takes 5.6 months on average for the recovery of an isolated meniscal tear [17]. Therefore, it can be said that the effectiveness of the function-oriented, aggressive rehabilitation protocol used in this study was proven.
The ultimate goal of recovery is to create a problem-free state 5–10 years after surgery [64]. However, because the failure rate of patients who undergo accelerated rehabilitation after meniscal repair is 10% after 3.5–20 months [40,50], the recurrence of injuries needs to be considered. In this context, we measured subjective function, isokinetic strength, and performance at a 10-year follow-up. We observed that the isokinetic muscle strength of the affected side exceeded 90% of that of the unaffected side. The results of the performance and subjective function measurements also suggested that the effect of the injury as an active player was eliminated. In particular, as is evident from the evaluation of single-leg forward, lateral, and medial hops (Table 4), no asymmetry between the injured and non-injured legs was observed in functional movements. After the follow-up, we prioritized evaluating the functional fitness required in sports situations to confirm that there were no problems for the patient with performing athletic activities.
Our study has certain limitations. First, although the player quickly returned to the game after the rehabilitation exercises, an assessment of fitness function was not conducted immediately after completion of the rehabilitation program. Therefore, in follow-up studies addressing LM tears, evaluation through measurements immediately before returning to the game should be considered, if necessary. Second, our study did not consider the volume and type of physical activity during follow-up after rehabilitation. Third, we examined various physical functions during follow-up and measured ROM and muscle volume on three occasions during rehabilitation. However, there is a lack of documentation quantifying a patient’s physical function after the completion of rehabilitation. Nevertheless, based on the patient’s subjective feeling regarding the LM tear, which is a relatively rare injury, weight bearing was performed in the early stages of rehabilitation; thus, this case report has implications through its focus on subjective function.

4. Conclusions

This study examined a case of isolated LM tears in a patient who returned to play 71 days after surgery and continued to play in collegiate and professional-level leagues for a period of 10 years. Furthermore, we present a training program that could provide implications for meniscal injuries, for which consistent guidelines have yet to be drawn up. Future researchers are urged to conduct examinations to identify a method to measure the strength and function of each rehabilitation phase and follow-up training programs. Finally, because LM tears are rare, it is difficult to apply the protocol of this study to all meniscal injuries.
However, this study could provide some preliminary clues owing to the lack of evidence in these cases. First, it may be more effective to adjust exercise intensity during aggressive rehabilitation based on the patient’s feelings than to supervise weight bearing and ROM limitations. Second, as revealed in this case, before the diagnosis of an LM tear, apart from muscle development, adolescents’ surrounding structures (e.g., ligaments and plica) do not develop together; therefore, training focused on ligaments and tendons may be important for injury prevention at a young age. Third, more long-term follow-up studies are needed to check both the objective symptoms and subjective feelings of patients with LM tears and to determine whether they interfere with sports-related activity performance.

Author Contributions

Conceptualization, H.G.J., J.H.L., S.Y.L. and B.H.K.; Methodology, H.G.J., J.H.L., T.K.K., D.W.L., K.U.O. and B.H.K.; Validation, D.W.L., K.U.O., S.Y.L. and B.H.K.; Investigation, H.G.J., J.H.L., T.K.K., D.W.L. and B.H.K.; Funding acquisition, B.H.K.; Manuscript preparation, H.G.J., J.H.L., K.U.O. and T.K.K.; Visualization, J.H.L., T.K.K. and K.U.O.; Supervision, S.Y.L. and B.H.K. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by the Dongguk University WISE Campus Research Fund of 2022.

Institutional Review Board Statement

Informed consent was obtained by the participant in this study.

Informed Consent Statement

To proceed with this case report, written informed consent was obtained from the patient.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request.

Conflicts of Interest

The authors declare that there are no conflicts of interest.

