Recently, Sebastiano Nutarelli, an experienced physical therapist and committee member of the International Arthrofibrosis Association, delivered a compelling presentation at the Scandinavian Sports Medicine Congress 2024 in Copenhagen. His expertise in knee arthrofibrosis, a condition marked by pain and abnormal scar tissue formation in the joint, shed light on the symptoms, pathology, and treatment of this often misunderstood and misdiagnosed disease.
Background
Nutarelli, a PhD student in Ireland with a focus on ACL rehabilitation, shared his journey into knee arthrofibrosis, citing personal experiences and insights gained from founding the EUKAF Center and Sports Rehab in Switzerland. His dedication to understanding and treating arthrofibrosis stems from facing the challenges first hand and recognizing the need for specialized care for affected individuals. Our 1-Day IAA Knee Arthrofibrosis Training Course for Professionals is delivered in-person by Sebastiano Nutarelli.
Key Insights from the Presentation
Pathophysiological Understanding:
Knee arthrofibrosis, as described by Nutarelli, involves an initial insult, often through surgery, leading to an excessive healing response.
Inflammation is a crucial part of the healing process, but in arthrofibrosis, it spirals out of control, triggering a cascade of events that result in the deposition of scar tissues both inside and outside the joint
Symptoms and Diagnosis:
Patients with knee arthrofibrosis may experience a range of symptoms, including loss of range of motion, patellar stiffness, increased pain, muscle atrophy, and a hyper-reactive knee.
Diagnosis is often challenging, as the pathology is frequently misdiagnosed or undiagnosed. Nutarelli emphasized the importance of recognizing key indicators and distinguishing arthrofibrosis from other knee conditions.
Primary Drivers and Risk Factors:
Nutarelli identified primary drivers such as insult (usually surgery), hypoxia, genetic predisposition, inflammation, and the possibility of infection.
Excessive immobilization and bleeding, common in medical procedures, were highlighted as potential risk factors contributing to arthrofibrosis.
Treatment Approach:
The treatment approach for knee arthrofibrosis involves a comprehensive, team-based strategy, including physical therapists, surgeons, pain specialists, and rheumatologists.
Nutarelli stressed the need for clear communication with patients about their unique rehabilitation journey, emphasizing joint-focused rehabilitation over muscle building.
Rehabilitation Program:
The rehabilitation program focuses on passive stretching, including low load prolonged stretch (LLPS), to address extension issues and gradually improve flexion.
Pharmacological interventions may be necessary to manage pain and inflammation, with a cautious approach needed to avoid exacerbating the condition.
Our Favorite Quotes
"Undoubtedly, knee arthrofibrosis is one of the most globally underlooked, misdiagnosed, and mistreated knee pathologies. Patients often find themselves dismissed, facing doctors who either claim ignorance or simply overlook the issue. Due to the lack of formal training, clinicians approach this pathology with complete unawareness, doing their best not even fully comprehend what they are dealing with."
"After various procedures, particularly in cases articular fractures, ACL-R reconstructions or total placements - but even following minor arthroscopic procedures when combined with immobilization and poor physical therapy - about 10% of patients tend to develop the onset of arthrofibrosis. Functional loss of range of motion, patella stiffness, patella baja, and general capsule shrinkage are typical outcomes. In 90% of these cases, we can intervene successfully, but our failure to act stems from a lack of knowledge."
"Ultimately, we need to reframe the situation for both the patient and caregivers. This condition is a life-altering pathology, causing significant stress. It's unfair to promise patients a complete recovery and proclaiming to have all the answers. Instead, we should convey that we understand the uncertainties, offer our guidance and expertise, delivering their best chance of recovery."
"The aim is to perform a 'joint-based' rehabilitation targeting knee homeostasis, not to regain muscles. Surgeons may suggest building muscle, but to do so we need to load the joint which in most of these cases would aggravate the situation."
"In the world of arthrofibrosis, we have two types: active, ongoing fibrosis, and residual, settled-down fibrosis. Distinguishing between them is essential for treatment."
"The fat pad is a significant player in arthrofibrosis. Sensitized to pain due to internal changes, it can't be provoked. Understanding its behavior is crucial for successful treatment."
Conclusion
Sebastiano Nutarelli's presentation at the Scandinavian Sports Medicine Congress provided valuable insights into knee arthrofibrosis, urging healthcare professionals to enhance their understanding of this complex pathology. By adopting a joint-focused rehabilitation approach rather than muscle building, and recognizing the unique challenges faced by patients, there is hope for improved outcomes and a better quality of life for those affected by knee arthrofibrosis.
Note
Readers are encouraged to consult healthcare professionals for personalized advice and treatment options related to knee arthrofibrosis.
What a crystal clear presentation!
I will try to bring this to the attention of the organization of orthopedic surgeons in the Netherlands.