In this comprehensive panel discussion, physiotherapists Jamie Palmer (USA), Othmar Hauer (Austria), and Sebastiano Nutarelli (Switzerland) share their insights on the diagnosis and management of arthrofibrosis—a challenging condition characterized by excessive scar tissue, joint stiffness, and pain, often following surgery or trauma. Moderated by Manon Raap, the discussion covers a wide range of topics including early detection strategies, the psychological impact of the condition, and rehabilitation techniques. Learn about the importance of multidisciplinary care, patient education, and when to consider specialist referrals. Whether you're a clinician or a patient, this session offers valuable information on navigating the complexities of arthrofibrosis treatment.
This is a controversial subject and the views expressed by the panellists do not necessarily represent the views of the IAA.
Sebastiano, how did you realize that specialized treatment for arthrofibrosis was lacking, and what sparked your interest?
Sebastiano Nutarelli: Thank you. It caught my interest because I was a patient myself. I was a professional athlete, and after a minor injury, I needed a knee procedure that led to knee stiffness. I went through the classic experience of undiagnosed stiffness for about a year and a half, traveling and seeking answers. It wasn’t initially a special interest; I was simply one of the patients. Now, as a clinician, my goal is to provide better care, including earlier diagnosis and treatment options.
Othmar Hauer: My first contact with this problem was when I was very young. I wasn’t a sports scientist or physiotherapist yet—I was just a boy. My mother had a similar condition, which left a lasting impression on me. Later, as a physiotherapist, a patient came to me with the same issue, and I remembered my mother’s experience. I realized there was a connection with Complex Regional Pain Syndrome (CRPS) and started to develop my own treatment approaches. Through study, I began achieving good results.
Jamie Palmer: I specialize in working with athletes after ACL or multi-ligament reconstruction, and I encountered a few patients with arthrofibrosis. Observing its impact on their lives highlighted the need for focused treatment. I worked with patients who had undergone multiple surgeries or consulted several physicians before a diagnosis. By concentrating on this group, I aim to improve care standards and educate more providers.
Early recognition and adaptation of treatment plans are crucial to preventing worsening symptoms and providing the best chance of recovery. Sebastiano, how do you detect the earliest signs of arthrofibrosis in your patients, and how do you adjust the treatment plan?
Sebastiano Nutarelli: If rehabilitation post-surgery isn't progressing as expected, it’s a red flag. We anticipate improvements in pain, range of motion, and inflammation. If these don’t follow the expected timeline—typically 7 to 15 days—it indicates a problem. Lack of knee extension beyond 7-10 days is a significant sign. Flexion is easier to recover, but poor extension often predicts long-term issues. At my clinic, we monitor patients closely, sometimes daily, to detect problems early. If we suspect arthrofibrosis, we focus solely on the joint and avoid rushing to crutch-free walking or strengthening exercises, aiming instead for joint homeostasis.
Otmar, how do you explain the chronic nature of arthrofibrosis to your patients and keep them motivated throughout the lengthy recovery process?
Othmar Hauer: I tell patients that arthrofibrosis is often stress-related, which can be physical, psychological, or mechanical. While mechanical stress might be addressed with surgery, psychological stress, like personal or family issues, can complicate recovery. Helping patients understand and manage stress is crucial. I also emphasize the need to lower expectations and effort temporarily. Many high-performing patients struggle with this, but it’s often necessary for progress.
Sebastiano Nutarelli: From personal experience, the pathology itself is a major stress factor. When patients realize the seriousness of their condition, they often feel a huge sense of relief upon diagnosis because it confirms the problem isn’t imagined. However, we must recognize how psychologically devastating it can be.
Jamie, patients often face forced range-of-motion exercises, sometimes called "overpressure", which can cause tissue damage and worsen their condition. What alternative techniques do you use to improve joint mobility without causing further harm?
Jamie Palmer: It starts with patient education. Pushing through pain during range-of-motion exercises won’t speed recovery and might actually slow it down. I use pain scales like the Delaware Pain and Soreness Rules, where pain shouldn’t increase by more than two out of ten during exercises, and delayed soreness shouldn’t last more than 24 hours. I also utilize joint mobilizations, avoiding overpressure, and encourage frequent, pain-free range-of-motion exercises throughout the day. If needed, I recommend devices like Continuous Passive Motion (CPM) machines or extended low-load, long-duration stretching.