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Figure 1. Arthroscopic finding showed anterior horn vertical long tear in lateral meniscus.
Figure 1. Arthroscopic finding showed anterior horn vertical long tear in lateral meniscus.
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Figure 2. Conducting debridement around the anterior cruciate ligament (ACL).
Figure 2. Conducting debridement around the anterior cruciate ligament (ACL).
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Figure 3. Performing arthroscopic lateral meniscal repair using all-inside technique with three suture materials.
Figure 3. Performing arthroscopic lateral meniscal repair using all-inside technique with three suture materials.
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Table 1. Subjective and objective measures and findings before surgery (at the point of hospitalization).
Table 1. Subjective and objective measures and findings before surgery (at the point of hospitalization).
Subjective and Objective ScalePre-Surgery/
Maximum Value		Pre-Injury/
Maximum Value
Subjectvive questionnaire
outcome		International Knee Documentation Committee Score49.4/100-
Knee injury and Osteoarthritis Outcome Score78.6/100-
Kujala Knee score72/100-
Lysholm Knee score66/100-
Visual Analogue Scale4/10-
Muscle circumferenceThigh56 cm-
Physical activity levelMarx activity scale3/1616/16
Tegner Activity Level Scale3/109/10
Table 2. Rehabilitation exercise protocol.
Table 2. Rehabilitation exercise protocol.
PhaseExercise and TreatmentSet/Repetition, DurationGoal
I: Protective
(4–24 days after surgery)		Quad-set5/15 s on, 5 s off
  • Reduce effusion, inflammation, and swelling
  • Restore full ROM
  • Restore knee flexion, extension activity of quadriceps muscle
  • Enable full weight bearing
Standing heel raise3/10
Single leg raise (0°, 30°, 45°, −30°, −45°)3/10
Wall slide1/10
Weight shift3/1 min
Patella joint mobilization30 times/direction
Standing physioball squat3/10
Icing20 min
Sit up3/60
Proprioception (brace locked at 0 degrees)
-D1, D2 pattern
-Throwing a ball with single leg standing		−3/3
−3/3
Arm ergometer1/15 min
Icing20 min
II: Restorative
(25–37 days after surgery)		Aqua running (with four kick board)-
  • Improve the strength of the quadriceps muscle
  • Recover cardiovascular endurance
  • Restore normal gait
Quad set5/15 s on, 5 s off
Standing heel raise3/10
Single leg raise (flexion, extension, abduction, adduction)3/10
Active ROM of knee flexion1/10
Weight shift3/12
Patella joint mobilization30 times/direction
Standing physioball squat3/10
Lunge (star, not deep)3/4
Uninjured single leg balance (close eyes, say “go,” open eyes, catch)3/4
Superman (arms and legs up together, alternating legs and arms)3/10
Supine dead-bug2/5
Perturbation for each side with eye-closed3/1 min/side
Upper thigh massage1/10 min
hamstring, iliotibial band, and calf stretching1/10 min
Icing1/20 min
III:
Return to full functional
activity
(38–71 days after surgery)		Stair step, step box1/5 min, 5 min
  • Recover full ROM without pain
  • Restore normal gait without brace or clutch
  • Familiarize normal sport-specific skill patterns
  • Recover symmetric functional level on both sides
Stationary bicycle1/10 min
Nordic hamstrings3/10
Back squat (80 kg)3/10
Kettle bell deadlift (20 kg)4/10
Single leg kettle bell pick-up on star excursion5/3
Lateral monster walks2/2
Side hopping3/3
Trampoline balance (catch tape roll)3/1 min
Treadmill running 7–8 km1/15 min
Icing1/20 min
Abbreviations: ROM, range of motion.
