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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.

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).

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.


  1. Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research7, doi:10.1038/s41413-019-0047-x (2019).

  2. 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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