Sebastiano Nutarelli: To add to Jamie’s points, low-load, long-duration stretching (LLPS) is one of the few evidence-supported interventions. Research shows that this method can promote effective recovery by encouraging plastic deformation of the tissue. While these knees might never be "normal" again, functional recovery is achievable.
Research indicates that inflammation is crucial in arthrofibrosis, and managing it is essential before starting strengthening exercises. Sebastiano, how do you incorporate inflammation management into your treatment plans?
Sebastiano Nutarelli: Managing inflammation is more of an art than a science. Arthrofibrosis involves an excessive healing response, so our goal is to slow it down. Cryotherapy and compression are key, as they help reduce metabolism. I encourage patients to use cryotherapy devices and to stay on crutches longer if needed. Managing load is essential to prevent further inflammation. We also involve physicians for pharmacological interventions, such as anti-inflammatories, which are necessary in some cases.
Given the signs indicating that exercise increases inflammation, strengthening exercises should be delayed until inflammation is effectively controlled to avoid worsening arthrofibrosis. Othmar, how do you determine when it's safe to transition from inflammation control to muscle strengthening in your patients?
Othmar Hauer: There isn't a specific test; it's more about assessing when the patient is ready to start strengthening exercises. Initially, we focus on natural movement patterns like standing up, sitting down, and walking, with an emphasis on eccentric rather than concentric exercises. Physical therapy often overemphasizes concentric exercises and underemphasizes eccentric ones. For example, a relaxed skier demonstrates good eccentric control, while a tense skier exhibits over-concentric movement, which makes them stiff. I apply a similar approach in therapy, aiming for relaxed, eccentric motion. We start with body-weight exercises in various positions and gradually progress to more demanding strengthening exercises. I avoid machine exercises to emphasize natural movement patterns and reactivate innate patterns that the pathology may have suppressed.
Despite patients' best efforts, arthrofibrosis can progress due to its underlying pathological mechanisms. Blaming patients for this condition is counterproductive. Jamie, how do you support and encourage patients who are following their exercise programs but still experience progression of arthrofibrosis?
Jamie Palmer: It’s challenging when patients feel they’re doing everything right but still not seeing the expected progress. It's important to reassure them that they’re not alone—this happens to others as well. Providing a sense of community and support can help alleviate feelings of hopelessness. Checking in on other aspects of their life, such as family and community roles, is also crucial. Encouraging patients to continue exercises as long as they are not painful is essential, as stopping could reverse any improvements. Mindfulness therapy can be helpful for some patients, and occasionally taking a short break from rehab to enjoy other parts of life can help them return with renewed focus.
Sebastiano Nutarelli: I’d like to add that we should destigmatize involving a psychologist here. As physical therapists, we might not always have the skills to provide psychological support. Involving a psychologist or mental health coach can be beneficial and should be presented as a supportive measure rather than implying a mental health issue. Acceptance of the possibility that we might not always succeed is part of providing the best support.
Jamie Palmer: To build on Sebastiano’s point, using the analogy of a team with multiple coaches can be helpful. Just as different coaches provide various aspects of guidance in team sports, a mental health coach or psychologist can play a crucial role. This analogy helps in understanding and destigmatizing the involvement of mental health professionals.
Pain is a critical indicator of inflammation and tissue damage in arthrofibrosis, and pushing through it can worsen symptoms. Sebastiano, how do you help patients distinguish between beneficial discomfort and harmful pain, and how do you adjust treatment if pain levels increase?
Sebastiano Nutarelli: Recognizing that pain tolerance varies among patients is crucial. I focus on educating patients to differentiate between discomfort, which should be tolerable, and harmful pain. I don’t rely heavily on specific pain scales but monitor pain levels and adjust treatment based on its severity and duration. If pain increases, we might reduce exercise intensity and switch to less demanding activities to prevent further irritation. Patients should also be advised to regress their exercises if needed, rather than stopping completely.
Massage of surrounding muscles, rather than the joint itself, is believed to help increase lymph flow, remove inflammatory cytokines, and reduce hypoxia in the short term. Othmar, how do you incorporate muscle massage and lymph drainage into your treatment plan?
Othmar Hauer: Muscle massage and lymph drainage are key components of the initial therapy phase. It’s less about specific techniques and more about a micromobilization approach, which helps calm the system. Patients often report feeling better and experiencing less pain after these sessions. In the early stages of arthrofibrosis, a manual approach is essential to stabilize effects and support recovery. I combine massage, lymph drainage, and an osteopathic approach to address the condition.
