I am very grateful to find this organization and forum. My wife had ACL replacement surgery 5 months ago. During recovery, she developed arthrofibrosis and was never able to get her knee flexion beyond 80 degrees. She had been vigilant throughout her PT, so she definitely wasn't slacking.
Her surgeon recommended knee arthroscopy to remove the scar tissue. She would then immediately have much more flexibility in her knee, and the important thing for her to do in the 6 weeks following surgery is to "bend, bend, bend". She had that surgery 8 days ago. During the surgery he was able to flex her knee 140 degrees. After surgery, she went straight to PT and for the next couple of days was able to bend 120 degrees. That has now diminished to apx. 110 degrees, when her physical therapist applies strong pressure. She is flexing her knee and doing other exercises every waking hour for 10-15 minutes (to a point of discomfort but not exceeding pain), taking her meds including anti-inflammatories, using an ice machine religiously, etc. But (I'm sure you know where I'm going here), our concern is that her arthrofibrosis is returning and this recovery regimen may be doing more harm than good.
The surgeon said the surgery and PT has a 90% success rate. (Who are those 90% and shouldn't we roll the dice and hope she is one of them...?) But the way this may be trending leads us to believe she may not be among the 90%. We are grappling with whether she should stick to the regimen, even for another week, or two weeks, to see if there is increased flexion; or immediately adjust to only gentle flexion. I realize every patient is unique, but very much appreciate any thoughts.
Thank you! Mark
All, thank you again for your previous comments to this thread. My wife and I have some questions about IAA's PT guidance.
She is now 3-1/2 weeks post-surgery for scar tissue removal. She has followed IAA's post-op PT recommendations (gentle and passive only, CPM, etc.) My wife continues to have moderate swelling of IFP which has remained steady. She is comfortably at 124 degrees flexion and virtually at full extension. IAA AF PT guidance indicates no weight-bearing until inflammation has fully resolved, which usually takes 4-6 weeks (acknowledging that every patient is different).
if swelling doesn't abate at 6 weeks, is IAA's guidance that she should continue no weight-bearing until inflammation disappears? And, if so, what is a reasonable estimate as to how long inflammation may stick around (absent any weight bearing)?
At what point can we assume that she is free and clear? For example, if there is no inflammation at 6 weeks, and then she starts moderate weight-bearing and swelling reappears at Week 7, should that be a cause for concern? Same question at, say, Week 12? We're wondering if there is a "normal" amount of swelling that, at a certain point, is no longer a concern.
Again, thank you so much for sharing your thoughts!
Hi Mark,
thanks, I hope we can help. We're also building the surgeon list, anybody can fill it out under the heading “More”. Unfortunately, Dr Singleton (Texas) is retiring soon, however he has recommended Dr Jason Dragoo. I've also heard that Dr Thomas Hackett has a lot of experience and uses AF-safe practices such as not using a tourniquet, good pain control, not using a mechanical shaver etc.
Kayley
Kayley,
Thank you so much for your prompt and thoughtful response. Your recommendations square with our intuition and observations. I will certainly have some follow-up questions after I've done the research you suggested. I do have a pressing question though and that is whether IAA has a list of physicians in the US that are knowledgeable and experienced in treating arthrofibrosis. We live in Boston, but are willing to travel to anywhere to find qualified care. Thank you again, Mark
Hi Mark,
Thanks for your post. I can't give medical advice because I'm not a clinician, but I can pass on what we have learnt so your wife can make an educated decision about her care. I'm assuming that infection or a poorly positioned ACL graft have been ruled out as the cause of the arthrofibrosis.
The first thing is, I personally would never allow anyone to force range of motion with strong pressure, this can do real harm by creating micro-tears in tissues. It seems that we need to work with our bodies and let them do the healing with our help, rather than fighting and trying to force cooperation. The body is in control after all, not us!
The next thing is that it's likely that your wife has an inflamed IFP (Hoffa’s fat pad) due to her surgery. Please read the section on the IAA about this, it's important for understanding what is happening. If it's inflamed, the IFP will be swollen and getting compressed and pinched when there is weight on the leg, and this feeds the cycle of inflammation and fibrosis. So, PTs experienced in treating AF recommend no weight bearing for the first 4 to 6 weeks post-op to allow this swelling to resolve, and then partial weight bearing as tolerated for another couple of weeks. A wheelchair is fine for non-weight bearing, and crutches are OK as well, if used carefully. Bear in mind that knees progress at their own speed, there is no "one size fits all" and the program should be adapted to the individual.
While your wife's knee is in this inflamed state it appears that passive movement is better than active movement (using your own muscles), and hiring a Continuous Passive Movement machine appears to help by reducing adhesions and contractions. Please read the section on this, it's very important that CPM is NOT used to force ROM, but to gently encourage it with regular daily use.
Finally, the focus at this point is on recovering function of the knee by allowing the inflammation to resolve, and not on building muscle. Building muscle can come well down the recovery track, because strengthening muscles in the affected leg will likely pressure and further inflame the IFP, even exercises like straight leg lifts (personal experience here). For most people exercising the non-affected parts of the body is fine.
We don't have a list of AF-aware PTs yet, but we'll be publishing a checklist soon so that we can begin making one.
Please feel free to ask more questions.
All the best,
Kayley