Table 3. Objective outcomes of the injured and uninjured leg during rehabilitation phases.
Table 3. Objective outcomes of the injured and uninjured leg during rehabilitation phases.
Measurement 1Measurement 2Measurement 3
Knee flexion ROMRight (injured leg) AROM85°112°128°
Right (injured leg) PROM99°138°143°
Left (uninjured leg) AROM116°119°119°
Left (uninjured leg) PROM134°147°147°
Thigh circumferenceRight (injured leg) Mid-patella36.4 cm37.1 cm37.1 cm
Right (injured leg) 5 cm41.8 cm42.5 cm42.5 cm
Right (injured leg) 10 cm47.4 cm49.3 cm49.3 cm
Right (injured leg) 15 cm53.6 cm54.1 cm54.1 cm
Left (uninjured leg) Mid-patella36.3 cm37.1 cm37.1 cm
Left (uninjured leg) 5 cm42.6 cm42.6 cm42.6 cm
Left (uninjured leg) 10 cm50.6 cm49.2 cm49.2 cm
Left (uninjured leg) 15 cm56.5 cm54.2 cm54.2 cm
Abbreviations: ROM, range of motion; AROM, active range of motion; PROM, passive range of motion. Measurement 1: 4 days after surgery. Measurement 2: 25 days after surgery. Measurement 3: 38 days after surgery.
Table 4. Patient-oriented subjective outcomes of measurements after 10-year follow-up.
Table 4. Patient-oriented subjective outcomes of measurements after 10-year follow-up.
Subjective OutcomeTotal Score/Maximum Value
Subjective questionnaire outcomeInternational Knee Documentation Committee100/100
Knee Injury and Osteoarthritis Outcome Score98/100
Kujala score98/100
Lysholm Knee score100/100
Visual Analogue Scale1/10
Physical activity levelMarx activity scale12/16
Tegner Activity Level Scale10/10
Table 5. Objective outcomes of injured and uninjured legs after 10-year follow-up.
Table 5. Objective outcomes of injured and uninjured legs after 10-year follow-up.
VariablesRight (Injured Leg)Left (Uninjured Leg)
ROMKnee flexion AROM124°140°
Knee flexion PROM148°150°
GirthMid-patella35.5 cm35.3 cm
5 cm41.9 cm42.1 cm
10 cm49.1 cm49.0 cm
15 cm53.1 cm53.2 cm
Isokinetic strengthKnee extensors a180°/s242.4% (187.6 Nm)242.9% (188.0 Nm)
240°/s218.2% (168.9 Nm)228.4% (176.8 Nm)
300°/s215.6% (166.9 Nm)212.1% (164.2 Nm)
Knee flexors a180°/s179.1% (138.6 Nm)167.3% (129.5 Nm)
240°/s209.0% (161.8 Nm)199.7% (154.6 Nm)
300°/s212.3% (164.3 Nm)212.0% (164.1 Nm)
Knee extensors ratio b180°/s99.8
240°/s95.5
300°/s101.6
Knee flexors ratio b180°/s107.0
240°/s104.7
300°/s100.1
Functional performance testSingle hop forward a119.1% (197 cm)117.3% (197 cm)
Lateral hop a109.0% (160 cm)95.3% (160 cm)
Medial hop a108.4% (180 cm)107.2% (180 cm)
Single hop forward ratio b101.5
Lateral hop ratio b114.4
Medial hop ratio b101.1
a Normalized by body weight to account for strength and height for distance. b Ratio of injured to non-injured side.
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Jeon, H.G.; Lee, J.H.; Kang, T.K.; Lee, D.W.; Oh, K.U.; Lee, S.Y.; Kim, B.H. Rehabilitation and Return to Play of an Ice Hockey Athlete after Lateral Meniscus Repair: A Case Report. Appl. Sci. 2024, 14, 4084. https://doi.org/10.3390/app14104084

AMA Style

Jeon HG, Lee JH, Kang TK, Lee DW, Oh KU, Lee SY, Kim BH. Rehabilitation and Return to Play of an Ice Hockey Athlete after Lateral Meniscus Repair: A Case Report. Applied Sciences. 2024; 14(10):4084. https://doi.org/10.3390/app14104084

Chicago/Turabian Style

Jeon, Hyung Gyu, Jong Hyeon Lee, Tae Kyu Kang, Dong Wook Lee, Kyoung Uk Oh, Sae Yong Lee, and Byong Hun Kim. 2024. "Rehabilitation and Return to Play of an Ice Hockey Athlete after Lateral Meniscus Repair: A Case Report" Applied Sciences 14, no. 10: 4084. https://doi.org/10.3390/app14104084

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