Maintaining overall physical health by exercising non-affected parts of the body is important to prevent deconditioning while protecting the affected joint. Jamie, what types of exercises do you recommend to maintain general fitness without risking the affected joint?
Jamie Palmer: The choice of exercises depends on the level of irritation. For aerobic exercise, equipment like fan bikes where they can set their affected leg up on a peg and work the other three limbs can provide cardio benefits while minimizing stress on the affected joint. Same thing if it was shoulder arthrofibrosis, they could use one arm and two legs, always checking in on their pain and how they're feeling the next day. For strength training, focus on exercises around (not using) the affected limb or joint. We see cross-training effects from the non-involved side that can be beneficial. If they're far enough along and their joint is not actively inflamed, strengthening through pain-free range of motion can be helpful. It’s important to keep the intensity moderate—around 70% effort—to avoid overstressing the body and worsening arthrofibrosis.
Research shows that regular pain-free continuous passive motion (CPM) or passive stretching can help maintain joint mobility. Sebastiano, when do you introduce CPM or passive stretching into a patient's treatment plan, and how do you monitor for potential adverse effects?
Sebastiano Nutarelli: For postoperative patients, we introduce CPM immediately, aiming for 8-12 hours per day, though not continuously. Overnight use is encouraged if possible to minimize scar tissue formation and adhesion. For chronic patients, CPM is less effective due to its limited ability to progress flexion in the presence of pain. For these patients, prolonged stretching is more suitable. CPM is generally not used for advanced chronic cases due to its limited effectiveness.
To prevent further injury to healing joints, non-weight bearing is often recommended immediately after surgery, with a gradual reintroduction of weight bearing as tolerated. Othmar, what criteria do you use to determine when it’s safe for a patient to progress from non-weight bearing to partial weight bearing activities?
Othmar Hauer: Typically, after surgery, the medical doctor specifies the weight-bearing guidelines. We start partial weight bearing as soon as feasible, as non-weight bearing can increase muscle tone and make movement more difficult. If patients can perform partial weight bearing with crutches in a proper movement pattern, they can relax with each step. I advise taking small steps and using crutches as necessary but as minimally as possible. If weight bearing increases pain, it should decrease by the next day. I tell patients to be patient and avoid pushing too hard, even if they feel good, as this can lead to setbacks. The goal is to keep the condition stable and improve gradually.
Sebastiano Nutarelli: It’s a matter of balancing based on daily observations. Patients often misjudge their progress, so walking with one crutch might seem fine, but the knee could swell significantly the next day. Many patients push too hard despite education, which can worsen their condition. For example, standing for long periods or engaging in activities like standing around drinking alcohol can exacerbate the condition. Patients may regress or need to start over, and aggressive activity can aggravate arthrofibrosis. It’s crucial to emphasize the importance of a slow and steady progression.
Cycling is often recommended as a low-impact exercise for maintaining joint mobility and overall fitness. However, in arthrofibrosis patients, cycling can worsen the condition due to pulling and stress on the fibrotic patellar tendon and Hoffa's fat pad. Jamie, how do you determine when cycling is appropriate, and what modifications or precautions do you implement?
Jamie Palmer: Cycling should be introduced based on the patient’s pain-free range of motion. It should not be used to push through a painful range or plateau. Patients need sufficient range of motion to complete a full cycle. Starting with backward cycling, which typically requires less range of motion, can be beneficial if it’s pain-free. As the patient improves, forward cycling can be introduced. Initially, cycling should be done with minimal or no resistance to focus on range of motion. Resistance should only be increased if there is no irritation or inflammation. Alternatives like standalone pedals that require less range of motion can also be used until the patient achieves the necessary range of motion, always within a pain-free range.
Given the complexity of arthrofibrosis, collaboration with other healthcare providers such as rheumatologists or pain specialists is often necessary. Sebastiano, how do you determine when a referral to a specialist is warranted, and how do you coordinate care to ensure comprehensive treatment?
Sebastiano Nutarelli: This is a complex issue. If there’s no measurable progress after four to six weeks of physical therapy, it’s time to consider referrals. We need specialists skilled in arthrofibrosis, and in Switzerland, we have a team that includes surgeons knowledgeable in this condition. We ensure that specialists are adequately trained to avoid harming the patient. Other professionals, like rheumatologists or psychologists, are involved as needed. While there’s limited evidence linking nutrition to improvement, some supplementation might be beneficial. Having a skilled rheumatologist on the team from the beginning would be ideal for detecting any additional issues.
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