Physiotherapy
Don’t “Push through the pain”, be extremely careful with exercise
Each individual with arthrofibrosis has a level of exercise that their affected joint can tolerate. Without the assistance of anti-inflammatory medications exercise tolerance may be minimal. For example, for some people with active arthrofibrosis of the knee even standing is painful and increases inflammation. For those with residual (stiff but pain-free) arthrofibrosis exercise tolerance may not be significantly limited.
The “take-home” message is to exercise the affected limb according to your abilities – do not compare yourself to others, or to your previous abilities. Continuing to exercise beyond the pain-free zone, either in intensity or duration, increases inflammation and causes damage that can be permanent. However, other parts of your body that aren’t inflamed can typically be exercised without a problem, and this likely has beneficial effects on health and wellbeing.
Getting the amount of exercise right
Possibly the most important aspect of treating a fibrotic joint is getting the amount of exercise right. This has been a controversial subject in the treatment of arthrofibrosis, however, it is becoming increasingly clear that exercise of the affected limb must be undertaken with extreme caution, and carefully tailored to the individual and their tolerance of it. It is safer to err on the side of caution, with no, or minimal (duration and intensity), exercise of the affected limb during recovery. If a knee has arthrofibrosis, even the amount of standing and walking needs to be monitored and adjusted as required.
However, exercising the rest of the body is likely to be beneficial, so long as the affected limb is not impacted. Mild to moderate exercise (of non-fibrotic areas) decreases inflammation, regulates the immune system and benefits mood [1].
Aggressive exercise of the affected limb used to be prescribed to those suffering from arthrofibrosis. However, research into the inflammatory effects of exercise, and the responses of patients with arthrofibrosis, now strongly suggests that this approach is dangerous, and could lead to permanent arthrofibrosis and disability.
Sadly, the idea that aggressive exercise is necessary persists in some areas, and arthrofibrosis forums are full of the accounts of people who have suffered permanent damage after being instructed to exercise vigorously post-surgery and “push through the pain”. This is not good advice!
Gentle passive stretching is thought to be beneficial
However, movement of the joint in the form of gentle passive stretching is though to be beneficial. Over time it may be possible to slowly and carefully increase the level of exercise of the affected limb if recovery is well under way or complete. As noted above, exercising other parts of the body is likely to be beneficial.
Long-term arthrofibrosis. Those who have long-term knee arthrofibrosis have typically become familiar with how much standing, walking and exercising they are capable of undertaking without suffering more pain and limitations in ROM.
Unfortunately, some people are extremely restricted in these activities.
Even mild exercise could significantly increase immune dysfunction
All people – even professional athletes – suffer muscle damage, inflammation and oxidative stress after prolonged, intense exercise, with evidence of systemic (whole body) immune dysfunction for hours to days afterwards [2]. This profound exercise-induced inflammatory reaction involves cytokines, mediators and cells, and is made worse by significant stress and lack of sleep [2]. As a result of this inflammatory reaction, athletes and others who do repeated bouts of heavy exercise appear to have double (or more) the risk of illness [2]. Depending on the level of inflammation already present in the fibrotic joint, even mild exercise such as walking (for a fibrotic knee) could significantly increase immune dysfunction.
Immune dysregulation and inflammation suffered after intense exercise (a marathon) compared to the beneficial effects of gentle exercise (walking) in healthy people (D. C. Nieman et al. 2019, The compelling link between physical activity and the body’s defence system. Journal of Sport and Health Science).
Interview with Sebastiano Nutarelli
Dr. Kayley Usher interviews Sebastiano Nutarelli about arthrofibrosis. Sebastiano Nutarelli is a physical therapist with a focus on treating arthrofibrosis. His lengthy journey with this disease led him to specialized care in the United States. In 2018 he co-founded the Sports Rehab PT clinic in Lugano, Switzerland. Sebastiano works with patients on a daily basis in order to help them recover from injury and surgery and is a strong supporter of Evidence-Based practice in rehabilitation.
"Arthrofibrosis is a bigger problem than we realise, because a lot of the time it’s not diagnosed."
"Every knee with arthrofibrosis is reacting in a different way."
"Never lie to your patients. That means if there is a diagnosis it is fair to frame the situation for what it is…. and we need to change completely the rehabilitation, the goal now is recovering range of motion and getting the knee back on track."
"You want to avoid unnecessary load on the joint."
"Regaining muscle mass is not the goal anymore… when you’re dealing with a knee that has an uncontrolled inflammatory loop as is the case with knee arthrofibrosis you just want the joint to get back to some level of homeostasis (normality)."
"You really want to play carefully with every kind of load post-op. So again, homeostasis is the goal."
"There is no prize for who comes first. In the end the only thing that matters is recovering and if you make the wrong choice, sometimes it's too late to come back."
"We need to educate the patient and understanding that he or she has to provide feedback in terms of 'this is too much', 'I'm feeling that it's going the right direction or in the wrong direction'"
"Quad strengthening… at the beginning, simply forget about it. It is has to be a strict and clear instruction. We need to make sure that the joint again calms down. Muscle will come later. So there is no rush at all."
"Sometimes these joints they look like things are in control and arthrofibrosis is just the just something that happened in the past. So we’re tempted to do things too fast and then it comes back. So we need to be to play with BFR very careful in these cases"
"Scar tissues can form overnight, it's really a fast process"
"There is such a huge lack of knowledge and training in relation to this pathology across all the health professionals,… there is really no one to blame."
References
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research7, doi:10.1038/s41413-019-0047-x (2019).
Nieman, D. C. & Wentz, L. M. The compelling link between physical activity and the body’s defense system. J Sport Health Sci8, 201-217, doi:10.1016/j.jshs.2018.09.009 (2019).
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